2009 Medicare Part D Plan Formulary Information |
CIGNA Medicare Rx Plan Two (S5617-015-0)
Benefit Details
|
The CIGNA Medicare Rx Plan Two (S5617-015-0) Formulary Drugs Starting with the Letter P in CMS PDP Region 3 which includes: NY
|
Drugs Starting with Letter P
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
PACERONE 100MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PACERONE 200MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PACERONE 300MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PACERONE 400MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PACLITAXEL INJECTION 30MG/5ML 50ML VIALMD |
2 |
Tier 2 |
$6.00 | $15.00 | P |
PACLITAXEL INJECTION 30MG/5ML VILMD CRTN |
2 |
Tier 2 |
$6.00 | $15.00 | P |
PACLITAXEL INJECTION SOLUTION 6MG 50ML VIALMD |
2 |
Tier 2 |
$6.00 | $15.00 | P |
PACLITAXEL INJECTION USP 6MG/ML 300MG/50ML VIALMD |
2 |
Tier 2 |
$6.00 | $15.00 | P |
PALCAPS 10 33.2K-10K CAPSULE DELAYED RELEASE |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PALCAPS 20 66.4-20-75 CAPSULE DELAYED RELEASE |
2 |
Tier 2 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PALGIC 4MG/5ML LIQUID |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PAMIDRONATE 60MG/10ML VIAL |
4 |
Tier 4 |
$85.00 | $212.50 | P |
PAMIDRONATE DISODIUM FOR INJECTION |
4 |
Tier 4 |
$85.00 | $212.50 | P |
PAMIDRONATE DISODIUM FOR INJECTION |
4 |
Tier 4 |
$85.00 | $212.50 | P |
PAMIDRONATE DISODIUM INJECTION 3MG 10ML VIALSD |
4 |
Tier 4 |
$85.00 | $212.50 | P |
PAMIDRONATE DISODIUM INJECTION 9MG 10ML VIALSD |
4 |
Tier 4 |
$85.00 | $212.50 | P |
PANCREASE MT 10 CAPSULE EC |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PANCREASE MT 16 CAPSULE EC |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PANCREASE MT 20 CAPSULE EC |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PANCREASE MT 4 CAPSULE EC |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PANCRECARB MS-16 52-16-52 CAPSULE DELAYED RELEASE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PANCRECARB MS-4 CAPSULE EC |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PANCRECARB MS-8 PANCRELIPASE CAPSULES 40000UNT (100 CT) |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PANCRELIPASE 16-48-48 CAPSULE |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PANCRELIPASE CAP 4500UNIT |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PANCRELIPASE TABLET 30000-8000UNT (500 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PANCRON 10 CAPSULE EC |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PANCRON 20 CAPSULE SA |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PANDEL 0.1% CREAM45GM |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PANGESTYME CAPSULE EC |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PANGESTYME CN 10 CAPSULE EC |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PANGESTYME CN 20 CAPSULE EC |
2 |
Tier 2 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PANGESTYME MT 16 CAPSULE EC |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PANGESTYME UL 12 CAPSULE EC |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PANGESTYME UL 18 CAPSULE EC |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PANGESTYME UL 20 CAPSULE EC |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PANGLOBULIN 12GM |
5 |
Tier 5 |
33% | 33% | P |
PANGLOBULIN 6GM VIAL |
5 |
Tier 5 |
33% | 33% | P |
PANGLOBULIN INJ 1GM |
5 |
Tier 5 |
33% | 33% | P |
PANGLOBULIN INJ 3GM |
5 |
Tier 5 |
33% | 33% | P |
PANOCAPS CAPSULE 4500UNT |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PANOCAPS MT 16 CAPSULE |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PANOCAPS MT 20 CAPSULE |
2 |
Tier 2 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PANOKASE 30K-8K-30K TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PANOKASE-16 60-16-60 TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PANRETIN 0.1% GEL 60GM TUBE |
5 |
Tier 5 |
33% | 33% | P |
PANTOPRAZOLE SODIUM 20MG TABLET DELAYED RELEASE |
3 |
Tier 3 |
$38.00 | $95.00 | Q:30 /30Days |
PANTOPRAZOLE SODIUM 40MG TABLET DELAYED RELEASE 90 CRC BOT |
3 |
Tier 3 |
$38.00 | $95.00 | Q:30 /30Days |
PARCAINE 0.5% DROPS |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PARCOPA 10MG/100MG TABLET |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PARCOPA 25MG/100MG TABLET |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PARCOPA 25MG/250MG TABLET |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PARNATE 10MG TABLET |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PAROMOMYCIN 250MG CAPSULE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAROXETINE 40MG TABLET (500 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | Q:30 /30Days |
PAROXETINE FILM COATED 20MG TABLET (100 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | Q:30 /30Days |
PAROXETINE HCL 10MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | Q:30 /30Days |
PAROXETINE HCL 10MG/5ML SUSPENSION ORAL |
2 |
Tier 2 |
$6.00 | $15.00 | Q:900 /30Days |
PAROXETINE HCL 30MG TABLET (30 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | Q:30 /30Days |
PATADAY 0.2% DROPS |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PATANOL 0.1% EYE DROPS |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PCE 333MG DISPERTAB |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PCE 500MG DISPERTAB |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PEDI-DRI TOPICAL POWDER |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PEDIARIX SOLUTION INJECTION 25-25-10 10 X .5ML VIAL |
3 |
Tier 3 |
$38.00 | $95.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEDIOTIC EAR SUSPENSION |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PEDVAXHIB VACCINE VIAL |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PEG 3350/ELECTROLYTE 240-22.72G SOLUTION RECONSTITUTED ORAL |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PEG-INTRON 100MCG KIT |
5 |
Tier 5 |
33% | 33% | P |
PEG-INTRON 160MCG KIT |
5 |
Tier 5 |
33% | 33% | P |
PEG-INTRON 240MCG KIT |
5 |
Tier 5 |
33% | 33% | P |
PEG-INTRON 300MCG KIT |
5 |
Tier 5 |
33% | 33% | P |
PEG-INTRON REDIPEN 120MCG |
5 |
Tier 5 |
33% | 33% | P |
PEG-INTRON REDIPEN 150MCG |
5 |
Tier 5 |
33% | 33% | P |
PEG-INTRON REDIPEN 50MCG |
5 |
Tier 5 |
33% | 33% | P |
PEG-INTRON REDIPEN 50MCG 4PK |
5 |
Tier 5 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEG-INTRON REDIPEN 80MCG |
5 |
Tier 5 |
33% | 33% | P |
PEG-INTRON REDIPEN 80MCG 4PK |
5 |
Tier 5 |
33% | 33% | P |
PEG-INTRON REDIPEN PAK 4 |
5 |
Tier 5 |
33% | 33% | P |
PEGANONE 250MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PEGASYS 180MCG/0.5ML CONV.PK |
5 |
Tier 5 |
33% | 33% | P |
PEGINTRON REDIPEN 150MCG 4PK |
5 |
Tier 5 |
33% | 33% | P |
PENICILLIN G POTASSIUM 1MMUNITS/50ML ISO-OSM |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PENICILLIN G POTASSIUM 2MMUNITS/50ML ISO-OSM |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PENICILLIN G POTASSIUM 3MMUNITS/50ML ISO-OSM |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PENICILLIN G POTASSIUM FOR INJECTION |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PENICILLIN G POTASSIUM FOR INJECTION |
2 |
Tier 2 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENICILLIN G PROCAINE 1200000UNT 2ML CTG |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PENICILLIN G SODIUM FOR INJECTION 5000000UNT 1 VIAL |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PENICILLIN V POTASSIUM 250MG TABLET (1000 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PENICILLIN V POTASSIUM 500MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PENICILLIN V POTASSIUM FOR ORAL SOLUTION CONCENTRATE 125MG 200ML BOT |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PENLAC 8% SOLUTION |
4 |
Tier 4 |
$85.00 | $212.50 | P |
PENTAM 300 INJ 300MG |
5 |
Tier 5 |
33% | 33% | P |
PENTASA 250MG CAPSULE SA |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PENTASA 500MG CAPSULE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PENTAZOCINE/ACETAMIN TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENTAZOCINE/NALOXONE HCL 50-0.5MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PENTOPAK 400MG TABLET SA |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PENTOSTATIN FOR INJECTION 10MG/VIAL |
5 |
Tier 5 |
33% | 33% | P |
PENTOXIFYLLINE 400MG TABLET SA |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PENTOXIL 400MG TABLET SA |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PERIDEX 0.12% LIQUID |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PERIOGARD 0.12% ORAL RINSE |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PERMETHRIN 5% CREAM |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PERPHENAZINE 16MG TABLET (100 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PERPHENAZINE 2MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PERPHENAZINE 4MG TABLET (500 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PERPHENAZINE 8MG TABLET (500 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | P |
PFIZERPEN 20MMU VIAL |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PFIZERPEN 5MMU VIAL |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PHENADOZ 12.5MG SUPPOSITORY |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PHENADOZ 25MG SUPPOSITORY |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PHENYTEK 200MG CAPSULE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PHENYTEK 300MG CAPSULE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PHENYTOIN SODIUM INJECTION 50MG 25 X 2ML AMP |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PHISOHEX 3% CLEANSER |
4 |
Tier 4 |
$85.00 | $212.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PHOSLO 667MG CAPSULE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PHOSPHOLINE IODIDE 0.125% |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PHOTOFRIN 75MG VIAL |
5 |
Tier 5 |
33% | 33% | P |
PHRENILIN W/CAFF/CODEINE CP |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PHYSIOLYTE SOLUTION FOR IRRIGATION |
3 |
Tier 3 |
$38.00 | $95.00 | P |
PHYSIOSOL IRRIGATION SOL |
3 |
Tier 3 |
$38.00 | $95.00 | P |
PHYSIOSOL IRRIGATION SOLUTION |
3 |
Tier 3 |
$38.00 | $95.00 | P |
PILOCARPINE HCL 5MG TABLET (100 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PILOCARPINE HCL 7.5MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PILOPINE HS 4% EYE GEL |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PINDOLOL 10MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PINDOLOL 5MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PIPERACILLIN 2GM VIAL |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PIPERACILLIN 3GM VIAL |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PIPERACILLIN 40GM BULK VIAL |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PIPERACILLIN 4GM VIAL |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PIROXICAM 10MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
PIROXICAM 20MG CAPSULE (500 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
PLAN B 0.75MG TABLET 2 BLPK |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PLARETASE 8000 30K-8K-30K TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PLASMA-LYTE 148 IV SOLUTION |
3 |
Tier 3 |
$38.00 | $95.00 | P |
PLASMA-LYTE 148/DEXTROSE 5% |
3 |
Tier 3 |
$38.00 | $95.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PLASMA-LYTE 56 INJECTION 32;128 MG/100ML; |
3 |
Tier 3 |
$38.00 | $95.00 | P |
PLASMA-LYTE 56/DEXTROSE 5% |
3 |
Tier 3 |
$38.00 | $95.00 | P |
PLASMA-LYTE A PH 7.4 SOLUTION 37;368; MG/100ML; |
3 |
Tier 3 |
$38.00 | $95.00 | P |
PLASMA-LYTE INJ-R |
3 |
Tier 3 |
$38.00 | $95.00 | P |
PLATINOL AQ INJECTION SOLUTION |
3 |
Tier 3 |
$38.00 | $95.00 | P |
PLAVIX 75MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PLENDIL 10MG TABLET SA |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PLENDIL 2.5MG TABLET SA |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PLENDIL 5MG TABLET SA |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PODOFILOX 0.5% TOPICAL TUBEX |
2 |
Tier 2 |
$6.00 | $15.00 | None |
POLY-DEX 0.1% SUSPENSION DROPS |
2 |
Tier 2 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POLY-DEX 3.5-10K-.1 OINTMENT |
2 |
Tier 2 |
$6.00 | $15.00 | None |
POLYCIN-B 500-10KU/G OINTMENT |
2 |
Tier 2 |
$6.00 | $15.00 | None |
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
POLYGAM S/D 0.5GM VL W/DILUEN |
4 |
Tier 4 |
$85.00 | $212.50 | P |
POLYGAM S/D 10GM VL W/DILUENT |
5 |
Tier 5 |
33% | 33% | P |
POLYGAM S/D 2.5GM VL W/DILUEN |
5 |
Tier 5 |
33% | 33% | P |
POLYGAM S/D 5GM VL W/DILUENT |
5 |
Tier 5 |
33% | 33% | P |
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1% |
2 |
Tier 2 |
$6.00 | $15.00 | None |
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1% |
2 |
Tier 2 |
$6.00 | $15.00 | None |
POLYMYXIN B SULFATE VIAL |
3 |
Tier 3 |
$38.00 | $95.00 | None |
POLYTRIM EYE DROP |
4 |
Tier 4 |
$85.00 | $212.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PORTIA 0.15-0.03 TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
POTASSIUM CHLORIDE 0.075%/D5W/SODIUM CHLORIDE 0.2% |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE 0.075%/D5W/SODIUM CHLORIDE 0.2% |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.3% |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.3% |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45% |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45% |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.9% 1000ML |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.2% |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE 10MEQ CAPSULE SA |
2 |
Tier 2 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE 10MEQ TABLET SA |
2 |
Tier 2 |
$6.00 | $15.00 | None |
POTASSIUM CHLORIDE 10MEQ/100ML SOL |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE 10MEQ/50ML SOL |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE 20MEQ IN D5W LACT RNG |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE 20MEQ IN D5W/NACL 0.225% |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE 20MEQ TABLET SR PARTICLES/CRYSTALS |
2 |
Tier 2 |
$6.00 | $15.00 | None |
POTASSIUM CHLORIDE 20MEQ/100ML SOL |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE 20MEQ/50ML SOL |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE 20MEQ/50ML SOL |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE 20MEQ/NS 1000ML IV SOLUTION |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE 20MEQ/NS 1000ML IV SOLUTION |
3 |
Tier 3 |
$38.00 | $95.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE 30MEQ/100ML SOL |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE 40MEQ IN D5W LACT RNG |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE 40MEQ IN D5W/NACL 0.9% |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE 40MEQ/100ML SOL |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE 40MEQ/NS 1000ML IV SOLUTION |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE 40MEQ/NS 1000ML IV SOLUTION |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE 8MEQ TABLET SA |
2 |
Tier 2 |
$6.00 | $15.00 | None |
POTASSIUM CHLORIDE 8MEQ TABLET SA |
2 |
Tier 2 |
$6.00 | $15.00 | None |
POTASSIUM CHLORIDE ER CPCR 8MEQ |
2 |
Tier 2 |
$6.00 | $15.00 | None |
POTASSIUM CHLORIDE FOR INJECTION CONCENTRATE |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE IN 10% DEXTROSE AND NACL SOLUTION FOR INJECTION |
3 |
Tier 3 |
$38.00 | $95.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE IN 5% DEXTROSE INJECTION 40 12 X 1000ML CTR |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE IN 5% DEXTROSE INJECTION USP 0.15% 1000ML PLASTIC BAGS X 12 CASE |
2 |
Tier 2 |
$6.00 | $15.00 | P |
POTASSIUM CHLORIDE IN DEXTROSE AND SODIUM CHLORIDE INJECTION 5-30-.225 12 X 1000ML CTR |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE IN DEXTROSE INJECTION 5GM/75MG |
2 |
Tier 2 |
$6.00 | $15.00 | P |
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION 0.15%-0.9% 12 X 1000ML BAG |
3 |
Tier 3 |
$38.00 | $95.00 | P |
POTASSIUM CHLORIDE TABLET ER USP 750MG (1000 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
POTASSIUM CHLORIDE TABLET ERD 1500MG (500 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CITRATE 10MEQ TABLET SA |
2 |
Tier 2 |
$6.00 | $15.00 | None |
POTASSIUM CITRATE 5MEQ TABLET SA |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PRANDIN 0.5MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PRANDIN 1MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PRANDIN 2MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PRAVASTATIN SODIUM 10MG TABLET (1000 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
PRAVASTATIN SODIUM 20MG TABLET 500 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
PRAVASTATIN SODIUM 40MG TABLET (500 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
PRAVASTATIN SODIUM 80MG TABLET (90 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
PRAZOSIN 5MG CAPSULE |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PRAZOSIN HCL 1MG CAPSULE |
2 |
Tier 2 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAZOSIN HCL 2MG CAPSULE |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PRECOSE 100MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PRECOSE 25MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PRECOSE 50MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PRED MILD 0.12% EYE DROPS |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PRED-G 1% EYE DROPS |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PRED-G S.O.P. EYE OINTMENT |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PREDNICARBATE 0.1% CREAM |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PREDNICARBATE 0.1% OINTMENT |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PREDNISOLONE 15MG/5ML SOLUTION ORAL |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PREDNISOLONE 5MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISOLONE 5MG/5ML SYRUP |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PREDNISOLONE 5MG/5ML TUBEX |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PREDNISOLONE SOD 1% EYE DROP |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PREDNISONE 10MG TABLET (100 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | P |
PREDNISONE 1MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | P |
PREDNISONE 2.5MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | P |
PREDNISONE 20MG TABLET (1000 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | P |
PREDNISONE 50MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | P |
PREDNISONE 5MG TABLET (100 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISONE 5MG/5ML SOLUTION |
2 |
Tier 2 |
$6.00 | $15.00 | P |
PREDNISONE 5MG/ML SOLUTION |
2 |
Tier 2 |
$6.00 | $15.00 | P |
PREFEST TABLET 1.033MG/.090MG |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PREMARIN 0.3MG (100 CT) |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PREMARIN 0.45MG TABLET |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PREMARIN 0.625MG (100 CT) |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PREMARIN 0.9MG TABLET |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PREMARIN 1.25MG (100 CT) |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PREMARIN 25MG VIAL |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PREMARIN VAGINAL CREAM /APPL |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PREMASOL 10% IV SOLUTION |
3 |
Tier 3 |
$38.00 | $95.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREMASOL 6% IV SOLUTION |
3 |
Tier 3 |
$38.00 | $95.00 | P |
PREMPHASE 0.625/5MG TABLET |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PREMPRO 0.3MG/1.5MG TABLET |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PREMPRO 0.45/1.5MG TABLET |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PREMPRO 0.625/2.5MG TABLET DIALPK |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PREMPRO 0.625/5MG TABLET |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PRENATAL RX 1 TABLET 4000UNT-400UNT (100 CT) |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PREVACID 15MG CAPSULE SA |
3 |
Tier 3 |
$38.00 | $95.00 | Q:30 /30Days |
PREVACID 15MG SOLUTAB |
3 |
Tier 3 |
$38.00 | $95.00 | Q:30 /30Days |
PREVACID 30MG CAPSULE SA |
3 |
Tier 3 |
$38.00 | $95.00 | Q:30 /30Days |
PREVACID 30MG SOLUTAB |
3 |
Tier 3 |
$38.00 | $95.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREVALITE POW 4GM |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PREVALITE POW 4GM PK |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PREVIFEM 0.25-0.035 TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PREZISTA 300MG TABLET |
5 |
Tier 5 |
33% | 33% | None |
PREZISTA TABLET |
5 |
Tier 5 |
33% | 33% | None |
PREZISTA TABLET 75MG |
5 |
Tier 5 |
33% | 33% | None |
PREZISTA TABLETS 400MG 60 TABLETS BOT |
5 |
Tier 5 |
33% | 33% | None |
PRIFTIN 150MG TABLET |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PRIMAQUINE 26.3MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PRIMAXIN 250MG VIAL ADD-VANTAG |
5 |
Tier 5 |
33% | 33% | None |
PRIMAXIN I.M. 500MG VIAL |
5 |
Tier 5 |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRIMAXIN IV 250MG VIAL |
5 |
Tier 5 |
33% | 33% | None |
PRIMAXIN IV INJ 500MG |
5 |
Tier 5 |
33% | 33% | None |
PRIMAXIN IV INJ 500MG |
5 |
Tier 5 |
33% | 33% | None |
PRIMIDONE 250MG TABLET (100 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PRIMIDONE 50MG TABLET (500 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PRIMSOL 50MG/5ML ORAL SOLUTION |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PRISTIQ 100MG TABLET SR 24HR |
4 |
Tier 4 |
$85.00 | $212.50 | P Q:30 /30Days |
PRISTIQ 50MG TABLET SR 24HR |
4 |
Tier 4 |
$85.00 | $212.50 | P Q:30 /30Days |
PROAIR HFA 90MCG HFA AEROSOL WITH ADAPTER |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PROBENECID 500MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROBENECID/COLCHICINE TABLET S |
2 |
Tier 2 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCAINAMIDE 100MG/ML VIAL |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROCAINAMIDE 500MG/ML VIAL |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROCALAMINE INJECTION 210MG-290MG-26MG 6 X 1000ML BOT |
3 |
Tier 3 |
$38.00 | $95.00 | P |
PROCANBID 1000MG TABLET SA |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PROCANBID 500MG TABLET SA |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | P |
PROCHLORPERAZINE MALEATE 25MG SUPPOSITORY RECTAL |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | P |
PROCRIT 10000U/ML VIAL |
5 |
Tier 5 |
33% | 33% | P |
PROCRIT 20000U/ML VIAL MDV |
5 |
Tier 5 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL |
3 |
Tier 3 |
$38.00 | $95.00 | P Q:12 /28Days |
PROCRIT 3000U/ML VIAL |
3 |
Tier 3 |
$38.00 | $95.00 | P Q:12 /28Days |
PROCRIT 40000U/ML VIAL PR |
5 |
Tier 5 |
33% | 33% | P |
PROCRIT 4000U/ML VIAL 25 X 1ML VIAL |
3 |
Tier 3 |
$38.00 | $95.00 | P Q:12 /28Days |
PROCTO-PAK 1% CREAM |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROCTOCORT 1% CREAM |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROCTOCREAM-HC 2.5% CREAM |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROCTOSOL-HC 2.5% CREAM |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROCTOZONE-HC 2.5% CREAM |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROGLYCEM 50MG/ML ORAL SUSP |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PROGRAF 0.5MG CAPSULE |
5 |
Tier 5 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROGRAF 1MG CAPSULE |
5 |
Tier 5 |
33% | 33% | P |
PROGRAF 5MG CAPSULE |
5 |
Tier 5 |
33% | 33% | P |
PROGRAF 5MG/ML AMPULE |
5 |
Tier 5 |
33% | 33% | P |
PROLASTIN 1000MG VIAL |
5 |
Tier 5 |
33% | 33% | P |
PROLASTIN 500MG VIAL |
5 |
Tier 5 |
33% | 33% | P |
PROLEUKIN 22 MILLION UNITS VL |
5 |
Tier 5 |
33% | 33% | P |
PROMACTA TABLETS |
5 |
Tier 5 |
33% | 33% | P |
PROMACTA TABLETS 25 MG |
5 |
Tier 5 |
33% | 33% | P |
PROMETHAZINE 50MG/ML AMPUL |
2 |
Tier 2 |
$6.00 | $15.00 | P |
PROMETHAZINE 50MG/ML VIAL |
2 |
Tier 2 |
$6.00 | $15.00 | P |
PROMETHAZINE HCL 12.5MG SUPPOSITORY RECTAL |
2 |
Tier 2 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMETHAZINE HCL 12.5MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | P |
PROMETHAZINE HCL 25MG SUPPOSITORY RECTAL |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROMETHAZINE HCL 25MG TABLET (1000 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | P |
PROMETHAZINE HCL 50MG SUPPOSITORY RECTAL |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROMETHAZINE HCL 50MG TABLET (100 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROMETHAZINE HCL 6.25MG/5ML SYRUP |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROMETHAZINE HCL INJECTION 25MG 10 X 1ML VIAL |
2 |
Tier 2 |
$6.00 | $15.00 | P |
PROMETHAZINE SYRUP PLAIN 6.25MG 16 FL OZ BOT |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROMETHAZINE VC PLAIN 6.25-5MG 16 FL OZ BOT |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROMETHEGAN 12.5MG SUPPOSITORY RECTAL |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROMETHEGAN 25MG SUPP |
2 |
Tier 2 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMETHEGAN 50MG SUPPOS |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROMETRIUM 100MG CAPSULE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PROMETRIUM 200MG CAPSULE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PRONESTYL 250MG CAPSULE |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PRONESTYL 375MG CAPSULE |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PRONESTYL-SR 500MG TABLET |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PROPAFENONE HCL 150MG TABLET (100 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROPAFENONE HCL 225MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROPAFENONE HCL 300MG TABLET (100 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROPANTHELINE 15MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROPARACAINE 0.5% EYE DROPS |
2 |
Tier 2 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPOXY-N/APAP 100-500MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROPOXY-N/APAP 100-650 TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROPOXY-N/APAP 50-325 TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROPOXYPHENE HCL AND ACETAMINOPHEN TABLET 650/65MG (500 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROPOXYPHENE HCL CAPSULES 65MG (100 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROPRANOLOL 20MG/5ML TUBEX |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROPRANOLOL 40MG/5ML TUBEX |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROPRANOLOL 60MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROPRANOLOL 80MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROPRANOLOL HCL 20MG TABLET (1000 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROPRANOLOL HCL CAPSULES ER 120MG (1000 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPRANOLOL HCL CAPSULES ER 160MG (1000 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROPRANOLOL HCL CAPSULES ER 60MG (100 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROPRANOLOL HCL CAPSULES ER 80MG (1000 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROPRANOLOL HCL INJECTION 1MG 10 PKG OF 10 CRTN |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROPRANOLOL HCL TABLET USP 10MG (1000 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROPRANOLOL HCL TABLET USP 40MG (1000 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROPRANOLOL/HCTZ 40/25 TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROPRANOLOL/HCTZ 80/25 TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROPYLTHIOURACIL 50MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PROQUAD VIAL |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PROSOL 20% INJECTION |
3 |
Tier 3 |
$38.00 | $95.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROTOPIC 0.03% OINTMENT 100GM TUBE |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PROTOPIC 0.1% OINTMENT 60GM TUBE |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PROVENTIL HFA INHALER 90MCG AE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
PROVIGIL 100MG TABLET |
4 |
Tier 4 |
$85.00 | $212.50 | P Q:30 /30Days |
PROVIGIL 200MG TABLET |
4 |
Tier 4 |
$85.00 | $212.50 | P Q:60 /30Days |
PULMICORT .25MG/2ML RESPULE |
4 |
Tier 4 |
$85.00 | $212.50 | P |
PULMICORT 0.5MG/2ML RESPULE |
4 |
Tier 4 |
$85.00 | $212.50 | P |
PULMICORT 1MG/2ML AMPUL FOR NEBULIZATION |
4 |
Tier 4 |
$85.00 | $212.50 | P |
PULMOZYME 1MG/ML AMPUL |
5 |
Tier 5 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PURINETHOL 50MG TABLET |
4 |
Tier 4 |
$85.00 | $212.50 | None |
PYRAZINAMIDE 500MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
PYRIDOSTIGMINE BROMIDE 60MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |