2009 Medicare Part D Plan Formulary Information |
MedicareBlue Rx Option 1 (S5743-001-0)
Benefit Details
|
The MedicareBlue Rx Option 1 (S5743-001-0) Formulary Drugs Starting with the Letter P in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
|
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 200MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PACLITAXEL INJECTION 30MG/5ML 50ML VIALMD |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PACLITAXEL INJECTION 30MG/5ML VILMD CRTN |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PACLITAXEL INJECTION SOLUTION 6MG 50ML VIALMD |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PACLITAXEL INJECTION USP 6MG/ML 300MG/50ML VIALMD |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PALGIC 4MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PAMIDRONATE 60MG/10ML VIAL |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PAMIDRONATE DISODIUM FOR INJECTION |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PAMIDRONATE DISODIUM FOR INJECTION |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PAMIDRONATE DISODIUM INJECTION 3MG 10ML VIALSD |
1 |
Level 1: Covered Generic |
10% | 10% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAMIDRONATE DISODIUM INJECTION 9MG 10ML VIALSD |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PANRETIN 0.1% GEL 60GM TUBE |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
PAROMOMYCIN 250MG CAPSULE |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PAROXETINE 40MG TABLET (500 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PAROXETINE FILM COATED 20MG TABLET (100 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PAROXETINE HCL 10MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PAROXETINE HCL 10MG/5ML SUSPENSION ORAL |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PAROXETINE HCL 30MG TABLET (30 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PAROXETINE HCL TABLET 24 12.5MG |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PAROXETINE HCL TABLET 24 25MG |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PATANOL 0.1% EYE DROPS |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEDI-DRI TOPICAL POWDER |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PEDIARIX SOLUTION INJECTION 25-25-10 10 X .5ML VIAL |
3 |
Level 3: Covered Brand |
50% | 50% | None |
PEDVAXHIB VACCINE VIAL |
3 |
Level 3: Covered Brand |
50% | 50% | None |
PEG 3350/ELECTROLYTE 240-22.72G SOLUTION RECONSTITUTED ORAL |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PEG-INTRON 100MCG KIT |
4 |
Covered Specialty |
25% | 25% | P |
PEG-INTRON 160MCG KIT |
4 |
Covered Specialty |
25% | 25% | P |
PEG-INTRON 240MCG KIT |
4 |
Covered Specialty |
25% | 25% | P |
PEG-INTRON 300MCG KIT |
4 |
Covered Specialty |
25% | 25% | P |
PEG-INTRON REDIPEN 120MCG |
4 |
Covered Specialty |
25% | 25% | P |
PEG-INTRON REDIPEN 150MCG |
4 |
Covered Specialty |
25% | 25% | P |
PEG-INTRON REDIPEN 50MCG |
4 |
Covered Specialty |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEG-INTRON REDIPEN 50MCG 4PK |
4 |
Covered Specialty |
25% | 25% | P |
PEG-INTRON REDIPEN 80MCG |
4 |
Covered Specialty |
25% | 25% | P |
PEG-INTRON REDIPEN 80MCG 4PK |
4 |
Covered Specialty |
25% | 25% | P |
PEG-INTRON REDIPEN PAK 4 |
4 |
Covered Specialty |
25% | 25% | P |
PEGANONE 250MG TABLET |
3 |
Level 3: Covered Brand |
50% | 50% | None |
PEGASYS 180MCG/0.5ML CONV.PK |
4 |
Covered Specialty |
25% | 25% | P |
PEGINTRON REDIPEN 150MCG 4PK |
4 |
Covered Specialty |
25% | 25% | P |
PENICILLIN G POTASSIUM 1MMUNITS/50ML ISO-OSM |
3 |
Level 3: Covered Brand |
50% | 50% | None |
PENICILLIN G POTASSIUM 2MMUNITS/50ML ISO-OSM |
3 |
Level 3: Covered Brand |
50% | 50% | None |
PENICILLIN G POTASSIUM 3MMUNITS/50ML ISO-OSM |
3 |
Level 3: Covered Brand |
50% | 50% | None |
PENICILLIN G POTASSIUM FOR INJECTION |
1 |
Level 1: Covered Generic |
10% | 10% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENICILLIN G POTASSIUM FOR INJECTION |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PENICILLIN G SODIUM FOR INJECTION 5000000UNT 1 VIAL |
3 |
Level 3: Covered Brand |
50% | 50% | None |
PENICILLIN V POTASSIUM 250MG TABLET (1000 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PENICILLIN V POTASSIUM 500MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PENICILLIN V POTASSIUM FOR ORAL SOLUTION CONCENTRATE 125MG 200ML BOT |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PENTAM 300 INJ 300MG |
3 |
Level 3: Covered Brand |
50% | 50% | P |
PENTASA 250MG CAPSULE SA |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
PENTASA 500MG CAPSULE |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
PENTOPAK 400MG TABLET SA |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PENTOSTATIN FOR INJECTION 10MG/VIAL |
4 |
Covered Specialty |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENTOXIFYLLINE 400MG TABLET SA |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PENTOXIL 400MG TABLET SA |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PERIOGARD 0.12% ORAL RINSE |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PERMETHRIN 5% CREAM |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PERPHENAZINE 16MG TABLET (100 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PERPHENAZINE 2MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PERPHENAZINE 4MG TABLET (500 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PERPHENAZINE 8MG TABLET (500 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PFIZERPEN 5MMU VIAL |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PHENADOZ 12.5MG SUPPOSITORY |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PHENADOZ 25MG SUPPOSITORY |
1 |
Level 1: Covered Generic |
10% | 10% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PHENYTEK 200MG CAPSULE |
3 |
Level 3: Covered Brand |
50% | 50% | None |
PHENYTEK 300MG CAPSULE |
3 |
Level 3: Covered Brand |
50% | 50% | None |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PHOSLO 667MG CAPSULE |
3 |
Level 3: Covered Brand |
50% | 50% | None |
PHOSPHOLINE IODIDE 0.125% |
3 |
Level 3: Covered Brand |
50% | 50% | None |
PHOTOFRIN 75MG VIAL |
4 |
Covered Specialty |
25% | 25% | None |
PHRENILIN W/CAFF/CODEINE CP |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PILOCARPINE HCL 5MG TABLET (100 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PILOCARPINE HCL 7.5MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PIPERACILLIN 2GM VIAL |
3 |
Level 3: Covered Brand |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PIPERACILLIN 3GM VIAL |
3 |
Level 3: Covered Brand |
50% | 50% | None |
PIPERACILLIN 40GM BULK VIAL |
3 |
Level 3: Covered Brand |
50% | 50% | None |
PIPERACILLIN 4GM VIAL |
3 |
Level 3: Covered Brand |
50% | 50% | None |
PIROXICAM 10MG CAPSULE |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PIROXICAM 20MG CAPSULE (500 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PLAVIX 75MG TABLET |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
PODOFILOX 0.5% TOPICAL TUBEX |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POLY-DEX 0.1% SUSPENSION DROPS |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POLY-DEX 3.5-10K-.1 OINTMENT |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POLYCIN-B 500-10KU/G OINTMENT |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1% |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1% |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PORTIA 0.15-0.03 TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POTASSIUM CHLORIDE 0.075%/D5W/SODIUM CHLORIDE 0.2% |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POTASSIUM CHLORIDE 0.075%/D5W/SODIUM CHLORIDE 0.2% |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.3% |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.3% |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45% |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45% |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.2% |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG |
1 |
Level 1: Covered Generic |
10% | 10% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE 10MEQ CAPSULE SA |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POTASSIUM CHLORIDE 10MEQ TABLET SA |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POTASSIUM CHLORIDE 20MEQ TABLET SR PARTICLES/CRYSTALS |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POTASSIUM CHLORIDE 40MEQ/NS 1000ML IV SOLUTION |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POTASSIUM CHLORIDE 8MEQ TABLET SA |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POTASSIUM CHLORIDE 8MEQ TABLET SA |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE INJECTION 40 12 X 1000ML CTR |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE INJECTION USP 0.15% 1000ML PLASTIC BAGS X 12 CASE |
1 |
Level 1: Covered Generic |
10% | 10% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE IN DEXTROSE AND SODIUM CHLORIDE INJECTION 5-30-.225 12 X 1000ML CTR |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION 0.15%-0.9% 12 X 1000ML BAG |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POTASSIUM CHLORIDE TABLET ER USP 750MG (1000 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POTASSIUM CHLORIDE TABLET ERD 1500MG (500 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POTASSIUM CITRATE 10MEQ TABLET SA |
1 |
Level 1: Covered Generic |
10% | 10% | None |
POTASSIUM CITRATE 5MEQ TABLET SA |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PRANDIN 0.5MG TABLET |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
PRANDIN 1MG TABLET |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
PRANDIN 2MG TABLET |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
PRAVASTATIN SODIUM 10MG TABLET (1000 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | Q:45 /30Days |
PRAVASTATIN SODIUM 20MG TABLET 500 BOT |
1 |
Level 1: Covered Generic |
10% | 10% | Q:45 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAVASTATIN SODIUM 40MG TABLET (500 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | Q:45 /30Days |
PRAVASTATIN SODIUM 80MG TABLET (90 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | Q:30 /30Days |
PRAZOSIN 5MG CAPSULE |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PRAZOSIN HCL 1MG CAPSULE |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PRAZOSIN HCL 2MG CAPSULE |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PREDNICARBATE 0.1% CREAM |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PREDNICARBATE 0.1% OINTMENT |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PREDNISOLONE 15MG/5ML SOLUTION ORAL |
1 |
Level 1: Covered Generic |
10% | 10% | P |
PREDNISOLONE 5MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | P |
PREDNISOLONE 5MG/5ML SYRUP |
1 |
Level 1: Covered Generic |
10% | 10% | P |
PREDNISOLONE 5MG/5ML TUBEX |
1 |
Level 1: Covered Generic |
10% | 10% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PREDNISOLONE SOD 1% EYE DROP |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PREDNISONE 10MG TABLET (100 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | P |
PREDNISONE 1MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | P |
PREDNISONE 2.5MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | P |
PREDNISONE 20MG TABLET (1000 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | P |
PREDNISONE 5MG TABLET (100 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | P |
PREGNYL INJ 10000UNT |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PREMARIN 0.3MG (100 CT) |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
PREMARIN 0.45MG TABLET |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREMARIN 0.625MG (100 CT) |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
PREMARIN 0.9MG TABLET |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
PREMARIN 1.25MG (100 CT) |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
PREMARIN VAGINAL CREAM /APPL |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
PREMASOL 6% IV SOLUTION |
1 |
Level 1: Covered Generic |
10% | 10% | P |
PREMPHASE 0.625/5MG TABLET |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
PREMPRO 0.3MG/1.5MG TABLET |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
PREMPRO 0.45/1.5MG TABLET |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
PREMPRO 0.625/2.5MG TABLET DIALPK |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
PREMPRO 0.625/5MG TABLET |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
PRENATAL RX 1 TABLET 4000UNT-400UNT (100 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREVALITE POW 4GM |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PREVALITE POW 4GM PK |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PREVIFEM 0.25-0.035 TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PREVPAC PATIENT PACK |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
PREZISTA 300MG TABLET |
3 |
Level 3: Covered Brand |
50% | 50% | None |
PREZISTA TABLET |
3 |
Level 3: Covered Brand |
50% | 50% | None |
PREZISTA TABLET 75MG |
3 |
Level 3: Covered Brand |
50% | 50% | None |
PREZISTA TABLETS 400MG 60 TABLETS BOT |
3 |
Level 3: Covered Brand |
50% | 50% | None |
PRIMAQUINE 26.3MG TABLET |
3 |
Level 3: Covered Brand |
50% | 50% | None |
PRIMAXIN 250MG VIAL ADD-VANTAG |
4 |
Covered Specialty |
25% | 25% | None |
PRIMAXIN I.M. 500MG VIAL |
4 |
Covered Specialty |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRIMAXIN IV 250MG VIAL |
4 |
Covered Specialty |
25% | 25% | None |
PRIMAXIN IV INJ 500MG |
4 |
Covered Specialty |
25% | 25% | None |
PRIMAXIN IV INJ 500MG |
4 |
Covered Specialty |
25% | 25% | None |
PRIMIDONE 250MG TABLET (100 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PRIMIDONE 50MG TABLET (500 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PRISTIQ 100MG TABLET SR 24HR |
3 |
Level 3: Covered Brand |
50% | 50% | S |
PRISTIQ 50MG TABLET SR 24HR |
3 |
Level 3: Covered Brand |
50% | 50% | S |
PROAIR HFA 90MCG HFA AEROSOL WITH ADAPTER |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | Q:36 /30Days |
PROBENECID 500MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROBENECID/COLCHICINE TABLET S |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN |
1 |
Level 1: Covered Generic |
10% | 10% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROCHLORPERAZINE MALEATE 25MG SUPPOSITORY RECTAL |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROCRIT 10000U/ML VIAL |
4 |
Covered Specialty |
25% | 25% | P |
PROCRIT 20000U/ML VIAL MDV |
4 |
Covered Specialty |
25% | 25% | P |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | P |
PROCRIT 3000U/ML VIAL |
3 |
Level 3: Covered Brand |
50% | 50% | P |
PROCRIT 40000U/ML VIAL PR |
4 |
Covered Specialty |
25% | 25% | P |
PROCRIT 4000U/ML VIAL 25 X 1ML VIAL |
3 |
Level 3: Covered Brand |
50% | 50% | P |
PROCTO-PAK 1% CREAM |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROCTOCREAM-HC 2.5% CREAM |
1 |
Level 1: Covered Generic |
10% | 10% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCTOSOL-HC 2.5% CREAM |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROCTOZONE-HC 2.5% CREAM |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROGLYCEM 50MG/ML ORAL SUSP |
3 |
Level 3: Covered Brand |
50% | 50% | None |
PROGRAF 0.5MG CAPSULE |
4 |
Covered Specialty |
25% | 25% | P |
PROGRAF 1MG CAPSULE |
4 |
Covered Specialty |
25% | 25% | P |
PROGRAF 5MG CAPSULE |
4 |
Covered Specialty |
25% | 25% | P |
PROGRAF 5MG/ML AMPULE |
3 |
Level 3: Covered Brand |
50% | 50% | P |
PROLASTIN 1000MG VIAL |
4 |
Covered Specialty |
25% | 25% | None |
PROLASTIN 500MG VIAL |
4 |
Covered Specialty |
25% | 25% | None |
PROLEUKIN 22 MILLION UNITS VL |
4 |
Covered Specialty |
25% | 25% | None |
PROMETHAZINE HCL 12.5MG SUPPOSITORY RECTAL |
1 |
Level 1: Covered Generic |
10% | 10% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMETHAZINE HCL 12.5MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROMETHAZINE HCL 25MG SUPPOSITORY RECTAL |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROMETHAZINE HCL 25MG TABLET (1000 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROMETHAZINE HCL 50MG SUPPOSITORY RECTAL |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROMETHAZINE HCL 50MG TABLET (100 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROMETHAZINE HCL 6.25MG/5ML SYRUP |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROMETHAZINE SYRUP PLAIN 6.25MG 16 FL OZ BOT |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROMETHAZINE VC PLAIN 6.25-5MG 16 FL OZ BOT |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROMETHEGAN 12.5MG SUPPOSITORY RECTAL |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROMETHEGAN 25MG SUPP |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROMETHEGAN 50MG SUPPOS |
1 |
Level 1: Covered Generic |
10% | 10% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRONESTYL-SR 500MG TABLET |
3 |
Level 3: Covered Brand |
50% | 50% | None |
PROPAFENONE HCL 150MG TABLET (100 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROPAFENONE HCL 225MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROPAFENONE HCL 300MG TABLET (100 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROPOXY-N/APAP 100-500MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROPOXY-N/APAP 100-650 TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROPOXY-N/APAP 50-325 TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROPOXYPHENE HCL AND ACETAMINOPHEN TABLET 650/65MG (500 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROPOXYPHENE HCL CAPSULES 65MG (100 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROPRANOLOL 60MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROPRANOLOL 80MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPRANOLOL HCL 20MG TABLET (1000 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROPRANOLOL HCL CAPSULES ER 120MG (1000 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROPRANOLOL HCL CAPSULES ER 160MG (1000 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROPRANOLOL HCL CAPSULES ER 60MG (100 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROPRANOLOL HCL CAPSULES ER 80MG (1000 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROPRANOLOL HCL TABLET USP 10MG (1000 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROPRANOLOL HCL TABLET USP 40MG (1000 CT) |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROPYLTHIOURACIL 50MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROQUAD VIAL |
3 |
Level 3: Covered Brand |
50% | 50% | None |
PROTOPIC 0.03% OINTMENT 100GM TUBE |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | S |
PROTOPIC 0.1% OINTMENT 60GM TUBE |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROTRIPTYLINE HYDROCHLORIDE TABLETS |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PROVIGIL 100MG TABLET |
3 |
Level 3: Covered Brand |
50% | 50% | P Q:30 /30Days |
PROVIGIL 200MG TABLET |
3 |
Level 3: Covered Brand |
50% | 50% | P Q:30 /30Days |
PULMICORT FLEXHALER 180MCG AEROSOL POWDER BREATH ACTIVATED |
3 |
Level 3: Covered Brand |
50% | 50% | Q:2 /30Days |
PULMICORT FLEXHALER 90MCG AEROSOL POWDER BREATH ACTIVATED |
3 |
Level 3: Covered Brand |
50% | 50% | Q:1 /30Days |
PULMOZYME 1MG/ML AMPUL |
4 |
Covered Specialty |
25% | 25% | P |
PYLERA 125-125MG CAPSULE |
2 |
Level 2: Covered Preferred Brand |
22% | 22% | None |
PYRAZINAMIDE 500MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |
PYRIDOSTIGMINE BROMIDE 60MG TABLET |
1 |
Level 1: Covered Generic |
10% | 10% | None |