2009 Medicare Part D Plan Formulary Information |
SierraRx Basic (S5917-011-0)
Benefit Details
|
The SierraRx Basic (S5917-011-0) Formulary Drugs Starting with the Letter A in CMS PDP Region 6 which includes: PA WV
|
Drugs Starting with Letter A
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
ABILIFY 10MG TABLET |
2 |
Tier 2 |
25% | 25% | S Q:90 /30Days |
ABILIFY 15MG TABLET |
2 |
Tier 2 |
25% | 25% | S Q:60 /30Days |
ABILIFY 1MG/ML SOLUTION |
2 |
Tier 2 |
25% | 25% | S Q:900 /30Days |
ABILIFY 20MG TABLET |
2 |
Tier 2 |
25% | 25% | S Q:30 /30Days |
ABILIFY 2MG TABLET |
2 |
Tier 2 |
25% | 25% | S Q:90 /30Days |
ABILIFY 30MG TABLET |
2 |
Tier 2 |
25% | 25% | S Q:30 /30Days |
ABILIFY 5MG TABLET (OTSUKA) |
2 |
Tier 2 |
25% | 25% | S Q:90 /30Days |
ABILIFY DISCMELT 10MG TABLET |
2 |
Tier 2 |
25% | 25% | S Q:90 /30Days |
ABILIFY DISCMELT 15MG TABLET |
2 |
Tier 2 |
25% | 25% | S Q:60 /30Days |
ABILIFY INJ 9.75MG |
2 |
Tier 2 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACARBOSE 100MG TABLET S |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
ACARBOSE 25MG TABLET S |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
ACARBOSE 50MG TABLET S |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
ACCOLATE 10MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
ACCOLATE 20MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
ACEBUTOLOL 200MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
ACEBUTOLOL 400MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-15MG (1000 CT) |
1 |
Tier 1 |
25% | 25% | Q:390 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) |
1 |
Tier 1 |
25% | 25% | Q:390 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT) |
1 |
Tier 1 |
25% | 25% | Q:390 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT) |
1 |
Tier 1 |
25% | 25% | Q:390 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
1 |
Tier 1 |
25% | 25% | Q:390 /30Days |
ACETAMINOPHEN/COD SOLUTION |
1 |
Tier 1 |
25% | 25% | Q:4800 /30Days |
ACETASOL HC SOLUTION 10ML 10 ML BOT |
1 |
Tier 1 |
25% | 25% | None |
ACETAZOLAMIDE 125MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
ACETIC ACID-HYDROCORTISONE 2%-1% DROPS |
1 |
Tier 1 |
25% | 25% | None |
ACETYLCYSTEINE 10% VIAL |
1 |
Tier 1 |
25% | 25% | None |
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN |
1 |
Tier 1 |
25% | 25% | None |
ACIPHEX 20MG TABLET EC |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ACTHIB VACCINE VIAL 10-24UNT/5ML |
2 |
Tier 2 |
25% | 25% | None |
ACTICIN 5% CREAM |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTIMMUNE SOLUTION FOR INJECTION 100MCG |
3 |
Tier 3 |
25% | 25% | P |
ACTOPLUS MET 15MG/500MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:90 /30Days |
ACTOPLUS MET 15MG/850MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:90 /30Days |
ACTOS 15MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ACTOS 30MG TABLET (500 CT) |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ACTOS 45MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ACULAR 0.5% EYE DROPS |
2 |
Tier 2 |
25% | 25% | Q:10 /30Days |
ACULAR LS 0.4% OPHTH SOL |
2 |
Tier 2 |
25% | 25% | Q:10 /30Days |
ACYCLOVIR 200MG CAPSULE (1000 CT) |
1 |
Tier 1 |
25% | 25% | None |
ACYCLOVIR 200MG/5ML SUSP |
1 |
Tier 1 |
25% | 25% | None |
ACYCLOVIR 400MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACYCLOVIR TABLET USP 800MG (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
ADAGEN 250U/ML VIAL |
3 |
Tier 3 |
25% | 25% | P |
ADDERALL XR 10MG CAPSULE SA |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
ADDERALL XR 15MG CAPSULE SA |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
ADDERALL XR 20MG CAPSULE SA |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
ADDERALL XR 25MG CAPSULE SA |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
ADDERALL XR 30MG CAPSULE SA |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
ADDERALL XR 5MG CAPSULE SA |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
AFEDITAB CR 30MG TABLET SA |
1 |
Tier 1 |
25% | 25% | Q:120 /30Days |
AFEDITAB CR 60MG TABLET SA |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
AGGRENOX 25-200MG CAPSULE |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AK-CON 0.1% EYE DROPS |
1 |
Tier 1 |
25% | 25% | None |
AK-POLY-BAC EYE OINTMENT 500UNT/1000UNT |
1 |
Tier 1 |
25% | 25% | Q:3 /30Days |
AK-SPORE EYE OINTMENT 3.5 MG |
1 |
Tier 1 |
25% | 25% | None |
AKTOB 0.3% EYE DROPS |
1 |
Tier 1 |
25% | 25% | None |
ALA-CORT 1% CREAM |
1 |
Tier 1 |
25% | 25% | None |
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER |
1 |
Tier 1 |
25% | 25% | P Q:375 /30Days |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
1 |
Tier 1 |
25% | 25% | P Q:375 /30Days |
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER |
1 |
Tier 1 |
25% | 25% | P Q:375 /30Days |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
1 |
Tier 1 |
25% | 25% | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
1 |
Tier 1 |
25% | 25% | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
1 |
Tier 1 |
25% | 25% | P Q:375 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
1 |
Tier 1 |
25% | 25% | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
1 |
Tier 1 |
25% | 25% | None |
ALBUTEROL TABLET 4MG (500 CT) |
1 |
Tier 1 |
25% | 25% | None |
ALCLOMETASONE DIPROPIONATE 0.05% CREAM |
1 |
Tier 1 |
25% | 25% | None |
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT |
1 |
Tier 1 |
25% | 25% | None |
ALCOHOL ANTISEPTIC PADS |
2 |
Tier 2 |
25% | 25% | None |
ALDARA 5% CREAM |
2 |
Tier 2 |
25% | 25% | Q:12 /30Days |
ALDURAZYME 2.9MG/5ML VIAL |
3 |
Tier 3 |
25% | 25% | P |
ALENDRONATE SODIUM 10MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ALENDRONATE SODIUM 40MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
ALENDRONATE SODIUM 5MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALENDRONATE SODIUM 70MG TABLET 4 BLPK |
1 |
Tier 1 |
25% | 25% | Q:4 /28Days |
ALENDRONATE SODIUM TABLET 35MG 20 CRTN |
1 |
Tier 1 |
25% | 25% | Q:4 /28Days |
ALINIA 100MG/5ML SUSPENSION |
2 |
Tier 2 |
25% | 25% | None |
ALINIA 500MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
ALLOPURINOL TABLET 300MG (1000 CT) |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
ALLOPURINOL TABLET USP 100MG (1000 CT) |
1 |
Tier 1 |
25% | 25% | Q:240 /30Days |
AMANTADINE 100MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
AMANTADINE 100MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
AMCINONIDE 0.1% CREAM |
1 |
Tier 1 |
25% | 25% | None |
AMCINONIDE 0.1% LOTION |
1 |
Tier 1 |
25% | 25% | None |
AMCINONIDE 0.1% OINTMENT 60GM TUBE |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMILORIDE HCL 5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
AMINESS 5.2% IV SOLUTION |
2 |
Tier 2 |
25% | 25% | None |
AMINOPHYLLINE 100MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
AMINOPHYLLINE 200MG TABLET (1000 CT) |
1 |
Tier 1 |
25% | 25% | None |
AMIODARONE HCL 200MG TABLET (60 CT) |
1 |
Tier 1 |
25% | 25% | None |
AMIODARONE HCL 400MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
AMITIZA 24 MCG CAPSULES |
2 |
Tier 2 |
25% | 25% | P Q:60 /30Days |
AMITRIP/CDP 25-10 TABLET |
1 |
Tier 1 |
25% | 25% | None |
AMITRIP/PERPHEN 10-2 TABLET |
1 |
Tier 1 |
25% | 25% | Q:240 /30Days |
AMITRIP/PERPHEN 10-4 TABLET |
1 |
Tier 1 |
25% | 25% | Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIP/PERPHEN 25-2 TABLET |
1 |
Tier 1 |
25% | 25% | Q:240 /30Days |
AMITRIP/PERPHEN 25-4 TABLET |
1 |
Tier 1 |
25% | 25% | Q:240 /30Days |
AMITRIP/PERPHEN 50-4 TABLET |
1 |
Tier 1 |
25% | 25% | Q:120 /30Days |
AMITRIPTYLINE HCL 100MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
AMITRIPTYLINE HCL 10MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
AMITRIPTYLINE HCL 150MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
AMITRIPTYLINE HCL 50MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
AMMONIUM CHLORIDE 5 MEQ/ML |
1 |
Tier 1 |
25% | 25% | P |
AMMONIUM LACTATE 12% LOTION |
1 |
Tier 1 |
25% | 25% | Q:400 /30Days |
AMMONIUM LACTATE 12% LOTION |
1 |
Tier 1 |
25% | 25% | Q:400 /30Days |
AMOCLAN 200-28.5/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
25% | 25% | None |
AMOCLAN 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
25% | 25% | None |
AMOX TR-K CLV 200-28.5 CHEW |
1 |
Tier 1 |
25% | 25% | None |
AMOX TR-K CLV 200-28.5/5 SU |
1 |
Tier 1 |
25% | 25% | None |
AMOX TR-K CLV 400-57 CHW TABLET |
1 |
Tier 1 |
25% | 25% | None |
AMOX TR-K CLV 400-57/5 SUSP |
1 |
Tier 1 |
25% | 25% | None |
AMOX TR-K CLV 500-125MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
25% | 25% | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
1 |
Tier 1 |
25% | 25% | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
1 |
Tier 1 |
25% | 25% | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
25% | 25% | None |
AMOX TR-POTASSIUM CLAVULANATE 500-125MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
AMOXAPINE 100MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
AMOXAPINE 150MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
AMOXAPINE 25MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
AMOXAPINE 50MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
AMOXICIILIN CLAVULNATE POTASSIUM FOR ORAL SUSPENSION |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN 125MG TABLET CHEW |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN 200MG TABLET CHEW |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN 250MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN 400MG TABLET CHEW |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN 500MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN 500MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN 875MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN CLAVULANATE POTASSIUM TABLET 875-125MG 1 BLPK |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT) |
1 |
Tier 1 |
25% | 25% | None |
AMOXIL 250MG/5ML SUSPENSION |
1 |
Tier 1 |
25% | 25% | None |
AMOXIL 500MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
AMPHET ASP/ AMPHET/ D-AMPHET 10MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:360 /30Days |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
AMPHETAMINE SALT COMBO 15MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
AMPHETAMINE SALT COMBO 30MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPHETAMINE SALTS 20MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
AMPHETAMINE SALTS 30MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
AMPICILLIN FOR INJECTION |
1 |
Tier 1 |
25% | 25% | Q:168 /30Days |
AMPICILLIN FOR INJECTION 1GM VIAL |
1 |
Tier 1 |
25% | 25% | Q:168 /30Days |
AMPICILLIN FOR INJECTION 2GM/ML 10 VIAL |
1 |
Tier 1 |
25% | 25% | Q:59 /30Days |
AMPICILLIN FOR INJECTION 500MG VIAL |
1 |
Tier 1 |
25% | 25% | Q:336 /30Days |
AMPICILLIN FOR INJECTION POWDER |
1 |
Tier 1 |
25% | 25% | Q:17 /30Days |
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL |
1 |
Tier 1 |
25% | 25% | Q:168 /30Days |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
1 |
Tier 1 |
25% | 25% | Q:200 /30Days |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
1 |
Tier 1 |
25% | 25% | Q:300 /30Days |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML |
1 |
Tier 1 |
25% | 25% | Q:168 /60Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN SODIUM STERILE 2 GM/VIAL |
1 |
Tier 1 |
25% | 25% | Q:5 /30Days |
AMPICILLIN TR 250MG CAPSULE |
1 |
Tier 1 |
25% | 25% | Q:56 /30Days |
AMPICILLIN TR 500MG CAPSULE |
1 |
Tier 1 |
25% | 25% | Q:56 /30Days |
ANADROL-50 50MG TABLET (100 CT) |
3 |
Tier 3 |
25% | 25% | P |
ANCOBON 250MG CAPSULE |
3 |
Tier 3 |
25% | 25% | P |
ANCOBON 500MG CAPSULE |
3 |
Tier 3 |
25% | 25% | P |
ANDROGEL 1%(25MG) GEL PACKET |
2 |
Tier 2 |
25% | 25% | Q:300 /30Days |
ANDROGEL 1.25G (1%) GEL IN METERED-DOSE PUMP |
2 |
Tier 2 |
25% | 25% | Q:300 /30Days |
ANDROGEL 1%(50MG) GEL PACKET |
2 |
Tier 2 |
25% | 25% | Q:300 /30Days |
ANTABUSE 250MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
ANTABUSE 500MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APOKYN FOR INJECTION 30MG 5 CTG |
3 |
Tier 3 |
25% | 25% | P Q:60 /30Days |
APRI 0.15-0.03 TABLET |
1 |
Tier 1 |
25% | 25% | Q:28 /28Days |
APTIVUS 250MG CAPSULE |
3 |
Tier 3 |
25% | 25% | Q:120 /30Days |
ARANELLE 7-9-5 TABLET |
1 |
Tier 1 |
25% | 25% | Q:28 /28Days |
ARANESP 100MCG/ML VIAL |
3 |
Tier 3 |
25% | 25% | P |
ARANESP 200MCG/0.4ML SYRINGE |
3 |
Tier 3 |
25% | 25% | P |
ARANESP 200MCG/ML VIAL |
3 |
Tier 3 |
25% | 25% | P |
ARANESP 25MCG/ML VIAL |
2 |
Tier 2 |
25% | 25% | P |
ARANESP 300MCG/ML VIAL |
3 |
Tier 3 |
25% | 25% | P |
ARANESP 500MCG/1ML SYRINGE |
3 |
Tier 3 |
25% | 25% | P |
ARANESP 60MCG/ML VIAL |
3 |
Tier 3 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR |
3 |
Tier 3 |
25% | 25% | P |
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR |
2 |
Tier 2 |
25% | 25% | P |
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR |
3 |
Tier 3 |
25% | 25% | P |
ARANESP SINGLE USE PREFILLED AUTOINJECTOR SOLUTION 100MCG/.5ML |
3 |
Tier 3 |
25% | 25% | P |
ARANESP SINGLE USE PREFILLED SURECLICK AUTOINJECTOR SOLUTION 500MCG/ML |
3 |
Tier 3 |
25% | 25% | P |
ARANESP SINGLE USE PREFILLED SURECLIK AUTOINJECTOR 60MCG/.3ML |
3 |
Tier 3 |
25% | 25% | P |
ARANESP SINGLE USE VIAL 150MCG 4 X 150MCG/ 0.75ML VIALSD |
3 |
Tier 3 |
25% | 25% | P |
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD |
3 |
Tier 3 |
25% | 25% | P |
ARICEPT 10MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ARICEPT 5MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ARICEPT ODT 10MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARICEPT ODT 5MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ARIMIDEX 1MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ARIXTRA 10MG SYRINGE |
3 |
Tier 3 |
25% | 25% | P |
ARIXTRA 2.5MG SYRINGE |
3 |
Tier 3 |
25% | 25% | P |
ARIXTRA 5MG SYRINGE |
3 |
Tier 3 |
25% | 25% | P |
ARIXTRA 7.5MG SYRINGE |
3 |
Tier 3 |
25% | 25% | P |
AROMASIN 25MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ASACOL 400MG TABLET EC |
2 |
Tier 2 |
25% | 25% | Q:360 /30Days |
ASMANEX 220MCG(14) AEROSOL POWDER BREATH ACTIVATED |
2 |
Tier 2 |
25% | 25% | Q:56 /30Days |
ASMANEX TWISTHALER 220MCG #120 |
2 |
Tier 2 |
25% | 25% | Q:120 /30Days |
ASMANEX TWISTHALER 220MCG #30 |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ASMANEX TWISTHALER 220MCG #60 |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
ASTELIN 137MCG AEROSOL SPRAY W/PUMP |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ASTRAMORPH-PF 0.5MG/ML VIAL |
1 |
Tier 1 |
25% | 25% | P |
ASTRAMORPH-PF 1MG/ML VIAL |
1 |
Tier 1 |
25% | 25% | P |
ATAMET |
1 |
Tier 1 |
25% | 25% | None |
ATENOLOL 25MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | Q:120 /30Days |
ATENOLOL TABLET 100MG (100 CT) |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
ATENOLOL TABLET USP 50MG (100 CT) |
1 |
Tier 1 |
25% | 25% | Q:120 /30Days |
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
ATRIPLA TABLET 600MG/200MG |
3 |
Tier 3 |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATROVENT HFA AER 17MCG |
2 |
Tier 2 |
25% | 25% | Q:25 /30Days |
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML |
2 |
Tier 2 |
25% | 25% | None |
AVALIDE 150-12.5MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
AVALIDE 300-12.5MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
AVALIDE 300-25MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
AVAPRO 150MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
AVAPRO 300MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
AVAPRO 75MG TABLET (30 CT) |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
AVIANE 0.1-0.02 TABLET |
1 |
Tier 1 |
25% | 25% | Q:28 /28Days |
AVITA 0.025% CREAM |
1 |
Tier 1 |
25% | 25% | P Q:45 /30Days |
AZACTAM 1GM VIAL |
3 |
Tier 3 |
25% | 25% | Q:30 /60Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZACTAM 2GM VIAL |
3 |
Tier 3 |
25% | 25% | Q:30 /60Days |
AZATHIOPRINE 50MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
25% | 25% | None |
AZITHROMYCIN 1G PACKET |
1 |
Tier 1 |
25% | 25% | Q:2 /30Days |
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
25% | 25% | None |
AZITHROMYCIN 250MG TABLET (30 CT) |
1 |
Tier 1 |
25% | 25% | Q:12 /30Days |
AZITHROMYCIN 500MG TABLET (30 CT) |
1 |
Tier 1 |
25% | 25% | Q:6 /30Days |
AZITHROMYCIN TABLET 600MG (30 CT) |
1 |
Tier 1 |
25% | 25% | Q:14 /30Days |