2009 Medicare Part D Plan Formulary Information |
SierraRx Basic (S5917-033-0)
Benefit Details
|
The SierraRx Basic (S5917-033-0) Formulary Drugs Starting with the Letter C in CMS PDP Region 32 which includes: CA
|
Drugs Starting with Letter C
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
CABERGOLINE 0.5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CALCIPOTRIENE TOPICAL SOLUTION |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY |
1 |
Tier 1 |
25% | 25% | Q:3 /30Days |
CALCITRIOL 0.25MCG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
CALCITRIOL 0.5MCG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
CALCIUM ACETATE CAPSULE 667 MG |
1 |
Tier 1 |
25% | 25% | None |
CAMILA 0.35MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:28 /28Days |
CAMPATH 30MG/ML VIAL |
3 |
Tier 3 |
25% | 25% | P |
CAPTOPRIL 100MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CAPTOPRIL 12.5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAPTOPRIL 25MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CAPTOPRIL 50MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CAPTOPRIL/HCTZ 25/15 TABLET |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
CAPTOPRIL/HCTZ 25/25 TABLET |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
CAPTOPRIL/HCTZ 50/15 TABLET |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
CAPTOPRIL/HCTZ 50/25 TABLET |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
CARAC CRE 0.5% |
2 |
Tier 2 |
25% | 25% | None |
CARBAMAZEPINE 100MG/5ML SUSPENSION ORAL |
1 |
Tier 1 |
25% | 25% | None |
CARBAMAZEPINE TABLET CHEWABLE 100MG (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
CARBAMAZEPINE TABLET USP 200MG (1000 CT) |
1 |
Tier 1 |
25% | 25% | None |
CARBIDOPA-LEVODOPA 25MG-100MG TABLET SA |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARBIDOPA-LEVODOPA 25MG-100MG TABLET SA |
1 |
Tier 1 |
25% | 25% | None |
CARBIDOPA-LEVODOPA 25MG-100MG TABLET SA |
1 |
Tier 1 |
25% | 25% | None |
CARBIDOPA-LEVODOPA 50MG-200MG TABLET SA |
1 |
Tier 1 |
25% | 25% | None |
CARBIDOPA-LEVODOPA 50MG-200MG TABLET SA |
1 |
Tier 1 |
25% | 25% | None |
CARBIDOPA/LEVO 10/100 TABLET |
1 |
Tier 1 |
25% | 25% | None |
CARBIDOPA/LEVO 25/100 TABLET |
1 |
Tier 1 |
25% | 25% | None |
CARBIDOPA/LEVO 25/250 TABLET |
1 |
Tier 1 |
25% | 25% | None |
CARISOPRODOL COMPOUND (CARISOPRODOL/ASPIRIN) 200-325MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
CARISOPRODOL CPD/CODEINE TABLET |
1 |
Tier 1 |
25% | 25% | S |
CARISOPRODOL TABLET USP 350MG (100 CT) |
1 |
Tier 1 |
25% | 25% | S Q:120 /30Days |
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARTIA XT 120MG CAPSULE SA |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
CARTIA XT 180MG CAPSULE SA |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
CARTIA XT 240MG CAPSULE SA |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
CARTIA XT 300MG CAPSULE SR 24 HR |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
CARVEDILOL 12.5MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
CARVEDILOL 25MG TABLET (500 CT) |
1 |
Tier 1 |
25% | 25% | Q:120 /30Days |
CARVEDILOL 3.125MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
CARVEDILOL 6.25MG TABLET (500 CT) |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
CASODEX 50MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
CEENU 100MG CAPSULE |
2 |
Tier 2 |
25% | 25% | None |
CEENU 10MG CAPSULE |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEENU 40MG CAPSULE |
2 |
Tier 2 |
25% | 25% | None |
CEENU PAK DOSEPACK 1 KIT |
2 |
Tier 2 |
25% | 25% | None |
CEFACLOR 250MG/5ML ORAL SUSP |
1 |
Tier 1 |
25% | 25% | Q:200 /60Days |
CEFACLOR 375MG/5ML ORAL SUSP |
1 |
Tier 1 |
25% | 25% | Q:200 /60Days |
CEFACLOR CAPSULES USP 250MG (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
CEFACLOR CAPSULES USP 500MG (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
CEFACLOR POWDER FOR ORAL SUSPENSION USP 125MG 75ML BOT |
1 |
Tier 1 |
25% | 25% | Q:200 /60Days |
CEFAZOLIN 1GM ADD-VAN VIAL |
1 |
Tier 1 |
25% | 25% | Q:42 /60Days |
CEFAZOLIN 1GM/D5W BAG |
1 |
Tier 1 |
25% | 25% | Q:42 /60Days |
CEFAZOLIN 20GM BULK VIAL |
1 |
Tier 1 |
25% | 25% | Q:2 /60Days |
CEFAZOLIN 500MG/D5W BAG |
1 |
Tier 1 |
25% | 25% | Q:42 /60Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFAZOLIN FOR INJECTION |
1 |
Tier 1 |
25% | 25% | Q:42 /60Days |
CEFAZOLIN FOR INJECTION 10GM 10 X 10 VIAL |
1 |
Tier 1 |
25% | 25% | Q:5 /60Days |
CEFAZOLIN FOR INJECTION 1MG 25 VIALGL |
1 |
Tier 1 |
25% | 25% | Q:42 /60Days |
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
25% | 25% | None |
CEFDINIR CAPSULES 300MG (60 CT) |
1 |
Tier 1 |
25% | 25% | None |
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
CEFEPIME HCL 2 GRAM VIAL |
1 |
Tier 1 |
25% | 25% | P Q:28 /60Days |
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL |
1 |
Tier 1 |
25% | 25% | P Q:56 /60Days |
CEFPROZIL 250MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
CEFPROZIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
25% | 25% | Q:200 /60Days |
CEFPROZIL 500MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFPROZIL FOR ORAL SUSPENSION 125MG/5ML 75ML BOT |
1 |
Tier 1 |
25% | 25% | Q:200 /60Days |
CEFTRIAXONE 10GM VIAL |
1 |
Tier 1 |
25% | 25% | Q:3 /60Days |
CEFTRIAXONE 1GM PIGGYBACK |
1 |
Tier 1 |
25% | 25% | Q:1 /60Days |
CEFTRIAXONE 2GM PIGGYBACK |
1 |
Tier 1 |
25% | 25% | Q:1 /60Days |
CEFTRIAXONE FOR INJECTION 1GM 10 VIALSU |
1 |
Tier 1 |
25% | 25% | Q:28 /60Days |
CEFTRIAXONE FOR INJECTION 250MG BOX OF 10 VIALGL |
1 |
Tier 1 |
25% | 25% | Q:112 /60Days |
CEFTRIAXONE FOR INJECTION 2GM 10 VIALSU |
1 |
Tier 1 |
25% | 25% | Q:14 /60Days |
CEFTRIAXONE FOR INJECTION 500MG BOX OF 10 VIALGL |
1 |
Tier 1 |
25% | 25% | Q:56 /60Days |
CEFTRIAXONE FOR INJECTION AND DEXTROSE INJECTION 1 GM/50ML |
1 |
Tier 1 |
25% | 25% | Q:28 /60Days |
CEFTRIAXONE FOR INJECTION AND DEXTROSE INJECTION 2 GM/50ML |
1 |
Tier 1 |
25% | 25% | Q:14 /60Days |
CEFUROXIME 250MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:28 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFUROXIME AXETIL 125MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
25% | 25% | Q:400 /30Days |
CEFUROXIME AXETIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
25% | 25% | Q:400 /30Days |
CEFUROXIME AXETIL 500MG TABLET (20 CT) |
1 |
Tier 1 |
25% | 25% | Q:40 /30Days |
CEFUROXIME FOR INJECTION |
1 |
Tier 1 |
25% | 25% | Q:42 /60Days |
CEFUROXIME FOR INJECTION |
1 |
Tier 1 |
25% | 25% | Q:42 /60Days |
CEFUROXIME FOR INJECTION 7.5GM 10 X 7.5 VIALPHR |
1 |
Tier 1 |
25% | 25% | Q:42 /60Days |
CEFUROXIME FOR INJECTION AND DEXTROSE INJECTION |
1 |
Tier 1 |
25% | 25% | Q:42 /60Days |
CELEBREX 100MG CAPSULE |
2 |
Tier 2 |
25% | 25% | S Q:240 /30Days |
CELEBREX 200MG CAPSULE |
2 |
Tier 2 |
25% | 25% | S Q:120 /30Days |
CELEBREX 400MG CAPSULE |
2 |
Tier 2 |
25% | 25% | S Q:60 /30Days |
CELEBREX 50MG CAPSULE |
2 |
Tier 2 |
25% | 25% | S Q:480 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CELLCEPT 200MG/ML ORAL SUSP |
2 |
Tier 2 |
25% | 25% | P |
CELLCEPT 500MG TABLET |
2 |
Tier 2 |
25% | 25% | P |
CELLCEPT CAPSULES 250MG (500 CT) |
2 |
Tier 2 |
25% | 25% | P |
CELONTIN 300MG KAPSEAL |
2 |
Tier 2 |
25% | 25% | None |
CEPHALEXIN 250MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
CEPHALEXIN 250MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CEPHALEXIN 250MG/5ML ORAL SUSP |
1 |
Tier 1 |
25% | 25% | None |
CEPHALEXIN 500MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CEPHALEXIN CAPSULES 500MG (500 CT) |
1 |
Tier 1 |
25% | 25% | None |
CEPHALEXIN POWDER FOR SUSPENSION ORAL USP 125MG 200ML BOT |
1 |
Tier 1 |
25% | 25% | None |
CEREDASE 80UNITS/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 |
CEREZYME INJ 200UNIT |
3 |
Tier 3 |
25% | 25% | P |
CEREZYME INJ 400UNIT |
3 |
Tier 3 |
25% | 25% | P |
CESIA 7 DAYS X 3 TABLET |
1 |
Tier 1 |
25% | 25% | Q:28 /28Days |
CHANTIX STARTING MONTH PAK |
2 |
Tier 2 |
25% | 25% | Q:53 /1Days |
CHLORDIAZEPOXIDE AND AMITRIPTYLINE HCL TABLET 12.5-5MG (500 CT) |
1 |
Tier 1 |
25% | 25% | None |
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH |
1 |
Tier 1 |
25% | 25% | None |
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH |
1 |
Tier 1 |
25% | 25% | None |
CHLOROQUINE PH 500MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CHLOROQUINE PHOSPHATE 250MG TABLET (50 CT) |
1 |
Tier 1 |
25% | 25% | None |
CHLOROTHIAZIDE 250MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CHLOROTHIAZIDE 500MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLORPROMAZINE 100MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CHLORPROMAZINE 10MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CHLORPROMAZINE 25MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CHLORPROMAZINE 25MG/ML AMP |
1 |
Tier 1 |
25% | 25% | None |
CHLORPROMAZINE 50MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CHLORPROMAZINE HCL 200MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CHLORTHALIDONE 25MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
CHLORTHALIDONE 50MG TABLET (1000 CT) |
1 |
Tier 1 |
25% | 25% | None |
CHOLESTYRAMINE LIGHT ORAL SUSP USP POWDER 4GM 210GM CAN |
1 |
Tier 1 |
25% | 25% | None |
CHOLESTYRAMINE LIGHT ORAL SUSP USP POWDER 4GM 60 X 5 SINGLE DOSE CRTN |
1 |
Tier 1 |
25% | 25% | None |
CHOLESTYRAMINE POWDER FOR ORAL SUSPENSION USP 4GM 60 X 9GM SINGLE DOSE CRTN |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHOLESTYRAMINE POWDER FOR ORAL SUSPENSION USP 4GM 378GM CAN |
1 |
Tier 1 |
25% | 25% | None |
CHORIONIC GONAD 10000U VIAL |
1 |
Tier 1 |
25% | 25% | P |
CICLOPIROX 0.77% CREAM |
1 |
Tier 1 |
25% | 25% | None |
CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6ML BOT |
1 |
Tier 1 |
25% | 25% | Q:6 /30Days |
CILOSTAZOL 50MG TABLET (60 CT) |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
CILOSTAZOL TABLET 100MG (60 CT) |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
CIMETIDINE 200MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:120 /30Days |
CIMETIDINE HCL 300MG/5ML SOL |
1 |
Tier 1 |
25% | 25% | Q:600 /30Days |
CIMETIDINE TABLET USP 300MG (1000 CT) |
1 |
Tier 1 |
25% | 25% | Q:120 /30Days |
CIMETIDINE TABLET USP 400MG (1000 CT) |
1 |
Tier 1 |
25% | 25% | Q:120 /30Days |
CIMETIDINE TABLET USP 800MG (30 CT) |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIMZIA KIT |
3 |
Tier 3 |
25% | 25% | P |
CIPROFLOXACIN 250MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
CIPROFLOXACIN 500MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CIPROFLOXACIN 750MG TABLET (50 CT) |
1 |
Tier 1 |
25% | 25% | None |
CIPROFLOXACIN ER 500MG TABLET (30 CT) |
1 |
Tier 1 |
25% | 25% | None |
CIPROFLOXACIN HCL 0.3% DROPS |
1 |
Tier 1 |
25% | 25% | None |
CIPROFLOXACIN HCL 100MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CITALOPRAM HBR 20MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
CITALOPRAM HBR 40MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | Q:45 /30Days |
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL |
1 |
Tier 1 |
25% | 25% | Q:600 /30Days |
CITOLOPRAM HBR 10MG TABLET (100 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 |
CLARITHROMYCIN 250MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CLARITHROMYCIN 250MG/5ML. SUS. 100ML |
1 |
Tier 1 |
25% | 25% | None |
CLARITHROMYCIN 500MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CLARITHROMYCIN ER 500MG TABLET (60 CT) |
2 |
Tier 2 |
25% | 25% | None |
CLARITHROMYCIN FOR ORAL SUSPENSION 125/5ML 125MG BOT |
1 |
Tier 1 |
25% | 25% | None |
CLINDAMYCIN 150MG/ML ADDVAN |
1 |
Tier 1 |
25% | 25% | Q:252 /30Days |
CLINDAMYCIN HCL 150MG CAPSULE |
1 |
Tier 1 |
25% | 25% | Q:168 /30Days |
CLINDAMYCIN HCL 300MG CAPS |
1 |
Tier 1 |
25% | 25% | Q:56 /30Days |
CLINDAMYCIN INJECTION 150MG/60ML VIAL PHAR CRTN |
1 |
Tier 1 |
25% | 25% | Q:252 /30Days |
CLINDAMYCIN PHOSP 1% LOTION |
1 |
Tier 1 |
25% | 25% | None |
CLINDAMYCIN PHOSPHATE 1% SOLUTION NON-ORAL |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINDAMYCIN PHOSPHATE 2% CREAM WITH APPLICATOR |
1 |
Tier 1 |
25% | 25% | None |
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE |
1 |
Tier 1 |
25% | 25% | None |
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX |
1 |
Tier 1 |
25% | 25% | None |
CLOBETASOL 0.05% CREAM |
1 |
Tier 1 |
25% | 25% | None |
CLOBETASOL 0.05% CREAM |
1 |
Tier 1 |
25% | 25% | None |
CLOBETASOL 0.05% GEL |
1 |
Tier 1 |
25% | 25% | None |
CLOBETASOL 0.05% OINTMENT |
1 |
Tier 1 |
25% | 25% | None |
CLOBETASOL 0.05% SOLUTION |
1 |
Tier 1 |
25% | 25% | None |
CLOBETASOL E 0.05% CREAM |
1 |
Tier 1 |
25% | 25% | None |
CLOBETASOL PROPIONATE CRM 0.05% 15GM |
1 |
Tier 1 |
25% | 25% | None |
CLOMIPRAMINE HCL 25MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOMIPRAMINE HCL 50MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
CLOMIPRAMINE HCL 75MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
CLONIDINE HCL 0.2MG TABLET (500 CT) |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
CLONIDINE HCL TABLET 0.1MG (500 CT) |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
CLONIDINE HCL TABLET 0.3MG (100 CT) |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
CLOTRIMAZOLE 1% CREAM |
1 |
Tier 1 |
25% | 25% | None |
CLOTRIMAZOLE 10MG TROCHE |
1 |
Tier 1 |
25% | 25% | None |
CLOTRIMAZOLE 10MG TROCHE |
1 |
Tier 1 |
25% | 25% | None |
CLOTRIMAZOLE SOLUTION TOPICAL 1% 30ML BOTPL |
1 |
Tier 1 |
25% | 25% | None |
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION |
1 |
Tier 1 |
25% | 25% | None |
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CREAM USP .5MG-10GM 45GM TUBE |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOZAPINE 100MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
CLOZAPINE 200MG TABLET (500 CT) |
1 |
Tier 1 |
25% | 25% | S |
CLOZAPINE 25MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | S |
CLOZAPINE 50MG TABLET (500 CT) |
1 |
Tier 1 |
25% | 25% | S |
CLOZARIL 100MG TABLET |
2 |
Tier 2 |
25% | 25% | S |
CLOZARIL 25MG TABLET |
2 |
Tier 2 |
25% | 25% | S |
CO-GESIC 5/500 TABLET |
1 |
Tier 1 |
25% | 25% | Q:240 /30Days |
COLCHICINE TABLET USP 0.6MG (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
COLISTIMETHATE 150MG VIAL |
3 |
Tier 3 |
25% | 25% | None |
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
COLOCORT 100MG ENEMA |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COMBIVIR TABLET |
3 |
Tier 3 |
25% | 25% | Q:60 /30Days |
COMPRO 25MG SUPPOSITORY |
1 |
Tier 1 |
25% | 25% | None |
COMTAN 200MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:240 /30Days |
COMVAX VACCINE VIAL |
2 |
Tier 2 |
25% | 25% | None |
CONSTULOSE 10GM/15ML SYRUP |
1 |
Tier 1 |
25% | 25% | None |
COPAXONE 20MG INJECTION KIT |
3 |
Tier 3 |
25% | 25% | P Q:1 /30Days |
CORMAX 0.05% CREAM |
1 |
Tier 1 |
25% | 25% | None |
CORMAX 0.05% OINTMENT |
1 |
Tier 1 |
25% | 25% | None |
CORMAX 0.05% SOLUTION |
1 |
Tier 1 |
25% | 25% | None |
CORTISONE ACETATE 25MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
CORTOMYCIN EAR SOLUTION |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CORTOMYCIN EAR SUSPENSION |
1 |
Tier 1 |
25% | 25% | None |
COUMADIN 10MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
COUMADIN 1MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
COUMADIN 2.5MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
COUMADIN 2MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
COUMADIN 3MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
COUMADIN 4MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
COUMADIN 5MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
COUMADIN 6MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
COUMADIN 7.5MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
CRIXIVAN 100MG CAPSULE |
2 |
Tier 2 |
25% | 25% | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CRIXIVAN 200MG CAPSULE |
2 |
Tier 2 |
25% | 25% | Q:270 /30Days |
CRIXIVAN 333MG CAPSULE |
2 |
Tier 2 |
25% | 25% | Q:270 /30Days |
CRIXIVAN 400MG CAPSULE (120 CT) |
2 |
Tier 2 |
25% | 25% | Q:180 /30Days |
CROMOLYN NEBULIZER SOLUTION |
1 |
Tier 1 |
25% | 25% | P |
CROMOLYN SODIUM 4% 40MG 10ML BOT |
1 |
Tier 1 |
25% | 25% | None |
CRYSELLE-28 TABLET 28 TABLET S |
1 |
Tier 1 |
25% | 25% | Q:28 /28Days |
CUPRIMINE 125MG CAPSULE |
2 |
Tier 2 |
25% | 25% | None |
CUPRIMINE CAPSULES 250MG (100 CT) |
2 |
Tier 2 |
25% | 25% | None |
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT) |
1 |
Tier 1 |
25% | 25% | S Q:90 /30Days |
CYCLOBENZAPRINE HCL 5MG TABLET (500 CT) |
1 |
Tier 1 |
25% | 25% | S Q:90 /30Days |
CYCLOSPORINE 100MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYCLOSPORINE 100MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P |
CYCLOSPORINE 100MG/ML SOLUTION ORAL |
1 |
Tier 1 |
25% | 25% | P |
CYCLOSPORINE 25MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P |
CYCLOSPORINE 25MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P |
CYCLOSPORINE 50MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT |
1 |
Tier 1 |
25% | 25% | P |
CYKLOKAPRON 100MG/ML AMPUL |
2 |
Tier 2 |
25% | 25% | None |
CYMBALTA 20MG CAPSULE |
2 |
Tier 2 |
25% | 25% | S Q:60 /30Days |
CYMBALTA 60MG CAPSULE |
2 |
Tier 2 |
25% | 25% | S Q:30 /30Days |
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT) |
2 |
Tier 2 |
25% | 25% | S Q:60 /30Days |
CYPROHEPTADINE 2MG/5ML SYRUP |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYPROHEPTADINE 4MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CYSTADANE POWDER FOR ORAL SOLUTION 180GM |
2 |
Tier 2 |
25% | 25% | P |
CYSTAGON 150MG CAPSULE |
2 |
Tier 2 |
25% | 25% | P |
CYSTAGON 50MG CAPSULE |
2 |
Tier 2 |
25% | 25% | P |
CYTOMEL 25MCG TABLET |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
CYTOMEL 50MCG TABLET |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
CYTOMEL 5MCG TABLET |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |