2009 Medicare Part D Plan Formulary Information |
EnvisionRxPlus Silver (S7694-006-0)
Benefit Details
|
The EnvisionRxPlus Silver (S7694-006-0) Formulary Drugs Starting with the Letter P in CMS PDP Region 6 which includes: PA WV
|
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 |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PACERONE 200MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PACERONE 300MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PALGIC 4MG/5ML LIQUID |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PANCRELIPASE CAP 4500UNIT |
2 |
Tier 2 Non Preferred Generics |
$32.00 | $96.00 | None |
PANCRELIPASE TABLET 30000-8000UNT (500 CT) |
2 |
Tier 2 Non Preferred Generics |
$32.00 | $96.00 | None |
PANGLOBULIN 12GM |
5 |
Tier 5 Specialty Drugs |
25% | N/A | P |
PANGLOBULIN 6GM VIAL |
5 |
Tier 5 Specialty Drugs |
25% | N/A | P |
PANGLOBULIN INJ 1GM |
5 |
Tier 5 Specialty Drugs |
25% | N/A | P |
PANGLOBULIN INJ 3GM |
5 |
Tier 5 Specialty Drugs |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PANRETIN 0.1% GEL 60GM TUBE |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | None |
PANTOPRAZOLE SODIUM 20MG TABLET DELAYED RELEASE |
2 |
Tier 2 Non Preferred Generics |
$32.00 | $96.00 | None |
PANTOPRAZOLE SODIUM 40MG TABLET DELAYED RELEASE 90 CRC BOT |
2 |
Tier 2 Non Preferred Generics |
$32.00 | $96.00 | None |
PARCAINE 0.5% DROPS |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PAROXETINE 40MG TABLET (500 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PAROXETINE FILM COATED 20MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PAROXETINE HCL 10MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PAROXETINE HCL 10MG/5ML SUSPENSION ORAL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PAROXETINE HCL 30MG TABLET (30 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PAROXETINE HCL TABLET 24 12.5MG |
2 |
Tier 2 Non Preferred Generics |
$32.00 | $96.00 | None |
PAROXETINE HCL TABLET 24 25MG |
2 |
Tier 2 Non Preferred Generics |
$32.00 | $96.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEDI-DRI TOPICAL POWDER |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PEDIARIX SOLUTION INJECTION 25-25-10 10 X .5ML VIAL |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | None |
PEG 3350/ELECTROLYTE 240-22.72G SOLUTION RECONSTITUTED ORAL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PEGANONE 250MG TABLET |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | None |
PEGASYS 180MCG/0.5ML CONV.PK |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
PENICILLIN G POTASSIUM FOR INJECTION |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PENICILLIN G POTASSIUM FOR INJECTION |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PENICILLIN G SODIUM FOR INJECTION 5000000UNT 1 VIAL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PENICILLIN V POTASSIUM 250MG TABLET (1000 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PENICILLIN V POTASSIUM 500MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENICILLIN V POTASSIUM FOR ORAL SOLUTION CONCENTRATE 125MG 200ML BOT |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PENTAZOCINE/ACETAMIN TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PENTAZOCINE/NALOXONE HCL 50-0.5MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PENTOPAK 400MG TABLET SA |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PENTOSTATIN FOR INJECTION 10MG/VIAL |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
PENTOXIFYLLINE 400MG TABLET SA |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PENTOXIL 400MG TABLET SA |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PERMETHRIN 5% CREAM |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PERPHENAZINE 16MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PERPHENAZINE 2MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PERPHENAZINE 4MG TABLET (500 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PERPHENAZINE 8MG TABLET (500 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PFIZERPEN 5MMU VIAL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PHENADOZ 12.5MG SUPPOSITORY |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PHENADOZ 25MG SUPPOSITORY |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PHENYTOIN SODIUM INJECTION 50MG 25 X 2ML AMP |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PHOSLO 667MG CAPSULE |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
PHRENILIN W/CAFF/CODEINE CP |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PHYSIOLYTE SOLUTION FOR IRRIGATION |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PHYSIOSOL IRRIGATION SOL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PILOCARPINE HCL 5MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PILOCARPINE HCL 7.5MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PILOPINE HS 4% EYE GEL |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
PINDOLOL 10MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PINDOLOL 5MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PIPERACILLIN 2GM VIAL |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | None |
PIPERACILLIN 3GM VIAL |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | None |
PIPERACILLIN 40GM BULK VIAL |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | None |
PIPERACILLIN 4GM VIAL |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | None |
PIROXICAM 10MG CAPSULE |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PIROXICAM 20MG CAPSULE (500 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PLASMA-LYTE 148 IV SOLUTION |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
PLASMA-LYTE 148/DEXTROSE 5% |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
PLASMA-LYTE 56 INJECTION 32;128 MG/100ML; |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
PLASMA-LYTE 56/DEXTROSE 5% |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
PLASMA-LYTE A PH 7.4 SOLUTION 37;368; MG/100ML; |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
PLASMA-LYTE INJ-R |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
PLAVIX 300MG TABLET |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
PLAVIX 75MG TABLET |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
PODOFILOX 0.5% TOPICAL TUBEX |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POLY-DEX 3.5-10K-.1 OINTMENT |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POLYCIN-B 500-10KU/G OINTMENT |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POLYGAM S/D 0.5GM VL W/DILUEN |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | P Q:10 /30Days |
POLYGAM S/D 10GM VL W/DILUENT |
5 |
Tier 5 Specialty Drugs |
25% | N/A | P |
POLYGAM S/D 2.5GM VL W/DILUEN |
5 |
Tier 5 Specialty Drugs |
25% | N/A | P |
POLYGAM S/D 5GM VL W/DILUENT |
5 |
Tier 5 Specialty Drugs |
25% | N/A | P |
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1% |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1% |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 0.075%/D5W/SODIUM CHLORIDE 0.2% |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 0.075%/D5W/SODIUM CHLORIDE 0.2% |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.3% |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.3% |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45% |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45% |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.2% |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 10MEQ CAPSULE SA |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 10MEQ TABLET SA |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 10MEQ/100ML SOL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 10MEQ/50ML SOL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 20MEQ IN D5W/NACL 0.225% |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 20MEQ TABLET SR PARTICLES/CRYSTALS |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 20MEQ/100ML SOL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE 20MEQ/50ML SOL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 20MEQ/NS 1000ML IV SOLUTION |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 30MEQ/100ML SOL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 40MEQ/100ML SOL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 40MEQ/NS 1000ML IV SOLUTION |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 8MEQ TABLET SA |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 8MEQ TABLET SA |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE ER CPCR 8MEQ |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE FOR INJECTION CONCENTRATE |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE INJECTION 40 12 X 1000ML CTR |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE INJECTION USP 0.15% 1000ML PLASTIC BAGS X 12 CASE |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE IN DEXTROSE AND SODIUM CHLORIDE INJECTION 5-30-.225 12 X 1000ML CTR |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE IN DEXTROSE INJECTION 5GM/75MG |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION 0.15%-0.9% 12 X 1000ML BAG |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE TABLET ER USP 750MG (1000 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE TABLET ERD 1500MG (500 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CITRATE 10MEQ TABLET SA |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CITRATE 5MEQ TABLET SA |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRANDIN 0.5MG TABLET |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | None |
PRANDIN 1MG TABLET |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | None |
PRANDIN 2MG TABLET |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | None |
PRAVASTATIN SODIUM 10MG TABLET (1000 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PRAVASTATIN SODIUM 20MG TABLET 500 BOT |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PRAVASTATIN SODIUM 40MG TABLET (500 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PRAVASTATIN SODIUM 80MG TABLET (90 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PRAZOSIN 5MG CAPSULE |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PRAZOSIN HCL 1MG CAPSULE |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PRAZOSIN HCL 2MG CAPSULE |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREDNICARBATE 0.1% CREAM |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNICARBATE 0.1% OINTMENT |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREDNISOLONE 15MG/5ML SOLUTION ORAL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREDNISOLONE 5MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREDNISOLONE 5MG/5ML SYRUP |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREDNISOLONE 5MG/5ML TUBEX |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREDNISOLONE SOD 1% EYE DROP |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREDNISONE 10MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREDNISONE 1MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREDNISONE 2.5MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISONE 20MG TABLET (1000 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREDNISONE 50MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREDNISONE 5MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREDNISONE 5MG/5ML SOLUTION |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREMARIN 0.3MG (100 CT) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
PREMARIN 0.45MG TABLET |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
PREMARIN 0.625MG (100 CT) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
PREMARIN 0.9MG TABLET |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
PREMARIN 1.25MG (100 CT) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
PREMARIN 25MG VIAL |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
PREMARIN VAGINAL CREAM /APPL |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREMASOL 6% IV SOLUTION |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | P |
PREMPHASE 0.625/5MG TABLET |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
PREMPRO 0.3MG/1.5MG TABLET |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
PREMPRO 0.45/1.5MG TABLET |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
PREMPRO 0.625/2.5MG TABLET DIALPK |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
PREMPRO 0.625/5MG TABLET |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
PRENATAL RX 1 TABLET 4000UNT-400UNT (100 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREVALITE POW 4GM |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREVALITE POW 4GM PK |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREZISTA 300MG TABLET |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | None |
PREZISTA TABLET |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREZISTA TABLET 75MG |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | None |
PREZISTA TABLETS 400MG 60 TABLETS BOT |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
PRIFTIN 150MG TABLET |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | None |
PRIMIDONE 250MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PRIMIDONE 50MG TABLET (500 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PRISTIQ 100MG TABLET SR 24HR |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | None |
PRISTIQ 50MG TABLET SR 24HR |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | None |
PROAIR HFA 90MCG HFA AEROSOL WITH ADAPTER |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | Q:27 /30Days |
PROBENECID 500MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROBENECID/COLCHICINE TABLET S |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROCAINAMIDE 100MG/ML VIAL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCAINAMIDE 500MG/ML VIAL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROCALAMINE INJECTION 210MG-290MG-26MG 6 X 1000ML BOT |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | P |
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROCHLORPERAZINE MALEATE 25MG SUPPOSITORY RECTAL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROCRIT 10000U/ML VIAL |
5 |
Tier 5 Specialty Drugs |
25% | N/A | P |
PROCRIT 20000U/ML VIAL MDV |
5 |
Tier 5 Specialty Drugs |
25% | N/A | P |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | P Q:23 /30Days |
PROCRIT 3000U/ML VIAL |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | P Q:16 /30Days |
PROCRIT 40000U/ML VIAL PR |
5 |
Tier 5 Specialty Drugs |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCRIT 4000U/ML VIAL 25 X 1ML VIAL |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | P Q:12 /30Days |
PROCTO-PAK 1% CREAM |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROCTOCREAM-HC 2.5% CREAM |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROCTOSOL-HC 2.5% CREAM |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROCTOZONE-HC 2.5% CREAM |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROGLYCEM 50MG/ML ORAL SUSP |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
PROGRAF 0.5MG CAPSULE |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | P |
PROGRAF 1MG CAPSULE |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | P |
PROGRAF 5MG CAPSULE |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | P |
PROGRAF 5MG/ML AMPULE |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | P |
PROLASTIN 1000MG VIAL |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROLASTIN 500MG VIAL |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
PROLEUKIN 22 MILLION UNITS VL |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
PROMETHAZINE 50MG/ML AMPUL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROMETHAZINE 50MG/ML VIAL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROMETHAZINE HCL 12.5MG SUPPOSITORY RECTAL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROMETHAZINE HCL 12.5MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROMETHAZINE HCL 25MG SUPPOSITORY RECTAL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROMETHAZINE HCL 25MG TABLET (1000 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROMETHAZINE HCL 50MG SUPPOSITORY RECTAL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROMETHAZINE HCL 50MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROMETHAZINE HCL 6.25MG/5ML SYRUP |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMETHAZINE HCL INJECTION 25MG 10 X 1ML VIAL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROMETHAZINE SYRUP PLAIN 6.25MG 16 FL OZ BOT |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROMETHAZINE VC PLAIN 6.25-5MG 16 FL OZ BOT |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROMETHEGAN 12.5MG SUPPOSITORY RECTAL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROMETHEGAN 25MG SUPP |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROMETHEGAN 50MG SUPPOS |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPAFENONE HCL 150MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPAFENONE HCL 225MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPAFENONE HCL 300MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPOXY-N/APAP 100-500MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPOXY-N/APAP 100-650 TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPOXY-N/APAP 50-325 TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPOXYPHENE HCL AND ACETAMINOPHEN TABLET 650/65MG (500 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPOXYPHENE HCL CAPSULES 65MG (100 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPRANOLOL 20MG/5ML TUBEX |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPRANOLOL 40MG/5ML TUBEX |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPRANOLOL 60MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPRANOLOL 80MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPRANOLOL HCL 20MG TABLET (1000 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPRANOLOL HCL CAPSULES ER 120MG (1000 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPRANOLOL HCL CAPSULES ER 160MG (1000 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPRANOLOL HCL CAPSULES ER 60MG (100 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPRANOLOL HCL CAPSULES ER 80MG (1000 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPRANOLOL HCL INJECTION 1MG 10 PKG OF 10 CRTN |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPRANOLOL HCL TABLET USP 10MG (1000 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPRANOLOL HCL TABLET USP 40MG (1000 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPRANOLOL/HCTZ 40/25 TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPRANOLOL/HCTZ 80/25 TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPYLTHIOURACIL 50MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROQUAD VIAL |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | None |
PROTONIX IV 40MG VIAL |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | None |
PROTOPIC 0.03% OINTMENT 100GM TUBE |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
PROTOPIC 0.1% OINTMENT 60GM TUBE |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROTRIPTYLINE HYDROCHLORIDE TABLETS |
2 |
Tier 2 Non Preferred Generics |
$32.00 | $96.00 | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG |
2 |
Tier 2 Non Preferred Generics |
$32.00 | $96.00 | None |
PROVENTIL HFA INHALER 90MCG AE |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | Q:21 /30Days |
PROVIGIL 100MG TABLET |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | P |
PROVIGIL 200MG TABLET |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | P |
PYRAZINAMIDE 500MG TABLET |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
PYRIDOSTIGMINE BROMIDE 60MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |