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2009 Medicare Part D Plan (PDP Only) Formulary Browser

This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
Select your search style and criteria below or use this example to get started
Search Criteria
PDP Plans
Scroll down to see formulary results.

Aetna Medicare Rx Plus (S5810-161-0)
Tier 1 (677)
Tier 2 (1491)
Tier 3 (525)
Tier 4 (2238)
Tier 5 (443)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
  *required
 
Cick on the first letter of your drug name to browse the formulary:

A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2009 Medicare Part D Plan Formulary Information
Aetna Medicare Rx Plus (S5810-161-0)
Benefit Details  
The Aetna Medicare Rx Plus (S5810-161-0)
Formulary Drugs Starting with the Letter C

in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
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   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CADUET 10MG/10MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:1
/1Days
CADUET 10MG/20MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:1
/1Days
CADUET 10MG/40MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:1
/1Days
CADUET 10MG/80MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:1
/1Days
CADUET 2.5MG/10MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:1
/1Days
CADUET 2.5MG/20MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:1
/1Days
CADUET 2.5MG/40MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:1
/1Days
CADUET 5MG/10MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:1
/1Days
CADUET 5MG/20MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:1
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CADUET 5MG/40MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:1
/1Days
CADUET 5MG/80MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:1
/1Days
CAFERGOT 1-100MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CALAN 120MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:4
/1Days
CALAN 40MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:4
/1Days
CALAN 80MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:4
/1Days
CALAN SR 120MG CAPLET SA   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:1
/1Days
CALAN SR 180MG CAPLET SA   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:2
/1Days
CALAN SR TABLET 240MG (500 CT)   4 Tier 4 - Non-Preferred Brand $77.00$154.00S
CALCIJEX 1 MCG/ML AMPUL   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CALCIPOTRIENE TOPICAL SOLUTION   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CALCITRIOL 0.25MCG CAPSULE   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CALCITRIOL 0.5MCG CAPSULE   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CALCITRIOL 1MCG/ML SOLUTION ORAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CALCITRIOL 2 MCG/ML VIAL   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CALCITRIOL INJECTION SOLUTION 1MCG 50 X 01ML AMP   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CALCIUM ACETATE CAPSULE 667 MG   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CAMILA 0.35MG TABLET   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CAMPATH 30MG/ML VIAL   5 Tier 5 - Specialty 33%33%P
CAMPRAL 333MG DOSE PAK   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CAMPTOSAR 20MG/ML VIAL   5 Tier 5 - Specialty 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX   3 Tier 3 - Preferred Brand $36.00$72.00Q:2
/1Days
CANCIDAS IV 50MG VIAL   5 Tier 5 - Specialty 33%33%P
CANCIDAS IV 70MG VIAL   5 Tier 5 - Specialty 33%33%P
CANTIL 25MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CAPASTAT SULFATE 1GM VIAL   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CAPEX SHA 0.01%   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CAPITAL W/CODEINE ORAL SUSP   4 Tier 4 - Non-Preferred Brand $77.00$154.00S
CAPOTEN 100 MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CAPOTEN 12.5MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00Q:3
/1Days
CAPOTEN 25MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00Q:3
/1Days
CAPOTEN 50MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CAPOZIDE 25MG-15MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CAPOZIDE 25MG-25MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CAPTOPRIL 100MG TABLET   1 Tier 1 - Preferred Generic $0.00$0.00None
CAPTOPRIL 12.5MG TABLET   1 Tier 1 - Preferred Generic $0.00$0.00Q:3
/1Days
CAPTOPRIL 25MG TABLET   1 Tier 1 - Preferred Generic $0.00$0.00Q:3
/1Days
CAPTOPRIL 50MG TABLET   1 Tier 1 - Preferred Generic $0.00$0.00Q:3
/1Days
CAPTOPRIL/HCTZ 25/15 TABLET   1 Tier 1 - Preferred Generic $0.00$0.00None
CAPTOPRIL/HCTZ 25/25 TABLET   1 Tier 1 - Preferred Generic $0.00$0.00None
CAPTOPRIL/HCTZ 50/15 TABLET   1 Tier 1 - Preferred Generic $0.00$0.00None
CAPTOPRIL/HCTZ 50/25 TABLET   1 Tier 1 - Preferred Generic $0.00$0.00None
CARAC CRE 0.5%   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARAFATE SUCRALFATE 1G TABLET ORAL   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CARAFATE SUS 1GM/10ML   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CARBAMAZEPINE 100MG/5ML SUSPENSION ORAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CARBAMAZEPINE TABLET CHEWABLE 100MG (100 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CARBAMAZEPINE TABLET USP 200MG (1000 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CARBATROL 100MG CAPSULE SA   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CARBATROL 200MG CAPSULE SA   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CARBATROL 300MG CAPSULE SA   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;100MG;MG 100 BOT   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;250MG;MG 100 BOT   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBIDOPA-LEVODOPA 25MG-100MG TABLET SA   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CARBIDOPA-LEVODOPA 25MG-100MG TABLET SA   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CARBIDOPA-LEVODOPA 25MG-100MG TABLET SA   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CARBIDOPA-LEVODOPA 50MG-200MG TABLET SA   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CARBIDOPA-LEVODOPA 50MG-200MG TABLET SA   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CARBIDOPA/LEVO 10/100 TABLET   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CARBIDOPA/LEVO 25/100 TABLET   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CARBIDOPA/LEVO 25/250 TABLET   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CARBINOXAMINE MALEATE SOLUTION 4MG/5ML 16 OZ BOT   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CARBINOXAMINE MALEATE TABLETS 4MG 100 BOT   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CARBOPLATIN AQUEOUS SOLUTION INJECTION 150MG 15ML VIAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBOPLATIN AQUEOUS SOLUTION INJECTION 50MG 5ML VIAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
CARBOPLATIN INJECTION 10MG 1 X 45ML VIAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
CARBOPLATIN INJECTION AQUEOUS SOLUTION 10MG 1 X 60ML VIAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
CARDENE 20MG CAPSULE   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:6
/1Days
CARDENE 30MG CAPSULE   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:4
/1Days
CARDENE IV 2.5MG/ML AMPUL   4 Tier 4 - Non-Preferred Brand $77.00$154.00S
CARDENE SR (NICARDIPINE HCL) 30MG CAPSULE SA   4 Tier 4 - Non-Preferred Brand $77.00$154.00Q:2
/1Days
CARDENE SR (NICARDIPINE HCL) 45MG CAPSULE SA   4 Tier 4 - Non-Preferred Brand $77.00$154.00Q:2
/1Days
CARDENE SR (NICARDIPINE HCL) 60MG CAPSULE SA   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CARDIZEM 120MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:3
/1Days
CARDIZEM 30MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:4
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARDIZEM 60MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:4
/1Days
CARDIZEM 90MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:4
/1Days
CARDIZEM CAPSULES 180MG (90 CT)   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:3
/1Days
CARDIZEM CD 120MG CAPSULE SR 24 HR   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:1
/1Days
CARDIZEM CD 240MG CAPSULE SR 24 HR   4 Tier 4 - Non-Preferred Brand $77.00$154.00S
CARDIZEM CD 300MG CAPSULE SR 24 HR   4 Tier 4 - Non-Preferred Brand $77.00$154.00S
CARDIZEM CD 360MG CAPSULE SR 24 HR   4 Tier 4 - Non-Preferred Brand $77.00$154.00S
CARDIZEM LA 120MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00Q:1
/1Days
CARDIZEM LA 180MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00Q:3
/1Days
CARDIZEM LA 240MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CARDIZEM LA 300MG TABLET SR 24HR   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARDIZEM LA 360MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CARDIZEM LA 420MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CARDURA 1MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CARDURA 2MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CARDURA 4MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CARDURA 8MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CARDURA XL 4MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CARDURA XL 8MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CARIMUNE NF 12GM VIAL   5 Tier 5 - Specialty 33%33%P
CARIMUNE NF 1GM VIAL   5 Tier 5 - Specialty 33%33%P
CARIMUNE NF 3GM VIAL   5 Tier 5 - Specialty 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARIMUNE NF 6GM VIAL   5 Tier 5 - Specialty 33%33%P
CARISOPRODOL COMPOUND (CARISOPRODOL/ASPIRIN) 200-325MG TABLET   2 Tier 2 - Non-Preferred Generic $10.00$20.00P Q:240
/30Days
CARISOPRODOL CPD/CODEINE TABLET   2 Tier 2 - Non-Preferred Generic $10.00$20.00P Q:240
/30Days
CARISOPRODOL TABLET USP 350MG (100 CT)   1 Tier 1 - Preferred Generic $0.00$0.00P Q:84
/30Days
CARMOL HC 1%-10% CREAM   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CARNITOR 100MG/ML ORAL TUBEX   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CARNITOR 1GM/5ML VIAL   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CARNITOR 330MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
carteolol 2.5MG oral TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S
carteolol 5MG oral TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARTIA XT 120MG CAPSULE SA   2 Tier 2 - Non-Preferred Generic $10.00$20.00Q:1
/1Days
CARTIA XT 180MG CAPSULE SA   2 Tier 2 - Non-Preferred Generic $10.00$20.00Q:3
/1Days
CARTIA XT 240MG CAPSULE SA   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CARTIA XT 300MG CAPSULE SR 24 HR   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CARVEDILOL 12.5MG TABLET (100 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00S
CARVEDILOL 25MG TABLET (500 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00S
CARVEDILOL 3.125MG TABLET (100 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00S
CARVEDILOL 6.25MG TABLET (500 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00S
CASODEX 50MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CATAFLAM 50MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CATAPRES 0.1MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CATAPRES 0.2MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CATAPRES 0.3MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CATAPRES-TTS DIS 0.3/24HR   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CATAPRES-TTS-1 PATCH 2.52.5MG/UNT 1 X 4 CRTN   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CATAPRES-TTS-2 PATCH 52.5MG/UNT 1 X 4 CRTN   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CEDAX 400MG CAPSULE   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CEDAX 90MG/5ML SUSPENSION RECONSTITUTED ORAL   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CEENU 100MG CAPSULE   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CEENU 10MG CAPSULE   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CEENU 40MG CAPSULE   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CEENU PAK DOSEPACK 1 KIT   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFACLOR 250MG/5ML ORAL SUSP   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFACLOR 375MG/5ML ORAL SUSP   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFACLOR CAPSULES USP 250MG (100 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFACLOR CAPSULES USP 500MG (100 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFACLOR ER 500MG TABLET SR 12HR   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFACLOR POWDER FOR ORAL SUSPENSION USP 125MG 75ML BOT   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFADROXIL 1G TABLET   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFADROXIL 500MG CAPSULE   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFADROXIL 500MG/5ML SUSPENSION RECONSTITUTED ORAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFADROXIL FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFAZOLIN 1GM ADD-VAN VIAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFAZOLIN 1GM/D5W BAG   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFAZOLIN 20GM BULK VIAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFAZOLIN 500MG/D5W BAG   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFAZOLIN FOR INJECTION   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFAZOLIN FOR INJECTION 10GM 10 X 10 VIAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFAZOLIN FOR INJECTION 1MG 25 VIALGL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFDINIR CAPSULES 300MG (60 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFEPIME HCL 2 GRAM VIAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFIZOX 1GM IN D5W 50ML   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CEFIZOX 2GM IN D5W 50ML   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CEFOTAXIME FOR INJECTION   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFOTAXIME FOR INJECTION 1GM 50 BOX VIALGL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFOTAXIME FOR INJECTION 2GM 25 VIAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFOTAXIME FOR INJECTION 500MG 10 VIAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFOTAXIME SODIUM 20GM VIAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFOTETAN 10 GM SOLR   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFOTETAN 1GM VIAL 1EA x 10   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFOTETAN 2GM VIAL 1EA x 10   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFOXITIN FOR INJECTION 10GM 10 X 100ML VIAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFOXITIN FOR INJECTION 1GM 25 X 20ML VIAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFOXITIN FOR INJECTION 2GM 20ML VIAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFPODOXIME PROXETIL 200MG TABLET   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 100MG 50ML BOT   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 50MG 50ML BOT   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFPROZIL 250MG TABLET (100 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFPROZIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFPROZIL 500MG TABLET   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFPROZIL FOR ORAL SUSPENSION 125MG/5ML 75ML BOT   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFTIN 125MG/5ML ORAL SUSP   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFTIN 250MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CEFTIN 250MG/5ML ORAL SUSP   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CEFTIN 500MG TABLET (20 CT)   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CEFTRIAXONE 10GM VIAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFTRIAXONE 1GM PIGGYBACK   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFTRIAXONE 2GM PIGGYBACK   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFTRIAXONE FOR INJECTION 1GM 10 VIALSU   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFTRIAXONE FOR INJECTION 250MG BOX OF 10 VIALGL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFTRIAXONE FOR INJECTION 2GM 10 VIALSU   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFTRIAXONE FOR INJECTION 500MG BOX OF 10 VIALGL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFTRIAXONE FOR INJECTION AND DEXTROSE INJECTION 1 GM/50ML   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFTRIAXONE FOR INJECTION AND DEXTROSE INJECTION 2 GM/50ML   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFUROXIME 250MG TABLET   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFUROXIME AXETIL 125MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 - Preferred Generic $0.00$0.00None
CEFUROXIME AXETIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 - Preferred Generic $0.00$0.00None
CEFUROXIME AXETIL 500MG TABLET (20 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFUROXIME FOR INJECTION   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFUROXIME FOR INJECTION   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFUROXIME FOR INJECTION 7.5GM 10 X 7.5 VIALPHR   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFUROXIME FOR INJECTION AND DEXTROSE INJECTION   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFUROXIME FOR INJECTION AND DEXTROSE INJECTION   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEFZIL 125MG/5ML SUSPENSION   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFZIL 250MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CEFZIL 250MG/5ML SUSPENSION   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CEFZIL 500MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CELEBREX 100MG CAPSULE   4 Tier 4 - Non-Preferred Brand $77.00$154.00P Q:2
/1Days
CELEBREX 200MG CAPSULE   4 Tier 4 - Non-Preferred Brand $77.00$154.00P Q:1
/1Days
CELEBREX 400MG CAPSULE   4 Tier 4 - Non-Preferred Brand $77.00$154.00P Q:2
/1Days
CELEBREX 50MG CAPSULE   4 Tier 4 - Non-Preferred Brand $77.00$154.00P Q:2
/1Days
CELESTONE 0.6MG/5ML SYRUP   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CELEXA 10MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:1
/1Days
CELEXA 10MG/5ML SOLUTION   4 Tier 4 - Non-Preferred Brand $77.00$154.00S
CELEXA 20MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:1
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CELEXA 40MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:1
/1Days
CELLCEPT 200MG/ML ORAL SUSP   3 Tier 3 - Preferred Brand $36.00$72.00P
CELLCEPT 500MG TABLET   3 Tier 3 - Preferred Brand $36.00$72.00P
CELLCEPT CAPSULES 250MG (500 CT)   3 Tier 3 - Preferred Brand $36.00$72.00P
CELLCEPT IV INJ 500MG   5 Tier 5 - Specialty 33%33%P
CELONTIN 300MG KAPSEAL   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CENESTIN 0.3MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CENESTIN 0.45MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CENESTIN 0.625MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CENESTIN 0.9MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CENESTIN 1.25MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEPHALEXIN 250MG CAPSULE   1 Tier 1 - Preferred Generic $0.00$0.00None
CEPHALEXIN 250MG TABLET   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEPHALEXIN 250MG/5ML ORAL SUSP   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEPHALEXIN 500MG TABLET   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEPHALEXIN CAPSULES 500MG (500 CT)   1 Tier 1 - Preferred Generic $0.00$0.00None
CEPHALEXIN POWDER FOR SUSPENSION ORAL USP 125MG 200ML BOT   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CEREBYX 50MG/ML INJECTION   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CEREDASE 80UNITS/ML VIAL   5 Tier 5 - Specialty 33%33%None
CEREZYME INJ 200UNIT   5 Tier 5 - Specialty 33%33%None
CEREZYME INJ 400UNIT   5 Tier 5 - Specialty 33%33%None
CERUBIDINE 20MG VIAL   4 Tier 4 - Non-Preferred Brand $77.00$154.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CESAMET 1MG CAPSULE   5 Tier 5 - Specialty 33%33%P
CESIA 7 DAYS X 3 TABLET   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CETIRIZINE HCL 5MG/5ML   2 Tier 2 - Non-Preferred Generic $10.00$20.00P Q:10
/1Days
CHANTIX 0.5MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:2
/1Days
CHANTIX 1MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:2
/1Days
CHANTIX STARTING MONTH PAK   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:2
/1Days
CHEMET 100MG CAPSULE   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CHLORAMPHEN NA SUCC 1GM VL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CHLORDIAZEPOXIDE AND AMITRIPTYLINE HCL TABLET 12.5-5MG (500 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH   1 Tier 1 - Preferred Generic $0.00$0.00None
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH   1 Tier 1 - Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHLOROQUINE PH 500MG TABLET   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CHLOROQUINE PHOSPHATE 250MG TABLET (50 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CHLOROTHIAZIDE 250MG TABLET   1 Tier 1 - Preferred Generic $0.00$0.00None
CHLOROTHIAZIDE 500MG TABLET   1 Tier 1 - Preferred Generic $0.00$0.00None
CHLORPROMAZINE 100MG TABLET   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CHLORPROMAZINE 10MG TABLET   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CHLORPROMAZINE 25MG TABLET   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CHLORPROMAZINE 25MG/ML AMP   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CHLORPROMAZINE 50MG TABLET   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CHLORPROMAZINE HCL 200MG TABLET   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CHLORPROPAMIDE 100MG TABLET   1 Tier 1 - Preferred Generic $0.00$0.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHLORPROPAMIDE 250MG TABLET (1000 CT)   1 Tier 1 - Preferred Generic $0.00$0.00P
CHLORTHALIDONE 25MG TABLET (100 CT)   1 Tier 1 - Preferred Generic $0.00$0.00None
CHLORTHALIDONE 50MG TABLET (1000 CT)   1 Tier 1 - Preferred Generic $0.00$0.00None
CHLORZOXAZONE 250MG TABLET   1 Tier 1 - Preferred Generic $0.00$0.00P
CHLORZOXAZONE 500MG TABLET   1 Tier 1 - Preferred Generic $0.00$0.00P
CHOLESTYRAMINE LIGHT ORAL SUSP USP POWDER 4GM 210GM CAN   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CHOLESTYRAMINE LIGHT ORAL SUSP USP POWDER 4GM 60 X 5 SINGLE DOSE CRTN   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CHOLESTYRAMINE POWDER FOR ORAL SUSPENSION USP 4GM 60 X 9GM SINGLE DOSE CRTN   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CHOLESTYRAMINE POWDER FOR ORAL SUSPENSION USP 4GM 378GM CAN   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CICLOPIROX 0.77% CREAM   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CICLOPIROX 0.77% GEL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CICLOPIROX 0.77% TOPICAL SUSPENSION   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6ML BOT   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
CILOSTAZOL 50MG TABLET (60 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CILOSTAZOL TABLET 100MG (60 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CILOXAN 0.3% OINTMENT   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CILOXAN SOLUTION 0.3% 5ML BOT   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CIMETIDINE 150MG/ML VIAL   1 Tier 1 - Preferred Generic $0.00$0.00None
CIMETIDINE 200MG TABLET   1 Tier 1 - Preferred Generic $0.00$0.00None
CIMETIDINE HCL 300MG/5ML SOL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CIMETIDINE TABLET USP 300MG (1000 CT)   1 Tier 1 - Preferred Generic $0.00$0.00None
CIMETIDINE TABLET USP 400MG (1000 CT)   1 Tier 1 - Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CIMETIDINE TABLET USP 800MG (30 CT)   1 Tier 1 - Preferred Generic $0.00$0.00None
CIMZIA KIT   5 Tier 5 - Specialty 33%33%None
CIPRO (10%) SUS 500MG/5   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CIPRO (5%) SUS 250MG/5   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CIPRO 250MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CIPRO 500MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CIPRO 750MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CIPRO HC OTIC SUSPENSION   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CIPRO IV 10MG/ML VIAL   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CIPRO IV 10MG/ML VIAL   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CIPRO IV INFUSION 200MG 100ML BAG   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CIPRO IV INJECTION 400MG 200ML BAG   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CIPRODEX OTIC SUSPENSION   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CIPROFLOXACIN 10MG/ML VIAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CIPROFLOXACIN 250MG TABLET (100 CT)   1 Tier 1 - Preferred Generic $0.00$0.00None
CIPROFLOXACIN 500MG TABLET   1 Tier 1 - Preferred Generic $0.00$0.00None
CIPROFLOXACIN 750MG TABLET (50 CT)   1 Tier 1 - Preferred Generic $0.00$0.00None
CIPROFLOXACIN ER 1000MG TABLET (30 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CIPROFLOXACIN ER 500MG TABLET (30 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CIPROFLOXACIN HCL 0.3% DROPS   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CIPROFLOXACIN HCL 100MG TABLET   1 Tier 1 - Preferred Generic $0.00$0.00None
CIPROFLOXACIN INJECTION IN DEXTROSE INJECTION   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CIPROFLOXACIN INJECTION IN DEXTROSE INJECTION   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CISPLATIN INJECTION 1MG   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
CITALOPRAM HBR 20MG TABLET (100 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00Q:1
/1Days
CITALOPRAM HBR 40MG TABLET (100 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00Q:1
/1Days
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CITOLOPRAM HBR 10MG TABLET (100 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00Q:1
/1Days
CLADRIBINE 1MG/ML VIAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
CLAFORAN 10GM VIAL   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLAFORAN 1GM VIAL   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLAFORAN 1GM/50ML GALAXY   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLAFORAN 2GM ADD-VANTAGE VL   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLAFORAN 2GM/50ML GALAXY   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLAFORAN 500MG VIAL   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLAFORAN INJECTION ADD VANTAGE SYSTEM 1GM 25 X 1GM VIAL   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLAFORAN INJECTION STERILE 2GM 10 X 2GM VIAL   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLARAVIS 10MG CAPSULE   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
CLARAVIS 20MG CAPSULE   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
CLARAVIS 30MG CAPSULE   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
CLARAVIS 40MG CAPSULE   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
CLARINEX 0.5MG/ML SYRUP   4 Tier 4 - Non-Preferred Brand $77.00$154.00P Q:10
/1Days
CLARINEX 2.5MG REDITABS   4 Tier 4 - Non-Preferred Brand $77.00$154.00P Q:1
/1Days
CLARINEX 5MG REDITABS   4 Tier 4 - Non-Preferred Brand $77.00$154.00P Q:1
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLARINEX 5MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00P Q:1
/1Days
CLARINEX-D 12 HOUR TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00Q:2
/1Days
CLARINEX-D 24 HOUR TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00Q:1
/1Days
CLARITHROMYCIN 250MG TABLET   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CLARITHROMYCIN 250MG/5ML. SUS. 100ML   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CLARITHROMYCIN 500MG TABLET   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CLARITHROMYCIN ER 500MG TABLET (60 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CLARITHROMYCIN FOR ORAL SUSPENSION 125/5ML 125MG BOT   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CLEMASTINE FUM 2.68MG TABLET   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CLEMASTINE FUMARATE 0.67MG/5ML SYRUP   1 Tier 1 - Preferred Generic $0.00$0.00None
CLEOCIN 100MG VAGINAL OVULE   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLEOCIN 2% VAGINAL CREAM   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLEOCIN 300MG/D5W/GALAXY   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLEOCIN 600MG/D5W/GALAXY   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLEOCIN 900MG/D5W/GALAXY   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLEOCIN HCL 150MG CAPSULE   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLEOCIN HCL 300MG CAPSULE   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLEOCIN HCL 75MG CAPSULE   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLEOCIN PED SOL 75MG/5ML   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLEOCIN PHOS 150MG/ML VIAL   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLEOCIN PHOS 150MG/ML VIAL   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLEOCIN T 1% GEL   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLEOCIN T 1% LOTION   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLEOCIN T 1% PLEDGETS   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLEOCIN T 1% SOLUTION   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLIMARA 0.025MG/DAY PATCH   4 Tier 4 - Non-Preferred Brand $77.00$154.00Q:4
/28Days
CLIMARA 0.0375MG/DAY PATCH   4 Tier 4 - Non-Preferred Brand $77.00$154.00Q:4
/28Days
CLIMARA 0.05MG/24H PATCH   4 Tier 4 - Non-Preferred Brand $77.00$154.00Q:4
/28Days
CLIMARA 0.06/MG DAY PATCH   4 Tier 4 - Non-Preferred Brand $77.00$154.00Q:4
/28Days
CLIMARA 0.075MG/DAY PATCH   4 Tier 4 - Non-Preferred Brand $77.00$154.00Q:4
/28Days
CLIMARA 0.1MG/24H PATCH   4 Tier 4 - Non-Preferred Brand $77.00$154.00Q:4
/28Days
CLIMARA PRO DIS WEEKLY 4.40MG/1.39MG   4 Tier 4 - Non-Preferred Brand $77.00$154.00Q:4
/28Days
CLINDAGEL 1% GEL   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINDAMYCIN 150MG/ML ADDVAN   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CLINDAMYCIN HCL 150MG CAPSULE   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CLINDAMYCIN HCL 300MG CAPS   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CLINDAMYCIN INJECTION 150MG/60ML VIAL PHAR CRTN   1 Tier 1 - Preferred Generic $0.00$0.00None
CLINDAMYCIN PHOSP 1% LOTION   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CLINDAMYCIN PHOSPHATE 1% SOLUTION NON-ORAL   1 Tier 1 - Preferred Generic $0.00$0.00None
CLINDAMYCIN PHOSPHATE 2% CREAM WITH APPLICATOR   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CLINDESSE 2% VAGINAL CREAM   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLINIMIX 2.75%/5% INJECTION 1000ML BAG   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINIMIX 4.25/10 SOLUTION   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLINIMIX 4.25/20 SOLUTION   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLINIMIX 4.25/25 SOLUTION   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLINIMIX 4.25/5 SOLUTION   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLINIMIX 5/15 SOLUTION   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLINIMIX 5/20 SOLUTION   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLINIMIX E 2.75/10 SOLUTION   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLINIMIX E 2.75/5 SOLUTION   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLINIMIX E 4.25/25 SOLUTION   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLINIMIX E 4.25/5 SOLUTION   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINIMIX E 5/20 SOLUTION   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLINIMIX E 5/25 SOLUTION   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLINIMIX E 5/35 SOLUTION   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLINIMIX E 5%/15% INJECTION 2000ML BAG   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLINISOL 15% SOLUTION   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLINORIL 200MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLOBETASOL 0.05% CREAM   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CLOBETASOL 0.05% CREAM   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CLOBETASOL 0.05% GEL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CLOBETASOL 0.05% OINTMENT   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CLOBETASOL 0.05% SOLUTION   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOBETASOL E 0.05% CREAM   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CLOBETASOL PROPIONATE 0.05% FOAM   1 Tier 1 - Preferred Generic $0.00$0.00None
CLOBETASOL PROPIONATE CRM 0.05% 15GM   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CLOBEX 0.05% SHAMPOO   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLOBEX 0.05% SPRAY NON-AEROSOL   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLOBEX 0.05% TOPICAL LOTION   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLODERM 0.1% CREAM   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLOLAR 1MG/ML VIAL   5 Tier 5 - Specialty 33%33%None
CLOMIPRAMINE HCL 25MG CAPSULE   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CLOMIPRAMINE HCL 50MG CAPSULE   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CLOMIPRAMINE HCL 75MG CAPSULE   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLONIDINE HCL 0.2MG TABLET (500 CT)   1 Tier 1 - Preferred Generic $0.00$0.00None
CLONIDINE HCL TABLET 0.1MG (500 CT)   1 Tier 1 - Preferred Generic $0.00$0.00None
CLONIDINE HCL TABLET 0.3MG (100 CT)   1 Tier 1 - Preferred Generic $0.00$0.00None
CLORPRES 0.1/15 TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLORPRES 0.2/15MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLORPRES 0.3/15MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CLOTRIMAZOLE 1% CREAM   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CLOTRIMAZOLE 10MG TROCHE   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CLOTRIMAZOLE 10MG TROCHE   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CLOTRIMAZOLE SOLUTION TOPICAL 1% 30ML BOTPL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CREAM USP .5MG-10GM 45GM TUBE   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CLOZAPINE 100MG TABLET   2 Tier 2 - Non-Preferred Generic $10.00$20.00Q:9
/1Days
CLOZAPINE 200MG TABLET (500 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00Q:4
/1Days
CLOZAPINE 25MG TABLET (100 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00Q:3
/1Days
CLOZAPINE 50MG TABLET (500 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00Q:3
/1Days
CLOZARIL 100MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00Q:9
/1Days
CLOZARIL 25MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00Q:3
/1Days
CO-GESIC 5/500 TABLET   1 Tier 1 - Preferred Generic $0.00$0.00None
COGENTIN 1MG/ML AMPUL   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
COGNEX 10MG CAPSULE   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
COGNEX 20MG CAPSULE   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COGNEX 30MG CAPSULE   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
COGNEX 40MG CAPSULE   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
COLAZAL 750MG CAPSULE   4 Tier 4 - Non-Preferred Brand $77.00$154.00Q:9
/1Days
COLCHICINE TABLET USP 0.6MG (100 CT)   1 Tier 1 - Preferred Generic $0.00$0.00None
COLESTID 1GM TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
COLESTID FLAVORED GRANULES   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
COLESTID FLAVORED GRANULES   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
COLESTID GRANULES   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
COLESTID GRANULES 5GM NS   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
COLESTIPOL HCL 1G TABLET   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
COLESTIPOL HCL 5G GRANULES   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COLISTIMETHATE 150MG VIAL   5 Tier 5 - Specialty 33%33%None
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
COLOCORT 100MG ENEMA   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
COLY-MYCIN M 150MG VIAL   5 Tier 5 - Specialty 33%33%None
COLY-MYCIN S EAR DROPS   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
COLYTE SOLUTION   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
COLYTE WITH FLAVOR PACKETS   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
COMBIGAN 0.2%-0.5% DROPS   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
COMBIPATCH 0.05/0.14MG PTCH   4 Tier 4 - Non-Preferred Brand $77.00$154.00Q:8
/28Days
COMBIPATCH 0.05/0.25MG PTCH   4 Tier 4 - Non-Preferred Brand $77.00$154.00Q:8
/28Days
COMBIVENT INHALER   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COMBIVIR TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
COMBUNOX 5/400MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:4
/1Days
COMPRO 25MG SUPPOSITORY   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
COMTAN 200MG TABLET   3 Tier 3 - Preferred Brand $36.00$72.00None
COMVAX VACCINE VIAL   3 Tier 3 - Preferred Brand $36.00$72.00None
CONCERTA 18MG TABLET SA   4 Tier 4 - Non-Preferred Brand $77.00$154.00P S Q:3
/1Days
CONCERTA 27MG TABLET SA   4 Tier 4 - Non-Preferred Brand $77.00$154.00P S Q:2
/1Days
CONCERTA 36MG TABLET SA   4 Tier 4 - Non-Preferred Brand $77.00$154.00P S Q:2
/1Days
CONCERTA 54MG TABLET SA   4 Tier 4 - Non-Preferred Brand $77.00$154.00P S Q:2
/1Days
CONDYLOX 0.5% GEL   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CONDYLOX 0.5% TOPICAL TUBEX   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CONSTULOSE 10GM/15ML SYRUP   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
COPAXONE 20MG INJECTION KIT   5 Tier 5 - Specialty 33%33%None
COPEGUS 200MG TABLET   5 Tier 5 - Specialty 33%33%P
CORDARONE 200MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CORDRAN 0.05% LOTION   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CORDRAN 24X3 TAP 4MCG/CM   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CORDRAN SP 0.05% CREAM   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
COREG 12.5MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S
COREG 25MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S
COREG 3.125MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S
COREG 6.25MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COREG CR 10MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Tier 3 - Preferred Brand $36.00$72.00S
COREG CR 20MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Tier 3 - Preferred Brand $36.00$72.00S
COREG CR 40MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Tier 3 - Preferred Brand $36.00$72.00S
COREG CR 80MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Tier 3 - Preferred Brand $36.00$72.00S
CORGARD (NADOLOL) 80MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S
CORGARD 20MG TABLET (100 CT)   4 Tier 4 - Non-Preferred Brand $77.00$154.00S
CORGARD 40MG TABLET (100 CT)   4 Tier 4 - Non-Preferred Brand $77.00$154.00S
CORMAX 0.05% CREAM   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CORMAX 0.05% OINTMENT   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CORMAX 0.05% SOLUTION   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CORTEF 10MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CORTEF 20MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CORTEF 5MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CORTENEMA 100MG/60ML ENEMA   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CORTIFOAM 10% FOAM   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CORTISONE ACETATE 25MG TABLET (100 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CORTISPORIN CRE 0.5%   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CORTISPORIN EAR SOLUTION   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CORTISPORIN EAR SUSPENSION   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CORTISPORIN EYE DROPS   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CORTISPORIN OINTMENT   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CORTISPORIN SUS -TC OTIC   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CORTOMYCIN EAR SOLUTION   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CORTOMYCIN EAR SUSPENSION   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CORZIDE 40-5MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CORZIDE 80-5MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
COSMEGEN 0.5MG VIAL   5 Tier 5 - Specialty 33%33%None
COSOPT PLUS EYE DROPS 22.3 MG/ML 6.8 MG/M   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
COUMADIN 10MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
COUMADIN 1MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
COUMADIN 2.5MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
COUMADIN 2MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
COUMADIN 3MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COUMADIN 4MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
COUMADIN 5MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
COUMADIN 5MG VIAL   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
COUMADIN 6MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
COUMADIN 7.5MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
COVERA-HS 180MG SA TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S Q:2
/1Days
COVERA-HS 240MG SA TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00S
COZAAR 100MG TABLET   3 Tier 3 - Preferred Brand $36.00$72.00None
COZAAR 25MG TABLET (1000 CT)   3 Tier 3 - Preferred Brand $36.00$72.00Q:2
/1Days
COZAAR 50MG TABLET 10000 BOT   3 Tier 3 - Preferred Brand $36.00$72.00Q:2
/1Days
CREON 10 CAPSULE EC   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CREON 20 CAPSULE SA   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CREON 5 CAPSULE EC   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CRESTOR 10MG TABLET   3 Tier 3 - Preferred Brand $36.00$72.00Q:1
/1Days
CRESTOR 20MG TABLET   3 Tier 3 - Preferred Brand $36.00$72.00Q:1
/1Days
CRESTOR 40MG TABLET   3 Tier 3 - Preferred Brand $36.00$72.00Q:1
/1Days
CRESTOR 5MG TABLET   3 Tier 3 - Preferred Brand $36.00$72.00Q:1
/1Days
CRINONE GEL 8% VAG   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CRIXIVAN 100MG CAPSULE   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CRIXIVAN 200MG CAPSULE   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CRIXIVAN 333MG CAPSULE   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CRIXIVAN 400MG CAPSULE (120 CT)   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CROLOM 4% EYE DROPS   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CROMOLYN NEBULIZER SOLUTION   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
CROMOLYN SODIUM 4% 40MG 10ML BOT   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CRYSELLE-28 TABLET 28 TABLET S   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CUBICIN 500MG VIAL   5 Tier 5 - Specialty 33%33%None
CUPRIMINE 125MG CAPSULE   3 Tier 3 - Preferred Brand $36.00$72.00None
CUPRIMINE CAPSULES 250MG (100 CT)   3 Tier 3 - Preferred Brand $36.00$72.00None
CUTIVATE CREAM 0.05%   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CUTIVATE LOTION 0.05%   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CUTIVATE OINTMENT 0.005% 60GM TUBE   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CYCLESSA 28 DAY TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
CYCLOBENZAPRINE HCL 5MG TABLET (500 CT)   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
CYCLOPHOSPHAMIDE 1GM VIAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
CYCLOPHOSPHAMIDE 25MG TABLET   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
CYCLOPHOSPHAMIDE 2GM VIAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
CYCLOPHOSPHAMIDE 500MG VIAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
CYCLOPHOSPHAMIDE 50MG TABLET   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
CYCLOSPORINE 100MG CAPSULE   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
CYCLOSPORINE 100MG CAPSULE   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
CYCLOSPORINE 100MG/ML SOLUTION ORAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
CYCLOSPORINE 25MG CAPSULE   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYCLOSPORINE 25MG CAPSULE   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
CYCLOSPORINE 50MG CAPSULE   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
CYCLOSPORINE 50MG/ML AMP   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
CYKLOKAPRON 100MG/ML AMPUL   5 Tier 5 - Specialty 33%33%None
CYMBALTA 20MG CAPSULE   3 Tier 3 - Preferred Brand $36.00$72.00S Q:2
/1Days
CYMBALTA 60MG CAPSULE   3 Tier 3 - Preferred Brand $36.00$72.00S Q:1
/1Days
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT)   3 Tier 3 - Preferred Brand $36.00$72.00S Q:2
/1Days
CYPROHEPTADINE 2MG/5ML SYRUP   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
CYPROHEPTADINE 4MG TABLET   2 Tier 2 - Non-Preferred Generic $10.00$20.00P
CYSTADANE POWDER FOR ORAL SOLUTION 180GM   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYSTAGON 150MG CAPSULE   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CYSTAGON 50MG CAPSULE   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CYTARABINE 100MG VIAL   2 Tier 2 - Non-Preferred Generic $10.00$20.00None
CYTARABINE 1GM VIAL   1 Tier 1 - Preferred Generic $0.00$0.00None
CYTARABINE 20MG/ML VIAL   1 Tier 1 - Preferred Generic $0.00$0.00None
CYTARABINE 2GM VIAL   1 Tier 1 - Preferred Generic $0.00$0.00None
CYTARABINE 500MG VIAL   1 Tier 1 - Preferred Generic $0.00$0.00None
CYTARABINE SOLUTION INJECTION 100MG 20ML VIALSD   1 Tier 1 - Preferred Generic $0.00$0.00None
CYTOMEL 25MCG TABLET   3 Tier 3 - Preferred Brand $36.00$72.00None
CYTOMEL 50MCG TABLET   3 Tier 3 - Preferred Brand $36.00$72.00None
CYTOMEL 5MCG TABLET   3 Tier 3 - Preferred Brand $36.00$72.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYTOTEC TABLET 100MCG (120 CT)   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CYTOTEC TABLET 200MCG (60 CT)   4 Tier 4 - Non-Preferred Brand $77.00$154.00None
CYTOVENE 500MG VIAL   5 Tier 5 - Specialty 33%33%None
CYTOXAN 1GM VIAL   4 Tier 4 - Non-Preferred Brand $77.00$154.00P
CYTOXAN 25MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00P
CYTOXAN 2GM VIAL   4 Tier 4 - Non-Preferred Brand $77.00$154.00P
CYTOXAN 500MG VIAL   4 Tier 4 - Non-Preferred Brand $77.00$154.00P
CYTOXAN 50MG TABLET   4 Tier 4 - Non-Preferred Brand $77.00$154.00P

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D Aetna Medicare Rx Plus Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $295 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.

  • Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
    • Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.

    • No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.

  • Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
  • Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
    • Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
    • Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
  • Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
    • Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
    • Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
  • Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
    • None - This drug does not fall under any drug utilization management controls.
    • P - Prior Authorization -This drug is subject to prior authorization.
    • S - Step Therapy -This drug is subject to step therapy.
    • Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.




(Chart Source: Centers for Medicare and Medicaid files: CMS Data October 2009 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.







Tips & Disclaimers
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  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDPCompare.com and MACompare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.