2009 Medicare Part D Plan Formulary Information |
Prescriba Rx Bronze (S5597-268-0)
Benefit Details
 |
The Prescriba Rx Bronze (S5597-268-0) Formulary Drugs Starting with the Letter A in CMS PDP Region 34 which includes: AK
|
Drugs Starting with Letter A
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
A METHAPRED METHLYPREDNISOLONE SODIUM SUCCINATE FOR INJECTION 125 MG  |
1 |
Tier 1 |
25% | 25% | None |
A-METHAPRED 40MG UNIVIAL  |
1 |
Tier 1 |
25% | 25% | None |
ABELCENT INJECTION SUSPENSION 5MG/ML  |
3 |
Tier 3 |
25% | 25% | P |
ABILIFY 10MG TABLET  |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ABILIFY 15MG TABLET  |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ABILIFY 1MG/ML SOLUTION  |
2 |
Tier 2 |
25% | 25% | Q:900 /30Days |
ABILIFY 20MG TABLET  |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ABILIFY 2MG TABLET  |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ABILIFY 30MG TABLET  |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ABILIFY 5MG TABLET (OTSUKA)  |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABILIFY DISCMELT 10MG TABLET  |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ABILIFY DISCMELT 15MG TABLET  |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
ABILIFY INJ 9.75MG  |
2 |
Tier 2 |
25% | 25% | Q:3 /1Days |
ACARBOSE 100MG TABLET S  |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
ACARBOSE 25MG TABLET S  |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
ACARBOSE 50MG TABLET S  |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
ACCOLATE 10MG TABLET  |
2 |
Tier 2 |
25% | 25% | S Q:60 /30Days |
ACCOLATE 20MG TABLET  |
2 |
Tier 2 |
25% | 25% | S Q:60 /30Days |
ACEBUTOLOL 200MG CAPSULE  |
1 |
Tier 1 |
25% | 25% | None |
ACEBUTOLOL 400MG CAPSULE  |
1 |
Tier 1 |
25% | 25% | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-15MG (1000 CT)  |
1 |
Tier 1 |
25% | 25% | Q:400 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)  |
1 |
Tier 1 |
25% | 25% | Q:400 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)  |
1 |
Tier 1 |
25% | 25% | Q:400 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)  |
1 |
Tier 1 |
25% | 25% | Q:400 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)  |
1 |
Tier 1 |
25% | 25% | Q:400 /30Days |
ACETAMINOPHEN/COD SOLUTION  |
1 |
Tier 1 |
25% | 25% | Q:5000 /30Days |
ACETASOL HC SOLUTION 10ML 10 ML BOT  |
1 |
Tier 1 |
25% | 25% | None |
ACETAZOLAMIDE 125MG TABLET  |
1 |
Tier 1 |
25% | 25% | None |
ACETAZOLAMIDE 250MG TABLET (100 CT)  |
1 |
Tier 1 |
25% | 25% | None |
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT  |
1 |
Tier 1 |
25% | 25% | None |
ACETIC ACID 2% SOLUTION NON-ORAL  |
1 |
Tier 1 |
25% | 25% | None |
ACETIC ACID-HYDROCORTISONE 2%-1% DROPS  |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETYLCYSTEINE 10% VIAL  |
1 |
Tier 1 |
25% | 25% | P |
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN  |
1 |
Tier 1 |
25% | 25% | P |
ACIPHEX 20MG TABLET EC  |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
ACTHIB VACCINE VIAL 10-24UNT/5ML  |
2 |
Tier 2 |
25% | 25% | None |
ACTICIN 5% CREAM  |
1 |
Tier 1 |
25% | 25% | None |
ACTIMMUNE SOLUTION FOR INJECTION 100MCG  |
3 |
Tier 3 |
25% | 25% | P |
ACTOPLUS MET 15MG/500MG TABLET  |
2 |
Tier 2 |
25% | 25% | Q:90 /30Days |
ACTOPLUS MET 15MG/850MG TABLET  |
2 |
Tier 2 |
25% | 25% | Q:90 /30Days |
ACTOS 15MG TABLET  |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ACTOS 30MG TABLET (500 CT)  |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ACTOS 45MG TABLET  |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACYCLOVIR 200MG CAPSULE (1000 CT)  |
1 |
Tier 1 |
25% | 25% | None |
ACYCLOVIR 200MG/5ML SUSP  |
1 |
Tier 1 |
25% | 25% | None |
ACYCLOVIR 400MG TABLET (100 CT)  |
1 |
Tier 1 |
25% | 25% | None |
ACYCLOVIR SOD 50MG/ML VIAL  |
1 |
Tier 1 |
25% | 25% | P |
ACYCLOVIR SODIUM 1GM VIAL  |
1 |
Tier 1 |
25% | 25% | P |
ACYCLOVIR SODIUM 500MG VIAL  |
1 |
Tier 1 |
25% | 25% | P |
ACYCLOVIR TABLET USP 800MG (100 CT)  |
1 |
Tier 1 |
25% | 25% | None |
ADACEL VIAL 2UNT/5UNT  |
2 |
Tier 2 |
25% | 25% | None |
ADAGEN 250U/ML VIAL  |
3 |
Tier 3 |
25% | 25% | None |
ADVAIR DISKU MIS 100/50  |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
ADVAIR DISKU MIS 250/50  |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADVAIR DISKU MIS 500/50  |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
ADVAIR HFA 115/21MCG INHALER  |
2 |
Tier 2 |
25% | 25% | Q:12 /30Days |
ADVAIR HFA 230/21MCG INHALER  |
2 |
Tier 2 |
25% | 25% | Q:12 /30Days |
ADVAIR HFA 45/21MCG INHALER  |
2 |
Tier 2 |
25% | 25% | Q:12 /30Days |
AFEDITAB CR 30MG TABLET SA  |
1 |
Tier 1 |
25% | 25% | S Q:30 /30Days |
AFEDITAB CR 60MG TABLET SA  |
1 |
Tier 1 |
25% | 25% | S Q:30 /30Days |
AGGRENOX 25-200MG CAPSULE  |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
AK-CON 0.1% EYE DROPS  |
1 |
Tier 1 |
25% | 25% | None |
AK-POLY-BAC EYE OINTMENT 500UNT/1000UNT  |
1 |
Tier 1 |
25% | 25% | None |
AK-SPORE EYE OINTMENT 3.5 MG  |
1 |
Tier 1 |
25% | 25% | None |
AKTOB 0.3% EYE DROPS  |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALA-CORT 1% CREAM  |
1 |
Tier 1 |
25% | 25% | None |
ALA-CORT 1% LOTION  |
1 |
Tier 1 |
25% | 25% | None |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER  |
1 |
Tier 1 |
25% | 25% | P Q:450 /30Days |
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER  |
1 |
Tier 1 |
25% | 25% | P Q:450 /30Days |
ALBUTEROL SULFATE 4MG TABLET SR 12HR  |
2 |
Tier 2 |
25% | 25% | Q:120 /30Days |
ALBUTEROL SULFATE 8MG TABLET SR 12HR  |
2 |
Tier 2 |
25% | 25% | Q:120 /30Days |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR  |
1 |
Tier 1 |
25% | 25% | P Q:100 /30Days |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT  |
1 |
Tier 1 |
25% | 25% | Q:2400 /30Days |
ALBUTEROL SULFATE TABLET 2MG (500 CT)  |
1 |
Tier 1 |
25% | 25% | Q:240 /30Days |
ALBUTEROL TABLET 4MG (500 CT)  |
1 |
Tier 1 |
25% | 25% | Q:240 /30Days |
ALCLOMETASONE DIPROPIONATE 0.05% CREAM  |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT  |
1 |
Tier 1 |
25% | 25% | None |
ALCOHOL ANTISEPTIC PADS  |
2 |
Tier 2 |
25% | 25% | Q:200 /30Days |
ALDACTAZIDE 50/50 TABLET  |
2 |
Tier 2 |
25% | 25% | None |
ALDARA 5% CREAM  |
2 |
Tier 2 |
25% | 25% | None |
ALDURAZYME 2.9MG/5ML VIAL  |
2 |
Tier 2 |
25% | 25% | None |
ALENDRONATE SODIUM 10MG TABLET  |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ALENDRONATE SODIUM 40MG TABLET  |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ALENDRONATE SODIUM 5MG TABLET  |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ALENDRONATE SODIUM 70MG TABLET 4 BLPK  |
1 |
Tier 1 |
25% | 25% | Q:4 /28Days |
ALENDRONATE SODIUM TABLET 35MG 20 CRTN  |
1 |
Tier 1 |
25% | 25% | Q:4 /28Days |
ALFERON N INJ 5MU/ML  |
3 |
Tier 3 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALINIA 500MG TABLET  |
2 |
Tier 2 |
25% | 25% | None |
ALLOPURINOL TABLET 300MG (1000 CT)  |
1 |
Tier 1 |
25% | 25% | None |
ALLOPURINOL TABLET USP 100MG (1000 CT)  |
1 |
Tier 1 |
25% | 25% | None |
ALOCRIL 2% EYE DROPS  |
2 |
Tier 2 |
25% | 25% | Q:10 /25Days |
ALORA 0.025MG PATCH  |
2 |
Tier 2 |
25% | 25% | Q:8 /28Days |
ALORA 0.05MG PATCH  |
2 |
Tier 2 |
25% | 25% | Q:8 /28Days |
ALORA 0.075MG PATCH  |
2 |
Tier 2 |
25% | 25% | Q:8 /28Days |
ALORA 0.1MG PATCH  |
2 |
Tier 2 |
25% | 25% | Q:8 /28Days |
ALPHAGAN P 0.1% DROPS  |
2 |
Tier 2 |
25% | 25% | Q:10 /30Days |
ALPHAGAN P 0.15% EYE DROPS  |
2 |
Tier 2 |
25% | 25% | Q:10 /30Days |
ALREX 0.2% EYE DROPS  |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMANTADINE 100MG CAPSULE  |
1 |
Tier 1 |
25% | 25% | None |
AMCINONIDE 0.1% CREAM  |
1 |
Tier 1 |
25% | 25% | None |
AMCINONIDE 0.1% LOTION  |
2 |
Tier 2 |
25% | 25% | None |
AMCINONIDE 0.1% OINTMENT 60GM TUBE  |
2 |
Tier 2 |
25% | 25% | None |
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM  |
3 |
Tier 3 |
25% | 25% | P Q:4 /28Days |
AMIKACIN 250MG/ML VIAL  |
1 |
Tier 1 |
25% | 25% | None |
AMIKACIN 50MG/ML VIAL  |
1 |
Tier 1 |
25% | 25% | None |
AMILORIDE HCL 5MG TABLET  |
1 |
Tier 1 |
25% | 25% | None |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET  |
1 |
Tier 1 |
25% | 25% | None |
AMINESS 5.2% IV SOLUTION  |
2 |
Tier 2 |
25% | 25% | P |
AMINOPHYLLINE 100MG TABLET (100 CT)  |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOPHYLLINE 200MG TABLET (1000 CT)  |
1 |
Tier 1 |
25% | 25% | None |
AMINOSYN 10% IV SOLUTION  |
2 |
Tier 2 |
25% | 25% | P |
AMINOSYN 3.5% IV SOLUTION  |
2 |
Tier 2 |
25% | 25% | P |
AMINOSYN 5% IV SOLUTION  |
2 |
Tier 2 |
25% | 25% | P |
AMINOSYN 7% IV SOLUTION  |
2 |
Tier 2 |
25% | 25% | P |
AMINOSYN 7%-ELECTROLYTE SOL  |
2 |
Tier 2 |
25% | 25% | P |
AMINOSYN 8.5% IV SOLUTION  |
2 |
Tier 2 |
25% | 25% | P |
AMINOSYN II 10% IV SOLUTION  |
2 |
Tier 2 |
25% | 25% | P |
AMINOSYN II 3.5% IN D25W IV  |
2 |
Tier 2 |
25% | 25% | P |
AMINOSYN II 3.5% IN D5W IV  |
2 |
Tier 2 |
25% | 25% | P |
AMINOSYN II 3.5% M/D5W IV  |
2 |
Tier 2 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN II 3.5% W/ELEC DEX  |
2 |
Tier 2 |
25% | 25% | P |
AMINOSYN II 4.25% IN D10W  |
2 |
Tier 2 |
25% | 25% | P |
AMINOSYN II 4.25% IN D20W  |
2 |
Tier 2 |
25% | 25% | P |
AMINOSYN II 4.25% M/D10W IV  |
2 |
Tier 2 |
25% | 25% | P |
AMINOSYN II 4.25% W/ELEC DW  |
2 |
Tier 2 |
25% | 25% | P |
AMINOSYN II 4.25%-D25W IV  |
2 |
Tier 2 |
25% | 25% | P |
AMINOSYN II 5% IN D25W IV  |
2 |
Tier 2 |
25% | 25% | P |
AMINOSYN II 7% IV SOLUTION  |
2 |
Tier 2 |
25% | 25% | P |
AMINOSYN II 8.5% ELECTROLYT  |
1 |
Tier 1 |
25% | 25% | P |
AMINOSYN II 8.5% IV SOLUTION  |
2 |
Tier 2 |
25% | 25% | P |
AMINOSYN M 3.5% IV SOLUTION  |
2 |
Tier 2 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN PF INJECTION  |
2 |
Tier 2 |
25% | 25% | P |
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%  |
1 |
Tier 1 |
25% | 25% | P |
AMINOSYN-HBC 7% IV SOLUTION  |
2 |
Tier 2 |
25% | 25% | P |
AMINOSYN-HF 8% IV SOLUTION  |
1 |
Tier 1 |
25% | 25% | P |
AMINOSYN-PF 7% IV SOLUTION  |
2 |
Tier 2 |
25% | 25% | P |
AMIODARONE HCL 200MG TABLET (60 CT)  |
1 |
Tier 1 |
25% | 25% | None |
AMIODARONE HCL 400MG TABLET  |
1 |
Tier 1 |
25% | 25% | None |
AMITIZA 24 MCG CAPSULES  |
2 |
Tier 2 |
25% | 25% | S Q:60 /30Days |
AMITIZA 8MCG CAPSULE  |
2 |
Tier 2 |
25% | 25% | S Q:60 /30Days |
AMITRIP/PERPHEN 10-2 TABLET  |
1 |
Tier 1 |
25% | 25% | None |
AMITRIP/PERPHEN 10-4 TABLET  |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIP/PERPHEN 25-2 TABLET  |
1 |
Tier 1 |
25% | 25% | None |
AMITRIP/PERPHEN 25-4 TABLET  |
1 |
Tier 1 |
25% | 25% | None |
AMITRIP/PERPHEN 50-4 TABLET  |
1 |
Tier 1 |
25% | 25% | None |
AMITRIPTYLINE HCL 100MG TABLET  |
1 |
Tier 1 |
25% | 25% | None |
AMITRIPTYLINE HCL 10MG TABLET  |
1 |
Tier 1 |
25% | 25% | None |
AMITRIPTYLINE HCL 150MG TABLET (100 CT)  |
1 |
Tier 1 |
25% | 25% | None |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)  |
1 |
Tier 1 |
25% | 25% | None |
AMITRIPTYLINE HCL 50MG TABLET  |
1 |
Tier 1 |
25% | 25% | None |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)  |
1 |
Tier 1 |
25% | 25% | None |
AMLODIPINE BESYLATE 10MG TABLET (90 CT)  |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)  |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE BESYLATE 5MG TABLET (90 CT)  |
1 |
Tier 1 |
25% | 25% | Q:45 /30Days |
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE  |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE  |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE  |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE  |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
AMMONIUM LACTATE 12% CREAM  |
1 |
Tier 1 |
25% | 25% | None |
AMMONIUM LACTATE 12% LOTION  |
1 |
Tier 1 |
25% | 25% | None |
AMMONIUM LACTATE 12% LOTION  |
1 |
Tier 1 |
25% | 25% | None |
AMNESTEEM 10MG CAPSULE  |
1 |
Tier 1 |
25% | 25% | P |
AMNESTEEM 20MG CAPSULE  |
1 |
Tier 1 |
25% | 25% | P |
AMNESTEEM 40MG CAPSULE  |
1 |
Tier 1 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOCLAN 200-28.5/5 SUSPENSION RECONSTITUTED ORAL  |
1 |
Tier 1 |
25% | 25% | None |
AMOCLAN 400-57MG/5 SUSPENSION RECONSTITUTED ORAL  |
1 |
Tier 1 |
25% | 25% | None |
AMOX TR-K CLV 200-28.5 CHEW  |
1 |
Tier 1 |
25% | 25% | None |
AMOX TR-K CLV 200-28.5/5 SU  |
1 |
Tier 1 |
25% | 25% | None |
AMOX TR-K CLV 400-57 CHW TABLET  |
1 |
Tier 1 |
25% | 25% | None |
AMOX TR-K CLV 400-57/5 SUSP  |
1 |
Tier 1 |
25% | 25% | None |
AMOX TR-K CLV 500-125MG TABLET  |
1 |
Tier 1 |
25% | 25% | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL  |
1 |
Tier 1 |
25% | 25% | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE  |
1 |
Tier 1 |
25% | 25% | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET  |
1 |
Tier 1 |
25% | 25% | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE  |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL  |
1 |
Tier 1 |
25% | 25% | None |
AMOX TR-POTASSIUM CLAVULANATE 500-125MG TABLET  |
1 |
Tier 1 |
25% | 25% | None |
AMOXAPINE 100MG TABLET  |
2 |
Tier 2 |
25% | 25% | None |
AMOXAPINE 150MG TABLET  |
2 |
Tier 2 |
25% | 25% | None |
AMOXAPINE 25MG TABLET  |
2 |
Tier 2 |
25% | 25% | None |
AMOXAPINE 50MG TABLET  |
2 |
Tier 2 |
25% | 25% | None |
AMOXICIILIN CLAVULNATE POTASSIUM FOR ORAL SUSPENSION  |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN 125MG TABLET CHEW  |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN 200MG TABLET CHEW  |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN 250MG CAPSULE  |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN 400MG TABLET CHEW  |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN 500MG CAPSULE  |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN 500MG TABLET (100 CT)  |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN 875MG TABLET  |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT  |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN CLAVULANATE POTASSIUM TABLET 875-125MG 1 BLPK  |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT  |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL  |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT  |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL  |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT)  |
1 |
Tier 1 |
25% | 25% | None |
AMOXIL 250MG/5ML SUSPENSION  |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXIL 500MG CAPSULE  |
1 |
Tier 1 |
25% | 25% | None |
AMOXIL 50MG/ML PED DROPS  |
2 |
Tier 2 |
25% | 25% | None |
AMPHET ASP/ AMPHET/ D-AMPHET 10MG TABLET  |
1 |
Tier 1 |
25% | 25% | None |
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET  |
1 |
Tier 1 |
25% | 25% | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET  |
1 |
Tier 1 |
25% | 25% | None |
AMPHETAMINE SALT COMBO 15MG TABLET  |
1 |
Tier 1 |
25% | 25% | None |
AMPHETAMINE SALT COMBO 30MG TABLET  |
1 |
Tier 1 |
25% | 25% | None |
AMPHETAMINE SALT COMBO 7.5MG TABLET  |
1 |
Tier 1 |
25% | 25% | None |
AMPHETAMINE SALTS 20MG TABLET  |
1 |
Tier 1 |
25% | 25% | None |
AMPHETAMINE SALTS 30MG TABLET  |
1 |
Tier 1 |
25% | 25% | None |
AMPHOTERICIN B FOR INJECTION 50 MG  |
1 |
Tier 1 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN AND SULBACTAM FOR INJECTION 1-0.5 10 VIAL VIAL  |
1 |
Tier 1 |
25% | 25% | None |
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL  |
1 |
Tier 1 |
25% | 25% | None |
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL  |
1 |
Tier 1 |
25% | 25% | None |
AMPICILLIN FOR INJECTION  |
1 |
Tier 1 |
25% | 25% | None |
AMPICILLIN FOR INJECTION 1GM VIAL  |
1 |
Tier 1 |
25% | 25% | None |
AMPICILLIN FOR INJECTION 2GM/ML 10 VIAL  |
1 |
Tier 1 |
25% | 25% | None |
AMPICILLIN FOR INJECTION 500MG VIAL  |
1 |
Tier 1 |
25% | 25% | None |
AMPICILLIN FOR INJECTION POWDER  |
2 |
Tier 2 |
25% | 25% | None |
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL  |
2 |
Tier 2 |
25% | 25% | None |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT  |
1 |
Tier 1 |
25% | 25% | None |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT  |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML  |
1 |
Tier 1 |
25% | 25% | None |
AMPICILLIN SODIUM STERILE 2 GM/VIAL  |
1 |
Tier 1 |
25% | 25% | None |
AMPICILLIN TR 250MG CAPSULE  |
1 |
Tier 1 |
25% | 25% | None |
AMPICILLIN TR 500MG CAPSULE  |
1 |
Tier 1 |
25% | 25% | None |
ANADROL-50 50MG TABLET (100 CT)  |
2 |
Tier 2 |
25% | 25% | P |
ANAGRELIDE HCL 0.5MG CAPSULE  |
1 |
Tier 1 |
25% | 25% | None |
ANAGRELIDE HCL 1MG CAPSULE  |
1 |
Tier 1 |
25% | 25% | None |
ANCOBON 250MG CAPSULE  |
2 |
Tier 2 |
25% | 25% | None |
ANCOBON 500MG CAPSULE  |
2 |
Tier 2 |
25% | 25% | None |
ANDRODERM 2.5MG/24HR PATCH  |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ANDRODERM 5MG/24HR PATCH  |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANDROID 10MG CAPSULE  |
2 |
Tier 2 |
25% | 25% | None |
ANTABUSE 250MG TABLET  |
2 |
Tier 2 |
25% | 25% | None |
ANTARA 130MG CAPSULE  |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ANTARA 43MG CAPSULE  |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
APOKYN FOR INJECTION 30MG 5 CTG  |
3 |
Tier 3 |
25% | 25% | None |
APRI 0.15-0.03 TABLET  |
1 |
Tier 1 |
25% | 25% | Q:28 /28Days |
APRISO CP24  |
2 |
Tier 2 |
25% | 25% | Q:120 /30Days |
APTIVUS 250MG CAPSULE  |
3 |
Tier 3 |
25% | 25% | None |
ARALAST 1000MG VIAL  |
3 |
Tier 3 |
25% | 25% | P |
ARALAST 500MG VIAL  |
3 |
Tier 3 |
25% | 25% | P |
ARANELLE 7-9-5 TABLET  |
1 |
Tier 1 |
25% | 25% | Q:28 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP 100MCG/ML VIAL  |
3 |
Tier 3 |
25% | 25% | P Q:8 /28Days |
ARANESP 200MCG/0.4ML SYRINGE  |
3 |
Tier 3 |
25% | 25% | P Q:3 /28Days |
ARANESP 200MCG/ML VIAL  |
3 |
Tier 3 |
25% | 25% | P Q:8 /28Days |
ARANESP 25MCG/ML VIAL  |
2 |
Tier 2 |
25% | 25% | P Q:8 /28Days |
ARANESP 300MCG/ML VIAL  |
3 |
Tier 3 |
25% | 25% | P Q:4 /28Days |
ARANESP 500MCG/1ML SYRINGE  |
3 |
Tier 3 |
25% | 25% | P Q:4 /28Days |
ARANESP 60MCG/ML VIAL  |
3 |
Tier 3 |
25% | 25% | P Q:8 /28Days |
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR  |
3 |
Tier 3 |
25% | 25% | P Q:2 /28Days |
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR  |
2 |
Tier 2 |
25% | 25% | P Q:3 /28Days |
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR  |
3 |
Tier 3 |
25% | 25% | P Q:3 /28Days |
ARANESP SINGLE USE PREFILLED AUTOINJECTOR SOLUTION 100MCG/.5ML  |
3 |
Tier 3 |
25% | 25% | P Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP SINGLE USE PREFILLED SURECLICK AUTOINJECTOR SOLUTION 500MCG/ML  |
3 |
Tier 3 |
25% | 25% | P Q:2 /28Days |
ARANESP SINGLE USE PREFILLED SURECLIK AUTOINJECTOR 60MCG/.3ML  |
3 |
Tier 3 |
25% | 25% | P Q:2 /28Days |
ARANESP SINGLE USE VIAL 150MCG 4 X 150MCG/ 0.75ML VIALSD  |
3 |
Tier 3 |
25% | 25% | P Q:8 /28Days |
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD  |
3 |
Tier 3 |
25% | 25% | P Q:8 /28Days |
ARICEPT 10MG TABLET  |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ARICEPT 5MG TABLET  |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ARICEPT ODT 10MG TABLET  |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ARICEPT ODT 5MG TABLET  |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ARIMIDEX 1MG TABLET  |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ARIXTRA 10MG SYRINGE  |
2 |
Tier 2 |
25% | 25% | Q:24 /30Days |
ARIXTRA 2.5MG SYRINGE  |
2 |
Tier 2 |
25% | 25% | Q:15 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARIXTRA 5MG SYRINGE  |
2 |
Tier 2 |
25% | 25% | Q:12 /30Days |
ARIXTRA 7.5MG SYRINGE  |
2 |
Tier 2 |
25% | 25% | Q:18 /30Days |
AROMASIN 25MG TABLET  |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
ASACOL 400MG TABLET EC  |
2 |
Tier 2 |
25% | 25% | None |
ASCOMP W/CODEINE 30-50-325 CAPSULE  |
1 |
Tier 1 |
25% | 25% | Q:180 /30Days |
ASMANEX 220MCG(14) AEROSOL POWDER BREATH ACTIVATED  |
2 |
Tier 2 |
25% | 25% | Q:240 /14Days |
ASMANEX TWISTHALER 220MCG #120  |
2 |
Tier 2 |
25% | 25% | Q:240 /30Days |
ASMANEX TWISTHALER 220MCG #30  |
2 |
Tier 2 |
25% | 25% | Q:240 /30Days |
ASMANEX TWISTHALER 220MCG #60  |
2 |
Tier 2 |
25% | 25% | Q:240 /30Days |
ASTELIN 137MCG AEROSOL SPRAY W/PUMP  |
2 |
Tier 2 |
25% | 25% | Q:30 /25Days |
ATAMET  |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATENOLOL 25MG TABLET (100 CT)  |
1 |
Tier 1 |
25% | 25% | None |
ATENOLOL TABLET 100MG (100 CT)  |
1 |
Tier 1 |
25% | 25% | None |
ATENOLOL TABLET USP 50MG (100 CT)  |
1 |
Tier 1 |
25% | 25% | None |
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)  |
1 |
Tier 1 |
25% | 25% | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)  |
1 |
Tier 1 |
25% | 25% | None |
ATRIPLA TABLET 600MG/200MG  |
3 |
Tier 3 |
25% | 25% | Q:30 /30Days |
ATROVENT HFA AER 17MCG  |
2 |
Tier 2 |
25% | 25% | Q:25 /30Days |
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML  |
2 |
Tier 2 |
25% | 25% | None |
AUGMENTIN 125 SUSPENSION  |
2 |
Tier 2 |
25% | 25% | None |
AUGMENTIN 250 SUSPENSION  |
2 |
Tier 2 |
25% | 25% | None |
AUGMENTIN 250 TABLET CHEW  |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AUGMENTIN XR 1000-62.5 TABLET  |
2 |
Tier 2 |
25% | 25% | None |
AVIANE 0.1-0.02 TABLET  |
1 |
Tier 1 |
25% | 25% | Q:28 /28Days |
AVINZA 120MG CAPSULE MULTIPHASIC RELEASE 24 HR  |
2 |
Tier 2 |
25% | 25% | S Q:300 /30Days |
AVINZA 30MG CAPSULE MULTIPHASIC RELEASE 24 HR  |
2 |
Tier 2 |
25% | 25% | S Q:30 /30Days |
AVINZA 60MG CAPSULE MULTIPHASIC RELEASE 24 HR  |
2 |
Tier 2 |
25% | 25% | S Q:30 /30Days |
AVINZA 90MG CAPSULE MULTIPHASIC RELEASE 24 HR  |
2 |
Tier 2 |
25% | 25% | S Q:30 /30Days |
AVINZA CAPSULES EXTENDED RELEASE 45MG 100 BOTPL  |
2 |
Tier 2 |
25% | 25% | S Q:30 /30Days |
AVINZA CAPSULES EXTENDED RELEASE 75MG 100 BOTPL  |
2 |
Tier 2 |
25% | 25% | S Q:30 /30Days |
AVITA 0.025% CREAM  |
1 |
Tier 1 |
25% | 25% | None |
AVODART 0.5MG SOFTGEL  |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
AVONEX ADMIN PACK 30MCG SYR  |
3 |
Tier 3 |
25% | 25% | P Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVONEX ADMIN PACK 30MCG VL  |
3 |
Tier 3 |
25% | 25% | P Q:4 /28Days |
AZACTAM 1GM VIAL  |
3 |
Tier 3 |
25% | 25% | None |
AZACTAM 2GM VIAL  |
3 |
Tier 3 |
25% | 25% | None |
AZACTAM INJECTION 1GM 50ML BAG  |
3 |
Tier 3 |
25% | 25% | None |
AZACTAM/ISO-OSMOT 2GM/50ML  |
3 |
Tier 3 |
25% | 25% | None |
AZASITE 1% DROPS  |
2 |
Tier 2 |
25% | 25% | Q:2 /30Days |
AZATHIOPRINE 50MG TABLET  |
1 |
Tier 1 |
25% | 25% | P |
AZILECT 0.5MG TABLET  |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
AZILECT 1MG TABLET  |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL  |
1 |
Tier 1 |
25% | 25% | None |
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL  |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZITHROMYCIN 250MG TABLET (30 CT)  |
1 |
Tier 1 |
25% | 25% | None |
AZITHROMYCIN 500MG TABLET (30 CT)  |
1 |
Tier 1 |
25% | 25% | None |
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD  |
1 |
Tier 1 |
25% | 25% | None |
AZITHROMYCIN TABLET 600MG (30 CT)  |
1 |
Tier 1 |
25% | 25% | None |
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT  |
2 |
Tier 2 |
25% | 25% | Q:10 /30Days |