2010 Medicare Part D Plan Formulary Information |
SecureBlue (HMO) (H2425-001-0)
Benefit Details
|
The SecureBlue (HMO) (H2425-001-0) Formulary Drugs Starting with the Letter C in Kandi County, MN: CMS MA Region 19 which includes: MN
|
Drugs Starting with Letter C
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
CABERGOLINE 0.5MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CALCIPOTRIENE TOPICAL SOLUTION |
1 |
Tier 1 |
N/A | N/A | None |
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY |
1 |
Tier 1 |
N/A | N/A | None |
CALCITRIOL 0.25MCG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
CALCITRIOL 0.5MCG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
CALCITRIOL 1MCG/ML SOLUTION ORAL |
1 |
Tier 1 |
N/A | N/A | None |
CALCITRIOL INJECTION SOLUTION 1MCG 50 X 01ML AMP |
1 |
Tier 1 |
N/A | N/A | None |
CALCIUM ACETATE CAPSULE 667 MG |
1 |
Tier 1 |
N/A | N/A | None |
CAMILA 0.35MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CAPTOPRIL 100MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAPTOPRIL 12.5MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CAPTOPRIL 25MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CAPTOPRIL 50MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CAPTOPRIL/HCTZ 25/15 TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CAPTOPRIL/HCTZ 25/25 TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CAPTOPRIL/HCTZ 50/15 TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CAPTOPRIL/HCTZ 50/25 TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CARBAMAZEPINE 100MG/5ML SUSPENSION ORAL |
1 |
Tier 1 |
N/A | N/A | None |
CARBAMAZEPINE EXTENDED RELEASE TABLETS 200MG |
1 |
Tier 1 |
N/A | N/A | None |
CARBAMAZEPINE EXTENDED RELEASE TABLETS 400MG |
1 |
Tier 1 |
N/A | N/A | None |
CARBAMAZEPINE TABLET CHEWABLE 100MG (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARBAMAZEPINE TABLET USP 200MG (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CARBIDOPA-LEVODOPA 25MG-100MG TABLET SA |
1 |
Tier 1 |
N/A | N/A | None |
CARBIDOPA-LEVODOPA 50MG-200MG TABLET SA |
1 |
Tier 1 |
N/A | N/A | None |
CARBIDOPA/LEVO 10/100 TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CARBIDOPA/LEVO 25/100 TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CARBIDOPA/LEVO 25/250 TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CARBINOXAMINE MALEATE SOLUTION 4MG/5ML 16 OZ BOT |
1 |
Tier 1 |
N/A | N/A | None |
CARBINOXAMINE MALEATE TABLETS 4MG 100 BOT |
1 |
Tier 1 |
N/A | N/A | None |
CARBOPLATIN AQUEOUS SOLUTION INJECTION 150MG 15ML VIAL |
1 |
Tier 1 |
N/A | N/A | None |
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT |
1 |
Tier 1 |
N/A | N/A | None |
CARTIA XT 120MG CAPSULE SA |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARTIA XT 180MG CAPSULE SA |
1 |
Tier 1 |
N/A | N/A | None |
CARTIA XT 240MG CAPSULE SA |
1 |
Tier 1 |
N/A | N/A | None |
CARTIA XT 300MG CAPSULE SR 24 HR |
1 |
Tier 1 |
N/A | N/A | None |
CARVEDILOL 12.5MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CARVEDILOL 25MG TABLET (500 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CARVEDILOL 3.125MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CARVEDILOL 6.25MG TABLET (500 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CEFACLOR CAPSULES USP 250MG (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CEFACLOR CAPSULES USP 500MG (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CEFADROXIL 1G TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CEFADROXIL 500MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFADROXIL 500MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
N/A | N/A | None |
CEFADROXIL FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Tier 1 |
N/A | N/A | None |
CEFAZOLIN 20GM BULK VIAL |
1 |
Tier 1 |
N/A | N/A | None |
CEFAZOLIN FOR INJECTION |
1 |
Tier 1 |
N/A | N/A | None |
CEFAZOLIN FOR INJECTION 1MG 25 VIALGL |
1 |
Tier 1 |
N/A | N/A | None |
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
N/A | N/A | None |
CEFDINIR CAPSULES 300MG (60 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CEFEPIME HCL 2 GRAM VIAL |
1 |
Tier 1 |
N/A | N/A | None |
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL |
1 |
Tier 1 |
N/A | N/A | None |
CEFOTAXIME FOR INJECTION |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFOTAXIME FOR INJECTION 1GM 50 BOX VIALGL |
1 |
Tier 1 |
N/A | N/A | None |
CEFOTAXIME FOR INJECTION 2GM 25 VIAL |
1 |
Tier 1 |
N/A | N/A | None |
CEFOTAXIME FOR INJECTION 500MG 10 VIAL |
1 |
Tier 1 |
N/A | N/A | None |
CEFOXITIN FOR INJECTION 10GM 10 X 100ML VIAL |
1 |
Tier 1 |
N/A | N/A | None |
CEFOXITIN FOR INJECTION 1GM 25 X 20ML VIAL |
1 |
Tier 1 |
N/A | N/A | None |
CEFOXITIN FOR INJECTION 2GM 20ML VIAL |
1 |
Tier 1 |
N/A | N/A | None |
CEFPODOXIME PROXETIL 200MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 100MG 50ML BOT |
1 |
Tier 1 |
N/A | N/A | None |
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 50MG 50ML BOT |
1 |
Tier 1 |
N/A | N/A | None |
CEFPROZIL 250MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFPROZIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
N/A | N/A | None |
CEFPROZIL FOR ORAL SUSPENSION 125MG/5ML 75ML BOT |
1 |
Tier 1 |
N/A | N/A | None |
CEFPROZIL TABLETS 500MG 100 BOT |
1 |
Tier 1 |
N/A | N/A | None |
CEFTAZIDIME FOR INJECTION 1GM/VIAL 1 SINGLE VIAL VIAL |
1 |
Tier 1 |
N/A | N/A | None |
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN |
1 |
Tier 1 |
N/A | N/A | None |
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN |
1 |
Tier 1 |
N/A | N/A | None |
CEFTRIAXONE 10GM VIAL |
1 |
Tier 1 |
N/A | N/A | None |
CEFTRIAXONE FOR INJECTION 250MG BOX OF 10 VIALGL |
1 |
Tier 1 |
N/A | N/A | None |
CEFTRIAXONE FOR INJECTION 500MG BOX OF 10 VIALGL |
1 |
Tier 1 |
N/A | N/A | None |
CEFUROXIME 250MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CEFUROXIME AXETIL 125MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFUROXIME AXETIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
N/A | N/A | None |
CEFUROXIME AXETIL 500MG TABLET (20 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CEFUROXIME FOR INJECTION |
1 |
Tier 1 |
N/A | N/A | None |
CEFUROXIME FOR INJECTION |
1 |
Tier 1 |
N/A | N/A | None |
CEFUROXIME FOR INJECTION 7.5GM 10 X 7.5 VIALPHR |
1 |
Tier 1 |
N/A | N/A | None |
CEPHALEXIN 250MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
CEPHALEXIN 250MG/5ML ORAL SUSP |
1 |
Tier 1 |
N/A | N/A | None |
CEPHALEXIN CAPSULES 500MG (500 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CEPHALEXIN POWDER FOR SUSPENSION ORAL USP 125MG 200ML BOT |
1 |
Tier 1 |
N/A | N/A | None |
CESIA 7 DAYS X 3 TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLOROQUINE PH 500MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CHLOROQUINE PHOSPHATE 250MG TABLET (50 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CHLOROTHIAZIDE 250MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CHLOROTHIAZIDE 500MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CHLORPROMAZINE 100MG TABLET |
1 |
Tier 1 |
N/A | N/A | P |
CHLORPROMAZINE 10MG TABLET |
1 |
Tier 1 |
N/A | N/A | P |
CHLORPROMAZINE 25MG TABLET |
1 |
Tier 1 |
N/A | N/A | P |
CHLORPROMAZINE 50MG TABLET |
1 |
Tier 1 |
N/A | N/A | P |
CHLORPROMAZINE HCL 200MG TABLET |
1 |
Tier 1 |
N/A | N/A | P |
CHLORTHALIDONE 25MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CHLORTHALIDONE 50MG TABLET (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHOLESTYRAMINE LIGHT ORAL SUSP USP POWDER 4GM 210GM CAN |
1 |
Tier 1 |
N/A | N/A | None |
CHOLESTYRAMINE LIGHT ORAL SUSP USP POWDER 4GM 60 X 5 SINGLE DOSE CRTN |
1 |
Tier 1 |
N/A | N/A | None |
CHOLESTYRAMINE POWDER FOR ORAL SUSPENSION USP 4GM 60 X 9GM SINGLE DOSE CRTN |
1 |
Tier 1 |
N/A | N/A | None |
CHOLESTYRAMINE POWDER FOR ORAL SUSPENSION USP 4GM 378GM CAN |
1 |
Tier 1 |
N/A | N/A | None |
CHORIONIC GONAD 10000U VIAL |
1 |
Tier 1 |
N/A | N/A | None |
CICLOPIROX 0.77% CREAM |
1 |
Tier 1 |
N/A | N/A | None |
CICLOPIROX 0.77% GEL |
1 |
Tier 1 |
N/A | N/A | None |
CICLOPIROX 0.77% TOPICAL SUSPENSION |
1 |
Tier 1 |
N/A | N/A | None |
CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6ML BOT |
1 |
Tier 1 |
N/A | N/A | None |
CILOSTAZOL 50MG TABLET (60 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CILOSTAZOL TABLET 100MG (60 CT) |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIMETIDINE 150MG/ML VIAL |
1 |
Tier 1 |
N/A | N/A | None |
CIMETIDINE 200MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CIMETIDINE HCL 300MG/5ML SOL |
1 |
Tier 1 |
N/A | N/A | None |
CIMETIDINE TABLET USP 300MG (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CIMETIDINE TABLET USP 400MG (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CIMETIDINE TABLET USP 800MG (30 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CIPROFLOXACIN 10MG/ML VIAL |
1 |
Tier 1 |
N/A | N/A | None |
CIPROFLOXACIN 250MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CIPROFLOXACIN 500MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CIPROFLOXACIN ER 1000MG TABLET (30 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CIPROFLOXACIN ER 500MG TABLET (30 CT) |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIPROFLOXACIN HCL 0.3% DROPS |
1 |
Tier 1 |
N/A | N/A | None |
CIPROFLOXACIN TABLETS 750MG 100 BOT |
1 |
Tier 1 |
N/A | N/A | None |
CISPLATIN INJECTION 1MG |
1 |
Tier 1 |
N/A | N/A | None |
CITALOPRAM HBR 20MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL |
1 |
Tier 1 |
N/A | N/A | None |
CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT |
1 |
Tier 1 |
N/A | N/A | None |
CITOLOPRAM HBR 10MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CLARAVIS 10MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
CLARAVIS 20MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
CLARAVIS 30MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
CLARAVIS 40MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLARITHROMYCIN 250MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CLARITHROMYCIN 250MG/5ML. SUS. 100ML |
1 |
Tier 1 |
N/A | N/A | None |
CLARITHROMYCIN 500MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CLARITHROMYCIN ER 500MG TABLET (60 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CLARITHROMYCIN FOR ORAL SUSPENSION 125/5ML 125MG BOT |
1 |
Tier 1 |
N/A | N/A | None |
CLEMASTINE FUM 2.68MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CLEMASTINE FUMARATE 0.67MG/5ML SYRUP |
1 |
Tier 1 |
N/A | N/A | None |
CLINDAMYCIN 150MG/ML ADDVAN |
1 |
Tier 1 |
N/A | N/A | None |
CLINDAMYCIN HCL 150MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
CLINDAMYCIN HCL 300MG CAPS |
1 |
Tier 1 |
N/A | N/A | None |
CLINDAMYCIN PHOSP 1% LOTION |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINDAMYCIN PHOSPHATE 1% SOLUTION NON-ORAL |
1 |
Tier 1 |
N/A | N/A | None |
CLINDAMYCIN PHOSPHATE 2% CREAM WITH APPLICATOR |
1 |
Tier 1 |
N/A | N/A | None |
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE |
1 |
Tier 1 |
N/A | N/A | None |
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX |
1 |
Tier 1 |
N/A | N/A | None |
CLINISOL 15% SOLUTION |
1 |
Tier 1 |
N/A | N/A | P |
CLOBETASOL 0.05% OINTMENT |
1 |
Tier 1 |
N/A | N/A | None |
CLOBETASOL 0.05% SOLUTION |
1 |
Tier 1 |
N/A | N/A | None |
CLOBETASOL E 0.05% CREAM |
1 |
Tier 1 |
N/A | N/A | None |
CLOBETASOL PROPIONATE CRM 0.05% 15GM |
1 |
Tier 1 |
N/A | N/A | None |
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE |
1 |
Tier 1 |
N/A | N/A | None |
CLOMIPRAMINE HCL 25MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOMIPRAMINE HCL 50MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
CLOMIPRAMINE HCL 75MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
CLONIDINE HCL 0.2MG TABLET (500 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CLONIDINE HCL TABLET 0.1MG (500 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CLONIDINE HCL TABLET 0.3MG (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CLOTRIMAZOLE 1% CREAM |
1 |
Tier 1 |
N/A | N/A | None |
CLOTRIMAZOLE 10MG TROCHE |
1 |
Tier 1 |
N/A | N/A | None |
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION |
1 |
Tier 1 |
N/A | N/A | None |
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CREAM USP .5MG-10GM 45GM TUBE |
1 |
Tier 1 |
N/A | N/A | None |
CLOZAPINE 25MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | P Q:90 /30Days |
CLOZAPINE 50MG TABLET (500 CT) |
1 |
Tier 1 |
N/A | N/A | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOZAPINE TABLETS 100MG 100 BOT |
1 |
Tier 1 |
N/A | N/A | P Q:270 /30Days |
CO-GESIC 5/500 TABLET |
1 |
Tier 1 |
N/A | N/A | None |
COLESTIPOL HCL 1G TABLET |
1 |
Tier 1 |
N/A | N/A | None |
COLESTIPOL HCL 5G GRANULES |
1 |
Tier 1 |
N/A | N/A | None |
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE |
2 |
Tier 2 |
N/A | N/A | None |
COLOCORT 100MG ENEMA |
1 |
Tier 1 |
N/A | N/A | None |
COMBIGAN 0.2%-0.5% DROPS |
2 |
Tier 2 |
N/A | N/A | None |
COMBIVIR TABLET |
2 |
Tier 2 |
N/A | N/A | None |
COMPRO 25MG SUPPOSITORY |
1 |
Tier 1 |
N/A | N/A | None |
CONSTULOSE 10GM/15ML SYRUP |
1 |
Tier 1 |
N/A | N/A | None |
CORMAX 0.05% CREAM |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CORTISONE ACETATE 25MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CORTOMYCIN EAR SOLUTION |
1 |
Tier 1 |
N/A | N/A | None |
CORTOMYCIN EAR SUSPENSION |
1 |
Tier 1 |
N/A | N/A | None |
CRESTOR 10MG TABLET |
2 |
Tier 2 |
N/A | N/A | S Q:45 /30Days |
CRESTOR 20MG TABLET |
2 |
Tier 2 |
N/A | N/A | S Q:45 /30Days |
CRESTOR 40MG TABLET |
2 |
Tier 2 |
N/A | N/A | S Q:30 /30Days |
CRESTOR 5MG TABLET |
2 |
Tier 2 |
N/A | N/A | S Q:45 /30Days |
CROMOLYN SODIUM 4% 40MG 10ML BOT |
1 |
Tier 1 |
N/A | N/A | None |
CRYSELLE-28 TABLET 28 TABLET S |
1 |
Tier 1 |
N/A | N/A | None |
CUPRIMINE 125MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | None |
CUPRIMINE CAPSULES 250MG (100 CT) |
2 |
Tier 2 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CYCLOBENZAPRINE HCL 5MG TABLET (500 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CYCLOSPORINE 100MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | P |
CYCLOSPORINE 100MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | P |
CYCLOSPORINE 25MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | P |
CYCLOSPORINE 50MG/ML AMP |
1 |
Tier 1 |
N/A | N/A | P |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT |
1 |
Tier 1 |
N/A | N/A | P |
CYKLOKAPRON 100MG/ML AMPUL |
2 |
Tier 2 |
N/A | N/A | None |
CYTARABINE 500MG VIAL |
1 |
Tier 1 |
N/A | N/A | P |