2010 Medicare Part D Plan Formulary Information |
HealthPartners Freedom III Std Plus Rx (Co (H2462-014-0)
Benefit Details
|
The HealthPartners Freedom III Std Plus Rx (Co (H2462-014-0) Formulary Drugs Starting with the Letter A in Statewide County, MN: CMS MA Region 19 which includes: MN
|
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 |
ABILIFY 10MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ABILIFY 15MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ABILIFY 1MG/ML SOLUTION |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ABILIFY 20MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ABILIFY 2MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ABILIFY 30MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ABILIFY 5MG TABLET (OTSUKA) |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ABILIFY DISCMELT 10MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | P |
ABILIFY DISCMELT 15MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | P |
ABILIFY INJ 9.75MG |
2 |
Tier 2 |
$40.00 | $80.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACARBOSE 100MG TABLET S |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ACARBOSE 25MG TABLET S |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ACARBOSE 50MG TABLET S |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD |
1* |
Tier 1 |
$10.00 | $20.00 | Q:166 /1Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | Q:12 /1Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | Q:12 /1Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | Q:12 /1Days |
ACETASOL HC OTIC SOLUTION |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ACETASOL HC SOLUTION 10ML 10 ML BOT |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ACETAZOLAMIDE 125MG TABLET |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ACETIC ACID 2% SOLUTION NON-ORAL |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ACETIC ACID IN AQUEOUS ALUMINUM ACETATE OTIC SOLUTION 2% 60 ML BOT |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ACETYLCYSTEINE 10% VIAL |
1* |
Tier 1 |
$10.00 | $20.00 | P |
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN |
1* |
Tier 1 |
$10.00 | $20.00 | P |
ACTHIB VACCINE VIAL 10-24UNT/5ML |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ACTIMMUNE SOLUTION FOR INJECTION 100MCG |
3* |
Tier 3 |
25% | N/A | P |
ACTONEL 150MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | S |
ACTONEL 30MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | S |
ACTONEL 35MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | S |
ACTONEL 5MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTONEL 75MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | S |
ACTONEL WITH CALCIUM TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | S |
ACTOPLUS MET 15MG/500MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | S |
ACTOPLUS MET 15MG/850MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | S |
ACTOS 15MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | S |
ACTOS 30MG TABLET (500 CT) |
2 |
Tier 2 |
$40.00 | $80.00 | S |
ACTOS 45MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | S |
ACULAR 0.5% EYE DROPS |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ACULAR LS 0.4% OPHTH SOL |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ACYCLOVIR 200MG CAPSULE (1000 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ACYCLOVIR 200MG/5ML SUSP |
1* |
Tier 1 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACYCLOVIR 400MG TABLET (100 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ACYCLOVIR TABLET USP 800MG (100 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ADACEL VIAL 2UNT/5UNT |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ADAGEN 250U/ML VIAL |
3* |
Tier 3 |
25% | N/A | P |
ADVAIR DISKU MIS 100/50 |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ADVAIR DISKU MIS 250/50 |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ADVAIR DISKU MIS 500/50 |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ADVAIR HFA INHALER 230;21MCG;MCG |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
2 |
Tier 2 |
$40.00 | $80.00 | None |
AFEDITAB CR 30MG TABLET SA |
1* |
Tier 1 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AFEDITAB CR 60MG TABLET SA |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AGGRENOX 25-200MG CAPSULE |
2 |
Tier 2 |
$40.00 | $80.00 | None |
AK-CON 0.1% EYE DROPS |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AK-POLY-BAC EYE OINTMENT 500UNT/1000UNT |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AKTOB 0.3% EYE DROPS |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ALAMAST 0.1% DROPS |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ALBENZA 200MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
1* |
Tier 1 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ALBUTEROL TABLET 4MG (500 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ALDACTAZIDE 50/50 TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ALDARA IMIQUIMOD CREAM 5% 24 PKT X 250 MG CRTN |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ALDURAZYME 2.9MG/5ML VIAL |
3* |
Tier 3 |
25% | N/A | P |
ALENDRONATE SODIUM 10MG TABLET |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ALENDRONATE SODIUM 40MG TABLET |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ALENDRONATE SODIUM 5MG TABLET |
1* |
Tier 1 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALENDRONATE SODIUM 70MG TABLET 4 BLPK |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ALENDRONATE SODIUM TABLET 35MG 20 CRTN |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ALINIA 100MG/5ML SUSPENSION |
2 |
Tier 2 |
$40.00 | $80.00 | S |
ALINIA 500MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | S |
ALLEGRA 30MG/5ML SUSPENSION ORAL |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ALLOPURINOL TABLET 300MG (1000 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ALLOPURINOL TABLET USP 100MG (1000 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ALPHAGAN P 0.1% DROPS |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ALPHAGAN P 0.15% EYE DROPS |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ALREX 0.2% EYE DROPS |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ALTABAX 1% OINTMENT |
2 |
Tier 2 |
$40.00 | $80.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMANTADINE 100MG CAPSULE |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMANTADINE 100MG TABLET |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMBIEN CR 12.5MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | S |
AMBIEN CR 6.25MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | S |
AMCINONIDE 0.1% CREAM |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMCINONIDE 0.1% LOTION |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMCINONIDE 0.1% OINTMENT 60GM TUBE |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMIKACIN 250MG/ML VIAL |
1* |
Tier 1 |
$10.00 | $20.00 | P |
AMIKACIN 50MG/ML VIAL |
1* |
Tier 1 |
$10.00 | $20.00 | P |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT |
1* |
Tier 1 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOPHYLLINE 100MG TABLET |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMINOPHYLLINE 200MG TABLET (1000 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMIODARONE HCL 200MG TABLET (60 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMIODARONE HCL 400MG TABLET |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMITIZA 8MCG CAPSULE |
2 |
Tier 2 |
$40.00 | $80.00 | P |
AMITIZA CAPSULES 24MCG 60 CAP BOT |
2 |
Tier 2 |
$40.00 | $80.00 | P |
AMITRIPTYLINE HCL 100MG TABLET |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMITRIPTYLINE HCL 10MG TABLET |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMITRIPTYLINE HCL 150MG TABLET (100 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMMONIUM CHLORIDE 5 MEQ/ML |
1* |
Tier 1 |
$10.00 | $20.00 | P |
AMMONIUM LACTATE 12% CREAM |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMMONIUM LACTATE 12% LOTION |
1* |
Tier 1 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMNESTEEM 10MG CAPSULE |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMNESTEEM 20MG CAPSULE |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMNESTEEM 40MG CAPSULE |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMOCLAN 200-28.5/5 SUSPENSION RECONSTITUTED ORAL |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMOCLAN 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 500-125MG TABLET |
1* |
Tier 1 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXAPINE 100MG TABLET |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMOXAPINE 150MG TABLET |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMOXAPINE 25MG TABLET |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMOXAPINE 50MG TABLET |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMOXICILLIN 125MG TABLET CHEW |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMOXICILLIN 200MG TABLET CHEW |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMOXICILLIN 250MG CAPSULE |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMOXICILLIN 400MG TABLET CHEW |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMOXICILLIN 500MG CAPSULE |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMOXICILLIN 500MG TABLET (100 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMOXICILLIN 875MG TABLET |
1* |
Tier 1 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMPHETAMINE SALT COMBO 15MG TABLET |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMPHETAMINE SALT COMBO 30MG TABLET |
1* |
Tier 1 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMPHETAMINE SALTS 20MG TABLET |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMPHOTERICIN B FOR INJECTION 50 MG |
1* |
Tier 1 |
$10.00 | $20.00 | P |
AMPICILLIN CAPSULES 250MG 100 BOT |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMPICILLIN FOR INJECTION POWDER |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ANADROL-50 50MG TABLET (100 CT) |
2 |
Tier 2 |
$40.00 | $80.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANAGRELIDE HCL 0.5MG CAPSULE |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ANAGRELIDE HCL 1MG CAPSULE |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ANCOBON 250MG CAPSULE |
2 |
Tier 2 |
$40.00 | $80.00 | P |
ANCOBON 500MG CAPSULE |
2 |
Tier 2 |
$40.00 | $80.00 | P |
ANDRODERM 2.5MG/24HR PATCH |
2 |
Tier 2 |
$40.00 | $80.00 | P |
ANDRODERM 5MG/24HR PATCH |
2 |
Tier 2 |
$40.00 | $80.00 | P |
ANDROGEL 1%(50MG) GEL PACKET |
2 |
Tier 2 |
$40.00 | $80.00 | P |
ANDROID 10MG CAPSULE |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ANTABUSE 250MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ANTABUSE 500MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ANUSOL-HC 2.5% CREAM |
1* |
Tier 1 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APOKYN FOR INJECTION 30MG 5 CTG |
3* |
Tier 3 |
25% | N/A | P |
APRI 0.15-0.03 TABLET |
1* |
Tier 1 |
$10.00 | $20.00 | None |
APTIVUS 250MG CAPSULE |
2 |
Tier 2 |
$40.00 | $80.00 | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ARANELLE 7-9-5 TABLET |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ARANESP 100MCG/ML VIAL |
2 |
Tier 2 |
$40.00 | $80.00 | P |
ARANESP 200MCG/0.4ML SYRINGE |
2 |
Tier 2 |
$40.00 | $80.00 | P |
ARANESP 200MCG/ML VIAL |
2 |
Tier 2 |
$40.00 | $80.00 | P |
ARANESP 25MCG/ML VIAL |
2 |
Tier 2 |
$40.00 | $80.00 | P |
ARANESP 300MCG/ML VIAL |
2 |
Tier 2 |
$40.00 | $80.00 | P |
ARANESP 500MCG/1ML SYRINGE |
2 |
Tier 2 |
$40.00 | $80.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP 60MCG/ML VIAL |
2 |
Tier 2 |
$40.00 | $80.00 | P |
ARANESP PREFILLED SYRINGE SINGLE USE 100MCG/0.5ML 1 SYR |
2 |
Tier 2 |
$40.00 | $80.00 | P |
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR |
2 |
Tier 2 |
$40.00 | $80.00 | P |
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR |
2 |
Tier 2 |
$40.00 | $80.00 | P |
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR |
2 |
Tier 2 |
$40.00 | $80.00 | P |
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR |
2 |
Tier 2 |
$40.00 | $80.00 | P |
ARANESP PREFILLED SYRINGE SINGLE USE 60MCG/0.3ML 60MCG/ 0.3ML SYR |
2 |
Tier 2 |
$40.00 | $80.00 | P |
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD |
2 |
Tier 2 |
$40.00 | $80.00 | P |
ARICEPT 10MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ARICEPT 5MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ARICEPT ODT 10MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARICEPT ODT 5MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ARIMIDEX 1MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ARIXTRA 10MG SYRINGE |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ARIXTRA 2.5MG SYRINGE |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ARIXTRA 5MG SYRINGE |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ARIXTRA 7.5MG SYRINGE |
2 |
Tier 2 |
$40.00 | $80.00 | None |
AROMASIN 25MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ASACOL 400MG TABLET EC |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ASACOL HD DELAYED RELEASE TABLETS 800MG 180 BOT |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ASMANEX TWISTHALER 220MCG #120 |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ASMANEX TWISTHALER 220MCG #30 |
2 |
Tier 2 |
$40.00 | $80.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ASMANEX TWISTHALER 220MCG #60 |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ASTELIN 137MCG AEROSOL SPRAY W/PUMP |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ATENOLOL 25MG TABLET (100 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ATENOLOL TABLET USP 50MG (100 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ATENOLOL TABLETS USP 100MG 1 BLPK |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | None |
ATGAM 50MG/ML AMPUL |
3* |
Tier 3 |
25% | N/A | P |
ATRIPLA TABLET 600MG/200MG |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ATROVENT HFA AER 17MCG |
2 |
Tier 2 |
$40.00 | $80.00 | None |
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML |
2 |
Tier 2 |
$40.00 | $80.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AUGMENTIN 125 SUSPENSION |
2 |
Tier 2 |
$40.00 | $80.00 | None |
AUGMENTIN 250 SUSPENSION |
2 |
Tier 2 |
$40.00 | $80.00 | None |
AUGMENTIN TABLETS COMBO |
2 |
Tier 2 |
$40.00 | $80.00 | None |
AVALIDE 150-12.5MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | S Q:45 /30Days |
AVALIDE 300-12.5MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | S Q:45 /30Days |
AVALIDE 300-25MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | S Q:45 /30Days |
AVAPRO 150MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | S Q:45 /30Days |
AVAPRO 300MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | S Q:45 /30Days |
AVAPRO 75MG TABLET (30 CT) |
2 |
Tier 2 |
$40.00 | $80.00 | S Q:45 /30Days |
AVELOX 400MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | None |
AVELOX ABC PACK 400MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVIANE 0.1-0.02 TABLET |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AVODART 0.5MG SOFTGEL |
2 |
Tier 2 |
$40.00 | $80.00 | None |
AVONEX ADMIN PACK 30MCG SYR |
3* |
Tier 3 |
25% | N/A | S |
AVONEX ADMIN PACK 30MCG VL |
3* |
Tier 3 |
25% | N/A | S |
AZASAN 100MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | P |
AZASAN 75MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | P |
AZASITE 1% DROPS |
2 |
Tier 2 |
$40.00 | $80.00 | S |
AZATHIOPRINE 50MG TABLET |
1* |
Tier 1 |
$10.00 | $20.00 | P |
AZELEX 20% CREAM 30GM TUBE |
2 |
Tier 2 |
$40.00 | $80.00 | None |
AZILECT 0.5MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | None |
AZILECT 1MG TABLET |
2 |
Tier 2 |
$40.00 | $80.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AZITHROMYCIN 250MG TABLET (30 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AZITHROMYCIN 500MG TABLET (30 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AZITHROMYCIN TABLET 600MG (30 CT) |
1* |
Tier 1 |
$10.00 | $20.00 | None |
AZMACORT INHALATION AEROSOL .1MG/1IHL 20 GM CSTR |
2 |
Tier 2 |
$40.00 | $80.00 | None |
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT |
2 |
Tier 2 |
$40.00 | $80.00 | None |