2010 Medicare Part D Plan Formulary Information |
Liberty Health Advantage Dual Power - NYC (H3337-003-0)
Benefit Details
|
The Liberty Health Advantage Dual Power - NYC (H3337-003-0) Formulary Drugs Starting with the Letter C in Bronx County, NY: CMS MA Region 3 which includes: NY
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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 |
15% | 15% | None |
CALCITRIOL 0.25MCG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
CALCITRIOL 0.5MCG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
CALCITRIOL 1MCG/ML SOLUTION ORAL |
2 |
Tier 2 |
15% | 15% | None |
CALCIUM ACETATE CAPSULE 667 MG |
2 |
Tier 2 |
15% | 15% | None |
CAMILA 0.35MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
CAPTOPRIL 100MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CAPTOPRIL 12.5MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CAPTOPRIL 25MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CAPTOPRIL 50MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAPTOPRIL/HCTZ 25/15 TABLET |
1 |
Tier 1 |
15% | 15% | None |
CAPTOPRIL/HCTZ 25/25 TABLET |
1 |
Tier 1 |
15% | 15% | None |
CAPTOPRIL/HCTZ 50/15 TABLET |
1 |
Tier 1 |
15% | 15% | None |
CAPTOPRIL/HCTZ 50/25 TABLET |
1 |
Tier 1 |
15% | 15% | None |
CARBAMAZEPINE 100MG/5ML SUSPENSION ORAL |
1 |
Tier 1 |
15% | 15% | None |
CARBAMAZEPINE TABLET CHEWABLE 100MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
CARBAMAZEPINE TABLET USP 200MG (1000 CT) |
1 |
Tier 1 |
15% | 15% | None |
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT |
2 |
Tier 2 |
15% | 15% | None |
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;100MG;MG 100 BOT |
2 |
Tier 2 |
15% | 15% | None |
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;250MG;MG 100 BOT |
2 |
Tier 2 |
15% | 15% | None |
CARBIDOPA-LEVODOPA 25MG-100MG TABLET SA |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARBIDOPA-LEVODOPA 50MG-200MG TABLET SA |
1 |
Tier 1 |
15% | 15% | None |
CARBIDOPA/LEVO 10/100 TABLET |
1 |
Tier 1 |
15% | 15% | None |
CARBIDOPA/LEVO 25/100 TABLET |
1 |
Tier 1 |
15% | 15% | None |
CARBIDOPA/LEVO 25/250 TABLET |
1 |
Tier 1 |
15% | 15% | None |
CARISOPRODOL AND ASPIRIN TABLETS USP 325;200MG;MG 100 BOTPL |
1 |
Tier 1 |
15% | 15% | None |
CARISOPRODOL ASPIRIN AND CODEINE PHOSPHATE TABLETS USP 325;200;16MG;MG;MG 100 BOTPL |
1 |
Tier 1 |
15% | 15% | None |
CARISOPRODOL TABLET USP 350MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT |
2 |
Tier 2 |
15% | 15% | None |
CARTIA XT 120MG CAPSULE SA |
2 |
Tier 2 |
15% | 15% | None |
CARTIA XT 180MG CAPSULE SA |
2 |
Tier 2 |
15% | 15% | None |
CARTIA XT 240MG CAPSULE SA |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARTIA XT 300MG CAPSULE SR 24 HR |
2 |
Tier 2 |
15% | 15% | None |
CARVEDILOL 12.5MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
CARVEDILOL 25MG TABLET (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
CARVEDILOL 3.125MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
CARVEDILOL 6.25MG TABLET (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
CEFACLOR 250MG/5ML ORAL SUSP |
1 |
Tier 1 |
15% | 15% | None |
CEFACLOR 375MG/5ML ORAL SUSP |
1 |
Tier 1 |
15% | 15% | None |
CEFACLOR CAPSULES USP 250MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
CEFACLOR CAPSULES USP 500MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
CEFACLOR ER 500MG TABLET SR 12HR |
1 |
Tier 1 |
15% | 15% | None |
CEFACLOR POWDER FOR ORAL SUSPENSION USP 125MG 75ML BOT |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFADROXIL 1G TABLET |
1 |
Tier 1 |
15% | 15% | None |
CEFADROXIL 500MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
CEFADROXIL 500MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
15% | 15% | None |
CEFADROXIL FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Tier 1 |
15% | 15% | None |
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Tier 2 |
15% | 15% | None |
CEFDINIR CAPSULES 300MG (60 CT) |
2 |
Tier 2 |
15% | 15% | None |
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT) |
2 |
Tier 2 |
15% | 15% | None |
CEFPODOXIME PROXETIL 200MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT) |
2 |
Tier 2 |
15% | 15% | None |
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 100MG 50ML BOT |
1 |
Tier 1 |
15% | 15% | None |
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 50MG 50ML BOT |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFPROZIL 250MG TABLET (100 CT) |
2 |
Tier 2 |
15% | 15% | None |
CEFPROZIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Tier 2 |
15% | 15% | None |
CEFPROZIL FOR ORAL SUSPENSION 125MG/5ML 75ML BOT |
2 |
Tier 2 |
15% | 15% | None |
CEFPROZIL TABLETS 500MG 100 BOT |
2 |
Tier 2 |
15% | 15% | None |
CEFUROXIME 250MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CEFUROXIME AXETIL 125MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
15% | 15% | None |
CEFUROXIME AXETIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
15% | 15% | None |
CEFUROXIME AXETIL 500MG TABLET (20 CT) |
1 |
Tier 1 |
15% | 15% | None |
CEPHALEXIN 250MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
CEPHALEXIN 250MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CEPHALEXIN 250MG/5ML ORAL SUSP |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEPHALEXIN 500MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CEPHALEXIN CAPSULES 500MG (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
CEPHALEXIN POWDER FOR SUSPENSION ORAL USP 125MG 200ML BOT |
1 |
Tier 1 |
15% | 15% | None |
CESIA 7 DAYS X 3 TABLET |
2 |
Tier 2 |
15% | 15% | None |
CETIRIZINE HCL 5MG/5ML |
2 |
Tier 2 |
15% | 15% | None |
CHLORDIAZEPOXIDE AND AMITRIPTYLINE HCL TABLET 12.5-5MG (500 CT) |
2 |
Tier 2 |
15% | 15% | None |
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH |
2 |
Tier 2 |
15% | 15% | None |
CHLOROQUINE PH 500MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
CHLOROQUINE PHOSPHATE 250MG TABLET (50 CT) |
2 |
Tier 2 |
15% | 15% | None |
CHLOROTHIAZIDE 250MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
CHLOROTHIAZIDE 500MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLORPROMAZINE 100MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CHLORPROMAZINE 10MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CHLORPROMAZINE 25MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CHLORPROMAZINE 50MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CHLORPROMAZINE HCL 200MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CHLORPROPAMIDE 100MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CHLORPROPAMIDE 250MG TABLET (1000 CT) |
1 |
Tier 1 |
15% | 15% | None |
CHLORTHALIDONE 25MG TABLET (100 CT) |
2 |
Tier 2 |
15% | 15% | None |
CHLORTHALIDONE 50MG TABLET (1000 CT) |
2 |
Tier 2 |
15% | 15% | None |
CHLORZOXAZONE 250MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
CHLORZOXAZONE 500MG TABLET |
2 |
Tier 2 |
15% | 15% | 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 |
2 |
Tier 2 |
15% | 15% | None |
CHOLESTYRAMINE POWDER FOR ORAL SUSPENSION USP 4GM 60 X 9GM SINGLE DOSE CRTN |
2 |
Tier 2 |
15% | 15% | None |
CHOLESTYRAMINE POWDER FOR ORAL SUSPENSION USP 4GM 378GM CAN |
2 |
Tier 2 |
15% | 15% | None |
CICLOPIROX 0.77% CREAM |
2 |
Tier 2 |
15% | 15% | None |
CICLOPIROX 0.77% TOPICAL SUSPENSION |
2 |
Tier 2 |
15% | 15% | None |
CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6ML BOT |
1 |
Tier 1 |
15% | 15% | None |
CILOSTAZOL 50MG TABLET (60 CT) |
2 |
Tier 2 |
15% | 15% | None |
CILOSTAZOL TABLET 100MG (60 CT) |
2 |
Tier 2 |
15% | 15% | None |
CIMETIDINE 200MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
CIMETIDINE HCL 300MG/5ML SOL |
2 |
Tier 2 |
15% | 15% | None |
CIMETIDINE TABLET USP 300MG (1000 CT) |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIMETIDINE TABLET USP 400MG (1000 CT) |
2 |
Tier 2 |
15% | 15% | None |
CIMETIDINE TABLET USP 800MG (30 CT) |
2 |
Tier 2 |
15% | 15% | None |
CIPROFLOXACIN 250MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
CIPROFLOXACIN 500MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CIPROFLOXACIN ER 1000MG TABLET (30 CT) |
1 |
Tier 1 |
15% | 15% | None |
CIPROFLOXACIN ER 500MG TABLET (30 CT) |
1 |
Tier 1 |
15% | 15% | None |
CIPROFLOXACIN HCL 0.3% DROPS |
2 |
Tier 2 |
15% | 15% | None |
CIPROFLOXACIN HCL 100MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CIPROFLOXACIN TABLETS 750MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
CITALOPRAM HBR 20MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT |
1 |
Tier 1 |
15% | 15% | None |
CITOLOPRAM HBR 10MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
CLARITHROMYCIN 250MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:28 /1Days |
CLARITHROMYCIN 250MG/5ML. SUS. 100ML |
2 |
Tier 2 |
15% | 15% | None |
CLARITHROMYCIN 500MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:28 /1Days |
CLARITHROMYCIN ER 500MG TABLET (60 CT) |
1 |
Tier 1 |
15% | 15% | Q:28 /1Days |
CLARITHROMYCIN FOR ORAL SUSPENSION 125/5ML 125MG BOT |
2 |
Tier 2 |
15% | 15% | None |
CLEMASTINE FUM 2.68MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CLEMASTINE FUMARATE 0.67MG/5ML SYRUP |
1 |
Tier 1 |
15% | 15% | None |
CLINDAMYCIN 150MG/ML ADDVAN |
2 |
Tier 2 |
15% | 15% | None |
CLINDAMYCIN HCL 150MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINDAMYCIN HCL 300MG CAPS |
1 |
Tier 1 |
15% | 15% | None |
CLINDAMYCIN PHOSP 1% LOTION |
2 |
Tier 2 |
15% | 15% | None |
CLINDAMYCIN PHOSPHATE 1% SOLUTION NON-ORAL |
2 |
Tier 2 |
15% | 15% | None |
CLINDAMYCIN PHOSPHATE 2% CREAM WITH APPLICATOR |
2 |
Tier 2 |
15% | 15% | None |
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE |
2 |
Tier 2 |
15% | 15% | None |
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX |
2 |
Tier 2 |
15% | 15% | None |
CLOBETASOL 0.05% OINTMENT |
1 |
Tier 1 |
15% | 15% | None |
CLOBETASOL 0.05% SOLUTION |
1 |
Tier 1 |
15% | 15% | None |
CLOBETASOL E 0.05% CREAM |
1 |
Tier 1 |
15% | 15% | None |
CLOBETASOL PROPIONATE CRM 0.05% 15GM |
1 |
Tier 1 |
15% | 15% | None |
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOMIPRAMINE HCL 25MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
CLOMIPRAMINE HCL 50MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
CLOMIPRAMINE HCL 75MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
CLONIDINE HCL 0.2MG TABLET (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
CLONIDINE HCL TABLET 0.1MG (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
CLONIDINE HCL TABLET 0.3MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
CLOTRIMAZOLE 1% CREAM |
2 |
Tier 2 |
15% | 15% | None |
CLOTRIMAZOLE 10MG TROCHE |
1 |
Tier 1 |
15% | 15% | None |
CLOTRIMAZOLE SOLUTION TOPICAL 1% 30ML BOTPL |
2 |
Tier 2 |
15% | 15% | None |
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION |
2 |
Tier 2 |
15% | 15% | None |
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CREAM USP .5MG-10GM 45GM TUBE |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOZAPINE 200MG TABLET (500 CT) |
1 |
Tier 1 |
15% | 15% | Q:120 /30Days |
CLOZAPINE 25MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | Q:120 /30Days |
CLOZAPINE 50MG TABLET (500 CT) |
1 |
Tier 1 |
15% | 15% | Q:120 /30Days |
CLOZAPINE TABLETS 100MG 100 BOT |
1 |
Tier 1 |
15% | 15% | Q:120 /30Days |
CO-GESIC 5/500 TABLET |
2 |
Tier 2 |
15% | 15% | Q:240 /30Days |
COLCHICINE TABLET USP 0.6MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
COLESTIPOL HCL 1G TABLET |
1 |
Tier 1 |
15% | 15% | None |
COLESTIPOL HCL 5G GRANULES |
1 |
Tier 1 |
15% | 15% | None |
COLISTIMETHATE 150MG VIAL |
2 |
Tier 2 |
15% | 15% | P |
COLOCORT 100MG ENEMA |
2 |
Tier 2 |
15% | 15% | None |
COLYTE SOLUTION |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COMPRO 25MG SUPPOSITORY |
2 |
Tier 2 |
15% | 15% | None |
CONSTULOSE 10GM/15ML SYRUP |
2 |
Tier 2 |
15% | 15% | None |
CORMAX 0.05% CREAM |
1 |
Tier 1 |
15% | 15% | None |
CORTISONE ACETATE 25MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
CORTOMYCIN EAR SOLUTION |
1 |
Tier 1 |
15% | 15% | None |
CORTOMYCIN EAR SUSPENSION |
1 |
Tier 1 |
15% | 15% | None |
CROMOLYN SODIUM 4% 40MG 10ML BOT |
2 |
Tier 2 |
15% | 15% | None |
CRYSELLE-28 TABLET 28 TABLET S |
2 |
Tier 2 |
15% | 15% | None |
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT) |
1 |
Tier 1 |
15% | 15% | None |
CYCLOBENZAPRINE HCL 5MG TABLET (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
CYCLOPHOSPHAMIDE 25MG TABLET |
2 |
Tier 2 |
15% | 15% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYCLOPHOSPHAMIDE 50MG TABLET |
2 |
Tier 2 |
15% | 15% | P |
CYCLOSPORINE 100MG CAPSULE |
2 |
Tier 2 |
15% | 15% | P |
CYCLOSPORINE 25MG CAPSULE |
2 |
Tier 2 |
15% | 15% | P |
CYCLOSPORINE 50MG CAPSULE |
1 |
Tier 1 |
15% | 15% | P |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT |
2 |
Tier 2 |
15% | 15% | P |
CYPROHEPTADINE 4MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL |
1 |
Tier 1 |
15% | 15% | None |