2010 Medicare Part D Plan Formulary Information |
Sierra Optima Select Rx (PFFS) (H4449-013-0)
Benefit Details
|
The Sierra Optima Select Rx (PFFS) (H4449-013-0) Formulary Drugs Starting with the Letter A in Statewide County, UT: CMS MA Region 23 which includes: UT
|
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 |
$6.00 | $12.00 | None |
A-METHAPRED 40MG UNIVIAL |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ABILIFY 10MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | S Q:90 /30Days |
ABILIFY 15MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | S Q:60 /30Days |
ABILIFY 1MG/ML SOLUTION |
3 |
Tier 3 |
$80.00 | N/A | S Q:900 /30Days |
ABILIFY 20MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | S Q:30 /30Days |
ABILIFY 2MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | S Q:90 /30Days |
ABILIFY 30MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | S Q:30 /30Days |
ABILIFY 5MG TABLET (OTSUKA) |
3 |
Tier 3 |
$80.00 | N/A | S Q:90 /30Days |
ABILIFY DISCMELT 10MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | S Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABILIFY DISCMELT 15MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | S Q:60 /30Days |
ABILIFY INJ 9.75MG |
3 |
Tier 3 |
$80.00 | N/A | P |
ACARBOSE 100MG TABLET S |
1 |
Tier 1 |
$6.00 | $12.00 | Q:90 /30Days |
ACARBOSE 25MG TABLET S |
1 |
Tier 1 |
$6.00 | $12.00 | Q:90 /30Days |
ACARBOSE 50MG TABLET S |
1 |
Tier 1 |
$6.00 | $12.00 | Q:90 /30Days |
ACCOLATE 10MG TABLET |
2 |
Tier 2 |
$45.00 | $134.00 | Q:60 /30Days |
ACCOLATE 20MG TABLET |
2 |
Tier 2 |
$45.00 | $134.00 | Q:60 /30Days |
ACCUNEB 0.63MG/3ML INH TUBEX |
3 |
Tier 3 |
$80.00 | N/A | P Q:375 /30Days |
ACCUNEB 1.25MG/3ML INH TUBEX |
3 |
Tier 3 |
$80.00 | N/A | P Q:375 /30Days |
ACEBUTOLOL 200MG CAPSULE |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ACEBUTOLOL 400MG CAPSULE |
1 |
Tier 1 |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACEON 2MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:60 /30Days |
ACEON 4MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:60 /30Days |
ACEON 8MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:60 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | Q:390 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | Q:390 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | Q:390 /30Days |
ACETASOL HC SOLUTION 10ML 10 ML BOT |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ACETAZOLAMIDE 125MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT |
3 |
Tier 3 |
$80.00 | N/A | None |
ACETYLCYSTEINE 10% VIAL |
1 |
Tier 1 |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ACIPHEX 20MG TABLET EC |
3 |
Tier 3 |
$80.00 | N/A | S Q:30 /30Days |
ACTHIB VACCINE VIAL 10-24UNT/5ML |
2 |
Tier 2 |
$45.00 | $134.00 | None |
ACTICIN 5% CREAM |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ACTIMMUNE SOLUTION FOR INJECTION 100MCG |
4 |
Tier 4 |
33% | 33% | P |
ACTONEL 150MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:1 /28Days |
ACTONEL 30MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | P Q:30 /30Days |
ACTONEL 35MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:4 /28Days |
ACTONEL 5MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:30 /30Days |
ACTONEL 75MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:2 /30Days |
ACTONEL WITH CALCIUM TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:28 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTOPLUS MET 15MG/500MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | Q:90 /30Days |
ACTOPLUS MET 15MG/850MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | Q:90 /30Days |
ACTOS 15MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | Q:30 /30Days |
ACTOS 30MG TABLET (500 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | Q:30 /30Days |
ACTOS 45MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | Q:30 /30Days |
ACULAR 0.5% EYE DROPS |
2 |
Tier 2 |
$45.00 | $134.00 | Q:10 /30Days |
ACULAR LS 0.4% OPHTH SOL |
2 |
Tier 2 |
$45.00 | $134.00 | Q:10 /30Days |
ACYCLOVIR 200MG CAPSULE (1000 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ACYCLOVIR 200MG/5ML SUSP |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ACYCLOVIR 400MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ACYCLOVIR TABLET USP 800MG (100 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADACEL VIAL 2UNT/5UNT |
3 |
Tier 3 |
$80.00 | N/A | None |
ADAGEN 250U/ML VIAL |
4 |
Tier 4 |
33% | 33% | P |
ADDERALL XR 10MG CAPSULE SA |
2 |
Tier 2 |
$45.00 | $134.00 | Q:60 /30Days |
ADDERALL XR 15MG CAPSULE SA |
2 |
Tier 2 |
$45.00 | $134.00 | Q:60 /30Days |
ADDERALL XR 20MG CAPSULE SA |
2 |
Tier 2 |
$45.00 | $134.00 | Q:60 /30Days |
ADDERALL XR 25MG CAPSULE SA |
2 |
Tier 2 |
$45.00 | $134.00 | Q:60 /30Days |
ADDERALL XR 30MG CAPSULE SA |
2 |
Tier 2 |
$45.00 | $134.00 | Q:60 /30Days |
ADDERALL XR 5MG CAPSULE SA |
2 |
Tier 2 |
$45.00 | $134.00 | Q:60 /30Days |
ADOXA 100MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | S |
ADOXA 50MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | S |
ADVAIR DISKU MIS 100/50 |
3 |
Tier 3 |
$80.00 | N/A | S Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADVAIR DISKU MIS 250/50 |
3 |
Tier 3 |
$80.00 | N/A | S Q:60 /30Days |
ADVAIR DISKU MIS 500/50 |
3 |
Tier 3 |
$80.00 | N/A | S Q:60 /30Days |
ADVAIR HFA INHALER 230;21MCG;MCG |
3 |
Tier 3 |
$80.00 | N/A | S Q:12 /30Days |
ADVICOR ER 20-750MG TABLET (90 CT) |
3 |
Tier 3 |
$80.00 | N/A | Q:60 /30Days |
ADVICOR EXTENDED RELEASE TABLETS 20;1000MG;MG 90 BOTPL |
3 |
Tier 3 |
$80.00 | N/A | Q:60 /30Days |
ADVICOR EXTENDED RELEASE TABLETS 20;500MG;MG 90 BOTPL |
3 |
Tier 3 |
$80.00 | N/A | Q:120 /30Days |
ADVICOR EXTENDED RELEASE TABLETS 40;1000MG;MG 90 BOTPL |
3 |
Tier 3 |
$80.00 | N/A | Q:60 /30Days |
AEROBID-M AEROSOL W/ADAPTER |
3 |
Tier 3 |
$80.00 | N/A | Q:21 /30Days |
AFEDITAB CR 30MG TABLET SA |
1 |
Tier 1 |
$6.00 | $12.00 | Q:180 /30Days |
AFEDITAB CR 60MG TABLET SA |
1 |
Tier 1 |
$6.00 | $12.00 | Q:90 /30Days |
AGGRENOX 25-200MG CAPSULE |
2 |
Tier 2 |
$45.00 | $134.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AK-CON 0.1% EYE DROPS |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AK-POLY-BAC EYE OINTMENT 500UNT/1000UNT |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ALAMAST 0.1% DROPS |
3 |
Tier 3 |
$80.00 | N/A | None |
ALBENZA 200MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | None |
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER |
1 |
Tier 1 |
$6.00 | $12.00 | P Q:525 /30Days |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
1 |
Tier 1 |
$6.00 | $12.00 | P Q:525 /30Days |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ALBUTEROL TABLET 4MG (500 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALCLOMETASONE DIPROPIONATE 0.05% CREAM |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ALDACTAZIDE 50/50 TABLET |
3 |
Tier 3 |
$80.00 | N/A | None |
ALDARA IMIQUIMOD CREAM 5% 24 PKT X 250 MG CRTN |
2 |
Tier 2 |
$45.00 | $134.00 | Q:12 /30Days |
ALDURAZYME 2.9MG/5ML VIAL |
4 |
Tier 4 |
33% | 33% | P |
ALENDRONATE SODIUM 10MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | Q:30 /30Days |
ALENDRONATE SODIUM 40MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | P |
ALENDRONATE SODIUM 5MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | Q:30 /30Days |
ALENDRONATE SODIUM 70MG TABLET 4 BLPK |
1 |
Tier 1 |
$6.00 | $12.00 | Q:4 /28Days |
ALENDRONATE SODIUM TABLET 35MG 20 CRTN |
1 |
Tier 1 |
$6.00 | $12.00 | Q:4 /28Days |
ALFERON N INJ 5MU/ML |
4 |
Tier 4 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALINIA 100MG/5ML SUSPENSION |
3 |
Tier 3 |
$80.00 | N/A | None |
ALINIA 500MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | None |
ALLOPURINOL TABLET 300MG (1000 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ALLOPURINOL TABLET USP 100MG (1000 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ALOCRIL 2% EYE DROPS |
3 |
Tier 3 |
$80.00 | N/A | None |
ALOMIDE 0.1% EYE DROPS |
3 |
Tier 3 |
$80.00 | N/A | None |
ALPHAGAN P 0.1% DROPS |
3 |
Tier 3 |
$80.00 | N/A | Q:15 /30Days |
ALPHAGAN P 0.15% EYE DROPS |
3 |
Tier 3 |
$80.00 | N/A | Q:15 /30Days |
ALREX 0.2% EYE DROPS |
3 |
Tier 3 |
$80.00 | N/A | Q:20 /30Days |
ALVESCO 160MCG/ACT AERS |
3 |
Tier 3 |
$80.00 | N/A | Q:12 /30Days |
ALVESCO 80MCG/ACT AERS |
3 |
Tier 3 |
$80.00 | N/A | Q:12 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMANTADINE 100MG CAPSULE |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMANTADINE 100MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMBIEN CR 12.5MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:30 /30Days |
AMBIEN CR 6.25MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:30 /30Days |
AMCINONIDE 0.1% CREAM |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMCINONIDE 0.1% LOTION |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMCINONIDE 0.1% OINTMENT 60GM TUBE |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMERGE 1MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:9 /30Days |
AMERGE 2.5MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:9 /30Days |
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM |
4 |
Tier 4 |
33% | 33% | P |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINESS 5.2% IV SOLUTION |
2 |
Tier 2 |
$45.00 | $134.00 | None |
AMINOPHYLLINE 100MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMINOPHYLLINE 200MG TABLET (1000 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMIODARONE HCL 200MG TABLET (60 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMIODARONE HCL 400MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMITIZA 8MCG CAPSULE |
3 |
Tier 3 |
$80.00 | N/A | Q:60 /30Days |
AMITIZA CAPSULES 24MCG 60 CAP BOT |
3 |
Tier 3 |
$80.00 | N/A | Q:60 /30Days |
AMITRIP/CDP 25-10 TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMITRIP/PERPHEN 10-2 TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMITRIP/PERPHEN 10-4 TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMITRIP/PERPHEN 25-2 TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIP/PERPHEN 25-4 TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMITRIP/PERPHEN 50-4 TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMITRIPTYLINE HCL 100MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMITRIPTYLINE HCL 10MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMITRIPTYLINE HCL 150MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | Q:30 /30Days |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | Q:30 /30Days |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE |
1 |
Tier 1 |
$6.00 | $12.00 | Q:30 /30Days |
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE |
1 |
Tier 1 |
$6.00 | $12.00 | Q:30 /30Days |
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE |
1 |
Tier 1 |
$6.00 | $12.00 | Q:30 /30Days |
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE |
1 |
Tier 1 |
$6.00 | $12.00 | Q:30 /30Days |
AMMONIUM CHLORIDE 5 MEQ/ML |
1 |
Tier 1 |
$6.00 | $12.00 | P |
AMMONIUM LACTATE 12% CREAM |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMMONIUM LACTATE 12% LOTION |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 500-125MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXAPINE 100MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMOXAPINE 150MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMOXAPINE 25MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMOXAPINE 50MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMOXICILLIN 250MG CAPSULE |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMOXICILLIN 500MG CAPSULE |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMOXICILLIN 875MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
1 |
Tier 1 |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | Q:360 /30Days |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | Q:120 /30Days |
AMPHETAMINE SALT COMBO 15MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | Q:120 /30Days |
AMPHETAMINE SALT COMBO 30MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | Q:60 /30Days |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | Q:240 /30Days |
AMPHETAMINE SALTS 20MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | Q:60 /30Days |
AMPICILLIN FOR INJECTION POWDER |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMRIX 30MG CAPSULE SR 24 HR |
3 |
Tier 3 |
$80.00 | N/A | P S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMRIX CAPSULES EXTENDED RELEASE 15MG 60 CAPSULES BOT |
3 |
Tier 3 |
$80.00 | N/A | P S Q:30 /30Days |
ANADROL-50 50MG TABLET (100 CT) |
4 |
Tier 4 |
33% | 33% | P |
ANCOBON 250MG CAPSULE |
3 |
Tier 3 |
$80.00 | N/A | None |
ANCOBON 500MG CAPSULE |
3 |
Tier 3 |
$80.00 | N/A | None |
ANDRODERM 2.5MG/24HR PATCH |
3 |
Tier 3 |
$80.00 | N/A | P Q:30 /30Days |
ANDRODERM 5MG/24HR PATCH |
3 |
Tier 3 |
$80.00 | N/A | P Q:30 /30Days |
ANDROGEL 1%(50MG) GEL PACKET |
2 |
Tier 2 |
$45.00 | $134.00 | Q:300 /30Days |
ANGELIQ 1-0.5MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:28 /28Days |
ANTABUSE 250MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | None |
ANTABUSE 500MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | None |
ANTARA 130MG CAPSULE |
3 |
Tier 3 |
$80.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANTARA 43MG CAPSULE |
3 |
Tier 3 |
$80.00 | N/A | Q:30 /30Days |
APHTHASOL 5% PASTE |
3 |
Tier 3 |
$80.00 | N/A | None |
APIDRA 100UNITS/ML VIAL |
3 |
Tier 3 |
$80.00 | N/A | None |
APOKYN FOR INJECTION 30MG 5 CTG |
4 |
Tier 4 |
33% | 33% | P Q:60 /30Days |
APRI 0.15-0.03 TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | Q:28 /28Days |
APTIVUS 250MG CAPSULE |
4 |
Tier 4 |
33% | 33% | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
4 |
Tier 4 |
33% | 33% | None |
ARANELLE 7-9-5 TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | Q:28 /28Days |
ARANESP 100MCG/ML VIAL |
4 |
Tier 4 |
33% | 33% | P |
ARANESP 200MCG/0.4ML SYRINGE |
4 |
Tier 4 |
33% | 33% | P |
ARANESP 200MCG/ML VIAL |
4 |
Tier 4 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP 25MCG/ML VIAL |
2 |
Tier 2 |
$45.00 | $134.00 | P |
ARANESP 300MCG/ML VIAL |
4 |
Tier 4 |
33% | 33% | P |
ARANESP 500MCG/1ML SYRINGE |
4 |
Tier 4 |
33% | 33% | P |
ARANESP 60MCG/ML VIAL |
4 |
Tier 4 |
33% | 33% | P |
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR |
4 |
Tier 4 |
33% | 33% | P |
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR |
2 |
Tier 2 |
$45.00 | $134.00 | P |
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR |
3 |
Tier 3 |
$80.00 | N/A | P |
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD |
4 |
Tier 4 |
33% | 33% | P |
ARICEPT 10MG TABLET |
2 |
Tier 2 |
$45.00 | $134.00 | Q:30 /30Days |
ARICEPT 5MG TABLET |
2 |
Tier 2 |
$45.00 | $134.00 | Q:30 /30Days |
ARICEPT ODT 10MG TABLET |
2 |
Tier 2 |
$45.00 | $134.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARICEPT ODT 5MG TABLET |
2 |
Tier 2 |
$45.00 | $134.00 | Q:30 /30Days |
ARIMIDEX 1MG TABLET |
2 |
Tier 2 |
$45.00 | $134.00 | Q:30 /30Days |
ARIXTRA 10MG SYRINGE |
4 |
Tier 4 |
33% | 33% | P |
ARIXTRA 2.5MG SYRINGE |
3 |
Tier 3 |
$80.00 | N/A | P |
ARIXTRA 5MG SYRINGE |
4 |
Tier 4 |
33% | 33% | P |
ARIXTRA 7.5MG SYRINGE |
4 |
Tier 4 |
33% | 33% | P |
AROMASIN 25MG TABLET |
2 |
Tier 2 |
$45.00 | $134.00 | None |
ARTHROTEC 50 50MG TABLET -200MCG (60 CT) |
3 |
Tier 3 |
$80.00 | N/A | None |
ARTHROTEC 75 TABLET EC |
3 |
Tier 3 |
$80.00 | N/A | None |
ASACOL 400MG TABLET EC |
2 |
Tier 2 |
$45.00 | $134.00 | Q:360 /30Days |
ASACOL HD DELAYED RELEASE TABLETS 800MG 180 BOT |
2 |
Tier 2 |
$45.00 | $134.00 | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ASMANEX 220MCG(14) AEROSOL POWDER BREATH ACTIVATED |
2 |
Tier 2 |
$45.00 | $134.00 | Q:56 /30Days |
ASMANEX TWISTHALER 220MCG #120 |
2 |
Tier 2 |
$45.00 | $134.00 | Q:120 /30Days |
ASMANEX TWISTHALER 220MCG #30 |
2 |
Tier 2 |
$45.00 | $134.00 | Q:60 /30Days |
ASMANEX TWISTHALER 220MCG #60 |
2 |
Tier 2 |
$45.00 | $134.00 | Q:60 /30Days |
ASTELIN 137MCG AEROSOL SPRAY W/PUMP |
3 |
Tier 3 |
$80.00 | N/A | Q:30 /30Days |
ASTEPRO NASAL SPRAY 137 MCG/SPRY |
2 |
Tier 2 |
$45.00 | $134.00 | Q:30 /25Days |
ATACAND 16MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:60 /30Days |
ATACAND 32MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:30 /30Days |
ATACAND 4MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:60 /30Days |
ATACAND 8MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:60 /30Days |
ATACAND HCT 16/12.5MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATACAND HCT 32/12.5MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:30 /30Days |
ATACAND HCT TABLETS 32;25MG;MG 90 TABLETS BOT |
3 |
Tier 3 |
$80.00 | N/A | Q:30 /30Days |
ATENOLOL 25MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ATENOLOL TABLET USP 50MG (100 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ATENOLOL TABLETS USP 100MG 1 BLPK |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ATRIPLA TABLET 600MG/200MG |
4 |
Tier 4 |
33% | 33% | Q:30 /30Days |
ATROVENT HFA AER 17MCG |
2 |
Tier 2 |
$45.00 | $134.00 | Q:26 /30Days |
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML |
2 |
Tier 2 |
$45.00 | $134.00 | None |
AUGMENTIN XR 1000-62.5 TABLET |
3 |
Tier 3 |
$80.00 | N/A | S Q:40 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVALIDE 150-12.5MG TABLET |
2 |
Tier 2 |
$45.00 | $134.00 | Q:30 /30Days |
AVALIDE 300-12.5MG TABLET |
2 |
Tier 2 |
$45.00 | $134.00 | Q:30 /30Days |
AVALIDE 300-25MG TABLET |
2 |
Tier 2 |
$45.00 | $134.00 | Q:30 /30Days |
AVANDAMET 2MG/1000MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | S Q:60 /30Days |
AVANDAMET 2MG/500MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | S Q:60 /30Days |
AVANDAMET 4MG/500MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | S Q:60 /30Days |
AVANDAMET TABLET 4-1000MG |
3 |
Tier 3 |
$80.00 | N/A | S Q:60 /30Days |
AVANDARYL 4MG/1MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | S Q:30 /30Days |
AVANDARYL 4MG/2MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | S Q:30 /30Days |
AVANDARYL 4MG/4MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | S Q:30 /30Days |
AVANDARYL 8MG-2MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVANDARYL 8MG-4MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | S Q:30 /30Days |
AVANDIA 2MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | S Q:30 /30Days |
AVANDIA 4MG TABLET (90 CT) |
3 |
Tier 3 |
$80.00 | N/A | S Q:30 /30Days |
AVANDIA 8MG TABLET (90 CT) |
3 |
Tier 3 |
$80.00 | N/A | S Q:30 /30Days |
AVAPRO 150MG TABLET |
2 |
Tier 2 |
$45.00 | $134.00 | Q:30 /30Days |
AVAPRO 300MG TABLET |
2 |
Tier 2 |
$45.00 | $134.00 | Q:30 /30Days |
AVAPRO 75MG TABLET (30 CT) |
2 |
Tier 2 |
$45.00 | $134.00 | Q:30 /30Days |
AVELOX 400MG TABLET |
2 |
Tier 2 |
$45.00 | $134.00 | S Q:21 /30Days |
AVIANE 0.1-0.02 TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | Q:28 /28Days |
AVINZA 120MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Tier 3 |
$80.00 | N/A | S Q:90 /30Days |
AVINZA 30MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Tier 3 |
$80.00 | N/A | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVINZA 60MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Tier 3 |
$80.00 | N/A | S Q:30 /30Days |
AVINZA 90MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Tier 3 |
$80.00 | N/A | S Q:60 /30Days |
AVITA 0.025% CREAM |
1 |
Tier 1 |
$6.00 | $12.00 | P Q:45 /60Days |
AVODART 0.5MG SOFTGEL |
3 |
Tier 3 |
$80.00 | N/A | Q:30 /30Days |
AXERT 12.5MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:8 /30Days |
AXERT 6.25MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:8 /30Days |
AXID 15MG/ML ORAL SOLUTION |
3 |
Tier 3 |
$80.00 | N/A | None |
AZACTAM 2GM VIAL |
2 |
Tier 2 |
$45.00 | $134.00 | None |
AZASAN 100MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | P |
AZASAN 75MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | P |
AZASITE 1% DROPS |
2 |
Tier 2 |
$45.00 | $134.00 | Q:5 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZATHIOPRINE 50MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | P |
AZELEX 20% CREAM 30GM TUBE |
3 |
Tier 3 |
$80.00 | N/A | None |
AZILECT 0.5MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:30 /30Days |
AZILECT 1MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:30 /30Days |
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AZITHROMYCIN 250MG TABLET (30 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | Q:12 /30Days |
AZITHROMYCIN 500MG TABLET (30 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | Q:6 /30Days |
AZITHROMYCIN TABLET 600MG (30 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | Q:14 /30Days |
AZMACORT INHALATION AEROSOL .1MG/1IHL 20 GM CSTR |
3 |
Tier 3 |
$80.00 | N/A | Q:40 /30Days |
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT |
3 |
Tier 3 |
$80.00 | N/A | Q:15 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZOR 10MG-20MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:30 /30Days |
AZOR 10MG-40MG TABLET (30 CT) |
3 |
Tier 3 |
$80.00 | N/A | Q:30 /30Days |
AZOR 5MG-20MG TABLET (30 CT) |
3 |
Tier 3 |
$80.00 | N/A | Q:30 /30Days |
AZOR 5MG-40MG TABLET |
3 |
Tier 3 |
$80.00 | N/A | Q:30 /30Days |