2010 Medicare Part D Plan Formulary Information |
PriorityMedicare Choice (PPO) (H4875-009-0)
Benefit Details
|
The PriorityMedicare Choice (PPO) (H4875-009-0) Formulary Drugs Starting with the Letter A in Statewide County, MI: CMS MA Region 11 which includes: MI
|
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 |
$30.00 | $75.00 | None |
ABILIFY 15MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ABILIFY 1MG/ML SOLUTION |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ABILIFY 20MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ABILIFY 2MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ABILIFY 30MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ABILIFY 5MG TABLET (OTSUKA) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ABILIFY DISCMELT 10MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ABILIFY DISCMELT 15MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ABILIFY INJ 9.75MG |
2 |
Tier 2 |
$30.00 | $75.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACARBOSE 100MG TABLET S |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ACARBOSE 25MG TABLET S |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ACARBOSE 50MG TABLET S |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ACCOLATE 10MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ACCOLATE 20MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ACEBUTOLOL 200MG CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ACEBUTOLOL 400MG CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ACETADOTE 200MG/ML VIAL |
2 |
Tier 2 |
$30.00 | $75.00 | P |
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ACETASOL HC OTIC SOLUTION |
1 |
Tier 1 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAZOLAMIDE 125MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ACETIC ACID 2% SOLUTION NON-ORAL |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ACETYLCYSTEINE 10% VIAL |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ACIPHEX 20MG TABLET EC |
2 |
Tier 2 |
$30.00 | $75.00 | S Q:31 /31Days |
ACTHIB VACCINE VIAL 10-24UNT/5ML |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ACTIMMUNE SOLUTION FOR INJECTION 100MCG |
4 |
Tier 4 |
25% | N/A | P |
ACTIVELLA 0.5-0.1MG TABLET 28 DLPK |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ACTONEL 150MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | Q:1 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTONEL 30MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | Q:31 /31Days |
ACTONEL 35MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | Q:4 /28Days |
ACTONEL 5MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | Q:31 /31Days |
ACTONEL 75MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | Q:2 /28Days |
ACTONEL WITH CALCIUM TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | Q:31 /31Days |
ACTOPLUS MET 15MG/500MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ACTOPLUS MET 15MG/850MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ACTOS 15MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ACTOS 30MG TABLET (500 CT) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ACTOS 45MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ACULAR 0.5% EYE DROPS |
2 |
Tier 2 |
$30.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACULAR LS 0.4% OPHTH SOL |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ACYCLOVIR 200MG CAPSULE (1000 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ACYCLOVIR 200MG/5ML SUSP |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ACYCLOVIR 400MG TABLET (100 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ACYCLOVIR TABLET USP 800MG (100 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ADACEL VIAL 2UNT/5UNT |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ADAGEN 250U/ML VIAL |
4 |
Tier 4 |
25% | N/A | P |
ADVAIR DISKU MIS 100/50 |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ADVAIR DISKU MIS 250/50 |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ADVAIR DISKU MIS 500/50 |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL |
2 |
Tier 2 |
$30.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADVAIR HFA INHALER 230;21MCG;MCG |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ADVICOR ER 20-750MG TABLET (90 CT) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ADVICOR EXTENDED RELEASE TABLETS 20;1000MG;MG 90 BOTPL |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ADVICOR EXTENDED RELEASE TABLETS 20;500MG;MG 90 BOTPL |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ADVICOR EXTENDED RELEASE TABLETS 40;1000MG;MG 90 BOTPL |
2 |
Tier 2 |
$30.00 | $75.00 | None |
AGGRENOX 25-200MG CAPSULE |
2 |
Tier 2 |
$30.00 | $75.00 | None |
AK-CON 0.1% EYE DROPS |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ALA-SCALP HP 2% LOTION |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ALBENZA 200MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER |
1 |
Tier 1 |
$8.00 | $20.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
1 |
Tier 1 |
$8.00 | $20.00 | P |
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER |
1 |
Tier 1 |
$8.00 | $20.00 | P Q:75 /31Days |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
1 |
Tier 1 |
$8.00 | $20.00 | P |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ALBUTEROL TABLET 4MG (500 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ALCLOMETASONE DIPROPIONATE 0.05% CREAM |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ALDARA IMIQUIMOD CREAM 5% 24 PKT X 250 MG CRTN |
2 |
Tier 2 |
$30.00 | $75.00 | Q:12 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALDURAZYME 2.9MG/5ML VIAL |
4 |
Tier 4 |
25% | N/A | P |
ALENDRONATE SODIUM 10MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | Q:31 /31Days |
ALENDRONATE SODIUM 40MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | Q:31 /31Days |
ALENDRONATE SODIUM 5MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | Q:31 /31Days |
ALENDRONATE SODIUM 70MG TABLET 4 BLPK |
1 |
Tier 1 |
$8.00 | $20.00 | Q:4 /28Days |
ALENDRONATE SODIUM TABLET 35MG 20 CRTN |
1 |
Tier 1 |
$8.00 | $20.00 | Q:4 /28Days |
ALFERON N INJ 5MU/ML |
4 |
Tier 4 |
25% | N/A | P |
ALINIA 100MG/5ML SUSPENSION |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ALINIA 500MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ALLEGRA-D 12 HOUR TABLET 60-120MG (500 CT) |
2 |
Tier 2 |
$30.00 | $75.00 | S |
ALLEGRA-D 24 HOUR TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALLOPURINOL SODIUM 500MG VIAL |
1 |
Tier 1 |
$8.00 | $20.00 | P |
ALLOPURINOL TABLET 300MG (1000 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ALLOPURINOL TABLET USP 100MG (1000 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ALOCRIL 2% EYE DROPS |
3 |
Tier 3 |
$60.00 | $150.00 | None |
ALOMIDE 0.1% EYE DROPS |
3 |
Tier 3 |
$60.00 | $150.00 | None |
ALORA 0.025MG PATCH |
3 |
Tier 3 |
$60.00 | $150.00 | None |
ALORA 0.05MG PATCH |
3 |
Tier 3 |
$60.00 | $150.00 | None |
ALORA 0.075MG PATCH |
3 |
Tier 3 |
$60.00 | $150.00 | None |
ALORA 0.1MG PATCH |
3 |
Tier 3 |
$60.00 | $150.00 | None |
ALPHAGAN P 0.1% DROPS |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ALPHAGAN P 0.15% EYE DROPS |
2 |
Tier 2 |
$30.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALREX 0.2% EYE DROPS |
3 |
Tier 3 |
$60.00 | $150.00 | None |
AMANTADINE 100MG CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMANTADINE 100MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMBIEN CR 12.5MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | S |
AMBIEN CR 6.25MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | S |
AMCINONIDE 0.1% CREAM |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMCINONIDE 0.1% LOTION |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMCINONIDE 0.1% OINTMENT 60GM TUBE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMERGE 1MG TABLET |
3 |
Tier 3 |
$60.00 | $150.00 | Q:28 /31Days |
AMERGE 2.5MG TABLET |
3 |
Tier 3 |
$60.00 | $150.00 | Q:18 /31Days |
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM |
4 |
Tier 4 |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMIKACIN 250MG/ML VIAL |
1 |
Tier 1 |
$8.00 | $20.00 | P |
AMIKACIN 50MG/ML VIAL |
1 |
Tier 1 |
$8.00 | $20.00 | P |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMINESS 5.2% IV SOLUTION |
2 |
Tier 2 |
$30.00 | $75.00 | P |
AMINOPHYLLINE 100MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMINOPHYLLINE 200MG TABLET (1000 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD |
1 |
Tier 1 |
$8.00 | $20.00 | P |
AMINOSYN 5% IV SOLUTION |
2 |
Tier 2 |
$30.00 | $75.00 | P |
AMINOSYN 7% IV SOLUTION |
2 |
Tier 2 |
$30.00 | $75.00 | P |
AMINOSYN 7%-ELECTROLYTE SOL |
2 |
Tier 2 |
$30.00 | $75.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN 8.5% IV SOLUTION |
2 |
Tier 2 |
$30.00 | $75.00 | P |
AMINOSYN II 3.5% M/D5W IV |
2 |
Tier 2 |
$30.00 | $75.00 | P |
AMINOSYN II 4.25% IN D10W |
2 |
Tier 2 |
$30.00 | $75.00 | P |
AMINOSYN II 4.25% IN D20W |
2 |
Tier 2 |
$30.00 | $75.00 | P |
AMINOSYN II 4.25%-D25W IV |
2 |
Tier 2 |
$30.00 | $75.00 | P |
AMINOSYN II 8.5% ELECTROLYT |
2 |
Tier 2 |
$30.00 | $75.00 | P |
AMINOSYN II 8.5% IV SOLUTION |
2 |
Tier 2 |
$30.00 | $75.00 | P |
AMINOSYN PF INJECTION |
2 |
Tier 2 |
$30.00 | $75.00 | P |
AMINOSYN-HF 8% IV SOLUTION |
1 |
Tier 1 |
$8.00 | $20.00 | P |
AMINOSYN-PF 7% IV SOLUTION |
2 |
Tier 2 |
$30.00 | $75.00 | P |
AMIODARONE HCL 200MG TABLET (60 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMIODARONE HCL 400MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMIODARONE HCL INJECTION |
1 |
Tier 1 |
$8.00 | $20.00 | P |
AMITIZA 8MCG CAPSULE |
2 |
Tier 2 |
$30.00 | $75.00 | S |
AMITIZA CAPSULES 24MCG 60 CAP BOT |
2 |
Tier 2 |
$30.00 | $75.00 | S |
AMITRIP/CDP 25-10 TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMITRIP/PERPHEN 10-2 TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMITRIP/PERPHEN 10-4 TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMITRIP/PERPHEN 25-2 TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMITRIP/PERPHEN 25-4 TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMITRIP/PERPHEN 50-4 TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMITRIPTYLINE HCL 100MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIPTYLINE HCL 10MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMITRIPTYLINE HCL 150MG TABLET (100 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMMONIUM LACTATE 12% CREAM |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMMONIUM LACTATE 12% LOTION |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMNESTEEM 10MG CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMNESTEEM 20MG CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMNESTEEM 40MG CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOX TR-POTASSIUM CLAVULANATE 500-125MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMOXAPINE 100MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMOXAPINE 150MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMOXAPINE 25MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMOXAPINE 50MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMOXICILLIN 125MG TABLET CHEW |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMOXICILLIN 200MG TABLET CHEW |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMOXICILLIN 250MG CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMOXICILLIN 400MG TABLET CHEW |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMOXICILLIN 500MG CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMOXICILLIN 500MG TABLET (100 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN 875MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMPHETAMINE SALT COMBO 15MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPHETAMINE SALT COMBO 30MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMPHETAMINE SALTS 20MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMPHOTERICIN B FOR INJECTION 50 MG |
1 |
Tier 1 |
$8.00 | $20.00 | P |
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL |
1 |
Tier 1 |
$8.00 | $20.00 | P |
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL |
1 |
Tier 1 |
$8.00 | $20.00 | P |
AMPICILLIN CAPSULES 250MG 100 BOT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL |
1 |
Tier 1 |
$8.00 | $20.00 | P |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
1 |
Tier 1 |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANADROL-50 50MG TABLET (100 CT) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ANAGRELIDE HCL 0.5MG CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ANAGRELIDE HCL 1MG CAPSULE |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ANCOBON 250MG CAPSULE |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ANCOBON 500MG CAPSULE |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ANDRODERM 2.5MG/24HR PATCH |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ANDRODERM 5MG/24HR PATCH |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ANDROGEL 1%(50MG) GEL PACKET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ANDROID 10MG CAPSULE |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ANTABUSE 250MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ANTABUSE 500MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANZEMET 100MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | P Q:20 /31Days |
ANZEMET 50MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | P Q:20 /31Days |
APIDRA 100UNITS/ML VIAL |
2 |
Tier 2 |
$30.00 | $75.00 | None |
APLENZIN TABLETS EXTENDED RELEASE 348 MG |
3 |
Tier 3 |
$60.00 | $150.00 | None |
APLENZIN TABLETS EXTENDED RELEASE 522 MG |
3 |
Tier 3 |
$60.00 | $150.00 | None |
APOKYN FOR INJECTION 30MG 5 CTG |
2 |
Tier 2 |
$30.00 | $75.00 | None |
APRI 0.15-0.03 TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
APRISO CP24 |
3 |
Tier 3 |
$60.00 | $150.00 | None |
APTIVUS 250MG CAPSULE |
4 |
Tier 4 |
25% | N/A | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
3 |
Tier 3 |
$60.00 | $150.00 | None |
ARALAST 500MG VIAL |
4 |
Tier 4 |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANELLE 7-9-5 TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ARANESP 100MCG/ML VIAL |
3 |
Tier 3 |
$60.00 | $150.00 | P |
ARANESP 200MCG/0.4ML SYRINGE |
4 |
Tier 4 |
25% | N/A | P |
ARANESP 200MCG/ML VIAL |
4 |
Tier 4 |
25% | N/A | P |
ARANESP 25MCG/ML VIAL |
3 |
Tier 3 |
$60.00 | $150.00 | P |
ARANESP 300MCG/ML VIAL |
4 |
Tier 4 |
25% | N/A | P |
ARANESP 500MCG/1ML SYRINGE |
4 |
Tier 4 |
25% | N/A | P |
ARANESP 60MCG/ML VIAL |
3 |
Tier 3 |
$60.00 | $150.00 | P |
ARANESP PREFILLED SYRINGE SINGLE USE 100MCG/0.5ML 1 SYR |
4 |
Tier 4 |
25% | N/A | P |
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR |
4 |
Tier 4 |
25% | N/A | P |
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR |
3 |
Tier 3 |
$60.00 | $150.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR |
4 |
Tier 4 |
25% | N/A | P |
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR |
3 |
Tier 3 |
$60.00 | $150.00 | P |
ARANESP PREFILLED SYRINGE SINGLE USE 60MCG/0.3ML 60MCG/ 0.3ML SYR |
4 |
Tier 4 |
25% | N/A | P |
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD |
3 |
Tier 3 |
$60.00 | $150.00 | P |
ARCALYST INJECTION 220MG/VIAL |
4 |
Tier 4 |
25% | N/A | None |
ARICEPT 10MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ARICEPT 5MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ARICEPT ODT 10MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ARICEPT ODT 5MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ARIMIDEX 1MG TABLET |
3 |
Tier 3 |
$60.00 | $150.00 | None |
ARIXTRA 10MG SYRINGE |
2 |
Tier 2 |
$30.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARIXTRA 2.5MG SYRINGE |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ARIXTRA 5MG SYRINGE |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ARIXTRA 7.5MG SYRINGE |
2 |
Tier 2 |
$30.00 | $75.00 | None |
AROMASIN 25MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ARTHROTEC 50 50MG TABLET -200MCG (60 CT) |
3 |
Tier 3 |
$60.00 | $150.00 | None |
ARTHROTEC 75 TABLET EC |
3 |
Tier 3 |
$60.00 | $150.00 | None |
ASACOL 400MG TABLET EC |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ASTELIN 137MCG AEROSOL SPRAY W/PUMP |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ASTEPRO NASAL SPRAY 137 MCG/SPRY |
3 |
Tier 3 |
$60.00 | $150.00 | None |
ATACAND 16MG TABLET |
3 |
Tier 3 |
$60.00 | $150.00 | S |
ATACAND 32MG TABLET |
3 |
Tier 3 |
$60.00 | $150.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATACAND 4MG TABLET |
3 |
Tier 3 |
$60.00 | $150.00 | S |
ATACAND 8MG TABLET |
3 |
Tier 3 |
$60.00 | $150.00 | S |
ATACAND HCT 16/12.5MG TABLET |
3 |
Tier 3 |
$60.00 | $150.00 | S |
ATACAND HCT 32/12.5MG TABLET |
3 |
Tier 3 |
$60.00 | $150.00 | S |
ATACAND HCT TABLETS 32;25MG;MG 90 TABLETS BOT |
3 |
Tier 3 |
$60.00 | $150.00 | S |
ATENOLOL 25MG TABLET (100 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ATENOLOL TABLET USP 50MG (100 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ATENOLOL TABLETS USP 100MG 1 BLPK |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
ATGAM 50MG/ML AMPUL |
4 |
Tier 4 |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATRIPLA TABLET 600MG/200MG |
4 |
Tier 4 |
25% | N/A | None |
ATROVENT HFA AER 17MCG |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML |
2 |
Tier 2 |
$30.00 | $75.00 | None |
AVALIDE 150-12.5MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | S |
AVALIDE 300-12.5MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | S |
AVALIDE 300-25MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | S |
AVANDAMET 2MG/1000MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
AVANDAMET 2MG/500MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
AVANDAMET 4MG/500MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
AVANDAMET TABLET 4-1000MG |
2 |
Tier 2 |
$30.00 | $75.00 | None |
AVANDARYL 4MG/1MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVANDARYL 4MG/2MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
AVANDARYL 4MG/4MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
AVANDARYL 8MG-2MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
AVANDARYL 8MG-4MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
AVANDIA 2MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
AVANDIA 4MG TABLET (90 CT) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
AVANDIA 8MG TABLET (90 CT) |
2 |
Tier 2 |
$30.00 | $75.00 | None |
AVAPRO 150MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | S |
AVAPRO 300MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | S |
AVAPRO 75MG TABLET (30 CT) |
2 |
Tier 2 |
$30.00 | $75.00 | S |
AVASTIN 100MG/4ML VIAL |
4 |
Tier 4 |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVELOX 400MG TABLET |
3 |
Tier 3 |
$60.00 | $150.00 | None |
AVIANE 0.1-0.02 TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AVINZA 120MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Tier 3 |
$60.00 | $150.00 | S |
AVINZA 30MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Tier 3 |
$60.00 | $150.00 | S |
AVINZA 60MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Tier 3 |
$60.00 | $150.00 | S |
AVINZA 90MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Tier 3 |
$60.00 | $150.00 | S |
AVINZA CAPSULES EXTENDED RELEASE 45MG 100 BOTPL |
3 |
Tier 3 |
$60.00 | $150.00 | S |
AVINZA CAPSULES EXTENDED RELEASE 75MG 100 BOTPL |
3 |
Tier 3 |
$60.00 | $150.00 | S |
AVODART 0.5MG SOFTGEL |
2 |
Tier 2 |
$30.00 | $75.00 | None |
AVONEX ADMIN PACK 30MCG SYR |
4 |
Tier 4 |
25% | N/A | S |
AVONEX ADMIN PACK 30MCG VL |
4 |
Tier 4 |
25% | N/A | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AXERT 12.5MG TABLET |
3 |
Tier 3 |
$60.00 | $150.00 | Q:12 /31Days |
AXERT 6.25MG TABLET |
3 |
Tier 3 |
$60.00 | $150.00 | Q:12 /31Days |
AZACTAM INJECTION 1GM 50ML BAG |
2 |
Tier 2 |
$30.00 | $75.00 | P |
AZACTAM/ISO-OSMOT 2GM/50ML |
2 |
Tier 2 |
$30.00 | $75.00 | P |
AZATHIOPRINE 50MG TABLET |
1 |
Tier 1 |
$8.00 | $20.00 | P |
AZATHIOPRINE SOD 100MG VIAL |
1 |
Tier 1 |
$8.00 | $20.00 | P |
AZELEX 20% CREAM 30GM TUBE |
2 |
Tier 2 |
$30.00 | $75.00 | None |
AZILECT 0.5MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
AZILECT 1MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
$8.00 | $20.00 | 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 |
$8.00 | $20.00 | None |
AZITHROMYCIN 500MG TABLET (30 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD |
1 |
Tier 1 |
$8.00 | $20.00 | P |
AZITHROMYCIN TABLET 600MG (30 CT) |
1 |
Tier 1 |
$8.00 | $20.00 | None |
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT |
2 |
Tier 2 |
$30.00 | $75.00 | None |
AZOR 10MG-20MG TABLET |
3 |
Tier 3 |
$60.00 | $150.00 | None |
AZOR 10MG-40MG TABLET (30 CT) |
3 |
Tier 3 |
$60.00 | $150.00 | None |
AZOR 5MG-20MG TABLET (30 CT) |
3 |
Tier 3 |
$60.00 | $150.00 | None |
AZOR 5MG-40MG TABLET |
3 |
Tier 3 |
$60.00 | $150.00 | None |