2010 Medicare Part D Plan Formulary Information |
Advantra Freedom (PPO) (H5509-011-0)
Benefit Details
|
The Advantra Freedom (PPO) (H5509-011-0) Formulary Drugs Starting with the Letter C in Webst County, MO: CMS MA Region 15 which includes: MO
|
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 |
3 |
Tier 3 |
$60.00 | $180.00 | None |
CADUET 10MG/10MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | S Q:30 /30Days |
CADUET 10MG/20MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | S Q:30 /30Days |
CADUET 10MG/40MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | S Q:30 /30Days |
CADUET 10MG/80MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | S Q:30 /30Days |
CADUET 2.5MG/10MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | S Q:30 /30Days |
CADUET 2.5MG/20MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | S Q:30 /30Days |
CADUET 2.5MG/40MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | S Q:30 /30Days |
CADUET 5MG/10MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | S Q:30 /30Days |
CADUET 5MG/20MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CADUET 5MG/40MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | S Q:30 /30Days |
CADUET 5MG/80MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | S Q:30 /30Days |
CALCIPOTRIENE TOPICAL SOLUTION |
3 |
Tier 3 |
$60.00 | $180.00 | None |
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CALCITRIOL 0.25MCG CAPSULE |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CALCITRIOL 0.5MCG CAPSULE |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CALCITRIOL 1MCG/ML SOLUTION ORAL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CALCITRIOL 2 MCG/ML VIAL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CALCITRIOL INJECTION SOLUTION 1MCG 50 X 01ML AMP |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CALCIUM ACETATE CAPSULE 667 MG |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CAMPATH 30MG/ML VIAL |
4 |
Tier 4 |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAMPRAL 333MG DOSE PAK |
3 |
Tier 3 |
$60.00 | $180.00 | Q:180 /30Days |
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX |
2 |
Tier 2 |
$35.00 | $87.50 | None |
CANCIDAS IV 50MG VIAL |
4 |
Tier 4 |
33% | N/A | P |
CANCIDAS IV 70MG VIAL |
4 |
Tier 4 |
33% | N/A | P |
CANTIL 25MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
CAPASTAT SULFATE 1GM VIAL |
3 |
Tier 3 |
$60.00 | $180.00 | None |
CAPEX SHA 0.01% |
2 |
Tier 2 |
$35.00 | $87.50 | None |
CAPITAL W/CODEINE ORAL SUSP |
2 |
Tier 2 |
$35.00 | $87.50 | None |
CAPTOPRIL 100MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CAPTOPRIL 12.5MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CAPTOPRIL 25MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAPTOPRIL 50MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CAPTOPRIL/HCTZ 25/15 TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CAPTOPRIL/HCTZ 25/25 TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CAPTOPRIL/HCTZ 50/15 TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CAPTOPRIL/HCTZ 50/25 TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CARAC CRE 0.5% |
3 |
Tier 3 |
$60.00 | $180.00 | None |
CARBAMAZEPINE 100MG/5ML SUSPENSION ORAL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CARBAMAZEPINE EXTENDED RELEASE TABLETS 200MG |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CARBAMAZEPINE EXTENDED RELEASE TABLETS 400MG |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CARBAMAZEPINE TABLET CHEWABLE 100MG (100 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CARBAMAZEPINE TABLET USP 200MG (1000 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARBATROL 100MG CAPSULE SA |
3 |
Tier 3 |
$60.00 | $180.00 | None |
CARBATROL 200MG CAPSULE SA |
3 |
Tier 3 |
$60.00 | $180.00 | None |
CARBATROL 300MG CAPSULE SA |
3 |
Tier 3 |
$60.00 | $180.00 | None |
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;100MG;MG 100 BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;250MG;MG 100 BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CARBIDOPA-LEVODOPA 25MG-100MG TABLET SA |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CARBIDOPA-LEVODOPA 50MG-200MG TABLET SA |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CARBIDOPA/LEVO 10/100 TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CARBIDOPA/LEVO 25/100 TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CARBIDOPA/LEVO 25/250 TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARBINOXAMINE MALEATE SOLUTION 4MG/5ML 16 OZ BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CARBINOXAMINE MALEATE TABLETS 4MG 100 BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CARDIZEM LA EXTENDED RELEASE TABLETS 120MG 90 BOT |
3 |
Tier 3 |
$60.00 | $180.00 | Q:30 /30Days |
CARDIZEM LA EXTENDED RELEASE TABLETS 180MG 90 BOT |
3 |
Tier 3 |
$60.00 | $180.00 | Q:30 /30Days |
CARDIZEM LA EXTENDED RELEASE TABLETS 240MG 90 BOT |
3 |
Tier 3 |
$60.00 | $180.00 | Q:60 /30Days |
CARDIZEM LA EXTENDED RELEASE TABLETS 300MG 90 BOT |
3 |
Tier 3 |
$60.00 | $180.00 | Q:30 /30Days |
CARDIZEM LA EXTENDED RELEASE TABLETS 360MG 30 BOT |
3 |
Tier 3 |
$60.00 | $180.00 | Q:30 /30Days |
CARDIZEM LA EXTENDED RELEASE TABLETS 420MG 30 BOT |
3 |
Tier 3 |
$60.00 | $180.00 | Q:30 /30Days |
CARISOPRODOL AND ASPIRIN TABLETS USP 325;200MG;MG 100 BOTPL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CARISOPRODOL ASPIRIN AND CODEINE PHOSPHATE TABLETS USP 325;200;16MG;MG;MG 100 BOTPL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CARISOPRODOL TABLET USP 350MG (100 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CARTIA XT 120MG CAPSULE SA |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CARTIA XT 180MG CAPSULE SA |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CARTIA XT 240MG CAPSULE SA |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CARTIA XT 300MG CAPSULE SR 24 HR |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CARVEDILOL 12.5MG TABLET (100 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CARVEDILOL 25MG TABLET (500 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CARVEDILOL 3.125MG TABLET (100 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CARVEDILOL 6.25MG TABLET (500 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CATAPRES-TTS DIS 0.3/24HR |
3 |
Tier 3 |
$60.00 | $180.00 | S Q:5 /30Days |
CATAPRES-TTS-1 PATCH 2.52.5MG/UNT 1 X 4 CRTN |
3 |
Tier 3 |
$60.00 | $180.00 | S Q:5 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CATAPRES-TTS-2 PATCH 52.5MG/UNT 1 X 4 CRTN |
3 |
Tier 3 |
$60.00 | $180.00 | S Q:5 /30Days |
CEDAX 400MG CAPSULE |
3 |
Tier 3 |
$60.00 | $180.00 | None |
CEDAX 90MG/5ML SUSPENSION RECONSTITUTED ORAL |
3 |
Tier 3 |
$60.00 | $180.00 | None |
CEENU 100MG CAPSULE |
2 |
Tier 2 |
$35.00 | $87.50 | None |
CEENU 10MG CAPSULE |
2 |
Tier 2 |
$35.00 | $87.50 | None |
CEENU 40MG CAPSULE |
2 |
Tier 2 |
$35.00 | $87.50 | None |
CEFACLOR 250MG/5ML ORAL SUSP |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFACLOR 375MG/5ML ORAL SUSP |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFACLOR CAPSULES USP 250MG (100 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFACLOR CAPSULES USP 500MG (100 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFACLOR ER 500MG TABLET SR 12HR |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFACLOR POWDER FOR ORAL SUSPENSION USP 125MG 75ML BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFADROXIL 1G TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFADROXIL 500MG CAPSULE |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFADROXIL 500MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFADROXIL FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFAZOLIN 20GM BULK VIAL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFAZOLIN FOR INJECTION |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFAZOLIN FOR INJECTION 1MG 25 VIALGL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFDINIR CAPSULES 300MG (60 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFEPIME HCL 2 GRAM VIAL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFOTAXIME FOR INJECTION |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFOTAXIME FOR INJECTION 1GM 50 BOX VIALGL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFOTAXIME FOR INJECTION 2GM 25 VIAL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFOTAXIME FOR INJECTION 500MG 10 VIAL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFOXITIN FOR INJECTION 10GM 10 X 100ML VIAL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFOXITIN FOR INJECTION 1GM 25 X 20ML VIAL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFOXITIN FOR INJECTION 2GM 20ML VIAL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFPODOXIME PROXETIL 200MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 100MG 50ML BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 50MG 50ML BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFPROZIL 250MG TABLET (100 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFPROZIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFPROZIL FOR ORAL SUSPENSION 125MG/5ML 75ML BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFPROZIL TABLETS 500MG 100 BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFTRIAXONE 10GM VIAL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFTRIAXONE FOR INJECTION 250MG BOX OF 10 VIALGL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFTRIAXONE FOR INJECTION 500MG BOX OF 10 VIALGL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFTRIAXONE FOR INJECTION AND DEXTROSE INJECTION 1 GM/50ML |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFTRIAXONE FOR INJECTION AND DEXTROSE INJECTION 2 GM/50ML |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFUROXIME 250MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFUROXIME AXETIL 125MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFUROXIME AXETIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFUROXIME AXETIL 500MG TABLET (20 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFUROXIME FOR INJECTION |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFUROXIME FOR INJECTION |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEFUROXIME FOR INJECTION 7.5GM 10 X 7.5 VIALPHR |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CELEBREX 100MG CAPSULE |
3 |
Tier 3 |
$60.00 | $180.00 | S Q:30 /30Days |
CELEBREX 200MG CAPSULE |
3 |
Tier 3 |
$60.00 | $180.00 | S Q:60 /30Days |
CELEBREX 400MG CAPSULE |
3 |
Tier 3 |
$60.00 | $180.00 | S Q:60 /30Days |
CELEBREX 50MG CAPSULE |
3 |
Tier 3 |
$60.00 | $180.00 | S Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CELESTONE 0.6MG/5ML SYRUP |
2 |
Tier 2 |
$35.00 | $87.50 | None |
CELLCEPT 200MG/ML ORAL SUSP |
3 |
Tier 3 |
$60.00 | $180.00 | P |
CELONTIN 300MG KAPSEAL |
2 |
Tier 2 |
$35.00 | $87.50 | None |
CENESTIN 0.3MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | Q:30 /30Days |
CENESTIN 0.45MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | Q:30 /30Days |
CENESTIN 0.625MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | Q:30 /30Days |
CENESTIN 0.9MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | Q:30 /30Days |
CENESTIN 1.25MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | Q:30 /30Days |
CEPHALEXIN 250MG CAPSULE |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEPHALEXIN 250MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEPHALEXIN 250MG/5ML ORAL SUSP |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEPHALEXIN 500MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEPHALEXIN CAPSULES 500MG (500 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEPHALEXIN POWDER FOR SUSPENSION ORAL USP 125MG 200ML BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CEREDASE 80UNITS/ML VIAL |
4 |
Tier 4 |
33% | N/A | P |
CEREZYME INJ 200UNIT |
4 |
Tier 4 |
33% | N/A | P |
CESAMET 1MG CAPSULE |
3 |
Tier 3 |
$60.00 | $180.00 | P Q:60 /30Days |
CHANTIX 1MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | P Q:60 /30Days |
CHANTIX STARTING MONTH PAK |
3 |
Tier 3 |
$60.00 | $180.00 | P Q:53 /30Days |
CHLORAMPHEN NA SUCC 1GM VL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CHLORDIAZEPOXIDE AND AMITRIPTYLINE HCL TABLET 12.5-5MG (500 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH |
1 |
Tier 1 |
$7.00 | $17.50 | 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 |
$7.00 | $17.50 | None |
CHLOROQUINE PHOSPHATE 250MG TABLET (50 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CHLOROTHIAZIDE 250MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CHLOROTHIAZIDE 500MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CHLORPROMAZINE 100MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CHLORPROMAZINE 10MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CHLORPROMAZINE 25MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CHLORPROMAZINE 25MG/ML AMP |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CHLORPROMAZINE 50MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CHLORPROMAZINE HCL 200MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CHLORPROPAMIDE 100MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLORPROPAMIDE 250MG TABLET (1000 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CHLORTHALIDONE 25MG TABLET (100 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CHLORTHALIDONE 50MG TABLET (1000 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CHLORZOXAZONE 250MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CHLORZOXAZONE 500MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CHOLESTYRAMINE LIGHT ORAL SUSP USP POWDER 4GM 210GM CAN |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CHOLESTYRAMINE POWDER FOR ORAL SUSPENSION USP 4GM 60 X 9GM SINGLE DOSE CRTN |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CHOLESTYRAMINE POWDER FOR ORAL SUSPENSION USP 4GM 378GM CAN |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CHORIONIC GONAD 10000U VIAL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CICLOPIROX 0.77% CREAM |
3 |
Tier 3 |
$60.00 | $180.00 | None |
CICLOPIROX 0.77% TOPICAL SUSPENSION |
3 |
Tier 3 |
$60.00 | $180.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6ML BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CILOSTAZOL 50MG TABLET (60 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CILOSTAZOL TABLET 100MG (60 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CILOXAN 0.3% OINTMENT |
2 |
Tier 2 |
$35.00 | $87.50 | None |
CIMETIDINE 150MG/ML VIAL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CIMETIDINE 200MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CIMETIDINE HCL 300MG/5ML SOL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CIMETIDINE TABLET USP 300MG (1000 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CIMETIDINE TABLET USP 400MG (1000 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CIMETIDINE TABLET USP 800MG (30 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CIMZIA KIT |
4 |
Tier 4 |
33% | N/A | P Q:3 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIPRO (10%) SUS 500MG/5 |
2 |
Tier 2 |
$35.00 | $87.50 | None |
CIPRO (5%) SUS 250MG/5 |
2 |
Tier 2 |
$35.00 | $87.50 | None |
CIPRO HC OTIC SUSPENSION |
3 |
Tier 3 |
$60.00 | $180.00 | None |
CIPRODEX OTIC SUSPENSION |
2 |
Tier 2 |
$35.00 | $87.50 | None |
CIPROFLOXACIN 10MG/ML VIAL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CIPROFLOXACIN 250MG TABLET (100 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CIPROFLOXACIN 500MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CIPROFLOXACIN ER 1000MG TABLET (30 CT) |
3 |
Tier 3 |
$60.00 | $180.00 | Q:14 /30Days |
CIPROFLOXACIN ER 500MG TABLET (30 CT) |
3 |
Tier 3 |
$60.00 | $180.00 | Q:60 /30Days |
CIPROFLOXACIN HCL 0.3% DROPS |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CIPROFLOXACIN HCL 100MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIPROFLOXACIN TABLETS 750MG 100 BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CISPLATIN INJECTION 1MG |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CITALOPRAM HBR 20MG TABLET (100 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CITOLOPRAM HBR 10MG TABLET (100 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLARINEX 0.5MG/ML SYRUP |
3 |
Tier 3 |
$60.00 | $180.00 | S Q:300 /30Days |
CLARINEX 2.5MG REDITABS |
3 |
Tier 3 |
$60.00 | $180.00 | S Q:30 /30Days |
CLARINEX 5MG REDITABS |
3 |
Tier 3 |
$60.00 | $180.00 | S Q:30 /30Days |
CLARINEX 5MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | S Q:30 /30Days |
CLARINEX-D 12 HOUR TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | S Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLARINEX-D 24 HOUR TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | S Q:30 /30Days |
CLARITHROMYCIN 250MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLARITHROMYCIN 250MG/5ML. SUS. 100ML |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLARITHROMYCIN 500MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLARITHROMYCIN ER 500MG TABLET (60 CT) |
3 |
Tier 3 |
$60.00 | $180.00 | Q:28 /14Days |
CLARITHROMYCIN FOR ORAL SUSPENSION 125/5ML 125MG BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLEMASTINE FUM 2.68MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLEMASTINE FUMARATE 0.67MG/5ML SYRUP |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLEOCIN 100MG VAGINAL OVULE |
2 |
Tier 2 |
$35.00 | $87.50 | None |
CLEOCIN HCL 75MG CAPSULE |
2 |
Tier 2 |
$35.00 | $87.50 | None |
CLEOCIN PED SOL 75MG/5ML |
2 |
Tier 2 |
$35.00 | $87.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLIMARA PRO DIS WEEKLY 4.40MG/1.39MG |
3 |
Tier 3 |
$60.00 | $180.00 | Q:4 /28Days |
CLINDAMYCIN 150MG/ML ADDVAN |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLINDAMYCIN HCL 150MG CAPSULE |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLINDAMYCIN HCL 300MG CAPS |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLINDAMYCIN PHOSP 1% LOTION |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLINDAMYCIN PHOSPHATE 1% SOLUTION NON-ORAL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLINDAMYCIN PHOSPHATE 2% CREAM WITH APPLICATOR |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLINDESSE 2% VAGINAL CREAM |
3 |
Tier 3 |
$60.00 | $180.00 | None |
CLINISOL 15% SOLUTION |
3 |
Tier 3 |
$60.00 | $180.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOBETASOL 0.05% OINTMENT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLOBETASOL 0.05% SOLUTION |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLOBETASOL E 0.05% CREAM |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLOBEX 0.05% SHAMPOO |
3 |
Tier 3 |
$60.00 | $180.00 | None |
CLOBEX 0.05% TOPICAL LOTION |
3 |
Tier 3 |
$60.00 | $180.00 | None |
CLODERM 0.1% CREAM |
3 |
Tier 3 |
$60.00 | $180.00 | None |
CLOMIPRAMINE HCL 25MG CAPSULE |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLOMIPRAMINE HCL 50MG CAPSULE |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLOMIPRAMINE HCL 75MG CAPSULE |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLONIDINE HCL 0.2MG TABLET (500 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLONIDINE HCL TABLET 0.1MG (500 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLONIDINE HCL TABLET 0.3MG (100 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLORPRES 0.1/15 TABLET |
2 |
Tier 2 |
$35.00 | $87.50 | None |
CLORPRES 0.2/15MG TABLET |
2 |
Tier 2 |
$35.00 | $87.50 | None |
CLORPRES 0.3/15MG TABLET |
2 |
Tier 2 |
$35.00 | $87.50 | None |
CLOTRIMAZOLE 10MG TROCHE |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLOTRIMAZOLE SOLUTION TOPICAL 1% 30ML BOTPL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CREAM USP .5MG-10GM 45GM TUBE |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLOZAPINE 200MG TABLET (500 CT) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
CLOZAPINE 25MG TABLET (100 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOZAPINE 50MG TABLET (500 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CLOZAPINE TABLETS 100MG 100 BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
COGNEX 10MG CAPSULE |
3 |
Tier 3 |
$60.00 | $180.00 | None |
COGNEX 20MG CAPSULE |
3 |
Tier 3 |
$60.00 | $180.00 | None |
COGNEX 30MG CAPSULE |
3 |
Tier 3 |
$60.00 | $180.00 | None |
COGNEX 40MG CAPSULE |
3 |
Tier 3 |
$60.00 | $180.00 | None |
COLCHICINE TABLET USP 0.6MG (100 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
COLESTIPOL HCL 1G TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
COLESTIPOL HCL 5G GRANULES |
1 |
Tier 1 |
$7.00 | $17.50 | None |
COLISTIMETHATE 150MG VIAL |
4 |
Tier 4 |
33% | N/A | None |
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE |
3 |
Tier 3 |
$60.00 | $180.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COLY MYCIN S OTIC SUSPENSION 3;3.3;10MG/ML;MG/ 5 ML BOTDR |
3 |
Tier 3 |
$60.00 | $180.00 | None |
COMBIGAN 0.2%-0.5% DROPS |
2 |
Tier 2 |
$35.00 | $87.50 | Q:5 /25Days |
COMBIPATCH 0.05/0.14MG PTCH |
3 |
Tier 3 |
$60.00 | $180.00 | Q:8 /28Days |
COMBIPATCH 0.05/0.25MG PTCH |
3 |
Tier 3 |
$60.00 | $180.00 | Q:8 /28Days |
COMBIVENT INHALER |
2 |
Tier 2 |
$35.00 | $87.50 | Q:29 /30Days |
COMBIVIR TABLET |
4 |
Tier 4 |
33% | N/A | None |
COMTAN 200MG TABLET |
2 |
Tier 2 |
$35.00 | $87.50 | None |
COMVAX VACCINE VIAL |
3 |
Tier 3 |
$60.00 | $180.00 | P |
CONCERTA ER TABLETS 18MG 100 TABLETS BOT |
3 |
Tier 3 |
$60.00 | $180.00 | Q:30 /30Days |
CONCERTA ER TABLETS 27MG 100 TABLETS BOT |
3 |
Tier 3 |
$60.00 | $180.00 | Q:30 /30Days |
CONCERTA ER TABLETS 36MG 100 TABLETS BOT |
3 |
Tier 3 |
$60.00 | $180.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CONCERTA ER TABLETS 54MG 100 BOT |
3 |
Tier 3 |
$60.00 | $180.00 | Q:30 /30Days |
CONDYLOX GEL 0.5% 3.5 GM CRTN |
3 |
Tier 3 |
$60.00 | $180.00 | None |
CONSTULOSE 10GM/15ML SYRUP |
1 |
Tier 1 |
$7.00 | $17.50 | None |
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN |
4 |
Tier 4 |
33% | N/A | P Q:30 /30Days |
CORDRAN 0.05% LOTION |
3 |
Tier 3 |
$60.00 | $180.00 | None |
CORDRAN SP 0.05% CREAM |
3 |
Tier 3 |
$60.00 | $180.00 | None |
CORDRAN TAPE 4MCG/SQCM 1 X 80 X 3 CTR |
3 |
Tier 3 |
$60.00 | $180.00 | None |
COREG CR 10MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
$35.00 | $87.50 | Q:30 /30Days |
COREG CR 20MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
$35.00 | $87.50 | Q:30 /30Days |
COREG CR 40MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
$35.00 | $87.50 | Q:30 /30Days |
COREG CR 80MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
$35.00 | $87.50 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CORTIFOAM 10% FOAM |
2 |
Tier 2 |
$35.00 | $87.50 | None |
CORTISONE ACETATE 25MG TABLET (100 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CORTOMYCIN EAR SOLUTION |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CORTOMYCIN EAR SUSPENSION |
1 |
Tier 1 |
$7.00 | $17.50 | None |
COUMADIN 10MG TABLET |
2 |
Tier 2 |
$35.00 | $87.50 | None |
COUMADIN 1MG TABLET |
2 |
Tier 2 |
$35.00 | $87.50 | None |
COUMADIN 2.5MG TABLET |
2 |
Tier 2 |
$35.00 | $87.50 | None |
COUMADIN 2MG TABLET |
2 |
Tier 2 |
$35.00 | $87.50 | None |
COUMADIN 3MG TABLET |
2 |
Tier 2 |
$35.00 | $87.50 | None |
COUMADIN 4MG TABLET |
2 |
Tier 2 |
$35.00 | $87.50 | None |
COUMADIN 5MG TABLET |
2 |
Tier 2 |
$35.00 | $87.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COUMADIN 6MG TABLET |
2 |
Tier 2 |
$35.00 | $87.50 | None |
COUMADIN 7.5MG TABLET |
2 |
Tier 2 |
$35.00 | $87.50 | None |
COVERA-HS 180MG SA TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
COVERA-HS 240MG SA TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | None |
COZAAR 100MG TABLET |
3 |
Tier 3 |
$60.00 | $180.00 | Q:60 /30Days |
COZAAR 25MG TABLET (1000 CT) |
3 |
Tier 3 |
$60.00 | $180.00 | Q:30 /30Days |
COZAAR 50MG TABLET 10000 BOT |
3 |
Tier 3 |
$60.00 | $180.00 | Q:30 /30Days |
CRESTOR 10MG TABLET |
2 |
Tier 2 |
$35.00 | $87.50 | Q:30 /30Days |
CRESTOR 20MG TABLET |
2 |
Tier 2 |
$35.00 | $87.50 | Q:30 /30Days |
CRESTOR 40MG TABLET |
2 |
Tier 2 |
$35.00 | $87.50 | Q:30 /30Days |
CRESTOR 5MG TABLET |
2 |
Tier 2 |
$35.00 | $87.50 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CRIXIVAN 100MG CAPSULE |
2 |
Tier 2 |
$35.00 | $87.50 | None |
CRIXIVAN 200MG CAPSULE |
2 |
Tier 2 |
$35.00 | $87.50 | None |
CRIXIVAN 333MG CAPSULE |
2 |
Tier 2 |
$35.00 | $87.50 | None |
CRIXIVAN 400MG CAPSULE (120 CT) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
CROMOLYN NEBULIZER SOLUTION |
1 |
Tier 1 |
$7.00 | $17.50 | P |
CROMOLYN SODIUM 4% 40MG 10ML BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CUBICIN 500MG VIAL |
4 |
Tier 4 |
33% | N/A | None |
CUPRIMINE 125MG CAPSULE |
2 |
Tier 2 |
$35.00 | $87.50 | None |
CUPRIMINE CAPSULES 250MG (100 CT) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CYCLOBENZAPRINE HCL 5MG TABLET (500 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYCLOPHOSPHAMIDE 25MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | P |
CYCLOPHOSPHAMIDE 50MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | P |
CYCLOSPORINE 100MG CAPSULE |
1 |
Tier 1 |
$7.00 | $17.50 | P |
CYCLOSPORINE 25MG CAPSULE |
1 |
Tier 1 |
$7.00 | $17.50 | P |
CYCLOSPORINE 50MG CAPSULE |
1 |
Tier 1 |
$7.00 | $17.50 | P |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT |
1 |
Tier 1 |
$7.00 | $17.50 | P |
CYKLOKAPRON 100MG/ML AMPUL |
2 |
Tier 2 |
$35.00 | $87.50 | None |
CYMBALTA 20MG CAPSULE |
3 |
Tier 3 |
$60.00 | $180.00 | P Q:60 /30Days |
CYMBALTA 60MG CAPSULE |
3 |
Tier 3 |
$60.00 | $180.00 | P Q:30 /30Days |
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT) |
3 |
Tier 3 |
$60.00 | $180.00 | P Q:60 /30Days |
CYPROHEPTADINE 4MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
CYSTADANE POWDER FOR ORAL SOLUTION 180GM |
3 |
Tier 3 |
$60.00 | $180.00 | P |
CYSTAGON 150MG CAPSULE |
3 |
Tier 3 |
$60.00 | $180.00 | P |
CYSTAGON 50MG CAPSULE |
3 |
Tier 3 |
$60.00 | $180.00 | P |