2010 Medicare Part D Plan Formulary Information |
Windsor Medicare Extra Diabetes Plan (HMO) (H5698-156-0)
Benefit Details
|
The Windsor Medicare Extra Diabetes Plan (HMO) (H5698-156-0) Formulary Drugs Starting with the Letter A in Lake County, TN: CMS MA Region 10 which includes: TN
|
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-HYDROCORT 100MG VIAL |
4 |
Tier 4 |
$45.00 | $135.00 | None |
ABILIFY 10MG TABLET |
4 |
Tier 4 |
$45.00 | $135.00 | S |
ABILIFY 15MG TABLET |
4 |
Tier 4 |
$45.00 | $135.00 | S |
ABILIFY 1MG/ML SOLUTION |
4 |
Tier 4 |
$45.00 | $135.00 | S |
ABILIFY 20MG TABLET |
4 |
Tier 4 |
$45.00 | $135.00 | S |
ABILIFY 2MG TABLET |
4 |
Tier 4 |
$45.00 | $135.00 | S |
ABILIFY 30MG TABLET |
4 |
Tier 4 |
$45.00 | $135.00 | S |
ABILIFY 5MG TABLET (OTSUKA) |
4 |
Tier 4 |
$45.00 | $135.00 | S |
ABILIFY DISCMELT 10MG TABLET |
4 |
Tier 4 |
$45.00 | $135.00 | S |
ABILIFY DISCMELT 15MG TABLET |
4 |
Tier 4 |
$45.00 | $135.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABILIFY INJ 9.75MG |
4 |
Tier 4 |
$45.00 | $135.00 | P |
ACARBOSE 100MG TABLET S |
2 |
Tier 2 |
$10.00 | $30.00 | None |
ACARBOSE 25MG TABLET S |
2 |
Tier 2 |
$10.00 | $30.00 | None |
ACARBOSE 50MG TABLET S |
2 |
Tier 2 |
$10.00 | $30.00 | None |
ACCOLATE 10MG TABLET |
4 |
Tier 4 |
$45.00 | $135.00 | Q:60 /30Days |
ACCOLATE 20MG TABLET |
4 |
Tier 4 |
$45.00 | $135.00 | Q:60 /30Days |
ACEBUTOLOL 200MG CAPSULE |
2 |
Tier 2 |
$10.00 | $30.00 | None |
ACEBUTOLOL 400MG CAPSULE |
2 |
Tier 2 |
$10.00 | $30.00 | None |
ACEON 2MG TABLET |
4 |
Tier 4 |
$45.00 | $135.00 | None |
ACEON 4MG TABLET |
4 |
Tier 4 |
$45.00 | $135.00 | None |
ACEON 8MG TABLET |
4 |
Tier 4 |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD |
2 |
Tier 2 |
$10.00 | $30.00 | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | Q:390 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | Q:390 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | Q:390 /30Days |
ACETASOL HC OTIC SOLUTION |
2 |
Tier 2 |
$10.00 | $30.00 | None |
ACETAZOLAMIDE 125MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT |
2 |
Tier 2 |
$10.00 | $30.00 | None |
ACETIC ACID 2% SOLUTION NON-ORAL |
2 |
Tier 2 |
$10.00 | $30.00 | None |
ACETYLCYSTEINE 10% VIAL |
2 |
Tier 2 |
$10.00 | $30.00 | P |
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN |
2 |
Tier 2 |
$10.00 | $30.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTHIB VACCINE VIAL 10-24UNT/5ML |
3 |
Tier 3 |
$25.00 | $75.00 | None |
ACTIMMUNE SOLUTION FOR INJECTION 100MCG |
5 |
Tier 5 |
33% | 33% | P |
ACTOPLUS MET 15MG/500MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | Q:90 /30Days |
ACTOPLUS MET 15MG/850MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | Q:90 /30Days |
ACTOS 15MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | None |
ACTOS 30MG TABLET (500 CT) |
3 |
Tier 3 |
$25.00 | $75.00 | None |
ACTOS 45MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | None |
ACULAR 0.5% EYE DROPS |
4 |
Tier 4 |
$45.00 | $135.00 | None |
ACULAR LS 0.4% OPHTH SOL |
4 |
Tier 4 |
$45.00 | $135.00 | None |
ACYCLOVIR 200MG CAPSULE (1000 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
ACYCLOVIR 200MG/5ML SUSP |
2 |
Tier 2 |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACYCLOVIR 400MG TABLET (100 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
ACYCLOVIR TABLET USP 800MG (100 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
ADACEL VIAL 2UNT/5UNT |
3 |
Tier 3 |
$25.00 | $75.00 | None |
ADAGEN 250U/ML VIAL |
5 |
Tier 5 |
33% | 33% | P |
ADVAIR DISKU MIS 100/50 |
3 |
Tier 3 |
$25.00 | $75.00 | Q:60 /30Days |
ADVAIR DISKU MIS 250/50 |
3 |
Tier 3 |
$25.00 | $75.00 | Q:60 /30Days |
ADVAIR DISKU MIS 500/50 |
3 |
Tier 3 |
$25.00 | $75.00 | Q:60 /30Days |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL |
3 |
Tier 3 |
$25.00 | $75.00 | Q:12 /30Days |
ADVAIR HFA INHALER 230;21MCG;MCG |
3 |
Tier 3 |
$25.00 | $75.00 | Q:12 /30Days |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
3 |
Tier 3 |
$25.00 | $75.00 | Q:12 /30Days |
AEROBID-M AEROSOL W/ADAPTER |
4 |
Tier 4 |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AFEDITAB CR 30MG TABLET SA |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AFEDITAB CR 60MG TABLET SA |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AGGRENOX 25-200MG CAPSULE |
3 |
Tier 3 |
$25.00 | $75.00 | None |
AK-CON 0.1% EYE DROPS |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AKNE-MYCIN 2% OINTMENT |
4 |
Tier 4 |
$45.00 | $135.00 | None |
ALA-SCALP HP 2% LOTION |
4 |
Tier 4 |
$45.00 | $135.00 | None |
ALAMAST 0.1% DROPS |
4 |
Tier 4 |
$45.00 | $135.00 | None |
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER |
2 |
Tier 2 |
$10.00 | $30.00 | P |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
2 |
Tier 2 |
$10.00 | $30.00 | P |
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER |
2 |
Tier 2 |
$10.00 | $30.00 | P |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
2 |
Tier 2 |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
2 |
Tier 2 |
$10.00 | $30.00 | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
2 |
Tier 2 |
$10.00 | $30.00 | P |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
2 |
Tier 2 |
$10.00 | $30.00 | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
ALBUTEROL TABLET 4MG (500 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
ALDACTAZIDE 50/50 TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | None |
ALDARA IMIQUIMOD CREAM 5% 24 PKT X 250 MG CRTN |
3 |
Tier 3 |
$25.00 | $75.00 | None |
ALDURAZYME 2.9MG/5ML VIAL |
4 |
Tier 4 |
$45.00 | $135.00 | P |
ALENDRONATE SODIUM 10MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
ALENDRONATE SODIUM 40MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
ALENDRONATE SODIUM 5MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALENDRONATE SODIUM 70MG TABLET 4 BLPK |
2 |
Tier 2 |
$10.00 | $30.00 | Q:4 /28Days |
ALENDRONATE SODIUM TABLET 35MG 20 CRTN |
2 |
Tier 2 |
$10.00 | $30.00 | Q:4 /28Days |
ALFERON N INJ 5MU/ML |
5 |
Tier 5 |
33% | 33% | P |
ALKERAN FOR INJECTION 50MG/VIAL 1 VIALSU |
3 |
Tier 3 |
$25.00 | $75.00 | P |
ALLOPURINOL TABLET 300MG (1000 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
ALLOPURINOL TABLET USP 100MG (1000 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
ALORA 0.025MG PATCH |
4 |
Tier 4 |
$45.00 | $135.00 | None |
ALORA 0.05MG PATCH |
4 |
Tier 4 |
$45.00 | $135.00 | None |
ALORA 0.075MG PATCH |
4 |
Tier 4 |
$45.00 | $135.00 | None |
ALORA 0.1MG PATCH |
4 |
Tier 4 |
$45.00 | $135.00 | None |
ALPHAGAN P 0.15% EYE DROPS |
4 |
Tier 4 |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALREX 0.2% EYE DROPS |
4 |
Tier 4 |
$45.00 | $135.00 | None |
AMANTADINE 100MG CAPSULE |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMIFOSTINE FOR INJECTION 500MG/VIAL |
5 |
Tier 5 |
33% | 33% | P |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMINESS 5.2% IV SOLUTION |
3 |
Tier 3 |
$25.00 | $75.00 | P |
AMINOPHYLLINE 100MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMINOPHYLLINE 200MG TABLET (1000 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMINOSYN 10% IV SOLUTION |
4 |
Tier 4 |
$45.00 | $135.00 | P |
AMINOSYN 3.5% IV SOLUTION |
4 |
Tier 4 |
$45.00 | $135.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN 5% IV SOLUTION |
4 |
Tier 4 |
$45.00 | $135.00 | P |
AMINOSYN 7% IV SOLUTION |
4 |
Tier 4 |
$45.00 | $135.00 | P |
AMINOSYN 8.5% IV SOLUTION |
4 |
Tier 4 |
$45.00 | $135.00 | P |
AMINOSYN II 10% IV SOLUTION |
4 |
Tier 4 |
$45.00 | $135.00 | P |
AMINOSYN II 15% IV SOLUTION |
4 |
Tier 4 |
$45.00 | $135.00 | P |
AMINOSYN II 4.25% IN D10W |
4 |
Tier 4 |
$45.00 | $135.00 | P |
AMINOSYN II 7% IV SOLUTION |
4 |
Tier 4 |
$45.00 | $135.00 | P |
AMINOSYN II 8.5% ELECTROLYT |
4 |
Tier 4 |
$45.00 | $135.00 | P |
AMINOSYN II 8.5% IV SOLUTION |
4 |
Tier 4 |
$45.00 | $135.00 | P |
AMINOSYN PF INJECTION |
4 |
Tier 4 |
$45.00 | $135.00 | P |
AMINOSYN-HBC 7% IV SOLUTION |
4 |
Tier 4 |
$45.00 | $135.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN-HF 8% IV SOLUTION |
4 |
Tier 4 |
$45.00 | $135.00 | P |
AMINOSYN-PF 7% IV SOLUTION |
4 |
Tier 4 |
$45.00 | $135.00 | P |
AMIODARONE HCL 200MG TABLET (60 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMIODARONE HCL 400MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMIODARONE HCL INJECTION |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMITIZA 8MCG CAPSULE |
3 |
Tier 3 |
$25.00 | $75.00 | P Q:60 /30Days |
AMITIZA CAPSULES 24MCG 60 CAP BOT |
3 |
Tier 3 |
$25.00 | $75.00 | P Q:60 /30Days |
AMITRIP/CDP 25-10 TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMITRIP/PERPHEN 10-2 TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMITRIP/PERPHEN 10-4 TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMITRIP/PERPHEN 25-2 TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIP/PERPHEN 25-4 TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMITRIP/PERPHEN 50-4 TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMITRIPTYLINE HCL 100MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
AMITRIPTYLINE HCL 10MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
AMITRIPTYLINE HCL 150MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
1 |
Tier 1 |
$5.00 | $15.00 | None |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMMONIUM LACTATE 12% CREAM |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMMONIUM LACTATE 12% LOTION |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
2 |
Tier 2 |
$10.00 | $30.00 | 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 |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMOXAPINE 100MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMOXAPINE 150MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMOXAPINE 25MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMOXAPINE 50MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMOXICILLIN 125MG TABLET CHEW |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMOXICILLIN 200MG TABLET CHEW |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMOXICILLIN 250MG CAPSULE |
1 |
Tier 1 |
$5.00 | $15.00 | None |
AMOXICILLIN 400MG TABLET CHEW |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMOXICILLIN 500MG CAPSULE |
1 |
Tier 1 |
$5.00 | $15.00 | None |
AMOXICILLIN 500MG TABLET (100 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN 875MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
1 |
Tier 1 |
$5.00 | $15.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Tier 1 |
$5.00 | $15.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMPHETAMINE SALT COMBO 15MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPHETAMINE SALT COMBO 30MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMPHETAMINE SALTS 20MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMPHOTERICIN B FOR INJECTION 50 MG |
2 |
Tier 2 |
$10.00 | $30.00 | P |
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMPICILLIN CAPSULES 250MG 100 BOT |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML |
2 |
Tier 2 |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANAGRELIDE HCL 0.5MG CAPSULE |
4 |
Tier 4 |
$45.00 | $135.00 | P |
ANAGRELIDE HCL 1MG CAPSULE |
4 |
Tier 4 |
$45.00 | $135.00 | P |
ANCOBON 250MG CAPSULE |
3 |
Tier 3 |
$25.00 | $75.00 | None |
ANCOBON 500MG CAPSULE |
3 |
Tier 3 |
$25.00 | $75.00 | None |
ANDRODERM 2.5MG/24HR PATCH |
3 |
Tier 3 |
$25.00 | $75.00 | P Q:30 /30Days |
ANDRODERM 5MG/24HR PATCH |
3 |
Tier 3 |
$25.00 | $75.00 | P Q:30 /30Days |
ANDROGEL 1%(50MG) GEL PACKET |
4 |
Tier 4 |
$45.00 | $135.00 | P |
ANTABUSE 250MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | None |
ANTABUSE 500MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | None |
APIDRA 100UNITS/ML VIAL |
4 |
Tier 4 |
$45.00 | $135.00 | None |
APRI 0.15-0.03 TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | Q:28 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APTIVUS 250MG CAPSULE |
5 |
Tier 5 |
33% | 33% | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
5 |
Tier 5 |
33% | 33% | None |
ARALAST 500MG VIAL |
5 |
Tier 5 |
33% | 33% | P |
ARANELLE 7-9-5 TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | Q:28 /28Days |
ARICEPT 10MG TABLET |
4 |
Tier 4 |
$45.00 | $135.00 | None |
ARICEPT 5MG TABLET |
4 |
Tier 4 |
$45.00 | $135.00 | None |
ARICEPT ODT 10MG TABLET |
4 |
Tier 4 |
$45.00 | $135.00 | None |
ARICEPT ODT 5MG TABLET |
4 |
Tier 4 |
$45.00 | $135.00 | None |
ARIMIDEX 1MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | None |
ARIXTRA 10MG SYRINGE |
5 |
Tier 5 |
33% | 33% | P Q:16 /10Days |
ARIXTRA 2.5MG SYRINGE |
4 |
Tier 4 |
$45.00 | $135.00 | P Q:10 /10Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARIXTRA 5MG SYRINGE |
5 |
Tier 5 |
33% | 33% | P Q:8 /10Days |
ARIXTRA 7.5MG SYRINGE |
5 |
Tier 5 |
33% | 33% | P Q:12 /10Days |
AROMASIN 25MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | None |
ARTHROTEC 50 50MG TABLET -200MCG (60 CT) |
4 |
Tier 4 |
$45.00 | $135.00 | S |
ARTHROTEC 75 TABLET EC |
4 |
Tier 4 |
$45.00 | $135.00 | S |
ASACOL 400MG TABLET EC |
4 |
Tier 4 |
$45.00 | $135.00 | Q:240 /30Days |
ASCOMP W/CODEINE 30-50-325 CAPSULE |
4 |
Tier 4 |
$45.00 | $135.00 | Q:360 /30Days |
ASMANEX 220MCG(14) AEROSOL POWDER BREATH ACTIVATED |
3 |
Tier 3 |
$25.00 | $75.00 | None |
ASMANEX TWISTHALER 220MCG #120 |
3 |
Tier 3 |
$25.00 | $75.00 | None |
ASMANEX TWISTHALER 220MCG #30 |
3 |
Tier 3 |
$25.00 | $75.00 | None |
ASMANEX TWISTHALER 220MCG #60 |
3 |
Tier 3 |
$25.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ASTELIN 137MCG AEROSOL SPRAY W/PUMP |
3 |
Tier 3 |
$25.00 | $75.00 | Q:30 /30Days |
ASTEPRO NASAL SPRAY 137 MCG/SPRY |
3 |
Tier 3 |
$25.00 | $75.00 | None |
ATACAND 16MG TABLET |
4 |
Tier 4 |
$45.00 | $135.00 | None |
ATACAND 32MG TABLET |
4 |
Tier 4 |
$45.00 | $135.00 | None |
ATACAND 4MG TABLET |
4 |
Tier 4 |
$45.00 | $135.00 | None |
ATACAND 8MG TABLET |
4 |
Tier 4 |
$45.00 | $135.00 | None |
ATACAND HCT 16/12.5MG TABLET |
4 |
Tier 4 |
$45.00 | $135.00 | None |
ATACAND HCT 32/12.5MG TABLET |
4 |
Tier 4 |
$45.00 | $135.00 | None |
ATACAND HCT TABLETS 32;25MG;MG 90 TABLETS BOT |
4 |
Tier 4 |
$45.00 | $135.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATGAM 50MG/ML AMPUL |
5 |
Tier 5 |
33% | 33% | P |
ATRIPLA TABLET 600MG/200MG |
3 |
Tier 3 |
$25.00 | $75.00 | None |
ATROVENT HFA AER 17MCG |
3 |
Tier 3 |
$25.00 | $75.00 | None |
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML |
3 |
Tier 3 |
$25.00 | $75.00 | None |
AVANDAMET 2MG/1000MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | None |
AVANDAMET 2MG/500MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | None |
AVANDAMET 4MG/500MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | None |
AVANDAMET TABLET 4-1000MG |
3 |
Tier 3 |
$25.00 | $75.00 | None |
AVANDARYL 4MG/4MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | None |
AVANDIA 2MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | None |
AVANDIA 4MG TABLET (90 CT) |
3 |
Tier 3 |
$25.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVANDIA 8MG TABLET (90 CT) |
3 |
Tier 3 |
$25.00 | $75.00 | None |
AVASTIN 100MG/4ML VIAL |
5 |
Tier 5 |
33% | 33% | P |
AVODART 0.5MG SOFTGEL |
3 |
Tier 3 |
$25.00 | $75.00 | None |
AVONEX ADMIN PACK 30MCG SYR |
5 |
Tier 5 |
33% | 33% | P |
AVONEX ADMIN PACK 30MCG VL |
5 |
Tier 5 |
33% | 33% | P |
AZACTAM 2GM VIAL |
3 |
Tier 3 |
$25.00 | $75.00 | None |
AZACTAM INJECTION 1GM 50ML BAG |
3 |
Tier 3 |
$25.00 | $75.00 | None |
AZACTAM/ISO-OSMOT 2GM/50ML |
3 |
Tier 3 |
$25.00 | $75.00 | None |
AZASAN 100MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | P |
AZASAN 75MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | P |
AZASITE 1% DROPS |
2 |
Tier 2 |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZATHIOPRINE 50MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | P |
AZATHIOPRINE SOD 100MG VIAL |
2 |
Tier 2 |
$10.00 | $30.00 | P |
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Tier 2 |
$10.00 | $30.00 | None |
AZITHROMYCIN 250MG TABLET (30 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | Q:30 /30Days |
AZITHROMYCIN 500MG TABLET (30 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | Q:30 /30Days |
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD |
2 |
Tier 2 |
$10.00 | $30.00 | P |
AZITHROMYCIN TABLET 600MG (30 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | Q:30 /30Days |
AZMACORT INHALATION AEROSOL .1MG/1IHL 20 GM CSTR |
4 |
Tier 4 |
$45.00 | $135.00 | None |
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT |
3 |
Tier 3 |
$25.00 | $75.00 | None |
AZOR 10MG-20MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZOR 10MG-40MG TABLET (30 CT) |
3 |
Tier 3 |
$25.00 | $75.00 | None |
AZOR 5MG-20MG TABLET (30 CT) |
3 |
Tier 3 |
$25.00 | $75.00 | None |
AZOR 5MG-40MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | None |