2010 Medicare Part D Plan Formulary Information |
Windsor Medicare Extra Fusion Plan (HMO) (H5698-141-0)
Benefit Details
|
The Windsor Medicare Extra Fusion Plan (HMO) (H5698-141-0) Formulary Drugs Starting with the Letter P in Union County, TN: CMS MA Region 10 which includes: TN
|
Drugs Starting with Letter P
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
PACERONE 100MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PACERONE 200MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PACERONE 300MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PAMIDRONATE 60MG/10ML VIAL |
2 |
Tier 2 |
$10.00 | $30.00 | P |
PAMIDRONATE DISODIUM INJECTION 3MG 10ML VIALSD |
2 |
Tier 2 |
$10.00 | $30.00 | P |
PANCREASE MT 10 CAPSULE EC |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PANCREASE MT 16 CAPSULE EC |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PANCREASE MT 20 CAPSULE EC |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PANCREASE MT 4 CAPSULE EC |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PANCRELIPASE 16-48-48 CAPSULE |
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 |
PANCRELIPASE TABLET 8000;30000 MG; |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PANCRON 10 CAPSULE EC |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PANRETIN 0.1% GEL 60GM TUBE |
4 |
Tier 4 |
$45.00 | $135.00 | None |
PANTOPRAZOLE SODIUM 20MG TABLET DELAYED RELEASE |
4 |
Tier 4 |
$45.00 | $135.00 | S Q:30 /30Days |
PANTOPRAZOLE SODIUM 40MG TABLET DELAYED RELEASE 90 CRC BOT |
4 |
Tier 4 |
$45.00 | $135.00 | S Q:30 /30Days |
PAROMOMYCIN 250MG CAPSULE |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PAROXETINE 40MG TABLET (500 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | Q:30 /30Days |
PAROXETINE FILM COATED 20MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | Q:90 /30Days |
PAROXETINE HCL 10MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | Q:180 /30Days |
PAROXETINE HCL 10MG/5ML SUSPENSION ORAL |
1 |
Tier 1 |
$5.00 | $15.00 | Q:900 /30Days |
PAROXETINE HCL TABLET 24 12.5MG |
4 |
Tier 4 |
$45.00 | $135.00 | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAROXETINE HCL TABLET 24 25MG |
4 |
Tier 4 |
$45.00 | $135.00 | Q:90 /30Days |
PAROXETINE TABLETS 30MG 90 BOT |
1 |
Tier 1 |
$5.00 | $15.00 | Q:45 /30Days |
PASER GRANULES 4GM PACKET |
4 |
Tier 4 |
$45.00 | $135.00 | P |
PATADAY 0.2% DROPS |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PATANOL 0.1% EYE DROPS |
4 |
Tier 4 |
$45.00 | $135.00 | None |
PEDIARIX SOLUTION INJECTION 25-25-10 10 X .5ML VIAL |
4 |
Tier 4 |
$45.00 | $135.00 | None |
PEDVAXHIB VACCINE VIAL |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PEG 3350/ELECTROLYTE 240-22.72G SOLUTION RECONSTITUTED ORAL |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PEG-INTRON 100MCG KIT |
5 |
Tier 5 |
33% | 33% | P |
PEG-INTRON REDIPEN 120MCG |
5 |
Tier 5 |
33% | 33% | P |
PEG-INTRON REDIPEN 150MCG |
5 |
Tier 5 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEG-INTRON REDIPEN 50MCG |
5 |
Tier 5 |
33% | 33% | P |
PEG-INTRON REDIPEN 80MCG |
5 |
Tier 5 |
33% | 33% | P |
PEG-INTRON REDIPEN 80MCG 4PK |
5 |
Tier 5 |
33% | 33% | P |
PEG-INTRON REDIPEN PAK 4 |
5 |
Tier 5 |
33% | 33% | P |
PEGANONE 250MG TABLET |
4 |
Tier 4 |
$45.00 | $135.00 | None |
PEGASYS 180MCG/0.5ML CONV.PK |
5 |
Tier 5 |
33% | 33% | P |
PEGINTRON REDIPEN 150MCG 4PK |
5 |
Tier 5 |
33% | 33% | P |
PENICILLIN G POTASSIUM FOR INJECTION |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PENICILLIN G POTASSIUM FOR INJECTION |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PENICILLIN V POTASSIUM 250MG TABLET (1000 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
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 |
PENICILLIN V POTASSIUM 500MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PENICILLIN V POTASSIUM FOR ORAL SOLUTION CONCENTRATE 125MG 200ML BOT |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PENTASA 250MG CAPSULE SA |
4 |
Tier 4 |
$45.00 | $135.00 | Q:240 /30Days |
PENTASA 500MG CAPSULE |
4 |
Tier 4 |
$45.00 | $135.00 | Q:240 /30Days |
PENTOXIFYLLINE 400MG TABLET SA |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PENTOXIL 400MG TABLET SA |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PERFOROMIST 20MCG/2ML VIAL NEBULIZER |
4 |
Tier 4 |
$45.00 | $135.00 | None |
PERMETHRIN 5% CREAM |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PERPHENAZINE TABLETS 16MG 100 BOT |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PERPHENAZINE TABLETS 8MG 100 BOT |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT |
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 |
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PHENYTOIN SODIUM INJECTION 50MG 25 X 2ML AMP |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PHOSPHOLINE IODIDE 0.125% |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PILOCARPINE HCL 5MG TABLET (100 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PILOCARPINE HCL 7.5MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PILOPINE HS 4% EYE GEL |
4 |
Tier 4 |
$45.00 | $135.00 | None |
PINDOLOL 10MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PIROXICAM 10MG CAPSULE |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PIROXICAM 20MG CAPSULE (500 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
PLAVIX 75MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PODOFILOX 0.5% TOPICAL TUBEX |
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 |
POLYGAM S/D 10GM VL W/DILUENT |
5 |
Tier 5 |
33% | 33% | P |
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1% |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PORTIA 0.15-0.03 TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | Q:28 /28Days |
POTASSIUM CHLORIDE 10MEQ TABLET SA |
2 |
Tier 2 |
$10.00 | $30.00 | None |
POTASSIUM CHLORIDE 20MEQ TABLET SR PARTICLES/CRYSTALS |
2 |
Tier 2 |
$10.00 | $30.00 | None |
POTASSIUM CHLORIDE 20MEQ/50ML SOL |
2 |
Tier 2 |
$10.00 | $30.00 | None |
POTASSIUM CHLORIDE 40MEQ IN D5W LACT RNG |
2 |
Tier 2 |
$10.00 | $30.00 | P |
POTASSIUM CHLORIDE 8MEQ TABLET SA |
2 |
Tier 2 |
$10.00 | $30.00 | None |
POTASSIUM CHLORIDE ER CAPSULES 10MEQ |
2 |
Tier 2 |
$10.00 | $30.00 | None |
POTASSIUM CHLORIDE ER CPCR 8MEQ |
2 |
Tier 2 |
$10.00 | $30.00 | None |
POTASSIUM CITRATE 10MEQ TABLET SA |
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 |
POTASSIUM CITRATE 5MEQ TABLET SA |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PRANDIN 0.5MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PRANDIN 1MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PRANDIN 2MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PRAVASTATIN SODIUM 20MG TABLET 500 BOT |
1 |
Tier 1 |
$5.00 | $15.00 | None |
PRAVASTATIN SODIUM 40MG TABLET (500 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
PRAVASTATIN SODIUM 80MG TABLET (90 CT) |
4 |
Tier 4 |
$45.00 | $135.00 | None |
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT |
1 |
Tier 1 |
$5.00 | $15.00 | None |
PRAZOSIN 5MG CAPSULE |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PRAZOSIN HCL 1MG CAPSULE |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PRAZOSIN HCL 2MG CAPSULE |
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 |
PRED MILD 0.12% EYE DROPS |
4 |
Tier 4 |
$45.00 | $135.00 | None |
PREDNISOLONE 5MG/5ML TUBEX |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PREDNISOLONE SOD 1% EYE DROP |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PREDNISONE 10MG TABLET (100 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PREDNISONE 1MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PREDNISONE 2.5MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PREDNISONE 20MG TABLET (1000 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PREDNISONE 50MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PREDNISONE 5MG 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 |
PREMARIN 0.3MG (100 CT) |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PREMARIN 0.45MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PREMARIN 0.625MG (100 CT) |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PREMARIN 0.9MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PREMARIN 1.25MG (100 CT) |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PREMARIN 25MG VIAL |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PREMARIN VAGINAL CREAM /APPL |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PREMPHASE 0.625/5MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PREMPRO 0.3MG/1.5MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PREMPRO 0.45/1.5MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PREMPRO 0.625/2.5MG TABLET DIALPK |
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 |
PREMPRO 0.625/5MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PRENATABS OBN TABLETS 200;1;150;MG;MG;MCG; 90 BOT |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PREVACID CAPSULES EXTENDED RELEASE 15MG 100 BOXUD |
3 |
Tier 3 |
$25.00 | $75.00 | S Q:30 /30Days |
PREVACID CAPSULES EXTENDED RELEASE 30MG 100 BOXUD |
3 |
Tier 3 |
$25.00 | $75.00 | S Q:30 /30Days |
PREVACID SOLUTAB EXTENDED RELEASE ORALLY DISINTEGRATING 30MG 100 BOXUD |
3 |
Tier 3 |
$25.00 | $75.00 | S Q:30 /30Days |
PREVACID SOLUTAB TABLETS DELAYED RELEASE ORALLY DISINTEGRATING 15MG 100 BOXUD |
3 |
Tier 3 |
$25.00 | $75.00 | S Q:30 /30Days |
PREVALITE POW 4GM |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PREVALITE POW 4GM PK |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PREVIFEM TABLETS .035;.25MG;MG 28 BLPK |
2 |
Tier 2 |
$10.00 | $30.00 | Q:28 /28Days |
PREZISTA TABLET 600MG |
5 |
Tier 5 |
33% | 33% | None |
PREZISTA TABLET 75MG |
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 |
PREZISTA TABLETS 400MG 60 TABLETS BOT |
5 |
Tier 5 |
33% | 33% | None |
PRIFTIN 150MG TABLET |
4 |
Tier 4 |
$45.00 | $135.00 | None |
PRIMAXIN I.M. 500MG VIAL |
5 |
Tier 5 |
33% | 33% | P |
PRIMAXIN IV 250MG VIAL |
4 |
Tier 4 |
$45.00 | $135.00 | P |
PRIMAXIN IV INJ 500MG |
5 |
Tier 5 |
33% | 33% | P |
PRIMIDONE 250MG TABLET (100 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PRIMIDONE 50MG TABLET (500 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PRISTIQ 100MG TABLET SR 24HR |
4 |
Tier 4 |
$45.00 | $135.00 | None |
PRISTIQ 50MG TABLET SR 24HR |
4 |
Tier 4 |
$45.00 | $135.00 | None |
PROAIR HFA 90MCG HFA AEROSOL WITH ADAPTER |
2 |
Tier 2 |
$10.00 | $30.00 | S |
PROBENECID 500MG 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 |
PROBENECID/COLCHICINE TABLET S |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROCAINAMIDE 100MG/ML VIAL |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROCRIT 10000U/ML VIAL |
4 |
Tier 4 |
$45.00 | $135.00 | P Q:12 /28Days |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL |
3 |
Tier 3 |
$25.00 | $75.00 | P Q:12 /28Days |
PROCRIT 3000U/ML VIAL |
3 |
Tier 3 |
$25.00 | $75.00 | P Q:12 /28Days |
PROCRIT 40000U/ML VIAL PR |
5 |
Tier 5 |
33% | 33% | P Q:3 /28Days |
PROCRIT 4000U/ML VIAL 25 X 1ML VIAL |
4 |
Tier 4 |
$45.00 | $135.00 | P Q:12 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY |
5 |
Tier 5 |
33% | 33% | P Q:6 /28Days |
PROCTO-PAK 1% CREAM |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROCTOCREAM-HC 2.5% CREAM |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROCTOSOL-HC 2.5% CREAM |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROCTOZONE-HC 2.5% CREAM |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROGLYCEM 50MG/ML ORAL SUSP |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PROGRAF 0.5MG CAPSULE |
4 |
Tier 4 |
$45.00 | $135.00 | P |
PROGRAF 1MG CAPSULE |
4 |
Tier 4 |
$45.00 | $135.00 | P |
PROGRAF 5MG CAPSULE |
5 |
Tier 5 |
33% | 33% | P |
PROGRAF 5MG/ML AMPULE |
4 |
Tier 4 |
$45.00 | $135.00 | P |
PROLASTIN 500MG VIAL |
5 |
Tier 5 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROLEUKIN 22 MILLION UNITS VL |
5 |
Tier 5 |
33% | 33% | P |
PROMACTA TABLETS |
5 |
Tier 5 |
33% | 33% | P |
PROMACTA TABLETS 25 MG |
5 |
Tier 5 |
33% | 33% | P |
PROMETHAZINE 50MG/ML VIAL |
2 |
Tier 2 |
$10.00 | $30.00 | P |
PROMETHAZINE HCL 12.5MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROMETHAZINE HCL 25MG TABLET (1000 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
PROMETHAZINE HCL 50MG TABLET (100 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROMETHAZINE HCL 6.25MG/5ML SYRUP |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROMETHAZINE HCL INJECTION 25MG 10 X 1ML VIAL |
2 |
Tier 2 |
$10.00 | $30.00 | P |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX |
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 |
PROMETRIUM 100MG CAPSULE |
4 |
Tier 4 |
$45.00 | $135.00 | None |
PROMETRIUM 200MG CAPSULE |
4 |
Tier 4 |
$45.00 | $135.00 | None |
PROPAFENONE HCL 150MG TABLET (100 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROPAFENONE HCL 225MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROPAFENONE HCL 300MG TABLET (100 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROPANTHELINE 15MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROPOXY-N/APAP 100-500MG TABLET |
4 |
Tier 4 |
$45.00 | $135.00 | Q:240 /30Days |
PROPOXY-N/APAP 100-650 TABLET |
4 |
Tier 4 |
$45.00 | $135.00 | Q:180 /30Days |
PROPOXY-N/APAP 50-325 TABLET |
4 |
Tier 4 |
$45.00 | $135.00 | Q:360 /30Days |
PROPOXYPHENE HCL AND ACETAMINOPHEN TABLET 650/65MG (500 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | Q:180 /30Days |
PROPOXYPHENE HCL CAPSULES 65MG (100 CT) |
4 |
Tier 4 |
$45.00 | $135.00 | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPRANOLOL 60MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROPRANOLOL 80MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
PROPRANOLOL HCL 20MG TABLET (1000 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
PROPRANOLOL HCL CAPSULES ER 120MG (1000 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROPRANOLOL HCL CAPSULES ER 160MG (1000 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROPRANOLOL HCL CAPSULES ER 60MG (100 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROPRANOLOL HCL CAPSULES ER 80MG (1000 CT) |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROPRANOLOL HCL INJECTION 1MG 10 PKG OF 10 CRTN |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROPRANOLOL HCL TABLET USP 10MG (1000 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
PROPRANOLOL HCL TABLET USP 40MG (1000 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
PROPRANOLOL/HCTZ 40/25 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 |
PROPRANOLOL/HCTZ 80/25 TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROPYLTHIOURACIL 50MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROQUAD VIAL |
3 |
Tier 3 |
$25.00 | $75.00 | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PROVIGIL 100MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | P |
PROVIGIL 200MG TABLET |
3 |
Tier 3 |
$25.00 | $75.00 | P |
PROZAC WEEKLY 90MG CAPSULE |
3 |
Tier 3 |
$25.00 | $75.00 | S Q:4 /23Days |
PULMICORT .25MG/2ML RESPULE |
4 |
Tier 4 |
$45.00 | $135.00 | P Q:120 /30Days |
PULMICORT 0.5MG/2ML RESPULE |
4 |
Tier 4 |
$45.00 | $135.00 | P Q:120 /30Days |
PULMICORT 1MG/2ML AMPUL FOR NEBULIZATION |
4 |
Tier 4 |
$45.00 | $135.00 | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PULMICORT FLEXHALER 180MCG AEROSOL POWDER BREATH ACTIVATED |
4 |
Tier 4 |
$45.00 | $135.00 | Q:120 /30Days |
PULMICORT FLEXHALER 90MCG AEROSOL POWDER BREATH ACTIVATED |
4 |
Tier 4 |
$45.00 | $135.00 | Q:120 /30Days |
PULMOZYME 1MG/ML AMPUL |
4 |
Tier 4 |
$45.00 | $135.00 | P Q:150 /30Days |
PYRAZINAMIDE 500MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |
PYRIDOSTIGMINE BROMIDE 60MG TABLET |
2 |
Tier 2 |
$10.00 | $30.00 | None |