2010 Medicare Part D Plan Formulary Information |
AbilityCare (HMO) (H5703-001-0)
Benefit Details
|
The AbilityCare (HMO) (H5703-001-0) Formulary Drugs Starting with the Letter A in Statewide County, MN: CMS MA Region 19 which includes: MN
|
Drugs Starting with Letter A
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
A METHAPRED METHLYPREDNISOLONE SODIUM SUCCINATE FOR INJECTION 125 MG |
1 |
Tier 1 |
N/A | N/A | None |
A-METHAPRED 40MG UNIVIAL |
1 |
Tier 1 |
N/A | N/A | None |
ACARBOSE 100MG TABLET S |
1 |
Tier 1 |
N/A | N/A | None |
ACARBOSE 25MG TABLET S |
1 |
Tier 1 |
N/A | N/A | None |
ACARBOSE 50MG TABLET S |
1 |
Tier 1 |
N/A | N/A | None |
ACCOLATE 10MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
ACCOLATE 20MG TABLET |
2 |
Tier 2 |
N/A | N/A | S |
ACEBUTOLOL 200MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
ACEBUTOLOL 400MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) |
1 |
Tier 1 |
N/A | N/A | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT) |
1 |
Tier 1 |
N/A | N/A | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
ACETAZOLAMIDE 125MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
ACETIC ACID 2% SOLUTION NON-ORAL |
1 |
Tier 1 |
N/A | N/A | None |
ACETIC ACID IN AQUEOUS ALUMINUM ACETATE OTIC SOLUTION 2% 60 ML BOT |
1 |
Tier 1 |
N/A | N/A | None |
ACTICIN 5% CREAM |
1 |
Tier 1 |
N/A | N/A | None |
ACTOPLUS MET 15MG/500MG TABLET |
2 |
Tier 2 |
N/A | N/A | S |
ACTOPLUS MET 15MG/850MG TABLET |
2 |
Tier 2 |
N/A | N/A | S |
ACTOS 15MG TABLET |
2 |
Tier 2 |
N/A | N/A | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTOS 30MG TABLET (500 CT) |
2 |
Tier 2 |
N/A | N/A | S |
ACTOS 45MG TABLET |
2 |
Tier 2 |
N/A | N/A | S |
ACYCLOVIR 200MG CAPSULE (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
ACYCLOVIR 200MG/5ML SUSP |
1 |
Tier 1 |
N/A | N/A | None |
ACYCLOVIR 400MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
ACYCLOVIR SODIUM 500MG VIAL |
1 |
Tier 1 |
N/A | N/A | P |
ACYCLOVIR TABLET USP 800MG (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
ADVAIR DISKU MIS 100/50 |
2 |
Tier 2 |
N/A | N/A | Q:60 /30Days |
ADVAIR DISKU MIS 250/50 |
2 |
Tier 2 |
N/A | N/A | Q:60 /30Days |
ADVAIR DISKU MIS 500/50 |
2 |
Tier 2 |
N/A | N/A | Q:60 /30Days |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL |
2 |
Tier 2 |
N/A | N/A | Q:12 /30Days |
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 |
N/A | N/A | Q:12 /30Days |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
2 |
Tier 2 |
N/A | N/A | Q:12 /30Days |
AFEDITAB CR 30MG TABLET SA |
1 |
Tier 1 |
N/A | N/A | None |
AFEDITAB CR 60MG TABLET SA |
1 |
Tier 1 |
N/A | N/A | None |
AK-CON 0.1% EYE DROPS |
1 |
Tier 1 |
N/A | N/A | None |
AK-POLY-BAC EYE OINTMENT 500UNT/1000UNT |
1 |
Tier 1 |
N/A | N/A | None |
AKTOB 0.3% EYE DROPS |
1 |
Tier 1 |
N/A | N/A | None |
ALA-CORT 1% CREAM |
1 |
Tier 1 |
N/A | N/A | None |
ALA-CORT 1% LOTION |
1 |
Tier 1 |
N/A | N/A | None |
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER |
1 |
Tier 1 |
N/A | N/A | P |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
1 |
Tier 1 |
N/A | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER |
1 |
Tier 1 |
N/A | N/A | P |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
1 |
Tier 1 |
N/A | N/A | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
1 |
Tier 1 |
N/A | N/A | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
1 |
Tier 1 |
N/A | N/A | P |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
1 |
Tier 1 |
N/A | N/A | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
1 |
Tier 1 |
N/A | N/A | None |
ALBUTEROL TABLET 4MG (500 CT) |
1 |
Tier 1 |
N/A | N/A | None |
ALCLOMETASONE DIPROPIONATE 0.05% CREAM |
1 |
Tier 1 |
N/A | N/A | None |
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT |
1 |
Tier 1 |
N/A | N/A | None |
ALENDRONATE SODIUM 10MG TABLET |
1 |
Tier 1 |
N/A | N/A | Q:30 /30Days |
ALENDRONATE SODIUM 40MG TABLET |
1 |
Tier 1 |
N/A | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALENDRONATE SODIUM 5MG TABLET |
1 |
Tier 1 |
N/A | N/A | Q:30 /30Days |
ALENDRONATE SODIUM 70MG TABLET 4 BLPK |
1 |
Tier 1 |
N/A | N/A | Q:4 /28Days |
ALENDRONATE SODIUM TABLET 35MG 20 CRTN |
1 |
Tier 1 |
N/A | N/A | Q:4 /28Days |
ALLOPURINOL SODIUM 500MG VIAL |
1 |
Tier 1 |
N/A | N/A | None |
ALLOPURINOL TABLET 300MG (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
ALLOPURINOL TABLET USP 100MG (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
AMANTADINE 100MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
AMCINONIDE 0.1% CREAM |
1 |
Tier 1 |
N/A | N/A | None |
AMIKACIN 250MG/ML VIAL |
1 |
Tier 1 |
N/A | N/A | None |
AMIKACIN 50MG/ML VIAL |
1 |
Tier 1 |
N/A | N/A | None |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT |
1 |
Tier 1 |
N/A | N/A | None |
AMINOPHYLLINE 100MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
AMINOPHYLLINE 200MG TABLET (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
AMINOSYN-HF 8% IV SOLUTION |
1 |
Tier 1 |
N/A | N/A | P |
AMIODARONE HCL 200MG TABLET (60 CT) |
1 |
Tier 1 |
N/A | N/A | None |
AMIODARONE HCL 400MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
AMITRIPTYLINE HCL 100MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
AMITRIPTYLINE HCL 10MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
AMITRIPTYLINE HCL 150MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
1 |
Tier 1 |
N/A | N/A | None |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
1 |
Tier 1 |
N/A | N/A | None |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1 |
Tier 1 |
N/A | N/A | None |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
1 |
Tier 1 |
N/A | N/A | None |
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
AMMONIUM LACTATE 12% CREAM |
1 |
Tier 1 |
N/A | N/A | None |
AMMONIUM LACTATE 12% LOTION |
1 |
Tier 1 |
N/A | N/A | None |
AMNESTEEM 10MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMNESTEEM 20MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
AMNESTEEM 40MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
AMOCLAN 200-28.5/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
N/A | N/A | None |
AMOCLAN 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
N/A | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
N/A | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
1 |
Tier 1 |
N/A | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
1 |
Tier 1 |
N/A | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
N/A | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 500-125MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
AMOXICILLIN 125MG TABLET CHEW |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN 200MG TABLET CHEW |
1 |
Tier 1 |
N/A | N/A | None |
AMOXICILLIN 250MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
AMOXICILLIN 500MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
AMOXICILLIN 500MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
AMOXICILLIN 875MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
1 |
Tier 1 |
N/A | N/A | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
1 |
Tier 1 |
N/A | N/A | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
1 |
Tier 1 |
N/A | N/A | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
1 |
Tier 1 |
N/A | N/A | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Tier 1 |
N/A | N/A | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT) |
1 |
Tier 1 |
N/A | N/A | None |
AMOXIL 250MG/5ML SUSPENSION |
1 |
Tier 1 |
N/A | N/A | None |
AMOXIL CAPSULES 500MG |
1 |
Tier 1 |
N/A | N/A | None |
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
AMPHETAMINE SALT COMBO 15MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
AMPHETAMINE SALT COMBO 30MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
AMPHETAMINE SALTS 20MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
AMPICILLIN CAPSULES 250MG 100 BOT |
1 |
Tier 1 |
N/A | N/A | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN FOR INJECTION POWDER |
1 |
Tier 1 |
N/A | N/A | None |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML |
1 |
Tier 1 |
N/A | N/A | None |
ANAGRELIDE HCL 0.5MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
ANAGRELIDE HCL 1MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
ANDRODERM 2.5MG/24HR PATCH |
2 |
Tier 2 |
N/A | N/A | None |
ANDRODERM 5MG/24HR PATCH |
2 |
Tier 2 |
N/A | N/A | None |
ANDROGEL 1%(50MG) GEL PACKET |
2 |
Tier 2 |
N/A | N/A | None |
ANESTACON 15ML |
1 |
Tier 1 |
N/A | N/A | None |
APAP-CAFFEINE-DIHYDROCODE TAB 30 EA |
1 |
Tier 1 |
N/A | N/A | None |
APRI 0.15-0.03 TABLET |
1 |
Tier 1 |
N/A | N/A | None |
ARANELLE 7-9-5 TABLET |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP 25MCG/ML VIAL |
2 |
Tier 2 |
N/A | N/A | P |
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR |
2 |
Tier 2 |
N/A | N/A | P |
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR |
2 |
Tier 2 |
N/A | N/A | P |
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD |
2 |
Tier 2 |
N/A | N/A | P |
ARICEPT 10MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
ARICEPT 5MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
ARICEPT ODT 10MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
ARICEPT ODT 5MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
AROMASIN 25MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
ASACOL 400MG TABLET EC |
2 |
Tier 2 |
N/A | N/A | None |
ASACOL HD DELAYED RELEASE TABLETS 800MG 180 BOT |
2 |
Tier 2 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ASTELIN 137MCG AEROSOL SPRAY W/PUMP |
2 |
Tier 2 |
N/A | N/A | Q:60 /30Days |
ASTEPRO NASAL SPRAY 137 MCG/SPRY |
2 |
Tier 2 |
N/A | N/A | Q:60 /30Days |
ASTRAMORPH-PF 0.5MG/ML VIAL |
1 |
Tier 1 |
N/A | N/A | P |
ASTRAMORPH-PF 1MG/ML VIAL |
1 |
Tier 1 |
N/A | N/A | P |
ATAMET |
1 |
Tier 1 |
N/A | N/A | None |
ATENOLOL 25MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
ATENOLOL TABLET USP 50MG (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
ATENOLOL TABLETS USP 100MG 1 BLPK |
1 |
Tier 1 |
N/A | N/A | None |
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
AVANDAMET 2MG/1000MG TABLET |
2 |
Tier 2 |
N/A | N/A | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVANDAMET 2MG/500MG TABLET |
2 |
Tier 2 |
N/A | N/A | S |
AVANDAMET 4MG/500MG TABLET |
2 |
Tier 2 |
N/A | N/A | S |
AVANDAMET TABLET 4-1000MG |
2 |
Tier 2 |
N/A | N/A | S |
AVANDARYL 4MG/1MG TABLET |
2 |
Tier 2 |
N/A | N/A | S |
AVANDARYL 4MG/2MG TABLET |
2 |
Tier 2 |
N/A | N/A | S |
AVANDARYL 4MG/4MG TABLET |
2 |
Tier 2 |
N/A | N/A | S |
AVANDARYL 8MG-2MG TABLET |
2 |
Tier 2 |
N/A | N/A | S |
AVANDARYL 8MG-4MG TABLET |
2 |
Tier 2 |
N/A | N/A | S |
AVANDIA 2MG TABLET |
2 |
Tier 2 |
N/A | N/A | S |
AVANDIA 4MG TABLET (90 CT) |
2 |
Tier 2 |
N/A | N/A | S |
AVANDIA 8MG TABLET (90 CT) |
2 |
Tier 2 |
N/A | N/A | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVIANE 0.1-0.02 TABLET |
1 |
Tier 1 |
N/A | N/A | None |
AVINZA 120MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
N/A | N/A | None |
AVINZA 30MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
N/A | N/A | None |
AVINZA 60MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
N/A | N/A | None |
AVINZA 90MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
N/A | N/A | None |
AVINZA CAPSULES EXTENDED RELEASE 45MG 100 BOTPL |
2 |
Tier 2 |
N/A | N/A | None |
AVINZA CAPSULES EXTENDED RELEASE 75MG 100 BOTPL |
2 |
Tier 2 |
N/A | N/A | None |
AVITA 0.025% CREAM |
1 |
Tier 1 |
N/A | N/A | None |
AVODART 0.5MG SOFTGEL |
2 |
Tier 2 |
N/A | N/A | None |
AZACTAM 2GM VIAL |
2 |
Tier 2 |
N/A | N/A | None |
AZACTAM INJECTION 1GM 50ML BAG |
2 |
Tier 2 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZACTAM/ISO-OSMOT 2GM/50ML |
2 |
Tier 2 |
N/A | N/A | None |
AZATHIOPRINE 50MG TABLET |
1 |
Tier 1 |
N/A | N/A | P |
AZILECT 0.5MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
AZILECT 1MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
N/A | N/A | None |
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
N/A | N/A | None |
AZITHROMYCIN 250MG TABLET (30 CT) |
1 |
Tier 1 |
N/A | N/A | None |
AZITHROMYCIN 500MG TABLET (30 CT) |
1 |
Tier 1 |
N/A | N/A | None |
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD |
1 |
Tier 1 |
N/A | N/A | None |
AZITHROMYCIN TABLET 600MG (30 CT) |
1 |
Tier 1 |
N/A | N/A | None |
AZOR 10MG-20MG TABLET |
2 |
Tier 2 |
N/A | N/A | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZOR 10MG-40MG TABLET (30 CT) |
2 |
Tier 2 |
N/A | N/A | S |
AZOR 5MG-20MG TABLET (30 CT) |
2 |
Tier 2 |
N/A | N/A | S |
AZOR 5MG-40MG TABLET |
2 |
Tier 2 |
N/A | N/A | S |