2010 Medicare Part D Plan Formulary Information |
Community CCRx Choice (PDP) (S5803-159-0)
Benefit Details
|
The Community CCRx Choice (PDP) (S5803-159-0) Formulary Drugs Starting with the Letter P in CMS PDP Region 22 which includes: TX
|
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 |
2 |
Preferred Brand |
$35.00 | N/A | None |
PACERONE 200MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
PACERONE 300MG TABLET |
2 |
Preferred Brand |
$35.00 | N/A | None |
PAMIDRONATE DISODIUM INJECTION 3MG 10ML VIALSD |
1 |
Generic |
$5.00 | N/A | None |
PAMIDRONATE DISODIUM INJECTION 9MG 10ML VIALSD |
1 |
Generic |
$5.00 | N/A | None |
PANCREASE MT 10 CAPSULE EC |
3 |
Non-Preferred Brand |
$65.00 | N/A | None |
PANCREASE MT 16 CAPSULE EC |
3 |
Non-Preferred Brand |
$65.00 | N/A | None |
PANCREASE MT 20 CAPSULE EC |
3 |
Non-Preferred Brand |
$65.00 | N/A | None |
PANCREASE MT 4 CAPSULE EC |
3 |
Non-Preferred Brand |
$65.00 | N/A | None |
PANCRECARB MS-16 52-16-52 CAPSULE DELAYED RELEASE |
3 |
Non-Preferred Brand |
$65.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PANCRECARB MS-4 CAPSULE EC |
3 |
Non-Preferred Brand |
$65.00 | N/A | None |
PANCRECARB MS-8 PANCRELIPASE CAPSULES 40000UNT (100 CT) |
3 |
Non-Preferred Brand |
$65.00 | N/A | None |
PANCRELIPASE 16-48-48 CAPSULE |
2 |
Preferred Brand |
$35.00 | N/A | None |
PANCRELIPASE TABLET 8000;30000 MG; |
2 |
Preferred Brand |
$35.00 | N/A | None |
PANCRON 10 CAPSULE EC |
2 |
Preferred Brand |
$35.00 | N/A | None |
PANCRON 20 CAPSULE SA |
2 |
Preferred Brand |
$35.00 | N/A | None |
PANRETIN 0.1% GEL 60GM TUBE |
4 |
Specialty |
29% | N/A | None |
PAROMOMYCIN 250MG CAPSULE |
1 |
Generic |
$5.00 | N/A | None |
PAROXETINE 40MG TABLET (500 CT) |
1 |
Generic |
$5.00 | N/A | Q:45 /30Days |
PAROXETINE FILM COATED 20MG TABLET (100 CT) |
1 |
Generic |
$5.00 | N/A | Q:45 /30Days |
PAROXETINE HCL 10MG TABLET |
1 |
Generic |
$5.00 | N/A | Q:45 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAROXETINE HCL 10MG/5ML SUSPENSION ORAL |
1 |
Generic |
$5.00 | N/A | Q:900 /30Days |
PAROXETINE TABLETS 30MG 90 BOT |
1 |
Generic |
$5.00 | N/A | Q:45 /30Days |
PASER GRANULES 4GM PACKET |
3 |
Non-Preferred Brand |
$65.00 | N/A | None |
PATADAY 0.2% DROPS |
2 |
Preferred Brand |
$35.00 | N/A | Q:5 /30Days |
PATANOL 0.1% EYE DROPS |
2 |
Preferred Brand |
$35.00 | N/A | Q:10 /30Days |
PEDI-DRI TOPICAL POWDER |
1 |
Generic |
$5.00 | N/A | None |
PEDIARIX SOLUTION INJECTION 25-25-10 10 X .5ML VIAL |
2 |
Preferred Brand |
$35.00 | N/A | None |
PEDVAXHIB VACCINE VIAL |
3 |
Non-Preferred Brand |
$65.00 | N/A | None |
PEG 3350/ELECTROLYTE 240-22.72G SOLUTION RECONSTITUTED ORAL |
1 |
Generic |
$5.00 | N/A | None |
PEG-INTRON 100MCG KIT |
4 |
Specialty |
29% | N/A | P Q:4 /28Days |
PEG-INTRON REDIPEN 120MCG |
4 |
Specialty |
29% | N/A | P Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEG-INTRON REDIPEN 150MCG |
4 |
Specialty |
29% | N/A | P Q:4 /28Days |
PEG-INTRON REDIPEN 50MCG |
4 |
Specialty |
29% | N/A | P Q:4 /28Days |
PEG-INTRON REDIPEN 80MCG |
4 |
Specialty |
29% | N/A | P Q:4 /28Days |
PEG-INTRON REDIPEN 80MCG 4PK |
4 |
Specialty |
29% | N/A | P Q:4 /28Days |
PEG-INTRON REDIPEN PAK 4 |
4 |
Specialty |
29% | N/A | P Q:4 /28Days |
PEGANONE 250MG TABLET |
3 |
Non-Preferred Brand |
$65.00 | N/A | None |
PEGASYS 180MCG/0.5ML CONV.PK |
4 |
Specialty |
29% | N/A | P Q:1 /28Days |
PEGINTRON REDIPEN 150MCG 4PK |
4 |
Specialty |
29% | N/A | P Q:4 /28Days |
PENICILLIN G POTASSIUM FOR INJECTION |
1 |
Generic |
$5.00 | N/A | None |
PENICILLIN G POTASSIUM FOR INJECTION |
1 |
Generic |
$5.00 | N/A | None |
PENICILLIN G SODIUM FOR INJECTION 5000000UNT 1 VIAL |
2 |
Preferred Brand |
$35.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENICILLIN V POTASSIUM 250MG TABLET (1000 CT) |
1 |
Generic |
$5.00 | N/A | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
1 |
Generic |
$5.00 | N/A | None |
PENICILLIN V POTASSIUM 500MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
PENICILLIN V POTASSIUM FOR ORAL SOLUTION CONCENTRATE 125MG 200ML BOT |
1 |
Generic |
$5.00 | N/A | None |
PENTASA 250MG CAPSULE SA |
3 |
Non-Preferred Brand |
$65.00 | N/A | None |
PENTASA 500MG CAPSULE |
3 |
Non-Preferred Brand |
$65.00 | N/A | None |
PENTOPAK 400MG TABLET SA |
1 |
Generic |
$5.00 | N/A | None |
PENTOXIFYLLINE 400MG TABLET SA |
1 |
Generic |
$5.00 | N/A | None |
PENTOXIL 400MG TABLET SA |
1 |
Generic |
$5.00 | N/A | None |
PERFOROMIST 20MCG/2ML VIAL NEBULIZER |
2 |
Preferred Brand |
$35.00 | N/A | P Q:120 /30Days |
PERIOGARD 0.12% ORAL RINSE |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PERMETHRIN 5% CREAM |
1 |
Generic |
$5.00 | N/A | None |
PERPHENAZINE TABLETS 16MG 100 BOT |
1 |
Generic |
$5.00 | N/A | None |
PERPHENAZINE TABLETS 4MG 100 BOXUD |
1 |
Generic |
$5.00 | N/A | None |
PERPHENAZINE TABLETS 8MG 100 BOT |
1 |
Generic |
$5.00 | N/A | None |
PERPHENAZINE TABLETS USP 2MG 100 BOT |
1 |
Generic |
$5.00 | N/A | None |
PFIZERPEN 5MMU VIAL |
1 |
Generic |
$5.00 | N/A | None |
PHENADOZ 12.5MG SUPPOSITORY |
1 |
Generic |
$5.00 | N/A | None |
PHENADOZ 25MG SUPPOSITORY |
1 |
Generic |
$5.00 | N/A | None |
PHENYTEK 200MG CAPSULE |
2 |
Preferred Brand |
$35.00 | N/A | None |
PHENYTEK 300MG CAPSULE |
2 |
Preferred Brand |
$35.00 | N/A | None |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT |
1 |
Generic |
$5.00 | N/A | 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) |
1 |
Generic |
$5.00 | N/A | None |
PHENYTOIN SODIUM INJECTION 50MG 25 X 2ML AMP |
1 |
Generic |
$5.00 | N/A | None |
PHOSLO 667MG CAPSULE |
2 |
Preferred Brand |
$35.00 | N/A | None |
PHOSPHOLINE IODIDE 0.125% |
3 |
Non-Preferred Brand |
$65.00 | N/A | None |
PHYSIOLYTE SOLUTION FOR IRRIGATION |
2 |
Preferred Brand |
$35.00 | N/A | None |
PHYSIOSOL IRRIGATION SOL |
2 |
Preferred Brand |
$35.00 | N/A | None |
PILOCARPINE HCL 5MG TABLET (100 CT) |
1 |
Generic |
$5.00 | N/A | None |
PILOCARPINE HCL 7.5MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
PILOPINE HS 4% EYE GEL |
2 |
Preferred Brand |
$35.00 | N/A | None |
PINDOLOL 10MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
PINDOLOL 5MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PIROXICAM 10MG CAPSULE |
1 |
Generic |
$5.00 | N/A | None |
PIROXICAM 20MG CAPSULE (500 CT) |
1 |
Generic |
$5.00 | N/A | None |
PLAN B 0.75MG TABLET 2 BLPK |
2 |
Preferred Brand |
$35.00 | N/A | None |
PLASMA-LYTE 148 IV SOLUTION |
3 |
Non-Preferred Brand |
$65.00 | N/A | None |
PLASMA-LYTE 148/DEXTROSE 5% |
3 |
Non-Preferred Brand |
$65.00 | N/A | None |
PLASMA-LYTE 56 INJECTION 32;128 MG/100ML; |
3 |
Non-Preferred Brand |
$65.00 | N/A | None |
PLASMA-LYTE 56/DEXTROSE 5% |
3 |
Non-Preferred Brand |
$65.00 | N/A | None |
PLASMA-LYTE A PH 7.4 SOLUTION 37;368; MG/100ML; |
3 |
Non-Preferred Brand |
$65.00 | N/A | None |
PLASMA-LYTE INJ-R |
1 |
Generic |
$5.00 | N/A | None |
PLAVIX 75MG TABLET |
2 |
Preferred Brand |
$35.00 | N/A | Q:30 /30Days |
PODOFILOX 0.5% TOPICAL TUBEX |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POLY-DEX 0.1% SUSPENSION DROPS |
1 |
Generic |
$5.00 | N/A | None |
POLY-DEX 3.5-10K-.1 OINTMENT |
1 |
Generic |
$5.00 | N/A | None |
POLYCIN-B 500-10KU/G OINTMENT |
1 |
Generic |
$5.00 | N/A | None |
POLYGAM S/D 10GM VL W/DILUENT |
4 |
Specialty |
29% | N/A | P |
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1% |
1 |
Generic |
$5.00 | N/A | None |
PORTIA 0.15-0.03 TABLET |
1 |
Generic |
$5.00 | N/A | Q:28 /28Days |
POTASSIUM CHLORIDE 0.075%/D5W/SODIUM CHLORIDE 0.2% |
2 |
Preferred Brand |
$35.00 | N/A | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.3% |
2 |
Preferred Brand |
$35.00 | N/A | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45% |
2 |
Preferred Brand |
$35.00 | N/A | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.9% 1000ML |
2 |
Preferred Brand |
$35.00 | N/A | None |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.2% |
2 |
Preferred Brand |
$35.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG |
2 |
Preferred Brand |
$35.00 | N/A | None |
POTASSIUM CHLORIDE 10MEQ TABLET SA |
1 |
Generic |
$5.00 | N/A | None |
POTASSIUM CHLORIDE 20MEQ IN D5W/NACL 0.225% |
2 |
Preferred Brand |
$35.00 | N/A | None |
POTASSIUM CHLORIDE 20MEQ TABLET SR PARTICLES/CRYSTALS |
1 |
Generic |
$5.00 | N/A | None |
POTASSIUM CHLORIDE 40MEQ IN D5W LACT RNG |
1 |
Generic |
$5.00 | N/A | None |
POTASSIUM CHLORIDE 40MEQ IN D5W/NACL 0.9% |
2 |
Preferred Brand |
$35.00 | N/A | None |
POTASSIUM CHLORIDE 40MEQ/NS 1000ML IV SOLUTION |
2 |
Preferred Brand |
$35.00 | N/A | None |
POTASSIUM CHLORIDE 8MEQ TABLET SA |
1 |
Generic |
$5.00 | N/A | None |
POTASSIUM CHLORIDE ER CAPSULES 10MEQ |
1 |
Generic |
$5.00 | N/A | None |
POTASSIUM CHLORIDE ER CPCR 8MEQ |
1 |
Generic |
$5.00 | N/A | None |
POTASSIUM CHLORIDE IN 10% DEXTROSE AND NACL SOLUTION FOR INJECTION |
3 |
Non-Preferred Brand |
$65.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE |
2 |
Preferred Brand |
$35.00 | N/A | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA |
2 |
Preferred Brand |
$35.00 | N/A | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION |
2 |
Preferred Brand |
$35.00 | N/A | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE INJECTION 40 12 X 1000ML CTR |
2 |
Preferred Brand |
$35.00 | N/A | None |
POTASSIUM CHLORIDE IN DEXTROSE AND SODIUM CHLORIDE INJECTION 5-30-.225 12 X 1000ML CTR |
2 |
Preferred Brand |
$35.00 | N/A | None |
POTASSIUM CHLORIDE IN DEXTROSE INJECTION 5GM/75MG |
2 |
Preferred Brand |
$35.00 | N/A | None |
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION 0.15%-0.9% 12 X 1000ML BAG |
1 |
Generic |
$5.00 | N/A | None |
POTASSIUM CITRATE 10MEQ TABLET SA |
1 |
Generic |
$5.00 | N/A | None |
POTASSIUM CITRATE 5MEQ TABLET SA |
1 |
Generic |
$5.00 | N/A | None |
PRANDIN 0.5MG TABLET |
3 |
Non-Preferred Brand |
$65.00 | N/A | Q:120 /30Days |
PRANDIN 1MG TABLET |
3 |
Non-Preferred Brand |
$65.00 | N/A | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRANDIN 2MG TABLET |
3 |
Non-Preferred Brand |
$65.00 | N/A | Q:240 /30Days |
PRAVASTATIN SODIUM 20MG TABLET 500 BOT |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
PRAVASTATIN SODIUM 40MG TABLET (500 CT) |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
PRAVASTATIN SODIUM 80MG TABLET (90 CT) |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
PRAZOSIN 5MG CAPSULE |
1 |
Generic |
$5.00 | N/A | None |
PRAZOSIN HCL 1MG CAPSULE |
1 |
Generic |
$5.00 | N/A | None |
PRAZOSIN HCL 2MG CAPSULE |
1 |
Generic |
$5.00 | N/A | None |
PRED MILD 0.12% EYE DROPS |
2 |
Preferred Brand |
$35.00 | N/A | None |
PRED-G S.O.P. EYE OINTMENT |
2 |
Preferred Brand |
$35.00 | N/A | None |
PREDNISOLONE 5MG/5ML TUBEX |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR |
1 |
Generic |
$5.00 | N/A | None |
PREDNISOLONE SOD 1% EYE DROP |
1 |
Generic |
$5.00 | N/A | None |
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL |
1 |
Generic |
$5.00 | N/A | None |
PREDNISONE 10MG TABLET (100 CT) |
1 |
Generic |
$5.00 | N/A | None |
PREDNISONE 1MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
PREDNISONE 2.5MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
PREDNISONE 20MG TABLET (1000 CT) |
1 |
Generic |
$5.00 | N/A | None |
PREDNISONE 50MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
PREDNISONE 5MG TABLET (100 CT) |
1 |
Generic |
$5.00 | N/A | None |
PREDNISONE 5MG/5ML SOLUTION |
1 |
Generic |
$5.00 | N/A | None |
PREDNISONE 5MG/ML SOLUTION |
3 |
Non-Preferred Brand |
$65.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREMARIN 0.3MG (100 CT) |
2 |
Preferred Brand |
$35.00 | N/A | Q:30 /30Days |
PREMARIN 0.45MG TABLET |
2 |
Preferred Brand |
$35.00 | N/A | Q:30 /30Days |
PREMARIN 0.625MG (100 CT) |
2 |
Preferred Brand |
$35.00 | N/A | Q:30 /30Days |
PREMARIN 0.9MG TABLET |
2 |
Preferred Brand |
$35.00 | N/A | Q:30 /30Days |
PREMARIN 1.25MG (100 CT) |
2 |
Preferred Brand |
$35.00 | N/A | None |
PREMARIN VAGINAL CREAM /APPL |
2 |
Preferred Brand |
$35.00 | N/A | Q:85 /28Days |
PREMASOL 10% IV SOLUTION |
1 |
Generic |
$5.00 | N/A | P |
PREMASOL 6% IV SOLUTION |
1 |
Generic |
$5.00 | N/A | P |
PREMPHASE 0.625/5MG TABLET |
2 |
Preferred Brand |
$35.00 | N/A | Q:28 /28Days |
PREMPRO 0.3MG/1.5MG TABLET |
2 |
Preferred Brand |
$35.00 | N/A | Q:28 /28Days |
PREMPRO 0.45/1.5MG TABLET |
2 |
Preferred Brand |
$35.00 | N/A | Q:28 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREMPRO 0.625/2.5MG TABLET DIALPK |
2 |
Preferred Brand |
$35.00 | N/A | Q:28 /28Days |
PREMPRO 0.625/5MG TABLET |
2 |
Preferred Brand |
$35.00 | N/A | Q:28 /28Days |
PRENATABS OBN TABLETS 200;1;150;MG;MG;MCG; 90 BOT |
3 |
Non-Preferred Brand |
$65.00 | N/A | None |
PREVALITE POW 4GM |
1 |
Generic |
$5.00 | N/A | None |
PREVALITE POW 4GM PK |
1 |
Generic |
$5.00 | N/A | None |
PREVIFEM TABLETS .035;.25MG;MG 28 BLPK |
1 |
Generic |
$5.00 | N/A | Q:28 /28Days |
PREZISTA TABLET 600MG |
4 |
Specialty |
29% | N/A | None |
PREZISTA TABLET 75MG |
4 |
Specialty |
29% | N/A | None |
PREZISTA TABLETS 400MG 60 TABLETS BOT |
4 |
Specialty |
29% | N/A | None |
PRIFTIN 150MG TABLET |
2 |
Preferred Brand |
$35.00 | N/A | None |
PRIMAQUINE 26.3MG TABLET |
2 |
Preferred Brand |
$35.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRIMAXIN I.M. 500MG VIAL |
4 |
Specialty |
29% | N/A | None |
PRIMAXIN IV 250MG VIAL |
3 |
Non-Preferred Brand |
$65.00 | N/A | None |
PRIMAXIN IV INJ 500MG |
4 |
Specialty |
29% | N/A | None |
PRIMIDONE 250MG TABLET (100 CT) |
1 |
Generic |
$5.00 | N/A | None |
PRIMIDONE 50MG TABLET (500 CT) |
1 |
Generic |
$5.00 | N/A | None |
PRISTIQ 100MG TABLET SR 24HR |
3 |
Non-Preferred Brand |
$65.00 | N/A | S Q:30 /30Days |
PRISTIQ 50MG TABLET SR 24HR |
3 |
Non-Preferred Brand |
$65.00 | N/A | S Q:30 /30Days |
PROBENECID 500MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
PROBENECID/COLCHICINE TABLET S |
1 |
Generic |
$5.00 | N/A | None |
PROCALAMINE INJECTION 210MG-290MG-26MG 6 X 1000ML BOT |
3 |
Non-Preferred Brand |
$65.00 | N/A | P |
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT) |
1 |
Generic |
$5.00 | N/A | None |
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT) |
1 |
Generic |
$5.00 | N/A | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX |
1 |
Generic |
$5.00 | N/A | None |
PROCRIT 10000U/ML VIAL |
2 |
Preferred Brand |
$35.00 | N/A | P Q:12 /28Days |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL |
2 |
Preferred Brand |
$35.00 | N/A | P Q:12 /28Days |
PROCRIT 3000U/ML VIAL |
2 |
Preferred Brand |
$35.00 | N/A | P Q:12 /28Days |
PROCRIT 40000U/ML VIAL PR |
4 |
Specialty |
29% | N/A | P Q:12 /28Days |
PROCRIT 4000U/ML VIAL 25 X 1ML VIAL |
2 |
Preferred Brand |
$35.00 | N/A | P Q:12 /28Days |
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY |
4 |
Specialty |
29% | N/A | P Q:12 /28Days |
PROCTO-PAK 1% CREAM |
1 |
Generic |
$5.00 | N/A | None |
PROCTOCREAM-HC 2.5% CREAM |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCTOSOL-HC 2.5% CREAM |
1 |
Generic |
$5.00 | N/A | None |
PROCTOZONE-HC 2.5% CREAM |
1 |
Generic |
$5.00 | N/A | None |
PROGLYCEM 50MG/ML ORAL SUSP |
2 |
Preferred Brand |
$35.00 | N/A | None |
PROGRAF 0.5MG CAPSULE |
3 |
Non-Preferred Brand |
$65.00 | N/A | P |
PROGRAF 1MG CAPSULE |
3 |
Non-Preferred Brand |
$65.00 | N/A | P |
PROGRAF 5MG CAPSULE |
4 |
Specialty |
29% | N/A | P |
PROGRAF 5MG/ML AMPULE |
3 |
Non-Preferred Brand |
$65.00 | N/A | P |
PROLASTIN 500MG VIAL |
4 |
Specialty |
29% | N/A | P |
PROLEUKIN 22 MILLION UNITS VL |
4 |
Specialty |
29% | N/A | P |
PROMACTA TABLETS |
4 |
Specialty |
29% | N/A | P Q:45 /30Days |
PROMACTA TABLETS 25 MG |
4 |
Specialty |
29% | N/A | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMETHAZINE 50MG/ML VIAL |
1 |
Generic |
$5.00 | N/A | None |
PROMETHAZINE HCL 12.5MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
PROMETHAZINE HCL 25MG TABLET (1000 CT) |
1 |
Generic |
$5.00 | N/A | None |
PROMETHAZINE HCL 50MG TABLET (100 CT) |
1 |
Generic |
$5.00 | N/A | None |
PROMETHAZINE HCL 6.25MG/5ML SYRUP |
1 |
Generic |
$5.00 | N/A | None |
PROMETHAZINE HCL INJECTION 25MG 10 X 1ML VIAL |
1 |
Generic |
$5.00 | N/A | None |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX |
1 |
Generic |
$5.00 | N/A | None |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX |
1 |
Generic |
$5.00 | N/A | None |
PROMETHEGAN 25MG SUPP |
1 |
Generic |
$5.00 | N/A | None |
PROMETHEGAN 50MG SUPPOS |
1 |
Generic |
$5.00 | N/A | None |
PROPAFENONE HCL 150MG TABLET (100 CT) |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPAFENONE HCL 225MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
PROPAFENONE HCL 300MG TABLET (100 CT) |
1 |
Generic |
$5.00 | N/A | None |
PROPANTHELINE 15MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
PROPOXY-N/APAP 100-650 TABLET |
1 |
Generic |
$5.00 | N/A | Q:180 /30Days |
PROPOXY-N/APAP 50-325 TABLET |
1 |
Generic |
$5.00 | N/A | Q:360 /30Days |
PROPOXYPHENE HCL AND ACETAMINOPHEN TABLET 650/65MG (500 CT) |
1 |
Generic |
$5.00 | N/A | Q:180 /30Days |
PROPOXYPHENE HCL CAPSULES 65MG (100 CT) |
1 |
Generic |
$5.00 | N/A | Q:180 /30Days |
PROPRANOLOL 20MG/5ML TUBEX |
1 |
Generic |
$5.00 | N/A | None |
PROPRANOLOL 40MG/5ML TUBEX |
1 |
Generic |
$5.00 | N/A | None |
PROPRANOLOL 60MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
PROPRANOLOL 80MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPRANOLOL HCL 20MG TABLET (1000 CT) |
1 |
Generic |
$5.00 | N/A | None |
PROPRANOLOL HCL CAPSULES ER 120MG (1000 CT) |
1 |
Generic |
$5.00 | N/A | Q:60 /30Days |
PROPRANOLOL HCL CAPSULES ER 160MG (1000 CT) |
1 |
Generic |
$5.00 | N/A | Q:60 /30Days |
PROPRANOLOL HCL CAPSULES ER 60MG (100 CT) |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
PROPRANOLOL HCL CAPSULES ER 80MG (1000 CT) |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
PROPRANOLOL HCL TABLET USP 10MG (1000 CT) |
1 |
Generic |
$5.00 | N/A | None |
PROPRANOLOL HCL TABLET USP 40MG (1000 CT) |
1 |
Generic |
$5.00 | N/A | None |
PROPRANOLOL/HCTZ 40/25 TABLET |
1 |
Generic |
$5.00 | N/A | None |
PROPRANOLOL/HCTZ 80/25 TABLET |
1 |
Generic |
$5.00 | N/A | None |
PROPYLTHIOURACIL 50MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
PROQUAD VIAL |
3 |
Non-Preferred Brand |
$65.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROSOL 20% INJECTION |
3 |
Non-Preferred Brand |
$65.00 | N/A | P |
PROTRIPTYLINE HYDROCHLORIDE TABLETS |
1 |
Generic |
$5.00 | N/A | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG |
1 |
Generic |
$5.00 | N/A | None |
PROVIGIL 100MG TABLET |
3 |
Non-Preferred Brand |
$65.00 | N/A | P Q:30 /30Days |
PROVIGIL 200MG TABLET |
3 |
Non-Preferred Brand |
$65.00 | N/A | P Q:30 /30Days |
PULMICORT .25MG/2ML RESPULE |
3 |
Non-Preferred Brand |
$65.00 | N/A | P Q:120 /30Days |
PULMICORT 0.5MG/2ML RESPULE |
3 |
Non-Preferred Brand |
$65.00 | N/A | P Q:120 /30Days |
PULMICORT 1MG/2ML AMPUL FOR NEBULIZATION |
3 |
Non-Preferred Brand |
$65.00 | N/A | P Q:60 /30Days |
PULMICORT FLEXHALER 180MCG AEROSOL POWDER BREATH ACTIVATED |
2 |
Preferred Brand |
$35.00 | N/A | Q:2 /30Days |
PULMICORT FLEXHALER 90MCG AEROSOL POWDER BREATH ACTIVATED |
2 |
Preferred Brand |
$35.00 | N/A | Q:1 /30Days |
PULMOZYME 1MG/ML AMPUL |
4 |
Specialty |
29% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PYRAZINAMIDE 500MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
PYRIDOSTIGMINE BROMIDE 60MG TABLET |
1 |
Generic |
$5.00 | N/A | None |