2010 Medicare Part D Plan Formulary Information |
Triple-S FarmaMed Plus (PDP) (S5907-002-0)
Benefit Details
|
The Triple-S FarmaMed Plus (PDP) (S5907-002-0) Formulary Drugs Starting with the Letter P in CMS PDP Region 38 which includes: PR
|
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 / Nivel 3 |
$50.00 | $150.00 | None |
PACERONE 300MG TABLET |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PACERONE 400MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PAMELOR 10MG/5ML SOLUTION ORAL |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PAMELOR 25MG CAPSULE |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PAMELOR 50MG CAPSULE |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PAMELOR CAPSULES 10 |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PAMELOR CAPSULES 75MG |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PAMINE 2.5MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PAMINE FORTE 5MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PANCREASE MT 10 CAPSULE EC |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PANCREASE MT 16 CAPSULE EC |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PANCREASE MT 20 CAPSULE EC |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PANCREASE MT 4 CAPSULE EC |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PANCRECARB MS-16 52-16-52 CAPSULE DELAYED RELEASE |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PANCRECARB MS-4 CAPSULE EC |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PANCRECARB MS-8 PANCRELIPASE CAPSULES 40000UNT (100 CT) |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PANCRELIPASE 16-48-48 CAPSULE |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PANCRELIPASE TABLET 8000;30000 MG; |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PANCRON 10 CAPSULE EC |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PANCRON 20 CAPSULE SA |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PANDEL 0.1% CREAM45GM |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | Q:80 /15Days |
PANRETIN 0.1% GEL 60GM TUBE |
5 |
Tier 5 / Nivel 5 |
25% | 25% | None |
PANTOPRAZOLE SODIUM 20MG TABLET DELAYED RELEASE |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | S |
PANTOPRAZOLE SODIUM 40MG TABLET DELAYED RELEASE 90 CRC BOT |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | S |
PARAFON FORTE DSC 500MG CPT |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PARLODEL 2.5MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PARLODEL 5MG CAPSULE |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PARNATE 10MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PAROXETINE 40MG TABLET (500 CT) |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PAROXETINE FILM COATED 20MG TABLET (100 CT) |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PAROXETINE HCL 10MG TABLET |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAROXETINE HCL 10MG/5ML SUSPENSION ORAL |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PAROXETINE TABLETS 30MG 90 BOT |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PASER GRANULES 4GM PACKET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PATANOL 0.1% EYE DROPS |
2 |
Tier 2 / Nivel 2 |
$35.00 | $105.00 | S Q:5 /15Days |
PAXIL 10MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PAXIL 10MG/5ML SUSPENSION |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PAXIL 20MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PAXIL 30MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PAXIL 40MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PCE 333MG DISPERTAB |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PCE 500MG DISPERTAB |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEDIAPRED 6.7MG/5ML TUBEX |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PEDIARIX SOLUTION INJECTION 25-25-10 10 X .5ML VIAL |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PEDVAXHIB VACCINE VIAL |
2 |
Tier 2 / Nivel 2 |
$35.00 | $105.00 | None |
PEG 3350/ELECTROLYTE 240-22.72G SOLUTION RECONSTITUTED ORAL |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | Q:4000 /15Days |
PEG-INTRON 100MCG KIT |
5 |
Tier 5 / Nivel 5 |
25% | 25% | P |
PEG-INTRON REDIPEN 120MCG |
5 |
Tier 5 / Nivel 5 |
25% | 25% | P |
PEG-INTRON REDIPEN 150MCG |
5 |
Tier 5 / Nivel 5 |
25% | 25% | P |
PEG-INTRON REDIPEN 50MCG |
5 |
Tier 5 / Nivel 5 |
25% | 25% | P |
PEG-INTRON REDIPEN 80MCG |
5 |
Tier 5 / Nivel 5 |
25% | 25% | P |
PEG-INTRON REDIPEN 80MCG 4PK |
5 |
Tier 5 / Nivel 5 |
25% | 25% | P |
PEG-INTRON REDIPEN PAK 4 |
5 |
Tier 5 / Nivel 5 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEGANONE 250MG TABLET |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PEGASYS 180MCG/0.5ML CONV.PK |
5 |
Tier 5 / Nivel 5 |
25% | 25% | P |
PEGINTRON REDIPEN 150MCG 4PK |
5 |
Tier 5 / Nivel 5 |
25% | 25% | P |
PENICILLIN G PROCAINE 1200000UNT 2ML CTG |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | P |
PENICILLIN V POTASSIUM 250MG TABLET (1000 CT) |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PENICILLIN V POTASSIUM 500MG TABLET |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PENICILLIN V POTASSIUM FOR ORAL SOLUTION CONCENTRATE 125MG 200ML BOT |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PENLAC 8% SOLUTION |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | Q:7 /90Days |
PENTAM 300 INJ 300MG |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | P |
PENTASA 250MG CAPSULE SA |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENTASA 500MG CAPSULE |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PENTOXIFYLLINE 400MG TABLET SA |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PEPCID 20MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PEPCID 40MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PERCOCET 10/325MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PERCOCET 10/650MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PERCOCET 2.5/325MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PERCOCET 7.5/325MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PERCOCET 7.5/500MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PERCOCET TABLET 5-325MG |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
Peridex 0.12% Solution 473ml Bottle |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | Q:473 /15Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PERMETHRIN 5% CREAM |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | Q:60 /30Days |
PERPHENAZINE TABLETS 16MG 100 BOT |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PERPHENAZINE TABLETS 4MG 100 BOXUD |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PERPHENAZINE TABLETS 8MG 100 BOT |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PERPHENAZINE TABLETS USP 2MG 100 BOT |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PERSANTINE 25MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PERSANTINE 50MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PERSANTINE 75MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PHENERGAN 25MG/ML VIAL |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PHENERGAN 50MG/ML VIAL |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | 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) |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PHENYTOIN SODIUM INJECTION 50MG 25 X 2ML AMP |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | P |
PHOSLO 667MG CAPSULE |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PILOCARPINE HCL 5MG TABLET (100 CT) |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PILOCARPINE HCL 7.5MG TABLET |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PILOPINE HS 4% EYE GEL |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PINDOLOL 10MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PINDOLOL 5MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PLAQUENIL 200MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PLASMA-LYTE 148 IV SOLUTION |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | P |
PLASMA-LYTE 56 INJECTION 32;128 MG/100ML; |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PLASMA-LYTE A PH 7.4 SOLUTION 37;368; MG/100ML; |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | P |
PLASMA-LYTE INJ-R |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | P |
PLAVIX 75MG TABLET |
2 |
Tier 2 / Nivel 2 |
$35.00 | $105.00 | P |
PLETAL 100MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PLETAL 50MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PODOFILOX 0.5% TOPICAL TUBEX |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
POLYGAM S/D 10GM VL W/DILUENT |
2 |
Tier 2 / Nivel 2 |
$35.00 | $105.00 | P |
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1% |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
POLYTRIM EYE DROP |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | Q:10 /15Days |
POTASSIUM CHLORIDE 10MEQ TABLET SA |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
POTASSIUM CHLORIDE 20MEQ TABLET SR PARTICLES/CRYSTALS |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE 40MEQ IN D5W LACT RNG |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | P |
POTASSIUM CHLORIDE 8MEQ TABLET SA |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
POTASSIUM CHLORIDE ER CAPSULES 10MEQ |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
POTASSIUM CHLORIDE ER CPCR 8MEQ |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
POTASSIUM CHLORIDE FOR INJECTION CONCENTRATE |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | P |
POTASSIUM CITRATE 10MEQ TABLET SA |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
POTASSIUM CITRATE 5MEQ TABLET SA |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PRANDIMET TABLET |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PRANDIMET TABLET |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PRANDIN 0.5MG TABLET |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PRANDIN 1MG TABLET |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRANDIN 2MG TABLET |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PRAVACHOL 10MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | S |
PRAVACHOL 20MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | S |
PRAVACHOL 40MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | S |
PRAVACHOL 80MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | S |
PRAVASTATIN SODIUM 20MG TABLET 500 BOT |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PRAVASTATIN SODIUM 40MG TABLET (500 CT) |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PRAVASTATIN SODIUM 80MG TABLET (90 CT) |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PRAZOSIN 5MG CAPSULE |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PRAZOSIN HCL 1MG CAPSULE |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAZOSIN HCL 2MG CAPSULE |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PRECOSE TABLETS 100MG 100 BOT |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PRECOSE TABLETS 25MG 100 BOT |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PRECOSE TABLETS 50MG 100 BOXUD |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PRED FORTE 1% EYE DROPS |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | Q:15 /15Days |
PRED G OPHTHALMIC SUSPENSION 1;0.3%;% 5 ML BOTDR |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | Q:10 /15Days |
PRED-G S.O.P. EYE OINTMENT |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | Q:4 /15Days |
PREDNICARBATE 0.1% CREAM |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PREDNICARBATE 0.1% OINTMENT |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PREDNISOLONE 5MG/5ML TUBEX |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISONE 10MG TABLET (100 CT) |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PREDNISONE 1MG TABLET |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PREDNISONE 2.5MG TABLET |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PREDNISONE 20MG TABLET (1000 CT) |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PREDNISONE 50MG TABLET |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PREDNISONE 5MG TABLET (100 CT) |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PREDNISONE 5MG/5ML SOLUTION |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PREDNISONE 5MG/ML SOLUTION |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PRELONE 15MG/5ML SOLUTION ORAL |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PREMARIN 0.3MG (100 CT) |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PREMARIN 0.45MG TABLET |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREMARIN 0.625MG (100 CT) |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PREMARIN 0.9MG TABLET |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PREMARIN 1.25MG (100 CT) |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PREMARIN VAGINAL CREAM /APPL |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | Q:43 /30Days |
PREMASOL 6% IV SOLUTION |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | P |
PREMPHASE 0.625/5MG TABLET |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PREMPRO 0.3MG/1.5MG TABLET |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PREMPRO 0.45/1.5MG TABLET |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PREMPRO 0.625/2.5MG TABLET DIALPK |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PREMPRO 0.625/5MG TABLET |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PRENATABS OBN TABLETS 200;1;150;MG;MG;MCG; 90 BOT |
2 |
Tier 2 / Nivel 2 |
$35.00 | $105.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREVACID CAPSULES EXTENDED RELEASE 15MG 100 BOXUD |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | S |
PREVACID CAPSULES EXTENDED RELEASE 30MG 100 BOXUD |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | S |
PREVACID SOLUTAB EXTENDED RELEASE ORALLY DISINTEGRATING 30MG 100 BOXUD |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | S |
PREVACID SOLUTAB TABLETS DELAYED RELEASE ORALLY DISINTEGRATING 15MG 100 BOXUD |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | S |
PREVALITE POW 4GM PK |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PREZISTA TABLET 600MG |
5 |
Tier 5 / Nivel 5 |
25% | 25% | None |
PREZISTA TABLET 75MG |
5 |
Tier 5 / Nivel 5 |
25% | 25% | None |
PREZISTA TABLETS 400MG 60 TABLETS BOT |
5 |
Tier 5 / Nivel 5 |
25% | 25% | None |
PRIFTIN 150MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PRILOSEC 10MG CAPSULE DR |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | S |
PRILOSEC 20MG CAPSULE DR |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRIMAQUINE 26.3MG TABLET |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | None |
PRIMAXIN I.M. 500MG VIAL |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | P |
PRIMAXIN IV 250MG VIAL |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | P |
PRIMAXIN IV INJ 500MG |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | P |
PRIMIDONE 250MG TABLET (100 CT) |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PRIMIDONE 50MG TABLET (500 CT) |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PRINIVIL 10MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PRINIVIL 20MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PRINIVIL 5MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PRINZIDE 10/12.5 TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PRINZIDE 20/12.5 TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRINZIDE 20/25 TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PRISTIQ 100MG TABLET SR 24HR |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | S |
PRISTIQ 50MG TABLET SR 24HR |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | S |
PROAMATINE 10MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PROAMATINE 2.5MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PROAMATINE 5MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PROBENECID 500MG TABLET |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROBENECID/COLCHICINE TABLET S |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROCALAMINE INJECTION 210MG-290MG-26MG 6 X 1000ML BOT |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | P |
PROCARDIA XL 30MG TABLET (300 CT) |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PROCARDIA XL 60MG TABLET SA |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCARDIA XL 90MG TABLET SA |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT) |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT) |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROCRIT 10000U/ML VIAL |
5 |
Tier 5 / Nivel 5 |
25% | 25% | P |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL |
2 |
Tier 2 / Nivel 2 |
$35.00 | $105.00 | P |
PROCRIT 3000U/ML VIAL |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | P |
PROCRIT 40000U/ML VIAL PR |
5 |
Tier 5 / Nivel 5 |
25% | 25% | P |
PROCRIT 4000U/ML VIAL 25 X 1ML VIAL |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | P |
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY |
5 |
Tier 5 / Nivel 5 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCTOZONE-HC 2.5% CREAM |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROGLYCEM 50MG/ML ORAL SUSP |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PROGRAF 0.5MG CAPSULE |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | P |
PROGRAF 1MG CAPSULE |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | P |
PROGRAF 5MG CAPSULE |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | P |
PROGRAF 5MG/ML AMPULE |
3 |
Tier 3 / Nivel 3 |
$50.00 | $150.00 | P |
PROLASTIN 500MG VIAL |
5 |
Tier 5 / Nivel 5 |
25% | 25% | P |
PROLEUKIN 22 MILLION UNITS VL |
5 |
Tier 5 / Nivel 5 |
25% | 25% | P |
PROMETHAZINE 50MG/ML VIAL |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROMETHAZINE HCL 12.5MG TABLET |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROMETHAZINE HCL 25MG TABLET (1000 CT) |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMETHAZINE HCL 50MG TABLET (100 CT) |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROMETHAZINE HCL 6.25MG/5ML SYRUP |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROMETHAZINE HCL INJECTION 25MG 10 X 1ML VIAL |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROMETHEGAN 50MG SUPPOS |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROMETRIUM 100MG CAPSULE |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PROMETRIUM 200MG CAPSULE |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PROPAFENONE HCL 150MG TABLET (100 CT) |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROPAFENONE HCL 225MG TABLET |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROPAFENONE HCL 300MG TABLET (100 CT) |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPOXY-N/APAP 100-500MG TABLET |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROPOXY-N/APAP 100-650 TABLET |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROPOXY-N/APAP 50-325 TABLET |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROPOXYPHENE HCL AND ACETAMINOPHEN TABLET 650/65MG (500 CT) |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROPRANOLOL 60MG TABLET |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROPRANOLOL 80MG TABLET |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROPRANOLOL HCL 20MG TABLET (1000 CT) |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROPRANOLOL HCL CAPSULES ER 120MG (1000 CT) |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROPRANOLOL HCL CAPSULES ER 160MG (1000 CT) |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROPRANOLOL HCL CAPSULES ER 60MG (100 CT) |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROPRANOLOL HCL CAPSULES ER 80MG (1000 CT) |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPRANOLOL HCL TABLET USP 10MG (1000 CT) |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROPRANOLOL HCL TABLET USP 40MG (1000 CT) |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROPYLTHIOURACIL 50MG TABLET |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROQUAD VIAL |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PROSCAR TABLETS 5MG 30 BOT |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PROTONIX 20MG TABLET EC |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | S |
PROTONIX 40MG TABLET EC |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | S |
PROTONIX IV 40MG VIAL |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | P |
PROTOPIC 0.03% OINTMENT 100GM TUBE |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | S Q:100 /15Days |
PROTOPIC 0.1% OINTMENT 60GM TUBE |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | S Q:100 /15Days |
PROTRIPTYLINE HYDROCHLORIDE TABLETS |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PROVENTIL HFA INHALER 90MCG AE |
2 |
Tier 2 / Nivel 2 |
$35.00 | $105.00 | Q:13 /30Days |
PROVERA 10MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PROVERA 2.5MG TABLET (100 CT) |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PROVERA 5MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PROVIGIL 100MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | P |
PROVIGIL 200MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | P |
PROZAC 10MG PULVULE |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PROZAC 20MG/5ML SOLUTION |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PROZAC 40MG PULVULE |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PROZAC CAPSULES 20MG (2000 CT) |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PULMICORT .25MG/2ML RESPULE |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | P Q:120 /30Days |
PULMICORT 0.5MG/2ML RESPULE |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | P Q:120 /30Days |
PULMICORT 1MG/2ML AMPUL FOR NEBULIZATION |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | P Q:60 /30Days |
PULMICORT FLEXHALER 180MCG AEROSOL POWDER BREATH ACTIVATED |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | Q:2 /30Days |
PULMICORT FLEXHALER 90MCG AEROSOL POWDER BREATH ACTIVATED |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | Q:2 /30Days |
PURINETHOL 50MG TABLET |
4 |
Tier 4 / Nivel 4: Greater of $50 or 25% |
25% | 25% | None |
PYRAZINAMIDE 500MG TABLET |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |
PYRIDOSTIGMINE BROMIDE 60MG TABLET |
1 |
Tier 1 / Nivel 1 |
$5.00 | $15.00 | None |