2010 Medicare Part D Plan Formulary Information |
Humana Complete S5884-043 (PDP) (S5884-043-0)
Benefit Details
 |
The Humana Complete S5884-043 (PDP) (S5884-043-0) Formulary Drugs Starting with the Letter A in CMS PDP Region 15 which includes: IN KY
|
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 |
Preferred Generic |
$7.00 | $0.00 | None |
A-HYDROCORT 100MG VIAL  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
A-METHAPRED 40MG UNIVIAL  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ABELCENT INJECTION SUSPENSION 5MG/ML  |
4 |
Specialty |
33% | N/A | None |
ABILIFY 10MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:30 /30Days |
ABILIFY 15MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:30 /30Days |
ABILIFY 1MG/ML SOLUTION  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ABILIFY 20MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:30 /30Days |
ABILIFY 2MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:30 /30Days |
ABILIFY 30MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABILIFY 5MG TABLET (OTSUKA)  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:30 /30Days |
ABILIFY DISCMELT 10MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:60 /30Days |
ABILIFY DISCMELT 15MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:60 /30Days |
ABILIFY INJ 9.75MG  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ABRAXANE 100MG VIAL  |
4 |
Specialty |
33% | N/A | P |
ACARBOSE 100MG TABLET S  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ACARBOSE 25MG TABLET S  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ACARBOSE 50MG TABLET S  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ACCOLATE 10MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
ACCOLATE 20MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
ACCUPRIL 10MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACCUPRIL 20MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ACCUPRIL 40MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ACCUPRIL 5MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ACCURETIC 10-12.5MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ACCURETIC 20-12.5MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ACCURETIC 20-25MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ACEBUTOLOL 200MG CAPSULE  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ACEBUTOLOL 400MG CAPSULE  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ACETADOTE 200MG/ML VIAL  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:390 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:390 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:390 /30Days |
ACETASOL HC OTIC SOLUTION  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ACETASOL HC SOLUTION 10ML 10 ML BOT  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ACETAZOLAMIDE 125MG TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ACETAZOLAMIDE 250MG TABLET (100 CT)  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ACETAZOLAMIDE SOD 500MG VL  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ACETIC ACID 2% SOLUTION NON-ORAL  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ACETIC ACID IN AQUEOUS ALUMINUM ACETATE OTIC SOLUTION 2% 60 ML BOT  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ACETYLCYSTEINE 10% VIAL  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ACTHIB VACCINE VIAL 10-24UNT/5ML  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ACTICIN 5% CREAM  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ACTIMMUNE SOLUTION FOR INJECTION 100MCG  |
4 |
Specialty |
33% | N/A | P |
ACTIVELLA 0.5-0.1MG TABLET 28 DLPK  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ACTIVELLA 1-0.5MG TABLET 28 DLPK  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ACTONEL 150MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:2 /30Days |
ACTONEL 30MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:30 /30Days |
ACTONEL 35MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:4 /28Days |
ACTONEL 5MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:30 /30Days |
ACTONEL 75MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:2 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTONEL WITH CALCIUM TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:28 /28Days |
ACTOPLUS MET 15MG/500MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:90 /30Days |
ACTOPLUS MET 15MG/850MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:90 /30Days |
ACTOS 15MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
ACTOS 30MG TABLET (500 CT)  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
ACTOS 45MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
ACULAR 0.5% EYE DROPS  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ACULAR LS 0.4% OPHTH SOL  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ACYCLOVIR 200MG CAPSULE (1000 CT)  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ACYCLOVIR 200MG/5ML SUSP  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ACYCLOVIR 400MG TABLET (100 CT)  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACYCLOVIR SODIUM 500MG VIAL  |
1 |
Preferred Generic |
$7.00 | $0.00 | P |
ACYCLOVIR TABLET USP 800MG (100 CT)  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ADACEL VIAL 2UNT/5UNT  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ADAGEN 250U/ML VIAL  |
4 |
Specialty |
33% | N/A | None |
ADALAT CC 30MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:60 /30Days |
ADALAT CC 60MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:60 /30Days |
ADALAT CC 90MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:60 /30Days |
ADCIRCA TABLETS 20MG 60 BOT  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P Q:60 /30Days |
ADVAIR DISKU MIS 100/50  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
ADVAIR DISKU MIS 250/50  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
ADVAIR DISKU MIS 500/50  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:12 /30Days |
ADVAIR HFA INHALER 230;21MCG;MCG  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:12 /30Days |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:12 /30Days |
AEROBID-M AEROSOL W/ADAPTER  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:21 /30Days |
AFEDITAB CR 30MG TABLET SA  |
1 |
Preferred Generic |
$7.00 | $0.00 | Q:60 /30Days |
AFEDITAB CR 60MG TABLET SA  |
1 |
Preferred Generic |
$7.00 | $0.00 | Q:60 /30Days |
AGGRENOX 25-200MG CAPSULE  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | None |
AK-CON 0.1% EYE DROPS  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AK-POLY-BAC EYE OINTMENT 500UNT/1000UNT  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AKNE-MYCIN 2% OINTMENT  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
AKTOB 0.3% EYE DROPS  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALA-CORT 1% CREAM  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ALA-CORT 1% LOTION  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ALA-SCALP HP 2% LOTION  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ALBENZA 200MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER  |
1 |
Preferred Generic |
$7.00 | $0.00 | P |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER  |
1 |
Preferred Generic |
$7.00 | $0.00 | P |
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER  |
1 |
Preferred Generic |
$7.00 | $0.00 | P |
ALBUTEROL SULFATE 4MG TABLET SR 12HR  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR  |
1 |
Preferred Generic |
$7.00 | $0.00 | P |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL SULFATE TABLET 2MG (500 CT)  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ALBUTEROL TABLET 4MG (500 CT)  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ALCAINE 0.5% EYE DROPS  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ALCLOMETASONE DIPROPIONATE 0.05% CREAM  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ALCOHOL 5%/DEXTROSE 5%  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ALDACTAZIDE 25/25 TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ALDACTAZIDE 50/50 TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ALDACTONE 100MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ALDACTONE 25MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ALDACTONE 50MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALDARA IMIQUIMOD CREAM 5% 24 PKT X 250 MG CRTN  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:12 /30Days |
ALDURAZYME 2.9MG/5ML VIAL  |
4 |
Specialty |
33% | N/A | None |
ALENDRONATE SODIUM 10MG TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ALENDRONATE SODIUM 40MG TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ALENDRONATE SODIUM 5MG TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ALENDRONATE SODIUM 70MG TABLET 4 BLPK  |
1 |
Preferred Generic |
$7.00 | $0.00 | Q:4 /28Days |
ALENDRONATE SODIUM TABLET 35MG 20 CRTN  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ALFERON N INJ 5MU/ML  |
4 |
Specialty |
33% | N/A | None |
ALIMTA 500MG VIAL  |
4 |
Specialty |
33% | N/A | None |
ALINIA 100MG/5ML SUSPENSION  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:150 /30Days |
ALINIA 500MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:6 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALKERAN FOR INJECTION 50MG/VIAL 1 VIALSU  |
4 |
Specialty |
33% | N/A | P |
ALLOPURINOL SODIUM 500MG VIAL  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ALLOPURINOL TABLET 300MG (1000 CT)  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ALLOPURINOL TABLET USP 100MG (1000 CT)  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ALOMIDE 0.1% EYE DROPS  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ALOPRIM SOLUTION FOR INJECTION 500MG/VIAL 30 ML VIALGL  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ALORA 0.025MG PATCH  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:8 /28Days |
ALORA 0.05MG PATCH  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:8 /28Days |
ALORA 0.075MG PATCH  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:8 /28Days |
ALORA 0.1MG PATCH  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:8 /28Days |
ALPHAGAN P 0.1% DROPS  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALPHAGAN P 0.15% EYE DROPS  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | None |
ALTABAX 1% OINTMENT  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
AMANTADINE 100MG CAPSULE  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMANTADINE 100MG TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMBISOME 50MG VIAL  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
AMCINONIDE 0.1% CREAM  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMCINONIDE 0.1% LOTION  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMCINONIDE 0.1% OINTMENT 60GM TUBE  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM  |
4 |
Specialty |
33% | N/A | P Q:4 /30Days |
AMIFOSTINE FOR INJECTION 500MG/VIAL  |
4 |
Specialty |
33% | N/A | None |
AMIKACIN 250MG/ML VIAL  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMIKACIN 50MG/ML VIAL  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | None |
AMIKIN 250MG/ML VIAL  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMIKIN POWDER FOR INJECTION  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMINESS 5.2% IV SOLUTION  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P |
AMINOPHYLLINE 100MG TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMINOPHYLLINE 200MG TABLET (1000 CT)  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMINOSYN 10% IV SOLUTION  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P |
AMINOSYN 3.5% IV SOLUTION  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN 5% IV SOLUTION  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P |
AMINOSYN 7% IV SOLUTION  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P |
AMINOSYN 7%-ELECTROLYTE SOL  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P |
AMINOSYN 8.5% IV SOLUTION  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P |
AMINOSYN II 10% IV SOLUTION  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P |
AMINOSYN II 15% IV SOLUTION  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P |
AMINOSYN II 3.5% IN D25W IV  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P |
AMINOSYN II 3.5% M/D5W IV  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P |
AMINOSYN II 3.5% W/ELEC DEX  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P |
AMINOSYN II 4.25% IN D10W  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P |
AMINOSYN II 4.25% IN D20W  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN II 4.25% W/ELEC DW  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P |
AMINOSYN II 4.25%-D25W IV  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P |
AMINOSYN II 5% IN D25W IV  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P |
AMINOSYN II 7% IV SOLUTION  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P |
AMINOSYN II 8.5% ELECTROLYT  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P |
AMINOSYN II 8.5% IV SOLUTION  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P |
AMINOSYN M 3.5% IV SOLUTION  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P |
AMINOSYN PF INJECTION  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P |
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P |
AMINOSYN-HBC 7% IV SOLUTION  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P |
AMINOSYN-HF 8% IV SOLUTION  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN-PF 7% IV SOLUTION  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P |
AMIODARONE HCL 200MG TABLET (60 CT)  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMIODARONE HCL 400MG TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMIODARONE HCL INJECTION  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMITIZA 8MCG CAPSULE  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
AMITIZA CAPSULES 24MCG 60 CAP BOT  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
AMITRIP/CDP 25-10 TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMITRIP/PERPHEN 10-2 TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMITRIP/PERPHEN 10-4 TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMITRIP/PERPHEN 25-2 TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMITRIP/PERPHEN 25-4 TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIP/PERPHEN 50-4 TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMITRIPTYLINE HCL 100MG TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMITRIPTYLINE HCL 10MG TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMITRIPTYLINE HCL 150MG TABLET (100 CT)  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMLODIPINE BESYLATE 10MG TABLET (90 CT)  |
1 |
Preferred Generic |
$7.00 | $0.00 | Q:60 /30Days |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)  |
1 |
Preferred Generic |
$7.00 | $0.00 | Q:60 /30Days |
AMLODIPINE BESYLATE 5MG TABLET (90 CT)  |
1 |
Preferred Generic |
$7.00 | $0.00 | Q:60 /30Days |
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
AMMONIUM CHLORIDE 5 MEQ/ML  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMMONIUM LACTATE 12% CREAM  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMMONIUM LACTATE 12% LOTION  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMNESTEEM 10MG CAPSULE  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | None |
AMNESTEEM 20MG CAPSULE  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | None |
AMNESTEEM 40MG CAPSULE  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | None |
AMOCLAN 200-28.5/5 SUSPENSION RECONSTITUTED ORAL  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMOCLAN 400-57MG/5 SUSPENSION RECONSTITUTED ORAL  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 500-125MG TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMOXAPINE 100MG TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMOXAPINE 150MG TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMOXAPINE 25MG TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMOXAPINE 50MG TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMOXICILLIN 125MG TABLET CHEW  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN 200MG TABLET CHEW  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMOXICILLIN 250MG CAPSULE  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMOXICILLIN 400MG TABLET CHEW  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMOXICILLIN 500MG CAPSULE  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMOXICILLIN 500MG TABLET (100 CT)  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMOXICILLIN 875MG TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT)  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMOXIL 250MG/5ML SUSPENSION  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
AMOXIL 400MG/5ML SUSPENSION  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
AMOXIL CAPSULES 500MG  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMPHETAMINE SALT COMBO 15MG TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMPHETAMINE SALT COMBO 30MG TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMPHETAMINE SALT COMBO 7.5MG TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMPHETAMINE SALTS 20MG TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPHOTEC INJ 50MG  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
AMPHOTERICIN B FOR INJECTION 50 MG  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | None |
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | None |
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | None |
AMPICILLIN CAPSULES 250MG 100 BOT  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMPICILLIN CAPSULES 500MG 100 BOT  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMPICILLIN FOR INJECTION POWDER  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | None |
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | None |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANADROL-50 50MG TABLET (100 CT)  |
4 |
Specialty |
33% | N/A | None |
ANAGRELIDE HCL 0.5MG CAPSULE  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ANAGRELIDE HCL 1MG CAPSULE  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ANAPROX 275MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ANCOBON 250MG CAPSULE  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ANCOBON 500MG CAPSULE  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ANDRODERM 2.5MG/24HR PATCH  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:90 /30Days |
ANDRODERM 5MG/24HR PATCH  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:30 /30Days |
ANDROGEL 1%(50MG) GEL PACKET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:300 /30Days |
ANDROID 10MG CAPSULE  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | None |
ANGELIQ 1-0.5MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANTABUSE 250MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ANTABUSE 500MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ANTARA 130MG CAPSULE  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:30 /30Days |
ANTARA 43MG CAPSULE  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:30 /30Days |
ANTIVERT 12.5MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ANTIVERT 25MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ANTIVERT 50MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ANTIZOL INJECTION 1GM 4 X 1.5ML VIAL CRTN  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ANUSOL-HC 2.5% CREAM  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
APAP-CAFFEINE-DIHYDROCODE TAB 30 EA  |
1 |
Preferred Generic |
$7.00 | $0.00 | Q:180 /30Days |
APHTHASOL 5% PASTE  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APIDRA 100UNITS/ML VIAL  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
APOKYN FOR INJECTION 30MG 5 CTG  |
4 |
Specialty |
33% | N/A | Q:60 /30Days |
APRI 0.15-0.03 TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
APTIVUS 250MG CAPSULE  |
4 |
Specialty |
33% | N/A | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ARALAST 500MG VIAL  |
4 |
Specialty |
33% | N/A | P |
ARALEN PHOSPHATE 500MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ARANELLE 7-9-5 TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ARCALYST INJECTION 220MG/VIAL  |
4 |
Specialty |
33% | N/A | P |
AREDIA 30MG VIAL  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:8 /30Days |
AREDIA 90MG VIAL  |
4 |
Specialty |
33% | N/A | Q:2 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARICEPT 10MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
ARICEPT 5MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
ARICEPT ODT 10MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
ARICEPT ODT 5MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
ARIMIDEX 1MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:30 /30Days |
ARIXTRA 10MG SYRINGE  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:14 /30Days |
ARIXTRA 2.5MG SYRINGE  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:14 /30Days |
ARIXTRA 5MG SYRINGE  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:14 /30Days |
ARIXTRA 7.5MG SYRINGE  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:14 /30Days |
AROMASIN 25MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ARRANON 250MG VIAL  |
4 |
Specialty |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ASACOL 400MG TABLET EC  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:360 /30Days |
ASACOL HD DELAYED RELEASE TABLETS 800MG 180 BOT  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:360 /30Days |
ASCOMP W/CODEINE 30-50-325 CAPSULE  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | None |
ASMANEX 220MCG(14) AEROSOL POWDER BREATH ACTIVATED  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:6 /30Days |
ASMANEX TWISTHALER 220MCG #120  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:53 /30Days |
ASMANEX TWISTHALER 220MCG #30  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:13 /30Days |
ASMANEX TWISTHALER 220MCG #60  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:26 /30Days |
ASTELIN 137MCG AEROSOL SPRAY W/PUMP  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
ASTEPRO NASAL SPRAY 137 MCG/SPRY  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
ASTRAMORPH-PF 0.5MG/ML VIAL  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ASTRAMORPH-PF 1MG/ML VIAL  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATAMET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ATENOLOL 25MG TABLET (100 CT)  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ATENOLOL TABLET USP 50MG (100 CT)  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ATENOLOL TABLETS USP 100MG 1 BLPK  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ATGAM 50MG/ML AMPUL  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | None |
ATRALIN 0.05% GEL  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
ATRIPLA TABLET 600MG/200MG  |
4 |
Specialty |
33% | N/A | None |
ATROPINE 0.05MG/ML SYRINGE  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
ATROPINE 0.1MG/ML SYRINGE  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATROVENT HFA AER 17MCG  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
ATROVENT NASAL SPRAY 0.03%  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:30 /30Days |
ATROVENT NASAL SPRAY 0.06%  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:45 /30Days |
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
AUGMENTIN ES-600 SUSPENSION  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
AUGMENTIN XR 1000-62.5 TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
AVALIDE 150-12.5MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
AVALIDE 300-12.5MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
AVALIDE 300-25MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
AVANDAMET 2MG/1000MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
AVANDAMET 2MG/500MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVANDAMET 4MG/500MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
AVANDAMET TABLET 4-1000MG  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
AVANDARYL 4MG/1MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
AVANDARYL 4MG/2MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
AVANDARYL 4MG/4MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
AVANDARYL 8MG-2MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
AVANDARYL 8MG-4MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
AVANDIA 2MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
AVANDIA 4MG TABLET (90 CT)  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
AVANDIA 8MG TABLET (90 CT)  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
AVAPRO 150MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVAPRO 300MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
AVAPRO 75MG TABLET (30 CT)  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
AVASTIN 100MG/4ML VIAL  |
4 |
Specialty |
33% | N/A | P |
AVELOX 400MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
AVELOX ABC PACK 400MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
AVELOX IV 400MG/250ML  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
AVIANE 0.1-0.02 TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AVINZA 120MG CAPSULE MULTIPHASIC RELEASE 24 HR  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
AVINZA 30MG CAPSULE MULTIPHASIC RELEASE 24 HR  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
AVINZA 60MG CAPSULE MULTIPHASIC RELEASE 24 HR  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
AVINZA 90MG CAPSULE MULTIPHASIC RELEASE 24 HR  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVINZA CAPSULES EXTENDED RELEASE 45MG 100 BOTPL  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
AVINZA CAPSULES EXTENDED RELEASE 75MG 100 BOTPL  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days |
AVITA 0.025% CREAM  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | P |
AVODART 0.5MG SOFTGEL  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
AVONEX ADMIN PACK 30MCG SYR  |
4 |
Specialty |
33% | N/A | P Q:4 /28Days |
AVONEX ADMIN PACK 30MCG VL  |
4 |
Specialty |
33% | N/A | P Q:4 /28Days |
AYGESTIN 5MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
AZACTAM 2GM VIAL  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
AZACTAM INJECTION 1GM 50ML BAG  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
AZACTAM/ISO-OSMOT 2GM/50ML  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
AZASITE 1% DROPS  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZATHIOPRINE 50MG TABLET  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AZATHIOPRINE SOD 100MG VIAL  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AZELEX 20% CREAM 30GM TUBE  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None |
AZILECT 0.5MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
AZILECT 1MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AZITHROMYCIN 250MG TABLET (30 CT)  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AZITHROMYCIN 500MG TABLET (30 CT)  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
AZITHROMYCIN TABLET 600MG (30 CT)  |
1 |
Preferred Generic |
$7.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZMACORT INHALATION AEROSOL .1MG/1IHL 20 GM CSTR  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:40 /30Days |
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | None |
AZOR 10MG-20MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
AZOR 10MG-40MG TABLET (30 CT)  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
AZOR 5MG-20MG TABLET (30 CT)  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
AZOR 5MG-40MG TABLET  |
2 |
Non-Preferred Generic/Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
AZULFIDINE 500MG TABLET  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:240 /30Days |
AZULFIDINE EN TABLET S 500MG TABLET 6 X (300 CT)PL  |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:240 /30Days |