2011 Medicare Part D Plan Formulary Information |
Health Net Seniority Plus Amber I (HMO SNP) (H0562-055-0)
Sanctioned Plan
|
The Health Net Seniority Plus Amber I (HMO SNP) (H0562-055-0) Formulary Drugs Starting with the Letter A in San Bernardino County, CA: CMS MA Region 24 which includes: CA
|
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 |
ABILIFY 10MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:1 /1Days |
ABILIFY 15MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:1 /1Days |
ABILIFY 1MG/ML SOLUTION |
2 |
Tier 2 |
15% | 15% | Q:30 /1Days |
ABILIFY 20MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:1 /1Days |
ABILIFY 2MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:2 /1Days |
ABILIFY 30MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:1 /1Days |
ABILIFY 5MG TABLET (OTSUKA) |
2 |
Tier 2 |
15% | 15% | Q:2 /1Days |
ABILIFY DISCMELT 10MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:2 /1Days |
ABILIFY DISCMELT 15MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:2 /1Days |
ACARBOSE 100MG TABLET S |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACARBOSE 25MG TABLET S |
1 |
Tier 1 |
15% | 15% | None |
ACARBOSE 50MG TABLET S |
1 |
Tier 1 |
15% | 15% | None |
ACCOLATE 10MG TABLET |
2 |
Tier 2 |
15% | 15% | S Q:2 /1Days |
ACCOLATE 20MG TABLET |
2 |
Tier 2 |
15% | 15% | S Q:2 /1Days |
ACEBUTOLOL 200MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
ACEBUTOLOL 400MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD |
1 |
Tier 1 |
15% | 15% | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) |
1 |
Tier 1 |
15% | 15% | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
ACETASOL HC SOLUTION 10ML 10 ML BOT |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAZOLAMIDE 125MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
ACETIC ACID 2% SOLUTION NON-ORAL |
1 |
Tier 1 |
15% | 15% | None |
ACETIC ACID 20 MG/ML / HYDROCORTISONE 10 MG/ML OTIC SOLUTION |
1 |
Tier 1 |
15% | 15% | None |
ACETYLCYSTEINE 10% VIAL |
1 |
Tier 1 |
15% | 15% | P |
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN |
1 |
Tier 1 |
15% | 15% | P |
ACIPHEX 20MG TABLET EC |
2 |
Tier 2 |
15% | 15% | Q:1 /1Days |
ACTICIN 5% CREAM |
1 |
Tier 1 |
15% | 15% | None |
ACTONEL 150MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
ACTONEL 30MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTONEL 35MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
ACTONEL 5MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:1 /1Days |
ACTOPLUS MET 15MG/500MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
ACTOPLUS MET 15MG/850MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
ACTOS 15MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
ACTOS 30MG TABLET (500 CT) |
2 |
Tier 2 |
15% | 15% | None |
ACTOS 45MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
ACYCLOVIR 200MG CAPSULE (1000 CT) |
1 |
Tier 1 |
15% | 15% | None |
ACYCLOVIR 200MG/5ML SUSP |
1 |
Tier 1 |
15% | 15% | None |
ACYCLOVIR 400MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
ACYCLOVIR 800 MG ORAL TABLET |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADVAIR DISKU MIS 100/50 |
2 |
Tier 2 |
15% | 15% | Q:2 /1Days |
ADVAIR DISKU MIS 250/50 |
2 |
Tier 2 |
15% | 15% | Q:2 /1Days |
ADVAIR DISKU MIS 500/50 |
2 |
Tier 2 |
15% | 15% | Q:2 /1Days |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL |
2 |
Tier 2 |
15% | 15% | None |
ADVAIR HFA INHALER 230;21MCG;MCG |
2 |
Tier 2 |
15% | 15% | None |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
2 |
Tier 2 |
15% | 15% | None |
AFEDITAB CR 30MG TABLET SA |
1 |
Tier 1 |
15% | 15% | None |
AFEDITAB CR 60MG TABLET SA |
1 |
Tier 1 |
15% | 15% | None |
AGGRENOX 25-200MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
AK-CON 0.1% EYE DROPS |
1 |
Tier 1 |
15% | 15% | None |
AKTOB 0.3% EYE DROPS |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALA-CORT 1% CREAM |
1 |
Tier 1 |
15% | 15% | None |
ALA-CORT 1% LOTION |
1 |
Tier 1 |
15% | 15% | None |
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER |
1 |
Tier 1 |
15% | 15% | P |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
1 |
Tier 1 |
15% | 15% | P |
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER |
1 |
Tier 1 |
15% | 15% | P |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
1 |
Tier 1 |
15% | 15% | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
1 |
Tier 1 |
15% | 15% | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
1 |
Tier 1 |
15% | 15% | P |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
1 |
Tier 1 |
15% | 15% | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
ALBUTEROL TABLET 4MG (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALDACTAZIDE 50/50 TABLET |
2 |
Tier 2 |
15% | 15% | None |
ALENDRONATE SODIUM 10MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:1 /1Days |
ALENDRONATE SODIUM 40MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:1 /1Days |
ALENDRONATE SODIUM 5MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:1 /1Days |
ALENDRONATE SODIUM TABLET 35MG 20 CRTN |
1 |
Tier 1 |
15% | 15% | None |
ALENDRONATE SODIUM TABLETS 70 MG |
1 |
Tier 1 |
15% | 15% | None |
ALISKIREN 150 MG / VALSARTAN 160 MG ORAL TABLET [VALTURNA] |
2 |
Tier 2 |
15% | 15% | Q:1 /1Days |
ALISKIREN 300 MG / VALSARTAN 320 MG ORAL TABLET [VALTURNA] |
2 |
Tier 2 |
15% | 15% | Q:1 /1Days |
ALLOPURINOL 100MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
ALLOPURINOL TABLET 300MG (1000 CT) |
1 |
Tier 1 |
15% | 15% | None |
ALPHAGAN P 0.1% DROPS |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMANTADINE 100MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
AMANTADINE 100MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMANTADINE HCL 50 MG/ 5 ML SYRUP |
1 |
Tier 1 |
15% | 15% | None |
AMBIEN CR 12.5MG TABLET |
2 |
Tier 2 |
15% | 15% | S Q:1 /1Days |
AMBIEN CR 6.25MG TABLET |
2 |
Tier 2 |
15% | 15% | S Q:1 /1Days |
AMERGE 1MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
AMERGE 2.5MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
AMIODARONE HCL 200MG TABLET (60 CT) |
1 |
Tier 1 |
15% | 15% | None |
AMIODARONE HCL 400MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITIZA 8MCG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
AMITIZA CAPSULES 24MCG 60 CAP BOT |
2 |
Tier 2 |
15% | 15% | None |
AMITRIP/PERPHEN 10-2 TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMITRIP/PERPHEN 10-4 TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMITRIP/PERPHEN 25-2 TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMITRIP/PERPHEN 25-4 TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMITRIP/PERPHEN 50-4 TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMITRIPTYLINE HCL 100MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMITRIPTYLINE HCL 10MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMITRIPTYLINE HCL 150 MG TAB |
1 |
Tier 1 |
15% | 15% | None |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
AMLODIPINE 10 MG / HYDROCHLOROTHIAZIDE 12.5 MG / VALSARTAN 160 MG ORAL TABLET [EXFORGE HCT 10/160/12 |
2 |
Tier 2 |
15% | 15% | None |
AMLODIPINE 10 MG / HYDROCHLOROTHIAZIDE 25 MG / VALSARTAN 160 MG ORAL TABLET [EXFORGE HCT 10/160/25] |
2 |
Tier 2 |
15% | 15% | None |
AMLODIPINE 10 MG / HYDROCHLOROTHIAZIDE 25 MG / VALSARTAN 320 MG ORAL TABLET [EXFORGE HCT 10/320/25] |
2 |
Tier 2 |
15% | 15% | None |
AMLODIPINE 5 MG / HYDROCHLOROTHIAZIDE 12.5 MG / VALSARTAN 160 MG ORAL TABLET [EXFORGE HCT 5/160/12.5 |
2 |
Tier 2 |
15% | 15% | None |
AMLODIPINE 5 MG / HYDROCHLOROTHIAZIDE 25 MG / VALSARTAN 160 MG ORAL TABLET [EXFORGE HCT 5/160/25] |
2 |
Tier 2 |
15% | 15% | None |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
1 |
Tier 1 |
15% | 15% | Q:1 /1Days |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1 |
Tier 1 |
15% | 15% | Q:1 /1Days |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
1 |
Tier 1 |
15% | 15% | Q:2 /1Days |
AMMONIUM LACTATE 12% CREAM |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMMONIUM LACTATE 12% LOTION |
1 |
Tier 1 |
15% | 15% | None |
AMNESTEEM 10MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
AMNESTEEM 20MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
AMNESTEEM 40MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
AMOX TR-K CLV 500-125 MG TAB |
1 |
Tier 1 |
15% | 15% | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
15% | 15% | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
1 |
Tier 1 |
15% | 15% | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
1 |
Tier 1 |
15% | 15% | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN 125MG TABLET CHEW |
1 |
Tier 1 |
15% | 15% | 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 |
15% | 15% | None |
AMOXICILLIN 250MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN 400MG TABLET CHEW |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN 500MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN 500MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN 875MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT) |
1 |
Tier 1 |
15% | 15% | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMPHETAMINE SALT COMBO 15MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMPHETAMINE SALT COMBO 30MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMPHETAMINE SALTS 20MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMPHETAMINE SALTS 5 MG TAB |
1 |
Tier 1 |
15% | 15% | None |
AMPICILLIN CAPSULES 250MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN CAPSULES 500MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
AMYLASES 109000 UNT / ENDOPEPTIDASES 68000 UNT / LIPASE 20000 UNT ENTERIC COATED CAPSULE [ZENPEP 20] |
2 |
Tier 2 |
15% | 15% | None |
AMYLASES 27000 UNT / ENDOPEPTIDASES 17000 UNT / LIPASE 5000 UNT ENTERIC COATED CAPSULE [ZENPEP 5] |
2 |
Tier 2 |
15% | 15% | None |
AMYLASES 55000 UNT / ENDOPEPTIDASES 34000 UNT / LIPASE 10000 UNT ENTERIC COATED CAPSULE [ZENPEP 10] |
2 |
Tier 2 |
15% | 15% | None |
AMYLASES 82000 UNT / ENDOPEPTIDASES 51000 UNT / LIPASE 15000 UNT ENTERIC COATED CAPSULE [ZENPEP 15] |
2 |
Tier 2 |
15% | 15% | None |
ANAGRELIDE HCL 0.5MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
ANAGRELIDE HCL 1MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
ANDRODERM 2.5MG/24HR PATCH |
2 |
Tier 2 |
15% | 15% | Q:2 /1Days |
ANDRODERM 5MG/24HR PATCH |
2 |
Tier 2 |
15% | 15% | Q:1 /1Days |
ANDROGEL 1%(50MG) GEL PACKET |
2 |
Tier 2 |
15% | 15% | Q:10 /1Days |
ANDROID 10MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANESTACON 15ML |
1 |
Tier 1 |
15% | 15% | None |
ANTABUSE 250MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
ANTABUSE 500MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
ANTARA 43MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
APRI 0.15-0.03 TABLET |
1 |
Tier 1 |
15% | 15% | Q:1 /1Days |
APRISO CP24 |
2 |
Tier 2 |
15% | 15% | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
2 |
Tier 2 |
15% | 15% | None |
ARANELLE 7-9-5 TABLET |
1 |
Tier 1 |
15% | 15% | Q:1 /1Days |
ARICEPT 10MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:1 /1Days |
ARICEPT 5MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:1 /1Days |
ARICEPT ODT 10MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARICEPT ODT 5MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:1 /1Days |
ARIMIDEX 1MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
AROMASIN 25MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
ASACOL 400MG TABLET EC |
2 |
Tier 2 |
15% | 15% | None |
ASACOL HD DELAYED RELEASE TABLETS 800MG 180 BOT |
2 |
Tier 2 |
15% | 15% | None |
ASMANEX 220MCG(14) AEROSOL POWDER BREATH ACTIVATED |
2 |
Tier 2 |
15% | 15% | None |
ASMANEX TWISTHALER 110 MCG #30 |
2 |
Tier 2 |
15% | 15% | None |
ASMANEX TWISTHALER 220MCG #120 |
2 |
Tier 2 |
15% | 15% | None |
ASMANEX TWISTHALER 220MCG #30 |
2 |
Tier 2 |
15% | 15% | None |
ASMANEX TWISTHALER 220MCG #60 |
2 |
Tier 2 |
15% | 15% | None |
ASTEPRO 0.15% NASAL SPRAY 30 ML |
2 |
Tier 2 |
15% | 15% | Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATAMET |
1 |
Tier 1 |
15% | 15% | None |
ATENOLOL 25MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
ATENOLOL TABLET USP 50MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
ATENOLOL TABLETS USP 100MG 1 BLPK |
1 |
Tier 1 |
15% | 15% | None |
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
ATROPINE 0.025 MG / DIPHENOXYLATE 2.5 MG ORAL TABLET |
1 |
Tier 1 |
15% | 15% | None |
ATROVENT HFA AER 17MCG |
2 |
Tier 2 |
15% | 15% | Q:1 /1Days |
AVANDAMET 2MG/1000MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
AVANDAMET 2MG/500MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
AVANDAMET 4MG/500MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVANDAMET TABLET 4-1000MG |
2 |
Tier 2 |
15% | 15% | None |
AVANDARYL 4MG/1MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
AVANDARYL 4MG/2MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
AVANDARYL 4MG/4MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
AVANDARYL 8MG-2MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
AVANDARYL 8MG-4MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
AVANDIA 2MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
AVANDIA 4MG TABLET (90 CT) |
2 |
Tier 2 |
15% | 15% | None |
AVANDIA 8MG TABLET (90 CT) |
2 |
Tier 2 |
15% | 15% | None |
AVELOX 400MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:1 /1Days |
AVELOX ABC PACK 400MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:1 /1Days |
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 |
15% | 15% | Q:1 /1Days |
AVINZA 120MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
15% | 15% | Q:13 /1Days |
AVINZA 30MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
15% | 15% | Q:1 /1Days |
AVINZA 60MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
15% | 15% | Q:1 /1Days |
AVINZA 90MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
15% | 15% | Q:17 /1Days |
AVINZA CAPSULES EXTENDED RELEASE 45MG 100 BOTPL |
2 |
Tier 2 |
15% | 15% | Q:1 /1Days |
AVINZA CAPSULES EXTENDED RELEASE 75MG 100 BOTPL |
2 |
Tier 2 |
15% | 15% | Q:1 /1Days |
AVITA 0.025% CREAM |
1 |
Tier 1 |
15% | 15% | P Q:1 /1Days |
AVODART 0.5MG SOFTGEL |
2 |
Tier 2 |
15% | 15% | None |
AZASAN 100MG TABLET |
2 |
Tier 2 |
15% | 15% | P |
AZASAN 75MG TABLET |
2 |
Tier 2 |
15% | 15% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZATHIOPRINE 50MG TABLET |
1 |
Tier 1 |
15% | 15% | P |
AZELASTINE 137 MCG NASAL SPRAY |
1 |
Tier 1 |
15% | 15% | Q:1 /1Days |
AZILECT 0.5MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
AZILECT 1MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
15% | 15% | Q:15 /5Days |
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
15% | 15% | Q:30 /5Days |
AZITHROMYCIN 250 MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:6 /5Days |
AZITHROMYCIN 500MG TABLET (30 CT) |
1 |
Tier 1 |
15% | 15% | Q:3 /3Days |
AZITHROMYCIN TABLET 600MG (30 CT) |
1 |
Tier 1 |
15% | 15% | None |
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT |
2 |
Tier 2 |
15% | 15% | None |
AZOR 10MG-20MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:1 /1Days |
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 |
15% | 15% | Q:1 /1Days |
AZOR 5MG-20MG TABLET (30 CT) |
2 |
Tier 2 |
15% | 15% | Q:1 /1Days |
AZOR 5MG-40MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:1 /1Days |