2011 Medicare Part D Plan Formulary Information |
FHCP Medvantage Rx Plus (HMO-POS) (H1035-002-0)
Benefit Details
|
The FHCP Medvantage Rx Plus (HMO-POS) (H1035-002-0) Formulary Drugs Starting with the Letter A in Volusia County, FL: CMS MA Region 9 which includes: FL
|
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 |
5 |
Tier 5 |
25% | 25% | None |
A-HYDROCORT 100MG VIAL |
5 |
Tier 5 |
25% | 25% | None |
A-METHAPRED 40MG UNIVIAL |
5 |
Tier 5 |
25% | 25% | None |
ABILIFY 10MG TABLET |
4 |
Tier 4 |
50% | 50% | P |
ABILIFY 15MG TABLET |
4 |
Tier 4 |
50% | 50% | P |
ABILIFY 1MG/ML SOLUTION |
4 |
Tier 4 |
50% | 50% | P |
ABILIFY 20MG TABLET |
4 |
Tier 4 |
50% | 50% | P |
ABILIFY 2MG TABLET |
4 |
Tier 4 |
50% | 50% | P |
ABILIFY 30MG TABLET |
4 |
Tier 4 |
50% | 50% | P |
ABILIFY 5MG TABLET (OTSUKA) |
4 |
Tier 4 |
50% | 50% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABILIFY DISCMELT 10MG TABLET |
4 |
Tier 4 |
50% | 50% | P |
ABILIFY DISCMELT 15MG TABLET |
4 |
Tier 4 |
50% | 50% | P |
ABILIFY INJ 9.75MG |
5 |
Tier 5 |
25% | 25% | None |
ACARBOSE 100MG TABLET S |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ACARBOSE 50MG TABLET S |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ACARBOSE TABLETS |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ACCOLATE 10MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
ACCOLATE 20MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
ACEBUTOLOL 200MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ACEBUTOLOL 400MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE |
5 |
Tier 5 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ACETAZOLAMIDE 125MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ACETIC ACID 2% SOLUTION NON-ORAL |
2 |
Tier 2 |
$7.00 | $18.00 | Q:15 /3Days |
ACTHIB VACCINE VIAL 10-24UNT/5ML |
5 |
Tier 5 |
25% | 25% | None |
ACTIMMUNE SOLUTION FOR INJECTION 100MCG |
6 |
Tier 6 |
33% | 33% | P |
ACTOS 15MG TABLET |
4 |
Tier 4 |
50% | 50% | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTOS 30MG TABLET (500 CT) |
4 |
Tier 4 |
50% | 50% | S |
ACTOS 45MG TABLET |
4 |
Tier 4 |
50% | 50% | S |
ACYCLOVIR 200MG CAPSULE (1000 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ACYCLOVIR 200MG/5ML SUSP |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ACYCLOVIR 400MG TABLET (100 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ACYCLOVIR 800 MG ORAL TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ADACEL VIAL 2UNT/5UNT |
5 |
Tier 5 |
25% | 25% | None |
ADAGEN 250U/ML VIAL |
6 |
Tier 6 |
33% | 33% | P |
ADVAIR DISKU MIS 100/50 |
4 |
Tier 4 |
50% | 50% | Q:60 /3Days |
ADVAIR DISKU MIS 250/50 |
4 |
Tier 4 |
50% | 50% | Q:60 /3Days |
ADVAIR DISKU MIS 500/50 |
4 |
Tier 4 |
50% | 50% | Q:60 /3Days |
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 |
4 |
Tier 4 |
50% | 50% | Q:12 /3Days |
ADVAIR HFA INHALER 230;21MCG;MCG |
4 |
Tier 4 |
50% | 50% | Q:12 /3Days |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
4 |
Tier 4 |
50% | 50% | Q:12 /3Days |
AEROBID-M AEROSOL W/ADAPTER |
4 |
Tier 4 |
50% | 50% | Q:7 /3Days |
AFEDITAB CR 30MG TABLET SA |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AFEDITAB CR 60MG TABLET SA |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AFINITOR TABLETS |
6 |
Tier 6 |
33% | 33% | None |
AFINITOR TABLETS |
6 |
Tier 6 |
33% | 33% | None |
AFINITOR TABLETS 5 MG |
6 |
Tier 6 |
33% | 33% | None |
AGGRENOX 25-200MG CAPSULE |
3 |
Tier 3 |
25% | 25% | None |
ALBUTEROL SULFATE SOLUTION FOR INHALATION |
5 |
Tier 5 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ALBUTEROL TABLET 4MG (500 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ALDURAZYME 2.9MG/5ML VIAL |
6 |
Tier 6 |
33% | 33% | P |
ALENDRONATE SODIUM 10MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | Q:4 /3Days |
ALENDRONATE SODIUM 5MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ALENDRONATE SODIUM TABLET 35MG 20 CRTN |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ALENDRONATE SODIUM TABLETS 70 MG |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ALIMTA 500MG VIAL |
6 |
Tier 6 |
33% | 33% | P |
ALLEGRA 30MG/5ML SUSPENSION ORAL |
3 |
Tier 3 |
25% | 25% | Q:360 /31Days |
ALLEGRA-D 24 HOUR TABLET |
3 |
Tier 3 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALLOPURINOL TABLET 300MG (1000 CT) |
1 |
Tier 1 |
$4.00 | $9.00 | None |
ALLOPURINOL TABLETS |
1 |
Tier 1 |
$4.00 | $9.00 | None |
ALOMIDE 0.1% EYE DROPS |
3 |
Tier 3 |
25% | 25% | Q:10 /3Days |
ALOXI 0.25MG/5ML |
5 |
Tier 5 |
25% | 25% | None |
ALREX 0.2% EYE DROPS |
4 |
Tier 4 |
50% | 50% | Q:5 /3Days |
AMANTADINE 100MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMIFOSTINE FOR INJECTION 500MG/VIAL |
5 |
Tier 5 |
25% | 25% | P |
AMIKACIN 250MG/ML VIAL |
5 |
Tier 5 |
25% | 25% | None |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMINOPHYLLINE 100MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOPHYLLINE 200MG TABLET (1000 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD |
5 |
Tier 5 |
25% | 25% | None |
AMINOSYN II 3.5% W/ELEC DEX |
5 |
Tier 5 |
25% | 25% | None |
AMIODARONE HCL INJECTION |
5 |
Tier 5 |
25% | 25% | None |
AMIODARONE HYDROCHLORIDE TABLETS |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMITRIP/PERPHEN 10-2 TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMITRIP/PERPHEN 10-4 TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMITRIP/PERPHEN 25-2 TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMITRIP/PERPHEN 25-4 TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMITRIP/PERPHEN 50-4 TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMITRIPTYLINE HCL 100MG TABLET |
1 |
Tier 1 |
$4.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIPTYLINE HCL 10MG TABLET |
1 |
Tier 1 |
$4.00 | $9.00 | None |
AMITRIPTYLINE HCL 150 MG TAB |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
1 |
Tier 1 |
$4.00 | $9.00 | None |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
1 |
Tier 1 |
$4.00 | $9.00 | None |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
1 |
Tier 1 |
$4.00 | $9.00 | None |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOX TR-K CLV 500-125 MG TAB |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL |
2 |
Tier 2 |
$7.00 | $18.00 | Q:100 /3Days |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
2 |
Tier 2 |
$7.00 | $18.00 | Q:100 /3Days |
AMOXAPINE 100MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOXAPINE 150MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOXAPINE 25MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOXAPINE 50MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOXICILLIN 125MG TABLET CHEW |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOXICILLIN 200MG TABLET CHEW |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOXICILLIN 250MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOXICILLIN 400MG TABLET CHEW |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION |
2 |
Tier 2 |
$7.00 | $18.00 | Q:150 /3Days |
AMOXICILLIN 500MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOXICILLIN 875MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
2 |
Tier 2 |
$7.00 | $18.00 | Q:200 /3Days |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
2 |
Tier 2 |
$7.00 | $18.00 | Q:150 /3Days |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
2 |
Tier 2 |
$7.00 | $18.00 | Q:100 /3Days |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
2 |
Tier 2 |
$7.00 | $18.00 | Q:150 /3Days |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
2 |
Tier 2 |
$7.00 | $18.00 | Q:100 /3Days |
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL |
5 |
Tier 5 |
25% | 25% | None |
AMPICILLIN CAPSULES 250MG 100 BOT |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
2 |
Tier 2 |
$7.00 | $18.00 | Q:200 /3Days |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
2 |
Tier 2 |
$7.00 | $18.00 | Q:200 /3Days |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML |
5 |
Tier 5 |
25% | 25% | None |
AMYLASES 109000 UNT / ENDOPEPTIDASES 68000 UNT / LIPASE 20000 UNT ENTERIC COATED CAPSULE [ZENPEP 20] |
4 |
Tier 4 |
50% | 50% | None |
AMYLASES 27000 UNT / ENDOPEPTIDASES 17000 UNT / LIPASE 5000 UNT ENTERIC COATED CAPSULE [ZENPEP 5] |
4 |
Tier 4 |
50% | 50% | None |
AMYLASES 55000 UNT / ENDOPEPTIDASES 34000 UNT / LIPASE 10000 UNT ENTERIC COATED CAPSULE [ZENPEP 10] |
4 |
Tier 4 |
50% | 50% | None |
AMYLASES 82000 UNT / ENDOPEPTIDASES 51000 UNT / LIPASE 15000 UNT ENTERIC COATED CAPSULE [ZENPEP 15] |
4 |
Tier 4 |
50% | 50% | None |
ANADROL-50 50MG TABLET (100 CT) |
4 |
Tier 4 |
50% | 50% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANAGRELIDE HCL 0.5MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ANAGRELIDE HCL 1MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ANASTROZOLE TABLETS |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ANCOBON 250MG CAPSULE |
4 |
Tier 4 |
50% | 50% | None |
ANCOBON 500MG CAPSULE |
4 |
Tier 4 |
50% | 50% | None |
ANDRODERM 2.5MG/24HR PATCH |
4 |
Tier 4 |
50% | 50% | None |
ANDRODERM 5MG/24HR PATCH |
4 |
Tier 4 |
50% | 50% | None |
ANIDULAFUNGIN 3.33 MG/ML INJECTABLE SOLUTION [ERAXIS] |
5 |
Tier 5 |
25% | 25% | None |
ANTABUSE 250MG TABLET |
4 |
Tier 4 |
50% | 50% | None |
ANTABUSE 500MG TABLET |
4 |
Tier 4 |
50% | 50% | None |
ANTIZOL INJECTION 1GM 4 X 1.5ML VIAL CRTN |
6 |
Tier 6 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANZEMET 20MG/ML VIAL |
5 |
Tier 5 |
25% | 25% | None |
APOKYN 30 MG/3 ML CARTRIDGE |
6 |
Tier 6 |
33% | 33% | P |
APRACLONIDINE 5 MG/ML OPHTHALMIC SOLUTION |
2 |
Tier 2 |
$7.00 | $18.00 | Q:5 /3Days |
APTIVUS 250MG CAPSULE |
3 |
Tier 3 |
25% | 25% | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
3 |
Tier 3 |
25% | 25% | None |
ARANESP 100MCG/ML VIAL |
6 |
Tier 6 |
33% | 33% | None |
ARANESP 200MCG/ML VIAL |
6 |
Tier 6 |
33% | 33% | None |
ARANESP 25MCG/ML VIAL |
5 |
Tier 5 |
25% | 25% | None |
ARANESP 60MCG/ML VIAL |
6 |
Tier 6 |
33% | 33% | None |
ARANESP PREFILLED SYRINGE SINGLE USE 100MCG/0.5ML 1 SYR |
6 |
Tier 6 |
33% | 33% | None |
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR |
6 |
Tier 6 |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR |
5 |
Tier 5 |
25% | 25% | None |
ARANESP PREFILLED SYRINGE SINGLE USE 60MCG/0.3ML 60MCG/ 0.3ML SYR |
6 |
Tier 6 |
33% | 33% | None |
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD |
5 |
Tier 5 |
25% | 25% | None |
ARCALYST INJECTION 220MG/VIAL |
6 |
Tier 6 |
33% | 33% | P |
AREDIA 90MG VIAL |
6 |
Tier 6 |
33% | 33% | None |
ARICEPT 10MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
ARICEPT 5MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
ARICEPT ODT 10MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
ARICEPT ODT 5MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
ARIMIDEX 1MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
ARIXTRA 10MG SYRINGE |
6 |
Tier 6 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARIXTRA 2.5MG SYRINGE |
5 |
Tier 5 |
25% | 25% | P |
ARIXTRA 5MG SYRINGE |
6 |
Tier 6 |
33% | 33% | P |
ARIXTRA 7.5MG SYRINGE |
6 |
Tier 6 |
33% | 33% | P |
AROMASIN 25MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
ASACOL 400MG TABLET EC |
3 |
Tier 3 |
25% | 25% | None |
ASACOL HD DELAYED RELEASE TABLETS 800MG 180 BOT |
3 |
Tier 3 |
25% | 25% | None |
ASENAPINE 10 MG SUBLINGUAL TABLET [SAPHRIS] |
4 |
Tier 4 |
50% | 50% | P |
ASENAPINE 5 MG SUBLINGUAL TABLET [SAPHRIS] |
4 |
Tier 4 |
50% | 50% | P |
ATENOLOL 25MG TABLET (100 CT) |
1 |
Tier 1 |
$4.00 | $9.00 | None |
ATENOLOL TABLET USP 50MG (100 CT) |
1 |
Tier 1 |
$4.00 | $9.00 | None |
ATENOLOL TABLETS USP 100MG 1 BLPK |
1 |
Tier 1 |
$4.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATRIPLA TABLET 600MG/200MG |
3 |
Tier 3 |
25% | 25% | None |
ATROPINE 0.025 MG / DIPHENOXYLATE 2.5 MG ORAL TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ATROPINE 0.1MG/ML SYRINGE |
5 |
Tier 5 |
25% | 25% | None |
ATROVENT HFA AER 17MCG |
3 |
Tier 3 |
25% | 25% | Q:12 /3Days |
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML |
5 |
Tier 5 |
25% | 25% | None |
AVANDIA 2MG TABLET |
3 |
Tier 3 |
25% | 25% | S |
AVANDIA 4MG TABLET (90 CT) |
3 |
Tier 3 |
25% | 25% | S |
AVANDIA 8MG TABLET (90 CT) |
3 |
Tier 3 |
25% | 25% | S |
AVASTIN 100MG/4ML VIAL |
6 |
Tier 6 |
33% | 33% | P |
AVIANE 0.1-0.02 TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AVODART 0.5MG SOFTGEL |
3 |
Tier 3 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVONEX ADMIN PACK 30MCG SYR |
6 |
Tier 6 |
33% | 33% | None |
AVONEX ADMIN PACK 30MCG VL |
6 |
Tier 6 |
33% | 33% | None |
AZATHIOPRINE 50MG TABLET |
5 |
Tier 5 |
25% | 25% | None |
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Tier 2 |
$7.00 | $18.00 | Q:15 /3Days |
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Tier 2 |
$7.00 | $18.00 | Q:30 /3Days |
AZITHROMYCIN 250 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AZITHROMYCIN 500MG TABLET (30 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD |
5 |
Tier 5 |
25% | 25% | None |
AZITHROMYCIN TABLETS |
2 |
Tier 2 |
$7.00 | $18.00 | None |