2011 Medicare Part D Plan Formulary Information |
Geisinger Gold Preferred 1 $0 Deductible Rx (PPO) (H3924-003-0)
Benefit Details
|
The Geisinger Gold Preferred 1 $0 Deductible Rx (PPO) (H3924-003-0) Formulary Drugs Starting with the Letter C in Montour County, PA: CMS MA Region 6 which includes: PA
|
Drugs Starting with Letter C
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
CABERGOLINE 0.5 MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CALCIUM ACETATE CAPSULE 667 MG |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CAMPATH 30MG/ML VIAL |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CAMPRAL 333MG DOSE PAK |
3 |
Tier 3 |
$69.00 | $172.50 | None |
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX |
3 |
Tier 3 |
$69.00 | $172.50 | None |
CANCIDAS IV 50MG VIAL |
3 |
Tier 3 |
$69.00 | $172.50 | None |
CANCIDAS IV 70MG VIAL |
3 |
Tier 3 |
$69.00 | $172.50 | None |
CAPREOMYCIN 500 MG/ML INJECTABLE SOLUTION [CAPASTAT] |
3 |
Tier 3 |
$69.00 | $172.50 | None |
CAPTOPRIL 100MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CAPTOPRIL 12.5MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAPTOPRIL 25MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CAPTOPRIL 50MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CAPTOPRIL/HCTZ 25/15 TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CARBAMAZEPINE ORAL SUSPENSION 200 MG |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CARBAMAZEPINE TABLET CHEWABLE 100MG (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CARBAMAZEPINE TABLET USP 200MG (1000 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CARBATROL 100MG CAPSULE SA |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CARBATROL 200MG CAPSULE SA |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CARBATROL 300MG CAPSULE SA |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CARBIDOPA-LEVODOPA 25MG-100MG TABLET SA |
1 |
Tier 1 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARBIDOPA-LEVODOPA 50MG-200MG TABLET SA |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CARBIDOPA/LEVO 10/100 TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CARBIDOPA/LEVO 25/100 TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CARBIDOPA/LEVO 25/250 TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CARIMUNE NF 3GM VIAL |
4 |
Tier 4 |
33% | 33% | P |
CARISOPRODOL TABLET USP 350MG (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CARVEDILOL 12.5MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CARVEDILOL 25MG TABLET (500 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CARVEDILOL 3.125MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CARVEDILOL 6.25MG TABLET (500 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CASODEX 50MG TABLET |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CEENU 100MG CAPSULE |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CEENU 10MG CAPSULE |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CEENU 40MG CAPSULE |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CEFACLOR CAPSULES |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEFADROXIL 1G TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEFADROXIL 500MG CAPSULE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEFADROXIL 500MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEFADROXIL FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEFAZOLIN 1 GM VIAL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEFAZOLIN 1GM/D5W BAG |
1 |
Tier 1 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEFDINIR CAPSULES 300MG (60 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEFOTAXIME FOR INJECTION |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEFOTAXIME FOR INJECTION 1GM 50 BOX VIALGL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEFOTAXIME FOR INJECTION 2GM 25 VIAL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEFOTAXIME FOR INJECTION 500MG 10 VIAL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEFPROZIL 250MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEFPROZIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEFPROZIL FOR ORAL SUSPENSION 125MG/5ML 75ML BOT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEFPROZIL TABLETS 500MG 100 BOT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFTRIAXONE 10GM VIAL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEFTRIAXONE FOR INJECTION 250MG BOX OF 10 VIALGL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEFTRIAXONE FOR INJECTION 500MG BOX OF 10 VIALGL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEFUROXIME 250MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEFUROXIME AXETIL 500MG TABLET (20 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEFUROXIME FOR INJECTION |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEFUROXIME FOR INJECTION |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEFUROXIME FOR INJECTION |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CELEBREX 100MG CAPSULE |
3 |
Tier 3 |
$69.00 | $172.50 | None |
CELEBREX 200MG CAPSULE |
3 |
Tier 3 |
$69.00 | $172.50 | None |
CELEBREX 400MG CAPSULE |
3 |
Tier 3 |
$69.00 | $172.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CELEBREX 50MG CAPSULE |
3 |
Tier 3 |
$69.00 | $172.50 | None |
CELLCEPT 200MG/ML ORAL SUSP |
3 |
Tier 3 |
$69.00 | $172.50 | None |
CELLCEPT 500MG TABLET |
3 |
Tier 3 |
$69.00 | $172.50 | None |
CELLCEPT CAPSULES 250MG (500 CT) |
3 |
Tier 3 |
$69.00 | $172.50 | None |
CELONTIN 300MG KAPSEAL |
3 |
Tier 3 |
$69.00 | $172.50 | None |
CENESTIN 0.3MG TABLET |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CENESTIN 0.45MG TABLET |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CENESTIN 0.625MG TABLET |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CENESTIN 0.9MG TABLET |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CENESTIN 1.25MG TABLET |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CEPHALEXIN 250MG CAPSULE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEPHALEXIN 250MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEPHALEXIN 250MG/5ML ORAL SUSP |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEPHALEXIN 500MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEPHALEXIN CAPSULES 500MG (500 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEPHALEXIN POWDER FOR SUSPENSION ORAL USP 125MG 200ML BOT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CEREDASE 80UNITS/ML VIAL |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CEREZYME INJ 200UNIT |
4 |
Tier 4 |
33% | 33% | P |
CHANTIX 0.5MG TABLET |
3 |
Tier 3 |
$69.00 | $172.50 | Q:60 /30Days |
CHANTIX 1MG TABLET |
3 |
Tier 3 |
$69.00 | $172.50 | Q:60 /30Days |
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CHLOROQUINE PH 500MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLOROQUINE PHOSPHATE 250MG TABLET (50 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CHLOROTHIAZIDE 250MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CHLOROTHIAZIDE 500MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CHLORPROMAZINE 100MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CHLORPROMAZINE 10MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CHLORPROMAZINE 25MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CHLORPROMAZINE 25MG/ML AMP |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CHLORPROMAZINE 50MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CHLORPROMAZINE HCL 200MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CHLORPROPAMIDE 100MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CHLORPROPAMIDE 250MG TABLET (1000 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLORTHALIDONE 25MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CHLORTHALIDONE 50MG TABLET (1000 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CHORIONIC GONAD 10000U VIAL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6ML BOT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CILOSTAZOL 50MG TABLET (60 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CILOSTAZOL TABLET 100MG (60 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CILOXAN 0.3% OINTMENT |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CIMETIDINE 200MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CIMETIDINE HCL 300MG/5ML SOL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CIMZIA 200 MG/ML SYRINGE KIT |
4 |
Tier 4 |
33% | 33% | P Q:2 /30Days |
CIMZIA KIT |
4 |
Tier 4 |
33% | 33% | P Q:2 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIPRODEX OTIC SUSPENSION |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CIPROFLOXACIN 250MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CIPROFLOXACIN 400 MG/40 ML VL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CIPROFLOXACIN HCL 0.3% DROPS |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CITALOPRAM HBR 20 MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CITOLOPRAM HBR 10MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CLARITHROMYCIN 250MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CLARITHROMYCIN 500MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CLARITHROMYCIN FOR ORAL SUSPENSION |
1 |
Tier 1 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLARITHROMYCIN FOR ORAL SUSPENSION |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CLEMASTINE FUM 2.68MG TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CLEMASTINE FUMARATE SYRUP |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CLINDAMYCIN HCL 150MG CAPSULE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CLINDAMYCIN HYDROCHLORIDE CAPSULES |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CLINDESSE 2% VAGINAL CREAM |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CLOBETASOL 0.05% OINTMENT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CLOBETASOL 0.05% SOLUTION |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CLOBETASOL E 0.05% CREAM |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CLOMIPRAMINE HCL 25MG CAPSULE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOMIPRAMINE HCL 50MG CAPSULE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CLOMIPRAMINE HCL 75MG CAPSULE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CLONIDINE HCL 0.2MG TABLET (500 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CLONIDINE HCL TABLET 0.1MG (500 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CLONIDINE HCL TABLET 0.3MG (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CLOTRIMAZOLE 1% CREAM |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CLOTRIMAZOLE 10MG TROCHE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CLOTRIMAZOLE SOLUTION TOPICAL 1% 30ML BOTPL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CLOZAPINE 100 MG DISINTEGRATING TABLET [FAZACLO] |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CLOZAPINE 100 MG ORAL TABLET |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CLOZAPINE 200MG TABLET (500 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOZAPINE 25 MG DISINTEGRATING TABLET [FAZACLO] |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CLOZAPINE 25MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CLOZAPINE 50MG TABLET (500 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
COLCHICINE 0.6 MG ORAL TABLET [COLCRYS] |
1 |
Tier 1 |
$6.00 | $15.00 | None |
COLESTIPOL HCL 5G GRANULES |
1 |
Tier 1 |
$6.00 | $15.00 | None |
COLISTIMETHATE 150MG VIAL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE |
2 |
Tier 2 |
$39.00 | $97.50 | None |
COMBIVENT INHALER |
2 |
Tier 2 |
$39.00 | $97.50 | None |
COMBIVIR TABLETS |
4 |
Tier 4 |
33% | 33% | None |
COMTAN 200MG TABLET |
2 |
Tier 2 |
$39.00 | $97.50 | None |
COMVAX VACCINE VIAL |
2 |
Tier 2 |
$39.00 | $97.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CONDYLOX GEL 0.5% 3.5 GM CRTN |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CONDYLOX TOPICAL SOLUTION .5% 3.5 ML CTR |
2 |
Tier 2 |
$39.00 | $97.50 | None |
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN |
4 |
Tier 4 |
33% | 33% | None |
COPEGUS 200MG TABLET |
3 |
Tier 3 |
$69.00 | $172.50 | None |
CORTISONE ACETATE 25MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
COZAAR 100MG TABLET |
2 |
Tier 2 |
$39.00 | $97.50 | None |
COZAAR 25MG TABLET (1000 CT) |
2 |
Tier 2 |
$39.00 | $97.50 | None |
COZAAR 50MG TABLET 10000 BOT |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT |
2 |
Tier 2 |
$39.00 | $97.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CRESTOR 10MG TABLET |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CRESTOR 20MG TABLET |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CRESTOR 40MG TABLET |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CRESTOR 5MG TABLET |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CRIXIVAN 100MG CAPSULE |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CRIXIVAN 200MG CAPSULE |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CRIXIVAN 333MG CAPSULE |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CRIXIVAN 400MG CAPSULE (120 CT) |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CROMOLYN NEBULIZER SOLUTION |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CUBICIN 500MG VIAL |
4 |
Tier 4 |
33% | 33% | None |
CUPRIMINE CAPSULES 250MG (100 CT) |
3 |
Tier 3 |
$69.00 | $172.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CYCLOBENZAPRINE HCL 5MG TABLET (500 CT) |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CYCLOSPORINE 100MG CAPSULE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CYCLOSPORINE 25MG CAPSULE |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CYCLOSPORINE 50MG/ML AMP |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CYKLOKAPRON 100MG/ML AMPUL |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CYMBALTA 20MG CAPSULE |
3 |
Tier 3 |
$69.00 | $172.50 | None |
CYMBALTA 60MG CAPSULE |
3 |
Tier 3 |
$69.00 | $172.50 | None |
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT) |
3 |
Tier 3 |
$69.00 | $172.50 | None |
CYPROHEPTADINE HCL 4 MG |
1 |
Tier 1 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL |
1 |
Tier 1 |
$6.00 | $15.00 | None |
CYSTADANE POWDER FOR ORAL SOLUTION 180GM |
2 |
Tier 2 |
$39.00 | $97.50 | None |
CYSTAGON 150MG CAPSULE |
3 |
Tier 3 |
$69.00 | $172.50 | None |
CYSTAGON 50MG CAPSULE |
3 |
Tier 3 |
$69.00 | $172.50 | None |
CYTOMEL 25MCG TABLET |
3 |
Tier 3 |
$69.00 | $172.50 | None |
CYTOMEL 50MCG TABLET |
3 |
Tier 3 |
$69.00 | $172.50 | None |
CYTOMEL 5MCG TABLET |
3 |
Tier 3 |
$69.00 | $172.50 | None |