2011 Medicare Part D Plan Formulary Information |
Medicare Blue Plus (PPO) (H4209-006-0)
Benefit Details
|
The Medicare Blue Plus (PPO) (H4209-006-0) Formulary Drugs Starting with the Letter C in Chesterfield County, SC: CMS MA Region 8 which includes: SC
|
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 |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CADUET 10MG/10MG TABLET |
4 |
Tier 4 |
$75.00 | $187.50 | None |
CADUET 10MG/20MG TABLET |
4 |
Tier 4 |
$75.00 | $187.50 | None |
CADUET 10MG/40MG TABLET |
4 |
Tier 4 |
$75.00 | $187.50 | None |
CADUET 10MG/80MG TABLET |
4 |
Tier 4 |
$75.00 | $187.50 | None |
CADUET 2.5MG/10MG TABLET |
4 |
Tier 4 |
$75.00 | $187.50 | None |
CADUET 2.5MG/20MG TABLET |
4 |
Tier 4 |
$75.00 | $187.50 | None |
CADUET 2.5MG/40MG TABLET |
4 |
Tier 4 |
$75.00 | $187.50 | None |
CADUET 5MG/10MG TABLET |
4 |
Tier 4 |
$75.00 | $187.50 | None |
CADUET 5MG/20MG TABLET |
4 |
Tier 4 |
$75.00 | $187.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CADUET 5MG/40MG TABLET |
4 |
Tier 4 |
$75.00 | $187.50 | None |
CADUET 5MG/80MG TABLET |
4 |
Tier 4 |
$75.00 | $187.50 | None |
CALCIPOTRIENE OINTMENT |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CALCIPOTRIENE TOPICAL SOLUTION |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CALCITRIOL 0.25MCG CAPSULE |
2 |
Tier 2 |
$9.00 | $22.50 | P |
CALCITRIOL 0.5MCG CAPSULE |
2 |
Tier 2 |
$9.00 | $22.50 | P |
CALCITRIOL 1MCG/ML SOLUTION ORAL |
2 |
Tier 2 |
$9.00 | $22.50 | P |
CALCITRIOL 2 MCG/ML VIAL |
3 |
Tier 3 |
$35.00 | $87.50 | P |
CALCITRIOL INJECTION SOLUTION 1MCG 50 X 01ML AMP |
2 |
Tier 2 |
$9.00 | $22.50 | P |
CALCIUM ACETATE CAPSULE 667 MG |
2 |
Tier 2 |
$9.00 | $22.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CALCIUM CHLORIDE 0.0014 MEQ/ML / POTASSIUM CHLORIDE 0.004 MEQ/ML / SODIUM CHLORIDE 0.103 MEQ/ML / SO |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CAMILA 0.35MG TABLET |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CAMPATH 30MG/ML VIAL |
3 |
Tier 3 |
$35.00 | $87.50 | P |
CAMPRAL 333MG DOSE PAK |
3 |
Tier 3 |
$35.00 | $87.50 | P |
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CANCIDAS IV 50MG VIAL |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CANCIDAS IV 70MG VIAL |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CAPREOMYCIN 500 MG/ML INJECTABLE SOLUTION [CAPASTAT] |
4 |
Tier 4 |
$75.00 | $187.50 | None |
CAPTOPRIL 100MG TABLET |
1 |
Tier 1 |
$2.00 | $4.00 | None |
CAPTOPRIL 12.5MG TABLET |
1 |
Tier 1 |
$2.00 | $4.00 | None |
CAPTOPRIL 25MG TABLET |
1 |
Tier 1 |
$2.00 | $4.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAPTOPRIL 50MG TABLET |
1 |
Tier 1 |
$2.00 | $4.00 | None |
CAPTOPRIL/HCTZ 25/15 TABLET |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CAPTOPRIL/HCTZ 25/25 TABLET |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CAPTOPRIL/HCTZ 50/15 TABLET |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CAPTOPRIL/HCTZ 50/25 TABLET |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CARAC CRE 0.5% |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CARAFATE SUS 1GM/10ML |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CARBAMAZEPINE EXTENDED RELEASE TABLETS 200MG |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CARBAMAZEPINE EXTENDED RELEASE TABLETS 400MG |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CARBAMAZEPINE ORAL SUSPENSION 200 MG |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CARBAMAZEPINE TABLET CHEWABLE 100MG (100 CT) |
2 |
Tier 2 |
$9.00 | $22.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARBAMAZEPINE TABLET USP 200MG (1000 CT) |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CARBATROL 100MG CAPSULE SA |
4 |
Tier 4 |
$75.00 | $187.50 | None |
CARBATROL 200MG CAPSULE SA |
4 |
Tier 4 |
$75.00 | $187.50 | None |
CARBATROL 300MG CAPSULE SA |
4 |
Tier 4 |
$75.00 | $187.50 | None |
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;100MG;MG 100 BOT |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;250MG;MG 100 BOT |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CARBIDOPA-LEVODOPA 25MG-100MG TABLET SA |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CARBIDOPA-LEVODOPA 50MG-200MG TABLET SA |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CARBIDOPA/LEVO 10/100 TABLET |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CARBIDOPA/LEVO 25/100 TABLET |
2 |
Tier 2 |
$9.00 | $22.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARBIDOPA/LEVO 25/250 TABLET |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CARBOPLATIN INJECTION |
2 |
Tier 2 |
$9.00 | $22.50 | P |
CARDIZEM CD 360MG CAPSULE SR 24 HR |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CARISOPRODOL TABLET USP 350MG (100 CT) |
1 |
Tier 1 |
$2.00 | $4.00 | None |
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CARTIA XT 120MG CAPSULE SA |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CARTIA XT 180MG CAPSULE SA |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CARTIA XT 240MG CAPSULE SA |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CARTIA XT 300MG CAPSULE SR 24 HR |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CARVEDILOL 12.5MG TABLET (100 CT) |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CARVEDILOL 25MG TABLET (500 CT) |
2 |
Tier 2 |
$9.00 | $22.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARVEDILOL 3.125MG TABLET (100 CT) |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CARVEDILOL 6.25MG TABLET (500 CT) |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CAYSTON KIT |
5 |
Tier 5 |
33% | 33% | P |
CEDAX 400MG CAPSULE |
4 |
Tier 4 |
$75.00 | $187.50 | None |
CEENU 100MG CAPSULE |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CEENU 10MG CAPSULE |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CEENU 40MG CAPSULE |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CEFACLOR 250MG/5ML ORAL SUSP |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFACLOR 375MG/5ML ORAL SUSP |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFACLOR CAPSULES |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFACLOR CAPSULES |
2 |
Tier 2 |
$9.00 | $22.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFACLOR ER 500MG TABLET SR 12HR |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CEFACLOR POWDER FOR ORAL SUSPENSION USP 125MG 75ML BOT |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFADROXIL 1G TABLET |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFADROXIL 500MG CAPSULE |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFADROXIL 500MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFADROXIL FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFAZOLIN 1 GM VIAL |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFAZOLIN 1GM/D5W BAG |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CEFAZOLIN 20GM BULK VIAL |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFAZOLIN FOR INJECTION |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Tier 2 |
$9.00 | $22.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFDINIR CAPSULES 300MG (60 CT) |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT) |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFEPIME HCL 2 GRAM VIAL |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFOTAXIME FOR INJECTION |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFOTAXIME FOR INJECTION 1GM 50 BOX VIALGL |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFOTAXIME FOR INJECTION 2GM 25 VIAL |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFOTAXIME FOR INJECTION 500MG 10 VIAL |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFOXITIN 180 MG/ML INJECTABLE SOLUTION |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFOXITIN 95 MG/ML INJECTABLE SOLUTION |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFOXITIN FOR INJECTION SOLUTION |
2 |
Tier 2 |
$9.00 | $22.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFPODOXIME PROXETIL 200MG TABLET |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT) |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 100MG 50ML BOT |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 50MG 50ML BOT |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFPROZIL 250MG TABLET (100 CT) |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFPROZIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFPROZIL FOR ORAL SUSPENSION 125MG/5ML 75ML BOT |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFPROZIL TABLETS 500MG 100 BOT |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFTRIAXONE 10GM VIAL |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFTRIAXONE FOR INJECTION 250MG BOX OF 10 VIALGL |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFTRIAXONE FOR INJECTION 500MG BOX OF 10 VIALGL |
2 |
Tier 2 |
$9.00 | $22.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFUROXIME 250MG TABLET |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFUROXIME AXETIL 125MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFUROXIME AXETIL 500MG TABLET (20 CT) |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFUROXIME FOR INJECTION |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFUROXIME FOR INJECTION |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEFUROXIME FOR INJECTION AND DEXTROSE INJECTION |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CELEBREX 100MG CAPSULE |
3 |
Tier 3 |
$35.00 | $87.50 | P |
CELEBREX 200MG CAPSULE |
3 |
Tier 3 |
$35.00 | $87.50 | P |
CELEBREX 400MG CAPSULE |
3 |
Tier 3 |
$35.00 | $87.50 | P |
CELEBREX 50MG CAPSULE |
3 |
Tier 3 |
$35.00 | $87.50 | P |
CELLCEPT 200MG/ML ORAL SUSP |
3 |
Tier 3 |
$35.00 | $87.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CELLCEPT 500MG TABLET |
3 |
Tier 3 |
$35.00 | $87.50 | P |
CELLCEPT CAPSULES 250MG (500 CT) |
3 |
Tier 3 |
$35.00 | $87.50 | P |
CELONTIN 300MG KAPSEAL |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CENESTIN 0.3MG TABLET |
4 |
Tier 4 |
$75.00 | $187.50 | None |
CENESTIN 0.45MG TABLET |
4 |
Tier 4 |
$75.00 | $187.50 | None |
CENESTIN 0.625MG TABLET |
4 |
Tier 4 |
$75.00 | $187.50 | None |
CENESTIN 0.9MG TABLET |
4 |
Tier 4 |
$75.00 | $187.50 | None |
CENESTIN 1.25MG TABLET |
4 |
Tier 4 |
$75.00 | $187.50 | None |
CEPHALEXIN 250MG CAPSULE |
1 |
Tier 1 |
$2.00 | $4.00 | None |
CEPHALEXIN 250MG/5ML ORAL SUSP |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEPHALEXIN CAPSULES 500MG (500 CT) |
1 |
Tier 1 |
$2.00 | $4.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEPHALEXIN POWDER FOR SUSPENSION ORAL USP 125MG 200ML BOT |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CEREZYME INJ 200UNIT |
5 |
Tier 5 |
33% | 33% | P |
CESIA 7 DAYS X 3 TABLET |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CETIRIZINE HCL 5MG/5ML |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CHANTIX 0.5MG TABLET |
4 |
Tier 4 |
$75.00 | $187.50 | P |
CHANTIX 1MG TABLET |
4 |
Tier 4 |
$75.00 | $187.50 | P |
CHANTIX STARTING MONTH PAK |
4 |
Tier 4 |
$75.00 | $187.50 | P |
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH |
1 |
Tier 1 |
$2.00 | $4.00 | None |
CHLOROQUINE PH 500MG TABLET |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CHLOROQUINE PHOSPHATE 250MG TABLET (50 CT) |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CHLOROTHIAZIDE 250MG TABLET |
1 |
Tier 1 |
$2.00 | $4.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLOROTHIAZIDE 500MG TABLET |
1 |
Tier 1 |
$2.00 | $4.00 | None |
CHLORPROMAZINE 100MG TABLET |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CHLORPROMAZINE 10MG TABLET |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CHLORPROMAZINE 25MG TABLET |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CHLORPROMAZINE 25MG/ML AMP |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CHLORPROMAZINE 50MG TABLET |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CHLORPROMAZINE HCL 200MG TABLET |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CHLORTHALIDONE 25MG TABLET (100 CT) |
1 |
Tier 1 |
$2.00 | $4.00 | None |
CHLORTHALIDONE 50MG TABLET (1000 CT) |
1 |
Tier 1 |
$2.00 | $4.00 | None |
CHLORZOXAZONE 500MG TABLET |
1 |
Tier 1 |
$2.00 | $4.00 | None |
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION |
2 |
Tier 2 |
$9.00 | $22.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHORIONIC GONAD 10000U VIAL |
2 |
Tier 2 |
$9.00 | $22.50 | P |
CICLOPIROX 0.77% CREAM |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CICLOPIROX 0.77% TOPICAL SUSPENSION |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CICLOPIROX 1% SHAMPOO |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CICLOPIROX GEL |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CILOSTAZOL 50MG TABLET (60 CT) |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CILOSTAZOL TABLET 100MG (60 CT) |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CILOXAN 0.3% OINTMENT |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CIMETIDINE 150MG/ML VIAL |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CIMETIDINE 200MG TABLET |
1 |
Tier 1 |
$2.00 | $4.00 | None |
CIMETIDINE HCL 300MG/5ML SOL |
2 |
Tier 2 |
$9.00 | $22.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIMETIDINE TABLETS |
1 |
Tier 1 |
$2.00 | $4.00 | None |
CIMETIDINE TABLETS |
1 |
Tier 1 |
$2.00 | $4.00 | None |
CIMETIDINE TABLETS USP |
1 |
Tier 1 |
$2.00 | $4.00 | None |
CIMZIA 200 MG/ML SYRINGE KIT |
5 |
Tier 5 |
33% | 33% | P |
CIMZIA KIT |
5 |
Tier 5 |
33% | 33% | P |
CIPRO (10%) SUS 500MG/5 |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CIPRO (5%) SUS 250MG/5 |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CIPRO HC OTIC SUSPENSION |
4 |
Tier 4 |
$75.00 | $187.50 | None |
CIPRODEX OTIC SUSPENSION |
4 |
Tier 4 |
$75.00 | $187.50 | None |
CIPROFLOXACIN 250MG TABLET (100 CT) |
1 |
Tier 1 |
$2.00 | $4.00 | None |
CIPROFLOXACIN 400 MG/40 ML VL |
2 |
Tier 2 |
$9.00 | $22.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIPROFLOXACIN 500MG TABLET |
1 |
Tier 1 |
$2.00 | $4.00 | None |
CIPROFLOXACIN ER 1000MG TABLET (30 CT) |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CIPROFLOXACIN ER 500MG TABLET (30 CT) |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CIPROFLOXACIN HCL 0.3% DROPS |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CIPROFLOXACIN HCL 100MG TABLET |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CIPROFLOXACIN TABLETS 750MG 100 BOT |
1 |
Tier 1 |
$2.00 | $4.00 | None |
CISPLATIN 1 MG/ML INJECTABLE SOLUTION |
2 |
Tier 2 |
$9.00 | $22.50 | P |
CITALOPRAM HBR 20 MG TABLET |
1 |
Tier 1 |
$2.00 | $4.00 | Q:45 /25Days |
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT |
1 |
Tier 1 |
$2.00 | $4.00 | None |
CITOLOPRAM HBR 10MG TABLET (100 CT) |
1 |
Tier 1 |
$2.00 | $4.00 | Q:45 /25Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLADRIBINE 1MG/ML VIAL |
2 |
Tier 2 |
$9.00 | $22.50 | P |
CLARAVIS 10MG CAPSULE |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLARAVIS 20MG CAPSULE |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLARAVIS 30MG CAPSULE |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLARAVIS 40MG CAPSULE |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLARITHROMYCIN 250MG TABLET |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLARITHROMYCIN 500MG TABLET |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLARITHROMYCIN ER 500MG TABLET (60 CT) |
2 |
Tier 2 |
$9.00 | $22.50 | Q:60 /25Days |
CLARITHROMYCIN FOR ORAL SUSPENSION |
2 |
Tier 2 |
$9.00 | $22.50 | Q:400 /10Days |
CLARITHROMYCIN FOR ORAL SUSPENSION |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLEMASTINE FUM 2.68MG TABLET |
2 |
Tier 2 |
$9.00 | $22.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLEMASTINE FUMARATE SYRUP |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLEOCIN 100MG VAGINAL OVULE |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CLEOCIN HCL 75MG CAPSULE |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CLEOCIN PED SOL 75MG/5ML |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CLIMARA PRO DIS WEEKLY 4.40MG/1.39MG |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CLINDAMYCIN 150MG/ML ADDVAN |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLINDAMYCIN HCL 150MG CAPSULE |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLINDAMYCIN HYDROCHLORIDE CAPSULES |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLINDAMYCIN PHOSP 1% LOTION |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLINDAMYCIN PHOSPHATE 1% SOLUTION NON-ORAL |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE |
2 |
Tier 2 |
$9.00 | $22.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLINDAMYCIN PHOSPHATE VAGINAL CREAM |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLINIMIX 2.75%/5% INJECTION 1000ML BAG |
3 |
Tier 3 |
$35.00 | $87.50 | P |
CLINIMIX 4.25/10 SOLUTION |
3 |
Tier 3 |
$35.00 | $87.50 | P |
CLINIMIX 4.25/20 SOLUTION |
3 |
Tier 3 |
$35.00 | $87.50 | P |
CLINIMIX 4.25/25 SOLUTION |
3 |
Tier 3 |
$35.00 | $87.50 | P |
CLINIMIX 4.25/5 SOLUTION |
3 |
Tier 3 |
$35.00 | $87.50 | P |
CLINIMIX 5/15 SOLUTION |
3 |
Tier 3 |
$35.00 | $87.50 | P |
CLINIMIX 5/20 SOLUTION |
3 |
Tier 3 |
$35.00 | $87.50 | P |
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG |
3 |
Tier 3 |
$35.00 | $87.50 | P |
CLINIMIX E 2.75/10 SOLUTION |
3 |
Tier 3 |
$35.00 | $87.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINIMIX E 2.75/5 SOLUTION |
3 |
Tier 3 |
$35.00 | $87.50 | P |
CLINIMIX E 4.25/25 SOLUTION |
3 |
Tier 3 |
$35.00 | $87.50 | P |
CLINIMIX E 4.25/5 SOLUTION |
3 |
Tier 3 |
$35.00 | $87.50 | P |
CLINIMIX E 5/20 SOLUTION |
3 |
Tier 3 |
$35.00 | $87.50 | P |
CLINIMIX E 5/25 SOLUTION |
3 |
Tier 3 |
$35.00 | $87.50 | P |
CLINIMIX E 5%/15% INJECTION 2000ML BAG |
3 |
Tier 3 |
$35.00 | $87.50 | P |
CLINISOL 15% SOLUTION |
2 |
Tier 2 |
$9.00 | $22.50 | P |
CLOBETASOL 0.05% OINTMENT |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLOBETASOL 0.05% SOLUTION |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLOBETASOL E 0.05% CREAM |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLOBETASOL PROPIONATE 0.05% FOAM |
2 |
Tier 2 |
$9.00 | $22.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOBETASOL PROPIONATE CRM 0.05% 15GM |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLOMIPRAMINE HCL 25MG CAPSULE |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLOMIPRAMINE HCL 50MG CAPSULE |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLOMIPRAMINE HCL 75MG CAPSULE |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLONIDINE HCL 0.2MG TABLET (500 CT) |
1 |
Tier 1 |
$2.00 | $4.00 | None |
CLONIDINE HCL TABLET 0.1MG (500 CT) |
1 |
Tier 1 |
$2.00 | $4.00 | None |
CLONIDINE HCL TABLET 0.3MG (100 CT) |
1 |
Tier 1 |
$2.00 | $4.00 | None |
CLONIDINE PATCH 0.1MG/DAY |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLONIDINE PATCH 0.2MG/DAY |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLONIDINE PATCH 0.3MG/DAY |
2 |
Tier 2 |
$9.00 | $22.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOTRIMAZOLE 1% CREAM |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLOTRIMAZOLE 10MG TROCHE |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLOTRIMAZOLE SOLUTION TOPICAL 1% 30ML BOTPL |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLOZAPINE 100 MG DISINTEGRATING TABLET [FAZACLO] |
4 |
Tier 4 |
$75.00 | $187.50 | P |
CLOZAPINE 100 MG ORAL TABLET |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLOZAPINE 12.5 MG DISINTEGRATING TABLET [FAZACLO] |
4 |
Tier 4 |
$75.00 | $187.50 | P |
CLOZAPINE 200MG TABLET (500 CT) |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLOZAPINE 25 MG DISINTEGRATING TABLET [FAZACLO] |
4 |
Tier 4 |
$75.00 | $187.50 | P |
CLOZAPINE 25MG TABLET (100 CT) |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CLOZAPINE 50MG TABLET (500 CT) |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CO-GESIC 5/500 TABLET |
2 |
Tier 2 |
$9.00 | $22.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COARTEM 20MG-120MG |
4 |
Tier 4 |
$75.00 | $187.50 | None |
COLCHICINE 0.6 MG ORAL TABLET [COLCRYS] |
4 |
Tier 4 |
$75.00 | $187.50 | Q:60 /25Days |
COLESTIPOL HCL 1G TABLET |
2 |
Tier 2 |
$9.00 | $22.50 | None |
COLESTIPOL HCL 5G GRANULES |
2 |
Tier 2 |
$9.00 | $22.50 | None |
COLISTIMETHATE 150MG VIAL |
2 |
Tier 2 |
$9.00 | $22.50 | P |
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE |
3 |
Tier 3 |
$35.00 | $87.50 | None |
COLOCORT 100MG ENEMA |
2 |
Tier 2 |
$9.00 | $22.50 | None |
COMBIGAN 0.2%-0.5% DROPS |
3 |
Tier 3 |
$35.00 | $87.50 | None |
COMBIPATCH 0.05/0.14MG PTCH |
3 |
Tier 3 |
$35.00 | $87.50 | None |
COMBIPATCH 0.05/0.25MG PTCH |
3 |
Tier 3 |
$35.00 | $87.50 | None |
COMBIVENT INHALER |
3 |
Tier 3 |
$35.00 | $87.50 | Q:30 /25Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COMBIVIR TABLETS |
3 |
Tier 3 |
$35.00 | $87.50 | None |
COMPRO 25MG SUPPOSITORY |
2 |
Tier 2 |
$9.00 | $22.50 | None |
COMTAN 200MG TABLET |
3 |
Tier 3 |
$35.00 | $87.50 | None |
COMVAX VACCINE VIAL |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CONCERTA ER TABLETS 18MG 100 TABLETS BOT |
4 |
Tier 4 |
$75.00 | $187.50 | P |
CONCERTA ER TABLETS 27MG 100 TABLETS BOT |
4 |
Tier 4 |
$75.00 | $187.50 | P |
CONCERTA ER TABLETS 36MG 100 TABLETS BOT |
4 |
Tier 4 |
$75.00 | $187.50 | P |
CONCERTA ER TABLETS 54MG 100 BOT |
4 |
Tier 4 |
$75.00 | $187.50 | P |
CONDYLOX GEL 0.5% 3.5 GM CRTN |
4 |
Tier 4 |
$75.00 | $187.50 | None |
CONSTULOSE 10GM/15ML SYRUP |
2 |
Tier 2 |
$9.00 | $22.50 | None |
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN |
5 |
Tier 5 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CORDRAN 0.05% LOTION |
4 |
Tier 4 |
$75.00 | $187.50 | None |
CORDRAN TAPE 4MCG/SQCM 1 X 80 X 3 CTR |
4 |
Tier 4 |
$75.00 | $187.50 | None |
COREG CR 10MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Tier 3 |
$35.00 | $87.50 | None |
COREG CR 20MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Tier 3 |
$35.00 | $87.50 | None |
COREG CR 40MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Tier 3 |
$35.00 | $87.50 | None |
COREG CR 80MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CORTIFOAM RECTAL FOAM |
4 |
Tier 4 |
$75.00 | $187.50 | None |
CORTISONE ACETATE 25MG TABLET (100 CT) |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CORTOMYCIN EAR SOLUTION |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CORTOMYCIN EAR SUSPENSION |
2 |
Tier 2 |
$9.00 | $22.50 | None |
COSMEGEN 0.5MG VIAL |
3 |
Tier 3 |
$35.00 | $87.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COUMADIN 10MG TABLET |
3 |
Tier 3 |
$35.00 | $87.50 | None |
COUMADIN 1MG TABLET |
3 |
Tier 3 |
$35.00 | $87.50 | None |
COUMADIN 2.5MG TABLET |
3 |
Tier 3 |
$35.00 | $87.50 | None |
COUMADIN 2MG TABLET |
3 |
Tier 3 |
$35.00 | $87.50 | None |
COUMADIN 3MG TABLET |
3 |
Tier 3 |
$35.00 | $87.50 | None |
COUMADIN 4MG TABLET |
3 |
Tier 3 |
$35.00 | $87.50 | None |
COUMADIN 5MG TABLET |
3 |
Tier 3 |
$35.00 | $87.50 | None |
COUMADIN 6MG TABLET |
3 |
Tier 3 |
$35.00 | $87.50 | None |
COUMADIN 7.5MG TABLET |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT |
3 |
Tier 3 |
$35.00 | $87.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CRESTOR 10MG TABLET |
3 |
Tier 3 |
$35.00 | $87.50 | Q:30 /25Days |
CRESTOR 20MG TABLET |
3 |
Tier 3 |
$35.00 | $87.50 | Q:30 /25Days |
CRESTOR 40MG TABLET |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CRESTOR 5MG TABLET |
3 |
Tier 3 |
$35.00 | $87.50 | Q:30 /25Days |
CRIXIVAN 100MG CAPSULE |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CRIXIVAN 200MG CAPSULE |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CRIXIVAN 333MG CAPSULE |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CRIXIVAN 400MG CAPSULE (120 CT) |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CROMOLYN NEBULIZER SOLUTION |
2 |
Tier 2 |
$9.00 | $22.50 | P Q:240 /25Days |
CROMOLYN SODIUM 4% 40MG 10ML BOT |
2 |
Tier 2 |
$9.00 | $22.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CUBICIN 500MG VIAL |
5 |
Tier 5 |
33% | 33% | P |
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT) |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CYCLOBENZAPRINE HCL 5MG TABLET (500 CT) |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CYCLOPHOSPHAMIDE 25MG TABLET |
2 |
Tier 2 |
$9.00 | $22.50 | P |
CYCLOPHOSPHAMIDE 50MG TABLET |
2 |
Tier 2 |
$9.00 | $22.50 | P |
CYCLOSPORINE 100MG CAPSULE |
2 |
Tier 2 |
$9.00 | $22.50 | P |
CYCLOSPORINE 100MG CAPSULE |
2 |
Tier 2 |
$9.00 | $22.50 | P |
CYCLOSPORINE 25MG CAPSULE |
2 |
Tier 2 |
$9.00 | $22.50 | P |
CYCLOSPORINE 50MG CAPSULE |
2 |
Tier 2 |
$9.00 | $22.50 | P |
CYCLOSPORINE 50MG/ML AMP |
2 |
Tier 2 |
$9.00 | $22.50 | P |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT |
2 |
Tier 2 |
$9.00 | $22.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYKLOKAPRON 100MG/ML AMPUL |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CYMBALTA 20MG CAPSULE |
3 |
Tier 3 |
$35.00 | $87.50 | Q:30 /25Days |
CYMBALTA 60MG CAPSULE |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT) |
3 |
Tier 3 |
$35.00 | $87.50 | Q:30 /25Days |
CYPROHEPTADINE HCL 4 MG |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL |
2 |
Tier 2 |
$9.00 | $22.50 | None |
CYSTADANE POWDER FOR ORAL SOLUTION 180GM |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CYSTAGON 150MG CAPSULE |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CYSTAGON 50MG CAPSULE |
3 |
Tier 3 |
$35.00 | $87.50 | None |
CYTARABINE 20MG/ML VIAL |
2 |
Tier 2 |
$9.00 | $22.50 | P |
CYTARABINE 500MG VIAL |
2 |
Tier 2 |
$9.00 | $22.50 | P |