2011 Medicare Part D Plan Formulary Information |
Freedom Savings Plan Rx (HMO) (H5427-053-0)
Benefit Details
|
The Freedom Savings Plan Rx (HMO) (H5427-053-0) Formulary Drugs Starting with the Letter A in Pinellas 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 |
ABELCENT INJECTION SUSPENSION 5MG/ML |
3 |
Tier 3 |
$65.00 | $130.00 | P |
ABILIFY 10MG TABLET |
3 |
Tier 3 |
$65.00 | $130.00 | P Q:30 /30Days |
ABILIFY 15MG TABLET |
3 |
Tier 3 |
$65.00 | $130.00 | P Q:30 /30Days |
ABILIFY 1MG/ML SOLUTION |
3 |
Tier 3 |
$65.00 | $130.00 | P Q:900 /30Days |
ABILIFY 20MG TABLET |
3 |
Tier 3 |
$65.00 | $130.00 | P Q:30 /30Days |
ABILIFY 2MG TABLET |
3 |
Tier 3 |
$65.00 | $130.00 | P Q:30 /30Days |
ABILIFY 30MG TABLET |
3 |
Tier 3 |
$65.00 | $130.00 | P Q:30 /30Days |
ABILIFY 5MG TABLET (OTSUKA) |
3 |
Tier 3 |
$65.00 | $130.00 | P Q:30 /30Days |
ABILIFY DISCMELT 10MG TABLET |
3 |
Tier 3 |
$65.00 | $130.00 | P Q:60 /30Days |
ABILIFY DISCMELT 15MG TABLET |
3 |
Tier 3 |
$65.00 | $130.00 | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABILIFY INJ 9.75MG |
3 |
Tier 3 |
$65.00 | $130.00 | P |
ACCOLATE 10MG TABLET |
2 |
Tier 2 |
$25.00 | $50.00 | Q:60 /30Days |
ACCOLATE 20MG TABLET |
2 |
Tier 2 |
$25.00 | $50.00 | Q:60 /30Days |
ACEBUTOLOL 200MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACEBUTOLOL 400MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE |
2 |
Tier 2 |
$25.00 | $50.00 | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:360 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:360 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:360 /30Days |
ACETAZOLAMIDE 125MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACETAZOLAMIDE SOD 500MG VL |
3 |
Tier 3 |
$65.00 | $130.00 | None |
ACETYLCYSTEINE 10% VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ACTEMRA INJECTION 200MG/10ML |
4 |
Tier 4 |
33% | 33% | P |
ACTHIB VACCINE VIAL 10-24UNT/5ML |
2 |
Tier 2 |
$25.00 | $50.00 | None |
ACTIMMUNE SOLUTION FOR INJECTION 100MCG |
3 |
Tier 3 |
$65.00 | $130.00 | P |
ACTOS 15MG TABLET |
3 |
Tier 3 |
$65.00 | $130.00 | S Q:30 /30Days |
ACTOS 30MG TABLET (500 CT) |
3 |
Tier 3 |
$65.00 | $130.00 | S Q:30 /30Days |
ACTOS 45MG TABLET |
3 |
Tier 3 |
$65.00 | $130.00 | S Q:30 /30Days |
ACULAR 0.5% EYE DROPS |
3 |
Tier 3 |
$65.00 | $130.00 | Q:15 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACULAR LS 0.4% OPHTH SOL |
3 |
Tier 3 |
$65.00 | $130.00 | Q:15 /30Days |
ACUVAIL 0.45% OPHTH SOLUTION #30X0.4 EA |
3 |
Tier 3 |
$65.00 | $130.00 | None |
ACYCLOVIR 200MG CAPSULE (1000 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACYCLOVIR 200MG/5ML SUSP |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACYCLOVIR 400MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACYCLOVIR 800 MG ORAL TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACYCLOVIR SODIUM 500MG VIAL |
3 |
Tier 3 |
$65.00 | $130.00 | P |
ADACEL VIAL 2UNT/5UNT |
2 |
Tier 2 |
$25.00 | $50.00 | None |
ADAGEN 250U/ML VIAL |
3 |
Tier 3 |
$65.00 | $130.00 | None |
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA] |
4 |
Tier 4 |
33% | 33% | P |
ADVAIR DISKU MIS 100/50 |
2 |
Tier 2 |
$25.00 | $50.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADVAIR DISKU MIS 250/50 |
2 |
Tier 2 |
$25.00 | $50.00 | Q:60 /30Days |
ADVAIR DISKU MIS 500/50 |
2 |
Tier 2 |
$25.00 | $50.00 | Q:60 /30Days |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL |
2 |
Tier 2 |
$25.00 | $50.00 | Q:120 /30Days |
ADVAIR HFA INHALER 230;21MCG;MCG |
2 |
Tier 2 |
$25.00 | $50.00 | Q:120 /30Days |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
2 |
Tier 2 |
$25.00 | $50.00 | Q:120 /30Days |
AEROBID-M AEROSOL W/ADAPTER |
3 |
Tier 3 |
$65.00 | $130.00 | None |
AFEDITAB CR 30MG TABLET SA |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
AFEDITAB CR 60MG TABLET SA |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
AFINITOR TABLETS |
4 |
Tier 4 |
33% | 33% | None |
AFINITOR TABLETS |
4 |
Tier 4 |
33% | 33% | None |
AFINITOR TABLETS 5 MG |
4 |
Tier 4 |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AGGRENOX 25-200MG CAPSULE |
3 |
Tier 3 |
$65.00 | $130.00 | None |
ALAMAST 0.1% DROPS |
3 |
Tier 3 |
$65.00 | $130.00 | None |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALBUTEROL TABLET 4MG (500 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALCLOMETASONE DIPROPIONATE 0.05% CREAM |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALDARA IMIQUIMOD CREAM 5% 24 PKT X 250 MG CRTN |
4 |
Tier 4 |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALDURAZYME 2.9MG/5ML VIAL |
3 |
Tier 3 |
$65.00 | $130.00 | P |
ALENDRONATE SODIUM 10MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
ALENDRONATE SODIUM 40MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
ALENDRONATE SODIUM 5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
ALENDRONATE SODIUM TABLET 35MG 20 CRTN |
1 |
Tier 1 |
$0.00 | $0.00 | Q:4 /28Days |
ALENDRONATE SODIUM TABLETS 70 MG |
1 |
Tier 1 |
$0.00 | $0.00 | Q:4 /28Days |
ALIMTA 500MG VIAL |
4 |
Tier 4 |
33% | 33% | P |
ALINIA 100MG/5ML SUSPENSION |
2 |
Tier 2 |
$25.00 | $50.00 | Q:60 /3Days |
ALINIA 500MG TABLET |
2 |
Tier 2 |
$25.00 | $50.00 | Q:6 /3Days |
ALKERAN FOR INJECTION 50MG/VIAL 1 VIALSU |
3 |
Tier 3 |
$65.00 | $130.00 | P |
ALLOPURINOL SODIUM 500MG VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | P |
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 |
$0.00 | $0.00 | None |
ALLOPURINOL TABLETS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALOCRIL 2% EYE DROPS |
3 |
Tier 3 |
$65.00 | $130.00 | None |
ALOMIDE 0.1% EYE DROPS |
3 |
Tier 3 |
$65.00 | $130.00 | None |
ALORA 0.025MG PATCH |
3 |
Tier 3 |
$65.00 | $130.00 | Q:10 /30Days |
ALORA 0.05MG PATCH |
3 |
Tier 3 |
$65.00 | $130.00 | Q:10 /30Days |
ALORA 0.075MG PATCH |
3 |
Tier 3 |
$65.00 | $130.00 | Q:10 /30Days |
ALORA 0.1MG PATCH |
3 |
Tier 3 |
$65.00 | $130.00 | Q:10 /30Days |
ALOXI 0.25MG/5ML |
3 |
Tier 3 |
$65.00 | $130.00 | P |
ALPHA-1-PROTEINASE INHIBITOR,HUMAN 16 MG/ML INJECTABLE SOLUTION [ARALAST] |
4 |
Tier 4 |
33% | 33% | P |
ALPHAGAN P 0.1% DROPS |
3 |
Tier 3 |
$65.00 | $130.00 | Q:10 /25Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALPHAGAN P 0.15% EYE DROPS |
3 |
Tier 3 |
$65.00 | $130.00 | Q:10 /25Days |
ALREX 0.2% EYE DROPS |
3 |
Tier 3 |
$65.00 | $130.00 | None |
AMANTADINE 100MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMANTADINE 100MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMBIEN 10MG TABLET |
3 |
Tier 3 |
$65.00 | $130.00 | Q:30 /30Days |
AMBIEN TABLETS 5MG 100 BOT |
3 |
Tier 3 |
$65.00 | $130.00 | Q:30 /30Days |
AMBISOME 50MG VIAL |
3 |
Tier 3 |
$65.00 | $130.00 | P |
AMCINONIDE 0.1% CREAM |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMCINONIDE 0.1% LOTION |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMCINONIDE 0.1% OINTMENT 60GM TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMERGE 1MG TABLET |
3 |
Tier 3 |
$65.00 | $130.00 | Q:9 /25Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMERGE 2.5MG TABLET |
3 |
Tier 3 |
$65.00 | $130.00 | Q:9 /25Days |
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM |
4 |
Tier 4 |
33% | 33% | P |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMINOPHYLLINE 100MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMINOPHYLLINE 200MG TABLET (1000 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMIODARONE HCL 400MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMIODARONE HCL INJECTION |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMIODARONE HYDROCHLORIDE TABLETS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMITIZA 8MCG CAPSULE |
3 |
Tier 3 |
$65.00 | $130.00 | S Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITIZA CAPSULES 24MCG 60 CAP BOT |
3 |
Tier 3 |
$65.00 | $130.00 | S Q:60 /30Days |
AMITRIPTYLINE HCL 100MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMITRIPTYLINE HCL 10MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMITRIPTYLINE HCL 150 MG TAB |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
AMMONIUM CHLORIDE 5 MEQ/ML |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOX TR-K CLV 500-125 MG TAB |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXAPINE 100MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXAPINE 150MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXAPINE 25MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXAPINE 50MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXICILLIN 125MG TABLET CHEW |
1 |
Tier 1 |
$0.00 | $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 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXICILLIN 250MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXICILLIN 400MG TABLET CHEW |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXICILLIN 500MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXICILLIN 500MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXICILLIN 875MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Tier 1 |
$0.00 | $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 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:90 /30Days |
AMPHETAMINE SALT COMBO 15MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:120 /30Days |
AMPHETAMINE SALT COMBO 30MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:90 /30Days |
AMPHETAMINE SALTS 20MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
AMPHOTEC FOR INJECTION 50MG/VIAL |
3 |
Tier 3 |
$65.00 | $130.00 | P |
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | P |
AMPICILLIN CAPSULES 250MG 100 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | P |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMYLASES 109000 UNT / ENDOPEPTIDASES 68000 UNT / LIPASE 20000 UNT ENTERIC COATED CAPSULE [ZENPEP 20] |
2 |
Tier 2 |
$25.00 | $50.00 | None |
AMYLASES 27000 UNT / ENDOPEPTIDASES 17000 UNT / LIPASE 5000 UNT ENTERIC COATED CAPSULE [ZENPEP 5] |
2 |
Tier 2 |
$25.00 | $50.00 | None |
AMYLASES 55000 UNT / ENDOPEPTIDASES 34000 UNT / LIPASE 10000 UNT ENTERIC COATED CAPSULE [ZENPEP 10] |
2 |
Tier 2 |
$25.00 | $50.00 | None |
AMYLASES 82000 UNT / ENDOPEPTIDASES 51000 UNT / LIPASE 15000 UNT ENTERIC COATED CAPSULE [ZENPEP 15] |
2 |
Tier 2 |
$25.00 | $50.00 | None |
ANADROL-50 50MG TABLET (100 CT) |
4 |
Tier 4 |
33% | 33% | None |
ANAGRELIDE HCL 0.5MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ANAGRELIDE HCL 1MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ANASTROZOLE TABLETS |
2 |
Tier 2 |
$25.00 | $50.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANCOBON 250MG CAPSULE |
2 |
Tier 2 |
$25.00 | $50.00 | None |
ANCOBON 500MG CAPSULE |
2 |
Tier 2 |
$25.00 | $50.00 | None |
ANDRODERM 2.5MG/24HR PATCH |
3 |
Tier 3 |
$65.00 | $130.00 | P Q:60 /30Days |
ANDRODERM 5MG/24HR PATCH |
3 |
Tier 3 |
$65.00 | $130.00 | P Q:30 /30Days |
ANIDULAFUNGIN 3.33 MG/ML INJECTABLE SOLUTION [ERAXIS] |
3 |
Tier 3 |
$65.00 | $130.00 | None |
ANTABUSE 250MG TABLET |
2 |
Tier 2 |
$25.00 | $50.00 | None |
ANTARA CAPSULES |
3 |
Tier 3 |
$65.00 | $130.00 | None |
ANTARA CAPSULES |
3 |
Tier 3 |
$65.00 | $130.00 | None |
ANTIZOL INJECTION 1GM 4 X 1.5ML VIAL CRTN |
4 |
Tier 4 |
33% | 33% | None |
ANZEMET 100MG TABLET |
3 |
Tier 3 |
$65.00 | $130.00 | P Q:5 /30Days |
ANZEMET 20MG/ML VIAL |
3 |
Tier 3 |
$65.00 | $130.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANZEMET 50MG TABLET |
3 |
Tier 3 |
$65.00 | $130.00 | P Q:5 /30Days |
APOKYN 30 MG/3 ML CARTRIDGE |
4 |
Tier 4 |
33% | 33% | P |
APRI 0.15-0.03 TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
APRISO CP24 |
3 |
Tier 3 |
$65.00 | $130.00 | Q:120 /30Days |
APTIVUS 250MG CAPSULE |
4 |
Tier 4 |
33% | 33% | Q:120 /30Days |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
4 |
Tier 4 |
33% | 33% | None |
ARANELLE 7-9-5 TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ARANESP 100MCG/ML VIAL |
4 |
Tier 4 |
33% | 33% | P |
ARANESP 200MCG/0.4ML SYRINGE |
4 |
Tier 4 |
33% | 33% | P |
ARANESP 200MCG/ML VIAL |
4 |
Tier 4 |
33% | 33% | P |
ARANESP 25MCG/ML VIAL |
3 |
Tier 3 |
$65.00 | $130.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP 300MCG/ML VIAL |
4 |
Tier 4 |
33% | 33% | P |
ARANESP 500MCG/1ML SYRINGE |
4 |
Tier 4 |
33% | 33% | P |
ARANESP 60MCG/ML VIAL |
4 |
Tier 4 |
33% | 33% | P |
ARANESP PREFILLED SYRINGE SINGLE USE 100MCG/0.5ML 1 SYR |
4 |
Tier 4 |
33% | 33% | P |
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR |
4 |
Tier 4 |
33% | 33% | P |
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR |
3 |
Tier 3 |
$65.00 | $130.00 | P |
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR |
4 |
Tier 4 |
33% | 33% | P |
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR |
3 |
Tier 3 |
$65.00 | $130.00 | P |
ARANESP PREFILLED SYRINGE SINGLE USE 60MCG/0.3ML 60MCG/ 0.3ML SYR |
4 |
Tier 4 |
33% | 33% | P |
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD |
3 |
Tier 3 |
$65.00 | $130.00 | P |
ARCALYST INJECTION 220MG/VIAL |
4 |
Tier 4 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARICEPT 10MG TABLET |
3 |
Tier 3 |
$65.00 | $130.00 | Q:30 /30Days |
ARICEPT 5MG TABLET |
3 |
Tier 3 |
$65.00 | $130.00 | Q:30 /30Days |
ARICEPT ODT 10MG TABLET |
3 |
Tier 3 |
$65.00 | $130.00 | Q:30 /30Days |
ARICEPT ODT 5MG TABLET |
3 |
Tier 3 |
$65.00 | $130.00 | Q:30 /30Days |
ARIMIDEX 1MG TABLET |
3 |
Tier 3 |
$65.00 | $130.00 | Q:30 /30Days |
ARIXTRA 10MG SYRINGE |
3 |
Tier 3 |
$65.00 | $130.00 | P |
ARIXTRA 2.5MG SYRINGE |
3 |
Tier 3 |
$65.00 | $130.00 | P |
ARIXTRA 5MG SYRINGE |
3 |
Tier 3 |
$65.00 | $130.00 | P |
ARIXTRA 7.5MG SYRINGE |
3 |
Tier 3 |
$65.00 | $130.00 | P |
AROMASIN 25MG TABLET |
2 |
Tier 2 |
$25.00 | $50.00 | None |
ARRANON 250MG VIAL |
4 |
Tier 4 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARZERRA INJECTION 100MG/5ML |
4 |
Tier 4 |
33% | 33% | P |
ASACOL 400MG TABLET EC |
2 |
Tier 2 |
$25.00 | $50.00 | None |
ASENAPINE 10 MG SUBLINGUAL TABLET [SAPHRIS] |
3 |
Tier 3 |
$65.00 | $130.00 | P Q:60 /30Days |
ASENAPINE 5 MG SUBLINGUAL TABLET [SAPHRIS] |
3 |
Tier 3 |
$65.00 | $130.00 | P Q:90 /30Days |
ASTELIN 137MCG AEROSOL SPRAY W/PUMP |
3 |
Tier 3 |
$65.00 | $130.00 | None |
ASTEPRO 0.15% NASAL SPRAY 30 ML |
3 |
Tier 3 |
$65.00 | $130.00 | None |
ATENOLOL 25MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ATENOLOL TABLET USP 50MG (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ATENOLOL TABLETS USP 100MG 1 BLPK |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATRIPLA TABLET 600MG/200MG |
4 |
Tier 4 |
33% | 33% | None |
ATROPINE 0.025 MG / DIPHENOXYLATE 2.5 MG ORAL TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ATROPINE 0.1MG/ML SYRINGE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ATROVENT HFA AER 17MCG |
2 |
Tier 2 |
$25.00 | $50.00 | Q:26 /30Days |
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML |
2 |
Tier 2 |
$25.00 | $50.00 | None |
AVANDAMET 2MG/1000MG TABLET |
2 |
Tier 2 |
$25.00 | $50.00 | S Q:60 /30Days |
AVANDAMET 2MG/500MG TABLET |
2 |
Tier 2 |
$25.00 | $50.00 | S Q:60 /30Days |
AVANDAMET 4MG/500MG TABLET |
2 |
Tier 2 |
$25.00 | $50.00 | S Q:60 /30Days |
AVANDAMET TABLET 4-1000MG |
2 |
Tier 2 |
$25.00 | $50.00 | S Q:60 /30Days |
AVANDARYL 4MG/1MG TABLET |
2 |
Tier 2 |
$25.00 | $50.00 | S Q:60 /30Days |
AVANDARYL 4MG/2MG TABLET |
2 |
Tier 2 |
$25.00 | $50.00 | S Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVANDARYL 4MG/4MG TABLET |
2 |
Tier 2 |
$25.00 | $50.00 | S Q:60 /30Days |
AVANDIA 2MG TABLET |
2 |
Tier 2 |
$25.00 | $50.00 | S Q:30 /30Days |
AVANDIA 4MG TABLET (90 CT) |
2 |
Tier 2 |
$25.00 | $50.00 | S Q:60 /30Days |
AVANDIA 8MG TABLET (90 CT) |
2 |
Tier 2 |
$25.00 | $50.00 | S Q:30 /30Days |
AVASTIN 100MG/4ML VIAL |
4 |
Tier 4 |
33% | 33% | P |
AVELOX 400MG TABLET |
3 |
Tier 3 |
$65.00 | $130.00 | Q:14 /14Days |
AVELOX IV 400MG/250ML |
3 |
Tier 3 |
$65.00 | $130.00 | P |
AVINZA 120MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Tier 3 |
$65.00 | $130.00 | None |
AVINZA 30MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Tier 3 |
$65.00 | $130.00 | None |
AVINZA 60MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Tier 3 |
$65.00 | $130.00 | None |
AVINZA 90MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Tier 3 |
$65.00 | $130.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVODART 0.5MG SOFTGEL |
2 |
Tier 2 |
$25.00 | $50.00 | Q:30 /30Days |
AVONEX ADMIN PACK 30MCG VL |
4 |
Tier 4 |
33% | 33% | P |
AZACTAM INJECTION |
2 |
Tier 2 |
$25.00 | $50.00 | None |
AZACTAM INJECTION 1GM/50ML |
2 |
Tier 2 |
$25.00 | $50.00 | None |
AZASAN 100MG TABLET |
2 |
Tier 2 |
$25.00 | $50.00 | P |
AZASAN 75MG TABLET |
2 |
Tier 2 |
$25.00 | $50.00 | P |
AZATHIOPRINE 50MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P |
AZATHIOPRINE SOD 100MG VIAL |
3 |
Tier 3 |
$65.00 | $130.00 | P |
AZILECT 0.5MG TABLET |
3 |
Tier 3 |
$65.00 | $130.00 | None |
AZILECT 1MG TABLET |
3 |
Tier 3 |
$65.00 | $130.00 | None |
AZITHROMYCIN 250 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:6 /10Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZITHROMYCIN 500MG TABLET (30 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:5 /10Days |
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AZITHROMYCIN TABLETS |
1 |
Tier 1 |
$0.00 | $0.00 | Q:10 /10Days |
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT |
3 |
Tier 3 |
$65.00 | $130.00 | Q:10 /25Days |