2011 Medicare Part D Plan Formulary Information |
Clarian Medicare Choice (HMO-POS) (H7220-004-0)
Benefit Details
|
The Clarian Medicare Choice (HMO-POS) (H7220-004-0) Formulary Drugs Starting with the Letter C in Monroe County, IN: CMS MA Region 13 which includes: IN
|
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 |
$5.00 | $10.00 | None |
CADUET 10MG/10MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CADUET 10MG/20MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CADUET 10MG/40MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CADUET 10MG/80MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CADUET 2.5MG/10MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CADUET 2.5MG/20MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CADUET 2.5MG/40MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CADUET 5MG/10MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CADUET 5MG/20MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CADUET 5MG/40MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CADUET 5MG/80MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CAFERGOT EROGOTAMINE TARTRATE AND CAFFINE TABLETS 1;100MG;MG 100 BOT |
3 |
Tier 3 |
$85.00 | $170.00 | P Q:40 /30Days |
CALAN 120MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CALAN 80MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CALAN SR 120MG CAPLET SA |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CALAN SR 180MG CAPLET SA |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CALAN SR TABLET 240MG (500 CT) |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CALCIPOTRIENE OINTMENT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CALCIPOTRIENE TOPICAL SOLUTION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CALCITRIOL 0.00025 MG ORAL CAPSULE [ROCALTROL] |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CALCITRIOL 0.0005 MG ORAL CAPSULE [ROCALTROL] |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CALCITRIOL 0.001 MG/ML ORAL SOLUTION [ROCALTROL] |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CALCITRIOL 0.25MCG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | P |
CALCITRIOL 0.5MCG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | P |
CALCITRIOL 1MCG/ML SOLUTION ORAL |
1 |
Tier 1 |
$5.00 | $10.00 | P |
CALCIUM ACETATE CAPSULE 667 MG |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CALCIUM CHLORIDE 0.0014 MEQ/ML / POTASSIUM CHLORIDE 0.004 MEQ/ML / SODIUM CHLORIDE 0.103 MEQ/ML / SO |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CAMILA 0.35MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CAMPATH 30MG/ML VIAL |
4 |
Tier 4 |
30% | N/A | P |
CAMPRAL 333MG DOSE PAK |
3 |
Tier 3 |
$85.00 | $170.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAMPTOSAR 20MG/ML VIAL |
4 |
Tier 4 |
30% | N/A | P |
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CAPREOMYCIN 500 MG/ML INJECTABLE SOLUTION [CAPASTAT] |
3 |
Tier 3 |
$85.00 | $170.00 | None |
CAPTOPRIL 100MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CAPTOPRIL 12.5MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CAPTOPRIL 25MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CAPTOPRIL 50MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CAPTOPRIL/HCTZ 25/15 TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CAPTOPRIL/HCTZ 25/25 TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CAPTOPRIL/HCTZ 50/15 TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CAPTOPRIL/HCTZ 50/25 TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARAC CRE 0.5% |
3 |
Tier 3 |
$85.00 | $170.00 | None |
CARAFATE SUCRALFATE 1G TABLET ORAL |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CARBAMAZEPINE EXTENDED RELEASE TABLETS 200MG |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CARBAMAZEPINE EXTENDED RELEASE TABLETS 400MG |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CARBAMAZEPINE ORAL SUSPENSION 200 MG |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CARBAMAZEPINE TABLET CHEWABLE 100MG (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CARBAMAZEPINE TABLET USP 200MG (1000 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CARBATROL 100MG CAPSULE SA |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CARBATROL 200MG CAPSULE SA |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CARBATROL 300MG CAPSULE SA |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CARBIDOPA-LEVODOPA 25MG-100MG TABLET SA |
1 |
Tier 1 |
$5.00 | $10.00 | 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 |
$5.00 | $10.00 | None |
CARBIDOPA/LEVO 10/100 TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CARBIDOPA/LEVO 25/100 TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CARBIDOPA/LEVO 25/250 TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CARBOPLATIN INJECTION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CARDIZEM 120MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CARDIZEM 30MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CARDIZEM 60MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CARDIZEM 90MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CARDIZEM CAPSULES 180MG (90 CT) |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CARDIZEM CD 120MG CAPSULE SR 24 HR |
3 |
Tier 3 |
$85.00 | $170.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARDIZEM CD 240MG CAPSULE SR 24 HR |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CARDIZEM CD 300MG CAPSULE SR 24 HR |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CARDURA 1MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CARDURA 2MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CARDURA 4MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CARDURA 8MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CARIMUNE NF 3GM VIAL |
4 |
Tier 4 |
30% | N/A | P |
CARISOPRODOL AND ASPIRIN TABLETS USP 325;200MG;MG 100 BOTPL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CARISOPRODOL ASPIRIN AND CODEINE PHOSPHATE TABLETS USP 325;200;16MG;MG;MG 100 BOTPL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CARISOPRODOL TABLET USP 350MG (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CARMOL HC 1%-10% CREAM |
3 |
Tier 3 |
$85.00 | $170.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARNITOR 100MG/ML ORAL TUBEX |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CARNITOR 330MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CARTIA XT 120MG CAPSULE SA |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CARTIA XT 180MG CAPSULE SA |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CARTIA XT 240MG CAPSULE SA |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CARTIA XT 300MG CAPSULE SR 24 HR |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CARVEDILOL 12.5MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CARVEDILOL 25MG TABLET (500 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CARVEDILOL 3.125MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CARVEDILOL 6.25MG TABLET (500 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CASODEX 50MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | None |
CATAFLAM 50MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CATAPRES 0.1MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CATAPRES 0.2MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CATAPRES 0.3MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CATAPRES-TTS DIS 0.3/24HR |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CATAPRES-TTS-1 PATCH 2.52.5MG/UNT 1 X 4 CRTN |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CATAPRES-TTS-2 PATCH 52.5MG/UNT 1 X 4 CRTN |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CEENU 100MG CAPSULE |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CEENU 10MG CAPSULE |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CEENU 40MG CAPSULE |
3 |
Tier 3 |
$85.00 | $170.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFACLOR 250MG/5ML ORAL SUSP |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEFACLOR 375MG/5ML ORAL SUSP |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEFACLOR CAPSULES |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEFACLOR CAPSULES |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEFACLOR ER 500MG TABLET SR 12HR |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEFACLOR POWDER FOR ORAL SUSPENSION USP 125MG 75ML BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEFADROXIL 1G TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEFADROXIL 500MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEFADROXIL 500MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEFADROXIL FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEFAZOLIN 1 GM VIAL |
1 |
Tier 1 |
$5.00 | $10.00 | 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 |
$5.00 | $10.00 | None |
CEFDINIR CAPSULES 300MG (60 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEFEPIME HCL 2 GRAM VIAL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEFPODOXIME PROXETIL 200MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 100MG 50ML BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 50MG 50ML BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEFPROZIL 250MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEFPROZIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFPROZIL FOR ORAL SUSPENSION 125MG/5ML 75ML BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEFPROZIL TABLETS 500MG 100 BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEFTIN 250MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CEFTIN 250MG/5ML ORAL SUSP |
3 |
Tier 3 |
$85.00 | $170.00 | None |
CEFTIN 500MG TABLET (20 CT) |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CEFUROXIME 250MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEFUROXIME AXETIL 125MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEFUROXIME AXETIL 500MG TABLET (20 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEFUROXIME FOR INJECTION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CELEBREX 100MG CAPSULE |
2 |
Tier 2 |
$35.00 | $70.00 | S |
CELEBREX 200MG CAPSULE |
2 |
Tier 2 |
$35.00 | $70.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CELEBREX 400MG CAPSULE |
2 |
Tier 2 |
$35.00 | $70.00 | S |
CELEBREX 50MG CAPSULE |
2 |
Tier 2 |
$35.00 | $70.00 | S |
CELEXA 10MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CELEXA 20MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CELEXA 40MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CELLCEPT 200MG/ML ORAL SUSP |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CELLCEPT 500MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CELLCEPT CAPSULES 250MG (500 CT) |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CELLCEPT IV INJ 500MG |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CELONTIN 300MG KAPSEAL |
3 |
Tier 3 |
$85.00 | $170.00 | None |
CENESTIN 0.3MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CENESTIN 0.45MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CENESTIN 0.625MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CENESTIN 0.9MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CENESTIN 1.25MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CEPHALEXIN 250MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEPHALEXIN 250MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEPHALEXIN 250MG/5ML ORAL SUSP |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEPHALEXIN 500MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEPHALEXIN CAPSULES 500MG (500 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEPHALEXIN POWDER FOR SUSPENSION ORAL USP 125MG 200ML BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CEREBYX 100 MG PE/2 ML VIAL |
3 |
Tier 3 |
$85.00 | $170.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEREDASE 80UNITS/ML VIAL |
4 |
Tier 4 |
30% | N/A | P |
CEREZYME INJ 200UNIT |
4 |
Tier 4 |
30% | N/A | P |
CERUBIDINE 20MG VIAL |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CESIA 7 DAYS X 3 TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CHANTIX 0.5MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | Q:336 /168Days |
CHANTIX 1MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | Q:336 /168Days |
CHANTIX STARTING MONTH PAK |
3 |
Tier 3 |
$85.00 | $170.00 | Q:336 /168Days |
CHLORDIAZEPOXIDE AND AMITRIPTYLINE HCL TABLET 12.5-5MG (500 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CHLOROQUINE PH 500MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CHLOROQUINE PHOSPHATE 250MG TABLET (50 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLOROTHIAZIDE 250MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CHLOROTHIAZIDE 500MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CHLORPROMAZINE 100MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CHLORPROMAZINE 10MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CHLORPROMAZINE 25MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CHLORPROMAZINE 25MG/ML AMP |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CHLORPROMAZINE 50MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CHLORPROMAZINE HCL 200MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CHLORPROPAMIDE 100MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CHLORPROPAMIDE 250MG TABLET (1000 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CHLORTHALIDONE 25MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLORTHALIDONE 50MG TABLET (1000 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CHLORZOXAZONE 500MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CHORIONIC GONAD 10000U VIAL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CICLOPIROX 0.77% CREAM |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CICLOPIROX 0.77% TOPICAL SUSPENSION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6ML BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CILOSTAZOL 50MG TABLET (60 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CILOSTAZOL TABLET 100MG (60 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CILOXAN SOLUTION 0.3% 5ML BOT |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CIMETIDINE 150MG/ML VIAL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIMETIDINE 200MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CIMETIDINE HCL 300MG/5ML SOL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CIMETIDINE TABLETS |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CIMETIDINE TABLETS |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CIMETIDINE TABLETS USP |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CIMZIA 200 MG/ML SYRINGE KIT |
4 |
Tier 4 |
30% | N/A | P |
CIPRO 250MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CIPRO 500MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CIPRO 750MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CIPRODEX OTIC SUSPENSION |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CIPROFLOXACIN 250MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIPROFLOXACIN 400 MG/40 ML VL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CIPROFLOXACIN 500MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CIPROFLOXACIN ER 1000MG TABLET (30 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CIPROFLOXACIN ER 500MG TABLET (30 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CIPROFLOXACIN HCL 0.3% DROPS |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CIPROFLOXACIN HCL 100MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CIPROFLOXACIN TABLETS 750MG 100 BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CISPLATIN 1 MG/ML INJECTABLE SOLUTION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CITALOPRAM HBR 20 MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CITOLOPRAM HBR 10MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLADRIBINE 1MG/ML VIAL |
4 |
Tier 4 |
30% | N/A | P |
CLAFORAN 500MG VIAL |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CLARAVIS 10MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLARAVIS 20MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLARAVIS 30MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLARAVIS 40MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLARINEX 0.5MG/ML SYRUP |
3 |
Tier 3 |
$85.00 | $170.00 | S |
CLARINEX 2.5MG REDITABS |
3 |
Tier 3 |
$85.00 | $170.00 | S |
CLARINEX 5MG REDITABS |
3 |
Tier 3 |
$85.00 | $170.00 | S |
CLARINEX 5MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLARINEX-D 12 HOUR TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | S |
CLARINEX-D 24 HOUR TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | S |
CLARITHROMYCIN 250MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLARITHROMYCIN 500MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLARITHROMYCIN ER 500MG TABLET (60 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLARITHROMYCIN FOR ORAL SUSPENSION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLARITHROMYCIN FOR ORAL SUSPENSION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLEMASTINE FUM 2.68MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLEMASTINE FUMARATE SYRUP |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLEOCIN 2% VAGINAL CREAM |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CLEOCIN HCL 150MG CAPSULE |
3 |
Tier 3 |
$85.00 | $170.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLEOCIN HCL 300MG CAPSULE |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CLEOCIN HCL 75MG CAPSULE |
3 |
Tier 3 |
$85.00 | $170.00 | None |
CLEOCIN PHOS 150MG/ML VIAL |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CLEOCIN T 1% GEL |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CLEOCIN T 1% LOTION |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CLEOCIN T 1% PLEDGETS |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CLEOCIN T 1% SOLUTION |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CLIMARA 0.025MG/DAY PATCH |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CLIMARA 0.0375MG/DAY PATCH |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CLIMARA 0.05MG/24H PATCH |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CLIMARA 0.06/MG DAY PATCH |
3 |
Tier 3 |
$85.00 | $170.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLIMARA 0.075MG/DAY PATCH |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CLIMARA 0.1MG/24H PATCH |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CLIMARA PRO DIS WEEKLY 4.40MG/1.39MG |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CLINDAMYCIN HCL 150MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLINDAMYCIN HYDROCHLORIDE CAPSULES |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLINDAMYCIN PHOSP 1% LOTION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLINDAMYCIN PHOSPHATE 1% SOLUTION NON-ORAL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLINDAMYCIN PHOSPHATE VAGINAL CREAM |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLINORIL 200MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOBETASOL 0.05% OINTMENT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLOBETASOL 0.05% SOLUTION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLOBETASOL E 0.05% CREAM |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLOBETASOL PROPIONATE 0.05% FOAM |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLOLAR 1MG/ML VIAL |
4 |
Tier 4 |
30% | N/A | P |
CLOMIPRAMINE HCL 25MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLOMIPRAMINE HCL 50MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLOMIPRAMINE HCL 75MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLONIDINE HCL 0.2MG TABLET (500 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLONIDINE HCL TABLET 0.1MG (500 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLONIDINE HCL TABLET 0.3MG (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLONIDINE PATCH 0.1MG/DAY |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLONIDINE PATCH 0.2MG/DAY |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLONIDINE PATCH 0.3MG/DAY |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLOTRIMAZOLE 1% CREAM |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLOTRIMAZOLE 10MG TROCHE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLOTRIMAZOLE SOLUTION TOPICAL 1% 30ML BOTPL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CREAM USP .5MG-10GM 45GM TUBE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLOZAPINE 100 MG DISINTEGRATING TABLET [FAZACLO] |
3 |
Tier 3 |
$85.00 | $170.00 | None |
CLOZAPINE 100 MG ORAL TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOZAPINE 12.5 MG DISINTEGRATING TABLET [FAZACLO] |
3 |
Tier 3 |
$85.00 | $170.00 | None |
CLOZAPINE 200MG TABLET (500 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLOZAPINE 25 MG DISINTEGRATING TABLET [FAZACLO] |
3 |
Tier 3 |
$85.00 | $170.00 | None |
CLOZAPINE 25MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLOZAPINE 50MG TABLET (500 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CLOZARIL 100MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | None |
CLOZARIL 25MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | None |
CO-GESIC 5/500 TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
COLAZAL 750MG CAPSULE |
3 |
Tier 3 |
$85.00 | $170.00 | P |
COLCHICINE 0.6 MG ORAL TABLET [COLCRYS] |
2 |
Tier 2 |
$35.00 | $70.00 | None |
COLESTID 1GM TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COLESTID GRANULES |
3 |
Tier 3 |
$85.00 | $170.00 | P |
COLESTIPOL HCL 1G TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
COLESTIPOL HCL 5G GRANULES |
1 |
Tier 1 |
$5.00 | $10.00 | None |
COLISTIMETHATE 150MG VIAL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE |
2 |
Tier 2 |
$35.00 | $70.00 | None |
COLOCORT 100MG ENEMA |
1 |
Tier 1 |
$5.00 | $10.00 | None |
COLYTE WITH FLAVOR PACKETS |
3 |
Tier 3 |
$85.00 | $170.00 | P |
COMBIPATCH 0.05/0.14MG PTCH |
2 |
Tier 2 |
$35.00 | $70.00 | None |
COMBIPATCH 0.05/0.25MG PTCH |
2 |
Tier 2 |
$35.00 | $70.00 | None |
COMBIVENT INHALER |
2 |
Tier 2 |
$35.00 | $70.00 | None |
COMBIVIR TABLETS |
2 |
Tier 2 |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COMPRO 25MG SUPPOSITORY |
1 |
Tier 1 |
$5.00 | $10.00 | None |
COMTAN 200MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
COMVAX VACCINE VIAL |
2 |
Tier 2 |
$35.00 | $70.00 | P |
CONCERTA ER TABLETS 18MG 100 TABLETS BOT |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CONCERTA ER TABLETS 27MG 100 TABLETS BOT |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CONCERTA ER TABLETS 36MG 100 TABLETS BOT |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CONCERTA ER TABLETS 54MG 100 BOT |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CONDYLOX TOPICAL SOLUTION .5% 3.5 ML CTR |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CONSTULOSE 10GM/15ML SYRUP |
1 |
Tier 1 |
$5.00 | $10.00 | None |
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN |
4 |
Tier 4 |
30% | N/A | P |
COPEGUS 200MG TABLET |
4 |
Tier 4 |
30% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CORDARONE 200MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
COREG 12.5MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
COREG 25MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
COREG 3.125MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
COREG 6.25MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
COREG CR 10MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
$35.00 | $70.00 | None |
COREG CR 20MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
$35.00 | $70.00 | None |
COREG CR 40MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
$35.00 | $70.00 | None |
COREG CR 80MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CORGARD (NADOLOL) 80MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CORGARD 20MG TABLET (100 CT) |
3 |
Tier 3 |
$85.00 | $170.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CORGARD 40MG TABLET (100 CT) |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CORTEF 10MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CORTEF 20MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CORTEF 5MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CORTENEMA 100MG/60ML ENEMA |
3 |
Tier 3 |
$85.00 | $170.00 | None |
CORTISONE ACETATE 25MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CORTISPORIN EAR SOLUTION |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CORTOMYCIN EAR SOLUTION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CORTOMYCIN EAR SUSPENSION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CORZIDE 40-5MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CORZIDE 80-5MG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COSMEGEN 0.5MG VIAL |
4 |
Tier 4 |
30% | N/A | P |
COSOPT PLUS EYE DROPS 22.3 MG/ML 6.8 MG/M |
3 |
Tier 3 |
$85.00 | $170.00 | P |
COUMADIN 10MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
COUMADIN 1MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
COUMADIN 2.5MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
COUMADIN 2MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
COUMADIN 3MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
COUMADIN 4MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
COUMADIN 5MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
COUMADIN 5MG VIAL |
2 |
Tier 2 |
$35.00 | $70.00 | None |
COUMADIN 6MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COUMADIN 7.5MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT |
3 |
Tier 3 |
$85.00 | $170.00 | None |
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT |
3 |
Tier 3 |
$85.00 | $170.00 | None |
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT |
3 |
Tier 3 |
$85.00 | $170.00 | None |
CRESTOR 10MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CRESTOR 20MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CRESTOR 40MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CRESTOR 5MG TABLET |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CRIXIVAN 100MG CAPSULE |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CRIXIVAN 200MG CAPSULE |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CRIXIVAN 333MG CAPSULE |
2 |
Tier 2 |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CRIXIVAN 400MG CAPSULE (120 CT) |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CROMOLYN NEBULIZER SOLUTION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CROMOLYN SODIUM 4% 40MG 10ML BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CUPRIMINE CAPSULES 250MG (100 CT) |
3 |
Tier 3 |
$85.00 | $170.00 | None |
CUTIVATE CREAM 0.05% |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CUTIVATE LOTION 0.05% |
3 |
Tier 3 |
$85.00 | $170.00 | None |
CUTIVATE OINTMENT 0.005% 60GM TUBE |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CYCLESSA 28 DAY TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CYCLOBENZAPRINE HCL 5MG TABLET (500 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CYCLOPHOSPHAMIDE 25MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYCLOPHOSPHAMIDE 50MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | P |
CYCLOSPORINE 100MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | P |
CYCLOSPORINE 100MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | P |
CYCLOSPORINE 25MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | P |
CYCLOSPORINE 50MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | P |
CYCLOSPORINE 50MG/ML AMP |
1 |
Tier 1 |
$5.00 | $10.00 | P |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT |
1 |
Tier 1 |
$5.00 | $10.00 | P |
CYKLOKAPRON 100MG/ML AMPUL |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CYMBALTA 20MG CAPSULE |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CYMBALTA 60MG CAPSULE |
2 |
Tier 2 |
$35.00 | $70.00 | None |
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT) |
2 |
Tier 2 |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYPROHEPTADINE HCL 4 MG |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CYSTADANE POWDER FOR ORAL SOLUTION 180GM |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CYSTAGON 150MG CAPSULE |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CYSTAGON 50MG CAPSULE |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CYTARABINE 20MG/ML VIAL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CYTARABINE 500MG VIAL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CYTARABINE SOLUTION INJECTION 100MG 20ML VIALSD |
1 |
Tier 1 |
$5.00 | $10.00 | None |
CYTOMEL 25MCG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CYTOMEL 50MCG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CYTOMEL 5MCG TABLET |
3 |
Tier 3 |
$85.00 | $170.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYTOTEC TABLET 100MCG (120 CT) |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CYTOTEC TABLET 200MCG (60 CT) |
3 |
Tier 3 |
$85.00 | $170.00 | P |
CYTOVENE IV INJECTION |
3 |
Tier 3 |
$85.00 | $170.00 | P |