2011 Medicare Part D Plan Formulary Information |
Evercare Plan RDP (Regional PPO SNP) (R5287-003-0)
Benefit Details
|
The Evercare Plan RDP (Regional PPO SNP) (R5287-003-0) Formulary Drugs Starting with the Letter A in Statewide County, FL: CMS MA Region 9 which includes: FL
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Drugs Starting with Letter A
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
A METHAPRED METHLYPREDNISOLONE SODIUM SUCCINATE FOR INJECTION 125 MG |
2 |
Tier 2 |
15% | 15% | None |
A-HYDROCORT 100MG VIAL |
2 |
Tier 2 |
15% | 15% | None |
A-METHAPRED 40MG UNIVIAL |
2 |
Tier 2 |
15% | 15% | None |
ACARBOSE 100MG TABLET S |
1 |
Tier 1 |
15% | 15% | None |
ACARBOSE 50MG TABLET S |
1 |
Tier 1 |
15% | 15% | None |
ACARBOSE TABLETS |
1 |
Tier 1 |
15% | 15% | None |
ACEBUTOLOL 200MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
ACEBUTOLOL 400MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE |
2 |
Tier 2 |
15% | 15% | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) |
1 |
Tier 1 |
15% | 15% | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
ACETASOL HC SOLUTION 10ML 10 ML BOT |
2 |
Tier 2 |
15% | 15% | None |
ACETAZOLAMIDE 125MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT |
2 |
Tier 2 |
15% | 15% | None |
ACETAZOLAMIDE SOD 500MG VL |
2 |
Tier 2 |
15% | 15% | None |
ACETIC ACID 2% SOLUTION NON-ORAL |
1 |
Tier 1 |
15% | 15% | None |
ACETYLCYSTEINE 10% VIAL |
1 |
Tier 1 |
15% | 15% | P |
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN |
1 |
Tier 1 |
15% | 15% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTHIB VACCINE VIAL 10-24UNT/5ML |
2 |
Tier 2 |
15% | 15% | None |
ACTICIN 5% CREAM |
1 |
Tier 1 |
15% | 15% | None |
ACTONEL 150MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:1 /28Days |
ACTONEL 30MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:31 /31Days |
ACTONEL 35MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:4 /28Days |
ACTONEL 5MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:31 /31Days |
ACTOPLUS MET 15MG/500MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
ACTOPLUS MET 15MG/850MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
ACTOS 15MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
ACTOS 30MG TABLET (500 CT) |
2 |
Tier 2 |
15% | 15% | None |
ACTOS 45MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACULAR 0.5% EYE DROPS |
2 |
Tier 2 |
15% | 15% | None |
ACULAR LS 0.4% OPHTH SOL |
2 |
Tier 2 |
15% | 15% | None |
ACYCLOVIR 200MG CAPSULE (1000 CT) |
1 |
Tier 1 |
15% | 15% | None |
ACYCLOVIR 200MG/5ML SUSP |
2 |
Tier 2 |
15% | 15% | None |
ACYCLOVIR 400MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
ACYCLOVIR 800 MG ORAL TABLET |
1 |
Tier 1 |
15% | 15% | None |
ACYCLOVIR SODIUM 500MG VIAL |
2 |
Tier 2 |
15% | 15% | P |
ADACEL VIAL 2UNT/5UNT |
2 |
Tier 2 |
15% | 15% | None |
ADAPALENE CREAM |
2 |
Tier 2 |
15% | 15% | None |
ADAPALENE GEL |
2 |
Tier 2 |
15% | 15% | None |
ADVAIR DISKU MIS 100/50 |
2 |
Tier 2 |
15% | 15% | 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 |
15% | 15% | Q:60 /30Days |
ADVAIR DISKU MIS 500/50 |
2 |
Tier 2 |
15% | 15% | Q:60 /30Days |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL |
2 |
Tier 2 |
15% | 15% | Q:12 /30Days |
ADVAIR HFA INHALER 230;21MCG;MCG |
2 |
Tier 2 |
15% | 15% | Q:12 /30Days |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
2 |
Tier 2 |
15% | 15% | Q:12 /30Days |
AFEDITAB CR 30MG TABLET SA |
1 |
Tier 1 |
15% | 15% | None |
AFEDITAB CR 60MG TABLET SA |
1 |
Tier 1 |
15% | 15% | None |
AGGRENOX 25-200MG CAPSULE |
2 |
Tier 2 |
15% | 15% | Q:62 /31Days |
AK-CON 0.1% EYE DROPS |
1 |
Tier 1 |
15% | 15% | None |
AKTOB 0.3% EYE DROPS |
1 |
Tier 1 |
15% | 15% | None |
ALA-CORT 1% CREAM |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALA-CORT 1% LOTION |
1 |
Tier 1 |
15% | 15% | None |
ALBENZA 200MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER |
1 |
Tier 1 |
15% | 15% | P |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
1 |
Tier 1 |
15% | 15% | P |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
1 |
Tier 1 |
15% | 15% | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
1 |
Tier 1 |
15% | 15% | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
1 |
Tier 1 |
15% | 15% | P |
ALBUTEROL SULFATE SOLUTION FOR INHALATION |
1 |
Tier 1 |
15% | 15% | P |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
1 |
Tier 1 |
15% | 15% | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
ALBUTEROL TABLET 4MG (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALCLOMETASONE DIPROPIONATE 0.05% CREAM |
1 |
Tier 1 |
15% | 15% | None |
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT |
1 |
Tier 1 |
15% | 15% | None |
ALCOHOL 5%/DEXTROSE 5% |
2 |
Tier 2 |
15% | 15% | None |
ALENDRONATE SODIUM 10MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
ALENDRONATE SODIUM 40MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
ALENDRONATE SODIUM 5MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
ALENDRONATE SODIUM TABLET 35MG 20 CRTN |
1 |
Tier 1 |
15% | 15% | None |
ALENDRONATE SODIUM TABLETS 70 MG |
1 |
Tier 1 |
15% | 15% | None |
ALLOPURINOL SODIUM 500MG VIAL |
2 |
Tier 2 |
15% | 15% | None |
ALLOPURINOL TABLET 300MG (1000 CT) |
1 |
Tier 1 |
15% | 15% | None |
ALLOPURINOL TABLETS |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALPHAGAN P 0.1% DROPS |
2 |
Tier 2 |
15% | 15% | None |
ALPHAGAN P 0.15% EYE DROPS |
2 |
Tier 2 |
15% | 15% | None |
ALREX 0.2% EYE DROPS |
2 |
Tier 2 |
15% | 15% | None |
AMANTADINE 100MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
AMANTADINE 100MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMANTADINE HCL 50 MG/ 5 ML SYRUP |
1 |
Tier 1 |
15% | 15% | None |
AMCINONIDE 0.1% CREAM |
1 |
Tier 1 |
15% | 15% | None |
AMCINONIDE 0.1% LOTION |
1 |
Tier 1 |
15% | 15% | None |
AMCINONIDE 0.1% OINTMENT 60GM TUBE |
1 |
Tier 1 |
15% | 15% | None |
AMIKACIN 250MG/ML VIAL |
2 |
Tier 2 |
15% | 15% | None |
AMIKACIN 50MG/ML VIAL |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
AMINOPHYLLINE 100MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMINOPHYLLINE 200MG TABLET (1000 CT) |
1 |
Tier 1 |
15% | 15% | None |
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD |
2 |
Tier 2 |
15% | 15% | None |
AMINOSYN II 8.5% ELECTROLYT |
2 |
Tier 2 |
15% | 15% | P |
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5% |
2 |
Tier 2 |
15% | 15% | P |
AMINOSYN-HF 8% IV SOLUTION |
2 |
Tier 2 |
15% | 15% | P |
AMIODARONE HCL 400MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMIODARONE HCL INJECTION |
2 |
Tier 2 |
15% | 15% | None |
AMIODARONE HYDROCHLORIDE TABLETS |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITIZA 8MCG CAPSULE |
2 |
Tier 2 |
15% | 15% | S Q:62 /31Days |
AMITIZA CAPSULES 24MCG 60 CAP BOT |
2 |
Tier 2 |
15% | 15% | S Q:62 /31Days |
AMITRIP/CDP 25-10 TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMITRIP/PERPHEN 10-2 TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMITRIP/PERPHEN 10-4 TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMITRIP/PERPHEN 25-2 TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMITRIP/PERPHEN 25-4 TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMITRIP/PERPHEN 50-4 TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMITRIPTYLINE HCL 100MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMITRIPTYLINE HCL 10MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMITRIPTYLINE HCL 150 MG TAB |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
AMLODIPINE 10 MG / HYDROCHLOROTHIAZIDE 12.5 MG / VALSARTAN 160 MG ORAL TABLET [EXFORGE HCT 10/160/12 |
2 |
Tier 2 |
15% | 15% | Q:31 /31Days |
AMLODIPINE 10 MG / HYDROCHLOROTHIAZIDE 25 MG / VALSARTAN 160 MG ORAL TABLET [EXFORGE HCT 10/160/25] |
2 |
Tier 2 |
15% | 15% | Q:31 /31Days |
AMLODIPINE 10 MG / HYDROCHLOROTHIAZIDE 25 MG / VALSARTAN 320 MG ORAL TABLET [EXFORGE HCT 10/320/25] |
2 |
Tier 2 |
15% | 15% | Q:31 /31Days |
AMLODIPINE 5 MG / HYDROCHLOROTHIAZIDE 12.5 MG / VALSARTAN 160 MG ORAL TABLET [EXFORGE HCT 5/160/12.5 |
2 |
Tier 2 |
15% | 15% | Q:31 /31Days |
AMLODIPINE 5 MG / HYDROCHLOROTHIAZIDE 25 MG / VALSARTAN 160 MG ORAL TABLET [EXFORGE HCT 5/160/25] |
2 |
Tier 2 |
15% | 15% | Q:31 /31Days |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
1 |
Tier 1 |
15% | 15% | None |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1 |
Tier 1 |
15% | 15% | None |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES |
2 |
Tier 2 |
15% | 15% | Q:31 /31Days |
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES |
2 |
Tier 2 |
15% | 15% | Q:31 /31Days |
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE |
1 |
Tier 1 |
15% | 15% | Q:31 /31Days |
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE |
1 |
Tier 1 |
15% | 15% | Q:31 /31Days |
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE |
1 |
Tier 1 |
15% | 15% | Q:31 /31Days |
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE |
1 |
Tier 1 |
15% | 15% | Q:31 /31Days |
AMMONIUM LACTATE 12% CREAM |
1 |
Tier 1 |
15% | 15% | None |
AMMONIUM LACTATE 12% LOTION |
1 |
Tier 1 |
15% | 15% | None |
AMNESTEEM 10MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
AMNESTEEM 20MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
AMNESTEEM 40MG CAPSULE |
2 |
Tier 2 |
15% | 15% | 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 |
15% | 15% | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
15% | 15% | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
1 |
Tier 1 |
15% | 15% | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
1 |
Tier 1 |
15% | 15% | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
15% | 15% | None |
AMOXAPINE 100MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMOXAPINE 150MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMOXAPINE 25MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMOXAPINE 50MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN 125MG TABLET CHEW |
1 |
Tier 1 |
15% | 15% | 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 |
15% | 15% | None |
AMOXICILLIN 250MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN 400MG TABLET CHEW |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN 500MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN 500MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN 875MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG |
2 |
Tier 2 |
15% | 15% | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT) |
1 |
Tier 1 |
15% | 15% | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:155 /31Days |
AMPHETAMINE SALT COMBO 15MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:124 /31Days |
AMPHETAMINE SALT COMBO 30MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:62 /31Days |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:248 /31Days |
AMPHETAMINE SALTS 20MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:93 /31Days |
AMPHETAMINE SALTS 5 MG TAB |
1 |
Tier 1 |
15% | 15% | Q:372 /31Days |
AMPHOTERICIN B FOR INJECTION 50 MG |
2 |
Tier 2 |
15% | 15% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL |
2 |
Tier 2 |
15% | 15% | None |
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL |
2 |
Tier 2 |
15% | 15% | None |
AMPICILLIN CAPSULES 250MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
AMPICILLIN FOR INJECTION POWDER |
2 |
Tier 2 |
15% | 15% | None |
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL |
2 |
Tier 2 |
15% | 15% | None |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
1 |
Tier 1 |
15% | 15% | None |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
1 |
Tier 1 |
15% | 15% | None |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML |
2 |
Tier 2 |
15% | 15% | None |
AMYLASES 109000 UNT / ENDOPEPTIDASES 68000 UNT / LIPASE 20000 UNT ENTERIC COATED CAPSULE [ZENPEP 20] |
2 |
Tier 2 |
15% | 15% | None |
AMYLASES 27000 UNT / ENDOPEPTIDASES 17000 UNT / LIPASE 5000 UNT ENTERIC COATED CAPSULE [ZENPEP 5] |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMYLASES 55000 UNT / ENDOPEPTIDASES 34000 UNT / LIPASE 10000 UNT ENTERIC COATED CAPSULE [ZENPEP 10] |
2 |
Tier 2 |
15% | 15% | None |
AMYLASES 82000 UNT / ENDOPEPTIDASES 51000 UNT / LIPASE 15000 UNT ENTERIC COATED CAPSULE [ZENPEP 15] |
2 |
Tier 2 |
15% | 15% | None |
ANAGRELIDE HCL 0.5MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
ANAGRELIDE HCL 1MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
ANASTROZOLE TABLETS |
1 |
Tier 1 |
15% | 15% | None |
ANDRODERM 2.5MG/24HR PATCH |
2 |
Tier 2 |
15% | 15% | P |
ANDRODERM 5MG/24HR PATCH |
2 |
Tier 2 |
15% | 15% | P |
ANDROGEL 1%(50MG) GEL PACKET |
2 |
Tier 2 |
15% | 15% | P |
ANESTACON 15ML |
1 |
Tier 1 |
15% | 15% | None |
ANTABUSE 250MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
ANTABUSE 500MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANTARA CAPSULES |
2 |
Tier 2 |
15% | 15% | None |
ANTARA CAPSULES |
2 |
Tier 2 |
15% | 15% | None |
APAP-CAFFEINE-DIHYDROCODE TAB 30 EA |
2 |
Tier 2 |
15% | 15% | None |
APIDRA 100UNITS/ML VIAL |
2 |
Tier 2 |
15% | 15% | None |
APRACLONIDINE 5 MG/ML OPHTHALMIC SOLUTION |
2 |
Tier 2 |
15% | 15% | None |
APRI 0.15-0.03 TABLET |
1 |
Tier 1 |
15% | 15% | None |
APRISO CP24 |
2 |
Tier 2 |
15% | 15% | Q:124 /31Days |
ARANELLE 7-9-5 TABLET |
1 |
Tier 1 |
15% | 15% | None |
ARICEPT 10MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:62 /31Days |
ARICEPT 5MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:31 /31Days |
ARICEPT ODT 10MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:62 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARICEPT ODT 5MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:31 /31Days |
ARICEPT TABLETS |
2 |
Tier 2 |
15% | 15% | Q:31 /31Days |
ASACOL 400MG TABLET EC |
2 |
Tier 2 |
15% | 15% | None |
ASCOMP W/CODEINE 30-50-325 CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
ASENAPINE 10 MG SUBLINGUAL TABLET [SAPHRIS] |
2 |
Tier 2 |
15% | 15% | Q:62 /31Days |
ASENAPINE 5 MG SUBLINGUAL TABLET [SAPHRIS] |
2 |
Tier 2 |
15% | 15% | Q:62 /31Days |
ASTELIN 137MCG AEROSOL SPRAY W/PUMP |
2 |
Tier 2 |
15% | 15% | Q:60 /31Days |
ASTEPRO 0.15% NASAL SPRAY 30 ML |
2 |
Tier 2 |
15% | 15% | Q:60 /31Days |
ASTRAMORPH PF INJECTION |
2 |
Tier 2 |
15% | 15% | None |
ASTRAMORPH PF INJECTION 1MG/ML |
2 |
Tier 2 |
15% | 15% | None |
ATAMET |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATENOLOL 25MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
ATENOLOL TABLET USP 50MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
ATENOLOL TABLETS USP 100MG 1 BLPK |
1 |
Tier 1 |
15% | 15% | None |
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
ATROPINE 0.025 MG / DIPHENOXYLATE 2.5 MG ORAL TABLET |
1 |
Tier 1 |
15% | 15% | None |
ATROPINE 0.05MG/ML SYRINGE |
1 |
Tier 1 |
15% | 15% | None |
ATROPINE 0.1MG/ML SYRINGE |
1 |
Tier 1 |
15% | 15% | None |
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML |
2 |
Tier 2 |
15% | 15% | None |
AVELOX 400MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
AVELOX ABC PACK 400MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVIANE 0.1-0.02 TABLET |
1 |
Tier 1 |
15% | 15% | None |
AVINZA 120MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
15% | 15% | Q:6 /1Days |
AVINZA 30MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
15% | 15% | Q:4 /1Days |
AVINZA 60MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
15% | 15% | Q:4 /1Days |
AVINZA 90MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
15% | 15% | Q:4 /1Days |
AVINZA CAPSULES EXTENDED RELEASE 45MG 100 BOTPL |
2 |
Tier 2 |
15% | 15% | Q:4 /1Days |
AVINZA CAPSULES EXTENDED RELEASE 75MG 100 BOTPL |
2 |
Tier 2 |
15% | 15% | Q:4 /1Days |
AVITA 0.025% CREAM |
1 |
Tier 1 |
15% | 15% | P |
AVODART 0.5MG SOFTGEL |
2 |
Tier 2 |
15% | 15% | Q:31 /31Days |
AZACTAM INJECTION 2GM/VIL |
2 |
Tier 2 |
15% | 15% | None |
AZASITE 1% DROPS |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZATHIOPRINE 50MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AZATHIOPRINE SOD 100MG VIAL |
1 |
Tier 1 |
15% | 15% | None |
AZELASTINE 137 MCG NASAL SPRAY |
2 |
Tier 2 |
15% | 15% | Q:60 /31Days |
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION |
2 |
Tier 2 |
15% | 15% | None |
AZILECT 0.5MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
AZILECT 1MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
15% | 15% | None |
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
15% | 15% | None |
AZITHROMYCIN 250 MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AZITHROMYCIN 500MG TABLET (30 CT) |
1 |
Tier 1 |
15% | 15% | None |
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZITHROMYCIN TABLETS |
1 |
Tier 1 |
15% | 15% | None |
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT |
2 |
Tier 2 |
15% | 15% | None |
AZOR 10MG-20MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:31 /31Days |
AZOR 10MG-40MG TABLET (30 CT) |
2 |
Tier 2 |
15% | 15% | Q:31 /31Days |
AZOR 5MG-20MG TABLET (30 CT) |
2 |
Tier 2 |
15% | 15% | Q:31 /31Days |
AZOR 5MG-40MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:31 /31Days |
AZTREONAM FOR INJECTION |
2 |
Tier 2 |
15% | 15% | None |