2011 Medicare Part D Plan Formulary Information |
CIGNA Medicare Rx Plan Two (PDP) (S5617-185-0)
Benefit Details
|
The CIGNA Medicare Rx Plan Two (PDP) (S5617-185-0) Formulary Drugs Starting with the Letter P in CMS PDP Region 15 which includes: IN KY
|
Drugs Starting with Letter P
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
PACERONE 100MG TABLET |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PACERONE 200MG TABLET |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PACERONE 400MG TABLET |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PACLITAXEL INJECTION SOLUTION 6MG 50ML VIALMD |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
PALGIC 4MG/5ML LIQUID |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA] |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | P |
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA] |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | P |
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA] |
5 |
Specialty Tier |
33% | 33% | P |
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA] |
5 |
Specialty Tier |
33% | 33% | P |
PALIPERIDONE PALMITATE 156 MG/ML PREFILLED SYRINGE [INVEGA] |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAMIDRONATE 60MG/10ML VIAL |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
PAMIDRONATE DISODIUM INJECTION 3MG 10ML VIALSD |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
PAMIDRONATE DISODIUM INJECTION 9MG 10ML VIALSD |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
PANDEL 0.1% CREAM45GM |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PANITUMUMAB 20 MG/ML INJECTABLE SOLUTION [VECTIBIX] |
5 |
Specialty Tier |
33% | 33% | P |
PANRETIN 0.1% GEL 60GM TUBE |
5 |
Specialty Tier |
33% | 33% | None |
PANTOPRAZOLE SODIUM 20MG TABLET DELAYED RELEASE |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | Q:30 /30Days |
PANTOPRAZOLE SODIUM 40MG TABLET DELAYED RELEASE 90 CRC BOT |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | Q:30 /30Days |
PARCAINE 0.5% DROPS |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PARCOPA 10MG/100MG TABLET |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | None |
PARCOPA 25MG/100MG TABLET |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PARCOPA 25MG/250MG TABLET |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | None |
PAROMOMYCIN 250MG CAPSULE |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PAROXETINE 40MG TABLET (500 CT) |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | Q:30 /30Days |
PAROXETINE FILM COATED 20MG TABLET (100 CT) |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | Q:30 /30Days |
PAROXETINE HCL 10MG/5ML SUSPENSION ORAL |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | Q:900 /30Days |
PAROXETINE TABLETS |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | Q:30 /30Days |
PAROXETINE TABLETS 30MG 90 BOT |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | Q:30 /30Days |
PASER GRANULES 4GM PACKET |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | None |
PATADAY 0.2% DROPS |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PATANOL 0.1% EYE DROPS |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PAXIL 10MG/5ML SUSPENSION |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | Q:900 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAZOPANIB 200 MG ORAL TABLET [VOTRIENT] |
5 |
Specialty Tier |
33% | 33% | P |
PCE 333MG DISPERTAB |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PCE 500MG DISPERTAB |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PEDI-DRI TOPICAL POWDER |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PEDIARIX SOLUTION INJECTION 25-25-10 10 X .5ML VIAL |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PEDVAXHIB VACCINE VIAL |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PEG-INTRON 100MCG KIT |
5 |
Specialty Tier |
33% | 33% | P |
PEG-INTRON REDIPEN 120MCG |
5 |
Specialty Tier |
33% | 33% | P |
PEG-INTRON REDIPEN 150MCG |
5 |
Specialty Tier |
33% | 33% | P |
PEG-INTRON REDIPEN 50MCG |
5 |
Specialty Tier |
33% | 33% | P |
PEG-INTRON REDIPEN 80MCG |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEGANONE 250MG TABLET |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PEGASYS 180MCG/0.5ML CONV.PK |
5 |
Specialty Tier |
33% | 33% | P |
PEGASYS INJECTION |
5 |
Specialty Tier |
33% | 33% | P |
PENICILLIN G POTASSIUM 2MMUNITS/50ML ISO-OSM |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PENICILLIN G POTASSIUM 3MMUNITS/50ML ISO-OSM |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PENICILLIN G POTASSIUM FOR INJECTION |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PENICILLIN G POTASSIUM FOR INJECTION 5000000UNIT/VIAL |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PENICILLIN G PROCAINE 1200000UNT 2ML CTG |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PENICILLIN G SODIUM FOR INJECTION 5000000UNT 1 VIAL |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PENICILLIN V POTASSIUM 250MG TABLET (1000 CT) |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENICILLIN V POTASSIUM 500MG TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PENICILLIN V POTASSIUM FOR ORAL SOLUTION CONCENTRATE 125MG 200ML BOT |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PENLAC 8% SOLUTION |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | P |
PENTAM 300 INJ 300MG |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | P |
PENTASA 250MG CAPSULE SA |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PENTASA 500MG CAPSULE |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PENTAZOCINE/ACETAMIN TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PENTAZOCINE/NALOXONE TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PENTOPAK 400MG TABLET SA |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PENTOSTATIN FOR INJECTION 10MG/VIAL |
5 |
Specialty Tier |
33% | 33% | P |
PENTOXIFYLLINE 400MG TABLET SA |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PERFOROMIST 20MCG/2ML VIAL NEBULIZER |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | P |
PERINDOPRIL ERBUMINE 2 MG ORAL TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PERINDOPRIL ERBUMINE 4 MG ORAL TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PERINDOPRIL ERBUMINE 8 MG ORAL TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PERIOGARD 0.12% ORAL RINSE |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PERMETHRIN 5% CREAM |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PERPHENAZINE TABLETS 16MG 100 BOT |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PERPHENAZINE TABLETS 4MG 100 BOXUD |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PERPHENAZINE TABLETS 8MG 100 BOT |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PERPHENAZINE TABLETS USP 2MG 100 BOT |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PFIZERPEN 20MMU VIAL |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PHENADOZ 12.5MG SUPPOSITORY |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PHENADOZ 25MG SUPPOSITORY |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PHENYTEK 200 MG CAPSULE |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PHENYTEK 300 MG CAPSULE |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PHENYTOIN SOD EXT 200 MG CAP |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT) |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PHENYTOIN SODIUM INJECTION 50MG 25 X 2ML AMP |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PHISOHEX 3% CLEANSER |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | None |
PHOSLO 667MG CAPSULE |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PHOSPHOLINE IODIDE 0.125% |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PHOTOFRIN 75MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
PHYSIOLYTE SOLUTION FOR IRRIGATION |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
PHYSIOSOL IRRIGATION SOL |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
PILOCARPINE HCL 5MG TABLET (100 CT) |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PILOCARPINE HCL 7.5MG TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PILOPINE HS 4% EYE GEL |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PINDOLOL 10MG TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PINDOLOL 5MG TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PIPERACILLIN 200 MG/ML / TAZOBACTAM 25 MG/ML INJECTABLE SOLUTION |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PIPERACILLIN 3GM VIAL |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PIPERACILLIN 40GM BULK VIAL |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PIROXICAM 10 MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
PIROXICAM 20MG CAPSULE (500 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
PLASMA-LYTE 148 IV SOLUTION |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
PLASMA-LYTE 148/DEXTROSE 5% |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
PLASMA-LYTE 56 INJECTION 32;128 MG/100ML; |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
PLASMA-LYTE 56/DEXTROSE 5% |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
PLASMA-LYTE A PH 7.4 SOLUTION 37;368; MG/100ML; |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
PLASMA-LYTE INJ-R |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
PLAVIX 75MG TABLET |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PODOFILOX 0.5% TOPICAL TUBEX |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
POLY-DEX 0.1% SUSPENSION DROPS |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POLY-DEX 3.5-10K-.1 OINTMENT |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
POLYCIN-B 500-10KU/G OINTMENT |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT) |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
POLYETHYLENE GLYCOL 3350 105 MG/ML / POTASSIUM CHLORIDE 0.005 MEQ/ML / SODIUM BICARBONATE 0.017 MEQ/ |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
POLYETHYLENE GLYCOL 3350 59 MG/ML / POTASSIUM CHLORIDE 0.1 MEQ/ML / SODIUM BICARBONATE 0.02 MEQ/ML / |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
POLYETHYLENE GLYCOL 3350 60 MG/ML / POTASSIUM CHLORIDE 0.01 MEQ/ML / SODIUM BICARBONATE 0.02 MEQ/ML |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1% |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
POLYMYXIN B SULFATE VIAL |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PORTIA 0.15-0.03 TABLET |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
POTASSIUM CHLORIDE 0.075%/D5W/SODIUM CHLORIDE 0.2% |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.3% |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45% |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.9% 1000ML |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.2% |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
POTASSIUM CHLORIDE 10MEQ/100ML SOL |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
POTASSIUM CHLORIDE 10MEQ/50ML SOL |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
POTASSIUM CHLORIDE 20MEQ IN D5W LACT RNG |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
POTASSIUM CHLORIDE 20MEQ IN D5W/NACL 0.225% |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
POTASSIUM CHLORIDE 20MEQ/50ML SOL |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
POTASSIUM CHLORIDE 30MEQ/100ML SOL |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
POTASSIUM CHLORIDE 40MEQ IN D5W LACT RNG |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE 40MEQ IN D5W/NACL 0.9% |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
POTASSIUM CHLORIDE 40MEQ/NS 1000ML IV SOLUTION |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
POTASSIUM CHLORIDE 8 MEQ EXTENDED RELEASE TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
POTASSIUM CHLORIDE ER CAPSULES 10MEQ |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
POTASSIUM CHLORIDE ER CPCR 8MEQ |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
POTASSIUM CHLORIDE EXTENDED RELEASE TABLETS |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
POTASSIUM CHLORIDE FOR INJECTION CONCENTRATE |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
POTASSIUM CHLORIDE IN 10% DEXTROSE AND NACL SOLUTION FOR INJECTION |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
POTASSIUM CHLORIDE IN 5% DEXTROSE INJECTION 40 12 X 1000ML CTR |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
POTASSIUM CHLORIDE IN DEXTROSE INJECTION 5GM/75MG |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | P |
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION 0.15%-0.9% 12 X 1000ML BAG |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
POTASSIUM CHLORIDE TABLET EXTENED RELEASE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
POTASSIUM CITRATE 10MEQ TABLET SA |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
POTASSIUM CITRATE 5MEQ TABLET SA |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PRAMIPEXOLE 0.125 MG TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PRAMIPEXOLE 0.25 MG TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PRAMIPEXOLE 0.5 MG TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAMIPEXOLE 1 MG TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PRAMIPEXOLE 1.5 MG TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PRAMIPEXOLE DIHYDROCHLORIDE TABLETS |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PRASUGREL 10 MG ORAL TABLET |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | Q:36 /30Days |
PRASUGREL 5 MG ORAL TABLET |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | Q:42 /30Days |
PRAVASTATIN SODIUM 20MG TABLET 500 BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
PRAVASTATIN SODIUM 40MG TABLET (500 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
PRAVASTATIN SODIUM 80MG TABLET (90 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
PRAZOSIN 5MG CAPSULE |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PRAZOSIN HCL 1MG CAPSULE |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAZOSIN HCL 2MG CAPSULE |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PRED MILD 0.12% EYE DROPS |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | None |
PREDNICARBATE 0.1% OINTMENT |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PREDNICARBATE 1 MG/ML TOPICAL CREAM |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PREDNISOLONE SOD 1% EYE DROP |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PREDNISONE 10MG TABLET (100 CT) |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | P |
PREDNISONE 1MG TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | P |
PREDNISONE 2.5MG TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISONE 20MG TABLET (1000 CT) |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | P |
PREDNISONE 5 MG TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | P |
PREDNISONE 50MG TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | P |
PREDNISONE 5MG/5ML SOLUTION |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | P |
PREDNISONE 5MG/ML SOLUTION |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | P |
PREFEST TABLET 30 EA |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | None |
PREMARIN 0.3MG (100 CT) |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | Q:30 /30Days |
PREMARIN 0.45MG TABLET |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | Q:30 /30Days |
PREMARIN 0.625MG (100 CT) |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | Q:30 /30Days |
PREMARIN 0.9MG TABLET |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | Q:30 /30Days |
PREMARIN 1.25MG (100 CT) |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREMARIN 25MG VIAL |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | None |
PREMARIN VAGINAL CREAM /APPL |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | None |
PREMASOL 10% IV SOLUTION |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
PREMASOL 6% IV SOLUTION |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
PREMPHASE 0.625/5MG TABLET |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | None |
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | Q:28 /28Days |
PREMPRO 0.45-1.5 MG TABLET 28 EA |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | Q:28 /28Days |
PRENATABS OBN TABLETS 200;1;150;MG;MG;MCG; 90 BOT |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PREVALITE POW 4GM |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PREVIFEM TABLETS .035;.25MG;MG 28 BLPK |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PREZISTA TABLET 600MG |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREZISTA TABLET 75MG |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | None |
PREZISTA TABLETS |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | None |
PREZISTA TABLETS 400MG 60 TABLETS BOT |
5 |
Specialty Tier |
33% | 33% | None |
PRIFTIN 150MG TABLET |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | None |
PRIMAQUINE 26.3MG TABLET |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | None |
PRIMAXIN I.M. 500MG VIAL |
5 |
Specialty Tier |
33% | 33% | None |
PRIMAXIN IV 250MG VIAL |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PRIMAXIN IV INJ 500MG |
5 |
Specialty Tier |
33% | 33% | None |
PRIMIDONE 250MG TABLET (100 CT) |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PRIMIDONE 50MG TABLET (500 CT) |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PRIMSOL 50MG/5ML ORAL SOLUTION |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRISTIQ 100MG TABLET SR 24HR |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | Q:30 /30Days |
PRISTIQ 50MG TABLET SR 24HR |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | Q:30 /30Days |
PRIVIGEN 10% VIAL |
5 |
Specialty Tier |
33% | 33% | P |
PROAIR HFA 90MCG HFA AEROSOL WITH ADAPTER |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PROBENECID 500MG TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROBENECID/COLCHICINE TABLET S |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROCAINAMIDE 100MG/ML VIAL |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROCAINAMIDE 500MG/ML VIAL |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROCALAMINE INJECTION 210MG-290MG-26MG 6 X 1000ML BOT |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT) |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT) |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROCRIT 10000U/ML VIAL |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P Q:12 /28Days |
PROCRIT 3000U/ML VIAL |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P Q:12 /28Days |
PROCRIT 40000U/ML VIAL PR |
5 |
Specialty Tier |
33% | 33% | P |
PROCRIT 4000U/ML VIAL 25 X 1ML VIAL |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | P Q:12 /28Days |
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY |
5 |
Specialty Tier |
33% | 33% | P |
PROCTO-PAK 1% CREAM |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROCTOCORT 1% CREAM |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | None |
PROCTOCREAM-HC 2.5% CREAM |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCTOSOL-HC 2.5% CREAM |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROCTOZONE-HC 2.5% CREAM |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROGLYCEM 50MG/ML ORAL SUSP |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PROGRAF 0.5MG CAPSULE |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | P |
PROGRAF 1MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P |
PROGRAF 5MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P |
PROGRAF 5MG/ML AMPULE |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | P |
PROLASTIN 500MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
PROLEUKIN 22 MILLION UNITS VL |
5 |
Specialty Tier |
33% | 33% | P |
PROMACTA TABLETS |
5 |
Specialty Tier |
33% | 33% | P |
PROMACTA TABLETS |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMACTA TABLETS 25 MG |
5 |
Specialty Tier |
33% | 33% | P |
PROMETHAZINE 50MG/ML VIAL |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | P |
PROMETHAZINE HCL 12.5MG TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | P |
PROMETHAZINE HCL 25MG TABLET (1000 CT) |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | P |
PROMETHAZINE HCL 50MG TABLET (100 CT) |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROMETHAZINE HCL 6.25MG/5ML SYRUP |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROMETHAZINE HCL INJECTION 25MG 10 X 1ML VIAL |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | P |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROMETHAZINE VC PLAIN 6.25-5MG 16 FL OZ BOT |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROMETHEGAN 25MG SUPP |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMETHEGAN 50MG SUPPOS |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROMETRIUM 100MG CAPSULE |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PROMETRIUM 200MG CAPSULE |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PROPAFENONE HCL 150MG TABLET (100 CT) |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROPAFENONE HCL 225MG TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROPAFENONE HCL 300MG TABLET (100 CT) |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROPARACAINE 0.5% EYE DROPS |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROPRANOLOL 20MG/5ML TUBEX |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROPRANOLOL 40MG/5ML TUBEX |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROPRANOLOL 60MG TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROPRANOLOL 80 MG TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPRANOLOL HCL 20MG TABLET (1000 CT) |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROPRANOLOL HCL CAPSULES ER 120MG (1000 CT) |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROPRANOLOL HCL CAPSULES ER 160MG (1000 CT) |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROPRANOLOL HCL CAPSULES ER 60MG (100 CT) |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROPRANOLOL HCL CAPSULES ER 80MG (1000 CT) |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROPRANOLOL HCL INJECTION 1MG 10 PKG OF 10 CRTN |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROPRANOLOL HCL TABLET USP 10MG (1000 CT) |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROPRANOLOL HCL TABLET USP 40MG (1000 CT) |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROPRANOLOL/HCTZ 40/25 TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROPRANOLOL/HCTZ 80/25 TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PROPYLTHIOURACIL 50MG TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROQUAD VIAL |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PROSOL 20% INJECTION |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | P |
PROTOPIC 0.03% OINTMENT 100GM TUBE |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | None |
PROTOPIC 0.1% OINTMENT 60GM TUBE |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG |
3 |
Non-Preferred Generic/Preferred Brand |
$36.00 | $90.00 | None |
PROVENTIL HFA INHALER 90MCG AE |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | None |
PULMICORT .25MG/2ML RESPULE |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | P |
PULMICORT 0.5MG/2ML RESPULE |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | P |
PULMICORT 1MG/2ML AMPUL FOR NEBULIZATION |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | P |
PULMOZYME 1MG/ML AMPUL |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PURINETHOL 50MG TABLET |
4 |
Non-Preferred Generic/Non-Preferred Brand |
$78.00 | $195.00 | None |
PYRAZINAMIDE 500MG TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
PYRIDOSTIGMINE BROMIDE 60MG TABLET |
2 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |