2011 Medicare Part D Plan Formulary Information |
WellCare Classic (PDP) (S5967-163-0)
Benefit Details
|
The WellCare Classic (PDP) (S5967-163-0) Formulary Drugs Starting with the Letter C in CMS PDP Region 26 which includes: NM
|
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 |
CALCIPOTRIENE OINTMENT |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CALCIPOTRIENE TOPICAL SOLUTION |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CALCITRIOL 0.25MCG CAPSULE |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | P |
CALCITRIOL 0.5MCG CAPSULE |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | P |
CALCITRIOL 1MCG/ML SOLUTION ORAL |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | P |
CALCITRIOL 2 MCG/ML VIAL |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | P |
CALCITRIOL INJECTION SOLUTION 1MCG 50 X 01ML AMP |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | P |
CALCIUM ACETATE CAPSULE 667 MG |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CALCIUM CHLORIDE 0.0014 MEQ/ML / POTASSIUM CHLORIDE 0.004 MEQ/ML / SODIUM CHLORIDE 0.103 MEQ/ML / SO |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAMILA 0.35MG TABLET |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CAMPATH 30MG/ML VIAL |
4 |
Specialty Tier |
25% | N/A | P |
CAMPRAL 333MG DOSE PAK |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CAPREOMYCIN 500 MG/ML INJECTABLE SOLUTION [CAPASTAT] |
4 |
Specialty Tier |
25% | N/A | None |
CAPTOPRIL 100MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CAPTOPRIL 12.5MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CAPTOPRIL 25MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CAPTOPRIL 50MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CAPTOPRIL/HCTZ 25/15 TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CAPTOPRIL/HCTZ 25/25 TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAPTOPRIL/HCTZ 50/15 TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CAPTOPRIL/HCTZ 50/25 TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CARAC CRE 0.5% |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CARAFATE SUS 1GM/10ML |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CARBAMAZEPINE ORAL SUSPENSION 200 MG |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CARBAMAZEPINE TABLET CHEWABLE 100MG (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CARBAMAZEPINE TABLET USP 200MG (1000 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CARBIDOPA-LEVODOPA 25MG-100MG TABLET SA |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CARBIDOPA-LEVODOPA 50MG-200MG TABLET SA |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CARBIDOPA/LEVO 10/100 TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CARBIDOPA/LEVO 25/100 TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARBIDOPA/LEVO 25/250 TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CARIMUNE NF 3GM VIAL |
4 |
Specialty Tier |
25% | N/A | P |
CARISOPRODOL TABLET USP 350MG (100 CT) |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | Q:124 /31Days |
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CARTIA XT 120MG CAPSULE SA |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CARTIA XT 180MG CAPSULE SA |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CARTIA XT 240MG CAPSULE SA |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CARTIA XT 300MG CAPSULE SR 24 HR |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CARVEDILOL 12.5MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CARVEDILOL 25MG TABLET (500 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CARVEDILOL 3.125MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARVEDILOL 6.25MG TABLET (500 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CEENU 100MG CAPSULE |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEENU 10MG CAPSULE |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEENU 40MG CAPSULE |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFACLOR 250MG/5ML ORAL SUSP |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFACLOR 375MG/5ML ORAL SUSP |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFACLOR CAPSULES |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFACLOR CAPSULES |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFACLOR POWDER FOR ORAL SUSPENSION USP 125MG 75ML BOT |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFADROXIL 1G TABLET |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFADROXIL 500MG CAPSULE |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFADROXIL 500MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFADROXIL FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFAZOLIN 1 GM VIAL |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFAZOLIN 1GM/D5W BAG |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFAZOLIN 20GM BULK VIAL |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFAZOLIN FOR INJECTION |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFDINIR CAPSULES 300MG (60 CT) |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT) |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFEPIME HCL 2 GRAM VIAL |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFOTAXIME FOR INJECTION |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CEFOTAXIME FOR INJECTION 1GM 50 BOX VIALGL |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CEFOTAXIME FOR INJECTION 2GM 25 VIAL |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CEFOTAXIME FOR INJECTION 500MG 10 VIAL |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CEFOXITIN 180 MG/ML INJECTABLE SOLUTION |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CEFOXITIN 95 MG/ML INJECTABLE SOLUTION |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CEFOXITIN FOR INJECTION SOLUTION |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CEFPODOXIME PROXETIL 200MG TABLET |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT) |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 100MG 50ML BOT |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 50MG 50ML BOT |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFPROZIL 250MG TABLET (100 CT) |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFPROZIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFPROZIL FOR ORAL SUSPENSION 125MG/5ML 75ML BOT |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFPROZIL TABLETS 500MG 100 BOT |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFTAZIDIME FOR INJECTION 1GM/VIAL 1 SINGLE VIAL VIAL |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CEFTRIAXONE 10GM VIAL |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFTRIAXONE FOR INJECTION |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFTRIAXONE FOR INJECTION |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFTRIAXONE FOR INJECTION 250MG BOX OF 10 VIALGL |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFTRIAXONE FOR INJECTION 500MG BOX OF 10 VIALGL |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFUROXIME 250MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CEFUROXIME AXETIL 125MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEFUROXIME AXETIL 500MG TABLET (20 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CEFUROXIME FOR INJECTION |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CEFUROXIME FOR INJECTION |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CELLCEPT 200MG/ML ORAL SUSP |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | P |
CELONTIN 300MG KAPSEAL |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CENESTIN 0.3MG TABLET |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CENESTIN 0.45MG TABLET |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CENESTIN 0.625MG TABLET |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CENESTIN 0.9MG TABLET |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CENESTIN 1.25MG TABLET |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CEPHALEXIN 250MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CEPHALEXIN 250MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CEPHALEXIN 250MG/5ML ORAL SUSP |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CEPHALEXIN 500MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CEPHALEXIN CAPSULES 500MG (500 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CEPHALEXIN POWDER FOR SUSPENSION ORAL USP 125MG 200ML BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CEREDASE 80UNITS/ML VIAL |
4 |
Specialty Tier |
25% | N/A | P |
CEREZYME INJ 200UNIT |
4 |
Specialty Tier |
25% | N/A | P |
CESIA 7 DAYS X 3 TABLET |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHANTIX 0.5MG TABLET |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | Q:340 /365Days |
CHANTIX 1MG TABLET |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | Q:340 /365Days |
CHANTIX STARTING MONTH PAK |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | Q:106 /365Days |
CHLORDIAZEPOXIDE AND AMITRIPTYLINE HCL TABLET 12.5-5MG (500 CT) |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CHLOROQUINE PH 500MG TABLET |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CHLOROQUINE PHOSPHATE 250MG TABLET (50 CT) |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CHLOROTHIAZIDE 250MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CHLOROTHIAZIDE 500MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CHLOROTHIAZIDE SODIUM FOR INJECTION 500MG/VIAL |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CHLORPROMAZINE 100MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLORPROMAZINE 10MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CHLORPROMAZINE 25MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CHLORPROMAZINE 25MG/ML AMP |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CHLORPROMAZINE 50MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CHLORPROMAZINE HCL 200MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CHLORPROPAMIDE 100MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CHLORPROPAMIDE 250MG TABLET (1000 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CHLORTHALIDONE 25MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CHLORTHALIDONE 50MG TABLET (1000 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CHLORZOXAZONE 500MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHORIONIC GONAD 10000U VIAL |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | P |
CICLOPIROX 0.77% CREAM |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CICLOPIROX 0.77% TOPICAL SUSPENSION |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CICLOPIROX 1% SHAMPOO |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6ML BOT |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CICLOPIROX GEL |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CILOSTAZOL 50MG TABLET (60 CT) |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CILOSTAZOL TABLET 100MG (60 CT) |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CIMETIDINE 200MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CIMETIDINE HCL 300MG/5ML SOL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CIMETIDINE TABLETS |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIMETIDINE TABLETS |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CIMETIDINE TABLETS USP |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CIPROFLOXACIN 250MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CIPROFLOXACIN 400 MG/40 ML VL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CIPROFLOXACIN 500MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CIPROFLOXACIN HCL 0.3% DROPS |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CIPROFLOXACIN TABLETS 750MG 100 BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CITALOPRAM HBR 20 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CITOLOPRAM HBR 10MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLARITHROMYCIN 250MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CLARITHROMYCIN 500MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CLARITHROMYCIN FOR ORAL SUSPENSION |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CLARITHROMYCIN FOR ORAL SUSPENSION |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CLINDAMYCIN 150MG/ML ADDVAN |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CLINDAMYCIN HCL 150MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CLINDAMYCIN HYDROCHLORIDE CAPSULES |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CLINDAMYCIN PHOSP 1% LOTION |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CLINDAMYCIN PHOSPHATE 1% SOLUTION NON-ORAL |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CLINDAMYCIN PHOSPHATE VAGINAL CREAM |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINIMIX 2.75%/5% INJECTION 1000ML BAG |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CLINIMIX 4.25/10 SOLUTION |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CLINIMIX 4.25/20 SOLUTION |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CLINIMIX 4.25/25 SOLUTION |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CLINIMIX 4.25/5 SOLUTION |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CLINIMIX 5/15 SOLUTION |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CLINIMIX 5/20 SOLUTION |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CLINISOL 15% SOLUTION |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CLOBETASOL 0.05% OINTMENT |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CLOBETASOL 0.05% SOLUTION |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOBETASOL E 0.05% CREAM |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CLODERM 0.1% CREAM |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CLOMIPRAMINE HCL 25MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CLOMIPRAMINE HCL 50MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CLOMIPRAMINE HCL 75MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CLONIDINE HCL 0.2MG TABLET (500 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CLONIDINE HCL TABLET 0.1MG (500 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CLONIDINE HCL TABLET 0.3MG (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CLORPRES 0.1-15 TABLET |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CLORPRES 0.2-15 TABLET |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLORPRES 0.3-15 TABLET |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CLOTRIMAZOLE 1% CREAM |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CREAM USP .5MG-10GM 45GM TUBE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CLOZAPINE 100 MG ORAL TABLET |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CLOZAPINE 12.5 MG DISINTEGRATING TABLET [FAZACLO] |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | P |
CLOZAPINE 200MG TABLET (500 CT) |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CLOZAPINE 25MG TABLET (100 CT) |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CLOZAPINE 50MG TABLET (500 CT) |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CO-GESIC 5/500 TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:248 /31Days |
CODEINE 60 MG ORAL TABLET |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | Q:248 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CODEINE SULFATE 30 MG TABLET 3100 |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | Q:248 /31Days |
CODEINE SULFATE TABLETS |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | Q:248 /31Days |
COLCHICINE 0.6 MG ORAL TABLET [COLCRYS] |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
COLESTIPOL HCL 1G TABLET |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
COLESTIPOL HCL 5G GRANULES |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
COLISTIMETHATE 150MG VIAL |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
COLOCORT 100MG ENEMA |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
COMBIPATCH 0.05/0.14MG PTCH |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
COMBIPATCH 0.05/0.25MG PTCH |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
COMBIVENT INHALER |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COMBIVIR TABLETS |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
COMPRO 25MG SUPPOSITORY |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
COMTAN 200MG TABLET |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
COMVAX VACCINE VIAL |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CONDYLOX GEL 0.5% 3.5 GM CRTN |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN |
4 |
Specialty Tier |
25% | N/A | P |
CORDRAN 0.05% LOTION |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
COREG CR 10MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
COREG CR 20MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
COREG CR 40MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
COREG CR 80MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CORTIFOAM RECTAL FOAM |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CORTISONE ACETATE 25MG TABLET (100 CT) |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CORTOMYCIN EAR SOLUTION |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CORTOMYCIN EAR SUSPENSION |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
COUMADIN 10MG TABLET |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
COUMADIN 1MG TABLET |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
COUMADIN 2.5MG TABLET |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
COUMADIN 2MG TABLET |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
COUMADIN 3MG TABLET |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
COUMADIN 4MG TABLET |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
COUMADIN 5MG TABLET |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COUMADIN 5MG VIAL |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
COUMADIN 6MG TABLET |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
COUMADIN 7.5MG TABLET |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | None |
CRIXIVAN 100MG CAPSULE |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CRIXIVAN 200MG CAPSULE |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CRIXIVAN 333MG CAPSULE |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CRIXIVAN 400MG CAPSULE (120 CT) |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CROMOLYN NEBULIZER SOLUTION |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CROMOLYN SODIUM 4% 40MG 10ML BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CUPRIMINE CAPSULES 250MG (100 CT) |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT) |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | Q:93 /31Days |
CYCLOBENZAPRINE HCL 5MG TABLET (500 CT) |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | Q:93 /31Days |
CYCLOPHOSPHAMIDE 25MG TABLET |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | P |
CYCLOPHOSPHAMIDE 50MG TABLET |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | P |
CYCLOSPORINE 100MG CAPSULE |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | P |
CYCLOSPORINE 100MG CAPSULE |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | P |
CYCLOSPORINE 25MG CAPSULE |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | P |
CYCLOSPORINE 50MG CAPSULE |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | P |
CYCLOSPORINE 50MG/ML AMP |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | P |
CYKLOKAPRON 100MG/ML AMPUL |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | None |
CYMBALTA 20MG CAPSULE |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | S |
CYMBALTA 60MG CAPSULE |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | S |
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT) |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | S |
CYPROHEPTADINE HCL 4 MG |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CYSTADANE POWDER FOR ORAL SOLUTION 180GM |
2 |
Generic and Preferred Brand |
$44.00 | $110.00 | P |
CYSTAGON 150MG CAPSULE |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | P |
CYSTAGON 50MG CAPSULE |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | P |
CYTOVENE IV INJECTION |
3 |
Generic and Non-Preferred Brand |
$93.00 | $232.00 | P |