2011 Medicare Part D Plan Formulary Information |
AAA3 Vantage PREMIUM (HMO-POS) (H5576-006-0)
Benefit Details
|
The AAA3 Vantage PREMIUM (HMO-POS) (H5576-006-0) Formulary Drugs Starting with the Letter A in East Baton Rouge Parish, LA: CMS MA Region 16 which includes: LA
|
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 |
1 |
Tier 1 |
$0.00 | $0.00 | None |
A-HYDROCORT 100MG VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
A-METHAPRED 40MG UNIVIAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ABELCENT INJECTION SUSPENSION 5MG/ML |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ABILIFY 10MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ABILIFY 15MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ABILIFY 1MG/ML SOLUTION |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ABILIFY 20MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ABILIFY 2MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ABILIFY 30MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABILIFY 5MG TABLET (OTSUKA) |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ABILIFY DISCMELT 10MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ABILIFY DISCMELT 15MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ABILIFY INJ 9.75MG |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ABRAXANE 100MG VIAL |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ACARBOSE 100MG TABLET S |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACARBOSE 50MG TABLET S |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACARBOSE TABLETS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACCOLATE 10MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ACCOLATE 20MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ACCUNEB 0.63MG/3ML INH TUBEX |
3 |
Tier 3 |
$75.00 | $225.00 | P Q:300 /25Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACCUNEB 1.25MG/3ML INH TUBEX |
3 |
Tier 3 |
$75.00 | $225.00 | P Q:300 /25Days |
ACEBUTOLOL 200MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACEBUTOLOL 400MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACETAMINOPHEN CAFFEINE AND DIHYDROCODEINE BITARTRATE TABLETS 712.8;60;MG;MG;MG 100 BOT |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ACETASOL HC SOLUTION 10ML 10 ML BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACETAZOLAMIDE 125MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACETAZOLAMIDE SOD 500MG VL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACETIC ACID 2% SOLUTION NON-ORAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACETYLCYSTEINE 10% VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACLOVATE ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT(GM) TOPICAL |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ACLOVATE CREAM 0.05% 15GM TUBE |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ACTEMRA INJECTION 200MG/10ML |
4 |
Tier 4 |
33% | N/A | P |
ACTHIB VACCINE VIAL 10-24UNT/5ML |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ACTICIN 5% CREAM |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTIGALL 300MG CAPSULE |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ACTIMMUNE SOLUTION FOR INJECTION 100MCG |
4 |
Tier 4 |
33% | N/A | None |
ACTIQ 1200MCG LOZENGE |
4 |
Tier 4 |
33% | N/A | P Q:120 /25Days |
ACTIQ 1600MCG LOZENGE |
4 |
Tier 4 |
33% | N/A | P Q:120 /25Days |
ACTIQ 200MCG LOZENGE |
4 |
Tier 4 |
33% | N/A | P Q:120 /25Days |
ACTIQ 400MCG LOZENGE |
4 |
Tier 4 |
33% | N/A | P Q:120 /25Days |
ACTIQ 600MCG LOZENGE |
4 |
Tier 4 |
33% | N/A | P Q:120 /25Days |
ACTIQ 800MCG LOZENGE |
4 |
Tier 4 |
33% | N/A | P Q:120 /25Days |
ACTIVELLA 0.5-0.1MG TABLET 28 DLPK |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ACTIVELLA 1-0.5MG TABLET 28 DLPK |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ACTONEL 150MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTONEL 30MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | S |
ACTONEL 35MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | S |
ACTONEL 5MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | S |
ACTOPLUS MET 15MG/500MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ACTOPLUS MET 15MG/850MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ACTOPLUS MET XR TABLETS EXTENDED RELEASE 15;1000 MG;MG |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ACTOPLUS MET XR TABLETS EXTENDED RELEASE 30;1000 MG;MG |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ACTOS 15MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ACTOS 30MG TABLET (500 CT) |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ACTOS 45MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ACULAR 0.5% EYE DROPS |
3 |
Tier 3 |
$75.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACULAR LS 0.4% OPHTH SOL |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ACUVAIL 0.45% OPHTH SOLUTION #30X0.4 EA |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ACYCLOVIR 200MG CAPSULE (1000 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACYCLOVIR 200MG/5ML SUSP |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACYCLOVIR 400MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACYCLOVIR 800 MG ORAL TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ACYCLOVIR SODIUM 500MG VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ADACEL VIAL 2UNT/5UNT |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ADAGEN 250U/ML VIAL |
4 |
Tier 4 |
33% | N/A | None |
ADALAT CC 30MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ADALAT CC 60MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADALAT CC 90MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA] |
4 |
Tier 4 |
33% | N/A | P |
ADAPALENE CREAM |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ADAPALENE GEL |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ADDERALL 10MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | P |
ADDERALL 12.5MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | P |
ADDERALL 15MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | P |
ADDERALL 20MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | P |
ADDERALL 30MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | P |
ADDERALL 5MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | P |
ADDERALL 7.5MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADDERALL XR 10MG CAPSULE SA |
3 |
Tier 3 |
$75.00 | $225.00 | P |
ADDERALL XR 15MG CAPSULE SA |
3 |
Tier 3 |
$75.00 | $225.00 | P |
ADDERALL XR 20MG CAPSULE SA |
3 |
Tier 3 |
$75.00 | $225.00 | P |
ADDERALL XR 25MG CAPSULE SA |
3 |
Tier 3 |
$75.00 | $225.00 | P |
ADDERALL XR 30MG CAPSULE SA |
3 |
Tier 3 |
$75.00 | $225.00 | P |
ADDERALL XR 5MG CAPSULE SA |
3 |
Tier 3 |
$75.00 | $225.00 | P |
ADVAIR DISKU MIS 100/50 |
2 |
Tier 2 |
$35.00 | $105.00 | Q:60 /25Days |
ADVAIR DISKU MIS 250/50 |
2 |
Tier 2 |
$35.00 | $105.00 | Q:60 /25Days |
ADVAIR DISKU MIS 500/50 |
2 |
Tier 2 |
$35.00 | $105.00 | Q:60 /25Days |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL |
2 |
Tier 2 |
$35.00 | $105.00 | Q:12 /25Days |
ADVAIR HFA INHALER 230;21MCG;MCG |
2 |
Tier 2 |
$35.00 | $105.00 | Q:12 /25Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
2 |
Tier 2 |
$35.00 | $105.00 | Q:12 /25Days |
ADVICOR ER 20-750MG TABLET (90 CT) |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ADVICOR EXTENDED RELEASE TABLETS 20;1000MG;MG 90 BOTPL |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ADVICOR EXTENDED RELEASE TABLETS 20;500MG;MG 90 BOTPL |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ADVICOR EXTENDED RELEASE TABLETS 40;1000MG;MG 90 BOTPL |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AEROBID-M AEROSOL W/ADAPTER |
3 |
Tier 3 |
$75.00 | $225.00 | Q:21 /25Days |
AFEDITAB CR 30MG TABLET SA |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AFEDITAB CR 60MG TABLET SA |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AFINITOR TABLETS |
4 |
Tier 4 |
33% | N/A | P Q:62 /31Days |
AFINITOR TABLETS |
4 |
Tier 4 |
33% | N/A | P Q:31 /31Days |
AFINITOR TABLETS 5 MG |
4 |
Tier 4 |
33% | N/A | P Q:31 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AGGRENOX 25-200MG CAPSULE |
2 |
Tier 2 |
$35.00 | $105.00 | None |
AGRYLIN 0.5MG CAPSULE |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AK-CON 0.1% EYE DROPS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AKNE-MYCIN 2% OINTMENT |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AKTOB 0.3% EYE DROPS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALA-CORT 1% CREAM |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALA-CORT 1% LOTION |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALA-SCALP HP 2% LOTION |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ALAMAST 0.1% DROPS |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ALBENZA 200MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER |
1 |
Tier 1 |
$0.00 | $0.00 | Q:300 /25Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
1 |
Tier 1 |
$0.00 | $0.00 | Q:300 /25Days |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /25Days |
ALBUTEROL SULFATE SOLUTION FOR INHALATION |
1 |
Tier 1 |
$0.00 | $0.00 | Q:300 /25Days |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALBUTEROL TABLET 4MG (500 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALCAINE 0.5% EYE DROPS |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ALCLOMETASONE DIPROPIONATE 0.05% CREAM |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALCOHOL 5%/DEXTROSE 5% |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALDACTAZIDE 25/25 TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ALDACTAZIDE 50/50 TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ALDARA IMIQUIMOD CREAM 5% 24 PKT X 250 MG CRTN |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ALDURAZYME 2.9MG/5ML VIAL |
4 |
Tier 4 |
33% | N/A | None |
ALENDRONATE SODIUM 10MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALENDRONATE SODIUM 40MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | S |
ALENDRONATE SODIUM 5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALENDRONATE SODIUM TABLET 35MG 20 CRTN |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALENDRONATE SODIUM TABLETS 70 MG |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALIMTA 500MG VIAL |
4 |
Tier 4 |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALINIA 100MG/5ML SUSPENSION |
2 |
Tier 2 |
$35.00 | $105.00 | Q:180 /25Days |
ALINIA 500MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | Q:12 /25Days |
ALISKIREN 150 MG / VALSARTAN 160 MG ORAL TABLET [VALTURNA] |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ALISKIREN 300 MG / VALSARTAN 320 MG ORAL TABLET [VALTURNA] |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ALKERAN FOR INJECTION 50MG/VIAL 1 VIALSU |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ALLEGRA 180MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ALLEGRA 30MG/5ML SUSPENSION ORAL |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ALLEGRA 60MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ALLEGRA-D 12 HOUR TABLET 60-120MG (500 CT) |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ALLEGRA-D 24 HOUR TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ALLOPURINOL SODIUM 500MG VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALLOPURINOL TABLET 300MG (1000 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALLOPURINOL TABLETS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALOCRIL 2% EYE DROPS |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ALOMIDE 0.1% EYE DROPS |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ALOPRIM SOLUTION FOR INJECTION 500MG/VIAL 30 ML VIALGL |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ALORA 0.025MG PATCH |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ALORA 0.05MG PATCH |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ALORA 0.075MG PATCH |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ALORA 0.1MG PATCH |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ALOXI 0.25MG/5ML |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ALPHA-1-PROTEINASE INHIBITOR,HUMAN 16 MG/ML INJECTABLE SOLUTION [ARALAST] |
4 |
Tier 4 |
33% | N/A | 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 |
$35.00 | $105.00 | None |
ALPHAGAN P 0.15% EYE DROPS |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ALREX 0.2% EYE DROPS |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ALTOPREV 20MG TABLET SR 24HR |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ALTOPREV 40MG TABLET SR 24HR |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ALTOPREV 60MG TABLET SR 24HR |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ALVESCO 160MCG/ACT AERS |
3 |
Tier 3 |
$75.00 | $225.00 | Q:13 /25Days |
ALVESCO 80MCG/ACT AERS |
3 |
Tier 3 |
$75.00 | $225.00 | Q:13 /25Days |
AMANTADINE 100MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMANTADINE 100MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMANTADINE HCL 50 MG/ 5 ML SYRUP |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMARYL 1MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AMARYL 2MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AMARYL 4MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AMBIEN 10MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AMBIEN CR 12.5MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AMBIEN CR 6.25MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AMBIEN TABLETS 5MG 100 BOT |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AMBISOME 50MG VIAL |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AMCINONIDE 0.1% CREAM |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMCINONIDE 0.1% LOTION |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMCINONIDE 0.1% OINTMENT 60GM TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMERGE 1MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | Q:9 /25Days |
AMERGE 2.5MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | Q:9 /25Days |
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM |
4 |
Tier 4 |
33% | N/A | None |
AMIFOSTINE FOR INJECTION 500MG/VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMIKACIN 250MG/ML VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMIKACIN 50MG/ML VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMINOPHYLLINE 100MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMINOPHYLLINE 200MG TABLET (1000 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN 10% IV SOLUTION |
2 |
Tier 2 |
$35.00 | $105.00 | P |
AMINOSYN 3.5% IV SOLUTION |
2 |
Tier 2 |
$35.00 | $105.00 | P |
AMINOSYN 5% IV SOLUTION |
2 |
Tier 2 |
$35.00 | $105.00 | P |
AMINOSYN 7% IV SOLUTION |
2 |
Tier 2 |
$35.00 | $105.00 | P |
AMINOSYN 7%-ELECTROLYTE SOL |
2 |
Tier 2 |
$35.00 | $105.00 | P |
AMINOSYN 8.5% IV SOLUTION |
2 |
Tier 2 |
$35.00 | $105.00 | P |
AMINOSYN HBC INJECTION SULFITE FREE 7% |
2 |
Tier 2 |
$35.00 | $105.00 | P |
AMINOSYN II 10% IV SOLUTION |
2 |
Tier 2 |
$35.00 | $105.00 | P |
AMINOSYN II 15% IV SOLUTION |
2 |
Tier 2 |
$35.00 | $105.00 | P |
AMINOSYN II 3.5% IN D25W IV |
2 |
Tier 2 |
$35.00 | $105.00 | P |
AMINOSYN II 3.5% IN D5W IV |
2 |
Tier 2 |
$35.00 | $105.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN II 3.5% M/D5W IV |
2 |
Tier 2 |
$35.00 | $105.00 | P |
AMINOSYN II 3.5% W/ELEC DEX |
2 |
Tier 2 |
$35.00 | $105.00 | P |
AMINOSYN II 4.25% IN D10W |
2 |
Tier 2 |
$35.00 | $105.00 | P |
AMINOSYN II 4.25% IN D20W |
2 |
Tier 2 |
$35.00 | $105.00 | P |
AMINOSYN II 4.25% W/ELEC DW |
2 |
Tier 2 |
$35.00 | $105.00 | P |
AMINOSYN II 4.25%-D25W IV |
2 |
Tier 2 |
$35.00 | $105.00 | P |
AMINOSYN II 5% IN D25W IV |
2 |
Tier 2 |
$35.00 | $105.00 | P |
AMINOSYN II 7% IV SOLUTION |
2 |
Tier 2 |
$35.00 | $105.00 | P |
AMINOSYN II 8.5% ELECTROLYT |
1 |
Tier 1 |
$0.00 | $0.00 | P |
AMINOSYN II 8.5% IV SOLUTION |
2 |
Tier 2 |
$35.00 | $105.00 | P |
AMINOSYN M 3.5% IV SOLUTION |
2 |
Tier 2 |
$35.00 | $105.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN PF INJECTION |
2 |
Tier 2 |
$35.00 | $105.00 | P |
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5% |
1 |
Tier 1 |
$0.00 | $0.00 | P |
AMINOSYN-HF 8% IV SOLUTION |
1 |
Tier 1 |
$0.00 | $0.00 | P |
AMINOSYN-PF 7% IV SOLUTION |
2 |
Tier 2 |
$35.00 | $105.00 | P |
AMIODARONE HCL 400MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMIODARONE HCL INJECTION |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMIODARONE HYDROCHLORIDE TABLETS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMITIZA 8MCG CAPSULE |
2 |
Tier 2 |
$35.00 | $105.00 | None |
AMITIZA CAPSULES 24MCG 60 CAP BOT |
2 |
Tier 2 |
$35.00 | $105.00 | None |
AMITRIP/CDP 25-10 TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMITRIP/PERPHEN 10-2 TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIP/PERPHEN 10-4 TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMITRIP/PERPHEN 25-2 TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMITRIP/PERPHEN 25-4 TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMITRIP/PERPHEN 50-4 TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMITRIPTYLINE HCL 100MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMITRIPTYLINE HCL 10MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMITRIPTYLINE HCL 150 MG TAB |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMLODIPINE 10 MG / HYDROCHLOROTHIAZIDE 12.5 MG / VALSARTAN 160 MG ORAL TABLET [EXFORGE HCT 10/160/12 |
2 |
Tier 2 |
$35.00 | $105.00 | Q:90 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE 10 MG / TELMISARTAN 40 MG ORAL TABLET [TWYNSTA 40/10] |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AMLODIPINE 10 MG / TELMISARTAN 80 MG ORAL TABLET [TWYNSTA 80/10] |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AMLODIPINE 5 MG / TELMISARTAN 40 MG ORAL TABLET [TWYNSTA 40/5] |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AMLODIPINE 5 MG / TELMISARTAN 80 MG ORAL TABLET [TWYNSTA 80/5] |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMMONIUM CHLORIDE 5 MEQ/ML |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AMMONIUM LACTATE 12% CREAM |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMMONIUM LACTATE 12% LOTION |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMMONIUM LACTATE 120 MG/ML TOPICAL CREAM [LAC-HYDRIN] |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AMMONIUM LACTATE 120 MG/ML TOPICAL LOTION [LAC-HYDRIN] |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AMNESTEEM 10MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMNESTEEM 20MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMNESTEEM 40MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOX TR-K CLV 500-125 MG TAB |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXAPINE 100MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXAPINE 150MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXAPINE 25MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXAPINE 50MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXICILLIN 125MG TABLET CHEW |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXICILLIN 200MG TABLET CHEW |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN 250MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXICILLIN 400MG TABLET CHEW |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXICILLIN 500MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXICILLIN 500MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXICILLIN 875MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P |
AMPHETAMINE SALT COMBO 15MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P |
AMPHETAMINE SALT COMBO 30MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P |
AMPHETAMINE SALTS 20MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P |
AMPHETAMINE SALTS 5 MG TAB |
1 |
Tier 1 |
$0.00 | $0.00 | P |
AMPHOTEC FOR INJECTION 50MG/VIAL |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AMPHOTERICIN B FOR INJECTION 50 MG |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMPICILLIN CAPSULES 250MG 100 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMPICILLIN FOR INJECTION POWDER |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMPYRA ER 10 MG TABLET |
4 |
Tier 4 |
33% | N/A | P Q:60 /30Days |
AMRIX 30MG CAPSULE SR 24 HR |
3 |
Tier 3 |
$75.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMRIX CAPSULES EXTENDED RELEASE 15MG 60 CAPSULES BOT |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AMYLASES 109000 UNT / ENDOPEPTIDASES 68000 UNT / LIPASE 20000 UNT ENTERIC COATED CAPSULE [ZENPEP 20] |
2 |
Tier 2 |
$35.00 | $105.00 | None |
AMYLASES 27000 UNT / ENDOPEPTIDASES 17000 UNT / LIPASE 5000 UNT ENTERIC COATED CAPSULE [ZENPEP 5] |
2 |
Tier 2 |
$35.00 | $105.00 | None |
AMYLASES 55000 UNT / ENDOPEPTIDASES 34000 UNT / LIPASE 10000 UNT ENTERIC COATED CAPSULE [ZENPEP 10] |
2 |
Tier 2 |
$35.00 | $105.00 | None |
AMYLASES 82000 UNT / ENDOPEPTIDASES 51000 UNT / LIPASE 15000 UNT ENTERIC COATED CAPSULE [ZENPEP 15] |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ANADROL-50 50MG TABLET (100 CT) |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ANAFRANIL 25MG CAPSULE |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ANAFRANIL 50MG CAPSULE |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ANAFRANIL 75MG CAPSULE |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ANAGRELIDE HCL 0.5MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ANAGRELIDE HCL 1MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANAPROX 275MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ANAPROX DS 550MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ANASTROZOLE TABLETS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ANCOBON 250MG CAPSULE |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ANCOBON 500MG CAPSULE |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ANDROGEL 1%(50MG) GEL PACKET |
2 |
Tier 2 |
$35.00 | $105.00 | P |
ANGELIQ 1-0.5MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ANIDULAFUNGIN 3.33 MG/ML INJECTABLE SOLUTION [ERAXIS] |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ANTABUSE 250MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ANTABUSE 500MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ANTARA CAPSULES |
3 |
Tier 3 |
$75.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANTARA CAPSULES |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ANTIVERT 12.5MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ANTIVERT 25MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ANTIVERT 50MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ANUSOL-HC 2.5% CREAM |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ANZEMET 100MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | P |
ANZEMET 20MG/ML VIAL |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ANZEMET 50MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | P |
APAP-CAFFEINE-DIHYDROCODE TAB 30 EA |
1 |
Tier 1 |
$0.00 | $0.00 | None |
APHTHASOL 5% PASTE |
3 |
Tier 3 |
$75.00 | $225.00 | None |
APIDRA 100UNITS/ML VIAL |
2 |
Tier 2 |
$35.00 | $105.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APOKYN 30 MG/3 ML CARTRIDGE |
4 |
Tier 4 |
33% | N/A | None |
APRACLONIDINE 5 MG/ML OPHTHALMIC SOLUTION |
1 |
Tier 1 |
$0.00 | $0.00 | None |
APRI 0.15-0.03 TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
APRISO CP24 |
3 |
Tier 3 |
$75.00 | $225.00 | None |
APTIVUS 250MG CAPSULE |
2 |
Tier 2 |
$35.00 | $105.00 | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ARALEN PHOSPHATE 500MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ARANELLE 7-9-5 TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ARANESP 100MCG/ML VIAL |
3 |
Tier 3 |
$75.00 | $225.00 | P |
ARANESP 200MCG/0.4ML SYRINGE |
3 |
Tier 3 |
$75.00 | $225.00 | P |
ARANESP 200MCG/ML VIAL |
3 |
Tier 3 |
$75.00 | $225.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP 25MCG/ML VIAL |
3 |
Tier 3 |
$75.00 | $225.00 | P |
ARANESP 300MCG/ML VIAL |
3 |
Tier 3 |
$75.00 | $225.00 | P |
ARANESP 500MCG/1ML SYRINGE |
3 |
Tier 3 |
$75.00 | $225.00 | P |
ARANESP 60MCG/ML VIAL |
3 |
Tier 3 |
$75.00 | $225.00 | P |
ARANESP PREFILLED SYRINGE SINGLE USE 100MCG/0.5ML 1 SYR |
3 |
Tier 3 |
$75.00 | $225.00 | P |
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR |
3 |
Tier 3 |
$75.00 | $225.00 | P |
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR |
3 |
Tier 3 |
$75.00 | $225.00 | P |
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR |
3 |
Tier 3 |
$75.00 | $225.00 | P |
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR |
3 |
Tier 3 |
$75.00 | $225.00 | P |
ARANESP PREFILLED SYRINGE SINGLE USE 60MCG/0.3ML 60MCG/ 0.3ML SYR |
3 |
Tier 3 |
$75.00 | $225.00 | P |
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD |
3 |
Tier 3 |
$75.00 | $225.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARAVA 10MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ARAVA 20MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ARCALYST INJECTION 220MG/VIAL |
4 |
Tier 4 |
33% | N/A | P |
AREDIA 30MG VIAL |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AREDIA 90MG VIAL |
4 |
Tier 4 |
33% | N/A | None |
ARICEPT 10MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ARICEPT 5MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ARICEPT ODT 10MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ARICEPT ODT 5MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ARICEPT TABLETS |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ARIMIDEX 1MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARIXTRA 10MG SYRINGE |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ARIXTRA 2.5MG SYRINGE |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ARIXTRA 5MG SYRINGE |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ARIXTRA 7.5MG SYRINGE |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ARMODAFINIL 150 MG ORAL TABLET [NUVIGIL] |
2 |
Tier 2 |
$35.00 | $105.00 | P Q:31 /30Days |
ARMODAFINIL 250 MG ORAL TABLET [NUVIGIL] |
2 |
Tier 2 |
$35.00 | $105.00 | P Q:31 /30Days |
ARMODAFINIL 50 MG ORAL TABLET [NUVIGIL] |
2 |
Tier 2 |
$35.00 | $105.00 | P Q:31 /30Days |
AROMASIN 25MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | None |
ARRANON 250MG VIAL |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ARTHROTEC 50 50MG TABLET -200MCG (60 CT) |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ARTHROTEC 75 TABLET EC |
3 |
Tier 3 |
$75.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARZERRA INJECTION 100MG/5ML |
4 |
Tier 4 |
33% | N/A | None |
ASACOL 400MG TABLET EC |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ASCOMP W/CODEINE 30-50-325 CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ASENAPINE 10 MG SUBLINGUAL TABLET [SAPHRIS] |
3 |
Tier 3 |
$75.00 | $225.00 | Q:62 /31Days |
ASENAPINE 5 MG SUBLINGUAL TABLET [SAPHRIS] |
3 |
Tier 3 |
$75.00 | $225.00 | Q:62 /31Days |
ASMANEX 220MCG(14) AEROSOL POWDER BREATH ACTIVATED |
2 |
Tier 2 |
$35.00 | $105.00 | Q:7 /25Days |
ASMANEX TWISTHALER 110 MCG #30 |
2 |
Tier 2 |
$35.00 | $105.00 | Q:30 /25Days |
ASMANEX TWISTHALER 220MCG #120 |
2 |
Tier 2 |
$35.00 | $105.00 | Q:58 /25Days |
ASMANEX TWISTHALER 220MCG #30 |
2 |
Tier 2 |
$35.00 | $105.00 | Q:15 /25Days |
ASMANEX TWISTHALER 220MCG #60 |
2 |
Tier 2 |
$35.00 | $105.00 | Q:29 /25Days |
ASTELIN 137MCG AEROSOL SPRAY W/PUMP |
2 |
Tier 2 |
$35.00 | $105.00 | Q:60 /25Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ASTEPRO 0.15% NASAL SPRAY 30 ML |
2 |
Tier 2 |
$35.00 | $105.00 | Q:60 /25Days |
ASTRAMORPH PF INJECTION |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ASTRAMORPH PF INJECTION 1MG/ML |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ATAMET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ATENOLOL 25MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ATENOLOL TABLET USP 50MG (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ATENOLOL TABLETS USP 100MG 1 BLPK |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ATGAM 50MG/ML AMPUL |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ATRALIN 0.05% GEL |
3 |
Tier 3 |
$75.00 | $225.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATRIPLA TABLET 600MG/200MG |
4 |
Tier 4 |
33% | N/A | None |
ATROPINE 0.025 MG / DIPHENOXYLATE 2.5 MG ORAL TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ATROPINE 0.025 MG / DIPHENOXYLATE 2.5 MG ORAL TABLET [LOMOTIL] |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ATROPINE 0.05MG/ML SYRINGE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ATROPINE 0.1MG/ML SYRINGE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ATROVENT HFA AER 17MCG |
2 |
Tier 2 |
$35.00 | $105.00 | Q:26 /25Days |
ATROVENT NASAL SPRAY 0.03% |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ATROVENT NASAL SPRAY 0.06% |
3 |
Tier 3 |
$75.00 | $225.00 | None |
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML |
2 |
Tier 2 |
$35.00 | $105.00 | None |
AVANDAMET 2MG/1000MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | None |
AVANDAMET 2MG/500MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVANDAMET 4MG/500MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | None |
AVANDAMET TABLET 4-1000MG |
2 |
Tier 2 |
$35.00 | $105.00 | None |
AVANDARYL 4MG/1MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | None |
AVANDARYL 4MG/2MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | None |
AVANDARYL 4MG/4MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | None |
AVANDARYL 8MG-2MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | None |
AVANDARYL 8MG-4MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | None |
AVANDIA 2MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | None |
AVANDIA 4MG TABLET (90 CT) |
2 |
Tier 2 |
$35.00 | $105.00 | None |
AVANDIA 8MG TABLET (90 CT) |
2 |
Tier 2 |
$35.00 | $105.00 | None |
AVASTIN 100MG/4ML VIAL |
4 |
Tier 4 |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVELOX 400MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | None |
AVELOX ABC PACK 400MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | None |
AVELOX IV 400MG/250ML |
2 |
Tier 2 |
$35.00 | $105.00 | None |
AVIANE 0.1-0.02 TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AVINZA 120MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
$35.00 | $105.00 | Q:60 /25Days |
AVINZA 30MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
$35.00 | $105.00 | Q:60 /25Days |
AVINZA 60MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
$35.00 | $105.00 | Q:60 /25Days |
AVINZA 90MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
$35.00 | $105.00 | Q:60 /25Days |
AVINZA CAPSULES EXTENDED RELEASE 45MG 100 BOTPL |
2 |
Tier 2 |
$35.00 | $105.00 | Q:60 /25Days |
AVINZA CAPSULES EXTENDED RELEASE 75MG 100 BOTPL |
2 |
Tier 2 |
$35.00 | $105.00 | Q:60 /25Days |
AVITA 0.025% CREAM |
1 |
Tier 1 |
$0.00 | $0.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVODART 0.5MG SOFTGEL |
2 |
Tier 2 |
$35.00 | $105.00 | None |
AVONEX ADMIN PACK 30MCG SYR |
4 |
Tier 4 |
33% | N/A | P |
AVONEX ADMIN PACK 30MCG VL |
4 |
Tier 4 |
33% | N/A | P |
AXERT 12.5MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | Q:12 /25Days |
AXERT 6.25MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | Q:12 /25Days |
AXID 150MG PULVULE |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AXID 15MG/ML ORAL SOLUTION |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AXID 300MG PULVULE |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AYGESTIN 5MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AZACTAM INJECTION |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AZACTAM INJECTION 1GM/50ML |
3 |
Tier 3 |
$75.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZACTAM INJECTION 2GM/VIL |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AZASAN 100MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | P |
AZASAN 75MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | P |
AZASITE 1% DROPS |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AZATHIOPRINE 50MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P |
AZATHIOPRINE SOD 100MG VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AZELASTINE 137 MCG NASAL SPRAY |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /25Days |
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AZELEX 20% CREAM 30GM TUBE |
2 |
Tier 2 |
$35.00 | $105.00 | None |
AZILECT 0.5MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | None |
AZILECT 1MG TABLET |
2 |
Tier 2 |
$35.00 | $105.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AZITHROMYCIN 250 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AZITHROMYCIN 33.3 MG/ML ER SUSPENSION [ZMAX] |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AZITHROMYCIN 500MG TABLET (30 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AZITHROMYCIN TABLETS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT |
2 |
Tier 2 |
$35.00 | $105.00 | None |
AZOR 10MG-20MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AZOR 10MG-40MG TABLET (30 CT) |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AZOR 5MG-20MG TABLET (30 CT) |
3 |
Tier 3 |
$75.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZOR 5MG-40MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AZTREONAM FOR INJECTION |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AZULFIDINE 500MG TABLET |
3 |
Tier 3 |
$75.00 | $225.00 | None |
AZULFIDINE EN TABLET S 500MG TABLET 6 X (300 CT)PL |
3 |
Tier 3 |
$75.00 | $225.00 | None |