2011 Medicare Part D Plan Formulary Information |
EnvisionRxPlus Gold (PDP) (S7694-065-0)
Benefit Details
|
The EnvisionRxPlus Gold (PDP) (S7694-065-0) Formulary Drugs Starting with the Letter A in CMS PDP Region 31 which includes: ID UT
|
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 |
ABILIFY 10MG TABLET |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
ABILIFY 15MG TABLET |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
ABILIFY 1MG/ML SOLUTION |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
ABILIFY 20MG TABLET |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
ABILIFY 2MG TABLET |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
ABILIFY 30MG TABLET |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
ABILIFY 5MG TABLET (OTSUKA) |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
ABILIFY DISCMELT 10MG TABLET |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
ABILIFY DISCMELT 15MG TABLET |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
ABILIFY INJ 9.75MG |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACARBOSE 100MG TABLET S |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ACARBOSE 50MG TABLET S |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ACARBOSE TABLETS |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ACCOLATE 10MG TABLET |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
ACCOLATE 20MG TABLET |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
ACEBUTOLOL 200MG CAPSULE |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ACEBUTOLOL 400MG CAPSULE |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ACETASOL HC SOLUTION 10ML 10 ML BOT |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
ACETAZOLAMIDE 125MG TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
ACETIC ACID 2% SOLUTION NON-ORAL |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ACTHIB VACCINE VIAL 10-24UNT/5ML |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
ACTICIN 5% CREAM |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ACTIMMUNE SOLUTION FOR INJECTION 100MCG |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
ACTOPLUS MET 15MG/500MG TABLET |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
ACTOPLUS MET 15MG/850MG TABLET |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTOS 15MG TABLET |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
ACTOS 30MG TABLET (500 CT) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
ACTOS 45MG TABLET |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
ACYCLOVIR 200MG CAPSULE (1000 CT) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ACYCLOVIR 200MG/5ML SUSP |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ACYCLOVIR 400MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ACYCLOVIR 800 MG ORAL TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ACYCLOVIR SODIUM 500MG VIAL |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ADACEL VIAL 2UNT/5UNT |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
ADAGEN 250U/ML VIAL |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA] |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADVAIR DISKU MIS 100/50 |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
ADVAIR DISKU MIS 250/50 |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
ADVAIR DISKU MIS 500/50 |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
ADVAIR HFA INHALER 230;21MCG;MCG |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
AFEDITAB CR 30MG TABLET SA |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AFEDITAB CR 60MG TABLET SA |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AFINITOR TABLETS |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
AFINITOR TABLETS |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
AFINITOR TABLETS 5 MG |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AGGRENOX 25-200MG CAPSULE |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
AK-CON 0.1% EYE DROPS |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AKTOB 0.3% EYE DROPS |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ALA-CORT 1% CREAM |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ALA-CORT 1% LOTION |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | P |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | P |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | P |
ALBUTEROL SULFATE SOLUTION FOR INHALATION |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ALBUTEROL TABLET 4MG (500 CT) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ALCLOMETASONE DIPROPIONATE 0.05% CREAM |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ALCOHOL 5%/DEXTROSE 5% |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ALDURAZYME 2.9MG/5ML VIAL |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
ALENDRONATE SODIUM 10MG TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ALENDRONATE SODIUM 40MG TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ALENDRONATE SODIUM 5MG TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ALENDRONATE SODIUM TABLET 35MG 20 CRTN |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALENDRONATE SODIUM TABLETS 70 MG |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ALIMTA 500MG VIAL |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
ALLEGRA-D 24 HOUR TABLET |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
ALLOPURINOL SODIUM 500MG VIAL |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ALLOPURINOL TABLET 300MG (1000 CT) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ALLOPURINOL TABLETS |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMANTADINE 100MG CAPSULE |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMANTADINE 100MG TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMANTADINE HCL 50 MG/ 5 ML SYRUP |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMCINONIDE 0.1% CREAM |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMCINONIDE 0.1% LOTION |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMCINONIDE 0.1% OINTMENT 60GM TUBE |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMIFOSTINE FOR INJECTION 500MG/VIAL |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMINOPHYLLINE 100MG TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMINOPHYLLINE 200MG TABLET (1000 CT) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMINOSYN 10% IV SOLUTION |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | P |
AMINOSYN 3.5% IV SOLUTION |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | P |
AMINOSYN 5% IV SOLUTION |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | P |
AMINOSYN 7% IV SOLUTION |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN 7%-ELECTROLYTE SOL |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | P |
AMINOSYN 8.5% IV SOLUTION |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | P |
AMINOSYN HBC INJECTION SULFITE FREE 7% |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | P |
AMINOSYN II 10% IV SOLUTION |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | P |
AMINOSYN II 3.5% IN D25W IV |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | P |
AMINOSYN II 3.5% IN D5W IV |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | P |
AMINOSYN II 3.5% M/D5W IV |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
AMINOSYN II 3.5% W/ELEC DEX |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | P |
AMINOSYN II 4.25% IN D10W |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | P |
AMINOSYN II 4.25% IN D20W |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | P |
AMINOSYN II 4.25% W/ELEC DW |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN II 4.25%-D25W IV |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | P |
AMINOSYN II 5% IN D25W IV |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | P |
AMINOSYN II 7% IV SOLUTION |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | P |
AMINOSYN II 8.5% ELECTROLYT |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | P |
AMINOSYN II 8.5% IV SOLUTION |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | P |
AMINOSYN M 3.5% IV SOLUTION |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | P |
AMINOSYN PF INJECTION |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | P |
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5% |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | P |
AMINOSYN-HF 8% IV SOLUTION |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | P |
AMINOSYN-PF 7% IV SOLUTION |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | P |
AMIODARONE HCL 400MG TABLET |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMIODARONE HCL INJECTION |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMIODARONE HYDROCHLORIDE TABLETS |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
AMITIZA 8MCG CAPSULE |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | S |
AMITIZA CAPSULES 24MCG 60 CAP BOT |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | S |
AMITRIP/CDP 25-10 TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMITRIP/PERPHEN 10-2 TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMITRIP/PERPHEN 10-4 TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMITRIP/PERPHEN 25-2 TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMITRIP/PERPHEN 25-4 TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMITRIP/PERPHEN 50-4 TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMITRIPTYLINE HCL 100MG TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIPTYLINE HCL 10MG TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMITRIPTYLINE HCL 150 MG TAB |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMOX TR-K CLV 500-125 MG TAB |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMOXAPINE 100MG TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMOXAPINE 150MG TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMOXAPINE 25MG TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMOXAPINE 50MG TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN 125MG TABLET CHEW |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMOXICILLIN 200MG TABLET CHEW |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMOXICILLIN 250MG CAPSULE |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMOXICILLIN 400MG TABLET CHEW |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMOXICILLIN 500MG CAPSULE |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMOXICILLIN 500MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMOXICILLIN 875MG TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | 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 Preferred Generics |
$4.00 | $12.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMPHETAMINE SALT COMBO 15MG TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMPHETAMINE SALT COMBO 30MG TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMPHETAMINE SALTS 20MG TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMPHETAMINE SALTS 5 MG TAB |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMPICILLIN CAPSULES 250MG 100 BOT |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN FOR INJECTION POWDER |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
AMPYRA ER 10 MG TABLET |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
ANADROL-50 50MG TABLET (100 CT) |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
ANASTROZOLE TABLETS |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
ANCOBON 250MG CAPSULE |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
ANCOBON 500MG CAPSULE |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
ANDRODERM 2.5MG/24HR PATCH |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANDRODERM 5MG/24HR PATCH |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
ANIDULAFUNGIN 3.33 MG/ML INJECTABLE SOLUTION [ERAXIS] |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
ANTABUSE 250MG TABLET |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
ANTABUSE 500MG TABLET |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
APIDRA 100UNITS/ML VIAL |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
APLENZIN TABLETS EXTENDED RELEASE 348 MG |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
APLENZIN TABLETS EXTENDED RELEASE 522 MG |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
APOKYN 30 MG/3 ML CARTRIDGE |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
APRISO CP24 |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
APTIVUS 250MG CAPSULE |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARCALYST INJECTION 220MG/VIAL |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
ARICEPT 10MG TABLET |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
ARICEPT 5MG TABLET |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
ARICEPT ODT 10MG TABLET |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
ARICEPT ODT 5MG TABLET |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
ARICEPT TABLETS |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
ARIMIDEX 1MG TABLET |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
ARIXTRA 10MG SYRINGE |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
ARIXTRA 2.5MG SYRINGE |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
ARIXTRA 5MG SYRINGE |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
ARIXTRA 7.5MG SYRINGE |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AROMASIN 25MG TABLET |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
ARZERRA INJECTION 100MG/5ML |
5 |
Tier 5 Specialty Drugs |
25% | N/A | P |
ASACOL 400MG TABLET EC |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
ASACOL HD DELAYED RELEASE TABLETS 800MG 180 BOT |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
ASCOMP W/CODEINE 30-50-325 CAPSULE |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ASENAPINE 10 MG SUBLINGUAL TABLET [SAPHRIS] |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
ASENAPINE 5 MG SUBLINGUAL TABLET [SAPHRIS] |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
ASTEPRO 0.15% NASAL SPRAY 30 ML |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
ASTRAMORPH PF INJECTION |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ASTRAMORPH PF INJECTION 1MG/ML |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ATENOLOL 25MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATENOLOL TABLET USP 50MG (100 CT) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ATENOLOL TABLETS USP 100MG 1 BLPK |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ATGAM 50MG/ML AMPUL |
5 |
Tier 5 Specialty Drugs |
25% | N/A | P |
ATRIPLA TABLET 600MG/200MG |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
ATROPINE 0.025 MG / DIPHENOXYLATE 2.5 MG ORAL TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ATROPINE 0.05MG/ML SYRINGE |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ATROPINE 0.1MG/ML SYRINGE |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
ATROVENT HFA AER 17MCG |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVANDAMET 2MG/1000MG TABLET |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
AVANDAMET 2MG/500MG TABLET |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
AVANDAMET 4MG/500MG TABLET |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
AVANDAMET TABLET 4-1000MG |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
AVANDARYL 4MG/1MG TABLET |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
AVANDARYL 4MG/2MG TABLET |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
AVANDARYL 4MG/4MG TABLET |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
AVANDARYL 8MG-2MG TABLET |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
AVANDARYL 8MG-4MG TABLET |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
AVANDIA 2MG TABLET |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
AVANDIA 4MG TABLET (90 CT) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVANDIA 8MG TABLET (90 CT) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
AVASTIN 100MG/4ML VIAL |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
AVODART 0.5MG SOFTGEL |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
AVONEX ADMIN PACK 30MCG SYR |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
AVONEX ADMIN PACK 30MCG VL |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
AZACTAM INJECTION |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
AZACTAM INJECTION 1GM/50ML |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
AZACTAM INJECTION 2GM/VIL |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
AZATHIOPRINE 50MG TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | P |
AZELASTINE 137 MCG NASAL SPRAY |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZILECT 0.5MG TABLET |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
AZILECT 1MG TABLET |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AZITHROMYCIN 250 MG TABLET |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AZITHROMYCIN 500MG TABLET (30 CT) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
AZITHROMYCIN TABLETS |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
AZTREONAM FOR INJECTION |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |