2012 Medicare Part D Plan Formulary Information |
Medco Medicare Prescription Plan - Value (PDP) (S5660-125-0)
Benefit Details
|
The Medco Medicare Prescription Plan - Value (PDP) (S5660-125-0) Formulary Drugs Starting with the Letter P in CMS PDP Region 23 which includes: OK
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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 |
Preferred Brand Drugs |
25% | 25% | None |
PACERONE 200MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PACLITAXEL INJECTION SOLUTION 6MG 50ML VIALMD |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PALGIC 4MG/5ML LIQUID |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Pandel 1mg/g 45 g in 1 TUBE |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PANRETIN 0.1% GEL 60GM TUBE |
3 |
Preferred Brand Drugs |
25% | 25% | None |
Pantoprazole 40mg/1 90 TABLET, DELAYED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | Q:180 /90Days |
PANTOPRAZOLE SODIUM 20MG TABLET DELAYED RELEASE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | Q:180 /90Days |
PAROMOMYCIN 250MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PAROXETINE FILM COATED 20MG TABLET (100 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | Q:90 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAROXETINE HCL 10MG/5ML SUSPENSION ORAL |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
PAROXETINE HCL TABLET 24 12.5MG |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | Q:180 /90Days |
PAROXETINE HCL TABLET 24 25MG |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | Q:270 /90Days |
Paroxetine Hydrochloride 37.5mg/1 30 BOTTLE in 1 BOTTLE / 30 TABLET, FILM COATED, EXTENDED RELEASE |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | Q:180 /90Days |
PAROXETINE HYDROCHLORIDE TABLETS 10 MG |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | Q:180 /90Days |
PAROXETINE TABLETS 30MG 90 BOT |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | Q:180 /90Days |
PAROXETINE40mg/1 |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | Q:90 /90Days |
PASER GRANULES 4GM PACKET |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PATADAY 0.2% DROPS |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PATANOL 0.1% EYE DROPS |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PAXIL ORAL SUSPENSION 10 MG/5ML |
3 |
Preferred Brand Drugs |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEDI-DRI TOPICAL POWDER |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
PEDVAXHIB VACCINE VIAL |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PEGANONE 250MG TABLET |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PEGASYS 180MCG/0.5ML CONV.PK |
5 |
Specialty Tier Drugs |
25% | 25% | P |
PEGASYS INJECTION |
5 |
Specialty Tier Drugs |
25% | 25% | P |
PEGASYS PROCLICK 135 MCG/0.5 |
5 |
Specialty Tier Drugs |
25% | 25% | P |
PEGINTRON 1 KIT in 1 CARTON |
5 |
Specialty Tier Drugs |
25% | 25% | P |
PegIntron 120ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE |
5 |
Specialty Tier Drugs |
25% | 25% | P |
PegIntron 150ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE |
5 |
Specialty Tier Drugs |
25% | 25% | P |
PegIntron 50ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE |
5 |
Specialty Tier Drugs |
25% | 25% | P |
PegIntron 80ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE |
5 |
Specialty Tier Drugs |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENICILLIN G POTASSIUM 2MMUNITS/50ML ISO-OSM |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PENICILLIN G POTASSIUM 3MMUNITS/50ML ISO-OSM |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PENICILLIN G POTASSIUM FOR INJECTION 5000000UNIT/VIAL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PENICILLIN G PROCAINE 1200000UNT 2ML CTG |
3 |
Preferred Brand Drugs |
25% | 25% | None |
Penicillin G Sodium 5000000[iU]/1 10 VIAL in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PENICILLIN V POTASSIUM 250MG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
PENICILLIN V POTASSIUM 500MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
PENICILLIN V POTASSIUM FOR ORAL SOLUTION CONCENTRATE 125MG 200ML BOT |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
PENNSAID SOLUTION |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PENTASA 250MG CAPSULE SA |
3 |
Preferred Brand Drugs |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENTASA 500MG CAPSULE |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PENTOPAK 400MG TABLET SA |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PENTOSTATIN FOR INJECTION 10MG/VIAL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PENTOXIFYLLINE 400MG TABLET SA |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PERFOROMIST 20MCG/2ML VIAL NEBULIZER |
3 |
Preferred Brand Drugs |
25% | 25% | P |
Perindopril Erbumine 2mg/1 100 TABLET in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Perindopril Erbumine 4mg/1 100 TABLET in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Perindopril Erbumine 8mg/1 100 TABLET in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PERIOGARD 0.12% ORAL RINSE |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
Permethrin 50mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PERPHENAZINE 16 MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PERPHENAZINE TABLETS 4MG 100 BOXUD |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PERPHENAZINE TABLETS 8MG 100 BOT |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PERPHENAZINE TABLETS USP 2MG 100 BOT |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PFIZERPEN 20MMU VIAL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PHENADOZ 12.5MG SUPPOSITORY |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PHENADOZ 25MG SUPPOSITORY |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Phenelzine Sulfate 15mg/1 60 TABLET in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PHENYTOIN SOD EXT 200 MG CAP |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT) |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PHENYTOIN SODIUM INJECTION 50MG 25 X 2ML AMP |
3 |
Preferred Brand Drugs |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PHISOHEX 3% CLEANSER |
3 |
Preferred Brand Drugs |
25% | 25% | None |
Phoslyra 667mg/5mL 1 BOTTLE in 1 CARTON / 473 mL in 1 BOTTLE |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PILOCARPINE HCL 5MG TABLET (100 CT) |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Pilocarpine Hydrochloride 7.5mg/1 100 TABLET, FILM COATED in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PILOPINE HS 4% EYE GEL |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PINDOLOL 10MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
PINDOLOL 5MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
PIPERACILLIN 200 MG/ML / TAZOBACTAM 25 MG/ML INJECTABLE SOLUTION |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Piperacillin and Tazobactam 4; 0.5g/1; g/1 10 VIAL, SINGLE-USE in 1 CARTON / 1 INJECTION, POWDER, L |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PIROXICAM 10 MG CAPSULE |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
Piroxicam 20mg/1 500 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PLASMA-LYTE 148 IV SOLUTION |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PLASMA-LYTE 56/DEXTROSE 5% |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PLASMA-LYTE A PH 7.4 SOLUTION 37;368; MG/100ML; |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PLAVIX 75MG TABLET |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PLAVIX TABLETS 300MG |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PODOFILOX 0.5% TOPICAL TUBEX |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
POLY-DEX 0.1% SUSPENSION DROPS |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
POLY-DEX 3.5-10K-.1 OINTMENT |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT) |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
POLYETHYLENE GLYCOL 3350 105 MG/ML / POTASSIUM CHLORIDE 0.00497 MEQ/ML / SODIUM BICARBONATE 1.43 MG/ |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | Q:4000 /30Days |
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1% |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PORTIA 0.15-0.03 TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
POTASSIUM CHLORIDE 0.075%/D5W/SODIUM CHLORIDE 0.2% |
3 |
Preferred Brand Drugs |
25% | 25% | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.3% |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45% |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.9% 1000ML |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.2% |
3 |
Preferred Brand Drugs |
25% | 25% | None |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
POTASSIUM CHLORIDE 10MEQ/100ML SOL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
POTASSIUM CHLORIDE 10MEQ/50ML SOL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
POTASSIUM CHLORIDE 149mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 5 mL in 1 VIAL, SINGLE-DOSE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Potassium Chloride 20.000000meq/1 |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE 20MEQ IN D5W/NACL 0.225% |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
POTASSIUM CHLORIDE 20MEQ/50ML SOL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
POTASSIUM CHLORIDE 30MEQ/100ML SOL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
POTASSIUM CHLORIDE 40MEQ IN D5W/NACL 0.9% |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
POTASSIUM CHLORIDE 40MEQ/NS 1000ML IV SOLUTION |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
POTASSIUM CHLORIDE ER CAPSULES 10MEQ |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
POTASSIUM CHLORIDE ER CPCR 8MEQ |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
POTASSIUM CHLORIDE EXTENDED RELEASE TABLETS |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
POTASSIUM CHLORIDE IN 10% DEXTROSE AND NACL SOLUTION FOR INJECTION |
3 |
Preferred Brand Drugs |
25% | 25% | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
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 |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE INJECTION 40 12 X 1000ML CTR |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Potassium Chloride in Lactated Ringers and Dextrose 20; 5; 179; 600; 310mg/100mL; g/100mL; mg/100mL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION 0.15%-0.9% 12 X 1000ML BAG |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
POTASSIUM CITRATE 10MEQ TABLET SA |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
POTASSIUM CITRATE 5MEQ TABLET SA |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
POTIGA 200 MG TABLET |
4 |
Non-Preferred Brand Drugs |
40% | 40% | None |
POTIGA 300 MG TABLET |
4 |
Non-Preferred Brand Drugs |
40% | 40% | None |
POTIGA 400 MG TABLET |
4 |
Non-Preferred Brand Drugs |
40% | 40% | None |
POTIGA 50 MG TABLET |
4 |
Non-Preferred Brand Drugs |
40% | 40% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRADAXA 150mg/1 1 BOTTLE in 1 CARTON / 60 CAPSULE in 1 BOTTLE |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PRADAXA 75mg/1 1 BOTTLE in 1 CARTON / 60 CAPSULE in 1 BOTTLE |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PRAMIPEXOLE 0.125 MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PRAMIPEXOLE 0.25 MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PRAMIPEXOLE 0.5 MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PRAMIPEXOLE 1 MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PRAMIPEXOLE 1.5 MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PRAMIPEXOLE DIHYDROCHLORIDE TABLETS |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PRANDIN 0.5MG TABLET |
3 |
Preferred Brand Drugs |
25% | 25% | Q:360 /90Days |
PRANDIN 1MG TABLET |
3 |
Preferred Brand Drugs |
25% | 25% | Q:360 /90Days |
PRANDIN 2MG TABLET |
3 |
Preferred Brand Drugs |
25% | 25% | Q:720 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAVASTATIN SODIUM 20MG TABLET 500 BOT |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | Q:90 /90Days |
PRAVASTATIN SODIUM 40MG TABLET (500 CT) |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | Q:180 /90Days |
PRAVASTATIN SODIUM 80MG TABLET (90 CT) |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | Q:90 /90Days |
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | Q:90 /90Days |
PRAZOSIN 5MG CAPSULE |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | Q:360 /90Days |
PRAZOSIN HCL 1MG CAPSULE |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | Q:360 /90Days |
PRAZOSIN HCL 2MG CAPSULE |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | Q:360 /90Days |
PREDNICARBATE 0.1% OINTMENT |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PREDNICARBATE 1 MG/ML TOPICAL CREAM |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PREDNISOLONE SOD 1% EYE DROP |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | P |
PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | P |
PREDNISONE 10MG TABLET (100 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | P |
PREDNISONE 1MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | P |
PREDNISONE 2.5MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | P |
PREDNISONE 20MG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | P |
PREDNISONE 5 MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | P |
PREDNISONE 50MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | P |
PREDNISONE 5MG/5ML SOLUTION |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | P |
PREDNISONE 5MG/ML SOLUTION |
3 |
Preferred Brand Drugs |
25% | 25% | P |
Prefest 6 POUCH in 1 CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER PACK |
4 |
Non-Preferred Brand Drugs |
40% | 40% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREMARIN 0.3MG (100 CT) |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PREMARIN 0.45MG TABLET |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PREMARIN 0.625MG (100 CT) |
3 |
Preferred Brand Drugs |
25% | 25% | None |
Premarin 0.625mg/g |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PREMARIN 0.9MG TABLET |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PREMARIN 1.25MG (100 CT) |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PREMASOL 10% IV SOLUTION |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PREMASOL 6% IV SOLUTION |
3 |
Preferred Brand Drugs |
25% | 25% | None |
Premphase 1 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PREMPRO 0.45-1.5 MG TABLET 28 EA |
3 |
Preferred Brand Drugs |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Prempro 0.625; 2.5mg/1; mg/1 1 BLISTER PACK in 1 CARTON / 28 TABLET, SUGAR COATED in 1 BLISTER PACK |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PREVALITE POW 4GM |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Previfem 6 BLISTER PACK in 1 BLISTER PACK / 1 KIT in 1 BLISTER PACK |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PREVPAC (TRIPLE THERAPY) KIT 30;500;500MG;MG;MG; 14 PKGCOM |
4 |
Non-Preferred Brand Drugs |
40% | 40% | None |
PREZISTA TABLET 600MG |
5 |
Specialty Tier Drugs |
25% | 25% | None |
PREZISTA TABLET 75MG |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PREZISTA TABLETS |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PREZISTA TABLETS 400MG 60 TABLETS BOT |
5 |
Specialty Tier Drugs |
25% | 25% | None |
PRIMAQUINE 26.3MG TABLET |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PRIMAXIN I.M. 500MG VIAL |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PRIMAXIN IV 250MG VIAL |
3 |
Preferred Brand Drugs |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRIMAXIN IV 500; 500mg/100mL; mg/100mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 100 mL in 1 VIAL, SINGLE-DOS |
3 |
Preferred Brand Drugs |
25% | 25% | None |
Primidone 250mg/1 100 TABLET in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Primidone 50mg/1 500 TABLET in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PRIMSOL 50MG/5ML ORAL SOLUTION |
4 |
Non-Preferred Brand Drugs |
40% | 40% | None |
PRISTIQ 100MG TABLET SR 24HR |
3 |
Preferred Brand Drugs |
25% | 25% | Q:90 /90Days |
Pristiq Extended-Release 50mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
3 |
Preferred Brand Drugs |
25% | 25% | Q:90 /90Days |
PRIVIGEN 10% VIAL |
5 |
Specialty Tier Drugs |
25% | 25% | P |
PROAIR HFA 90MCG HFA AEROSOL WITH ADAPTER |
3 |
Preferred Brand Drugs |
25% | 25% | Q:51 /90Days |
PROBENECID 500MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PROBENECID/COLCHICINE TABLET S |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PROCAINAMIDE 100MG/ML VIAL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCAINAMIDE 500MG/ML VIAL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PROCRIT 10000U/ML VIAL |
3 |
Preferred Brand Drugs |
25% | 25% | P Q:36 /90Days |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL |
3 |
Preferred Brand Drugs |
25% | 25% | P Q:36 /90Days |
PROCRIT 3000U/ML VIAL |
3 |
Preferred Brand Drugs |
25% | 25% | P Q:36 /90Days |
PROCRIT 40000U/ML VIAL PR |
3 |
Preferred Brand Drugs |
25% | 25% | P Q:18 /90Days |
PROCRIT 4000U/ML VIAL 25 X 1ML VIAL |
3 |
Preferred Brand Drugs |
25% | 25% | P Q:36 /90Days |
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY |
3 |
Preferred Brand Drugs |
25% | 25% | P Q:36 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCTO-PAK 1% CREAM |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
PROCTOSOL-HC 2.5% CREAM |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
PROCTOZONE-HC 2.5% CREAM |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
PROGESTERONE 100 MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PROGESTERONE 200 MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Proglycem 50mg/mL 1 BOTTLE, DROPPER in 1 BOX / 30 mL in 1 BOTTLE, DROPPER |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PROGRAF 5MG/ML AMPULE |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PROLASTIN 500MG VIAL |
5 |
Specialty Tier Drugs |
25% | 25% | None |
PROLASTIN-C 1 KIT in 1 CARTON |
5 |
Specialty Tier Drugs |
25% | 25% | None |
PROLEUKIN 1.1mg/mL 1 VIAL, SINGLE-USE in 1 BOX / 1 mL in 1 VIAL, SINGLE-USE |
5 |
Specialty Tier Drugs |
25% | 25% | None |
PROLIA INJECTION |
4 |
Non-Preferred Brand Drugs |
40% | 40% | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMACTA 12.5 MG TABLET |
5 |
Specialty Tier Drugs |
25% | 25% | P |
PROMACTA 25 MG TABLET |
5 |
Specialty Tier Drugs |
25% | 25% | P Q:270 /90Days |
PROMACTA 50 MG TABLET |
5 |
Specialty Tier Drugs |
25% | 25% | P Q:90 /90Days |
PROMACTA 75 MG TABLET |
5 |
Specialty Tier Drugs |
25% | 25% | P Q:90 /90Days |
PROMETHAZINE 50MG/ML VIAL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PROMETHAZINE HCL 25MG TABLET (1000 CT) |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PROMETHAZINE HCL 50MG TABLET (100 CT) |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PROMETHAZINE HCL 6.25MG/5ML SYRUP |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PROMETHAZINE HCL INJECTION 25MG 10 X 1ML VIAL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Promethazine Hydrochloride 12.5mg/1 100 TABLET in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PROMETHEGAN 25MG SUPP |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PROMETHEGAN 50MG SUPPOS |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PROMETRIUM 100MG CAPSULE |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PROMETRIUM 200MG CAPSULE |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PROPAFENONE HCL 150MG TABLET (100 CT) |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PROPAFENONE HCL 225MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PROPAFENONE HCL 300MG TABLET (100 CT) |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Propafenone Hydrochloride 225mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Propantheline Bromide 15mg/1 100 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PROPRANOLOL 20MG/5ML TUBEX |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
PROPRANOLOL 40MG/5ML TUBEX |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
PROPRANOLOL 60MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
PROPRANOLOL 80 MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
PROPRANOLOL HCL 20MG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
PROPRANOLOL HCL INJECTION 1MG 10 PKG OF 10 CRTN |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
PROPRANOLOL HCL TABLET USP 10MG (1000 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
PROPRANOLOL HCL TABLET USP 40MG (1000 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
Propranolol Hydrochloride 120mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
Propranolol Hydrochloride 160mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Propranolol Hydrochloride 60mg/1 1000 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
Propranolol Hydrochloride 80mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
PROPRANOLOL/HCTZ 40/25 TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PROPRANOLOL/HCTZ 80/25 TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PROPYLTHIOURACIL 50MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PROQUAD VIAL |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PROTOPIC 0.03% OINTMENT 100GM TUBE |
4 |
Non-Preferred Brand Drugs |
40% | 40% | None |
PROTOPIC 0.1% OINTMENT 60GM TUBE |
4 |
Non-Preferred Brand Drugs |
40% | 40% | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PROVIGIL 100MG TABLET |
3 |
Preferred Brand Drugs |
25% | 25% | P Q:90 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROVIGIL 200MG TABLET |
3 |
Preferred Brand Drugs |
25% | 25% | P Q:90 /90Days |
PULMICORT 1MG/2ML AMPUL FOR NEBULIZATION |
3 |
Preferred Brand Drugs |
25% | 25% | P |
PULMOZYME 1MG/ML AMPUL |
5 |
Specialty Tier Drugs |
25% | 25% | P |
PYLERA 125-125MG CAPSULE |
3 |
Preferred Brand Drugs |
25% | 25% | None |
PYRAZINAMIDE 500MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
PYRIDOSTIGMINE BROMIDE 60MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |