2012 Medicare Part D Plan Formulary Information |
Rite Aid EnvisionRxPlus (PDP) (S7694-076-0)
Benefit Details
|
The Rite Aid EnvisionRxPlus (PDP) (S7694-076-0) Formulary Drugs Starting with the Letter C in CMS PDP Region 5 which includes: DC DE MD
|
Drugs Starting with Letter C
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
CALCIPOTRIENE TOPICAL SOLUTION |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY |
2 |
Non-Preferred Generic Drugs |
20% | 20% | P |
CALCITRIOL 0.25MCG CAPSULE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | P |
CALCITRIOL 0.5MCG CAPSULE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | P |
CALCITRIOL 1MCG/ML SOLUTION ORAL |
2 |
Non-Preferred Generic Drugs |
20% | 20% | P |
CALCITRIOL INJ 1MCG/ML |
2 |
Non-Preferred Generic Drugs |
20% | 20% | P |
CALCIUM ACETATE CAPSULE 667 MG |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CAMPATH INJECTION 30 MG/ML |
5 |
Specialty Tier Drugs |
33% | N/A | None |
CAPASTAT SULFATE 1g/1 1 INJECTION, POWDER, FOR SOLUTION in 1 CARTON |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
CAPRELSA 100mg/1 30 TABLET in 1 BOTTLE, PLASTIC |
5 |
Specialty Tier Drugs |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAPRELSA 300mg/1 30 TABLET in 1 BOTTLE, PLASTIC |
5 |
Specialty Tier Drugs |
33% | N/A | None |
CAPTOPRIL 100MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CAPTOPRIL 12.5MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CAPTOPRIL 25MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CAPTOPRIL 50MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
Captopril and Hydrochlorothiazide 25; 15mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
Captopril and Hydrochlorothiazide 25; 25mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
Captopril and Hydrochlorothiazide 50; 15mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
Captopril and Hydrochlorothiazide 50; 25mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CARAFATE SUS 1GM/10ML |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
Carbaglu 200mg/1 5 TABLET in 1 BOTTLE |
5 |
Specialty Tier Drugs |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Carbamazepine 100mg/1 100 TABLET, CHEWABLE in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Carbamazepine 100mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Carbamazepine 200mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Carbamazepine 300mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CARBAMAZEPINE EXTENDED RELEASE TABLETS 200MG |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CARBAMAZEPINE EXTENDED RELEASE TABLETS 400MG |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CARBAMAZEPINE ORAL SUSPENSION 100 MG/5ML |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CARBAMAZEPINE TABLET USP 200MG (1000 CT) |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Carbatrol 100mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
CARBATROL 200MG CAPSULE SA |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
CARBATROL 300MG CAPSULE SA |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Carbidopa and Levodopa 25; 100mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Carbidopa and Levodopa 50; 200mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;100MG;MG 100 BOT |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;250MG;MG 100 BOT |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CARBIDOPA/LEVO 10/100 TABLET |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CARBIDOPA/LEVO 25/100 TABLET |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CARBIDOPA/LEVO 25/250 TABLET |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CARIMUNE NF 3GM VIAL |
5 |
Specialty Tier Drugs |
33% | N/A | P |
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CARTIA XT 120MG CAPSULE SA |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARTIA XT 180MG CAPSULE SA |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CARTIA XT 240MG CAPSULE SA |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CARTIA XT 300MG CAPSULE SR 24 HR |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Carvedilol 12.5mg/1 |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
Carvedilol 25mg/1 |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
Carvedilol 3.125mg/1 |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
Carvedilol 6.25mg/1 500 TABLET, FILM COATED in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CAYSTON KIT |
5 |
Specialty Tier Drugs |
33% | N/A | None |
CEENU 100MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
CEENU 10MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
CEENU 40MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFACLOR CAPSULES |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CEFACLOR CAPSULES |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CEFACLOR ER 500MG TABLET SR 12HR |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
Cefazolin 1g/1 |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CEFAZOLIN 1GM/D5W BAG |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CEFAZOLIN FOR INJECTION |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CEFDINIR CAPSULES 300MG (60 CT) |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CEFEPIME HCL 2 GRAM VIAL |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Cefoxitin 1g/1 10 POWDER in 1 CARTON |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Cefoxitin 2g/1 10 POWDER in 1 CARTON |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CEFOXITIN FOR INJECTION SOLUTION |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Cefpodoxime Proxetil 100mg/5mL 1 BOTTLE in 1 CARTON / 100 mL in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Cefpodoxime Proxetil 50mg/5mL 1 BOTTLE in 1 CARTON / 100 mL in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT) |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CEFPODOXIME TAB 200MG |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CEFTRIAXONE 10GM VIAL |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CEFTRIAXONE FOR INJECTION 250MG BOX OF 10 VIALGL |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Ceftriaxone Sodium 500mg/1 |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFUROXIME 250MG TABLET |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CEFUROXIME AXETIL 125MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CEFUROXIME AXETIL 500MG TABLET (20 CT) |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CEFUROXIME FOR INJECTION |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CEFUROXIME FOR INJECTION |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CEFUROXIME FOR INJECTION |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CELEBREX 100MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
CELEBREX 200MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
CELEBREX 400MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
CELEBREX 50MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
CELLCEPT 200MG/ML ORAL SUSP |
3 |
Preferred Brand Drugs |
15% | 15% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CELLCEPT IV INJ 500MG |
3 |
Preferred Brand Drugs |
15% | 15% | P |
CELONTIN 300MG KAPSEAL |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
Cephalexin 125mg/5mL 200 mL in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CEPHALEXIN 250MG CAPSULE |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CEPHALEXIN 250MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CEPHALEXIN 250MG/5ML ORAL SUSP |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CEPHALEXIN 500MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CEPHALEXIN CAPSULES 500MG (500 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CEREDASE 80UNITS/ML VIAL |
5 |
Specialty Tier Drugs |
33% | N/A | None |
CEREZYME INJ 200UNIT |
5 |
Specialty Tier Drugs |
33% | N/A | None |
CETIRIZINE HCL 5MG/5ML |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHANTIX 0.5MG TABLET |
4 |
Non-Preferred Brand Drugs |
30% | 30% | Q:11 /30Days |
CHANTIX 1MG TABLET |
4 |
Non-Preferred Brand Drugs |
30% | 30% | Q:180 /90Days |
CHANTIX STARTING MONTH PAK |
4 |
Non-Preferred Brand Drugs |
30% | 30% | Q:53 /30Days |
CHLORDIAZEPOXIDE AND AMITRIPTYLINE HCL TABLET 12.5-5MG (500 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CHLOROQUINE PH 500MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CHLOROQUINE PHOSPHATE 250MG TABLET (50 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CHLOROTHIAZIDE 250MG TABLET |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CHLOROTHIAZIDE 500MG TABLET |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CHLORPROMAZINE 10MG TABLET |
2 |
Non-Preferred Generic Drugs |
20% | 20% | P |
CHLORPROMAZINE 25MG TABLET |
2 |
Non-Preferred Generic Drugs |
20% | 20% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLORPROMAZINE 25MG/ML AMP |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | P |
CHLORPROMAZINE 50MG TABLET |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CHLORPROMAZINE HCL 200MG TABLET |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Chlorpromazine Hydrochloride 100mg/1 1000 TABLET, SUGAR COATED in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CHLORTHALIDONE 25MG TABLET (100 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CHLORTHALIDONE 50MG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CHORIONIC GONAD 10000U VIAL |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Cialis 2.5mg/1 2 BLISTER PACK in 1 CARTON / 15 TABLET, FILM COATED in 1 BLISTER PACK |
4 |
Non-Preferred Brand Drugs |
30% | 30% | P |
Cialis 5mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
30% | 30% | P |
Ciclopirox 7.7mg/mL 60 mL in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6ML BOT |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CICLOPIROX GEL |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Ciclopirox Olamine 7.7mg/g 1 TUBE in 1 TUBE / 15 g in 1 TUBE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CILOSTAZOL 50 MG TABLET |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CILOSTAZOL TABLET 100MG (60 CT) |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CIPROFLOXACIN 0.3% EYE DROP |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CIPROFLOXACIN 250MG TABLET (100 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
Ciprofloxacin 400mg/40mL 1 VIAL in 1 CARTON / 40 mL in 1 VIAL |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CIPROFLOXACIN 500MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
Ciprofloxacin ER 212.6; 287.5mg/1; mg/1 50 TABLET, FILM COATED, in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Ciprofloxacin ER 425.2; 574.9mg/1; mg/1 50 TABLET, FILM COATED, in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CIPROFLOXACIN HCL 100MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIPROFLOXACIN TABLETS 750MG 100 BOT |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CITALOPRAM HBR 20 MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CITOLOPRAM HBR 10MG TABLET (100 CT) |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CLARAVIS 10MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CLARAVIS 20MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Claravis 30mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CLARAVIS 40MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CLEMASTINE FUMARATE SYRUP |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CLINDAMYCIN 150MG/ML ADDVAN |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINDAMYCIN HCL 150MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CLINDAMYCIN HYDROCHLORIDE CAPSULES |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CLINDAMYCIN PHOSP 1% LOTION |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
clindamycin phosphate 10mg/mL 1 BOTTLE in 1 CARTON / 60 mL in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Clindamycin Phosphate and Benzoyl Peroxide 1 KIT |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CLINIMIX 2.75%/5% INJECTION 1000ML BAG |
4 |
Non-Preferred Brand Drugs |
30% | 30% | P |
CLINIMIX 4.25/10 SOLUTION |
4 |
Non-Preferred Brand Drugs |
30% | 30% | P |
CLINIMIX 4.25/20 SOLUTION |
4 |
Non-Preferred Brand Drugs |
30% | 30% | P |
CLINIMIX 4.25/25 SOLUTION |
4 |
Non-Preferred Brand Drugs |
30% | 30% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINIMIX 4.25/5 SOLUTION |
4 |
Non-Preferred Brand Drugs |
30% | 30% | P |
CLINIMIX 5/15 SOLUTION |
4 |
Non-Preferred Brand Drugs |
30% | 30% | P |
CLINIMIX 5/20 SOLUTION |
4 |
Non-Preferred Brand Drugs |
30% | 30% | P |
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG |
4 |
Non-Preferred Brand Drugs |
30% | 30% | P |
CLINIMIX E 2.75/10 SOLUTION |
4 |
Non-Preferred Brand Drugs |
30% | 30% | P |
CLINIMIX E 2.75/5 SOLUTION |
4 |
Non-Preferred Brand Drugs |
30% | 30% | P |
CLINIMIX E 4.25/25 SOLUTION |
4 |
Non-Preferred Brand Drugs |
30% | 30% | P |
CLINIMIX E 4.25/5 SOLUTION |
4 |
Non-Preferred Brand Drugs |
30% | 30% | P |
CLINIMIX E 5/20 SOLUTION |
4 |
Non-Preferred Brand Drugs |
30% | 30% | P |
CLINIMIX E 5/25 SOLUTION |
4 |
Non-Preferred Brand Drugs |
30% | 30% | P |
CLINIMIX E 5%/15% INJECTION 2000ML BAG |
4 |
Non-Preferred Brand Drugs |
30% | 30% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOBETASOL 0.05% OINTMENT |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CLOBETASOL E 0.05% CREAM |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Clobetasol Propionate 0.5mg/mL 50 mL in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CLOMIPRAMINE HCL 25MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CLOMIPRAMINE HCL 50MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CLOMIPRAMINE HCL 75MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CLONIDINE HCL 0.2MG TABLET (500 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CLONIDINE HCL TABLET 0.1MG (500 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CLONIDINE HCL TABLET 0.3MG (100 CT) |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CLOPIDOGREL 300 MG tablet |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOPIDOGREL TAB 75MG |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CLOTRIMAZOLE 1% CREAM |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CLOTRIMAZOLE SOLUTION TOPICAL 1% 30ML BOTPL |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CLOZAPINE 100mg/1 100 TABLET in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CLOZAPINE 200MG TABLET (500 CT) |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CLOZAPINE 25MG TABLET (100 CT) |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CLOZAPINE 50MG TABLET (500 CT) |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CO-GESIC 5/500 TABLET |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Colcrys 0.6mg/1 100 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
3 |
Preferred Brand Drugs |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COLESTIPOL HCL 1G TABLET |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
COLESTIPOL HYDROCHLORIDE 5g/1 100 SUSPENSION in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
colistimethate 150mg/2mL 1 VIAL in 1 CARTON / 2 mL in 1 VIAL |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
COMBIVENT INHALER |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
COMBIVENT RESPIMAT INHAL SPRAY 20-100 MCG |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1 |
5 |
Specialty Tier Drugs |
33% | N/A | None |
COMPRO 25MG SUPPOSITORY |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
COMTAN 200MG TABLET |
3 |
Preferred Brand Drugs |
15% | 15% | None |
COMVAX VACCINE VIAL |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
CONDYLOX GEL 0.5% 3.5 GM CRTN |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CONSTULOSE 10GM/15ML SYRUP |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN |
5 |
Specialty Tier Drugs |
33% | N/A | None |
Cortomycin 10; 3.5; 10000mg/mL; mg/mL; [USP'U]/mL 1 10 mL BOTTLE, DROPPER |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
Cortomycin 10; 3.5; 10000mg/mL; mg/mL; [USP'U]/mL 1 10 mL BOTTLE, DROPPER |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CRESTOR 10MG TABLET |
3 |
Preferred Brand Drugs |
15% | 15% | None |
CRESTOR 20MG TABLET |
3 |
Preferred Brand Drugs |
15% | 15% | None |
CRESTOR 40mg/1 30 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
3 |
Preferred Brand Drugs |
15% | 15% | None |
CRESTOR 5MG TABLET |
3 |
Preferred Brand Drugs |
15% | 15% | None |
CRIXIVAN 100MG CAPSULE |
3 |
Preferred Brand Drugs |
15% | 15% | None |
CRIXIVAN 200MG CAPSULE |
3 |
Preferred Brand Drugs |
15% | 15% | None |
CRIXIVAN 400mg/1 90 CAPSULE in 1 BOTTLE |
3 |
Preferred Brand Drugs |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CROMOLYN NEBULIZER SOLUTION |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | P |
CROMOLYN SODIUM 4% 40MG 10ML BOT |
2 |
Non-Preferred Generic Drugs |
20% | 20% | None |
CUPRIMINE CAPSULES 250MG (100 CT) |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CYCLOBENZAPRINE HCL 5MG TABLET (500 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $6.00 | None |
CYCLOSPORINE 100MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | P |
Cyclosporine 100mg/1 30 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK |
2 |
Non-Preferred Generic Drugs |
20% | 20% | P |
CYCLOSPORINE 25MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
20% | 20% | P |
Cyclosporine 50mg/1 30 BLISTER PACK in 1 CARTON / 1 CAPSULE, LIQUID FILLED in 1 BLISTER PACK |
2 |
Non-Preferred Generic Drugs |
20% | 20% | P |
Cyclosporine 50mg/mL 10 VIAL in 1 BOX / 5 mL in 1 VIAL |
2 |
Non-Preferred Generic Drugs |
20% | 20% | P |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT |
2 |
Non-Preferred Generic Drugs |
20% | 20% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYMBALTA 20MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
Cymbalta 60mg/1 1000 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT) |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
CYSTADANE POWDER FOR ORAL SOLUTION 180GM |
3 |
Preferred Brand Drugs |
15% | 15% | None |
CYSTAGON 150MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |
CYSTAGON 50MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
30% | 30% | None |