2012 Medicare Part D Plan Formulary Information |
Community Care's Partnership Program Disabled (HMO SNP) (H2034-002-0)
Benefit Details
|
The Community Care's Partnership Program Disabled (HMO SNP) (H2034-002-0) Formulary Drugs Starting with the Letter C in Calumet County, WI: CMS MA Region 14 which includes: WI
|
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 |
CABERGOLINE 0.5 MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
Calcipotriene 50ug/g 60 g in 1 CARTON |
1 |
Tier 1 |
N/A | N/A | None |
CALCIPOTRIENE TOPICAL SOLUTION |
1 |
Tier 1 |
N/A | N/A | None |
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY |
1 |
Tier 1 |
N/A | N/A | None |
CALCITRIOL 0.25MCG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
CALCITRIOL 0.5MCG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
CALCITRIOL INJ 1MCG/ML |
1 |
Tier 1 |
N/A | N/A | None |
Calcium Acetate 667mg/1 200 TABLET in 1 BOTTLE |
1 |
Tier 1 |
N/A | N/A | None |
CALCIUM ACETATE CAPSULE 667 MG |
1 |
Tier 1 |
N/A | N/A | None |
CAMPATH INJECTION 30 MG/ML |
2 |
Tier 2 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAMPRAL 333MG DOSE PAK |
2 |
Tier 2 |
N/A | N/A | P |
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX |
2 |
Tier 2 |
N/A | N/A | None |
CANCIDAS IV 50MG VIAL |
2 |
Tier 2 |
N/A | N/A | None |
CANCIDAS IV 70MG VIAL |
2 |
Tier 2 |
N/A | N/A | None |
CAPASTAT SULFATE 1g/1 1 INJECTION, POWDER, FOR SOLUTION in 1 CARTON |
2 |
Tier 2 |
N/A | N/A | None |
CAPRELSA 100mg/1 30 TABLET in 1 BOTTLE, PLASTIC |
2 |
Tier 2 |
N/A | N/A | None |
CAPRELSA 300mg/1 30 TABLET in 1 BOTTLE, PLASTIC |
2 |
Tier 2 |
N/A | N/A | None |
Carbamazepine 100mg/1 100 TABLET, CHEWABLE in 1 BOTTLE |
1 |
Tier 1 |
N/A | N/A | None |
Carbamazepine 100mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
1 |
Tier 1 |
N/A | N/A | None |
Carbamazepine 200mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
1 |
Tier 1 |
N/A | N/A | None |
Carbamazepine 300mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARBAMAZEPINE EXTENDED RELEASE TABLETS 200MG |
1 |
Tier 1 |
N/A | N/A | None |
CARBAMAZEPINE EXTENDED RELEASE TABLETS 400MG |
1 |
Tier 1 |
N/A | N/A | None |
CARBAMAZEPINE ORAL SUSPENSION 100 MG/5ML |
1 |
Tier 1 |
N/A | N/A | None |
CARBAMAZEPINE TABLET USP 200MG (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
Carbatrol 100mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
2 |
Tier 2 |
N/A | N/A | None |
CARBATROL 200MG CAPSULE SA |
2 |
Tier 2 |
N/A | N/A | None |
CARBATROL 300MG CAPSULE SA |
2 |
Tier 2 |
N/A | N/A | None |
Carbidopa and Levodopa 25; 100mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED |
1 |
Tier 1 |
N/A | N/A | None |
Carbidopa and Levodopa 50; 200mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED |
1 |
Tier 1 |
N/A | N/A | None |
CARBIDOPA/LEVO 10/100 TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CARBIDOPA/LEVO 25/100 TABLET |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARBIDOPA/LEVO 25/250 TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CARIMUNE NF 3GM VIAL |
2 |
Tier 2 |
N/A | N/A | None |
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT |
1 |
Tier 1 |
N/A | N/A | None |
CARTIA XT 120MG CAPSULE SA |
1 |
Tier 1 |
N/A | N/A | None |
CARTIA XT 180MG CAPSULE SA |
1 |
Tier 1 |
N/A | N/A | None |
CARTIA XT 240MG CAPSULE SA |
1 |
Tier 1 |
N/A | N/A | None |
CARTIA XT 300MG CAPSULE SR 24 HR |
1 |
Tier 1 |
N/A | N/A | None |
Carvedilol 12.5mg/1 |
1 |
Tier 1 |
N/A | N/A | None |
Carvedilol 25mg/1 |
1 |
Tier 1 |
N/A | N/A | None |
Carvedilol 3.125mg/1 |
1 |
Tier 1 |
N/A | N/A | None |
Carvedilol 6.25mg/1 500 TABLET, FILM COATED in 1 BOTTLE |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEENU 100MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | None |
CEENU 10MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | None |
CEENU 40MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | None |
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE |
1 |
Tier 1 |
N/A | N/A | None |
Cefazolin 1g/1 |
1 |
Tier 1 |
N/A | N/A | None |
CEFAZOLIN 1GM/D5W BAG |
2 |
Tier 2 |
N/A | N/A | None |
CEFAZOLIN FOR INJECTION |
1 |
Tier 1 |
N/A | N/A | None |
CEFEPIME HCL 2 GRAM VIAL |
1 |
Tier 1 |
N/A | N/A | None |
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL |
1 |
Tier 1 |
N/A | N/A | None |
Cefpodoxime Proxetil 100mg/5mL 1 BOTTLE in 1 CARTON / 100 mL in 1 BOTTLE |
1 |
Tier 1 |
N/A | N/A | None |
Cefpodoxime Proxetil 50mg/5mL 1 BOTTLE in 1 CARTON / 100 mL in 1 BOTTLE |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CEFPODOXIME TAB 200MG |
1 |
Tier 1 |
N/A | N/A | None |
CEFTRIAXONE 10GM VIAL |
1 |
Tier 1 |
N/A | N/A | None |
CEFTRIAXONE FOR INJECTION |
1 |
Tier 1 |
N/A | N/A | None |
CEFTRIAXONE FOR INJECTION |
1 |
Tier 1 |
N/A | N/A | None |
CEFTRIAXONE FOR INJECTION 250MG BOX OF 10 VIALGL |
1 |
Tier 1 |
N/A | N/A | None |
Ceftriaxone Sodium 500mg/1 |
1 |
Tier 1 |
N/A | N/A | None |
CEFUROXIME 250MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CEFUROXIME AXETIL 500MG TABLET (20 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CEFUROXIME FOR INJECTION |
1 |
Tier 1 |
N/A | N/A | None |
CEFUROXIME FOR INJECTION |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFUROXIME FOR INJECTION |
1 |
Tier 1 |
N/A | N/A | None |
CELEBREX 100MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | P |
CELEBREX 200MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | P |
CELESTONE 0.6MG/5ML SYRUP |
2 |
Tier 2 |
N/A | N/A | None |
CELLCEPT 200MG/ML ORAL SUSP |
2 |
Tier 2 |
N/A | N/A | P |
CELLCEPT IV INJ 500MG |
2 |
Tier 2 |
N/A | N/A | P |
CELONTIN 300MG KAPSEAL |
2 |
Tier 2 |
N/A | N/A | None |
Cephalexin 125mg/5mL 200 mL in 1 BOTTLE |
1 |
Tier 1 |
N/A | N/A | None |
CEPHALEXIN 250MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
CEPHALEXIN 250MG/5ML ORAL SUSP |
1 |
Tier 1 |
N/A | N/A | None |
CEPHALEXIN CAPSULES 500MG (500 CT) |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEREDASE 80UNITS/ML VIAL |
2 |
Tier 2 |
N/A | N/A | None |
CEREZYME INJ 200UNIT |
2 |
Tier 2 |
N/A | N/A | None |
CHANTIX 0.5MG TABLET |
2 |
Tier 2 |
N/A | N/A | P |
CHANTIX 1MG TABLET |
2 |
Tier 2 |
N/A | N/A | P |
CHANTIX STARTING MONTH PAK |
2 |
Tier 2 |
N/A | N/A | P |
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH |
1 |
Tier 1 |
N/A | N/A | None |
CHLORPROMAZINE 10MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CHLORPROMAZINE 25MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CHLORPROMAZINE 25MG/ML AMP |
2 |
Tier 2 |
N/A | N/A | None |
CHLORPROMAZINE 50MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CHLORPROMAZINE HCL 200MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Chlorpromazine Hydrochloride 100mg/1 1000 TABLET, SUGAR COATED in 1 BOTTLE |
1 |
Tier 1 |
N/A | N/A | None |
CHLORTHALIDONE 25MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CHLORTHALIDONE 50MG TABLET (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION |
1 |
Tier 1 |
N/A | N/A | None |
CHORIONIC GONAD 10000U VIAL |
1 |
Tier 1 |
N/A | N/A | None |
CILOSTAZOL 50 MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CILOSTAZOL TABLET 100MG (60 CT) |
1 |
Tier 1 |
N/A | N/A | None |
Cipro 1 KIT in 1 KIT |
2 |
Tier 2 |
N/A | N/A | None |
Cipro 1 KIT in 1 KIT |
2 |
Tier 2 |
N/A | N/A | None |
CIPRO HC OTIC SUSPENSION |
2 |
Tier 2 |
N/A | N/A | None |
CIPRO IV INFUSION 200MG 100ML BAG |
2 |
Tier 2 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIPROFLOXACIN 0.3% EYE DROP |
1 |
Tier 1 |
N/A | N/A | None |
CIPROFLOXACIN 250MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
Ciprofloxacin 400mg/40mL 1 VIAL in 1 CARTON / 40 mL in 1 VIAL |
1 |
Tier 1 |
N/A | N/A | None |
CIPROFLOXACIN 500MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CIPROFLOXACIN TABLETS 750MG 100 BOT |
1 |
Tier 1 |
N/A | N/A | None |
CITALOPRAM HBR 20 MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT |
1 |
Tier 1 |
N/A | N/A | None |
CITOLOPRAM HBR 10MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CLARINEX 5MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
CLARITHROMYCIN 250MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CLARITHROMYCIN 500MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLARITHROMYCIN FOR ORAL SUSPENSION |
1 |
Tier 1 |
N/A | N/A | None |
CLARITHROMYCIN FOR ORAL SUSPENSION |
1 |
Tier 1 |
N/A | N/A | None |
CLEMASTINE FUM 2.68MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
CLEOCIN 100MG VAGINAL OVULE |
2 |
Tier 2 |
N/A | N/A | None |
CLINDAMYCIN 150MG/ML ADDVAN |
1 |
Tier 1 |
N/A | N/A | None |
CLINDAMYCIN HCL 150MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
CLINDAMYCIN HYDROCHLORIDE CAPSULES |
1 |
Tier 1 |
N/A | N/A | None |
CLINDAMYCIN PHOSP 1% LOTION |
1 |
Tier 1 |
N/A | N/A | None |
clindamycin phosphate 10mg/mL 1 BOTTLE in 1 CARTON / 60 mL in 1 BOTTLE |
1 |
Tier 1 |
N/A | N/A | None |
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE |
1 |
Tier 1 |
N/A | N/A | None |
CLINIMIX 4.25/10 SOLUTION |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINIMIX 4.25/20 SOLUTION |
1 |
Tier 1 |
N/A | N/A | None |
CLINIMIX 4.25/25 SOLUTION |
1 |
Tier 1 |
N/A | N/A | None |
CLOBETASOL 0.05% OINTMENT |
1 |
Tier 1 |
N/A | N/A | None |
CLOBETASOL E 0.05% CREAM |
1 |
Tier 1 |
N/A | N/A | None |
Clobetasol Propionate 0.5mg/mL 50 mL in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
N/A | N/A | None |
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE |
1 |
Tier 1 |
N/A | N/A | None |
CLOMIPRAMINE HCL 25MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
CLOMIPRAMINE HCL 50MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
CLOMIPRAMINE HCL 75MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
Clonidine 0.1mg/d 4 POUCH in 1 CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
1 |
Tier 1 |
N/A | N/A | None |
Clonidine 0.2mg/d 4 POUCH in 1 CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Clonidine 0.3mg/d 4 POUCH in 1 CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
1 |
Tier 1 |
N/A | N/A | None |
CLONIDINE HCL 0.2MG TABLET (500 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CLONIDINE HCL TABLET 0.1MG (500 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CLONIDINE HCL TABLET 0.3MG (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CLOPIDOGREL TAB 75MG |
1 |
Tier 1 |
N/A | N/A | P |
CLOTRIMAZOLE 1% CREAM |
1 |
Tier 1 |
N/A | N/A | None |
CLOTRIMAZOLE 10MG TROCHE |
1 |
Tier 1 |
N/A | N/A | None |
CLOTRIMAZOLE SOLUTION TOPICAL 1% 30ML BOTPL |
1 |
Tier 1 |
N/A | N/A | None |
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE |
1 |
Tier 1 |
N/A | N/A | None |
CLOZAPINE 100mg/1 100 TABLET in 1 BOTTLE |
1 |
Tier 1 |
N/A | N/A | None |
CLOZAPINE 200MG TABLET (500 CT) |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOZAPINE 25MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CLOZAPINE 50MG TABLET (500 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CODEINE SULFATE 30 MG TABLET 3100 |
2 |
Tier 2 |
N/A | N/A | None |
Codeine sulfate 60mg/1 100 TABLET in 1 BOTTLE |
2 |
Tier 2 |
N/A | N/A | None |
CODEINE SULFATE TABLETS |
2 |
Tier 2 |
N/A | N/A | None |
Colcrys 0.6mg/1 100 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
2 |
Tier 2 |
N/A | N/A | None |
colistimethate 150mg/2mL 1 VIAL in 1 CARTON / 2 mL in 1 VIAL |
1 |
Tier 1 |
N/A | N/A | None |
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE |
2 |
Tier 2 |
N/A | N/A | None |
Colyte with flavor packs 240; 2.98; 6.72; 5.84; 22.72g/4L; g/4L; g/4L; g/4L; g/4L |
2 |
Tier 2 |
N/A | N/A | None |
COMBIGAN 0.2%-0.5% DROPS |
2 |
Tier 2 |
N/A | N/A | None |
COMBIVENT INHALER |
2 |
Tier 2 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COMBIVIR 150; 300mg/1; mg/1 120 TABLET, FILM COATED in 1 DOSE PACK |
2 |
Tier 2 |
N/A | N/A | None |
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1 |
2 |
Tier 2 |
N/A | N/A | None |
COMTAN 200MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
COMVAX VACCINE VIAL |
2 |
Tier 2 |
N/A | N/A | None |
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN |
2 |
Tier 2 |
N/A | N/A | P |
CRESTOR 10MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
CRESTOR 20MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
CRESTOR 40mg/1 30 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
2 |
Tier 2 |
N/A | N/A | None |
CRIXIVAN 100MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | None |
CRIXIVAN 200MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | None |
CRIXIVAN 400mg/1 90 CAPSULE in 1 BOTTLE |
2 |
Tier 2 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CROMOLYN NEBULIZER SOLUTION |
1 |
Tier 1 |
N/A | N/A | None |
CROMOLYN SODIUM 4% 40MG 10ML BOT |
1 |
Tier 1 |
N/A | N/A | None |
Cyclafem 1/35 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
1 |
Tier 1 |
N/A | N/A | None |
Cyclafem 7/7/7 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
1 |
Tier 1 |
N/A | N/A | None |
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CYCLOBENZAPRINE HCL 5MG TABLET (500 CT) |
1 |
Tier 1 |
N/A | N/A | None |
CYCLOSPORINE 100MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | P |
Cyclosporine 100mg/1 30 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK |
1 |
Tier 1 |
N/A | N/A | None |
CYCLOSPORINE 25MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | P |
Cyclosporine 50mg/1 30 BLISTER PACK in 1 CARTON / 1 CAPSULE, LIQUID FILLED in 1 BLISTER PACK |
2 |
Tier 2 |
N/A | N/A | P |
Cyclosporine 50mg/mL 10 VIAL in 1 BOX / 5 mL in 1 VIAL |
1 |
Tier 1 |
N/A | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT |
1 |
Tier 1 |
N/A | N/A | P |
CYKLOKAPRON 100MG/ML AMPUL |
2 |
Tier 2 |
N/A | N/A | None |
CYMBALTA 20MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | P Q:34 /34Days |
Cymbalta 60mg/1 1000 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
2 |
Tier 2 |
N/A | N/A | P Q:34 /34Days |
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT) |
2 |
Tier 2 |
N/A | N/A | P Q:34 /34Days |
CYSTADANE POWDER FOR ORAL SOLUTION 180GM |
2 |
Tier 2 |
N/A | N/A | None |
CYSTAGON 150MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | None |
CYSTAGON 50MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | None |