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 A in Calumet County, WI: CMS MA Region 14 which includes: WI
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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 |
ABACAVIR TAB 300MG |
1 |
Tier 1 |
N/A | N/A | None |
ABILIFY 10MG TABLET |
2 |
Tier 2 |
N/A | N/A | Q:34 /34Days |
ABILIFY 15MG TABLET |
2 |
Tier 2 |
N/A | N/A | Q:34 /34Days |
ABILIFY 1MG/ML SOLUTION |
2 |
Tier 2 |
N/A | N/A | None |
ABILIFY 20MG TABLET |
2 |
Tier 2 |
N/A | N/A | Q:34 /34Days |
ABILIFY 2MG TABLET |
2 |
Tier 2 |
N/A | N/A | Q:34 /34Days |
ABILIFY 30MG TABLET |
2 |
Tier 2 |
N/A | N/A | Q:34 /34Days |
ABILIFY 5MG TABLET (OTSUKA) |
2 |
Tier 2 |
N/A | N/A | None |
ABILIFY DISCMELT 10MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
ABILIFY DISCMELT 15MG TABLET |
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 |
ABILIFY INJ 9.75MG |
2 |
Tier 2 |
N/A | N/A | S Q:90 /3Days |
Acarbose 100mg/1 90 TABLET in 1 BOTTLE, |
1 |
Tier 1 |
N/A | N/A | None |
acarbose 50 mg tablet |
1 |
Tier 1 |
N/A | N/A | None |
ACARBOSE TABLETS |
1 |
Tier 1 |
N/A | N/A | None |
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE |
2 |
Tier 2 |
N/A | N/A | None |
Acetaminophen and Codeine Phosphate 300; 60mg/1; mg/1 500 TABLET in 1 BOTTLE |
1 |
Tier 1 |
N/A | N/A | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD |
1 |
Tier 1 |
N/A | N/A | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) |
1 |
Tier 1 |
N/A | N/A | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
ACETASOL HC SOLUTION 10ML 10 ML BOT |
1 |
Tier 1 |
N/A | N/A | None |
ACETAZOLAMIDE 125MG 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 |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT |
1 |
Tier 1 |
N/A | N/A | None |
ACETIC ACID 2% SOLUTION NON-ORAL |
1 |
Tier 1 |
N/A | N/A | None |
ACETYLCYSTEINE 10% VIAL |
1 |
Tier 1 |
N/A | N/A | P |
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN |
1 |
Tier 1 |
N/A | N/A | P |
ACTHIB VACCINE VIAL 10-24UNT/5ML |
2 |
Tier 2 |
N/A | N/A | None |
ACTIMMUNE SOLUTION FOR INJECTION 100MCG |
2 |
Tier 2 |
N/A | N/A | None |
ACTOPLUS MET 15MG/500MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
ACTOPLUS MET 15MG/850MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
ACTOPLUS MET XR TABLETS EXTENDED RELEASE 15;1000 MG;MG |
2 |
Tier 2 |
N/A | N/A | None |
ACTOPLUS MET XR TABLETS EXTENDED RELEASE 30;1000 MG;MG |
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 |
ACTOS 15MG TABLET |
2 |
Tier 2 |
N/A | N/A | Q:34 /34Days |
ACTOS 30MG TABLET (500 CT) |
2 |
Tier 2 |
N/A | N/A | Q:34 /34Days |
ACTOS 45MG TABLET |
2 |
Tier 2 |
N/A | N/A | Q:34 /34Days |
Acyclovir 200mg/1 |
1 |
Tier 1 |
N/A | N/A | None |
Acyclovir 400mg/1 100 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK |
1 |
Tier 1 |
N/A | N/A | None |
Acyclovir 800mg/1 100 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK |
1 |
Tier 1 |
N/A | N/A | None |
ACYCLOVIR SODIUM 500MG VIAL |
1 |
Tier 1 |
N/A | N/A | None |
ADACEL VIAL 2UNT/5UNT |
2 |
Tier 2 |
N/A | N/A | None |
ADAGEN 250U/ML VIAL |
2 |
Tier 2 |
N/A | N/A | None |
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA] |
2 |
Tier 2 |
N/A | N/A | P |
ADCIRCA TABLETS 20MG 60 BOT |
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 |
ADVAIR DISKUS MIS 100/50 |
2 |
Tier 2 |
N/A | N/A | Q:60 /30Days |
ADVAIR DISKUS MIS 250/50 |
2 |
Tier 2 |
N/A | N/A | Q:60 /30Days |
ADVAIR DISKUS MIS 500/50 |
2 |
Tier 2 |
N/A | N/A | Q:60 /30Days |
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER |
2 |
Tier 2 |
N/A | N/A | None |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL |
2 |
Tier 2 |
N/A | N/A | None |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
2 |
Tier 2 |
N/A | N/A | None |
AFEDITAB CR 30MG TABLET SA |
1 |
Tier 1 |
N/A | N/A | None |
AFEDITAB CR 60MG TABLET SA |
1 |
Tier 1 |
N/A | N/A | None |
Afinitor 7.5mg/1 28 BLISTER PACK in 1 CARTON / 1 TABLET in 1 BLISTER PACK |
2 |
Tier 2 |
N/A | N/A | None |
AFINITOR TABLETS 10 MG |
2 |
Tier 2 |
N/A | N/A | None |
AFINITOR TABLETS 2.5 MG |
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 |
AFINITOR TABLETS 5 MG |
2 |
Tier 2 |
N/A | N/A | None |
AGGRENOX 25-200MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | None |
AKNE-MYCIN 2% OINTMENT |
2 |
Tier 2 |
N/A | N/A | None |
ALBENZA 200 MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
Albuterol Sulfate 0.63mg/3mL 25 POUCH in 1 CARTON / 5 VIAL in 1 POUCH / 3 mL in 1 VIAL |
1 |
Tier 1 |
N/A | N/A | P |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
1 |
Tier 1 |
N/A | N/A | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
1 |
Tier 1 |
N/A | N/A | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
1 |
Tier 1 |
N/A | N/A | P |
ALBUTEROL SULFATE SOLUTION FOR INHALATION |
1 |
Tier 1 |
N/A | N/A | P |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
1 |
Tier 1 |
N/A | N/A | None |
ALBUTEROL TABLET 4MG (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 |
ALDACTAZIDE 50/50 TABLET |
2 |
Tier 2 |
N/A | N/A | None |
ALDURAZYME 2.9MG/5ML VIAL |
2 |
Tier 2 |
N/A | N/A | None |
ALENDRONATE SODIUM 70mg/1 |
1 |
Tier 1 |
N/A | N/A | Q:4 /28Days |
ALFUZOSIN HYDROCHLORIDE 10mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
1 |
Tier 1 |
N/A | N/A | None |
ALIMTA 500MG VIAL |
2 |
Tier 2 |
N/A | N/A | None |
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET in 1 BLISTER PACK |
1 |
Tier 1 |
N/A | N/A | None |
ALLOPURINOL TABLETS |
1 |
Tier 1 |
N/A | N/A | None |
ALOCRIL 2% EYE DROPS |
2 |
Tier 2 |
N/A | N/A | None |
AMANTADINE 100MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
AMANTADINE 100MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
Amantadine Hydrochloride 50mg/5mL |
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 |
Amethia 2 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
1 |
Tier 1 |
N/A | N/A | None |
AMIFOSTINE FOR INJECTION 500MG/VIAL |
1 |
Tier 1 |
N/A | N/A | None |
AMIKACIN 250MG/ML VIAL |
1 |
Tier 1 |
N/A | N/A | None |
AMIKACIN 50MG/ML VIAL |
1 |
Tier 1 |
N/A | N/A | None |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT |
1 |
Tier 1 |
N/A | N/A | None |
AMINOPHYLLINE 100MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
AMINOPHYLLINE 200MG TABLET (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
AMINOSYN II 3.5% M/D5W IV |
2 |
Tier 2 |
N/A | N/A | None |
AMINOSYN II 8.5% ELECTROLYT |
1 |
Tier 1 |
N/A | N/A | None |
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5% |
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 |
AMIODARONE HCL 400MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
Amiodarone hydrochloride 200mg/1 |
1 |
Tier 1 |
N/A | N/A | None |
AMITRIPTYLINE HCL 100MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
AMITRIPTYLINE HCL 10MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
AMITRIPTYLINE HCL 150 MG TAB |
1 |
Tier 1 |
N/A | N/A | None |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
1 |
Tier 1 |
N/A | N/A | None |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
1 |
Tier 1 |
N/A | N/A | None |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1 |
Tier 1 |
N/A | N/A | None |
AMLODIPINE BESYLATE 5MG TABLET (90 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 |
AMMONIUM LACTATE 12% CREAM |
1 |
Tier 1 |
N/A | N/A | None |
AMMONIUM LACTATE 12% LOTION |
1 |
Tier 1 |
N/A | N/A | None |
AMOX TR-K CLV 500-125 MG TAB |
1 |
Tier 1 |
N/A | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
N/A | N/A | None |
AMOXAPINE 100MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
AMOXAPINE 150MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
AMOXAPINE 25MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
AMOXAPINE 50MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
AMOXICILLIN 250MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
Amoxicillin 250mg/1 500 TABLET, CHEWABLE in 1 BOTTLE |
1 |
Tier 1 |
N/A | N/A | None |
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION |
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 |
AMOXICILLIN 500MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
1 |
Tier 1 |
N/A | N/A | None |
AMOXICILLIN CAP 500MG |
1 |
Tier 1 |
N/A | N/A | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Tier 1 |
N/A | N/A | None |
AMPHETAMINE CAP 10MG ER |
1 |
Tier 1 |
N/A | N/A | None |
AMPHETAMINE CAP 15MG ER |
1 |
Tier 1 |
N/A | N/A | None |
AMPHETAMINE CAP 20MG ER |
1 |
Tier 1 |
N/A | N/A | None |
AMPHETAMINE CAP 25MG ER |
1 |
Tier 1 |
N/A | N/A | None |
AMPHETAMINE CAP 30MG ER |
1 |
Tier 1 |
N/A | N/A | None |
AMPHETAMINE CAP 5MG ER |
1 |
Tier 1 |
N/A | N/A | None |
AMPHETAMINE SALT COMBO 12.5MG 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 |
AMPHETAMINE SALT COMBO 15MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
AMPHETAMINE SALT COMBO 30MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
AMPHETAMINE SALTS 20MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
AMPHETAMINE SALTS 5 MG TAB |
1 |
Tier 1 |
N/A | N/A | None |
amphotericin b 50mg/10mL 10 mL in 1 VIAL |
1 |
Tier 1 |
N/A | N/A | None |
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL |
1 |
Tier 1 |
N/A | N/A | None |
ANADROL-50 50MG TABLET (100 CT) |
2 |
Tier 2 |
N/A | N/A | None |
ANASTROZOLE TABLETS |
1 |
Tier 1 |
N/A | N/A | None |
ANCOBON 250MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | None |
ANCOBON 500MG CAPSULE |
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 |
ANDRODERM 2 MG/24HR PATCH |
2 |
Tier 2 |
N/A | N/A | None |
ANDRODERM 2.5MG/24HR PATCH |
2 |
Tier 2 |
N/A | N/A | None |
ANDRODERM 4 MG/24HR PATCH |
2 |
Tier 2 |
N/A | N/A | None |
ANDRODERM 5MG/24HR PATCH |
2 |
Tier 2 |
N/A | N/A | None |
APOKYN 30mg/3mL 5 CARTRIDGE in 1 CARTON / 3 mL in 1 CARTRIDGE |
2 |
Tier 2 |
N/A | N/A | P |
APRI 0.15-0.03 TABLET |
1 |
Tier 1 |
N/A | N/A | None |
APRISO CP24 |
2 |
Tier 2 |
N/A | N/A | None |
APTIVUS 250MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
2 |
Tier 2 |
N/A | N/A | None |
ARCALYST INJECTION 220MG/VIAL |
2 |
Tier 2 |
N/A | N/A | None |
ARIXTRA 10MG SYRINGE |
2 |
Tier 2 |
N/A | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARIXTRA 2.5MG SYRINGE |
2 |
Tier 2 |
N/A | N/A | P |
ARIXTRA 5MG SYRINGE |
2 |
Tier 2 |
N/A | N/A | P |
ARIXTRA 7.5MG SYRINGE |
2 |
Tier 2 |
N/A | N/A | P |
ARZERRA 20mg/mL 3 VIAL in 1 CARTON / 5 mL in 1 VIAL |
2 |
Tier 2 |
N/A | N/A | None |
ASACOL 400mg/1 12 BOTTLE in 1 CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE |
2 |
Tier 2 |
N/A | N/A | None |
ASACOL HD 800mg/1 12 BOTTLE in 1 CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE |
2 |
Tier 2 |
N/A | N/A | None |
ATENOLOL 100mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
N/A | N/A | None |
Atenolol 25mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
N/A | N/A | None |
ATENOLOL TABLET USP 50MG (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 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 |
ATGAM 50MG/ML AMPUL |
2 |
Tier 2 |
N/A | N/A | None |
ATORVASTATIN 10 MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
ATORVASTATIN 20 MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
ATORVASTATIN 40 MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
ATORVASTATIN 80 MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
2 |
Tier 2 |
N/A | N/A | None |
ATROVENT HFA AER 17MCG |
2 |
Tier 2 |
N/A | N/A | None |
AVANDIA 2mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
N/A | N/A | None |
AVANDIA 4mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
N/A | N/A | None |
AVANDIA 8mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
N/A | N/A | None |
AVASTIN 100MG/4ML VIAL |
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 |
AVODART 0.5MG SOFTGEL |
2 |
Tier 2 |
N/A | N/A | S |
AVONEX ADMIN PACK 30MCG SYR |
2 |
Tier 2 |
N/A | N/A | P |
AVONEX ADMIN PACK 30MCG VL |
2 |
Tier 2 |
N/A | N/A | P |
AZATHIOPRINE 50MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
AZATHIOPRINE SOD 100MG VIAL |
2 |
Tier 2 |
N/A | N/A | None |
AZELASTINE 137 MCG NASAL SPRAY |
1 |
Tier 1 |
N/A | N/A | None |
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION |
1 |
Tier 1 |
N/A | N/A | None |
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
N/A | N/A | None |
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
N/A | N/A | None |
AZITHROMYCIN 250 MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR 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 |
Azithromycin 500mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
1 |
Tier 1 |
N/A | N/A | None |
Azithromycin 600mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
1 |
Tier 1 |
N/A | N/A | None |
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT |
2 |
Tier 2 |
N/A | N/A | None |
AZTREONAM FOR INJECTION |
1 |
Tier 1 |
N/A | N/A | None |