2012 Medicare Part D Plan Formulary Information |
WindsorSterling Gold Access Plan (PFFS) (H5006-017-17)
Benefit Details
|
The WindsorSterling Gold Access Plan (PFFS) (H5006-017-17) Formulary Drugs Starting with the Letter C in WORTH County, MO: CMS MA Region 15 which includes: MO
|
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 50ug/g 60 g in 1 CARTON |
4 |
Tier 4 |
$84.00 | $252.00 | Q:60 /30Days |
CALCIPOTRIENE TOPICAL SOLUTION |
4 |
Tier 4 |
$84.00 | $252.00 | None |
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CALCITRIOL 0.25MCG CAPSULE |
2* |
Tier 2 |
$15.00 | $45.00 | P |
CALCITRIOL 0.5MCG CAPSULE |
2* |
Tier 2 |
$15.00 | $45.00 | P |
CALCITRIOL INJ 1MCG/ML |
2* |
Tier 2 |
$15.00 | $45.00 | P |
Calcium Acetate 667mg/1 200 TABLET in 1 BOTTLE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CALCIUM ACETATE CAPSULE 667 MG |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CAMILA 0.35MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | Q:28 /28Days |
CAMPATH INJECTION 30 MG/ML |
5 |
Tier 5 |
30% | 30% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAMPRAL 333MG DOSE PAK |
4 |
Tier 4 |
$84.00 | $252.00 | P |
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX |
3 |
Tier 3 |
$34.00 | $102.00 | Q:30 /30Days |
CANCIDAS IV 50MG VIAL |
5 |
Tier 5 |
30% | 30% | P |
CANCIDAS IV 70MG VIAL |
5 |
Tier 5 |
30% | 30% | P |
CAPASTAT SULFATE 1g/1 1 INJECTION, POWDER, FOR SOLUTION in 1 CARTON |
4 |
Tier 4 |
$84.00 | $252.00 | P |
CAPEX SHA 0.01% |
4 |
Tier 4 |
$84.00 | $252.00 | None |
CAPRELSA 100mg/1 30 TABLET in 1 BOTTLE, PLASTIC |
5 |
Tier 5 |
30% | 30% | P |
CAPRELSA 300mg/1 30 TABLET in 1 BOTTLE, PLASTIC |
5 |
Tier 5 |
30% | 30% | P |
CAPTOPRIL 100MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CAPTOPRIL 12.5MG TABLET |
1* |
Tier 1 |
$5.00 | $15.00 | None |
CAPTOPRIL 25MG TABLET |
1* |
Tier 1 |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAPTOPRIL 50MG TABLET |
1* |
Tier 1 |
$5.00 | $15.00 | None |
Captopril and Hydrochlorothiazide 25; 15mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Captopril and Hydrochlorothiazide 25; 25mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1* |
Tier 1 |
$5.00 | $15.00 | None |
Captopril and Hydrochlorothiazide 50; 15mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Captopril and Hydrochlorothiazide 50; 25mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CARAFATE SUS 1GM/10ML |
4 |
Tier 4 |
$84.00 | $252.00 | None |
Carbaglu 200mg/1 5 TABLET in 1 BOTTLE |
5 |
Tier 5 |
30% | 30% | P |
Carbamazepine 100mg/1 100 TABLET, CHEWABLE in 1 BOTTLE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Carbamazepine 100mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
4 |
Tier 4 |
$84.00 | $252.00 | None |
Carbamazepine 200mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
4 |
Tier 4 |
$84.00 | $252.00 | None |
Carbamazepine 300mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
4 |
Tier 4 |
$84.00 | $252.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARBAMAZEPINE EXTENDED RELEASE TABLETS 200MG |
4 |
Tier 4 |
$84.00 | $252.00 | None |
CARBAMAZEPINE EXTENDED RELEASE TABLETS 400MG |
4 |
Tier 4 |
$84.00 | $252.00 | None |
CARBAMAZEPINE ORAL SUSPENSION 100 MG/5ML |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CARBAMAZEPINE TABLET USP 200MG (1000 CT) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Carbidopa and Levodopa 25; 100mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Carbidopa and Levodopa 50; 200mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CARBIDOPA/LEVO 10/100 TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CARBIDOPA/LEVO 25/100 TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CARBIDOPA/LEVO 25/250 TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Carboplatin 10mg/mL |
2* |
Tier 2 |
$15.00 | $45.00 | P |
CARIMUNE NF 3GM VIAL |
5 |
Tier 5 |
30% | 30% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARISOPRODOL TABLET USP 350MG (100 CT) |
2* |
Tier 2 |
$15.00 | $45.00 | P Q:120 /30Days |
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CARTIA XT 120MG CAPSULE SA |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CARTIA XT 180MG CAPSULE SA |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CARTIA XT 240MG CAPSULE SA |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CARTIA XT 300MG CAPSULE SR 24 HR |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Carvedilol 12.5mg/1 |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Carvedilol 25mg/1 |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Carvedilol 3.125mg/1 |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Carvedilol 6.25mg/1 500 TABLET, FILM COATED in 1 BOTTLE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CAYSTON KIT |
5 |
Tier 5 |
30% | 30% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEENU 100MG CAPSULE |
3 |
Tier 3 |
$34.00 | $102.00 | None |
CEENU 10MG CAPSULE |
3 |
Tier 3 |
$34.00 | $102.00 | None |
CEENU 40MG CAPSULE |
3 |
Tier 3 |
$34.00 | $102.00 | None |
CEFACLOR CAPSULES |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CEFACLOR CAPSULES |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CEFACLOR ER 500MG TABLET SR 12HR |
4 |
Tier 4 |
$84.00 | $252.00 | None |
CEFADROXIL 1G TABLET |
4 |
Tier 4 |
$84.00 | $252.00 | None |
Cefadroxil 500mg/1 |
4 |
Tier 4 |
$84.00 | $252.00 | None |
Cefadroxil 500mg/5mL |
4 |
Tier 4 |
$84.00 | $252.00 | None |
CEFADROXIL FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
4 |
Tier 4 |
$84.00 | $252.00 | None |
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE |
2* |
Tier 2 |
$15.00 | $45.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cefazolin 1g/1 |
2* |
Tier 2 |
$15.00 | $45.00 | P |
CEFAZOLIN FOR INJECTION |
2* |
Tier 2 |
$15.00 | $45.00 | P |
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
4 |
Tier 4 |
$84.00 | $252.00 | None |
CEFDINIR CAPSULES 300MG (60 CT) |
4 |
Tier 4 |
$84.00 | $252.00 | None |
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT) |
4 |
Tier 4 |
$84.00 | $252.00 | None |
CEFEPIME HCL 2 GRAM VIAL |
4 |
Tier 4 |
$84.00 | $252.00 | P |
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL |
4 |
Tier 4 |
$84.00 | $252.00 | P |
CEFOTAXIME FOR INJECTION |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CEFOTAXIME FOR INJECTION 1GM 50 BOX VIALGL |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CEFOTAXIME FOR INJECTION 2GM 25 VIAL |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CEFOTAXIME FOR INJECTION 500MG 10 VIAL |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFOTETAN 10 GM SOLR |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Cefoxitin 1g/1 10 POWDER in 1 CARTON |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Cefoxitin 2g/1 10 POWDER in 1 CARTON |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CEFOXITIN FOR INJECTION SOLUTION |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Cefpodoxime Proxetil 100mg/5mL 1 BOTTLE in 1 CARTON / 100 mL in 1 BOTTLE |
4 |
Tier 4 |
$84.00 | $252.00 | None |
Cefpodoxime Proxetil 50mg/5mL 1 BOTTLE in 1 CARTON / 100 mL in 1 BOTTLE |
4 |
Tier 4 |
$84.00 | $252.00 | None |
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT) |
4 |
Tier 4 |
$84.00 | $252.00 | None |
CEFPODOXIME TAB 200MG |
4 |
Tier 4 |
$84.00 | $252.00 | None |
CEFPROZIL 125mg/5mL |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Cefprozil 250mg/1 100 TABLET, FILM COATED in 1 BOTTLE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CEFPROZIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFPROZIL TABLETS 500MG 100 BOT |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CEFTRIAXONE 10GM VIAL |
4 |
Tier 4 |
$84.00 | $252.00 | None |
CEFTRIAXONE FOR INJECTION |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CEFTRIAXONE FOR INJECTION |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CEFTRIAXONE FOR INJECTION 250MG BOX OF 10 VIALGL |
4 |
Tier 4 |
$84.00 | $252.00 | None |
Ceftriaxone Sodium 500mg/1 |
4 |
Tier 4 |
$84.00 | $252.00 | None |
CEFUROXIME 250MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CEFUROXIME AXETIL 125MG/5ML SUSPENSION RECONSTITUTED ORAL |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CEFUROXIME AXETIL 500MG TABLET (20 CT) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CEFUROXIME FOR INJECTION |
4 |
Tier 4 |
$84.00 | $252.00 | None |
CEFUROXIME FOR INJECTION |
4 |
Tier 4 |
$84.00 | $252.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CELEBREX 100MG CAPSULE |
4 |
Tier 4 |
$84.00 | $252.00 | S |
CELEBREX 200MG CAPSULE |
4 |
Tier 4 |
$84.00 | $252.00 | S |
CELEBREX 400MG CAPSULE |
4 |
Tier 4 |
$84.00 | $252.00 | S |
CELEBREX 50MG CAPSULE |
4 |
Tier 4 |
$84.00 | $252.00 | S |
CELLCEPT 200MG/ML ORAL SUSP |
3 |
Tier 3 |
$34.00 | $102.00 | P |
CELLCEPT IV INJ 500MG |
3 |
Tier 3 |
$34.00 | $102.00 | P |
CELONTIN 300MG KAPSEAL |
4 |
Tier 4 |
$84.00 | $252.00 | None |
Cephalexin 125mg/5mL 200 mL in 1 BOTTLE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CEPHALEXIN 250MG CAPSULE |
1* |
Tier 1 |
$5.00 | $15.00 | None |
CEPHALEXIN 250MG/5ML ORAL SUSP |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CEPHALEXIN CAPSULES 500MG (500 CT) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEREDASE 80UNITS/ML VIAL |
5 |
Tier 5 |
30% | 30% | P |
CEREZYME INJ 200UNIT |
5 |
Tier 5 |
30% | 30% | P |
CETIRIZINE HCL 5MG/5ML |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CHANTIX 0.5MG TABLET |
4 |
Tier 4 |
$84.00 | $252.00 | P |
CHANTIX 1MG TABLET |
4 |
Tier 4 |
$84.00 | $252.00 | P |
CHEMET 100MG CAPSULE |
4 |
Tier 4 |
$84.00 | $252.00 | None |
CHLORDIAZEPOXIDE AND AMITRIPTYLINE HCL TABLET 12.5-5MG (500 CT) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CHLOROQUINE PH 500MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CHLOROQUINE PHOSPHATE 250MG TABLET (50 CT) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CHLOROTHIAZIDE 250MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLOROTHIAZIDE 500MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CHLORPROMAZINE 10MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CHLORPROMAZINE 25MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CHLORPROMAZINE 25MG/ML AMP |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CHLORPROMAZINE 50MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CHLORPROMAZINE HCL 200MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Chlorpromazine Hydrochloride 100mg/1 1000 TABLET, SUGAR COATED in 1 BOTTLE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CHLORPROPAMIDE 100MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Chlorpropamide 250mg/1 1000 TABLET in 1 BOTTLE, PLASTIC |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CHLORTHALIDONE 25MG TABLET (100 CT) |
1* |
Tier 1 |
$5.00 | $15.00 | None |
CHLORTHALIDONE 50MG TABLET (1000 CT) |
1* |
Tier 1 |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLORZOXAZONE 500 MG TABLET |
1* |
Tier 1 |
$5.00 | $15.00 | P |
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CHORIONIC GONAD 10000U VIAL |
3 |
Tier 3 |
$34.00 | $102.00 | P |
CICLOPIROX 1% SHAMPOO |
4 |
Tier 4 |
$84.00 | $252.00 | None |
Ciclopirox Olamine 7.7mg/g 1 TUBE in 1 TUBE / 15 g in 1 TUBE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CILOSTAZOL 50 MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CILOSTAZOL TABLET 100MG (60 CT) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CILOXAN 0.3% OINTMENT |
4 |
Tier 4 |
$84.00 | $252.00 | None |
Cimetidine 400mg/1 100 TABLET, FILM COATED in 1 BOTTLE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Cimzia 2 KIT in 1 CARTON / 1 KIT in 1 KIT |
5 |
Tier 5 |
30% | 30% | P |
CIMZIA 200 MG/ML SYRINGE KIT |
5 |
Tier 5 |
30% | 30% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIPROFLOXACIN 0.3% EYE DROP |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CIPROFLOXACIN 250MG TABLET (100 CT) |
1* |
Tier 1 |
$5.00 | $15.00 | None |
Ciprofloxacin 400mg/40mL 1 VIAL in 1 CARTON / 40 mL in 1 VIAL |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CIPROFLOXACIN 500MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CIPROFLOXACIN HCL 100MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CIPROFLOXACIN TABLETS 750MG 100 BOT |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Cisplatin 100mg/100mL 1 VIAL in 1 CARTON / 100 mL in 1 VIAL |
1* |
Tier 1 |
$5.00 | $15.00 | P |
CITALOPRAM HBR 20 MG TABLET |
1* |
Tier 1 |
$5.00 | $15.00 | Q:90 /30Days |
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL |
2* |
Tier 2 |
$15.00 | $45.00 | Q:900 /30Days |
CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT |
1* |
Tier 1 |
$5.00 | $15.00 | Q:30 /30Days |
CITOLOPRAM HBR 10MG TABLET (100 CT) |
1* |
Tier 1 |
$5.00 | $15.00 | Q:45 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLADRIBINE 1MG/ML VIAL |
5 |
Tier 5 |
30% | 30% | P |
CLARAVIS 10MG CAPSULE |
4 |
Tier 4 |
$84.00 | $252.00 | P |
CLARAVIS 20MG CAPSULE |
4 |
Tier 4 |
$84.00 | $252.00 | P |
Claravis 30mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK |
4 |
Tier 4 |
$84.00 | $252.00 | None |
CLARAVIS 40MG CAPSULE |
4 |
Tier 4 |
$84.00 | $252.00 | P |
CLARITHROMYCIN 250MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CLARITHROMYCIN 500MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CLARITHROMYCIN FOR ORAL SUSPENSION |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CLARITHROMYCIN FOR ORAL SUSPENSION |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CLEMASTINE FUM 2.68MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CLEMASTINE FUMARATE SYRUP |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINDAMYCIN 150MG/ML ADDVAN |
1* |
Tier 1 |
$5.00 | $15.00 | None |
CLINDAMYCIN HCL 150MG CAPSULE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
clindamycin phosphate 10mg/mL 1 BOTTLE in 1 CARTON / 60 mL in 1 BOTTLE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Clindamycin Phosphate and Benzoyl Peroxide 1 KIT |
1* |
Tier 1 |
$5.00 | $15.00 | None |
CLINDAMYCIN PHOSPHATE VAGINAL CREAM |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CLOBETASOL 0.05% OINTMENT |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CLOMIPRAMINE HCL 25MG CAPSULE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CLOMIPRAMINE HCL 50MG CAPSULE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CLOMIPRAMINE HCL 75MG CAPSULE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Clonidine 0.1mg/d 4 POUCH in 1 CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
4 |
Tier 4 |
$84.00 | $252.00 | None |
Clonidine 0.2mg/d 4 POUCH in 1 CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
4 |
Tier 4 |
$84.00 | $252.00 | 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 |
4 |
Tier 4 |
$84.00 | $252.00 | None |
CLONIDINE HCL 0.2MG TABLET (500 CT) |
1* |
Tier 1 |
$5.00 | $15.00 | None |
CLONIDINE HCL TABLET 0.1MG (500 CT) |
1* |
Tier 1 |
$5.00 | $15.00 | None |
CLONIDINE HCL TABLET 0.3MG (100 CT) |
1* |
Tier 1 |
$5.00 | $15.00 | None |
CLOPIDOGREL TAB 75MG |
4 |
Tier 4 |
$84.00 | $252.00 | None |
CLOTRIMAZOLE 1% CREAM |
4 |
Tier 4 |
$84.00 | $252.00 | None |
CLOTRIMAZOLE 10MG TROCHE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CLOZAPINE 100mg/1 100 TABLET in 1 BOTTLE |
4 |
Tier 4 |
$84.00 | $252.00 | None |
CLOZAPINE 200MG TABLET (500 CT) |
4 |
Tier 4 |
$84.00 | $252.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOZAPINE 25MG TABLET (100 CT) |
4 |
Tier 4 |
$84.00 | $252.00 | None |
CLOZAPINE 50MG TABLET (500 CT) |
4 |
Tier 4 |
$84.00 | $252.00 | None |
COARTEM 20MG-120MG |
4 |
Tier 4 |
$84.00 | $252.00 | Q:24 /30Days |
Colcrys 0.6mg/1 100 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
4 |
Tier 4 |
$84.00 | $252.00 | Q:60 /30Days |
COLESTIPOL HCL 1G TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
colistimethate 150mg/2mL 1 VIAL in 1 CARTON / 2 mL in 1 VIAL |
2* |
Tier 2 |
$15.00 | $45.00 | P |
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE |
4 |
Tier 4 |
$84.00 | $252.00 | None |
COMBIGAN 0.2%-0.5% DROPS |
4 |
Tier 4 |
$84.00 | $252.00 | None |
COMBIVENT INHALER |
4 |
Tier 4 |
$84.00 | $252.00 | Q:30 /30Days |
COMBIVENT RESPIMAT INHAL SPRAY 20-100 MCG |
4 |
Tier 4 |
$84.00 | $252.00 | Q:8 /30Days |
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1 |
5 |
Tier 5 |
30% | 30% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COMPRO 25MG SUPPOSITORY |
2* |
Tier 2 |
$15.00 | $45.00 | None |
COMTAN 200MG TABLET |
4 |
Tier 4 |
$84.00 | $252.00 | None |
COMVAX VACCINE VIAL |
3 |
Tier 3 |
$34.00 | $102.00 | None |
CONSTULOSE 10GM/15ML SYRUP |
2* |
Tier 2 |
$15.00 | $45.00 | None |
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN |
5 |
Tier 5 |
30% | 30% | P |
COREG CR 10MG CAPSULE MULTIPHASIC RELEASE 24 HR |
4 |
Tier 4 |
$84.00 | $252.00 | None |
COREG CR 20MG CAPSULE MULTIPHASIC RELEASE 24 HR |
4 |
Tier 4 |
$84.00 | $252.00 | None |
COREG CR 40MG CAPSULE MULTIPHASIC RELEASE 24 HR |
4 |
Tier 4 |
$84.00 | $252.00 | None |
COREG CR 80MG CAPSULE MULTIPHASIC RELEASE 24 HR |
4 |
Tier 4 |
$84.00 | $252.00 | None |
Cortomycin 10; 3.5; 10000mg/mL; mg/mL; [USP'U]/mL 1 10 mL BOTTLE, DROPPER |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Cortomycin 10; 3.5; 10000mg/mL; mg/mL; [USP'U]/mL 1 10 mL BOTTLE, DROPPER |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COUMADIN 10MG TABLET |
4 |
Tier 4 |
$84.00 | $252.00 | None |
COUMADIN 1MG TABLET |
4 |
Tier 4 |
$84.00 | $252.00 | None |
COUMADIN 2.5MG TABLET |
4 |
Tier 4 |
$84.00 | $252.00 | None |
COUMADIN 2MG TABLET |
4 |
Tier 4 |
$84.00 | $252.00 | None |
COUMADIN 3mg/1 1 BOTTLE in 1 CARTON / 100 TABLET in 1 BOTTLE |
4 |
Tier 4 |
$84.00 | $252.00 | None |
COUMADIN 4mg/1 1 BOTTLE in 1 CARTON / 100 TABLET in 1 BOTTLE |
4 |
Tier 4 |
$84.00 | $252.00 | None |
COUMADIN 5MG TABLET |
4 |
Tier 4 |
$84.00 | $252.00 | None |
COUMADIN 5MG VIAL |
4 |
Tier 4 |
$84.00 | $252.00 | None |
COUMADIN 6MG TABLET |
4 |
Tier 4 |
$84.00 | $252.00 | None |
COUMADIN 7.5MG TABLET |
4 |
Tier 4 |
$84.00 | $252.00 | None |
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT |
4 |
Tier 4 |
$84.00 | $252.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT |
4 |
Tier 4 |
$84.00 | $252.00 | S |
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT |
4 |
Tier 4 |
$84.00 | $252.00 | S |
CRESTOR 10MG TABLET |
3 |
Tier 3 |
$34.00 | $102.00 | Q:30 /30Days |
CRESTOR 20MG TABLET |
3 |
Tier 3 |
$34.00 | $102.00 | Q:30 /30Days |
CRESTOR 40mg/1 30 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
3 |
Tier 3 |
$34.00 | $102.00 | Q:30 /30Days |
CRESTOR 5MG TABLET |
3 |
Tier 3 |
$34.00 | $102.00 | Q:30 /30Days |
CRIXIVAN 100MG CAPSULE |
3 |
Tier 3 |
$34.00 | $102.00 | None |
CRIXIVAN 200MG CAPSULE |
3 |
Tier 3 |
$34.00 | $102.00 | None |
CRIXIVAN 400mg/1 90 CAPSULE in 1 BOTTLE |
3 |
Tier 3 |
$34.00 | $102.00 | None |
CROMOLYN NEBULIZER SOLUTION |
2* |
Tier 2 |
$15.00 | $45.00 | P Q:240 /30Days |
CROMOLYN SODIUM 100 MG/5 ML |
4 |
Tier 4 |
$84.00 | $252.00 | Q:960 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CROMOLYN SODIUM 4% 40MG 10ML BOT |
2* |
Tier 2 |
$15.00 | $45.00 | None |
CUBICIN 500MG VIAL |
5 |
Tier 5 |
30% | 30% | P |
CUPRIMINE CAPSULES 250MG (100 CT) |
4 |
Tier 4 |
$84.00 | $252.00 | None |
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT) |
2* |
Tier 2 |
$15.00 | $45.00 | P |
CYCLOBENZAPRINE HCL 5MG TABLET (500 CT) |
2* |
Tier 2 |
$15.00 | $45.00 | P |
CYCLOPHOSPHAMIDE 25MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | P |
CYCLOPHOSPHAMIDE 50MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | P |
Cyclosporine 100mg/1 30 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK |
4 |
Tier 4 |
$84.00 | $252.00 | P |
Cyclosporine 50mg/1 30 BLISTER PACK in 1 CARTON / 1 CAPSULE, LIQUID FILLED in 1 BLISTER PACK |
2* |
Tier 2 |
$15.00 | $45.00 | P |
Cyclosporine 50mg/mL 10 VIAL in 1 BOX / 5 mL in 1 VIAL |
2* |
Tier 2 |
$15.00 | $45.00 | P |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT |
2* |
Tier 2 |
$15.00 | $45.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYKLOKAPRON 100MG/ML AMPUL |
3 |
Tier 3 |
$34.00 | $102.00 | P |
CYMBALTA 20MG CAPSULE |
4 |
Tier 4 |
$84.00 | $252.00 | Q:30 /30Days |
Cymbalta 60mg/1 1000 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
4 |
Tier 4 |
$84.00 | $252.00 | Q:60 /30Days |
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT) |
4 |
Tier 4 |
$84.00 | $252.00 | Q:30 /30Days |
CYPROHEPTADINE HCL 4 MG |
4 |
Tier 4 |
$84.00 | $252.00 | P |
CYSTADANE POWDER FOR ORAL SOLUTION 180GM |
4 |
Tier 4 |
$84.00 | $252.00 | None |
CYTARABINE 20MG/ML VIAL |
2* |
Tier 2 |
$15.00 | $45.00 | P |
CYTARABINE 500MG VIAL |
2* |
Tier 2 |
$15.00 | $45.00 | P |