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 P in RIPLEY County, MO: CMS MA Region 15 which includes: MO
|
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 |
PANCREAZE 10,500 UNIT CAP DR |
3 |
Tier 3 |
$34.00 | $102.00 | None |
PANCREAZE 16,800 UNIT CAP DR |
3 |
Tier 3 |
$34.00 | $102.00 | None |
PANCREAZE 21,000 UNIT CAP DR |
3 |
Tier 3 |
$34.00 | $102.00 | None |
PANCREAZE 4,200 UNIT CAP DR |
3 |
Tier 3 |
$34.00 | $102.00 | None |
PANRETIN 0.1% GEL 60GM TUBE |
4 |
Tier 4 |
$84.00 | $252.00 | None |
Pantoprazole 40mg/1 90 TABLET, DELAYED RELEASE in 1 BOTTLE |
4 |
Tier 4 |
$84.00 | $252.00 | Q:30 /30Days |
PANTOPRAZOLE SODIUM 20MG TABLET DELAYED RELEASE |
4 |
Tier 4 |
$84.00 | $252.00 | Q:30 /30Days |
PAROMOMYCIN 250MG CAPSULE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PAROXETINE FILM COATED 20MG TABLET (100 CT) |
2* |
Tier 2 |
$15.00 | $45.00 | Q:45 /30Days |
PAROXETINE HCL 10MG/5ML SUSPENSION ORAL |
2* |
Tier 2 |
$15.00 | $45.00 | Q:900 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAROXETINE HCL TABLET 24 12.5MG |
4 |
Tier 4 |
$84.00 | $252.00 | Q:30 /30Days |
PAROXETINE HCL TABLET 24 25MG |
4 |
Tier 4 |
$84.00 | $252.00 | Q:90 /30Days |
Paroxetine Hydrochloride 37.5mg/1 30 BOTTLE in 1 BOTTLE / 30 TABLET, FILM COATED, EXTENDED RELEASE |
4 |
Tier 4 |
$84.00 | $252.00 | Q:60 /30Days |
PAROXETINE HYDROCHLORIDE TABLETS 10 MG |
2* |
Tier 2 |
$15.00 | $45.00 | Q:45 /30Days |
PAROXETINE TABLETS 30MG 90 BOT |
2* |
Tier 2 |
$15.00 | $45.00 | Q:60 /30Days |
PAROXETINE40mg/1 |
2* |
Tier 2 |
$15.00 | $45.00 | Q:45 /30Days |
PATADAY 0.2% DROPS |
4 |
Tier 4 |
$84.00 | $252.00 | None |
PATANOL 0.1% EYE DROPS |
4 |
Tier 4 |
$84.00 | $252.00 | None |
PEDVAXHIB VACCINE VIAL |
3 |
Tier 3 |
$34.00 | $102.00 | None |
PEGANONE 250MG TABLET |
4 |
Tier 4 |
$84.00 | $252.00 | None |
PEGASYS 180MCG/0.5ML CONV.PK |
5 |
Tier 5 |
30% | 30% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEGASYS INJECTION |
5 |
Tier 5 |
30% | 30% | P |
PEGASYS PROCLICK 135 MCG/0.5 |
5 |
Tier 5 |
30% | 30% | P |
PEGINTRON 1 KIT in 1 CARTON |
5 |
Tier 5 |
30% | 30% | P |
PegIntron 120ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE |
5 |
Tier 5 |
30% | 30% | P |
PegIntron 150ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE |
5 |
Tier 5 |
30% | 30% | P |
PegIntron 50ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE |
5 |
Tier 5 |
30% | 30% | P |
PegIntron 80ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE |
5 |
Tier 5 |
30% | 30% | P |
PENICILLIN G POTASSIUM FOR INJECTION 5000000UNIT/VIAL |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PENICILLIN V POTASSIUM 250MG TABLET (1000 CT) |
1* |
Tier 1 |
$5.00 | $15.00 | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PENICILLIN V POTASSIUM 500MG 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 |
PENICILLIN V POTASSIUM FOR ORAL SOLUTION CONCENTRATE 125MG 200ML BOT |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PENTASA 250MG CAPSULE SA |
4 |
Tier 4 |
$84.00 | $252.00 | Q:240 /30Days |
PENTASA 500MG CAPSULE |
4 |
Tier 4 |
$84.00 | $252.00 | Q:240 /30Days |
PENTOXIFYLLINE 400MG TABLET SA |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Perindopril Erbumine 2mg/1 100 TABLET in 1 BOTTLE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Perindopril Erbumine 4mg/1 100 TABLET in 1 BOTTLE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Perindopril Erbumine 8mg/1 100 TABLET in 1 BOTTLE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Permethrin 50mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PERPHENAZINE 16 MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PERPHENAZINE TABLETS 4MG 100 BOXUD |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PERPHENAZINE TABLETS 8MG 100 BOT |
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 |
PERPHENAZINE TABLETS USP 2MG 100 BOT |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Phenelzine Sulfate 15mg/1 60 TABLET in 1 BOTTLE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PHENYTOIN SOD EXT 200 MG CAP |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PHENYTOIN SODIUM INJECTION 50MG 25 X 2ML AMP |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PHOSPHOLINE IODIDE 0.125% |
3 |
Tier 3 |
$34.00 | $102.00 | None |
PILOCARPINE HCL 5MG TABLET (100 CT) |
4 |
Tier 4 |
$84.00 | $252.00 | None |
Pilocarpine Hydrochloride 7.5mg/1 100 TABLET, FILM COATED in 1 BOTTLE |
4 |
Tier 4 |
$84.00 | $252.00 | None |
PILOPINE HS 4% EYE GEL |
4 |
Tier 4 |
$84.00 | $252.00 | None |
PINDOLOL 10MG 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 |
PINDOLOL 5MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PIPERACILLIN 200 MG/ML / TAZOBACTAM 25 MG/ML INJECTABLE SOLUTION |
2* |
Tier 2 |
$15.00 | $45.00 | P |
Piperacillin and Tazobactam 4; 0.5g/1; g/1 10 VIAL, SINGLE-USE in 1 CARTON / 1 INJECTION, POWDER, L |
2* |
Tier 2 |
$15.00 | $45.00 | P |
PIROXICAM 10 MG CAPSULE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Piroxicam 20mg/1 500 CAPSULE in 1 BOTTLE |
1* |
Tier 1 |
$5.00 | $15.00 | None |
PLAVIX 75MG TABLET |
3 |
Tier 3 |
$34.00 | $102.00 | None |
PODOFILOX 0.5% TOPICAL TUBEX |
2* |
Tier 2 |
$15.00 | $45.00 | None |
POLY-DEX 0.1% SUSPENSION DROPS |
1* |
Tier 1 |
$5.00 | $15.00 | None |
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
POLYETHYLENE GLYCOL 3350 105 MG/ML / POTASSIUM CHLORIDE 0.00497 MEQ/ML / SODIUM BICARBONATE 1.43 MG/ |
2* |
Tier 2 |
$15.00 | $45.00 | None |
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1% |
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 |
POLYMYXIN B SULFATE VIAL |
4 |
Tier 4 |
$84.00 | $252.00 | None |
PORTIA 0.15-0.03 TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | Q:28 /28Days |
POTASSIUM CHLORIDE 10MEQ/100ML SOL |
2* |
Tier 2 |
$15.00 | $45.00 | None |
POTASSIUM CHLORIDE 149mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 5 mL in 1 VIAL, SINGLE-DOSE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Potassium Chloride 20.000000meq/1 |
2* |
Tier 2 |
$15.00 | $45.00 | None |
POTASSIUM CHLORIDE 20MEQ/50ML SOL |
2* |
Tier 2 |
$15.00 | $45.00 | None |
POTASSIUM CHLORIDE ER CAPSULES 10MEQ |
2* |
Tier 2 |
$15.00 | $45.00 | None |
POTASSIUM CHLORIDE ER CPCR 8MEQ |
2* |
Tier 2 |
$15.00 | $45.00 | None |
POTASSIUM CHLORIDE EXTENDED RELEASE TABLETS |
2* |
Tier 2 |
$15.00 | $45.00 | None |
POTASSIUM CITRATE 10MEQ TABLET SA |
2* |
Tier 2 |
$15.00 | $45.00 | None |
POTASSIUM CITRATE 5MEQ TABLET SA |
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 |
POTIGA 200 MG TABLET |
4 |
Tier 4 |
$84.00 | $252.00 | Q:180 /30Days |
POTIGA 300 MG TABLET |
4 |
Tier 4 |
$84.00 | $252.00 | Q:120 /30Days |
POTIGA 400 MG TABLET |
4 |
Tier 4 |
$84.00 | $252.00 | Q:90 /30Days |
POTIGA 50 MG TABLET |
4 |
Tier 4 |
$84.00 | $252.00 | Q:720 /30Days |
PRADAXA 150mg/1 1 BOTTLE in 1 CARTON / 60 CAPSULE in 1 BOTTLE |
4 |
Tier 4 |
$84.00 | $252.00 | P Q:60 /30Days |
PRADAXA 75mg/1 1 BOTTLE in 1 CARTON / 60 CAPSULE in 1 BOTTLE |
4 |
Tier 4 |
$84.00 | $252.00 | P Q:60 /30Days |
PRAMIPEXOLE 0.125 MG TABLET |
4 |
Tier 4 |
$84.00 | $252.00 | None |
PRAMIPEXOLE 0.25 MG TABLET |
4 |
Tier 4 |
$84.00 | $252.00 | None |
PRAMIPEXOLE 0.5 MG TABLET |
4 |
Tier 4 |
$84.00 | $252.00 | None |
PRAMIPEXOLE 1 MG TABLET |
4 |
Tier 4 |
$84.00 | $252.00 | None |
PRAMIPEXOLE 1.5 MG TABLET |
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 |
PRAMIPEXOLE DIHYDROCHLORIDE TABLETS |
4 |
Tier 4 |
$84.00 | $252.00 | None |
PRANDIN 0.5MG TABLET |
4 |
Tier 4 |
$84.00 | $252.00 | None |
PRANDIN 1MG TABLET |
4 |
Tier 4 |
$84.00 | $252.00 | None |
PRANDIN 2MG TABLET |
4 |
Tier 4 |
$84.00 | $252.00 | None |
PRAVASTATIN SODIUM 20MG TABLET 500 BOT |
2* |
Tier 2 |
$15.00 | $45.00 | Q:30 /30Days |
PRAVASTATIN SODIUM 40MG TABLET (500 CT) |
2* |
Tier 2 |
$15.00 | $45.00 | Q:30 /30Days |
PRAVASTATIN SODIUM 80MG TABLET (90 CT) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT |
2* |
Tier 2 |
$15.00 | $45.00 | Q:30 /30Days |
PRAZOSIN 5MG CAPSULE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PRAZOSIN HCL 1MG CAPSULE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PRAZOSIN HCL 2MG CAPSULE |
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 |
PRED MILD 0.12% EYE DROPS |
4 |
Tier 4 |
$84.00 | $252.00 | None |
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PREDNISOLONE SOD 1% EYE DROP |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PREDNISONE 10MG TABLET (100 CT) |
1* |
Tier 1 |
$5.00 | $15.00 | None |
PREDNISONE 1MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PREDNISONE 2.5MG TABLET |
1* |
Tier 1 |
$5.00 | $15.00 | None |
PREDNISONE 20MG TABLET (1000 CT) |
1* |
Tier 1 |
$5.00 | $15.00 | None |
PREDNISONE 5 MG TABLET |
1* |
Tier 1 |
$5.00 | $15.00 | None |
PREDNISONE 50MG 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 |
PREDNISONE 5MG/5ML SOLUTION |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PREDNISONE 5MG/ML SOLUTION |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PREMARIN 0.3MG (100 CT) |
4 |
Tier 4 |
$84.00 | $252.00 | P |
PREMARIN 0.45MG TABLET |
4 |
Tier 4 |
$84.00 | $252.00 | P |
PREMARIN 0.625MG (100 CT) |
4 |
Tier 4 |
$84.00 | $252.00 | P |
Premarin 0.625mg/g |
4 |
Tier 4 |
$84.00 | $252.00 | Q:43 /30Days |
PREMARIN 0.9MG TABLET |
4 |
Tier 4 |
$84.00 | $252.00 | P |
PREMARIN 1.25MG (100 CT) |
4 |
Tier 4 |
$84.00 | $252.00 | P |
PREMARIN 25MG VIAL |
4 |
Tier 4 |
$84.00 | $252.00 | P |
Premphase 1 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
4 |
Tier 4 |
$84.00 | $252.00 | P |
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA |
4 |
Tier 4 |
$84.00 | $252.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREMPRO 0.45-1.5 MG TABLET 28 EA |
4 |
Tier 4 |
$84.00 | $252.00 | P |
Prempro 0.625; 2.5mg/1; mg/1 1 BLISTER PACK in 1 CARTON / 28 TABLET, SUGAR COATED in 1 BLISTER PACK |
4 |
Tier 4 |
$84.00 | $252.00 | P |
PREVALITE POW 4GM |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Previfem 6 BLISTER PACK in 1 BLISTER PACK / 1 KIT in 1 BLISTER PACK |
2* |
Tier 2 |
$15.00 | $45.00 | Q:28 /28Days |
PREVPAC (TRIPLE THERAPY) KIT 30;500;500MG;MG;MG; 14 PKGCOM |
4 |
Tier 4 |
$84.00 | $252.00 | Q:14 /365Days |
PREZISTA TABLET 600MG |
5 |
Tier 5 |
30% | 30% | None |
PREZISTA TABLET 75MG |
4 |
Tier 4 |
$84.00 | $252.00 | None |
PREZISTA TABLETS |
4 |
Tier 4 |
$84.00 | $252.00 | None |
PREZISTA TABLETS 400MG 60 TABLETS BOT |
5 |
Tier 5 |
30% | 30% | None |
PRIFTIN 150MG TABLET |
4 |
Tier 4 |
$84.00 | $252.00 | None |
PRIMAXIN I.M. 500MG VIAL |
4 |
Tier 4 |
$84.00 | $252.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Primidone 250mg/1 100 TABLET in 1 BOTTLE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Primidone 50mg/1 500 TABLET in 1 BOTTLE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PRISTIQ 100MG TABLET SR 24HR |
4 |
Tier 4 |
$84.00 | $252.00 | None |
Pristiq Extended-Release 50mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
4 |
Tier 4 |
$84.00 | $252.00 | Q:30 /30Days |
PROAIR HFA 90MCG HFA AEROSOL WITH ADAPTER |
3 |
Tier 3 |
$34.00 | $102.00 | Q:34 /30Days |
PROBENECID 500MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PROBENECID/COLCHICINE TABLET S |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PROCAINAMIDE 100MG/ML VIAL |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT) |
1* |
Tier 1 |
$5.00 | $15.00 | None |
PROCHLORPERAZINE MALEATE 5MG TABLET (100 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 |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PROCRIT 10000U/ML VIAL |
3 |
Tier 3 |
$34.00 | $102.00 | P Q:12 /30Days |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL |
3 |
Tier 3 |
$34.00 | $102.00 | P Q:12 /30Days |
PROCRIT 3000U/ML VIAL |
3 |
Tier 3 |
$34.00 | $102.00 | P Q:12 /30Days |
PROCRIT 40000U/ML VIAL PR |
5 |
Tier 5 |
30% | 30% | P Q:6 /30Days |
PROCRIT 4000U/ML VIAL 25 X 1ML VIAL |
3 |
Tier 3 |
$34.00 | $102.00 | P Q:12 /30Days |
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY |
5 |
Tier 5 |
30% | 30% | P Q:12 /30Days |
PROCTO-PAK 1% CREAM |
1* |
Tier 1 |
$5.00 | $15.00 | None |
Proctocream HC 25mg/g |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PROCTOSOL-HC 2.5% CREAM |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PROCTOZONE-HC 2.5% CREAM |
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 |
PROGESTERONE 100 MG CAPSULE |
4 |
Tier 4 |
$84.00 | $252.00 | Q:12 /28Days |
PROGESTERONE 200 MG CAPSULE |
4 |
Tier 4 |
$84.00 | $252.00 | Q:20 /28Days |
Proglycem 50mg/mL 1 BOTTLE, DROPPER in 1 BOX / 30 mL in 1 BOTTLE, DROPPER |
4 |
Tier 4 |
$84.00 | $252.00 | None |
PROLASTIN 500MG VIAL |
5 |
Tier 5 |
30% | 30% | P |
PROLASTIN-C 1 KIT in 1 CARTON |
5 |
Tier 5 |
30% | 30% | P |
PROLEUKIN 1.1mg/mL 1 VIAL, SINGLE-USE in 1 BOX / 1 mL in 1 VIAL, SINGLE-USE |
5 |
Tier 5 |
30% | 30% | P |
PROLIA INJECTION |
4 |
Tier 4 |
$84.00 | $252.00 | P |
PROMACTA 12.5 MG TABLET |
5 |
Tier 5 |
30% | 30% | P |
PROMACTA 25 MG TABLET |
5 |
Tier 5 |
30% | 30% | P |
PROMACTA 50 MG TABLET |
5 |
Tier 5 |
30% | 30% | P |
PROMACTA 75 MG TABLET |
5 |
Tier 5 |
30% | 30% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMETHAZINE 50MG/ML VIAL |
4 |
Tier 4 |
$84.00 | $252.00 | P |
PROMETHAZINE HCL 25MG TABLET (1000 CT) |
2* |
Tier 2 |
$15.00 | $45.00 | P |
PROMETHAZINE HCL 50MG TABLET (100 CT) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PROMETHAZINE HCL 6.25MG/5ML SYRUP |
2* |
Tier 2 |
$15.00 | $45.00 | P |
PROMETHAZINE HCL INJECTION 25MG 10 X 1ML VIAL |
4 |
Tier 4 |
$84.00 | $252.00 | P |
Promethazine Hydrochloride 12.5mg/1 100 TABLET in 1 BOTTLE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX |
2* |
Tier 2 |
$15.00 | $45.00 | P |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PROMETRIUM 100MG CAPSULE |
4 |
Tier 4 |
$84.00 | $252.00 | None |
PROMETRIUM 200MG CAPSULE |
4 |
Tier 4 |
$84.00 | $252.00 | None |
PROPAFENONE HCL 150MG TABLET (100 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 |
PROPAFENONE HCL 225MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PROPAFENONE HCL 300MG TABLET (100 CT) |
4 |
Tier 4 |
$84.00 | $252.00 | None |
Propafenone Hydrochloride 225mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PROPRANOLOL 60MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PROPRANOLOL 80 MG TABLET |
1* |
Tier 1 |
$5.00 | $15.00 | None |
PROPRANOLOL HCL 20MG TABLET (1000 CT) |
1* |
Tier 1 |
$5.00 | $15.00 | None |
PROPRANOLOL HCL INJECTION 1MG 10 PKG OF 10 CRTN |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PROPRANOLOL HCL TABLET USP 10MG (1000 CT) |
1* |
Tier 1 |
$5.00 | $15.00 | None |
PROPRANOLOL HCL TABLET USP 40MG (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 |
Propranolol Hydrochloride 120mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
4 |
Tier 4 |
$84.00 | $252.00 | None |
Propranolol Hydrochloride 160mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
4 |
Tier 4 |
$84.00 | $252.00 | None |
Propranolol Hydrochloride 60mg/1 1000 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
4 |
Tier 4 |
$84.00 | $252.00 | None |
Propranolol Hydrochloride 80mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
4 |
Tier 4 |
$84.00 | $252.00 | None |
PROPRANOLOL/HCTZ 40/25 TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PROPRANOLOL/HCTZ 80/25 TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PROPYLTHIOURACIL 50MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PROQUAD VIAL |
4 |
Tier 4 |
$84.00 | $252.00 | None |
Protonix I.V. 40mg/10mL 10 CARTON in 1 PACKAGE / 1 VIAL in 1 CARTON / 40 mL in 1 VIAL |
3 |
Tier 3 |
$34.00 | $102.00 | P |
PROTRIPTYLINE HYDROCHLORIDE TABLETS |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG |
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 |
PULMOZYME 1MG/ML AMPUL |
4 |
Tier 4 |
$84.00 | $252.00 | P Q:150 /30Days |
PYRAZINAMIDE 500MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |
PYRIDOSTIGMINE BROMIDE 60MG TABLET |
2* |
Tier 2 |
$15.00 | $45.00 | None |