2012 Medicare Part D Plan Formulary Information |
Advantage by Managed Health Services (HMO SNP) (H8189-001-0)
Sanctioned Plan
|
The Advantage by Managed Health Services (HMO SNP) (H8189-001-0) Formulary Drugs Starting with the Letter C in Marathon 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 |
$0.00 | $0.00 | None |
CALCIJEX 1 MCG/ML AMPUL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CALCIPOTRIENE TOPICAL SOLUTION |
1* |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY |
1* |
Tier 1 |
$0.00 | $0.00 | Q:4 /30Days |
CALCITRIOL 0.25MCG CAPSULE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CALCITRIOL 0.5MCG CAPSULE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CALCITRIOL 1MCG/ML SOLUTION ORAL |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CALCITRIOL INJ 1MCG/ML |
4 |
Tier 4 |
$95.00 | $95.00 | None |
Calcium Acetate 667mg/1 200 TABLET in 1 BOTTLE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CALCIUM ACETATE CAPSULE 667 MG |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAMILA 0.35MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | Q:28 /28Days |
CAMPATH INJECTION 30 MG/ML |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CAMPRAL 333MG DOSE PAK |
2 |
Tier 2 |
$45.00 | $45.00 | None |
Camptosar 20mg/mL 1 VIAL, SINGLE-DOSE in 1 CARTON / 5 mL in 1 VIAL, SINGLE-DOSE |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX |
2 |
Tier 2 |
$45.00 | $45.00 | None |
CANCIDAS IV 50MG VIAL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CANCIDAS IV 70MG VIAL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CAPASTAT SULFATE 1g/1 1 INJECTION, POWDER, FOR SOLUTION in 1 CARTON |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CAPRELSA 100mg/1 30 TABLET in 1 BOTTLE, PLASTIC |
2 |
Tier 2 |
$45.00 | $45.00 | None |
CAPRELSA 300mg/1 30 TABLET in 1 BOTTLE, PLASTIC |
2 |
Tier 2 |
$45.00 | $45.00 | None |
CAPTOPRIL 100MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAPTOPRIL 12.5MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CAPTOPRIL 25MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CAPTOPRIL 50MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Captopril and Hydrochlorothiazide 25; 15mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Captopril and Hydrochlorothiazide 25; 25mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Captopril and Hydrochlorothiazide 50; 15mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Captopril and Hydrochlorothiazide 50; 25mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Carbamazepine 100mg/1 100 TABLET, CHEWABLE in 1 BOTTLE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Carbamazepine 100mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Carbamazepine 200mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Carbamazepine 300mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
1* |
Tier 1 |
$0.00 | $0.00 | 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 |
$0.00 | $0.00 | None |
CARBAMAZEPINE EXTENDED RELEASE TABLETS 400MG |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CARBAMAZEPINE ORAL SUSPENSION 100 MG/5ML |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CARBAMAZEPINE TABLET USP 200MG (1000 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Carbatrol 100mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
2 |
Tier 2 |
$45.00 | $45.00 | None |
CARBATROL 200MG CAPSULE SA |
2 |
Tier 2 |
$45.00 | $45.00 | None |
CARBATROL 300MG CAPSULE SA |
2 |
Tier 2 |
$45.00 | $45.00 | None |
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Carbidopa and Levodopa 25; 100mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Carbidopa and Levodopa 50; 200mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;100MG;MG 100 BOT |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;250MG;MG 100 BOT |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CARBIDOPA/LEVO 10/100 TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CARBIDOPA/LEVO 25/100 TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CARBIDOPA/LEVO 25/250 TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Carboplatin 10mg/mL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CARIMUNE NF 3GM VIAL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CARTIA XT 120MG CAPSULE SA |
1* |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
CARTIA XT 180MG CAPSULE SA |
1* |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
CARTIA XT 240MG CAPSULE SA |
1* |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
CARTIA XT 300MG CAPSULE SR 24 HR |
1* |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Carvedilol 12.5mg/1 |
1* |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
Carvedilol 25mg/1 |
1* |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
Carvedilol 3.125mg/1 |
1* |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
Carvedilol 6.25mg/1 500 TABLET, FILM COATED in 1 BOTTLE |
1* |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
CEENU 100MG CAPSULE |
2 |
Tier 2 |
$45.00 | $45.00 | None |
CEENU 10MG CAPSULE |
2 |
Tier 2 |
$45.00 | $45.00 | None |
CEENU 40MG CAPSULE |
2 |
Tier 2 |
$45.00 | $45.00 | None |
CEFACLOR CAPSULES |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CEFACLOR CAPSULES |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CEFACLOR ER 500MG TABLET SR 12HR |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CEFADROXIL 1G TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cefadroxil 500mg/1 |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Cefadroxil 500mg/5mL |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CEFADROXIL FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE |
4 |
Tier 4 |
$95.00 | $95.00 | None |
Cefazolin 1g/1 |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CEFAZOLIN 1GM/D5W BAG |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CEFAZOLIN FOR INJECTION |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CEFDINIR CAPSULES 300MG (60 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CEFEPIME HCL 2 GRAM VIAL |
4 |
Tier 4 |
$95.00 | $95.00 | 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 |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CEFOTAXIME FOR INJECTION |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CEFOTAXIME FOR INJECTION 1GM 50 BOX VIALGL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CEFOTAXIME FOR INJECTION 2GM 25 VIAL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CEFOTAXIME FOR INJECTION 500MG 10 VIAL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
Cefoxitin 1g/1 10 POWDER in 1 CARTON |
4 |
Tier 4 |
$95.00 | $95.00 | None |
Cefoxitin 2g/1 10 POWDER in 1 CARTON |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CEFOXITIN FOR INJECTION SOLUTION |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CEFPODOXIME TAB 200MG |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CEFPROZIL 125mg/5mL |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cefprozil 250mg/1 100 TABLET, FILM COATED in 1 BOTTLE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CEFPROZIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CEFTRIAXONE 10GM VIAL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CEFTRIAXONE FOR INJECTION |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CEFTRIAXONE FOR INJECTION |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CEFTRIAXONE FOR INJECTION 250MG BOX OF 10 VIALGL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
Ceftriaxone Sodium 500mg/1 |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CEFUROXIME 250MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CEFUROXIME AXETIL 500MG TABLET (20 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CEFUROXIME FOR INJECTION |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CEFUROXIME FOR INJECTION |
4 |
Tier 4 |
$95.00 | $95.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFUROXIME FOR INJECTION |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CELLCEPT 200MG/ML ORAL SUSP |
2 |
Tier 2 |
$45.00 | $45.00 | P |
CELLCEPT IV INJ 500MG |
4 |
Tier 4 |
$95.00 | $95.00 | P |
CELONTIN 300MG KAPSEAL |
2 |
Tier 2 |
$45.00 | $45.00 | None |
Cephalexin 125mg/5mL 200 mL in 1 BOTTLE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CEPHALEXIN 250MG CAPSULE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CEPHALEXIN 250MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CEPHALEXIN 250MG/5ML ORAL SUSP |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CEPHALEXIN 500MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CEPHALEXIN CAPSULES 500MG (500 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CEREDASE 80UNITS/ML VIAL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEREZYME INJ 200UNIT |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CERUBIDINE 20MG VIAL |
2 |
Tier 2 |
$45.00 | $45.00 | None |
CESIA 7 DAYS X 3 TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | Q:28 /28Days |
CHANTIX 0.5MG TABLET |
2 |
Tier 2 |
$45.00 | $45.00 | Q:56 /28Days |
CHANTIX 1MG TABLET |
2 |
Tier 2 |
$45.00 | $45.00 | Q:56 /28Days |
CHANTIX STARTING MONTH PAK |
2 |
Tier 2 |
$45.00 | $45.00 | None |
CHEMET 100MG CAPSULE |
2 |
Tier 2 |
$45.00 | $45.00 | None |
CHLORAMPHEN NA SUCC 1GM VL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CHLORDIAZEPOXIDE AND AMITRIPTYLINE HCL TABLET 12.5-5MG (500 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CHLOROQUINE PH 500MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLOROQUINE PHOSPHATE 250MG TABLET (50 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CHLOROTHIAZIDE 250MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CHLOROTHIAZIDE 500MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CHLORPROMAZINE 10MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CHLORPROMAZINE 25MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CHLORPROMAZINE 25MG/ML AMP |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CHLORPROMAZINE 50MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CHLORPROMAZINE HCL 200MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Chlorpromazine Hydrochloride 100mg/1 1000 TABLET, SUGAR COATED in 1 BOTTLE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CHLORPROPAMIDE 100MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Chlorpropamide 250mg/1 1000 TABLET in 1 BOTTLE, PLASTIC |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLORTHALIDONE 25MG TABLET (100 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CHLORTHALIDONE 50MG TABLET (1000 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CHLORZOXAZONE 500 MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CHORIONIC GONAD 10000U VIAL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
Ciclopirox 7.7mg/mL 60 mL in 1 BOTTLE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Ciclopirox Olamine 7.7mg/g 1 TUBE in 1 TUBE / 15 g in 1 TUBE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CILOSTAZOL 50 MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CILOSTAZOL TABLET 100MG (60 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CIMETIDINE 150MG/ML VIAL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
Cimetidine 200mg/1 100 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cimetidine 400mg/1 100 TABLET, FILM COATED in 1 BOTTLE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Cimetidine 800mg/1 100 TABLET, FILM COATED in 1 BOTTLE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Cimetidine Hydrochloride Oral Solution 300mg/5mL 237 mL in 1 BOTTLE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CIMETIDINE TABLETS |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CIPRO IV INFUSION 200MG 100ML BAG |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CIPRODEX OTIC SUSPENSION |
2 |
Tier 2 |
$45.00 | $45.00 | None |
CIPROFLOXACIN 0.3% EYE DROP |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CIPROFLOXACIN 250MG TABLET (100 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Ciprofloxacin 400mg/40mL 1 VIAL in 1 CARTON / 40 mL in 1 VIAL |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CIPROFLOXACIN 500MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CIPROFLOXACIN HCL 100MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIPROFLOXACIN TABLETS 750MG 100 BOT |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Cisplatin 100mg/100mL 1 VIAL in 1 CARTON / 100 mL in 1 VIAL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CITALOPRAM HBR 20 MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CITOLOPRAM HBR 10MG TABLET (100 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLADRIBINE 1MG/ML VIAL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CLAFORAN 10GM VIAL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CLAFORAN 500MG VIAL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CLAFORAN INJECTION ADD VANTAGE SYSTEM 1GM 25 X 1GM VIAL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CLAFORAN INJECTION STERILE 2GM 10 X 2GM VIAL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLARAVIS 10MG CAPSULE |
1* |
Tier 1 |
$0.00 | $0.00 | P |
CLARAVIS 20MG CAPSULE |
1* |
Tier 1 |
$0.00 | $0.00 | P |
Claravis 30mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLARAVIS 40MG CAPSULE |
1* |
Tier 1 |
$0.00 | $0.00 | P |
CLARITHROMYCIN 250MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | Q:28 /14Days |
CLARITHROMYCIN 500MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | Q:42 /21Days |
CLARITHROMYCIN FOR ORAL SUSPENSION |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLARITHROMYCIN FOR ORAL SUSPENSION |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLEMASTINE FUM 2.68MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLEMASTINE FUMARATE SYRUP |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLEOCIN 300MG/D5W/GALAXY |
4 |
Tier 4 |
$95.00 | $95.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLEOCIN 600MG/D5W/GALAXY |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CLEOCIN 900MG/D5W/GALAXY |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CLIMARA 0.025MG/DAY PATCH |
2 |
Tier 2 |
$45.00 | $45.00 | Q:4 /28Days |
CLIMARA 0.0375MG/DAY PATCH |
2 |
Tier 2 |
$45.00 | $45.00 | Q:4 /28Days |
CLIMARA 0.05MG/24H PATCH |
2 |
Tier 2 |
$45.00 | $45.00 | Q:4 /28Days |
CLIMARA 0.06/MG DAY PATCH |
2 |
Tier 2 |
$45.00 | $45.00 | Q:4 /28Days |
CLIMARA 0.075MG/DAY PATCH |
2 |
Tier 2 |
$45.00 | $45.00 | Q:4 /28Days |
CLIMARA 0.1MG/24H PATCH |
2 |
Tier 2 |
$45.00 | $45.00 | Q:4 /28Days |
CLIMARA PRO DIS WEEKLY 4.40MG/1.39MG |
2 |
Tier 2 |
$45.00 | $45.00 | Q:4 /28Days |
CLINDAMYCIN 150MG/ML ADDVAN |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CLINDAMYCIN HCL 150MG CAPSULE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINDAMYCIN HYDROCHLORIDE CAPSULES |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLINDAMYCIN PHOSP 1% LOTION |
1* |
Tier 1 |
$0.00 | $0.00 | None |
clindamycin phosphate 10mg/mL 1 BOTTLE in 1 CARTON / 60 mL in 1 BOTTLE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Clindamycin Phosphate and Benzoyl Peroxide 1 KIT |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLINDAMYCIN PHOSPHATE VAGINAL CREAM |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLINIMIX 2.75%/5% INJECTION 1000ML BAG |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CLINIMIX 4.25/10 SOLUTION |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CLINIMIX 4.25/20 SOLUTION |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CLINIMIX 4.25/25 SOLUTION |
4 |
Tier 4 |
$95.00 | $95.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINIMIX 4.25/5 SOLUTION |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CLINIMIX 5/15 SOLUTION |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CLINIMIX 5/20 SOLUTION |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CLINIMIX E 2.75/10 SOLUTION |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CLINIMIX E 2.75/5 SOLUTION |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CLINIMIX E 4.25/25 SOLUTION |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CLINIMIX E 4.25/5 SOLUTION |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CLINIMIX E 5/20 SOLUTION |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CLINIMIX E 5/25 SOLUTION |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CLINIMIX E 5%/15% INJECTION 2000ML BAG |
4 |
Tier 4 |
$95.00 | $95.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINISOL 15% SOLUTION |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CLOBETASOL 0.05% OINTMENT |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLOBETASOL E 0.05% CREAM |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Clobetasol Propionate 0.5mg/mL 50 mL in 1 BOTTLE, PLASTIC |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLOLAR 1MG/ML VIAL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CLOMIPRAMINE HCL 25MG CAPSULE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLOMIPRAMINE HCL 50MG CAPSULE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLOMIPRAMINE HCL 75MG CAPSULE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLONIDINE HCL 0.2MG TABLET (500 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLONIDINE HCL TABLET 0.1MG (500 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLONIDINE HCL TABLET 0.3MG (100 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOPIDOGREL 300 MG tablet |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLOPIDOGREL TAB 75MG |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLOTRIMAZOLE 1% CREAM |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLOTRIMAZOLE 10MG TROCHE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLOTRIMAZOLE SOLUTION TOPICAL 1% 30ML BOTPL |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLOZAPINE 100mg/1 100 TABLET in 1 BOTTLE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLOZAPINE 200MG TABLET (500 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLOZAPINE 25MG TABLET (100 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CLOZAPINE 50MG TABLET (500 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CO-GESIC 5/500 TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | Q:240 /30Days |
COARTEM 20MG-120MG |
2 |
Tier 2 |
$45.00 | $45.00 | None |
COGENTIN 1MG/ML AMPUL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
Colcrys 0.6mg/1 100 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
2 |
Tier 2 |
$45.00 | $45.00 | None |
COLESTIPOL HCL 1G TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
COLESTIPOL HYDROCHLORIDE 5g/1 100 SUSPENSION in 1 BOTTLE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
colistimethate 150mg/2mL 1 VIAL in 1 CARTON / 2 mL in 1 VIAL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE |
2 |
Tier 2 |
$45.00 | $45.00 | None |
COMBIGAN 0.2%-0.5% DROPS |
2 |
Tier 2 |
$45.00 | $45.00 | None |
COMBIVENT INHALER |
2 |
Tier 2 |
$45.00 | $45.00 | Q:45 /30Days |
COMBIVIR 150; 300mg/1; mg/1 120 TABLET, FILM COATED in 1 DOSE PACK |
2 |
Tier 2 |
$45.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1 |
2 |
Tier 2 |
$45.00 | $45.00 | None |
COMPRO 25MG SUPPOSITORY |
1* |
Tier 1 |
$0.00 | $0.00 | None |
COMTAN 200MG TABLET |
2 |
Tier 2 |
$45.00 | $45.00 | Q:240 /30Days |
COMVAX VACCINE VIAL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CONSTULOSE 10GM/15ML SYRUP |
1* |
Tier 1 |
$0.00 | $0.00 | None |
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CORDARONE 200MG TABLET |
2 |
Tier 2 |
$45.00 | $45.00 | None |
CORTEF 5MG TABLET |
2 |
Tier 2 |
$45.00 | $45.00 | None |
CORTISONE ACETATE 25MG TABLET (100 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Cortomycin 10; 3.5; 10000mg/mL; mg/mL; [USP'U]/mL 1 10 mL BOTTLE, DROPPER |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Cortomycin 10; 3.5; 10000mg/mL; mg/mL; [USP'U]/mL 1 10 mL BOTTLE, DROPPER |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COSMEGEN 0.5MG VIAL |
2 |
Tier 2 |
$45.00 | $45.00 | None |
COUMADIN 10MG TABLET |
2 |
Tier 2 |
$45.00 | $45.00 | None |
COUMADIN 1MG TABLET |
2 |
Tier 2 |
$45.00 | $45.00 | None |
COUMADIN 2.5MG TABLET |
2 |
Tier 2 |
$45.00 | $45.00 | None |
COUMADIN 2MG TABLET |
2 |
Tier 2 |
$45.00 | $45.00 | None |
COUMADIN 3mg/1 1 BOTTLE in 1 CARTON / 100 TABLET in 1 BOTTLE |
2 |
Tier 2 |
$45.00 | $45.00 | None |
COUMADIN 4mg/1 1 BOTTLE in 1 CARTON / 100 TABLET in 1 BOTTLE |
2 |
Tier 2 |
$45.00 | $45.00 | None |
COUMADIN 5MG TABLET |
2 |
Tier 2 |
$45.00 | $45.00 | None |
COUMADIN 5MG VIAL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
COUMADIN 6MG TABLET |
2 |
Tier 2 |
$45.00 | $45.00 | None |
COUMADIN 7.5MG TABLET |
2 |
Tier 2 |
$45.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT |
2 |
Tier 2 |
$45.00 | $45.00 | None |
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT |
2 |
Tier 2 |
$45.00 | $45.00 | None |
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT |
2 |
Tier 2 |
$45.00 | $45.00 | None |
CRIXIVAN 100MG CAPSULE |
2 |
Tier 2 |
$45.00 | $45.00 | None |
CRIXIVAN 200MG CAPSULE |
2 |
Tier 2 |
$45.00 | $45.00 | None |
CRIXIVAN 400mg/1 90 CAPSULE in 1 BOTTLE |
2 |
Tier 2 |
$45.00 | $45.00 | None |
CROMOLYN NEBULIZER SOLUTION |
1* |
Tier 1 |
$0.00 | $0.00 | P |
CROMOLYN SODIUM 4% 40MG 10ML BOT |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CUBICIN 500MG VIAL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CUPRIMINE CAPSULES 250MG (100 CT) |
2 |
Tier 2 |
$45.00 | $45.00 | None |
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYCLOBENZAPRINE HCL 5MG TABLET (500 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | Q:90 /30Days |
CYCLOPHOSPHAMIDE 25MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CYCLOPHOSPHAMIDE 50MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CYCLOSPORINE 100MG CAPSULE |
1* |
Tier 1 |
$0.00 | $0.00 | P |
Cyclosporine 100mg/1 30 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK |
1* |
Tier 1 |
$0.00 | $0.00 | P |
CYCLOSPORINE 25MG CAPSULE |
1* |
Tier 1 |
$0.00 | $0.00 | P |
Cyclosporine 50mg/1 30 BLISTER PACK in 1 CARTON / 1 CAPSULE, LIQUID FILLED in 1 BLISTER PACK |
1* |
Tier 1 |
$0.00 | $0.00 | P |
Cyclosporine 50mg/mL 10 VIAL in 1 BOX / 5 mL in 1 VIAL |
4 |
Tier 4 |
$95.00 | $95.00 | P |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT |
1* |
Tier 1 |
$0.00 | $0.00 | P |
CYKLOKAPRON 100MG/ML AMPUL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CYMBALTA 20MG CAPSULE |
2 |
Tier 2 |
$45.00 | $45.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cymbalta 60mg/1 1000 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
2 |
Tier 2 |
$45.00 | $45.00 | Q:30 /30Days |
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT) |
2 |
Tier 2 |
$45.00 | $45.00 | Q:60 /30Days |
CYPROHEPTADINE HCL 4 MG |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL |
1* |
Tier 1 |
$0.00 | $0.00 | None |
CYSTADANE POWDER FOR ORAL SOLUTION 180GM |
2 |
Tier 2 |
$45.00 | $45.00 | None |
CYSTAGON 150MG CAPSULE |
2 |
Tier 2 |
$45.00 | $45.00 | None |
CYSTAGON 50MG CAPSULE |
2 |
Tier 2 |
$45.00 | $45.00 | None |
CYTARABINE 20MG/ML VIAL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CYTARABINE 500MG VIAL |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CYTARABINE SOLUTION INJECTION 100MG 20ML VIALSD |
4 |
Tier 4 |
$95.00 | $95.00 | None |
CYTOMEL 25MCG TABLET |
2 |
Tier 2 |
$45.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYTOMEL 50MCG TABLET |
2 |
Tier 2 |
$45.00 | $45.00 | None |
CYTOMEL 5MCG TABLET |
2 |
Tier 2 |
$45.00 | $45.00 | None |