2012 Medicare Part D Plan Formulary Information |
BlueMedicare Regional PPO (Regional PPO) (R3332-001-0)
Benefit Details
|
The BlueMedicare Regional PPO (Regional PPO) (R3332-001-0) Formulary Drugs Starting with the Letter P in Statewide County, FL: CMS MA Region 9 which includes: FL
|
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 |
PACERONE 200MG TABLET |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PACLITAXEL INJECTION SOLUTION 6MG 50ML VIALMD |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PAMELOR 10mg/1 30 CAPSULE in 1 BOTTLE |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PAMELOR 25mg/1 30 CAPSULE in 1 BOTTLE |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PAMELOR 50mg/1 30 CAPSULE in 1 BOTTLE |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PAMELOR 75mg/1 30 CAPSULE in 1 BOTTLE |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PAMINE FORTE TAB 5MG |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PAMINE TAB 2.5MG |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PANRETIN 0.1% GEL 60GM TUBE |
4 |
Tier 4 |
33% | 33% | None |
Pantoprazole 40mg/1 90 TABLET, DELAYED RELEASE in 1 BOTTLE |
1 |
Tier 1 |
$6.00 | $0.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PANTOPRAZOLE SODIUM 20MG TABLET DELAYED RELEASE |
1 |
Tier 1 |
$6.00 | $0.00 | Q:30 /30Days |
Parcopa 10; 100mg/1; mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
3 |
Tier 3 |
$85.00 | $255.00 | None |
Parcopa 25; 100mg/1; mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
3 |
Tier 3 |
$85.00 | $255.00 | None |
Parcopa 25; 250mg/1; mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PARLODEL 2.5MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PARLODEL 5MG CAPSULE |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PARNATE 10MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PAROMOMYCIN 250MG CAPSULE |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PAROXETINE FILM COATED 20MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $0.00 | Q:30 /30Days |
PAROXETINE HCL 10MG/5ML SUSPENSION ORAL |
1 |
Tier 1 |
$6.00 | $0.00 | Q:900 /30Days |
PAROXETINE HCL TABLET 24 12.5MG |
1 |
Tier 1 |
$6.00 | $0.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAROXETINE HCL TABLET 24 25MG |
1 |
Tier 1 |
$6.00 | $0.00 | Q:60 /30Days |
Paroxetine Hydrochloride 37.5mg/1 30 BOTTLE in 1 BOTTLE / 30 TABLET, FILM COATED, EXTENDED RELEASE |
1 |
Tier 1 |
$6.00 | $0.00 | Q:60 /30Days |
PAROXETINE HYDROCHLORIDE TABLETS 10 MG |
1 |
Tier 1 |
$6.00 | $0.00 | Q:30 /30Days |
PAROXETINE TABLETS 30MG 90 BOT |
1 |
Tier 1 |
$6.00 | $0.00 | Q:60 /30Days |
PAROXETINE40mg/1 |
1 |
Tier 1 |
$6.00 | $0.00 | Q:30 /30Days |
PASER GRANULES 4GM PACKET |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PATADAY 0.2% DROPS |
2 |
Tier 2 |
$45.00 | $135.00 | None |
PATANASE 665ug/1 240 SPRAY, METERED in 1 BOTTLE |
3 |
Tier 3 |
$85.00 | $255.00 | Q:31 /30Days |
PATANOL 0.1% EYE DROPS |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PAXIL CR 25mg/1 30 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE |
3 |
Tier 3 |
$85.00 | $255.00 | S Q:60 /30Days |
PAXIL CR TABLETS CONTROLLED RELEASE 12.5 MG |
3 |
Tier 3 |
$85.00 | $255.00 | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAXIL CR TABLETS EXTENDED RELEASE 37.5 MG |
3 |
Tier 3 |
$85.00 | $255.00 | S Q:60 /30Days |
PAXIL ORAL SUSPENSION 10 MG/5ML |
3 |
Tier 3 |
$85.00 | $255.00 | S Q:900 /30Days |
PAXIL TABLETS 10 MG |
3 |
Tier 3 |
$85.00 | $255.00 | S Q:30 /30Days |
PAXIL TABLETS 20 MG |
3 |
Tier 3 |
$85.00 | $255.00 | S Q:30 /30Days |
PAXIL TABLETS 30 MG |
3 |
Tier 3 |
$85.00 | $255.00 | S Q:60 /30Days |
PAXIL TABLETS 40 MG |
3 |
Tier 3 |
$85.00 | $255.00 | S Q:30 /30Days |
PEDI-DRI TOPICAL POWDER |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PEDIAPRED 6.7MG/5ML TUBEX |
3 |
Tier 3 |
$85.00 | $255.00 | P |
PEDVAXHIB VACCINE VIAL |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PEGANONE 250MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PEGASYS 180MCG/0.5ML CONV.PK |
4 |
Tier 4 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEGASYS INJECTION |
4 |
Tier 4 |
33% | 33% | P |
PEGASYS PROCLICK 135 MCG/0.5 |
4 |
Tier 4 |
33% | 33% | P |
PEGINTRON 1 KIT in 1 CARTON |
4 |
Tier 4 |
33% | 33% | P |
PegIntron 120ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE |
4 |
Tier 4 |
33% | 33% | P |
PegIntron 150ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE |
4 |
Tier 4 |
33% | 33% | P |
PegIntron 50ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE |
4 |
Tier 4 |
33% | 33% | P |
PegIntron 80ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE |
4 |
Tier 4 |
33% | 33% | P |
PENICILLIN G POTASSIUM 2MMUNITS/50ML ISO-OSM |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PENICILLIN G POTASSIUM 3MMUNITS/50ML ISO-OSM |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PENICILLIN G POTASSIUM FOR INJECTION 5000000UNIT/VIAL |
1 |
Tier 1 |
$6.00 | $0.00 | None |
Penicillin G Sodium 5000000[iU]/1 10 VIAL in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL |
3 |
Tier 3 |
$85.00 | $255.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENICILLIN V POTASSIUM 250MG TABLET (1000 CT) |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PENICILLIN V POTASSIUM 500MG TABLET |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PENICILLIN V POTASSIUM FOR ORAL SOLUTION CONCENTRATE 125MG 200ML BOT |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PENLAC 8% SOLUTION |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PENNSAID SOLUTION |
2 |
Tier 2 |
$45.00 | $135.00 | S Q:300 /30Days |
PENTAM 300 INJ 300MG |
3 |
Tier 3 |
$85.00 | $255.00 | P |
PENTASA 250MG CAPSULE SA |
2 |
Tier 2 |
$45.00 | $135.00 | None |
PENTASA 500MG CAPSULE |
2 |
Tier 2 |
$45.00 | $135.00 | None |
PENTOPAK 400MG TABLET SA |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PENTOSTATIN FOR INJECTION 10MG/VIAL |
4 |
Tier 4 |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENTOXIFYLLINE 400MG TABLET SA |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PEPCID 20MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PEPCID 40MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PERCODAN TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | Q:360 /30Days |
Perindopril Erbumine 2mg/1 100 TABLET in 1 BOTTLE |
1 |
Tier 1 |
$6.00 | $0.00 | None |
Perindopril Erbumine 4mg/1 100 TABLET in 1 BOTTLE |
1 |
Tier 1 |
$6.00 | $0.00 | None |
Perindopril Erbumine 8mg/1 100 TABLET in 1 BOTTLE |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PERIOGARD 0.12% ORAL RINSE |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PERIOSTAT DOXYCYCLINE HYCLATE TABLETS 20MG 100 BOT |
3 |
Tier 3 |
$85.00 | $255.00 | None |
Permethrin 50mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PERPHENAZINE 16 MG TABLET |
1 |
Tier 1 |
$6.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PERPHENAZINE TABLETS 4MG 100 BOXUD |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PERPHENAZINE TABLETS 8MG 100 BOT |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PERPHENAZINE TABLETS USP 2MG 100 BOT |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PERSANTINE 25MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PERSANTINE 50MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PERSANTINE 75MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PFIZERPEN 20MMU VIAL |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PHENADOZ 12.5MG SUPPOSITORY |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PHENADOZ 25MG SUPPOSITORY |
1 |
Tier 1 |
$6.00 | $0.00 | None |
Phenelzine Sulfate 15mg/1 60 TABLET in 1 BOTTLE |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PHENYTEK 200 MG CAPSULE |
3 |
Tier 3 |
$85.00 | $255.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PHENYTEK 300 MG CAPSULE |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PHENYTOIN SOD EXT 200 MG CAP |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT) |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PHOSLO 667MG CAPSULE |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PHOSPHOLINE IODIDE 0.125% |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PICATO 0.015% GEL |
2 |
Tier 2 |
$45.00 | $135.00 | None |
PICATO 0.05% GEL |
2 |
Tier 2 |
$45.00 | $135.00 | None |
PILOCARPINE HCL 5MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $0.00 | None |
Pilocarpine Hydrochloride 7.5mg/1 100 TABLET, FILM COATED in 1 BOTTLE |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PINDOLOL 10MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PINDOLOL 5MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PIPERACILLIN 200 MG/ML / TAZOBACTAM 25 MG/ML INJECTABLE SOLUTION |
1 |
Tier 1 |
$6.00 | $0.00 | None |
Piperacillin and Tazobactam 4; 0.5g/1; g/1 10 VIAL, SINGLE-USE in 1 CARTON / 1 INJECTION, POWDER, L |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PIROXICAM 10 MG CAPSULE |
1 |
Tier 1 |
$6.00 | $0.00 | None |
Piroxicam 20mg/1 500 CAPSULE in 1 BOTTLE |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PLAQUENIL 200MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PLAVIX 75MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PLETAL 100MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PLETAL 50MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PODOFILOX 0.5% TOPICAL TUBEX |
1 |
Tier 1 |
$6.00 | $0.00 | None |
POLY-DEX 0.1% SUSPENSION DROPS |
1 |
Tier 1 |
$6.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POLY-DEX 3.5-10K-.1 OINTMENT |
1 |
Tier 1 |
$6.00 | $0.00 | None |
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT) |
1 |
Tier 1 |
$6.00 | $0.00 | None |
POLYETHYLENE GLYCOL 3350 105 MG/ML / POTASSIUM CHLORIDE 0.00497 MEQ/ML / SODIUM BICARBONATE 1.43 MG/ |
1 |
Tier 1 |
$6.00 | $0.00 | None |
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1% |
1 |
Tier 1 |
$6.00 | $0.00 | None |
POLYTRIM EYE DROP |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PORTIA 0.15-0.03 TABLET |
1 |
Tier 1 |
$6.00 | $0.00 | None |
POTASSIUM CHLORIDE 0.075%/D5W/SODIUM CHLORIDE 0.2% |
1 |
Tier 1 |
$6.00 | $0.00 | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.3% |
1 |
Tier 1 |
$6.00 | $0.00 | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45% |
1 |
Tier 1 |
$6.00 | $0.00 | None |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.2% |
1 |
Tier 1 |
$6.00 | $0.00 | None |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG |
1 |
Tier 1 |
$6.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Potassium Chloride 20.000000meq/1 |
1 |
Tier 1 |
$6.00 | $0.00 | None |
POTASSIUM CHLORIDE ER CAPSULES 10MEQ |
1 |
Tier 1 |
$6.00 | $0.00 | None |
POTASSIUM CHLORIDE ER CPCR 8MEQ |
1 |
Tier 1 |
$6.00 | $0.00 | None |
POTASSIUM CHLORIDE EXTENDED RELEASE TABLETS |
1 |
Tier 1 |
$6.00 | $0.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE |
1 |
Tier 1 |
$6.00 | $0.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA |
1 |
Tier 1 |
$6.00 | $0.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION |
1 |
Tier 1 |
$6.00 | $0.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE INJECTION 40 12 X 1000ML CTR |
1 |
Tier 1 |
$6.00 | $0.00 | None |
Potassium Chloride in Lactated Ringers and Dextrose 20; 5; 179; 600; 310mg/100mL; g/100mL; mg/100mL |
3 |
Tier 3 |
$85.00 | $255.00 | None |
POTASSIUM CITRATE 10MEQ TABLET SA |
1 |
Tier 1 |
$6.00 | $0.00 | None |
POTASSIUM CITRATE 5MEQ TABLET SA |
1 |
Tier 1 |
$6.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTIGA 200 MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | S |
POTIGA 300 MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | S |
POTIGA 400 MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | S |
POTIGA 50 MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | S |
PRADAXA 150mg/1 1 BOTTLE in 1 CARTON / 60 CAPSULE in 1 BOTTLE |
2 |
Tier 2 |
$45.00 | $135.00 | Q:60 /30Days |
PRADAXA 75mg/1 1 BOTTLE in 1 CARTON / 60 CAPSULE in 1 BOTTLE |
2 |
Tier 2 |
$45.00 | $135.00 | Q:60 /30Days |
PRAMIPEXOLE 0.125 MG TABLET |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PRAMIPEXOLE 0.25 MG TABLET |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PRAMIPEXOLE 0.5 MG TABLET |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PRAMIPEXOLE 1 MG TABLET |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PRAMIPEXOLE 1.5 MG TABLET |
1 |
Tier 1 |
$6.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAMIPEXOLE DIHYDROCHLORIDE TABLETS |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PRANDIN 0.5MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | Q:120 /30Days |
PRANDIN 1MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | Q:120 /30Days |
PRANDIN 2MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | Q:240 /30Days |
PRAVACHOL 10MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | Q:45 /30Days |
PRAVACHOL 20MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | Q:45 /30Days |
PRAVACHOL 40MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | Q:45 /30Days |
PRAVACHOL 80MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | Q:30 /30Days |
PRAVASTATIN SODIUM 20MG TABLET 500 BOT |
1 |
Tier 1 |
$6.00 | $0.00 | Q:45 /30Days |
PRAVASTATIN SODIUM 40MG TABLET (500 CT) |
1 |
Tier 1 |
$6.00 | $0.00 | Q:45 /30Days |
PRAVASTATIN SODIUM 80MG TABLET (90 CT) |
1 |
Tier 1 |
$6.00 | $0.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT |
1 |
Tier 1 |
$6.00 | $0.00 | Q:45 /30Days |
PRAZOSIN 5MG CAPSULE |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PRAZOSIN HCL 1MG CAPSULE |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PRAZOSIN HCL 2MG CAPSULE |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PRECOSE 50 MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | Q:90 /30Days |
PRECOSE TABLETS 100MG 100 BOT |
3 |
Tier 3 |
$85.00 | $255.00 | Q:90 /30Days |
PRECOSE TABLETS 25MG 100 BOT |
3 |
Tier 3 |
$85.00 | $255.00 | Q:90 /30Days |
PRED FORTE 1% EYE DROPS |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PREDNICARBATE 0.1% OINTMENT |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PREDNICARBATE 1 MG/ML TOPICAL CREAM |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR |
1 |
Tier 1 |
$6.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL |
1 |
Tier 1 |
$6.00 | $0.00 | P |
PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION |
1 |
Tier 1 |
$6.00 | $0.00 | P |
PREDNISONE 10MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $0.00 | P |
PREDNISONE 1MG TABLET |
1 |
Tier 1 |
$6.00 | $0.00 | P |
PREDNISONE 2.5MG TABLET |
1 |
Tier 1 |
$6.00 | $0.00 | P |
PREDNISONE 20MG TABLET (1000 CT) |
1 |
Tier 1 |
$6.00 | $0.00 | P |
PREDNISONE 5 MG TABLET |
1 |
Tier 1 |
$6.00 | $0.00 | P |
PREDNISONE 50MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | P |
PREDNISONE 5MG/5ML SOLUTION |
3 |
Tier 3 |
$85.00 | $255.00 | P |
PREGNYL INJ 10000UNT |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PREMARIN 0.3MG (100 CT) |
2 |
Tier 2 |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREMARIN 0.45MG TABLET |
2 |
Tier 2 |
$45.00 | $135.00 | None |
PREMARIN 0.625MG (100 CT) |
2 |
Tier 2 |
$45.00 | $135.00 | None |
Premarin 0.625mg/g |
2 |
Tier 2 |
$45.00 | $135.00 | None |
PREMARIN 0.9MG TABLET |
2 |
Tier 2 |
$45.00 | $135.00 | None |
PREMARIN 1.25MG (100 CT) |
2 |
Tier 2 |
$45.00 | $135.00 | None |
PREMASOL 6% IV SOLUTION |
1 |
Tier 1 |
$6.00 | $0.00 | P |
Premphase 1 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
2 |
Tier 2 |
$45.00 | $135.00 | None |
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA |
2 |
Tier 2 |
$45.00 | $135.00 | None |
PREMPRO 0.45-1.5 MG TABLET 28 EA |
2 |
Tier 2 |
$45.00 | $135.00 | None |
Prempro 0.625; 2.5mg/1; mg/1 1 BLISTER PACK in 1 CARTON / 28 TABLET, SUGAR COATED in 1 BLISTER PACK |
2 |
Tier 2 |
$45.00 | $135.00 | None |
PREVACID CAPSULES DELAYED RELEASE 15 MG |
3 |
Tier 3 |
$85.00 | $255.00 | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREVACID CAPSULES DELAYED RELEASE 30 MG |
3 |
Tier 3 |
$85.00 | $255.00 | S Q:30 /30Days |
PREVACID SOLUTAB EXTENDED RELEASE ORALLY DISINTEGRATING 30MG 100 BOXUD |
3 |
Tier 3 |
$85.00 | $255.00 | S Q:30 /30Days |
PREVACID SOLUTAB TABLETS DELAYED RELEASE ORALLY DISINTEGRATING 15MG 100 BOXUD |
3 |
Tier 3 |
$85.00 | $255.00 | S Q:30 /30Days |
PREVALITE POW 4GM |
1 |
Tier 1 |
$6.00 | $0.00 | None |
Previfem 6 BLISTER PACK in 1 BLISTER PACK / 1 KIT in 1 BLISTER PACK |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PREVPAC (TRIPLE THERAPY) KIT 30;500;500MG;MG;MG; 14 PKGCOM |
2 |
Tier 2 |
$45.00 | $135.00 | None |
PREZISTA TABLET 600MG |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PREZISTA TABLET 75MG |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PREZISTA TABLETS |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PREZISTA TABLETS 400MG 60 TABLETS BOT |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PRIFTIN 150MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRILOSEC 10mg/1 1000 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
3 |
Tier 3 |
$85.00 | $255.00 | S Q:30 /30Days |
PRILOSEC 20mg/1 1000 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
3 |
Tier 3 |
$85.00 | $255.00 | S Q:30 /30Days |
PRILOSEC 40mg/1 100 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
3 |
Tier 3 |
$85.00 | $255.00 | S Q:30 /30Days |
PRIMAQUINE 26.3MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PRIMAXIN I.M. 500MG VIAL |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PRIMAXIN IV 250MG VIAL |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PRIMAXIN IV 500; 500mg/100mL; mg/100mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 100 mL in 1 VIAL, SINGLE-DOS |
3 |
Tier 3 |
$85.00 | $255.00 | None |
Primidone 250mg/1 100 TABLET in 1 BOTTLE |
1 |
Tier 1 |
$6.00 | $0.00 | None |
Primidone 50mg/1 500 TABLET in 1 BOTTLE |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PRINIVIL 10MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PRINIVIL 20MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRINIVIL TABLETS |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PRINZIDE 10/12.5 TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PRINZIDE 20/12.5 TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PRISTIQ 100MG TABLET SR 24HR |
3 |
Tier 3 |
$85.00 | $255.00 | S Q:30 /30Days |
Pristiq Extended-Release 50mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
3 |
Tier 3 |
$85.00 | $255.00 | S Q:30 /30Days |
PROAIR HFA 90MCG HFA AEROSOL WITH ADAPTER |
2 |
Tier 2 |
$45.00 | $135.00 | Q:17 /30Days |
PROBENECID 500MG TABLET |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PROBENECID/COLCHICINE TABLET S |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PROCARDIA XL 30MG TABLET (300 CT) |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PROCARDIA XL 60MG TABLET SA |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PROCARDIA XL 90MG TABLET SA |
3 |
Tier 3 |
$85.00 | $255.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PROCRIT 10000U/ML VIAL |
3 |
Tier 3 |
$85.00 | $255.00 | P |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL |
3 |
Tier 3 |
$85.00 | $255.00 | P |
PROCRIT 3000U/ML VIAL |
3 |
Tier 3 |
$85.00 | $255.00 | P |
PROCRIT 40000U/ML VIAL PR |
4 |
Tier 4 |
33% | 33% | P |
PROCRIT 4000U/ML VIAL 25 X 1ML VIAL |
3 |
Tier 3 |
$85.00 | $255.00 | P |
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY |
4 |
Tier 4 |
33% | 33% | P |
PROCTO-PAK 1% CREAM |
1 |
Tier 1 |
$6.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Proctocream HC 25mg/g |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PROCTOSOL-HC 2.5% CREAM |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PROCTOZONE-HC 2.5% CREAM |
1 |
Tier 1 |
$6.00 | $0.00 | None |
Proglycem 50mg/mL 1 BOTTLE, DROPPER in 1 BOX / 30 mL in 1 BOTTLE, DROPPER |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PROGRAF 0.5MG CAPSULE |
3 |
Tier 3 |
$85.00 | $255.00 | P |
PROGRAF 1MG CAPSULE |
3 |
Tier 3 |
$85.00 | $255.00 | P |
Prograf 5mg/1 1 BOTTLE in 1 CARTON / 100 CAPSULE, GELATIN COATED in 1 BOTTLE |
3 |
Tier 3 |
$85.00 | $255.00 | P |
PROGRAF 5MG/ML AMPULE |
3 |
Tier 3 |
$85.00 | $255.00 | P |
PROLASTIN 500MG VIAL |
4 |
Tier 4 |
33% | 33% | None |
PROLASTIN-C 1 KIT in 1 CARTON |
4 |
Tier 4 |
33% | 33% | None |
PROLEUKIN 1.1mg/mL 1 VIAL, SINGLE-USE in 1 BOX / 1 mL in 1 VIAL, SINGLE-USE |
4 |
Tier 4 |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROLIA INJECTION |
3 |
Tier 3 |
$85.00 | $255.00 | P |
PROMACTA 12.5 MG TABLET |
4 |
Tier 4 |
33% | 33% | P |
PROMACTA 25 MG TABLET |
4 |
Tier 4 |
33% | 33% | P |
PROMACTA 50 MG TABLET |
4 |
Tier 4 |
33% | 33% | P |
PROMACTA 75 MG TABLET |
4 |
Tier 4 |
33% | 33% | P |
PROMETHAZINE HCL 25MG TABLET (1000 CT) |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PROMETHAZINE HCL 50MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PROMETHAZINE HCL 6.25MG/5ML SYRUP |
1 |
Tier 1 |
$6.00 | $0.00 | None |
Promethazine Hydrochloride 12.5mg/1 100 TABLET in 1 BOTTLE |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX |
1 |
Tier 1 |
$6.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMETHAZINE VC PLAIN 6.25-5MG 16 FL OZ BOT |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PROMETHEGAN 25MG SUPP |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PROMETHEGAN 50MG SUPPOS |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PROPAFENONE HCL 150MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PROPAFENONE HCL 225MG TABLET |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PROPAFENONE HCL 300MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $0.00 | None |
Propafenone Hydrochloride 225mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PROPRANOLOL 60MG TABLET |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PROPRANOLOL 80 MG TABLET |
1 |
Tier 1 |
$6.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPRANOLOL HCL 20MG TABLET (1000 CT) |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PROPRANOLOL HCL TABLET USP 10MG (1000 CT) |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PROPRANOLOL HCL TABLET USP 40MG (1000 CT) |
1 |
Tier 1 |
$6.00 | $0.00 | None |
Propranolol Hydrochloride 120mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
$6.00 | $0.00 | None |
Propranolol Hydrochloride 160mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
$6.00 | $0.00 | None |
Propranolol Hydrochloride 60mg/1 1000 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
1 |
Tier 1 |
$6.00 | $0.00 | None |
Propranolol Hydrochloride 80mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PROPYLTHIOURACIL 50MG TABLET |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PROQUAD VIAL |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PROSCAR TABLETS 5MG 30 BOT |
3 |
Tier 3 |
$85.00 | $255.00 | Q:30 /30Days |
PROTONIX 20MG TABLET EC |
3 |
Tier 3 |
$85.00 | $255.00 | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROTONIX 40MG TABLET EC |
3 |
Tier 3 |
$85.00 | $255.00 | S Q:30 /30Days |
PROTOPIC 0.03% OINTMENT 100GM TUBE |
2 |
Tier 2 |
$45.00 | $135.00 | S |
PROTOPIC 0.1% OINTMENT 60GM TUBE |
2 |
Tier 2 |
$45.00 | $135.00 | S |
PROTRIPTYLINE HYDROCHLORIDE TABLETS |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PROVERA 10MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PROVERA 2.5MG TABLET (100 CT) |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PROVERA 5MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PROVIGIL 100MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | P Q:30 /30Days |
PROVIGIL 200MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | P Q:30 /30Days |
PROZAC 10MG PULVULE |
3 |
Tier 3 |
$85.00 | $255.00 | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROZAC 40MG PULVULE |
3 |
Tier 3 |
$85.00 | $255.00 | S Q:60 /30Days |
PROZAC CAPSULES 20MG (2000 CT) |
3 |
Tier 3 |
$85.00 | $255.00 | S Q:120 /30Days |
PROZAC WEEKLY 90MG CAPSULE |
3 |
Tier 3 |
$85.00 | $255.00 | S Q:4 /28Days |
PULMOZYME 1MG/ML AMPUL |
4 |
Tier 4 |
33% | 33% | P |
PURINETHOL 50MG TABLET |
3 |
Tier 3 |
$85.00 | $255.00 | None |
PYLERA 125-125MG CAPSULE |
2 |
Tier 2 |
$45.00 | $135.00 | None |
PYRAZINAMIDE 500MG TABLET |
1 |
Tier 1 |
$6.00 | $0.00 | None |
PYRIDOSTIGMINE BROMIDE 60MG TABLET |
1 |
Tier 1 |
$6.00 | $0.00 | None |