2012 Medicare Part D Plan Formulary Information |
MedicareBlue PPO (Regional PPO) (R5566-005-0)
Benefit Details
|
The MedicareBlue PPO (Regional PPO) (R5566-005-0) Formulary Drugs Starting with the Letter A in Statewide County, IA: CMS MA Region 19 which includes: IA MN MT NE ND SD WY
|
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 |
A METHAPRED METHLYPREDNISOLONE SODIUM SUCCINATE FOR INJECTION 125 MG |
2 |
Tier 2 |
$11.00 | $22.00 | None |
A-METHAPRED INJ 40MG |
2 |
Tier 2 |
$11.00 | $22.00 | None |
ABACAVIR TAB 300MG |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ABILIFY 10MG TABLET |
3 |
Tier 3 |
$33.00 | $66.00 | Q:30 /30Days |
ABILIFY 15MG TABLET |
3 |
Tier 3 |
$33.00 | $66.00 | Q:30 /30Days |
ABILIFY 1MG/ML SOLUTION |
3 |
Tier 3 |
$33.00 | $66.00 | Q:750 /30Days |
ABILIFY 20MG TABLET |
3 |
Tier 3 |
$33.00 | $66.00 | Q:30 /30Days |
ABILIFY 2MG TABLET |
3 |
Tier 3 |
$33.00 | $66.00 | Q:30 /30Days |
ABILIFY 30MG TABLET |
3 |
Tier 3 |
$33.00 | $66.00 | Q:30 /30Days |
ABILIFY 5MG TABLET (OTSUKA) |
3 |
Tier 3 |
$33.00 | $66.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABILIFY DISCMELT 10MG TABLET |
3 |
Tier 3 |
$33.00 | $66.00 | Q:60 /30Days |
ABILIFY DISCMELT 15MG TABLET |
3 |
Tier 3 |
$33.00 | $66.00 | Q:60 /30Days |
ABILIFY INJ 9.75MG |
3 |
Tier 3 |
$33.00 | $66.00 | Q:120 /30Days |
ABRAXANE 100MG VIAL |
4 |
Tier 4 |
45% | 45% | None |
Acarbose 100mg/1 90 TABLET in 1 BOTTLE, |
1 |
Tier 1 |
$6.00 | $12.00 | Q:90 /30Days |
acarbose 50 mg tablet |
1 |
Tier 1 |
$6.00 | $12.00 | Q:90 /30Days |
ACARBOSE TABLETS |
1 |
Tier 1 |
$6.00 | $12.00 | Q:90 /30Days |
ACEBUTOLOL 200MG CAPSULE |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ACEBUTOLOL 400MG CAPSULE |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE |
4 |
Tier 4 |
45% | 45% | None |
Acetaminophen and Codeine Phosphate 300; 60mg/1; mg/1 500 TABLET in 1 BOTTLE |
2 |
Tier 2 |
$11.00 | $22.00 | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD |
2 |
Tier 2 |
$11.00 | $22.00 | Q:2700 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) |
2 |
Tier 2 |
$11.00 | $22.00 | Q:360 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
2 |
Tier 2 |
$11.00 | $22.00 | Q:360 /30Days |
ACETASOL HC SOLUTION 10ML 10 ML BOT |
2 |
Tier 2 |
$11.00 | $22.00 | None |
ACETAZOLAMIDE 125MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ACETIC ACID 2% SOLUTION NON-ORAL |
2 |
Tier 2 |
$11.00 | $22.00 | None |
ACETYLCYSTEINE 10% VIAL |
2 |
Tier 2 |
$11.00 | $22.00 | P |
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN |
2 |
Tier 2 |
$11.00 | $22.00 | P |
ACTHIB VACCINE VIAL 10-24UNT/5ML |
4 |
Tier 4 |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTICIN 5% CREAM |
2 |
Tier 2 |
$11.00 | $22.00 | None |
ACTIMMUNE SOLUTION FOR INJECTION 100MCG |
4 |
Tier 4 |
45% | 45% | None |
Actonel 150mg/1 36 DOSE PACK in 1 CASE / 1 TRAY in 1 DOSE PACK / 1 TABLET, FILM COATED in 1 TRAY |
4 |
Tier 4 |
45% | 45% | S Q:1 /30Days |
Actonel 30mg/1 12 BOTTLE in 1 CASE / 30 TABLET, FILM COATED in 1 BOTTLE |
4 |
Tier 4 |
45% | 45% | S Q:30 /30Days |
Actonel 35mg/1 36 DOSE PACK in 1 CASE / 1 TRAY in 1 DOSE PACK / 4 TABLET, FILM COATED in 1 TRAY |
4 |
Tier 4 |
45% | 45% | S Q:4 /28Days |
Actonel 5mg/1 12 BOTTLE in 1 CASE / 30 TABLET, FILM COATED in 1 BOTTLE |
4 |
Tier 4 |
45% | 45% | S Q:30 /30Days |
ACTOS 15MG TABLET |
4 |
Tier 4 |
45% | 45% | S Q:30 /30Days |
ACTOS 30MG TABLET (500 CT) |
4 |
Tier 4 |
45% | 45% | S Q:30 /30Days |
ACTOS 45MG TABLET |
4 |
Tier 4 |
45% | 45% | S Q:30 /30Days |
Acyclovir 200mg/1 |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Acyclovir 200mg/5mL 473 mL in 1 BOTTLE |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Acyclovir 400mg/1 100 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Acyclovir 800mg/1 100 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK |
2 |
Tier 2 |
$11.00 | $22.00 | None |
ACYCLOVIR SODIUM 500MG VIAL |
2 |
Tier 2 |
$11.00 | $22.00 | P |
ADACEL VIAL 2UNT/5UNT |
4 |
Tier 4 |
45% | 45% | None |
ADAGEN 250U/ML VIAL |
4 |
Tier 4 |
45% | 45% | None |
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA] |
4 |
Tier 4 |
45% | 45% | P |
ADCIRCA TABLETS 20MG 60 BOT |
3 |
Tier 3 |
$33.00 | $66.00 | P Q:60 /30Days |
ADVAIR DISKUS MIS 100/50 |
3 |
Tier 3 |
$33.00 | $66.00 | Q:60 /30Days |
ADVAIR DISKUS MIS 250/50 |
3 |
Tier 3 |
$33.00 | $66.00 | Q:60 /30Days |
ADVAIR DISKUS MIS 500/50 |
3 |
Tier 3 |
$33.00 | $66.00 | Q:60 /30Days |
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Tier 3 |
$33.00 | $66.00 | Q:12 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL |
3 |
Tier 3 |
$33.00 | $66.00 | Q:12 /30Days |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
3 |
Tier 3 |
$33.00 | $66.00 | Q:12 /30Days |
AFEDITAB CR 30MG TABLET SA |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AFEDITAB CR 60MG TABLET SA |
1 |
Tier 1 |
$6.00 | $12.00 | None |
Afinitor 7.5mg/1 28 BLISTER PACK in 1 CARTON / 1 TABLET in 1 BLISTER PACK |
4 |
Tier 4 |
45% | 45% | P Q:30 /30Days |
AFINITOR TABLETS 10 MG |
4 |
Tier 4 |
45% | 45% | P Q:30 /30Days |
AFINITOR TABLETS 2.5 MG |
4 |
Tier 4 |
45% | 45% | P Q:30 /30Days |
AFINITOR TABLETS 5 MG |
4 |
Tier 4 |
45% | 45% | P Q:30 /30Days |
AGGRENOX 25-200MG CAPSULE |
4 |
Tier 4 |
45% | 45% | None |
AK-CON 0.1% EYE DROPS |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AKTOB 0.3% EYE DROPS |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALA-CORT 1% CREAM |
2 |
Tier 2 |
$11.00 | $22.00 | None |
ALA-CORT 1% LOTION |
2 |
Tier 2 |
$11.00 | $22.00 | None |
ALBENZA 200 MG TABLET |
4 |
Tier 4 |
45% | 45% | None |
Albuterol Sulfate 0.63mg/3mL 25 POUCH in 1 CARTON / 5 VIAL in 1 POUCH / 3 mL in 1 VIAL |
1 |
Tier 1 |
$6.00 | $12.00 | P |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
1 |
Tier 1 |
$6.00 | $12.00 | P |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
1 |
Tier 1 |
$6.00 | $12.00 | P |
ALBUTEROL SULFATE SOLUTION FOR INHALATION |
1 |
Tier 1 |
$6.00 | $12.00 | P |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL TABLET 4MG (500 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ALCLOMETASONE DIPROPIONATE 0.05% CREAM |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Alclometasone Dipropionate 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
2 |
Tier 2 |
$11.00 | $22.00 | None |
ALDURAZYME 2.9MG/5ML VIAL |
4 |
Tier 4 |
45% | 45% | None |
ALENDRONATE SODIUM 10MG TABLET |
2 |
Tier 2 |
$11.00 | $22.00 | Q:30 /30Days |
ALENDRONATE SODIUM 40MG TABLET |
2 |
Tier 2 |
$11.00 | $22.00 | Q:30 /30Days |
ALENDRONATE SODIUM 5MG TABLET |
2 |
Tier 2 |
$11.00 | $22.00 | Q:30 /30Days |
ALENDRONATE SODIUM 70mg/1 |
2 |
Tier 2 |
$11.00 | $22.00 | Q:4 /28Days |
ALENDRONATE SODIUM TABLET 35MG 20 CRTN |
2 |
Tier 2 |
$11.00 | $22.00 | Q:4 /28Days |
ALFUZOSIN HYDROCHLORIDE 10mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2 |
Tier 2 |
$11.00 | $22.00 | Q:30 /30Days |
ALIMTA 500MG VIAL |
4 |
Tier 4 |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALINIA 100MG/5ML SUSPENSION |
4 |
Tier 4 |
45% | 45% | None |
ALINIA 500MG TABLET |
4 |
Tier 4 |
45% | 45% | None |
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET in 1 BLISTER PACK |
2 |
Tier 2 |
$11.00 | $22.00 | None |
ALLOPURINOL SODIUM 500MG VIAL |
2 |
Tier 2 |
$11.00 | $22.00 | None |
ALLOPURINOL TABLETS |
2 |
Tier 2 |
$11.00 | $22.00 | None |
ALOXI 0.25MG/5ML |
4 |
Tier 4 |
45% | 45% | None |
ALPHAGAN P 0.1% DROPS |
4 |
Tier 4 |
45% | 45% | None |
AMANTADINE 100MG CAPSULE |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMANTADINE 100MG TABLET |
4 |
Tier 4 |
45% | 45% | None |
Amantadine Hydrochloride 50mg/5mL |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMCINONIDE 0.1% CREAM |
2 |
Tier 2 |
$11.00 | $22.00 | 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 |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Amethyst 20; 90ug/1; ug/1 1 BLISTER PACK in 1 CARTON / 28 TABLET in 1 BLISTER PACK |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM |
4 |
Tier 4 |
45% | 45% | P |
AMIFOSTINE FOR INJECTION 500MG/VIAL |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMIKACIN 250MG/ML VIAL |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMIKACIN 50MG/ML VIAL |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMINOPHYLLINE 100MG TABLET |
4 |
Tier 4 |
45% | 45% | None |
AMINOPHYLLINE 200MG TABLET (1000 CT) |
4 |
Tier 4 |
45% | 45% | None |
AMINOSYN-HF 8% IV SOLUTION |
2 |
Tier 2 |
$11.00 | $22.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMIODARONE HCL 400MG TABLET |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Amiodarone hydrochloride 200mg/1 |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMITRIP/PERPHEN 10-2 TABLET |
4 |
Tier 4 |
45% | 45% | None |
AMITRIP/PERPHEN 10-4 TABLET |
4 |
Tier 4 |
45% | 45% | None |
AMITRIP/PERPHEN 25-2 TABLET |
4 |
Tier 4 |
45% | 45% | None |
AMITRIP/PERPHEN 25-4 TABLET |
4 |
Tier 4 |
45% | 45% | None |
AMITRIP/PERPHEN 50-4 TABLET |
4 |
Tier 4 |
45% | 45% | None |
AMITRIPTYLINE HCL 100MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMITRIPTYLINE HCL 10MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMITRIPTYLINE HCL 150 MG TAB |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE |
1 |
Tier 1 |
$6.00 | $12.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE |
1 |
Tier 1 |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMMONIUM LACTATE 12% CREAM |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMMONIUM LACTATE 12% LOTION |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Amnesteem 10mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Amnesteem 20mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Amnesteem 40mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMOX TR-K CLV 500-125 MG TAB |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXAPINE 100MG TABLET |
4 |
Tier 4 |
45% | 45% | None |
AMOXAPINE 150MG TABLET |
4 |
Tier 4 |
45% | 45% | None |
AMOXAPINE 25MG TABLET |
4 |
Tier 4 |
45% | 45% | None |
AMOXAPINE 50MG TABLET |
4 |
Tier 4 |
45% | 45% | None |
AMOXICILLIN 125MG TABLET CHEW |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMOXICILLIN 200MG TABLET CHEW |
4 |
Tier 4 |
45% | 45% | None |
AMOXICILLIN 250MG CAPSULE |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Amoxicillin 250mg/1 500 TABLET, CHEWABLE in 1 BOTTLE |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMOXICILLIN 500MG TABLET (100 CT) |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMOXICILLIN 875MG TABLET |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN CAP 500MG |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
2 |
Tier 2 |
$11.00 | $22.00 | Q:60 /30Days |
AMPHETAMINE SALT COMBO 15MG TABLET |
2 |
Tier 2 |
$11.00 | $22.00 | Q:60 /30Days |
AMPHETAMINE SALT COMBO 30MG TABLET |
2 |
Tier 2 |
$11.00 | $22.00 | Q:60 /30Days |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
2 |
Tier 2 |
$11.00 | $22.00 | Q:60 /30Days |
AMPHETAMINE SALTS 20MG TABLET |
2 |
Tier 2 |
$11.00 | $22.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPHETAMINE SALTS 5 MG TAB |
2 |
Tier 2 |
$11.00 | $22.00 | Q:60 /30Days |
amphotericin b 50mg/10mL 10 mL in 1 VIAL |
4 |
Tier 4 |
45% | 45% | P |
Ampicillin 125mg/1 10 VIAL in 1 BOX / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMPICILLIN CAPSULES 250MG 100 BOT |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMPICILLIN FOR INJECTION POWDER |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
4 |
Tier 4 |
45% | 45% | None |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
4 |
Tier 4 |
45% | 45% | None |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AMPYRA ER 10 MG TABLET |
4 |
Tier 4 |
45% | 45% | P Q:60 /30Days |
ANADROL-50 50MG TABLET (100 CT) |
4 |
Tier 4 |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE in 1 BOTTLE |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Anagrelide Hydrochloride 1mg/1 100 CAPSULE in 1 BOTTLE |
2 |
Tier 2 |
$11.00 | $22.00 | None |
ANASTROZOLE TABLETS |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ANCOBON 250MG CAPSULE |
4 |
Tier 4 |
45% | 45% | None |
ANCOBON 500MG CAPSULE |
4 |
Tier 4 |
45% | 45% | None |
ANDRODERM 2 MG/24HR PATCH |
3 |
Tier 3 |
$33.00 | $66.00 | None |
ANDRODERM 2.5MG/24HR PATCH |
3 |
Tier 3 |
$33.00 | $66.00 | None |
ANDRODERM 4 MG/24HR PATCH |
3 |
Tier 3 |
$33.00 | $66.00 | None |
ANDRODERM 5MG/24HR PATCH |
3 |
Tier 3 |
$33.00 | $66.00 | None |
ANDROGEL 1%(50MG) GEL PACKET |
3 |
Tier 3 |
$33.00 | $66.00 | None |
Androgel 16.2mg/g 1 BOTTLE, PUMP in 1 CARTON / 88 g in 1 BOTTLE, PUMP |
3 |
Tier 3 |
$33.00 | $66.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANTABUSE 250MG TABLET |
4 |
Tier 4 |
45% | 45% | None |
ANTABUSE 500MG TABLET |
4 |
Tier 4 |
45% | 45% | None |
APAP-CAFFEINE-DIHYDROCODE TAB 30 EA |
2 |
Tier 2 |
$11.00 | $22.00 | Q:150 /30Days |
APOKYN 30mg/3mL 5 CARTRIDGE in 1 CARTON / 3 mL in 1 CARTRIDGE |
4 |
Tier 4 |
45% | 45% | None |
APRI 0.15-0.03 TABLET |
2 |
Tier 2 |
$11.00 | $22.00 | None |
APRISO CP24 |
3 |
Tier 3 |
$33.00 | $66.00 | None |
APTIVUS 250MG CAPSULE |
4 |
Tier 4 |
45% | 45% | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
4 |
Tier 4 |
45% | 45% | None |
ARANELLE 7-9-5 TABLET |
2 |
Tier 2 |
$11.00 | $22.00 | None |
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE in 1 BLISTER PACK / 0.5 mL in 1 SYRINGE |
3 |
Tier 3 |
$33.00 | $66.00 | P |
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
3 |
Tier 3 |
$33.00 | $66.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP 200MCG/0.4ML SYRINGE |
4 |
Tier 4 |
45% | 45% | P |
ARANESP 200MCG/ML VIAL |
4 |
Tier 4 |
45% | 45% | P |
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE in 1 BLISTER PACK / 0.42 mL in 1 SYRING |
3 |
Tier 3 |
$33.00 | $66.00 | P |
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
3 |
Tier 3 |
$33.00 | $66.00 | P |
ARANESP 300MCG/ML VIAL |
4 |
Tier 4 |
45% | 45% | P |
ARANESP 500MCG/1ML SYRINGE |
4 |
Tier 4 |
45% | 45% | P |
ARANESP 60MCG/ML VIAL |
3 |
Tier 3 |
$33.00 | $66.00 | P |
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE in 1 BLISTER PACK / 0.3 mL in 1 SYRINGE |
3 |
Tier 3 |
$33.00 | $66.00 | P |
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR |
4 |
Tier 4 |
45% | 45% | P |
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR |
4 |
Tier 4 |
45% | 45% | P |
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR |
3 |
Tier 3 |
$33.00 | $66.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD |
3 |
Tier 3 |
$33.00 | $66.00 | P |
ARCALYST INJECTION 220MG/VIAL |
4 |
Tier 4 |
45% | 45% | P |
ARIXTRA 10MG SYRINGE |
4 |
Tier 4 |
45% | 45% | Q:24 /90Days |
ARIXTRA 2.5MG SYRINGE |
4 |
Tier 4 |
45% | 45% | Q:15 /90Days |
ARIXTRA 5MG SYRINGE |
4 |
Tier 4 |
45% | 45% | Q:12 /90Days |
ARIXTRA 7.5MG SYRINGE |
4 |
Tier 4 |
45% | 45% | Q:18 /90Days |
AROMASIN 25MG TABLET |
3 |
Tier 3 |
$33.00 | $66.00 | None |
ARRANON 250MG VIAL |
4 |
Tier 4 |
45% | 45% | None |
ARZERRA 20mg/mL 3 VIAL in 1 CARTON / 5 mL in 1 VIAL |
3 |
Tier 3 |
$33.00 | $66.00 | None |
ASACOL 400mg/1 12 BOTTLE in 1 CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE |
3 |
Tier 3 |
$33.00 | $66.00 | None |
ASACOL HD 800mg/1 12 BOTTLE in 1 CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE |
3 |
Tier 3 |
$33.00 | $66.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ASMANEX 220ug/1 1 POUCH in 1 POUCH / 1 INHALER in 1 POUCH / 14 INHALANT in 1 INHALER |
3 |
Tier 3 |
$33.00 | $66.00 | Q:1 /30Days |
ASMANEX TWISTHALER 110 MCG #30 |
3 |
Tier 3 |
$33.00 | $66.00 | Q:1 /30Days |
ASMANEX TWISTHALER 220MCG #120 |
3 |
Tier 3 |
$33.00 | $66.00 | Q:1 /30Days |
ASMANEX TWISTHALER 220MCG #30 |
3 |
Tier 3 |
$33.00 | $66.00 | Q:1 /30Days |
ASMANEX TWISTHALER 220MCG #60 |
3 |
Tier 3 |
$33.00 | $66.00 | Q:1 /30Days |
ASTEPRO 0.15% NASAL SPRAY 30 ML |
3 |
Tier 3 |
$33.00 | $66.00 | Q:60 /30Days |
ASTRAMORPH PF INJECTION 0.5MG/ML |
2 |
Tier 2 |
$11.00 | $22.00 | P |
ASTRAMORPH PF INJECTION 1MG/ML |
2 |
Tier 2 |
$11.00 | $22.00 | P |
Atelvia 35mg/1 36 DOSE PACK in 1 CASE / 4 TABLET, DELAYED RELEASE in 1 DOSE PACK |
3 |
Tier 3 |
$33.00 | $66.00 | S Q:4 /28Days |
ATENOLOL 100mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
$6.00 | $12.00 | None |
Atenolol 25mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATENOLOL TABLET USP 50MG (100 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
ATGAM 50MG/ML AMPUL |
4 |
Tier 4 |
45% | 45% | P |
ATORVASTATIN 10 MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | Q:45 /30Days |
ATORVASTATIN 20 MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | Q:45 /30Days |
ATORVASTATIN 40 MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | Q:45 /30Days |
ATORVASTATIN 80 MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | Q:30 /30Days |
Atovaquone and Proguanil Hydrochloride 250; 100mg/1; mg/1 |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
4 |
Tier 4 |
45% | 45% | None |
ATROVENT HFA AER 17MCG |
4 |
Tier 4 |
45% | 45% | Q:26 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AUGMENTED BETAMETHASONE DIPROPIONATE OINTMENT |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AVASTIN 100MG/4ML VIAL |
3 |
Tier 3 |
$33.00 | $66.00 | None |
AVELOX 400MG TABLET |
3 |
Tier 3 |
$33.00 | $66.00 | None |
AVELOX ABC PACK 400MG TABLET |
3 |
Tier 3 |
$33.00 | $66.00 | None |
AVELOX IV 400MG/250ML |
3 |
Tier 3 |
$33.00 | $66.00 | None |
AVIANE 0.1-0.02 TABLET |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AVINZA 120MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Tier 3 |
$33.00 | $66.00 | Q:30 /30Days |
AVINZA 30MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Tier 3 |
$33.00 | $66.00 | Q:30 /30Days |
AVINZA 60MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Tier 3 |
$33.00 | $66.00 | Q:30 /30Days |
AVINZA 90MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Tier 3 |
$33.00 | $66.00 | Q:30 /30Days |
AVINZA CAPSULES EXTENDED RELEASE 45MG 100 BOTPL |
3 |
Tier 3 |
$33.00 | $66.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVINZA CAPSULES EXTENDED RELEASE 75MG 100 BOTPL |
3 |
Tier 3 |
$33.00 | $66.00 | Q:30 /30Days |
AVITA 0.025% CREAM |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Avita 0.25mg/g 45 g in 1 TUBE |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AVODART 0.5MG SOFTGEL |
3 |
Tier 3 |
$33.00 | $66.00 | Q:30 /30Days |
AVONEX ADMIN PACK 30MCG SYR |
4 |
Tier 4 |
45% | 45% | Q:4 /28Days |
AVONEX ADMIN PACK 30MCG VL |
4 |
Tier 4 |
45% | 45% | Q:4 /28Days |
AZACTAM INJECTION 1GM/50ML |
4 |
Tier 4 |
45% | 45% | None |
AZACTAM INJECTION 2GM/50ML |
4 |
Tier 4 |
45% | 45% | None |
AZASAN 100MG TABLET |
4 |
Tier 4 |
45% | 45% | P |
AZASAN 75MG TABLET |
4 |
Tier 4 |
45% | 45% | P |
AZATHIOPRINE 50MG TABLET |
2 |
Tier 2 |
$11.00 | $22.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZATHIOPRINE SOD 100MG VIAL |
4 |
Tier 4 |
45% | 45% | P |
AZELASTINE 137 MCG NASAL SPRAY |
2 |
Tier 2 |
$11.00 | $22.00 | Q:60 /30Days |
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AZELEX 20% CREAM 30GM TUBE |
4 |
Tier 4 |
45% | 45% | None |
AZILECT 0.5MG TABLET |
3 |
Tier 3 |
$33.00 | $66.00 | None |
AZILECT 1MG TABLET |
3 |
Tier 3 |
$33.00 | $66.00 | None |
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AZITHROMYCIN 250 MG TABLET |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Azithromycin 500mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Azithromycin 600mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
$11.00 | $22.00 | None |
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT |
4 |
Tier 4 |
45% | 45% | None |
AZOR 10MG-20MG TABLET |
3 |
Tier 3 |
$33.00 | $66.00 | S Q:30 /30Days |
AZOR 10MG-40MG TABLET (30 CT) |
3 |
Tier 3 |
$33.00 | $66.00 | S Q:30 /30Days |
AZOR 5MG-20MG TABLET (30 CT) |
3 |
Tier 3 |
$33.00 | $66.00 | S Q:30 /30Days |
AZOR 5MG-40MG TABLET |
3 |
Tier 3 |
$33.00 | $66.00 | S Q:30 /30Days |
AZTREONAM FOR INJECTION |
2 |
Tier 2 |
$11.00 | $22.00 | None |