2012 Medicare Part D Plan Formulary Information |
Windsor Rx (PDP) (S4802-030-0)
Benefit Details
|
The Windsor Rx (PDP) (S4802-030-0) Formulary Drugs Starting with the Letter A in CMS PDP Region 25 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 |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
A-HYDROCORT 100MG VIAL |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ABACAVIR TAB 300MG |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ABILIFY 10MG TABLET |
3 |
Non-Preferred Brand Drugs |
$90.00 | $270.00 | Q:30 /30Days |
ABILIFY 15MG TABLET |
3 |
Non-Preferred Brand Drugs |
$90.00 | $270.00 | Q:30 /30Days |
ABILIFY 1MG/ML SOLUTION |
3 |
Non-Preferred Brand Drugs |
$90.00 | $270.00 | None |
ABILIFY 20MG TABLET |
3 |
Non-Preferred Brand Drugs |
$90.00 | $270.00 | None |
ABILIFY 2MG TABLET |
3 |
Non-Preferred Brand Drugs |
$90.00 | $270.00 | None |
ABILIFY 30MG TABLET |
3 |
Non-Preferred Brand Drugs |
$90.00 | $270.00 | None |
ABILIFY 5MG TABLET (OTSUKA) |
3 |
Non-Preferred Brand Drugs |
$90.00 | $270.00 | 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 |
Non-Preferred Brand Drugs |
$90.00 | $270.00 | None |
ABILIFY DISCMELT 15MG TABLET |
3 |
Non-Preferred Brand Drugs |
$90.00 | $270.00 | None |
ABILIFY INJ 9.75MG |
3 |
Non-Preferred Brand Drugs |
$90.00 | $270.00 | None |
Acarbose 100mg/1 90 TABLET in 1 BOTTLE, |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
acarbose 50 mg tablet |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ACARBOSE TABLETS |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ACEBUTOLOL 200MG CAPSULE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ACEBUTOLOL 400MG CAPSULE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
Acetaminophen and Codeine Phosphate 300; 60mg/1; mg/1 500 TABLET in 1 BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | Q:390 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | Q:390 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | Q:390 /30Days |
ACETASOL HC SOLUTION 10ML 10 ML BOT |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ACETAZOLAMIDE 125MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ACETIC ACID 2% SOLUTION NON-ORAL |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ACETYLCYSTEINE 10% VIAL |
1 |
Generic Drugs |
$6.00 | $18.00 | P |
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN |
1 |
Generic Drugs |
$6.00 | $18.00 | P |
ACTEMRA INJECTION 200MG/10ML |
4 |
Specialty Tier Drugs |
25% | 25% | P |
ACTHIB VACCINE VIAL 10-24UNT/5ML |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
ACTIMMUNE SOLUTION FOR INJECTION 100MCG |
4 |
Specialty Tier Drugs |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTOPLUS MET 15MG/500MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
ACTOPLUS MET 15MG/850MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
ACTOPLUS MET XR TABLETS EXTENDED RELEASE 15;1000 MG;MG |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
ACTOPLUS MET XR TABLETS EXTENDED RELEASE 30;1000 MG;MG |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
ACTOS 15MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
ACTOS 30MG TABLET (500 CT) |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
ACTOS 45MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
Acyclovir 200mg/1 |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Acyclovir 200mg/5mL 473 mL in 1 BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Acyclovir 400mg/1 100 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Acyclovir 800mg/1 100 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACYCLOVIR SODIUM 500MG VIAL |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ADACEL VIAL 2UNT/5UNT |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
ADAGEN 250U/ML VIAL |
4 |
Specialty Tier Drugs |
25% | 25% | P |
ADALAT CC 30MG TABLET |
3 |
Non-Preferred Brand Drugs |
$90.00 | $270.00 | None |
ADALAT CC 60MG TABLET |
3 |
Non-Preferred Brand Drugs |
$90.00 | $270.00 | None |
ADALAT CC 90MG TABLET |
3 |
Non-Preferred Brand Drugs |
$90.00 | $270.00 | None |
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA] |
4 |
Specialty Tier Drugs |
25% | 25% | P |
ADAPALENE CREAM |
1 |
Generic Drugs |
$6.00 | $18.00 | P |
ADAPALENE GEL |
1 |
Generic Drugs |
$6.00 | $18.00 | P |
ADCIRCA TABLETS 20MG 60 BOT |
4 |
Specialty Tier Drugs |
25% | 25% | P |
AFEDITAB CR 30MG TABLET SA |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AFEDITAB CR 60MG TABLET SA |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Afinitor 7.5mg/1 28 BLISTER PACK in 1 CARTON / 1 TABLET in 1 BLISTER PACK |
4 |
Specialty Tier Drugs |
25% | 25% | None |
AFINITOR TABLETS 10 MG |
4 |
Specialty Tier Drugs |
25% | 25% | None |
AFINITOR TABLETS 2.5 MG |
4 |
Specialty Tier Drugs |
25% | 25% | None |
AFINITOR TABLETS 5 MG |
4 |
Specialty Tier Drugs |
25% | 25% | None |
AGGRENOX 25-200MG CAPSULE |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
AK-CON 0.1% EYE DROPS |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AKTOB 0.3% EYE DROPS |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ALBENZA 200 MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
Albuterol Sulfate 0.63mg/3mL 25 POUCH in 1 CARTON / 5 VIAL in 1 POUCH / 3 mL in 1 VIAL |
1 |
Generic Drugs |
$6.00 | $18.00 | P Q:300 /30Days |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
1 |
Generic Drugs |
$6.00 | $18.00 | P Q:300 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
1 |
Generic Drugs |
$6.00 | $18.00 | P Q:60 /30Days |
ALBUTEROL SULFATE SOLUTION FOR INHALATION |
1 |
Generic Drugs |
$6.00 | $18.00 | P Q:300 /30Days |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ALBUTEROL TABLET 4MG (500 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ALCLOMETASONE DIPROPIONATE 0.05% CREAM |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Alclometasone Dipropionate 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ALDACTAZIDE 50/50 TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
ALDURAZYME 2.9MG/5ML VIAL |
4 |
Specialty Tier Drugs |
25% | 25% | P |
ALENDRONATE SODIUM 10MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ALENDRONATE SODIUM 5MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALENDRONATE SODIUM 70mg/1 |
1 |
Generic Drugs |
$6.00 | $18.00 | Q:4 /30Days |
ALENDRONATE SODIUM TABLET 35MG 20 CRTN |
1 |
Generic Drugs |
$6.00 | $18.00 | Q:4 /30Days |
ALFUZOSIN HYDROCHLORIDE 10mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | Q:30 /30Days |
ALIMTA 500MG VIAL |
4 |
Specialty Tier Drugs |
25% | 25% | P |
ALINIA 100MG/5ML SUSPENSION |
3 |
Non-Preferred Brand Drugs |
$90.00 | $270.00 | None |
ALINIA 500MG TABLET |
3 |
Non-Preferred Brand Drugs |
$90.00 | $270.00 | None |
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET in 1 BLISTER PACK |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ALLOPURINOL TABLETS |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ALPHAGAN P 0.1% DROPS |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
ALREX 0.2% EYE DROPS |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
ALTABAX 10mg/g 30 g in 1 TUBE |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMANTADINE 100MG CAPSULE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Amantadine Hydrochloride 50mg/5mL |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMIFOSTINE FOR INJECTION 500MG/VIAL |
1 |
Generic Drugs |
$6.00 | $18.00 | P |
AMIKACIN 250MG/ML VIAL |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMIKACIN 50MG/ML VIAL |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMINOPHYLLINE 100MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMINOPHYLLINE 200MG TABLET (1000 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Aminophylline 25mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIA |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMINOSYN 10% IV SOLUTION |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN 3.5% IV SOLUTION |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | P |
AMINOSYN 5% IV SOLUTION |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | P |
AMINOSYN 7% IV SOLUTION |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | P |
AMINOSYN 8.5% IV SOLUTION |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | P |
AMINOSYN HBC INJECTION SULFITE FREE 7% |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | P |
AMINOSYN II 10% IV SOLUTION |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | P |
AMINOSYN II 15% IV SOLUTION |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | P |
AMINOSYN II 3.5% IN D25W IV |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | P |
AMINOSYN II 3.5% IN D5W IV |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | P |
AMINOSYN II 3.5% M/D5W IV |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | P |
AMINOSYN II 3.5% W/ELEC DEX |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN II 4.25% IN D10W |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | P |
AMINOSYN II 4.25% IN D20W |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | P |
AMINOSYN II 4.25% W/ELEC DW |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | P |
AMINOSYN II 4.25%-D25W IV |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | P |
AMINOSYN II 5% IN D25W IV |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | P |
AMINOSYN II 7% IV SOLUTION |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | P |
AMINOSYN II 8.5% ELECTROLYT |
1 |
Generic Drugs |
$6.00 | $18.00 | P |
AMINOSYN II 8.5% IV SOLUTION |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | P |
AMINOSYN M 3.5% IV SOLUTION |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | P |
AMINOSYN PF INJECTION |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | P |
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5% |
1 |
Generic Drugs |
$6.00 | $18.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN-HF 8% IV SOLUTION |
1 |
Generic Drugs |
$6.00 | $18.00 | P |
AMINOSYN-PF 7% IV SOLUTION |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | P |
AMIODARONE HCL INJECTION |
1 |
Generic Drugs |
$6.00 | $18.00 | P |
Amiodarone hydrochloride 200mg/1 |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMITIZA 8MCG CAPSULE |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | Q:60 /30Days |
AMITIZA CAPSULES 24MCG 60 CAP BOT |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | Q:60 /30Days |
AMITRIP/PERPHEN 10-2 TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMITRIP/PERPHEN 10-4 TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMITRIP/PERPHEN 25-2 TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMITRIP/PERPHEN 25-4 TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMITRIP/PERPHEN 50-4 TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIPTYLINE HCL 100MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMITRIPTYLINE HCL 10MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMITRIPTYLINE HCL 150 MG TAB |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMMONIUM LACTATE 12% CREAM |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMMONIUM LACTATE 12% LOTION |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMOX TR-K CLV 500-125 MG TAB |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMOXAPINE 100MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
AMOXAPINE 150MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXAPINE 25MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
AMOXAPINE 50MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
AMOXICILLIN 125MG TABLET CHEW |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMOXICILLIN 200MG TABLET CHEW |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMOXICILLIN 250MG CAPSULE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Amoxicillin 250mg/1 500 TABLET, CHEWABLE in 1 BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMOXICILLIN 875MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMOXICILLIN CAP 500MG |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMPHETAMINE SALT COMBO 15MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMPHETAMINE SALT COMBO 30MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMPHETAMINE SALTS 20MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMPHETAMINE SALTS 5 MG TAB |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
amphotericin b 50mg/10mL 10 mL in 1 VIAL |
1 |
Generic Drugs |
$6.00 | $18.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN CAPSULES 250MG 100 BOT |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AMPYRA ER 10 MG TABLET |
4 |
Specialty Tier Drugs |
25% | 25% | P |
Amturnide 150; 5; 12.5mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | S |
Amturnide 300; 10; 12.5mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | S |
Amturnide 300; 10; 25mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | S |
Amturnide 300; 5; 12.5mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | S |
Amturnide 300; 5; 25mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANADROL-50 50MG TABLET (100 CT) |
3 |
Non-Preferred Brand Drugs |
$90.00 | $270.00 | None |
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | P |
Anagrelide Hydrochloride 1mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | P |
ANASTROZOLE TABLETS |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ANCOBON 250MG CAPSULE |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
ANCOBON 500MG CAPSULE |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
ANTABUSE 250MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ANTABUSE 500MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ANTARA CAPSULES |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
ANTARA CAPSULES |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
APOKYN 30mg/3mL 5 CARTRIDGE in 1 CARTON / 3 mL in 1 CARTRIDGE |
4 |
Specialty Tier Drugs |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Apraclonidine Ophthalmic 5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 10 mL in 1 BOTTLE, DROPPER |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
APRI 0.15-0.03 TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | Q:28 /28Days |
APTIVUS 250MG CAPSULE |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
Aralast NP 1 KIT in 1 CARTON |
4 |
Specialty Tier Drugs |
25% | 25% | P |
ARANELLE 7-9-5 TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ARCALYST INJECTION 220MG/VIAL |
4 |
Specialty Tier Drugs |
25% | 25% | P |
ARIXTRA 10MG SYRINGE |
4 |
Specialty Tier Drugs |
25% | 25% | Q:16 /10Days |
ARIXTRA 2.5MG SYRINGE |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | Q:10 /10Days |
ARIXTRA 5MG SYRINGE |
4 |
Specialty Tier Drugs |
25% | 25% | Q:8 /10Days |
ARIXTRA 7.5MG SYRINGE |
4 |
Specialty Tier Drugs |
25% | 25% | Q:12 /10Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ASTEPRO 0.15% NASAL SPRAY 30 ML |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | Q:60 /30Days |
ATENOLOL 100mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Atenolol 25mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ATENOLOL TABLET USP 50MG (100 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ATORVASTATIN 10 MG TABLET |
3 |
Non-Preferred Brand Drugs |
$90.00 | $270.00 | Q:30 /30Days |
ATORVASTATIN 20 MG TABLET |
3 |
Non-Preferred Brand Drugs |
$90.00 | $270.00 | Q:30 /30Days |
ATORVASTATIN 40 MG TABLET |
3 |
Non-Preferred Brand Drugs |
$90.00 | $270.00 | Q:30 /30Days |
ATORVASTATIN 80 MG TABLET |
3 |
Non-Preferred Brand Drugs |
$90.00 | $270.00 | Q:30 /30Days |
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
4 |
Specialty Tier Drugs |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATROVENT HFA AER 17MCG |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | Q:26 /30Days |
AVASTIN 100MG/4ML VIAL |
4 |
Specialty Tier Drugs |
25% | 25% | P |
AVELOX 400MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
AVELOX ABC PACK 400MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
AVELOX IV 400MG/250ML |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
AVIANE 0.1-0.02 TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AVONEX ADMIN PACK 30MCG VL |
4 |
Specialty Tier Drugs |
25% | 25% | P |
AZASITE 1% DROPS |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
AZATHIOPRINE 50MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | P |
AZATHIOPRINE SOD 100MG VIAL |
1 |
Generic Drugs |
$6.00 | $18.00 | P |
AZELASTINE 137 MCG NASAL SPRAY |
1 |
Generic Drugs |
$6.00 | $18.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Generic Drugs |
$6.00 | $18.00 | Q:120 /30Days |
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Generic Drugs |
$6.00 | $18.00 | Q:113 /30Days |
AZITHROMYCIN 250 MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | Q:30 /30Days |
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Azithromycin 500mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | Q:30 /30Days |
Azithromycin 600mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | Q:30 /30Days |
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
AZOR 10MG-20MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
AZOR 10MG-40MG TABLET (30 CT) |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
AZOR 5MG-20MG TABLET (30 CT) |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZOR 5MG-40MG TABLET |
2 |
Preferred Brand Drugs |
$45.00 | $135.00 | None |