2012 Medicare Part D Plan Formulary Information |
EnvisionRxPlus Silver (PDP) (S7694-030-0)
Benefit Details
|
The EnvisionRxPlus Silver (PDP) (S7694-030-0) Formulary Drugs Starting with the Letter P in CMS PDP Region 30 which includes: OR WA
|
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 100MG TABLET |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PACERONE 200MG TABLET |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PALGIC 4MG/5ML LIQUID |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PANRETIN 0.1% GEL 60GM TUBE |
4 |
Non-Preferred Brand Drugs |
25% | N/A | None |
PARCAINE 0.5% DROPS |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PAROMOMYCIN 250MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PAROXETINE FILM COATED 20MG TABLET (100 CT) |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PAROXETINE HCL 10MG/5ML SUSPENSION ORAL |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PAROXETINE HCL TABLET 24 12.5MG |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PAROXETINE HCL TABLET 24 25MG |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Paroxetine Hydrochloride 37.5mg/1 30 BOTTLE in 1 BOTTLE / 30 TABLET, FILM COATED, EXTENDED RELEASE |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PAROXETINE HYDROCHLORIDE TABLETS 10 MG |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PAROXETINE TABLETS 30MG 90 BOT |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PAROXETINE40mg/1 |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PASER GRANULES 4GM PACKET |
4 |
Non-Preferred Brand Drugs |
25% | N/A | None |
PATADAY 0.2% DROPS |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PATANOL 0.1% EYE DROPS |
4 |
Non-Preferred Brand Drugs |
25% | N/A | None |
PEDI-DRI TOPICAL POWDER |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PEDVAXHIB VACCINE VIAL |
4 |
Non-Preferred Brand Drugs |
25% | N/A | None |
PEGANONE 250MG TABLET |
4 |
Non-Preferred Brand Drugs |
25% | N/A | None |
PEGASYS 180MCG/0.5ML CONV.PK |
5 |
Specialty Tier Drugs |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEGASYS INJECTION |
5 |
Specialty Tier Drugs |
25% | N/A | None |
PEGASYS PROCLICK 135 MCG/0.5 |
5 |
Specialty Tier Drugs |
25% | N/A | None |
PEGINTRON 1 KIT in 1 CARTON |
5 |
Specialty Tier Drugs |
25% | N/A | None |
PegIntron 120ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE |
5 |
Specialty Tier Drugs |
25% | N/A | None |
PegIntron 150ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE |
5 |
Specialty Tier Drugs |
25% | N/A | None |
PegIntron 50ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE |
5 |
Specialty Tier Drugs |
25% | N/A | None |
PegIntron 80ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE |
5 |
Specialty Tier Drugs |
25% | N/A | None |
PENICILLIN G POTASSIUM FOR INJECTION 5000000UNIT/VIAL |
1 |
Preferred Generic Drugs |
25% | N/A | None |
Penicillin G Sodium 5000000[iU]/1 10 VIAL in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PENICILLIN V POTASSIUM 250MG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
1 |
Preferred Generic Drugs |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENICILLIN V POTASSIUM 500MG TABLET |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PENICILLIN V POTASSIUM FOR ORAL SOLUTION CONCENTRATE 125MG 200ML BOT |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PENTAZOCINE/ACETAMIN TABLET |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PENTAZOCINE/NALOXONE TABLET |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PENTOPAK 400MG TABLET SA |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PENTOXIFYLLINE 400MG TABLET SA |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
Permethrin 50mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PERPHENAZINE 16 MG TABLET |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PERPHENAZINE TABLETS 4MG 100 BOXUD |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PERPHENAZINE TABLETS 8MG 100 BOT |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PERPHENAZINE TABLETS USP 2MG 100 BOT |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEXEVA 10MG TABLET |
4 |
Non-Preferred Brand Drugs |
25% | N/A | None |
PEXEVA 20MG TABLET |
4 |
Non-Preferred Brand Drugs |
25% | N/A | None |
PEXEVA 30MG TABLET |
4 |
Non-Preferred Brand Drugs |
25% | N/A | None |
PEXEVA 40MG TABLET |
4 |
Non-Preferred Brand Drugs |
25% | N/A | None |
Phenelzine Sulfate 15mg/1 60 TABLET in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PHENYTOIN SOD EXT 200 MG CAP |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT) |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PHENYTOIN SODIUM INJECTION 50MG 25 X 2ML AMP |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PHOSPHOLINE IODIDE 0.125% |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PHYSIOLYTE SOLUTION FOR IRRIGATION |
1 |
Preferred Generic Drugs |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PHYSIOSOL IRRIGATION SOL |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PICATO 0.015% GEL |
5 |
Specialty Tier Drugs |
25% | N/A | None |
PICATO 0.05% GEL |
5 |
Specialty Tier Drugs |
25% | N/A | None |
PILOCARPINE HCL 5MG TABLET (100 CT) |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
Pilocarpine Hydrochloride 7.5mg/1 100 TABLET, FILM COATED in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PILOPINE HS 4% EYE GEL |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PINDOLOL 10MG TABLET |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PINDOLOL 5MG TABLET |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PIPERACILLIN 3GM VIAL |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PIPERACILLIN 40GM BULK VIAL |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PIROXICAM 10 MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Piroxicam 20mg/1 500 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PLASMA-LYTE 148 IV SOLUTION |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PLASMA-LYTE 148/DEXTROSE 5% |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PLASMA-LYTE 56 INJECTION 32;128 MG/100ML; |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PLASMA-LYTE 56/DEXTROSE 5% |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PLASMA-LYTE A PH 7.4 SOLUTION 37;368; MG/100ML; |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PLASMA-LYTE INJ-R |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PLAVIX 75MG TABLET |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PLAVIX TABLETS 300MG |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PODOFILOX 0.5% TOPICAL TUBEX |
1 |
Preferred Generic Drugs |
25% | N/A | None |
POLY-DEX 3.5-10K-.1 OINTMENT |
1 |
Preferred Generic Drugs |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT) |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1% |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
POTASSIUM CHLORIDE 0.075%/D5W/SODIUM CHLORIDE 0.2% |
1 |
Preferred Generic Drugs |
25% | N/A | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.3% |
1 |
Preferred Generic Drugs |
25% | N/A | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45% |
1 |
Preferred Generic Drugs |
25% | N/A | None |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.2% |
1 |
Preferred Generic Drugs |
25% | N/A | None |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG |
1 |
Preferred Generic Drugs |
25% | N/A | None |
POTASSIUM CHLORIDE 10MEQ/100ML SOL |
1 |
Preferred Generic Drugs |
25% | N/A | None |
POTASSIUM CHLORIDE 10MEQ/50ML SOL |
1 |
Preferred Generic Drugs |
25% | N/A | None |
POTASSIUM CHLORIDE 149mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 5 mL in 1 VIAL, SINGLE-DOSE |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
Potassium Chloride 20.000000meq/1 |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE 20MEQ IN D5W/NACL 0.225% |
1 |
Preferred Generic Drugs |
25% | N/A | None |
POTASSIUM CHLORIDE 20MEQ/50ML SOL |
1 |
Preferred Generic Drugs |
25% | N/A | None |
POTASSIUM CHLORIDE 30MEQ/100ML SOL |
1 |
Preferred Generic Drugs |
25% | N/A | None |
POTASSIUM CHLORIDE ER CAPSULES 10MEQ |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
POTASSIUM CHLORIDE ER CPCR 8MEQ |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
POTASSIUM CHLORIDE EXTENDED RELEASE TABLETS |
1 |
Preferred Generic Drugs |
25% | N/A | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA |
1 |
Preferred Generic Drugs |
25% | N/A | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION |
1 |
Preferred Generic Drugs |
25% | N/A | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION |
1 |
Preferred Generic Drugs |
25% | N/A | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE INJECTION 40 12 X 1000ML CTR |
1 |
Preferred Generic Drugs |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE IN DEXTROSE INJECTION 5GM/75MG |
1 |
Preferred Generic Drugs |
25% | N/A | None |
Potassium Chloride in Lactated Ringers and Dextrose 20; 5; 179; 600; 310mg/100mL; g/100mL; mg/100mL |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION |
1 |
Preferred Generic Drugs |
25% | N/A | None |
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION 0.15%-0.9% 12 X 1000ML BAG |
1 |
Preferred Generic Drugs |
25% | N/A | None |
POTASSIUM CITRATE 10MEQ TABLET SA |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
POTASSIUM CITRATE 5MEQ TABLET SA |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
POTIGA 200 MG TABLET |
4 |
Non-Preferred Brand Drugs |
25% | N/A | None |
POTIGA 300 MG TABLET |
4 |
Non-Preferred Brand Drugs |
25% | N/A | None |
POTIGA 400 MG TABLET |
4 |
Non-Preferred Brand Drugs |
25% | N/A | None |
POTIGA 50 MG TABLET |
4 |
Non-Preferred Brand Drugs |
25% | N/A | None |
PRADAXA 150mg/1 1 BOTTLE in 1 CARTON / 60 CAPSULE in 1 BOTTLE |
3 |
Preferred Brand Drugs |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRADAXA 75mg/1 1 BOTTLE in 1 CARTON / 60 CAPSULE in 1 BOTTLE |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PRAMIPEXOLE 0.125 MG TABLET |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PRAMIPEXOLE 0.25 MG TABLET |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PRAMIPEXOLE 0.5 MG TABLET |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PRAMIPEXOLE 1 MG TABLET |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PRAMIPEXOLE 1.5 MG TABLET |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PRAMIPEXOLE DIHYDROCHLORIDE TABLETS |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PRANDIN 0.5MG TABLET |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PRANDIN 1MG TABLET |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PRANDIN 2MG TABLET |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PRAVASTATIN SODIUM 20MG TABLET 500 BOT |
1 |
Preferred Generic Drugs |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAVASTATIN SODIUM 40MG TABLET (500 CT) |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PRAVASTATIN SODIUM 80MG TABLET (90 CT) |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PRAZOSIN 5MG CAPSULE |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PRAZOSIN HCL 1MG CAPSULE |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PRAZOSIN HCL 2MG CAPSULE |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PREDNICARBATE 0.1% OINTMENT |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PREDNICARBATE 1 MG/ML TOPICAL CREAM |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PREDNISOLONE SOD 1% EYE DROP |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PREDNISONE 10MG TABLET (100 CT) |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PREDNISONE 1MG TABLET |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PREDNISONE 2.5MG TABLET |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PREDNISONE 20MG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PREDNISONE 5 MG TABLET |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PREDNISONE 50MG TABLET |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PREDNISONE 5MG/5ML SOLUTION |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PREMARIN 0.3MG (100 CT) |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PREMARIN 0.45MG TABLET |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PREMARIN 0.625MG (100 CT) |
3 |
Preferred Brand Drugs |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Premarin 0.625mg/g |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PREMARIN 0.9MG TABLET |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PREMARIN 1.25MG (100 CT) |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PREMARIN 25MG VIAL |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PREMASOL 6% IV SOLUTION |
1 |
Preferred Generic Drugs |
25% | N/A | P |
Premphase 1 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PREMPRO 0.45-1.5 MG TABLET 28 EA |
3 |
Preferred Brand Drugs |
25% | N/A | None |
Prempro 0.625; 2.5mg/1; mg/1 1 BLISTER PACK in 1 CARTON / 28 TABLET, SUGAR COATED in 1 BLISTER PACK |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PREVALITE POW 4GM |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PREZISTA TABLET 600MG |
5 |
Specialty Tier Drugs |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREZISTA TABLET 75MG |
4 |
Non-Preferred Brand Drugs |
25% | N/A | None |
PREZISTA TABLETS |
4 |
Non-Preferred Brand Drugs |
25% | N/A | None |
PREZISTA TABLETS 400MG 60 TABLETS BOT |
5 |
Specialty Tier Drugs |
25% | N/A | None |
PRIFTIN 150MG TABLET |
4 |
Non-Preferred Brand Drugs |
25% | N/A | None |
Primidone 250mg/1 100 TABLET in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
Primidone 50mg/1 500 TABLET in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PRISTIQ 100MG TABLET SR 24HR |
3 |
Preferred Brand Drugs |
25% | N/A | None |
Pristiq Extended-Release 50mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PROAIR HFA 90MCG HFA AEROSOL WITH ADAPTER |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PROBENECID 500MG TABLET |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PROCAINAMIDE 100MG/ML VIAL |
1 |
Preferred Generic Drugs |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCAINAMIDE 500MG/ML VIAL |
1 |
Preferred Generic Drugs |
25% | N/A | None |
ProcalAmine 0.21; 0.29; 0.026; 0.014; 3; 0.42; 0.085; 0.21; 0.27; 0.22; 0.054; 0.16; 0.17; 0.041; 0 |
3 |
Preferred Brand Drugs |
25% | N/A | P |
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT) |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT) |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PROCRIT 10000U/ML VIAL |
4 |
Non-Preferred Brand Drugs |
25% | N/A | P |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL |
3 |
Preferred Brand Drugs |
25% | N/A | P Q:23 /30Days |
PROCRIT 3000U/ML VIAL |
3 |
Preferred Brand Drugs |
25% | N/A | P Q:16 /30Days |
PROCRIT 40000U/ML VIAL PR |
5 |
Specialty Tier Drugs |
25% | N/A | P |
PROCRIT 4000U/ML VIAL 25 X 1ML VIAL |
4 |
Non-Preferred Brand Drugs |
25% | N/A | P Q:12 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY |
5 |
Specialty Tier Drugs |
25% | N/A | P |
PROCTO-PAK 1% CREAM |
1 |
Preferred Generic Drugs |
25% | N/A | None |
Proctocream HC 25mg/g |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PROCTOSOL-HC 2.5% CREAM |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PROCTOZONE-HC 2.5% CREAM |
1 |
Preferred Generic Drugs |
25% | N/A | None |
Proglycem 50mg/mL 1 BOTTLE, DROPPER in 1 BOX / 30 mL in 1 BOTTLE, DROPPER |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PROGRAF 5MG/ML AMPULE |
4 |
Non-Preferred Brand Drugs |
25% | N/A | P |
PROLASTIN 500MG VIAL |
5 |
Specialty Tier Drugs |
25% | N/A | None |
PROLASTIN-C 1 KIT in 1 CARTON |
5 |
Specialty Tier Drugs |
25% | N/A | None |
PROLEUKIN 1.1mg/mL 1 VIAL, SINGLE-USE in 1 BOX / 1 mL in 1 VIAL, SINGLE-USE |
5 |
Specialty Tier Drugs |
25% | N/A | None |
PROLIA INJECTION |
4 |
Non-Preferred Brand Drugs |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMACTA 12.5 MG TABLET |
5 |
Specialty Tier Drugs |
25% | N/A | None |
PROMACTA 25 MG TABLET |
5 |
Specialty Tier Drugs |
25% | N/A | None |
PROMACTA 50 MG TABLET |
5 |
Specialty Tier Drugs |
25% | N/A | None |
PROMACTA 75 MG TABLET |
5 |
Specialty Tier Drugs |
25% | N/A | None |
PROPAFENONE HCL 150MG TABLET (100 CT) |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PROPAFENONE HCL 225MG TABLET |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PROPAFENONE HCL 300MG TABLET (100 CT) |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PROPRANOLOL 20MG/5ML TUBEX |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PROPRANOLOL 40MG/5ML TUBEX |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PROPRANOLOL 60MG TABLET |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PROPRANOLOL 80 MG TABLET |
1 |
Preferred Generic Drugs |
25% | N/A | 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 |
Preferred Generic Drugs |
25% | N/A | None |
PROPRANOLOL HCL INJECTION 1MG 10 PKG OF 10 CRTN |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PROPRANOLOL HCL TABLET USP 10MG (1000 CT) |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PROPRANOLOL HCL TABLET USP 40MG (1000 CT) |
1 |
Preferred Generic Drugs |
25% | N/A | None |
Propranolol Hydrochloride 120mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
Propranolol Hydrochloride 160mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
Propranolol Hydrochloride 60mg/1 1000 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
Propranolol Hydrochloride 80mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PROPRANOLOL/HCTZ 40/25 TABLET |
1 |
Preferred Generic Drugs |
25% | N/A | None |
PROPRANOLOL/HCTZ 80/25 TABLET |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PROPYLTHIOURACIL 50MG TABLET |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROQUAD VIAL |
4 |
Non-Preferred Brand Drugs |
25% | N/A | None |
Protonix I.V. 40mg/10mL 10 CARTON in 1 PACKAGE / 1 VIAL in 1 CARTON / 40 mL in 1 VIAL |
4 |
Non-Preferred Brand Drugs |
25% | N/A | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PROVIGIL 100MG TABLET |
3 |
Preferred Brand Drugs |
25% | N/A | P |
PROVIGIL 200MG TABLET |
3 |
Preferred Brand Drugs |
25% | N/A | P |
PULMICORT .25MG/2ML RESPULE |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PULMICORT 1MG/2ML AMPUL FOR NEBULIZATION |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PULMICORT FLEXHALER 180MCG AEROSOL POWDER BREATH ACTIVATED |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PULMICORT FLEXHALER 90MCG AEROSOL POWDER BREATH ACTIVATED |
3 |
Preferred Brand Drugs |
25% | N/A | None |
PULMICORT RESPULES 0.5mg/2mL 6 POUCH in 1 CARTON / 5 AMPULE in 1 POUCH / 2 mL in 1 AMPULE |
3 |
Preferred Brand Drugs |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PULMOZYME 1MG/ML AMPUL |
5 |
Specialty Tier Drugs |
25% | N/A | P |
PYRAZINAMIDE 500MG TABLET |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |
PYRIDOSTIGMINE BROMIDE 60MG TABLET |
2 |
Non-Preferred Generic Drugs |
25% | N/A | None |