2012 Medicare Part D Plan Formulary Information |
Triple-S FarmaMed (PDP) (S5907-001-0)
Benefit Details
|
The Triple-S FarmaMed (PDP) (S5907-001-0) Formulary Drugs Starting with the Letter C in CMS PDP Region 38 which includes: PR
|
Drugs Starting with Letter C
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
CABERGOLINE 0.5 MG TABLET |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CAFERGOT EROGOTAMINE TARTRATE AND CAFFINE TABLETS 1;100MG;MG 100 BOT |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CALAN 120MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CALAN 80MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CALAN SR 120MG CAPLET SA |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CALAN SR 180MG CAPLET SA |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CALAN SR TABLET 240MG (500 CT) |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CALCIPOTRIENE TOPICAL SOLUTION |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CALCITRIOL 0.25MCG CAPSULE |
1 |
Generic Drugs |
$7.00 | $21.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CALCITRIOL 0.5MCG CAPSULE |
1 |
Generic Drugs |
$7.00 | $21.00 | P |
CALCITRIOL 1MCG/ML SOLUTION ORAL |
1 |
Generic Drugs |
$7.00 | $21.00 | P |
CALCIUM ACETATE CAPSULE 667 MG |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CAMILA 0.35MG TABLET |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CAMPATH INJECTION 30 MG/ML |
4 |
Specialty Tier Drugs |
25% | 25% | P |
CAMPRAL 333MG DOSE PAK |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
CANCIDAS IV 50MG VIAL |
4 |
Specialty Tier Drugs |
25% | 25% | P |
CANCIDAS IV 70MG VIAL |
4 |
Specialty Tier Drugs |
25% | 25% | P |
CAPASTAT SULFATE 1g/1 1 INJECTION, POWDER, FOR SOLUTION in 1 CARTON |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CAPRELSA 100mg/1 30 TABLET in 1 BOTTLE, PLASTIC |
4 |
Specialty Tier Drugs |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAPRELSA 300mg/1 30 TABLET in 1 BOTTLE, PLASTIC |
4 |
Specialty Tier Drugs |
25% | 25% | P |
CAPTOPRIL 100MG TABLET |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CAPTOPRIL 12.5MG TABLET |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CAPTOPRIL 25MG TABLET |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CAPTOPRIL 50MG TABLET |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Captopril and Hydrochlorothiazide 25; 15mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Captopril and Hydrochlorothiazide 25; 25mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Captopril and Hydrochlorothiazide 50; 15mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Captopril and Hydrochlorothiazide 50; 25mg/1; mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CARAC CRE 0.5% |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CARAFATE SUCRALFATE 1G TABLET ORAL |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARAFATE SUS 1GM/10ML |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
Carbamazepine 100mg/1 100 TABLET, CHEWABLE in 1 BOTTLE |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CARBAMAZEPINE EXTENDED RELEASE TABLETS 200MG |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CARBAMAZEPINE EXTENDED RELEASE TABLETS 400MG |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CARBAMAZEPINE ORAL SUSPENSION 100 MG/5ML |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CARBAMAZEPINE TABLET USP 200MG (1000 CT) |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Carbidopa and Levodopa 25; 100mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Carbidopa and Levodopa 50; 200mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CARBIDOPA/LEVO 10/100 TABLET |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CARBIDOPA/LEVO 25/100 TABLET |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CARBIDOPA/LEVO 25/250 TABLET |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARDIZEM 120MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CARDIZEM 30MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CARDIZEM 60MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CARDIZEM 90MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CARDIZEM CAPSULES 180MG (90 CT) |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CARDIZEM CD 120 MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CARDIZEM CD 240MG CAPSULE SR 24 HR |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CARDIZEM CD 300 MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CARDIZEM CD 360 MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CARDURA 1MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CARDURA 2MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARDURA 4MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CARDURA 8MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CARIMUNE NF 3GM VIAL |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | P |
CARNITOR 100MG/ML ORAL TUBEX |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CARNITOR 330MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CARTIA XT 180MG CAPSULE SA |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Carvedilol 12.5mg/1 |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Carvedilol 25mg/1 |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Carvedilol 3.125mg/1 |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Carvedilol 6.25mg/1 500 TABLET, FILM COATED in 1 BOTTLE |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CASODEX 50mg/1 30 TABLET in 1 BOTTLE, PLASTIC |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CATAFLAM 50MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CATAPRES 0.1MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CATAPRES 0.2MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CATAPRES 0.3MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CATAPRES-TTS DIS 0.3/24HR |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CATAPRES-TTS-1 PATCH 2.52.5MG/UNT 1 X 4 CRTN |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CATAPRES-TTS-2 PATCH 52.5MG/UNT 1 X 4 CRTN |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CEENU 100MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CEENU 10MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CEENU 40MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFACLOR CAPSULES |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CEFACLOR CAPSULES |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CEFADROXIL 1G TABLET |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Cefadroxil 500mg/1 |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Cefadroxil 500mg/5mL |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CEFADROXIL FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Cefazolin 1g/1 |
1 |
Generic Drugs |
$7.00 | $21.00 | P |
CEFAZOLIN FOR INJECTION |
1 |
Generic Drugs |
$7.00 | $21.00 | P |
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CEFDINIR CAPSULES 300MG (60 CT) |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT) |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFEPIME HCL 2 GRAM VIAL |
1 |
Generic Drugs |
$7.00 | $21.00 | P |
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL |
1 |
Generic Drugs |
$7.00 | $21.00 | P |
Cefpodoxime Proxetil 100mg/5mL 1 BOTTLE in 1 CARTON / 100 mL in 1 BOTTLE |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Cefpodoxime Proxetil 50mg/5mL 1 BOTTLE in 1 CARTON / 100 mL in 1 BOTTLE |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT) |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CEFPODOXIME TAB 200MG |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CEFPROZIL 125mg/5mL |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Cefprozil 250mg/1 100 TABLET, FILM COATED in 1 BOTTLE |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CEFPROZIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CEFPROZIL TABLETS 500MG 100 BOT |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Ceftazidime 1g/1 25 VIAL in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL |
1 |
Generic Drugs |
$7.00 | $21.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFTIN 125mg/5mL 100 mL in 1 BOTTLE, GLASS |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CEFTIN 250MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CEFTIN 250MG/5ML ORAL SUSP |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CEFTIN 500MG TABLET (20 CT) |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CEFTRIAXONE FOR INJECTION 250MG BOX OF 10 VIALGL |
1 |
Generic Drugs |
$7.00 | $21.00 | P |
Ceftriaxone Sodium 500mg/1 |
1 |
Generic Drugs |
$7.00 | $21.00 | P |
CEFUROXIME 250MG TABLET |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CEFUROXIME AXETIL 125MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CEFUROXIME AXETIL 500MG TABLET (20 CT) |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CEFUROXIME FOR INJECTION |
1 |
Generic Drugs |
$7.00 | $21.00 | P |
CEFUROXIME FOR INJECTION |
1 |
Generic Drugs |
$7.00 | $21.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CELEBREX 100MG CAPSULE |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | S |
CELEBREX 200MG CAPSULE |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | S |
CELEBREX 400MG CAPSULE |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | S |
CELEBREX 50MG CAPSULE |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | S |
CELESTONE 0.6MG/5ML SYRUP |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CELEXA 10MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | S |
CELEXA 20MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | S |
CELEXA 40MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | S |
CELLCEPT 200MG/ML ORAL SUSP |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CELLCEPT 500MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CELLCEPT CAPSULES 250MG (500 CT) |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CELONTIN 300MG KAPSEAL |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
Cephalexin 125mg/5mL 200 mL in 1 BOTTLE |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CEPHALEXIN 250MG CAPSULE |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CEPHALEXIN 250MG/5ML ORAL SUSP |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CEPHALEXIN CAPSULES 500MG (500 CT) |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CEREDASE 80UNITS/ML VIAL |
4 |
Specialty Tier Drugs |
25% | 25% | P |
CEREZYME INJ 200UNIT |
4 |
Specialty Tier Drugs |
25% | 25% | P |
CHANTIX 0.5MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CHANTIX 1MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CHANTIX STARTING MONTH PAK |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CHLORDIAZEPOXIDE AND AMITRIPTYLINE HCL TABLET 12.5-5MG (500 CT) |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CHLOROQUINE PH 500MG TABLET |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CHLOROQUINE PHOSPHATE 250MG TABLET (50 CT) |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CHLOROTHIAZIDE 250MG TABLET |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CHLOROTHIAZIDE 500MG TABLET |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CHLORPROMAZINE 10MG TABLET |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CHLORPROMAZINE 25MG TABLET |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CHLORPROMAZINE 25MG/ML AMP |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CHLORPROMAZINE 50MG TABLET |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CHLORPROMAZINE HCL 200MG TABLET |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Chlorpromazine Hydrochloride 100mg/1 1000 TABLET, SUGAR COATED in 1 BOTTLE |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLORPROPAMIDE 100MG TABLET |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Chlorpropamide 250mg/1 1000 TABLET in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CHLORTHALIDONE 25MG TABLET (100 CT) |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CHLORTHALIDONE 50MG TABLET (1000 CT) |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CHLORZOXAZONE 500 MG TABLET |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CHORIONIC GONAD 10000U VIAL |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6ML BOT |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Ciclopirox Olamine 7.7mg/g 1 TUBE in 1 TUBE / 15 g in 1 TUBE |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CILOSTAZOL 50 MG TABLET |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CILOSTAZOL TABLET 100MG (60 CT) |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CILOXAN SOLUTION 0.3% 5ML BOT |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CIMETIDINE 150MG/ML VIAL |
1 |
Generic Drugs |
$7.00 | $21.00 | P |
Cimetidine 400mg/1 100 TABLET, FILM COATED in 1 BOTTLE |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Cimetidine 800mg/1 100 TABLET, FILM COATED in 1 BOTTLE |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CIMETIDINE TABLETS |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Cipro 1 KIT in 1 KIT |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
Cipro 1 KIT in 1 KIT |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CIPRO 250MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
Cipro 500mg/1 100 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CIPRO 750MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CIPRODEX OTIC SUSPENSION |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIPROFLOXACIN 0.3% EYE DROP |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CIPROFLOXACIN 250MG TABLET (100 CT) |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Ciprofloxacin 400mg/40mL 1 VIAL in 1 CARTON / 40 mL in 1 VIAL |
1 |
Generic Drugs |
$7.00 | $21.00 | P |
CIPROFLOXACIN 500MG TABLET |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Ciprofloxacin ER 212.6; 287.5mg/1; mg/1 50 TABLET, FILM COATED, in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Ciprofloxacin ER 425.2; 574.9mg/1; mg/1 50 TABLET, FILM COATED, in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CIPROFLOXACIN TABLETS 750MG 100 BOT |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CITALOPRAM HBR 20 MG TABLET |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CITOLOPRAM HBR 10MG TABLET (100 CT) |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLARAVIS 10MG CAPSULE |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CLARAVIS 20MG CAPSULE |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Claravis 30mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CLARAVIS 40MG CAPSULE |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Clarinex 0.5mg/mL 473 mL in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | S |
CLARINEX 2.5MG REDITABS |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | S |
CLARINEX 5MG REDITABS |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | S |
CLARINEX 5MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | S |
CLARINEX-D 12 HOUR TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | S |
CLARINEX-D 24 HOUR 5; 240mg/1; mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | S |
CLARITHROMYCIN 250MG TABLET |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLARITHROMYCIN 500MG TABLET |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CLARITHROMYCIN FOR ORAL SUSPENSION |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CLARITHROMYCIN FOR ORAL SUSPENSION |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CLEOCIN 2% VAGINAL CREAM |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CLEOCIN HCL 150MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CLEOCIN HCL 300MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CLEOCIN PED SOL 75MG/5ML |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CLEOCIN PHOS 150MG/ML VIAL |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CLEOCIN T 1% SOLUTION |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CLIMARA 0.025MG/DAY PATCH |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CLIMARA 0.0375MG/DAY PATCH |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLIMARA 0.05MG/24H PATCH |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CLIMARA 0.06/MG DAY PATCH |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CLIMARA 0.075MG/DAY PATCH |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CLIMARA 0.1MG/24H PATCH |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CLIMARA PRO DIS WEEKLY 4.40MG/1.39MG |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CLINDAMYCIN HCL 150MG CAPSULE |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CLINDAMYCIN HYDROCHLORIDE CAPSULES |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
clindamycin phosphate 10mg/mL 1 BOTTLE in 1 CARTON / 60 mL in 1 BOTTLE |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CLINDAMYCIN PHOSPHATE VAGINAL CREAM |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CLINIMIX 2.75%/5% INJECTION 1000ML BAG |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CLINIMIX 4.25/10 SOLUTION |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINIMIX 4.25/20 SOLUTION |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CLINIMIX 4.25/25 SOLUTION |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CLINIMIX 4.25/5 SOLUTION |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CLINIMIX 5/15 SOLUTION |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CLINIMIX 5/20 SOLUTION |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CLINIMIX E 2.75/10 SOLUTION |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CLINIMIX E 2.75/5 SOLUTION |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CLINIMIX E 4.25/25 SOLUTION |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CLINIMIX E 4.25/5 SOLUTION |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CLINIMIX E 5/20 SOLUTION |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINIMIX E 5/25 SOLUTION |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CLINIMIX E 5%/15% INJECTION 2000ML BAG |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CLINISOL 15% SOLUTION |
1 |
Generic Drugs |
$7.00 | $21.00 | P |
CLINORIL 200MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CLOBETASOL 0.05% OINTMENT |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CLOBETASOL E 0.05% CREAM |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Clobetasol Propionate 0.5mg/mL 50 mL in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CLOMIPRAMINE HCL 25MG CAPSULE |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CLOMIPRAMINE HCL 50MG CAPSULE |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CLOMIPRAMINE HCL 75MG CAPSULE |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Clonidine 0.1mg/d 4 POUCH in 1 CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Clonidine 0.2mg/d 4 POUCH in 1 CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Clonidine 0.3mg/d 4 POUCH in 1 CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CLONIDINE HCL 0.2MG TABLET (500 CT) |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CLONIDINE HCL TABLET 0.1MG (500 CT) |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CLONIDINE HCL TABLET 0.3MG (100 CT) |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CLOTRIMAZOLE 1% CREAM |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CLOTRIMAZOLE 10MG TROCHE |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CLOTRIMAZOLE SOLUTION TOPICAL 1% 30ML BOTPL |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOZAPINE 100mg/1 100 TABLET in 1 BOTTLE |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CLOZAPINE 200MG TABLET (500 CT) |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CLOZAPINE 25MG TABLET (100 CT) |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CLOZAPINE 50MG TABLET (500 CT) |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CLOZARIL 100MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CLOZARIL 25MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
COARTEM 20MG-120MG |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
COLAZAL 750MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
Colcrys 0.6mg/1 100 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
COLESTID 1GM TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
COLESTID GRANULES |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COLESTIPOL HCL 1G TABLET |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
COLESTIPOL HYDROCHLORIDE 5g/1 100 SUSPENSION in 1 BOTTLE |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
colistimethate 150mg/2mL 1 VIAL in 1 CARTON / 2 mL in 1 VIAL |
1 |
Generic Drugs |
$7.00 | $21.00 | P |
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
COLY MYCIN M FOR INJECTION 150MG/VIAL 5 ML VIALSD |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
Colyte with flavor packs 240; 2.98; 6.72; 5.84; 22.72g/4L; g/4L; g/4L; g/4L; g/4L |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
COMBIGAN 0.2%-0.5% DROPS |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
COMBIVENT INHALER |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
COMBIVENT RESPIMAT INHAL SPRAY 20-100 MCG |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
COMBIVIR 150; 300mg/1; mg/1 120 TABLET, FILM COATED in 1 DOSE PACK |
4 |
Specialty Tier Drugs |
25% | 25% | None |
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1 |
4 |
Specialty Tier Drugs |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COMTAN 200MG TABLET |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
COMVAX VACCINE VIAL |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CONDYLOX GEL 0.5% 3.5 GM CRTN |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN |
4 |
Specialty Tier Drugs |
25% | 25% | P |
COPEGUS 200MG TABLET |
4 |
Specialty Tier Drugs |
25% | 25% | None |
CORDARONE 200MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
COREG 12.5MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
COREG 25MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
COREG 3.125MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
COREG 6.25MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CORGARD (NADOLOL) 80MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CORGARD 20MG TABLET (100 CT) |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CORGARD 40MG TABLET (100 CT) |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CORTEF 10MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CORTEF 20MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CORTEF 5MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CORTENEMA 100MG/60ML ENEMA |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CORTISONE ACETATE 25MG TABLET (100 CT) |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CORTISPORIN EAR SOLUTION |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CORZIDE 40-5MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CORZIDE 80-5MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
COSOPT PLUS EYE DROPS 22.3 MG/ML 6.8 MG/M |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COUMADIN 10MG TABLET |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
COUMADIN 1MG TABLET |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
COUMADIN 2.5MG TABLET |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
COUMADIN 2MG TABLET |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
COUMADIN 3mg/1 1 BOTTLE in 1 CARTON / 100 TABLET in 1 BOTTLE |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
COUMADIN 4mg/1 1 BOTTLE in 1 CARTON / 100 TABLET in 1 BOTTLE |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
COUMADIN 5MG TABLET |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
COUMADIN 6MG TABLET |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
COUMADIN 7.5MG TABLET |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
COZAAR 100mg/1 1000 TABLET, FILM COATED in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
COZAAR 50mg/1 90 TABLET, FILM COATED in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COZAAR25MG TABLET (1000 CT) |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CRIXIVAN 100MG CAPSULE |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
CRIXIVAN 200MG CAPSULE |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
CRIXIVAN 400mg/1 90 CAPSULE in 1 BOTTLE |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
CROMOLYN NEBULIZER SOLUTION |
1 |
Generic Drugs |
$7.00 | $21.00 | P |
CROMOLYN SODIUM 4% 40MG 10ML BOT |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CUBICIN 500MG VIAL |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CUPRIMINE CAPSULES 250MG (100 CT) |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | None |
Cutivate 0.5mg/g 60 g in 1 TUBE |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CUTIVATE OINTMENT 0.005% 60GM TUBE |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT) |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYCLOSPORINE 100MG CAPSULE |
1 |
Generic Drugs |
$7.00 | $21.00 | P |
Cyclosporine 100mg/1 30 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK |
1 |
Generic Drugs |
$7.00 | $21.00 | P |
CYCLOSPORINE 25MG CAPSULE |
1 |
Generic Drugs |
$7.00 | $21.00 | P |
Cyclosporine 50mg/mL 10 VIAL in 1 BOX / 5 mL in 1 VIAL |
1 |
Generic Drugs |
$7.00 | $21.00 | P |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT |
1 |
Generic Drugs |
$7.00 | $21.00 | P |
CYKLOKAPRON 100MG/ML AMPUL |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CYMBALTA 20MG CAPSULE |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | S |
Cymbalta 60mg/1 1000 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | S |
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT) |
2 |
Preferred Brand Drugs |
$25.00 | $75.00 | S |
CYPROHEPTADINE HCL 4 MG |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL |
1 |
Generic Drugs |
$7.00 | $21.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYSTADANE POWDER FOR ORAL SOLUTION 180GM |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CYSTAGON 150MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CYSTAGON 50MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | P |
CYTOMEL 25MCG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CYTOMEL 50MCG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CYTOMEL 5MCG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CYTOTEC TABLET 100MCG (120 CT) |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |
CYTOTEC TABLET 200MCG (60 CT) |
3 |
Non-Preferred Brand Drugs Greater of $45 or |
25% | 25% | None |