2012 Medicare Part D Plan Formulary Information |
Ozark Health Plan - Dual Plus (HMO SNP) (H5416-019-0)
Sanctioned Plan
|
The Ozark Health Plan - Dual Plus (HMO SNP) (H5416-019-0) Formulary Drugs Starting with the Letter P in Barry County, MO: CMS MA Region 15 which includes: MO
|
Drugs Starting with Letter P
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
PACERONE 200MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
PACLITAXEL INJECTION SOLUTION 6MG 50ML VIALMD |
2 |
Tier 2 |
N/A | N/A | P |
PAROMOMYCIN 250MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | None |
PAROXETINE FILM COATED 20MG TABLET (100 CT) |
2 |
Tier 2 |
N/A | N/A | Q:45 /30Days |
PAROXETINE HCL 10MG/5ML SUSPENSION ORAL |
2 |
Tier 2 |
N/A | N/A | None |
PAROXETINE HCL TABLET 24 12.5MG |
2 |
Tier 2 |
N/A | N/A | Q:30 /30Days |
PAROXETINE HCL TABLET 24 25MG |
2 |
Tier 2 |
N/A | N/A | None |
Paroxetine Hydrochloride 37.5mg/1 30 BOTTLE in 1 BOTTLE / 30 TABLET, FILM COATED, EXTENDED RELEASE |
2 |
Tier 2 |
N/A | N/A | None |
PAROXETINE HYDROCHLORIDE TABLETS 10 MG |
2 |
Tier 2 |
N/A | N/A | Q:45 /30Days |
PAROXETINE TABLETS 30MG 90 BOT |
2 |
Tier 2 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAROXETINE40mg/1 |
2 |
Tier 2 |
N/A | N/A | None |
PEDI-DRI TOPICAL POWDER |
2 |
Tier 2 |
N/A | N/A | None |
PENICILLIN G POTASSIUM FOR INJECTION 5000000UNIT/VIAL |
2 |
Tier 2 |
N/A | N/A | None |
PENICILLIN V POTASSIUM 250MG TABLET (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
1 |
Tier 1 |
N/A | N/A | None |
PENICILLIN V POTASSIUM 500MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PENICILLIN V POTASSIUM FOR ORAL SOLUTION CONCENTRATE 125MG 200ML BOT |
1 |
Tier 1 |
N/A | N/A | None |
PENTOPAK 400MG TABLET SA |
2 |
Tier 2 |
N/A | N/A | None |
PENTOSTATIN FOR INJECTION 10MG/VIAL |
2 |
Tier 2 |
N/A | N/A | P |
PENTOXIFYLLINE 400MG TABLET SA |
2 |
Tier 2 |
N/A | N/A | None |
Perindopril Erbumine 2mg/1 100 TABLET in 1 BOTTLE |
2 |
Tier 2 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Perindopril Erbumine 4mg/1 100 TABLET in 1 BOTTLE |
2 |
Tier 2 |
N/A | N/A | None |
Perindopril Erbumine 8mg/1 100 TABLET in 1 BOTTLE |
2 |
Tier 2 |
N/A | N/A | None |
PERIOGARD 0.12% ORAL RINSE |
1 |
Tier 1 |
N/A | N/A | None |
Permethrin 50mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
1 |
Tier 1 |
N/A | N/A | None |
PERPHENAZINE 16 MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
PERPHENAZINE TABLETS 4MG 100 BOXUD |
2 |
Tier 2 |
N/A | N/A | None |
PERPHENAZINE TABLETS 8MG 100 BOT |
2 |
Tier 2 |
N/A | N/A | None |
PERPHENAZINE TABLETS USP 2MG 100 BOT |
2 |
Tier 2 |
N/A | N/A | None |
PHENADOZ 12.5MG SUPPOSITORY |
2 |
Tier 2 |
N/A | N/A | P |
PHENADOZ 25MG SUPPOSITORY |
2 |
Tier 2 |
N/A | N/A | P |
Phenelzine Sulfate 15mg/1 60 TABLET in 1 BOTTLE |
2 |
Tier 2 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT |
2 |
Tier 2 |
N/A | N/A | None |
PHENYTOIN SOD EXT 200 MG CAP |
2 |
Tier 2 |
N/A | N/A | None |
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT) |
2 |
Tier 2 |
N/A | N/A | None |
PHENYTOIN SODIUM INJECTION 50MG 25 X 2ML AMP |
2 |
Tier 2 |
N/A | N/A | None |
PILOCARPINE HCL 5MG TABLET (100 CT) |
2 |
Tier 2 |
N/A | N/A | None |
Pilocarpine Hydrochloride 7.5mg/1 100 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
N/A | N/A | None |
PINDOLOL 10MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PINDOLOL 5MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PIPERACILLIN 200 MG/ML / TAZOBACTAM 25 MG/ML INJECTABLE SOLUTION |
2 |
Tier 2 |
N/A | N/A | None |
Piperacillin and Tazobactam 4; 0.5g/1; g/1 10 VIAL, SINGLE-USE in 1 CARTON / 1 INJECTION, POWDER, L |
2 |
Tier 2 |
N/A | N/A | None |
PIROXICAM 10 MG CAPSULE |
2 |
Tier 2 |
N/A | 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 |
2 |
Tier 2 |
N/A | N/A | None |
PLASMA-LYTE INJ-R |
2 |
Tier 2 |
N/A | N/A | None |
PODOFILOX 0.5% TOPICAL TUBEX |
2 |
Tier 2 |
N/A | N/A | None |
POLY-DEX 0.1% SUSPENSION DROPS |
1 |
Tier 1 |
N/A | N/A | None |
POLY-DEX 3.5-10K-.1 OINTMENT |
1 |
Tier 1 |
N/A | N/A | None |
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT) |
2 |
Tier 2 |
N/A | N/A | None |
POLYETHYLENE GLYCOL 3350 105 MG/ML / POTASSIUM CHLORIDE 0.00497 MEQ/ML / SODIUM BICARBONATE 1.43 MG/ |
2 |
Tier 2 |
N/A | N/A | None |
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1% |
1 |
Tier 1 |
N/A | N/A | None |
PORTIA 0.15-0.03 TABLET |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE 0.075%/D5W/SODIUM CHLORIDE 0.2% |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.3% |
2 |
Tier 2 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45% |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.9% 1000ML |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.2% |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE 10MEQ/100ML SOL |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE 10MEQ/50ML SOL |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE 149mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 5 mL in 1 VIAL, SINGLE-DOSE |
2 |
Tier 2 |
N/A | N/A | None |
Potassium Chloride 20.000000meq/1 |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE 20MEQ/50ML SOL |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE 30MEQ/100ML SOL |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE ER CAPSULES 10MEQ |
2 |
Tier 2 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE ER CPCR 8MEQ |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE EXTENDED RELEASE TABLETS |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE INJECTION 40 12 X 1000ML CTR |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION 0.15%-0.9% 12 X 1000ML BAG |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CITRATE 10MEQ TABLET SA |
2 |
Tier 2 |
N/A | N/A | None |
POTASSIUM CITRATE 5MEQ TABLET SA |
2 |
Tier 2 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAMIPEXOLE 0.125 MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
PRAMIPEXOLE 0.25 MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
PRAMIPEXOLE 0.5 MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
PRAMIPEXOLE 1 MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
PRAMIPEXOLE 1.5 MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
PRAMIPEXOLE DIHYDROCHLORIDE TABLETS |
2 |
Tier 2 |
N/A | N/A | None |
PRAVASTATIN SODIUM 20MG TABLET 500 BOT |
2 |
Tier 2 |
N/A | N/A | Q:45 /30Days |
PRAVASTATIN SODIUM 40MG TABLET (500 CT) |
2 |
Tier 2 |
N/A | N/A | Q:45 /30Days |
PRAVASTATIN SODIUM 80MG TABLET (90 CT) |
2 |
Tier 2 |
N/A | N/A | None |
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT |
2 |
Tier 2 |
N/A | N/A | Q:45 /30Days |
PRAZOSIN 5MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAZOSIN HCL 1MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
PRAZOSIN HCL 2MG CAPSULE |
1 |
Tier 1 |
N/A | N/A | None |
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR |
1 |
Tier 1 |
N/A | N/A | None |
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL |
2 |
Tier 2 |
N/A | N/A | None |
PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION |
2 |
Tier 2 |
N/A | N/A | None |
PREDNISONE 10MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PREDNISONE 1MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PREDNISONE 2.5MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PREDNISONE 20MG TABLET (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PREDNISONE 5 MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PREDNISONE 50MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISONE 5MG/5ML SOLUTION |
2 |
Tier 2 |
N/A | N/A | None |
PREGNYL INJ 10000UNT |
2 |
Tier 2 |
N/A | N/A | P |
PREMASOL 6% IV SOLUTION |
2 |
Tier 2 |
N/A | N/A | P |
PREVALITE POW 4GM |
2 |
Tier 2 |
N/A | N/A | None |
Previfem 6 BLISTER PACK in 1 BLISTER PACK / 1 KIT in 1 BLISTER PACK |
2 |
Tier 2 |
N/A | N/A | None |
Primidone 250mg/1 100 TABLET in 1 BOTTLE |
2 |
Tier 2 |
N/A | N/A | None |
Primidone 50mg/1 500 TABLET in 1 BOTTLE |
2 |
Tier 2 |
N/A | N/A | None |
PROBENECID 500MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
PROBENECID/COLCHICINE TABLET S |
2 |
Tier 2 |
N/A | N/A | None |
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN |
2 |
Tier 2 |
N/A | N/A | None |
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX |
2 |
Tier 2 |
N/A | N/A | None |
PROCTO-PAK 1% CREAM |
1 |
Tier 1 |
N/A | N/A | None |
Proctocream HC 25mg/g |
1 |
Tier 1 |
N/A | N/A | None |
PROCTOSOL-HC 2.5% CREAM |
1 |
Tier 1 |
N/A | N/A | None |
PROCTOZONE-HC 2.5% CREAM |
1 |
Tier 1 |
N/A | N/A | None |
PROGESTERONE 100 MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | None |
PROGESTERONE 200 MG CAPSULE |
2 |
Tier 2 |
N/A | N/A | None |
PROMETHAZINE 50MG/ML VIAL |
2 |
Tier 2 |
N/A | N/A | None |
PROMETHAZINE HCL 25MG TABLET (1000 CT) |
2 |
Tier 2 |
N/A | N/A | P |
PROMETHAZINE HCL 50MG TABLET (100 CT) |
2 |
Tier 2 |
N/A | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMETHAZINE HCL 6.25MG/5ML SYRUP |
1 |
Tier 1 |
N/A | N/A | P |
PROMETHAZINE HCL INJECTION 25MG 10 X 1ML VIAL |
2 |
Tier 2 |
N/A | N/A | None |
Promethazine Hydrochloride 12.5mg/1 100 TABLET in 1 BOTTLE |
2 |
Tier 2 |
N/A | N/A | P |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX |
2 |
Tier 2 |
N/A | N/A | P |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX |
2 |
Tier 2 |
N/A | N/A | P |
PROMETHAZINE VC PLAIN 6.25-5MG 16 FL OZ BOT |
2 |
Tier 2 |
N/A | N/A | P |
PROMETHEGAN 25MG SUPP |
2 |
Tier 2 |
N/A | N/A | P |
PROMETHEGAN 50MG SUPPOS |
2 |
Tier 2 |
N/A | N/A | P |
PROPAFENONE HCL 150MG TABLET (100 CT) |
2 |
Tier 2 |
N/A | N/A | None |
PROPAFENONE HCL 225MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
PROPAFENONE HCL 300MG TABLET (100 CT) |
2 |
Tier 2 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Propafenone Hydrochloride 225mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Tier 2 |
N/A | N/A | None |
PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE |
2 |
Tier 2 |
N/A | N/A | None |
PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE |
2 |
Tier 2 |
N/A | N/A | None |
PROPARACAINE 0.5% EYE DROPS |
2 |
Tier 2 |
N/A | N/A | None |
PROPRANOLOL 20MG/5ML TUBEX |
2 |
Tier 2 |
N/A | N/A | None |
PROPRANOLOL 40MG/5ML TUBEX |
2 |
Tier 2 |
N/A | N/A | None |
PROPRANOLOL 60MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
PROPRANOLOL 80 MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PROPRANOLOL HCL 20MG TABLET (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
PROPRANOLOL HCL INJECTION 1MG 10 PKG OF 10 CRTN |
2 |
Tier 2 |
N/A | N/A | None |
PROPRANOLOL HCL TABLET USP 10MG (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPRANOLOL HCL TABLET USP 40MG (1000 CT) |
1 |
Tier 1 |
N/A | N/A | None |
Propranolol Hydrochloride 120mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Tier 2 |
N/A | N/A | None |
Propranolol Hydrochloride 160mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Tier 2 |
N/A | N/A | None |
Propranolol Hydrochloride 60mg/1 1000 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
2 |
Tier 2 |
N/A | N/A | None |
Propranolol Hydrochloride 80mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Tier 2 |
N/A | N/A | None |
PROPYLTHIOURACIL 50MG TABLET |
1 |
Tier 1 |
N/A | N/A | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS |
2 |
Tier 2 |
N/A | N/A | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG |
2 |
Tier 2 |
N/A | N/A | None |
PYRAZINAMIDE 500MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |
PYRIDOSTIGMINE BROMIDE 60MG TABLET |
2 |
Tier 2 |
N/A | N/A | None |