2012 Medicare Part D Plan Formulary Information |
Blue Cross MedicareRx Gold (PDP) (S5596-035-0)
Benefit Details
 |
The Blue Cross MedicareRx Gold (PDP) (S5596-035-0) Formulary Drugs Starting with the Letter A in CMS PDP Region 32 which includes: CA
|
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  |
5 |
Injectable Drug |
33% | 33% | None |
A-HYDROCORT 100MG VIAL  |
5 |
Injectable Drug |
33% | 33% | None |
A-METHAPRED INJ 40MG  |
5 |
Injectable Drug |
33% | 33% | None |
ABACAVIR TAB 300MG  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ABELCENT INJECTION SUSPENSION 5MG/ML  |
6 |
Specialty Tier Drugs |
33% | N/A | None |
ABILIFY 10MG TABLET  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:30 /30Days |
ABILIFY 15MG TABLET  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:30 /30Days |
ABILIFY 1MG/ML SOLUTION  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:900 /30Days |
ABILIFY 20MG TABLET  |
6 |
Specialty Tier Drugs |
33% | N/A | Q:60 /30Days |
ABILIFY 2MG TABLET  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABILIFY 30MG TABLET  |
6 |
Specialty Tier Drugs |
33% | N/A | Q:30 /30Days |
ABILIFY 5MG TABLET (OTSUKA)  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:30 /30Days |
ABILIFY DISCMELT 10MG TABLET  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:60 /30Days |
ABILIFY DISCMELT 15MG TABLET  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:60 /30Days |
ABILIFY INJ 9.75MG  |
5 |
Injectable Drug |
33% | 33% | None |
ABRAXANE 100MG VIAL  |
6 |
Specialty Tier Drugs |
33% | N/A | P |
Abstral 100ug/1 32 TABLET in 1 BLISTER PACK  |
6 |
Specialty Tier Drugs |
33% | N/A | P Q:120 /30Days |
Abstral 200ug/1 32 TABLET in 1 BLISTER PACK  |
6 |
Specialty Tier Drugs |
33% | N/A | P Q:120 /30Days |
Abstral 300ug/1 32 TABLET in 1 BLISTER PACK  |
6 |
Specialty Tier Drugs |
33% | N/A | P Q:120 /30Days |
Abstral 400ug/1 32 TABLET in 1 BLISTER PACK  |
6 |
Specialty Tier Drugs |
33% | N/A | P Q:120 /30Days |
Abstral 600ug/1 32 TABLET in 1 BLISTER PACK  |
6 |
Specialty Tier Drugs |
33% | N/A | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Abstral 800ug/1 32 TABLET in 1 BLISTER PACK  |
6 |
Specialty Tier Drugs |
33% | N/A | P Q:120 /30Days |
Acarbose 100mg/1 90 TABLET in 1 BOTTLE,  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
acarbose 50 mg tablet  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
ACARBOSE TABLETS  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
ACCOLATE 10MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:60 /30Days |
ACCOLATE 20MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:60 /30Days |
ACCUNEB 0.63MG/3ML INH TUBEX  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | P Q:360 /30Days |
ACCUNEB 1.25MG/3ML INH TUBEX  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | P Q:360 /30Days |
ACCURETIC 10-12.5MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ACCURETIC 20-12.5MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ACCURETIC 20-25MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACEBUTOLOL 200MG CAPSULE  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
ACEBUTOLOL 400MG CAPSULE  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
ACEON 2MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ACEON 4MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ACEON 8MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
Acetaminophen and Codeine Phosphate 300; 60mg/1; mg/1 500 TABLET in 1 BOTTLE  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:390 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:4500 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:390 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:390 /30Days |
ACETASOL HC SOLUTION 10ML 10 ML BOT  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAZOLAMIDE 125MG TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
ACETAZOLAMIDE 250MG TABLET (100 CT)  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
ACETAZOLAMIDE SOD 500MG VL  |
5 |
Injectable Drug |
33% | 33% | None |
ACETIC ACID 2% SOLUTION NON-ORAL  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
ACETYLCYSTEINE 10% VIAL  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | P |
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | P |
Aclovate 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
Aclovate 0.5mg/g 60 g in 1 TUBE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ACTEMRA INJECTION 200MG/10ML  |
6 |
Specialty Tier Drugs |
33% | N/A | P |
ACTHIB VACCINE VIAL 10-24UNT/5ML  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTICIN 5% CREAM  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
ACTIGALL 300MG CAPSULE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ACTIMMUNE SOLUTION FOR INJECTION 100MCG  |
6 |
Specialty Tier Drugs |
33% | N/A | P |
ACTIQ 1200MCG LOZENGE  |
6 |
Specialty Tier Drugs |
33% | N/A | P Q:120 /30Days |
ACTIQ 1600MCG LOZENGE  |
6 |
Specialty Tier Drugs |
33% | N/A | P Q:120 /30Days |
ACTIQ 200MCG LOZENGE  |
6 |
Specialty Tier Drugs |
33% | N/A | P Q:120 /30Days |
ACTIQ 400MCG LOZENGE  |
6 |
Specialty Tier Drugs |
33% | N/A | P Q:120 /30Days |
ACTIQ 600MCG LOZENGE  |
6 |
Specialty Tier Drugs |
33% | N/A | P Q:120 /30Days |
ACTIQ 800MCG LOZENGE  |
6 |
Specialty Tier Drugs |
33% | N/A | P Q:120 /30Days |
ACTIVELLA 0.5-0.1MG TABLET 28 DLPK  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ACTIVELLA 1-0.5MG TABLET 28 DLPK  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Actonel 150mg/1 36 DOSE PACK in 1 CASE / 1 TRAY in 1 DOSE PACK / 1 TABLET, FILM COATED in 1 TRAY  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | S Q:1 /30Days |
Actonel 30mg/1 12 BOTTLE in 1 CASE / 30 TABLET, FILM COATED in 1 BOTTLE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | S Q:30 /30Days |
Actonel 35mg/1 36 DOSE PACK in 1 CASE / 1 TRAY in 1 DOSE PACK / 4 TABLET, FILM COATED in 1 TRAY  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | S Q:4 /28Days |
Actonel 5mg/1 12 BOTTLE in 1 CASE / 30 TABLET, FILM COATED in 1 BOTTLE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | S Q:30 /30Days |
ACTOPLUS MET 15MG/500MG TABLET  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:90 /30Days |
ACTOPLUS MET 15MG/850MG TABLET  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:90 /30Days |
ACTOPLUS MET XR TABLETS EXTENDED RELEASE 15;1000 MG;MG  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:60 /30Days |
ACTOPLUS MET XR TABLETS EXTENDED RELEASE 30;1000 MG;MG  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:30 /30Days |
ACTOS 15MG TABLET  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:30 /30Days |
ACTOS 30MG TABLET (500 CT)  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:30 /30Days |
ACTOS 45MG TABLET  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACULAR 0.5% EYE DROPS  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ACULAR LS 0.4% OPHTH SOL  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
Acyclovir 200mg/1  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
Acyclovir 200mg/5mL 473 mL in 1 BOTTLE  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
Acyclovir 400mg/1 100 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
Acyclovir 800mg/1 100 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
ACYCLOVIR SODIUM 500MG VIAL  |
5 |
Injectable Drug |
33% | 33% | None |
ADACEL VIAL 2UNT/5UNT  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
ADAGEN 250U/ML VIAL  |
6 |
Specialty Tier Drugs |
33% | N/A | None |
ADALAT CC 30MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ADALAT CC 60MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADALAT CC 90MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA] ![Compare how all Medicare Part D PDP plans in CA cover ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
6 |
Specialty Tier Drugs |
33% | N/A | P Q:2 /28Days |
ADAPALENE CREAM  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ADAPALENE GEL  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
ADCIRCA TABLETS 20MG 60 BOT  |
6 |
Specialty Tier Drugs |
33% | N/A | P Q:60 /30Days |
ADOXA 100MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ADOXA 50MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ADOXA PAK 100MG TABLET DSPK-31  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ADOXA PAK 100MG TABLET DSPK-60  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ADOXA PAK 150MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ADVAIR DISKUS MIS 100/50  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADVAIR DISKUS MIS 250/50  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:60 /30Days |
ADVAIR DISKUS MIS 500/50  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:60 /30Days |
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:12 /30Days |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:12 /30Days |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:12 /30Days |
AFEDITAB CR 30MG TABLET SA  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AFEDITAB CR 60MG TABLET SA  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
Afinitor 7.5mg/1 28 BLISTER PACK in 1 CARTON / 1 TABLET in 1 BLISTER PACK  |
6 |
Specialty Tier Drugs |
33% | N/A | P |
AFINITOR TABLETS 10 MG  |
6 |
Specialty Tier Drugs |
33% | N/A | P |
AFINITOR TABLETS 2.5 MG  |
6 |
Specialty Tier Drugs |
33% | N/A | P |
AFINITOR TABLETS 5 MG  |
6 |
Specialty Tier Drugs |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AGGRENOX 25-200MG CAPSULE  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:60 /30Days |
AGRYLIN 0.5MG CAPSULE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
AK-CON 0.1% EYE DROPS  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
AKNE-MYCIN 2% OINTMENT  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
AKTOB 0.3% EYE DROPS  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
ALA-CORT 1% CREAM  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ALA-CORT 1% LOTION  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ALA-SCALP HP 2% LOTION  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ALAMAST 0.1% DROPS  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ALBENZA 200 MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
Albuterol Sulfate 0.63mg/3mL 25 POUCH in 1 CARTON / 5 VIAL in 1 POUCH / 3 mL in 1 VIAL  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | P Q:360 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | P Q:360 /30Days |
ALBUTEROL SULFATE 4MG TABLET SR 12HR  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | P Q:60 /30Days |
ALBUTEROL SULFATE SOLUTION FOR INHALATION  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | P Q:360 /30Days |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT)  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
ALBUTEROL TABLET 4MG (500 CT)  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
ALCAINE 0.5% EYE DROPS  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ALCLOMETASONE DIPROPIONATE 0.05% CREAM  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
Alclometasone Dipropionate 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALDACTAZIDE 25/25 TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ALDACTAZIDE 50/50 TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ALDACTONE 100MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ALDACTONE 25MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ALDACTONE 50MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ALDARA 5% CREAM  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ALDURAZYME 2.9MG/5ML VIAL  |
6 |
Specialty Tier Drugs |
33% | N/A | P |
ALENDRONATE SODIUM 10MG TABLET  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | Q:30 /30Days |
ALENDRONATE SODIUM 40MG TABLET  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | Q:30 /30Days |
ALENDRONATE SODIUM 5MG TABLET  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | Q:30 /30Days |
ALENDRONATE SODIUM 70mg/1  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALENDRONATE SODIUM TABLET 35MG 20 CRTN  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | Q:4 /28Days |
ALFUZOSIN HYDROCHLORIDE 10mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
ALIMTA 500MG VIAL  |
6 |
Specialty Tier Drugs |
33% | N/A | None |
ALINIA 100MG/5ML SUSPENSION  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ALINIA 500MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ALKERAN 1 KIT in 1 CARTON  |
6 |
Specialty Tier Drugs |
33% | N/A | P |
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET in 1 BLISTER PACK  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
ALLOPURINOL SODIUM 500MG VIAL  |
5 |
Injectable Drug |
33% | 33% | None |
ALLOPURINOL TABLETS  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
ALOCRIL 2% EYE DROPS  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ALOMIDE 0.1% EYE DROPS  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALOPRIM SOLUTION FOR INJECTION 500MG/VIAL 30 ML VIALGL  |
5 |
Injectable Drug |
33% | 33% | None |
ALORA 0.025MG PATCH  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:8 /28Days |
ALORA 0.05MG PATCH  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:8 /28Days |
ALORA 0.075MG PATCH  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:8 /28Days |
ALORA 0.1MG PATCH  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:8 /28Days |
ALOXI 0.25MG/5ML  |
5 |
Injectable Drug |
33% | 33% | None |
ALPHAGAN P 0.1% DROPS  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
ALPHAGAN P 0.15% EYE DROPS  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ALREX 0.2% EYE DROPS  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ALTABAX 10mg/g 30 g in 1 TUBE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:30 /30Days |
AMANTADINE 100MG CAPSULE  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMANTADINE 100MG TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
Amantadine Hydrochloride 50mg/5mL  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMARYL 1MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
AMARYL 2MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
AMARYL 4MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
AMBIEN 10MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | P Q:30 /30Days |
AMBIEN CR 12.5MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | P Q:30 /30Days |
AMBIEN CR 6.25MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | P Q:30 /30Days |
AMBIEN TABLETS 5MG 100 BOT  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | P Q:30 /30Days |
AMBISOME 50MG VIAL  |
6 |
Specialty Tier Drugs |
33% | N/A | None |
AMCINONIDE 0.1% CREAM  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMCINONIDE 0.1% LOTION  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMCINONIDE 0.1% OINTMENT 60GM TUBE  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMERGE 1MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | S Q:9 /30Days |
AMERGE 2.5MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | S Q:9 /30Days |
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM  |
6 |
Specialty Tier Drugs |
33% | N/A | P |
AMIFOSTINE FOR INJECTION 500MG/VIAL  |
6 |
Specialty Tier Drugs |
33% | N/A | None |
AMIKACIN 250MG/ML VIAL  |
5 |
Injectable Drug |
33% | 33% | None |
AMIKACIN 50MG/ML VIAL  |
5 |
Injectable Drug |
33% | 33% | None |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMINOPHYLLINE 100MG TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOPHYLLINE 200MG TABLET (1000 CT)  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
Aminophylline 25mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIA  |
5 |
Injectable Drug |
33% | 33% | None |
AMINOSYN 10% IV SOLUTION  |
5 |
Injectable Drug |
33% | 33% | None |
AMINOSYN 3.5% IV SOLUTION  |
5 |
Injectable Drug |
33% | 33% | None |
AMINOSYN 5% IV SOLUTION  |
5 |
Injectable Drug |
33% | 33% | None |
AMINOSYN 7% IV SOLUTION  |
5 |
Injectable Drug |
33% | 33% | None |
AMINOSYN 8.5% IV SOLUTION  |
5 |
Injectable Drug |
33% | 33% | None |
AMINOSYN HBC INJECTION SULFITE FREE 7%  |
5 |
Injectable Drug |
33% | 33% | None |
AMINOSYN II 10% IV SOLUTION  |
5 |
Injectable Drug |
33% | 33% | None |
AMINOSYN II 15% IV SOLUTION  |
5 |
Injectable Drug |
33% | 33% | None |
AMINOSYN II 3.5% IN D25W IV  |
5 |
Injectable Drug |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN II 3.5% IN D5W IV  |
5 |
Injectable Drug |
33% | 33% | None |
AMINOSYN II 3.5% M/D5W IV  |
5 |
Injectable Drug |
33% | 33% | None |
AMINOSYN II 3.5% W/ELEC DEX  |
5 |
Injectable Drug |
33% | 33% | None |
AMINOSYN II 4.25% IN D10W  |
5 |
Injectable Drug |
33% | 33% | None |
AMINOSYN II 4.25% IN D20W  |
5 |
Injectable Drug |
33% | 33% | None |
AMINOSYN II 4.25% W/ELEC DW  |
5 |
Injectable Drug |
33% | 33% | None |
AMINOSYN II 4.25%-D25W IV  |
5 |
Injectable Drug |
33% | 33% | None |
AMINOSYN II 5% IN D25W IV  |
5 |
Injectable Drug |
33% | 33% | None |
AMINOSYN II 7% IV SOLUTION  |
5 |
Injectable Drug |
33% | 33% | None |
AMINOSYN II 8.5% ELECTROLYT  |
5 |
Injectable Drug |
33% | 33% | None |
AMINOSYN II 8.5% IV SOLUTION  |
5 |
Injectable Drug |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN M 3.5% IV SOLUTION  |
5 |
Injectable Drug |
33% | 33% | None |
AMINOSYN PF INJECTION  |
5 |
Injectable Drug |
33% | 33% | None |
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%  |
5 |
Injectable Drug |
33% | 33% | None |
AMINOSYN-HF 8% IV SOLUTION  |
5 |
Injectable Drug |
33% | 33% | None |
AMINOSYN-PF 7% IV SOLUTION  |
5 |
Injectable Drug |
33% | 33% | None |
AMIODARONE HCL 400MG TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMIODARONE HCL INJECTION  |
5 |
Injectable Drug |
33% | 33% | None |
Amiodarone hydrochloride 200mg/1  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMITIZA 8MCG CAPSULE  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
AMITIZA CAPSULES 24MCG 60 CAP BOT  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
AMITRIP/CDP 25-10 TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIP/PERPHEN 10-2 TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMITRIP/PERPHEN 10-4 TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMITRIP/PERPHEN 25-2 TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMITRIP/PERPHEN 25-4 TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMITRIP/PERPHEN 50-4 TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMITRIPTYLINE HCL 100MG TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMITRIPTYLINE HCL 10MG TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMITRIPTYLINE HCL 150 MG TAB  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE BESYLATE 10MG TABLET (90 CT)  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | Q:30 /30Days |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | Q:30 /30Days |
AMLODIPINE BESYLATE 5MG TABLET (90 CT)  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | Q:45 /30Days |
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMMONIUM CHLORIDE 5 MEQ/ML  |
5 |
Injectable Drug |
33% | 33% | None |
AMMONIUM LACTATE 12% CREAM  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMMONIUM LACTATE 12% LOTION  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
Amnesteem 10mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
Amnesteem 20mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
Amnesteem 40mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMOX TR-K CLV 500-125 MG TAB  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMOXAPINE 100MG TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXAPINE 150MG TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMOXAPINE 25MG TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMOXAPINE 50MG TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMOXICILLIN 125MG TABLET CHEW  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
AMOXICILLIN 200MG TABLET CHEW  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
AMOXICILLIN 250MG CAPSULE  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
Amoxicillin 250mg/1 500 TABLET, CHEWABLE in 1 BOTTLE  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMOXICILLIN 500MG TABLET (100 CT)  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
AMOXICILLIN 875MG TABLET  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMOXICILLIN CAP 500MG  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:120 /30Days |
AMPHETAMINE SALT COMBO 15MG TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:30 /30Days |
AMPHETAMINE SALT COMBO 30MG TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:60 /30Days |
AMPHETAMINE SALT COMBO 7.5MG TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPHETAMINE SALTS 20MG TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:90 /30Days |
AMPHETAMINE SALTS 5 MG TAB  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:30 /30Days |
AMPHOTEC FOR INJECTION 50MG/VIAL  |
5 |
Injectable Drug |
33% | 33% | None |
amphotericin b 50mg/10mL 10 mL in 1 VIAL  |
5 |
Injectable Drug |
33% | 33% | None |
Ampicillin 125mg/1 10 VIAL in 1 BOX / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL  |
5 |
Injectable Drug |
33% | 33% | None |
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL  |
5 |
Injectable Drug |
33% | 33% | None |
AMPICILLIN CAPSULES 250MG 100 BOT  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
AMPICILLIN CAPSULES 500MG 100 BOT  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
AMPICILLIN FOR INJECTION POWDER  |
5 |
Injectable Drug |
33% | 33% | None |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML  |
5 |
Injectable Drug |
33% | 33% | None |
ampicillin-sulbactam 15 gm vl  |
5 |
Injectable Drug |
33% | 33% | None |
AMPYRA ER 10 MG TABLET  |
6 |
Specialty Tier Drugs |
33% | N/A | P Q:60 /30Days |
ANADROL-50 50MG TABLET (100 CT)  |
6 |
Specialty Tier Drugs |
33% | N/A | P |
ANAFRANIL 25mg/1 30 CAPSULE in 1 BOTTLE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ANAFRANIL 50mg/1 30 CAPSULE in 1 BOTTLE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ANAFRANIL 75mg/1 30 CAPSULE in 1 BOTTLE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE in 1 BOTTLE  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
Anagrelide Hydrochloride 1mg/1 100 CAPSULE in 1 BOTTLE  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
ANAPROX 275MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ANAPROX DS 550MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANASTROZOLE TABLETS  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
ANCOBON 250MG CAPSULE  |
6 |
Specialty Tier Drugs |
33% | N/A | None |
ANCOBON 500MG CAPSULE  |
6 |
Specialty Tier Drugs |
33% | N/A | None |
ANDRODERM 2 MG/24HR PATCH  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | P Q:30 /30Days |
ANDRODERM 2.5MG/24HR PATCH  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | P Q:60 /30Days |
ANDRODERM 4 MG/24HR PATCH  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | P Q:30 /30Days |
ANDRODERM 5MG/24HR PATCH  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | P Q:30 /30Days |
ANDROGEL 1%(50MG) GEL PACKET  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | P Q:300 /30Days |
Androgel 16.2mg/g 1 BOTTLE, PUMP in 1 CARTON / 88 g in 1 BOTTLE, PUMP  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | P Q:150 /30Days |
ANDROID 10MG CAPSULE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | P |
ANTABUSE 250MG TABLET  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANTABUSE 500MG TABLET  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
ANTARA CAPSULES  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | S |
ANTARA CAPSULES  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | S |
ANTIVERT 12.5MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ANTIVERT 25MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ANTIVERT 50MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ANTIZOL INJECTION 1GM 4 X 1.5ML VIAL CRTN  |
6 |
Specialty Tier Drugs |
33% | N/A | None |
ANUSOL-HC 2.5% CREAM  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ANZEMET 100MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | P Q:5 /30Days |
ANZEMET 20MG/ML VIAL  |
5 |
Injectable Drug |
33% | 33% | None |
ANZEMET 50MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | P Q:5 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APAP-CAFFEINE-DIHYDROCODE TAB 30 EA  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:180 /30Days |
APIDRA 100UNITS/ML VIAL  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | S |
APOKYN 30mg/3mL 5 CARTRIDGE in 1 CARTON / 3 mL in 1 CARTRIDGE  |
6 |
Specialty Tier Drugs |
33% | N/A | None |
Apraclonidine Ophthalmic 5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 10 mL in 1 BOTTLE, DROPPER  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
APRI 0.15-0.03 TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
APRISO CP24  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
APTIVUS 250MG CAPSULE  |
6 |
Specialty Tier Drugs |
33% | N/A | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT  |
6 |
Specialty Tier Drugs |
33% | N/A | None |
Aralast NP 1 KIT in 1 CARTON  |
5 |
Injectable Drug |
33% | 33% | None |
ARALEN PHOSPHATE 500MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ARANELLE 7-9-5 TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE in 1 BLISTER PACK / 0.5 mL in 1 SYRINGE  |
6 |
Specialty Tier Drugs |
33% | N/A | P |
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE  |
6 |
Specialty Tier Drugs |
33% | N/A | P |
ARANESP 200MCG/0.4ML SYRINGE  |
6 |
Specialty Tier Drugs |
33% | N/A | P |
ARANESP 200MCG/ML VIAL  |
6 |
Specialty Tier Drugs |
33% | N/A | P |
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE in 1 BLISTER PACK / 0.42 mL in 1 SYRING  |
5 |
Injectable Drug |
33% | 33% | P |
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE  |
5 |
Injectable Drug |
33% | 33% | P |
ARANESP 300MCG/ML VIAL  |
6 |
Specialty Tier Drugs |
33% | N/A | P |
ARANESP 500MCG/1ML SYRINGE  |
6 |
Specialty Tier Drugs |
33% | N/A | P |
ARANESP 60MCG/ML VIAL  |
6 |
Specialty Tier Drugs |
33% | N/A | P |
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE in 1 BLISTER PACK / 0.3 mL in 1 SYRINGE  |
5 |
Injectable Drug |
33% | 33% | P |
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR  |
6 |
Specialty Tier Drugs |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR  |
6 |
Specialty Tier Drugs |
33% | N/A | P |
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR  |
5 |
Injectable Drug |
33% | 33% | P |
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD  |
5 |
Injectable Drug |
33% | 33% | P |
ARAVA 10MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ARAVA 20MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ARCALYST INJECTION 220MG/VIAL  |
6 |
Specialty Tier Drugs |
33% | N/A | P |
AREDIA 30MG VIAL  |
5 |
Injectable Drug |
33% | 33% | P |
AREDIA 90MG VIAL  |
5 |
Injectable Drug |
33% | 33% | P |
ARICEPT 10MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:30 /30Days |
ARICEPT 5MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:30 /30Days |
ARICEPT ODT 10MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARICEPT ODT 5MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:30 /30Days |
ARICEPT TABLETS  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | S Q:30 /30Days |
ARIMIDEX 1MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ARIXTRA 10MG SYRINGE  |
6 |
Specialty Tier Drugs |
33% | N/A | S |
ARIXTRA 2.5MG SYRINGE  |
5 |
Injectable Drug |
33% | 33% | S |
ARIXTRA 5MG SYRINGE  |
6 |
Specialty Tier Drugs |
33% | N/A | S |
ARIXTRA 7.5MG SYRINGE  |
6 |
Specialty Tier Drugs |
33% | N/A | S |
AROMASIN 25MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ARRANON 250MG VIAL  |
5 |
Injectable Drug |
33% | 33% | P |
ARTHROTEC 50 50MG TABLET -200MCG (60 CT)  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
ARTHROTEC 75 TABLET EC  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARZERRA 20mg/mL 3 VIAL in 1 CARTON / 5 mL in 1 VIAL  |
6 |
Specialty Tier Drugs |
33% | N/A | P |
ASACOL 400mg/1 12 BOTTLE in 1 CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
ASACOL HD 800mg/1 12 BOTTLE in 1 CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
Ascomp with Codeine 325; 50; 40; 30mg/1; mg/1; mg/1; mg/1 500 CAPSULE in 1 BOTTLE, PLASTIC  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
ASTELIN 137MCG AEROSOL SPRAY W/PUMP  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:30 /25Days |
ASTEPRO 0.15% NASAL SPRAY 30 ML  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:30 /25Days |
ASTRAMORPH PF INJECTION 0.5MG/ML  |
5 |
Injectable Drug |
33% | 33% | None |
ASTRAMORPH PF INJECTION 1MG/ML  |
5 |
Injectable Drug |
33% | 33% | None |
ATACAND 16MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:60 /30Days |
ATACAND 32MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:30 /30Days |
ATACAND 4MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATACAND 8MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:60 /30Days |
ATACAND HCT 16/12.5MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:60 /30Days |
ATACAND HCT 32/12.5MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:30 /30Days |
ATACAND HCT TABLETS 32;25MG;MG 90 TABLETS BOT  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:30 /30Days |
ATENOLOL 100mg/1 100 TABLET in 1 BOTTLE, PLASTIC  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
Atenolol 25mg/1 100 TABLET in 1 BOTTLE, PLASTIC  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
ATENOLOL TABLET USP 50MG (100 CT)  |
1 |
Preferred Generic Drugs |
$2.00 | $3.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
ATORVASTATIN 10 MG TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:30 /30Days |
ATORVASTATIN 20 MG TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATORVASTATIN 40 MG TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:30 /30Days |
ATORVASTATIN 80 MG TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:30 /30Days |
Atovaquone and Proguanil Hydrochloride 250; 100mg/1; mg/1  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE, PLASTIC  |
6 |
Specialty Tier Drugs |
33% | N/A | None |
ATROPINE 0.05MG/ML SYRINGE  |
5 |
Injectable Drug |
33% | 33% | None |
ATROPINE 0.1MG/ML SYRINGE  |
5 |
Injectable Drug |
33% | 33% | None |
ATROVENT HFA AER 17MCG  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:39 /30Days |
ATROVENT NASAL SPRAY 0.03%  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:30 /30Days |
ATROVENT NASAL SPRAY 0.06%  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:15 /30Days |
AUGMENTED BETAMETHASONE DIPROPIONATE OINTMENT  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AVALIDE 12.5; 150mg/1; mg/1 90 TABLET, FILM COATED in 1 BOTTLE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVALIDE 12.5; 300mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:30 /30Days |
AVALIDE 300-25MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:30 /30Days |
AVANDAMET 1000; 2mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | P Q:60 /30Days |
AVANDAMET 1000; 4mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | P Q:60 /30Days |
AVANDAMET 500; 2mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | P Q:120 /30Days |
AVANDAMET 500; 4mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | P Q:60 /30Days |
AVANDARYL 1; 4mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | P Q:60 /30Days |
AVANDARYL 2; 4mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | P Q:60 /30Days |
AVANDARYL 2; 8mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | P Q:30 /30Days |
AVANDARYL 4; 4mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | P Q:30 /30Days |
AVANDARYL 4; 8mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVANDIA 2mg/1 60 TABLET, FILM COATED in 1 BOTTLE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | P Q:60 /30Days |
AVANDIA 4mg/1 30 TABLET, FILM COATED in 1 BOTTLE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | P Q:60 /30Days |
AVANDIA 8mg/1 30 TABLET, FILM COATED in 1 BOTTLE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | P Q:30 /30Days |
AVAPRO 150MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:30 /30Days |
AVAPRO 300MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:30 /30Days |
AVAPRO 75MG TABLET (30 CT)  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:30 /30Days |
AVASTIN 100MG/4ML VIAL  |
6 |
Specialty Tier Drugs |
33% | N/A | P |
AVELOX 400MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:21 /1Days |
AVELOX ABC PACK 400MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:5 /1Days |
AVELOX IV 400MG/250ML  |
5 |
Injectable Drug |
33% | 33% | None |
AVIANE 0.1-0.02 TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVITA 0.025% CREAM  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:90 /30Days |
Avita 0.25mg/g 45 g in 1 TUBE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:90 /30Days |
AVODART 0.5MG SOFTGEL  |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
AVONEX ADMIN PACK 30MCG SYR  |
6 |
Specialty Tier Drugs |
33% | N/A | P |
AVONEX ADMIN PACK 30MCG VL  |
6 |
Specialty Tier Drugs |
33% | N/A | P |
AXERT 12.5MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | S Q:9 /30Days |
AXERT 6.25MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | S Q:9 /30Days |
AXID 15MG/ML ORAL SOLUTION  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
Aygestin 5mg/1 50 TABLET in 1 BOTTLE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
AZACTAM INJECTION 1GM/50ML  |
5 |
Injectable Drug |
33% | 33% | None |
AZACTAM INJECTION 2GM/50ML  |
5 |
Injectable Drug |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZACTAM INJECTION 2GM/VIL  |
5 |
Injectable Drug |
33% | 33% | None |
AZASAN 100MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | P |
AZASAN 75MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | P |
AZASITE 1% DROPS  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
AZATHIOPRINE 50MG TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | P |
AZATHIOPRINE SOD 100MG VIAL  |
5 |
Injectable Drug |
33% | 33% | P |
AZELASTINE 137 MCG NASAL SPRAY  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:30 /25Days |
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
AZELEX 20% CREAM 30GM TUBE  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
AZILECT 0.5MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
AZILECT 1MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:15 /1Days |
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:46 /1Days |
AZITHROMYCIN 250 MG TABLET  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:6 /1Days |
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION  |
5 |
Injectable Drug |
33% | 33% | None |
Azithromycin 500mg/1 30 TABLET, FILM COATED in 1 BOTTLE  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:3 /1Days |
Azithromycin 600mg/1 30 TABLET, FILM COATED in 1 BOTTLE  |
2 |
Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:8 /1Days |
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
AZOR 10MG-20MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:30 /30Days |
AZOR 10MG-40MG TABLET (30 CT)  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:30 /30Days |
AZOR 5MG-20MG TABLET (30 CT)  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:30 /30Days |
AZOR 5MG-40MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZTREONAM FOR INJECTION  |
5 |
Injectable Drug |
33% | 33% | None |
AZULFIDINE 500MG TABLET  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |
AZULFIDINE EN TABLET S 500MG TABLET 6 X (300 CT)PL  |
4 |
Non-Preferred Brand Drugs |
$90.00 | $225.00 | None |