2013 Medicare Part D Plan Formulary Information |
Blue MedicareRx Value (PDP) (S5715-010-0)
Benefit Details
|
The Blue MedicareRx Value (PDP) (S5715-010-0) Formulary Drugs Starting with the Letter C in CMS PDP Region 23 which includes: OK
|
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 |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CALCIPOTRIENE 0.005% CREAM |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Calcipotriene 50ug/g 60 g in 1 CARTON |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CALCIPOTRIENE TOPICAL SOLUTION |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CALCITRIOL 0.25MCG CAPSULE |
1* |
Preferred Generic |
$3.00 | $7.50 | P |
CALCITRIOL 0.5MCG CAPSULE |
1* |
Preferred Generic |
$3.00 | $7.50 | P |
CALCITRIOL 1MCG/ML SOLUTION ORAL |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | P |
CALCITRIOL INJ 1MCG/ML |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | P |
CALCIUM ACETATE CAPSULE 667 MG |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAMILA 0.35MG TABLET |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CAMPATH INJECTION 30 MG/ML |
5 |
Specialty Tier |
25% | N/A | None |
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX |
3 |
Preferred Brand |
$38.00 | $95.00 | None |
CANCIDAS IV 50MG VIAL |
5 |
Specialty Tier |
25% | N/A | None |
CANCIDAS IV 70MG VIAL |
5 |
Specialty Tier |
25% | N/A | None |
candesartan-hctz 16-12.5 mg tablet |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | Q:30 /30Days |
candesartan-hctz 32-12.5 mg tablet |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | Q:30 /30Days |
candesartan-hctz 32-25 mg |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | Q:30 /30Days |
CAPASTAT SULFATE 1g/1 1 INJECTION, POWDER, FOR SOLUTION in 1 CARTON |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CAPRELSA 100mg/1 30 TABLET BOTTLE, PLASTIC |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
CAPRELSA 300mg/1 30 TABLET BOTTLE, PLASTIC |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAPTOPRIL 100MG TABLET |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
CAPTOPRIL 12.5MG TABLET |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
CAPTOPRIL 25MG TABLET |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
CAPTOPRIL 50MG TABLET |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
CARAC CRE 0.5% |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CARBAMAZEPINE 100 MG/5 ML SUSP |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
Carbamazepine 100mg, CHEWABLE 100 TABLET BOTTLE |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
Carbamazepine 100mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Carbamazepine 200mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Carbamazepine 300mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CARBAMAZEPINE TABLET USP 200MG (1000 CT) |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARBAMAZEPINE XR 200 MG TABLET |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CARBAMAZEPINE XR 400 MG TABLET |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;100MG;MG 100 BOT |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;250MG;MG 100 BOT |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CARBIDOPA-LEVODOPA ER 25-100 TAB |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CARBIDOPA-LEVODOPA ER 50-200 TAB |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CARBIDOPA/LEVO 10/100 TABLET |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CARBIDOPA/LEVO 25/100 TABLET |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CARBIDOPA/LEVO 25/250 TABLET |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Carboplatin 10mg/mL |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CARTIA XT 120MG CAPSULE SA |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CARTIA XT 180MG CAPSULE SA |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CARTIA XT 240MG CAPSULE SA |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CARTIA XT 300MG CAPSULE SR 24 HR |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Carvedilol 12.5mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
Carvedilol 25mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
Carvedilol 3.125mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
Carvedilol 6.25mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
CEENU 100MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CEENU 10MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEENU 40MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CEFACLOR CAPSULES |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CEFACLOR CAPSULES |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CEFADROXIL 1G TABLET |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Cefadroxil 500mg/1 100 CAPSULE in 1 BOTTLE |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Cefadroxil 500mg/5mL |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CEFADROXIL FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CEFAZOLIN 1 GM VIAL |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CEFAZOLIN FOR INJECTION |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFDINIR CAPSULES 300MG (60 CT) |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT) |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CEFEPIME HCL 2 GRAM VIAL |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Cefotaxime 1g/1 25 INJECTION in 1 PACKAGE |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CEFOTAXIME FOR INJECTION |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CEFOTAXIME FOR INJECTION 2GM 25 VIAL |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Cefoxitin 1g/1 10 POWDER in 1 CARTON |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Cefoxitin 2g/1 10 POWDER in 1 CARTON |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CEFOXITIN FOR INJECTION SOLUTION |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CEFPODOXIME 100 MG/5 ML SUSP |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFPODOXIME 200 MG TABLET |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CEFPODOXIME 50 MG/5 ML SUSP |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT) |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
cefprozil 125 mg/5 ml susp |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
cefprozil 250 mg/5 ml susp |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Cefprozil 250mg/1 100 FILM COATED TABLETS in BOTTLE |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CEFPROZIL TABLETS 500MG 100 BOT |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CEFTAZIDIME 1g/1 25 VIAL in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CEFTRIAXONE 10GM VIAL |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFTRIAXONE 250 MG VIAL |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CEFTRIAXONE FOR INJECTION |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CEFTRIAXONE FOR INJECTION |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Ceftriaxone Sodium 500mg/1 |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
cefuroxime axetil 250mg/1 |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CEFUROXIME AXETIL 500 MG TAB |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CEFUROXIME FOR INJECTION |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CEFUROXIME FOR INJECTION |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CEFUROXIME FOR INJECTION |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CELEBREX 100MG CAPSULE |
3 |
Preferred Brand |
$38.00 | $95.00 | Q:60 /30Days |
CELEBREX 200MG CAPSULE |
3 |
Preferred Brand |
$38.00 | $95.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CELEBREX 400MG CAPSULE |
3 |
Preferred Brand |
$38.00 | $95.00 | Q:30 /30Days |
CELEBREX 50MG CAPSULE |
3 |
Preferred Brand |
$38.00 | $95.00 | Q:60 /30Days |
CELLCEPT 200MG/ML ORAL SUSP |
5 |
Specialty Tier |
25% | N/A | P |
CELLCEPT IV INJ 500MG |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
CELONTIN 300MG KAPSEAL |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Cephalexin 125mg/5mL 200 mL in 1 BOTTLE |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
CEPHALEXIN 250MG CAPSULE |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
CEPHALEXIN 250MG/5ML ORAL SUSP |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
CEPHALEXIN CAPSULES 500MG (500 CT) |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
CEREZYME INJ 200UNIT |
5 |
Specialty Tier |
25% | N/A | None |
CHANTIX 0.5MG TABLET |
3 |
Preferred Brand |
$38.00 | $95.00 | Q:336 /365Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHANTIX 1 KIT in 1 CARTON |
3 |
Preferred Brand |
$38.00 | $95.00 | Q:336 /365Days |
CHANTIX 1MG TABLET |
3 |
Preferred Brand |
$38.00 | $95.00 | Q:336 /365Days |
CHEMET 100MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Chenodal 250mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
5 |
Specialty Tier |
25% | N/A | None |
CHLORAMPHEN NA SUCC 1GM VL |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
CHLOROQUINE PH 500MG TABLET |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CHLOROQUINE PHOSPHATE 250MG TABLET (50 CT) |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CHLOROTHIAZIDE 250MG TABLET |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
CHLOROTHIAZIDE 500MG TABLET |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
CHLORPROMAZINE 10MG TABLET |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLORPROMAZINE 25MG TABLET |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
CHLORPROMAZINE 25MG/ML AMP |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CHLORPROMAZINE 50 MG TABLET |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
CHLORPROMAZINE HCL 200MG TABLET |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
Chlorpromazine Hydrochloride 100mg SUGAR COATED 1000 TABLET BOTTLE |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
CHLORTHALIDONE 25MG TABLET (100 CT) |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
CHLORTHALIDONE 50MG TABLET (1000 CT) |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
CHORIONIC GONAD 10000U VIAL |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Ciclopirox 1mL/100mL 1 BOTTLE in 1 CARTON / 120 mL in 1 BOTTLE |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Ciclopirox 7.7mg/mL 60 mL in 1 BOTTLE |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6ML BOT |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
CICLOPIROX GEL |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Ciclopirox Olamine 7.7mg/g 1 TUBE in 1 TUBE / 15 g in 1 TUBE |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
cidofovir 375 mg/5 ml vial |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Cilostazol 50mg/1 60 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CILOSTAZOL TABLET 100MG (60 CT) |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CIMETIDINE 150MG/ML VIAL |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Cimetidine 200mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Cimetidine 400mg/1 100 FILM COATED TABLETS in BOTTLE |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Cimetidine 800mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Cimetidine Hydrochloride Oral Solution 300mg/5mL 237 mL in 1 BOTTLE |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIMETIDINE TABLETS |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Cipro 1 KIT in 1 KIT |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Cipro 1 KIT in 1 KIT |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CIPRODEX OTIC SUSPENSION |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CIPROFLOXACIN 0.3% EYE DROP |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
CIPROFLOXACIN 250MG TABLET (100 CT) |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
Ciprofloxacin 400mg/40mL 1 VIAL in 1 CARTON / 40 mL in 1 VIAL |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CIPROFLOXACIN 500MG TABLET |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
Ciprofloxacin and Dextrose 2mg/mL 24 BAG in 1 CASE / 100 mL in 1 BAG |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Ciprofloxacin ER 212.6; 287.5mg/1; mg/1 50 TABLET, FILM COATED, in 1 BOTTLE, PLASTIC |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Ciprofloxacin ER 425.2; 574.9mg/1; mg/1 50 TABLET, FILM COATED, in 1 BOTTLE, PLASTIC |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIPROFLOXACIN TABLETS 750MG 100 BOT |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
Cisplatin 100mg/100mL 1 VIAL in 1 CARTON / 100 mL in 1 VIAL |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CITALOPRAM HBR 20 MG TABLET |
1* |
Preferred Generic |
$3.00 | $7.50 | Q:30 /30Days |
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | Q:600 /30Days |
CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT |
1* |
Preferred Generic |
$3.00 | $7.50 | Q:30 /30Days |
CITOLOPRAM HBR 10MG TABLET (100 CT) |
1* |
Preferred Generic |
$3.00 | $7.50 | Q:30 /30Days |
CLADRIBINE 1MG/ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
CLARAVIS 10MG CAPSULE |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CLARAVIS 20MG CAPSULE |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Claravis 30mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CLARAVIS 40MG CAPSULE |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLARITHROMYCIN 250MG TABLET |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CLARITHROMYCIN 500MG TABLET |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CLARITHROMYCIN ER 500MG TABLET (60 CT) |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CLARITHROMYCIN FOR ORAL SUSPENSION |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CLARITHROMYCIN FOR ORAL SUSPENSION |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CLEOCIN 300MG/D5W/GALAXY |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CLEOCIN 600MG/D5W/GALAXY |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CLEOCIN 900MG/D5W/GALAXY |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CLINDAMYCIN 150MG/ML ADDVAN |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CLINDAMYCIN HCL 150MG CAPSULE |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
Clindamycin Hydrochloride 75mg/1 200 CAPSULE in 1 BOTTLE |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINDAMYCIN HYDROCHLORIDE CAPSULES |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
CLINDAMYCIN PHOSP 1% LOTION |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
clindamycin phosphate 10mg/mL 1 BOTTLE in 1 CARTON / 60 mL in 1 BOTTLE |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Clindamycin Phosphate and Benzoyl Peroxide 1 KIT |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CLINDAMYCIN PHOSPHATE VAGINAL CREAM |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
clindamycin-d5w 300 mg/50 ml |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
clindamycin-d5w 600 mg/50 ml |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
clindamycin-d5w 900 mg/50 ml |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CLINISOL 15% SOLUTION |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOBETASOL 0.05% OINTMENT |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CLOBETASOL E 0.05% CREAM |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Clobetasol Propionate 0.4625mg/mL 1 BOTTLE in 1 CARTON / 50 mL in 1 BOTTLE |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CLOLAR 1MG/ML VIAL |
5 |
Specialty Tier |
25% | N/A | None |
CLOMIPRAMINE HCL 25MG CAPSULE |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
CLOMIPRAMINE HCL 50MG CAPSULE |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
CLOMIPRAMINE HCL 75MG CAPSULE |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
Clonazepam 0.125mg/1 10 BLISTER PACK in 1 CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PAC |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | P Q:90 /30Days |
Clonazepam 0.25mg/1 10 BLISTER PACK in 1 CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | P Q:90 /30Days |
Clonazepam 0.5mg/1 10 BLISTER PACK in 1 CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Clonazepam 0.5mg/1 100 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | P Q:90 /30Days |
Clonazepam 1mg/1 10 BLISTER PACK in 1 CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | P Q:90 /30Days |
Clonazepam 1mg/1 90 TABLET BOTTLE, PLASTIC |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | P Q:90 /30Days |
Clonazepam 2mg/1 10 BLISTER PACK in 1 CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | P Q:300 /30Days |
Clonazepam 2mg/1 100 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | P Q:300 /30Days |
Clonidine 0.1mg/d 4 POUCH in 1 CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Clonidine 0.2mg/d 4 POUCH in 1 CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Clonidine 0.3mg/d 4 POUCH in 1 CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CLONIDINE HCL 0.2MG TABLET (500 CT) |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
CLONIDINE HCL TABLET 0.1MG (500 CT) |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
CLONIDINE HCL TABLET 0.3MG (100 CT) |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOPIDOGREL TAB 75MG |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CLORAZEPATE 15 MG TABLET |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | P Q:180 /30Days |
Clorazepate Dipotassium 3.75mg/1 500 TABLET BOTTLE, PLASTIC |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | P Q:90 /30Days |
Clorazepate Dipotassium 7.5mg/1 500 TABLET BOTTLE, PLASTIC |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | P Q:90 /30Days |
CLOTRIMAZOLE 1% CREAM |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
CLOTRIMAZOLE 10MG TROCHE |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Clozapine 100mg/1 100 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | Q:270 /30Days |
CLOZAPINE 200MG TABLET (500 CT) |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | Q:120 /30Days |
CLOZAPINE 25MG TABLET (100 CT) |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOZAPINE 50MG TABLET (500 CT) |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | Q:90 /30Days |
CO-GESIC 5/500 TABLET |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | Q:240 /30Days |
COARTEM 20MG-120MG |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CODEINE SULFATE 30 MG TABLET 3100 |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Codeine sulfate 60mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CODEINE SULFATE TABLETS |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
COLCRYS 0.6 MG TABLET |
3 |
Preferred Brand |
$38.00 | $95.00 | None |
COLESTIPOL HCL 1G TABLET |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
COLESTIPOL HYDROCHLORIDE 5g/1 100 SUSPENSION in 1 BOTTLE |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
colistimethate 150mg/2mL 1 VIAL in 1 CARTON / 2 mL in 1 VIAL |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE |
3 |
Preferred Brand |
$38.00 | $95.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COLOCORT 100MG ENEMA |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
COMBIGAN 0.2%-0.5% DROPS |
3 |
Preferred Brand |
$38.00 | $95.00 | None |
COMBIPATCH 0.05/0.14MG PTCH |
3 |
Preferred Brand |
$38.00 | $95.00 | None |
COMBIPATCH 0.05/0.25MG PTCH |
3 |
Preferred Brand |
$38.00 | $95.00 | None |
COMBIVENT INHALER |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:29 /30Days |
COMBIVENT RESPIMAT INHAL SPRAY |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:8 /30Days |
COMETRIQ 100 MG DAILY-DOSE PK |
5 |
Specialty Tier |
25% | N/A | P Q:56 /28Days |
COMETRIQ 140 MG DAILY-DOSE PK |
5 |
Specialty Tier |
25% | N/A | P Q:112 /28Days |
COMETRIQ 60 MG DAILY-DOSE PACK |
5 |
Specialty Tier |
25% | N/A | P Q:84 /28Days |
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1 |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:30 /30Days |
COMPRO 25MG SUPPOSITORY |
1* |
Preferred Generic |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COMTAN 200MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
COMVAX VACCINE VIAL |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CONSTULOSE 10 GM/15 ML SOLN |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN |
5 |
Specialty Tier |
25% | N/A | P Q:1 /30Days |
CORTIFOAM RECTAL FOAM |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CORTISONE ACETATE 25MG TABLET (100 CT) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
COSMEGEN 0.5MG VIAL |
5 |
Specialty Tier |
25% | N/A | None |
Creon 256.11mg/1 1 BOTTLE in 1 CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
3 |
Preferred Brand |
$38.00 | $95.00 | None |
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT |
3 |
Preferred Brand |
$38.00 | $95.00 | None |
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT |
3 |
Preferred Brand |
$38.00 | $95.00 | None |
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT |
3 |
Preferred Brand |
$38.00 | $95.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CREON DR 36,000 UNITS CAPSULE |
3 |
Preferred Brand |
$38.00 | $95.00 | None |
CRESTOR 10MG TABLET |
3 |
Preferred Brand |
$38.00 | $95.00 | Q:45 /30Days |
CRESTOR 20MG TABLET |
3 |
Preferred Brand |
$38.00 | $95.00 | Q:45 /30Days |
CRESTOR 40mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Preferred Brand |
$38.00 | $95.00 | Q:30 /30Days |
CRESTOR 5MG TABLET |
3 |
Preferred Brand |
$38.00 | $95.00 | Q:45 /30Days |
CRIXIVAN 200MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:270 /30Days |
CRIXIVAN 400mg/1 90 CAPSULE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:180 /30Days |
CROMOLYN NEBULIZER SOLUTION |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | P |
CROMOLYN SODIUM 100 MG/5 ML |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CROMOLYN SODIUM 4% 40MG 10ML BOT |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CUBICIN 500MG VIAL |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cyclafem 1/35 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Cyclafem 7/7/7 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT) |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
Cyclobenzaprine Hydrochloride 5mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CYCLOBENZAPRINE HYROCHLORIDE 7.5mg/1 |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | None |
CYCLOPHOSPHAMIDE 25MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
CYCLOPHOSPHAMIDE 50MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
CYCLOSPORINE 100MG CAPSULE |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | P |
Cyclosporine 100mg/1 30 BLISTER PACK in 1 CARTON / 1 CAPSULE, LIQUID FILLED in 1 BLISTER PACK |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | P |
CYCLOSPORINE 25MG CAPSULE |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | P |
Cyclosporine 25mg/1 30 BLISTER PACK in 1 CARTON / 1 CAPSULE, LIQUID FILLED in 1 BLISTER PACK |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cyclosporine 50mg/1 30 BLISTER PACK in 1 CARTON / 1 CAPSULE, LIQUID FILLED in 1 BLISTER PACK |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
Cyclosporine 50mg/mL 10 VIAL in 1 BOX / 5 mL in 1 VIAL |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | P |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | P |
CYMBALTA 20MG CAPSULE |
3 |
Preferred Brand |
$38.00 | $95.00 | S Q:60 /30Days |
Cymbalta 60mg/1 1000 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
3 |
Preferred Brand |
$38.00 | $95.00 | S Q:60 /30Days |
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT) |
3 |
Preferred Brand |
$38.00 | $95.00 | S Q:60 /30Days |
CYSTADANE POWDER FOR ORAL SOLUTION 180GM |
5 |
Specialty Tier |
25% | N/A | None |
CYSTAGON 150MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CYSTAGON 50MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CYTARABINE 20MG/ML VIAL |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | P |
CYTARABINE 500MG VIAL |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYTARABINE SOLUTION INJECTION 100MG 20ML VIALSD |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | P |