2013 Medicare Part D Plan Formulary Information |
Care Improvement Plus Silver Rx (PPO SNP) (H0084-018-0)
Benefit Details
|
The Care Improvement Plus Silver Rx (PPO SNP) (H0084-018-0) Formulary Drugs Starting with the Letter C in RIO ARRIBA County, NM: CMS MA Region 20 which includes: NM
|
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 |
Tier 1 |
25% | 25% | None |
CALCIPOTRIENE 0.005% CREAM |
1 |
Tier 1 |
25% | 25% | None |
Calcipotriene 50ug/g 60 g in 1 CARTON |
1 |
Tier 1 |
25% | 25% | None |
CALCIPOTRIENE TOPICAL SOLUTION |
1 |
Tier 1 |
25% | 25% | None |
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY |
1 |
Tier 1 |
25% | 25% | None |
CALCITRIOL 0.25MCG CAPSULE |
1 |
Tier 1 |
25% | 25% | P |
CALCITRIOL 0.5MCG CAPSULE |
1 |
Tier 1 |
25% | 25% | P |
CALCITRIOL 1MCG/ML SOLUTION ORAL |
1 |
Tier 1 |
25% | 25% | P |
CALCITRIOL INJ 1MCG/ML |
1 |
Tier 1 |
25% | 25% | P |
CALCIUM ACETATE CAPSULE 667 MG |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAMILA 0.35MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CAMPATH INJECTION 30 MG/ML |
2 |
Tier 2 |
25% | 25% | None |
Campral 333mg/1 180 TABLET, DELAYED RELEASE in 1 BOTTLE |
2 |
Tier 2 |
25% | 25% | None |
Camptosar 20mg/mL 1 VIAL, SINGLE-DOSE in 1 CARTON / 5 mL in 1 VIAL, SINGLE-DOSE |
2 |
Tier 2 |
25% | 25% | None |
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX |
2 |
Tier 2 |
25% | 25% | None |
CANCIDAS IV 50MG VIAL |
2 |
Tier 2 |
25% | 25% | None |
CANCIDAS IV 70MG VIAL |
2 |
Tier 2 |
25% | 25% | None |
candesartan-hctz 16-12.5 mg tablet |
1 |
Tier 1 |
25% | 25% | None |
candesartan-hctz 32-12.5 mg tablet |
1 |
Tier 1 |
25% | 25% | None |
candesartan-hctz 32-25 mg |
1 |
Tier 1 |
25% | 25% | None |
CAPASTAT SULFATE 1g/1 1 INJECTION, POWDER, FOR SOLUTION in 1 CARTON |
3 |
Tier 3 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAPRELSA 100mg/1 30 TABLET BOTTLE, PLASTIC |
4 |
Tier 4 |
25% | 25% | None |
CAPRELSA 300mg/1 30 TABLET BOTTLE, PLASTIC |
4 |
Tier 4 |
25% | 25% | None |
CAPTOPRIL 100MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CAPTOPRIL 12.5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CAPTOPRIL 25MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CAPTOPRIL 50MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Captopril and Hydrochlorothiazide 25; 15mg 100 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
Captopril and Hydrochlorothiazide 25; 25mg 100 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
Captopril and Hydrochlorothiazide 50; 15mg 100 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
Captopril and Hydrochlorothiazide 50; 25mg 100 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
CARAC CRE 0.5% |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARAFATE SUS 1GM/10ML |
1 |
Tier 1 |
25% | 25% | None |
Carbaglu 200mg/1 5 TABLET BOTTLE |
4 |
Tier 4 |
25% | 25% | None |
CARBAMAZEPINE 100 MG/5 ML SUSP |
1 |
Tier 1 |
25% | 25% | None |
Carbamazepine 100mg, CHEWABLE 100 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
Carbamazepine 100mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
Carbamazepine 200mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
Carbamazepine 300mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
CARBAMAZEPINE TABLET USP 200MG (1000 CT) |
1 |
Tier 1 |
25% | 25% | None |
CARBAMAZEPINE XR 200 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CARBAMAZEPINE XR 400 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;100MG;MG 100 BOT |
1 |
Tier 1 |
25% | 25% | None |
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;250MG;MG 100 BOT |
1 |
Tier 1 |
25% | 25% | None |
CARBIDOPA-LEVODOPA ER 25-100 TAB |
1 |
Tier 1 |
25% | 25% | None |
CARBIDOPA-LEVODOPA ER 50-200 TAB |
1 |
Tier 1 |
25% | 25% | None |
CARBIDOPA/LEVO 10/100 TABLET |
1 |
Tier 1 |
25% | 25% | None |
CARBIDOPA/LEVO 25/100 TABLET |
1 |
Tier 1 |
25% | 25% | None |
CARBIDOPA/LEVO 25/250 TABLET |
1 |
Tier 1 |
25% | 25% | None |
Carboplatin 10mg/mL |
1 |
Tier 1 |
25% | 25% | None |
CARDIZEM CD 360 MG CAPSULE |
2 |
Tier 2 |
25% | 25% | None |
CARDIZEM LA EXTENDED RELEASE TABLETS 120MG 90 BOT |
3 |
Tier 3 |
25% | 25% | None |
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARTIA XT 120MG CAPSULE SA |
1 |
Tier 1 |
25% | 25% | None |
CARTIA XT 180MG CAPSULE SA |
1 |
Tier 1 |
25% | 25% | None |
CARTIA XT 240MG CAPSULE SA |
1 |
Tier 1 |
25% | 25% | None |
CARTIA XT 300MG CAPSULE SR 24 HR |
1 |
Tier 1 |
25% | 25% | None |
Carvedilol 12.5mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Tier 1 |
25% | 25% | None |
Carvedilol 25mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Tier 1 |
25% | 25% | None |
Carvedilol 3.125mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Tier 1 |
25% | 25% | None |
Carvedilol 6.25mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Tier 1 |
25% | 25% | None |
CAYSTON KIT |
4 |
Tier 4 |
25% | 25% | None |
CEDAX 400mg/1 |
3 |
Tier 3 |
25% | 25% | None |
CEENU 100MG CAPSULE |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEENU 10MG CAPSULE |
2 |
Tier 2 |
25% | 25% | None |
CEENU 40MG CAPSULE |
2 |
Tier 2 |
25% | 25% | None |
CEFACLOR CAPSULES |
1 |
Tier 1 |
25% | 25% | None |
CEFACLOR CAPSULES |
1 |
Tier 1 |
25% | 25% | None |
CEFACLOR ER 500MG TABLET SR 12HR |
1 |
Tier 1 |
25% | 25% | None |
CEFADROXIL 1G TABLET |
1 |
Tier 1 |
25% | 25% | None |
Cefadroxil 500mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
Cefadroxil 500mg/5mL |
1 |
Tier 1 |
25% | 25% | None |
CEFADROXIL FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Tier 1 |
25% | 25% | None |
CEFAZOLIN 1 GM VIAL |
1 |
Tier 1 |
25% | 25% | None |
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFAZOLIN 1GM/D5W BAG |
1 |
Tier 1 |
25% | 25% | None |
CEFAZOLIN FOR INJECTION |
1 |
Tier 1 |
25% | 25% | None |
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
25% | 25% | None |
CEFDINIR CAPSULES 300MG (60 CT) |
1 |
Tier 1 |
25% | 25% | None |
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
CEFEPIME HCL 2 GRAM VIAL |
1 |
Tier 1 |
25% | 25% | None |
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL |
1 |
Tier 1 |
25% | 25% | None |
Cefotaxime 1g/1 25 INJECTION in 1 PACKAGE |
1 |
Tier 1 |
25% | 25% | None |
CEFOTAXIME FOR INJECTION |
1 |
Tier 1 |
25% | 25% | None |
CEFOTAXIME FOR INJECTION 2GM 25 VIAL |
1 |
Tier 1 |
25% | 25% | None |
Cefoxitin 1g/1 10 POWDER in 1 CARTON |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cefoxitin 2g/1 10 POWDER in 1 CARTON |
1 |
Tier 1 |
25% | 25% | None |
CEFOXITIN FOR INJECTION 1 GM/50ML |
1 |
Tier 1 |
25% | 25% | None |
CEFOXITIN FOR INJECTION 2MG/50ML 50 ML BOT |
1 |
Tier 1 |
25% | 25% | None |
CEFOXITIN FOR INJECTION SOLUTION |
1 |
Tier 1 |
25% | 25% | None |
CEFPODOXIME 100 MG/5 ML SUSP |
1 |
Tier 1 |
25% | 25% | None |
CEFPODOXIME 200 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CEFPODOXIME 50 MG/5 ML SUSP |
1 |
Tier 1 |
25% | 25% | None |
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT) |
1 |
Tier 1 |
25% | 25% | None |
cefprozil 125 mg/5 ml susp |
1 |
Tier 1 |
25% | 25% | None |
cefprozil 250 mg/5 ml susp |
1 |
Tier 1 |
25% | 25% | None |
Cefprozil 250mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFPROZIL TABLETS 500MG 100 BOT |
1 |
Tier 1 |
25% | 25% | None |
CEFTAZIDIME 1g/1 25 VIAL in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL |
1 |
Tier 1 |
25% | 25% | None |
Ceftazidime and Dextrose 1g/50mL 24 CONTAINER in 1 CASE / 50 mL in 1 CONTAINER |
1 |
Tier 1 |
25% | 25% | None |
Ceftazidime and Dextrose 2g/50mL 24 CONTAINER in 1 CASE / 50 mL in 1 CONTAINER |
1 |
Tier 1 |
25% | 25% | None |
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN |
1 |
Tier 1 |
25% | 25% | None |
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN |
1 |
Tier 1 |
25% | 25% | None |
CEFTIN 125mg/5mL 100 mL in 1 BOTTLE, GLASS |
2 |
Tier 2 |
25% | 25% | None |
CEFTIN 250MG/5ML ORAL SUSP |
2 |
Tier 2 |
25% | 25% | None |
CEFTRIAXONE 10GM VIAL |
1 |
Tier 1 |
25% | 25% | None |
CEFTRIAXONE 250 MG VIAL |
1 |
Tier 1 |
25% | 25% | None |
CEFTRIAXONE FOR INJECTION |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFTRIAXONE FOR INJECTION |
1 |
Tier 1 |
25% | 25% | None |
Ceftriaxone Sodium 500mg/1 |
1 |
Tier 1 |
25% | 25% | None |
cefuroxime axetil 250mg/1 |
1 |
Tier 1 |
25% | 25% | None |
CEFUROXIME AXETIL 500 MG TAB |
1 |
Tier 1 |
25% | 25% | None |
CEFUROXIME FOR INJECTION |
1 |
Tier 1 |
25% | 25% | None |
CEFUROXIME FOR INJECTION |
1 |
Tier 1 |
25% | 25% | None |
CEFUROXIME FOR INJECTION |
1 |
Tier 1 |
25% | 25% | None |
CELEBREX 100MG CAPSULE |
2 |
Tier 2 |
25% | 25% | P |
CELEBREX 200MG CAPSULE |
2 |
Tier 2 |
25% | 25% | P |
CELEBREX 400MG CAPSULE |
2 |
Tier 2 |
25% | 25% | P |
CELEBREX 50MG CAPSULE |
2 |
Tier 2 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CELLCEPT 200MG/ML ORAL SUSP |
2 |
Tier 2 |
25% | 25% | P |
CELLCEPT IV INJ 500MG |
2 |
Tier 2 |
25% | 25% | None |
CELONTIN 300MG KAPSEAL |
2 |
Tier 2 |
25% | 25% | None |
CENESTIN 0.3MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
CENESTIN 0.45MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
CENESTIN 0.625MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
CENESTIN 0.9MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
CENESTIN 1.25MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
Cephalexin 125mg/5mL 200 mL in 1 BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
CEPHALEXIN 250MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
CEPHALEXIN 250MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEPHALEXIN 250MG/5ML ORAL SUSP |
1 |
Tier 1 |
25% | 25% | None |
CEPHALEXIN 500MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CEPHALEXIN CAPSULES 500MG (500 CT) |
1 |
Tier 1 |
25% | 25% | None |
CEREZYME INJ 200UNIT |
4 |
Tier 4 |
25% | 25% | None |
CEVIMELINE HCL 30 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
CHANTIX 0.5MG TABLET |
2 |
Tier 2 |
25% | 25% | P |
CHANTIX 1 KIT in 1 CARTON |
2 |
Tier 2 |
25% | 25% | P |
CHANTIX 1MG TABLET |
2 |
Tier 2 |
25% | 25% | P |
CHEMET 100MG CAPSULE |
2 |
Tier 2 |
25% | 25% | None |
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH |
1 |
Tier 1 |
25% | 25% | None |
CHLOROQUINE PH 500MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLOROQUINE PHOSPHATE 250MG TABLET (50 CT) |
1 |
Tier 1 |
25% | 25% | None |
CHLOROTHIAZIDE SODIUM FOR INJECTION 500MG/VIAL |
1 |
Tier 1 |
25% | 25% | None |
CHLORPROMAZINE 10MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CHLORPROMAZINE 25MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CHLORPROMAZINE 25MG/ML AMP |
1 |
Tier 1 |
25% | 25% | None |
CHLORPROMAZINE 50 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CHLORPROMAZINE HCL 200MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Chlorpromazine Hydrochloride 100mg SUGAR COATED 1000 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
CHLORTHALIDONE 25MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
CHLORTHALIDONE 50MG TABLET (1000 CT) |
1 |
Tier 1 |
25% | 25% | None |
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHORIONIC GONAD 10000U VIAL |
1 |
Tier 1 |
25% | 25% | P |
Cialis 2.5mg/1 2 BLISTER PACK in 1 CARTON / 15 FILM COATED TABLETS in BLISTER PACK |
2 |
Tier 2 |
25% | 25% | P Q:90 /90Days |
Cialis 5mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Tier 2 |
25% | 25% | P Q:90 /90Days |
Ciclopirox 1mL/100mL 1 BOTTLE in 1 CARTON / 120 mL in 1 BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
Ciclopirox 7.7mg/mL 60 mL in 1 BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6ML BOT |
1 |
Tier 1 |
25% | 25% | None |
CICLOPIROX GEL |
1 |
Tier 1 |
25% | 25% | None |
Ciclopirox Olamine 7.7mg/g 1 TUBE in 1 TUBE / 15 g in 1 TUBE |
1 |
Tier 1 |
25% | 25% | None |
cidofovir 375 mg/5 ml vial |
4 |
Tier 4 |
25% | 25% | None |
Cilostazol 50mg/1 60 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
CILOSTAZOL TABLET 100MG (60 CT) |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CILOXAN 0.3% OINTMENT |
2 |
Tier 2 |
25% | 25% | None |
Cimzia 2 KIT in 1 CARTON / 1 KIT in 1 KIT |
4 |
Tier 4 |
25% | 25% | P Q:6 /28Days |
CIMZIA 200 MG/ML SYRINGE KIT |
4 |
Tier 4 |
25% | 25% | P Q:6 /28Days |
Cinryze 500[iU]/5mL 1 VIAL in 1 CARTON / 5 mL in 1 VIAL |
4 |
Tier 4 |
25% | 25% | P Q:60 /90Days |
Cipro 1 KIT in 1 KIT |
2 |
Tier 2 |
25% | 25% | None |
Cipro 1 KIT in 1 KIT |
2 |
Tier 2 |
25% | 25% | None |
CIPRO HC OTIC SUSPENSION |
3 |
Tier 3 |
25% | 25% | None |
CIPRODEX OTIC SUSPENSION |
3 |
Tier 3 |
25% | 25% | None |
CIPROFLOXACIN 0.3% EYE DROP |
1 |
Tier 1 |
25% | 25% | None |
CIPROFLOXACIN 250MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
Ciprofloxacin 400mg/40mL 1 VIAL in 1 CARTON / 40 mL in 1 VIAL |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIPROFLOXACIN 500MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Ciprofloxacin and Dextrose 2mg/mL 24 BAG in 1 CASE / 100 mL in 1 BAG |
1 |
Tier 1 |
25% | 25% | None |
Ciprofloxacin ER 212.6; 287.5mg/1; mg/1 50 TABLET, FILM COATED, in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
25% | 25% | None |
Ciprofloxacin ER 425.2; 574.9mg/1; mg/1 50 TABLET, FILM COATED, in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
25% | 25% | None |
CIPROFLOXACIN HCL 100MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CIPROFLOXACIN TABLETS 750MG 100 BOT |
1 |
Tier 1 |
25% | 25% | None |
Cisplatin 100mg/100mL 1 VIAL in 1 CARTON / 100 mL in 1 VIAL |
1 |
Tier 1 |
25% | 25% | None |
CITALOPRAM HBR 20 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL |
1 |
Tier 1 |
25% | 25% | None |
CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT |
1 |
Tier 1 |
25% | 25% | None |
CITOLOPRAM HBR 10MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLADRIBINE 1MG/ML VIAL |
1 |
Tier 1 |
25% | 25% | None |
CLARAVIS 10MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
CLARAVIS 20MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
Claravis 30mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK |
4 |
Tier 4 |
25% | 25% | None |
CLARAVIS 40MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
CLARITHROMYCIN 250MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CLARITHROMYCIN 500MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
CLARITHROMYCIN ER 500MG TABLET (60 CT) |
1 |
Tier 1 |
25% | 25% | None |
CLARITHROMYCIN FOR ORAL SUSPENSION |
1 |
Tier 1 |
25% | 25% | None |
CLARITHROMYCIN FOR ORAL SUSPENSION |
1 |
Tier 1 |
25% | 25% | None |
CLEMASTINE FUM 2.68MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Clemastine Fumarate 0.5mg/5mL 120 mL in 1 BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
CLEOCIN 100MG VAGINAL OVULE |
2 |
Tier 2 |
25% | 25% | None |
Cleocin Pediatric 75mg/5mL 75 mL in 1 BOTTLE |
2 |
Tier 2 |
25% | 25% | None |
CLIMARA PRO DIS WEEKLY 4.40MG/1.39MG |
2 |
Tier 2 |
25% | 25% | None |
CLINDAMYCIN 150MG/ML ADDVAN |
1 |
Tier 1 |
25% | 25% | None |
CLINDAMYCIN HCL 150MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
Clindamycin Hydrochloride 75mg/1 200 CAPSULE in 1 BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
CLINDAMYCIN HYDROCHLORIDE CAPSULES |
1 |
Tier 1 |
25% | 25% | None |
CLINDAMYCIN PHOSP 1% LOTION |
1 |
Tier 1 |
25% | 25% | None |
CLINDAMYCIN PHOSPHATE 1% FOAM |
1 |
Tier 1 |
25% | 25% | None |
clindamycin phosphate 10mg/mL 1 BOTTLE in 1 CARTON / 60 mL in 1 BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Clindamycin Phosphate and Benzoyl Peroxide 1 KIT |
1 |
Tier 1 |
25% | 25% | None |
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE |
1 |
Tier 1 |
25% | 25% | None |
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX |
1 |
Tier 1 |
25% | 25% | None |
CLINDAMYCIN PHOSPHATE VAGINAL CREAM |
1 |
Tier 1 |
25% | 25% | None |
clindamycin-d5w 300 mg/50 ml |
1 |
Tier 1 |
25% | 25% | None |
clindamycin-d5w 600 mg/50 ml |
1 |
Tier 1 |
25% | 25% | None |
clindamycin-d5w 900 mg/50 ml |
1 |
Tier 1 |
25% | 25% | None |
CLINIMIX 2.75%/5% INJECTION 1000ML BAG |
2 |
Tier 2 |
25% | 25% | None |
CLINIMIX 4.25/10 SOLUTION |
2 |
Tier 2 |
25% | 25% | None |
CLINIMIX 4.25/20 SOLUTION |
2 |
Tier 2 |
25% | 25% | None |
CLINIMIX 4.25/25 SOLUTION |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINIMIX 4.25/5 SOLUTION |
2 |
Tier 2 |
25% | 25% | None |
CLINIMIX 5/15 SOLUTION |
2 |
Tier 2 |
25% | 25% | None |
CLINIMIX 5/20 SOLUTION |
2 |
Tier 2 |
25% | 25% | None |
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG |
2 |
Tier 2 |
25% | 25% | None |
CLINIMIX E 2.75/10 SOLUTION |
2 |
Tier 2 |
25% | 25% | None |
CLINIMIX E 2.75/5 SOLUTION |
2 |
Tier 2 |
25% | 25% | None |
CLINIMIX E 4.25/25 SOLUTION |
2 |
Tier 2 |
25% | 25% | None |
CLINIMIX E 4.25/5 SOLUTION |
2 |
Tier 2 |
25% | 25% | None |
CLINIMIX E 5/20 SOLUTION |
2 |
Tier 2 |
25% | 25% | None |
CLINIMIX E 5/25 SOLUTION |
2 |
Tier 2 |
25% | 25% | None |
CLINIMIX E 5%/15% INJECTION 2000ML BAG |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINISOL 15% SOLUTION |
2 |
Tier 2 |
25% | 25% | None |
CLOBETASOL 0.05% OINTMENT |
1 |
Tier 1 |
25% | 25% | None |
CLOBETASOL 0.05% SHAMPOO |
1 |
Tier 1 |
25% | 25% | None |
CLOBETASOL 0.05% TOPICAL LOTION |
1 |
Tier 1 |
25% | 25% | None |
CLOBETASOL E 0.05% CREAM |
1 |
Tier 1 |
25% | 25% | None |
Clobetasol Propionate 0.4625mg/mL 1 BOTTLE in 1 CARTON / 50 mL in 1 BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
Clobetasol Propionate 0.5mg/g 1 CAN in 1 CARTON / 100 g in 1 CAN |
1 |
Tier 1 |
25% | 25% | None |
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE |
1 |
Tier 1 |
25% | 25% | None |
CLOLAR 1MG/ML VIAL |
3 |
Tier 3 |
25% | 25% | None |
CLOMIPRAMINE HCL 25MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
CLOMIPRAMINE HCL 50MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOMIPRAMINE HCL 75MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
Clonazepam 0.125mg/1 10 BLISTER PACK in 1 CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PAC |
1 |
Tier 1 |
25% | 25% | P |
Clonazepam 0.25mg/1 10 BLISTER PACK in 1 CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK |
1 |
Tier 1 |
25% | 25% | P |
Clonazepam 0.5mg/1 10 BLISTER PACK in 1 CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK |
1 |
Tier 1 |
25% | 25% | P |
Clonazepam 0.5mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | P |
Clonazepam 1mg/1 10 BLISTER PACK in 1 CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK |
1 |
Tier 1 |
25% | 25% | P |
Clonazepam 1mg/1 90 TABLET BOTTLE, PLASTIC |
1 |
Tier 1 |
25% | 25% | P |
Clonazepam 2mg/1 10 BLISTER PACK in 1 CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK |
1 |
Tier 1 |
25% | 25% | P |
Clonazepam 2mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | P |
Clonidine 0.1mg/d 4 POUCH in 1 CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
1 |
Tier 1 |
25% | 25% | None |
Clonidine 0.2mg/d 4 POUCH in 1 CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Clonidine 0.3mg/d 4 POUCH in 1 CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
1 |
Tier 1 |
25% | 25% | None |
CLONIDINE HCL 0.2MG TABLET (500 CT) |
1 |
Tier 1 |
25% | 25% | None |
CLONIDINE HCL TABLET 0.1MG (500 CT) |
1 |
Tier 1 |
25% | 25% | None |
CLONIDINE HCL TABLET 0.3MG (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
CLOPIDOGREL 300 MG tablet |
1 |
Tier 1 |
25% | 25% | None |
CLOPIDOGREL TAB 75MG |
1 |
Tier 1 |
25% | 25% | None |
CLORAZEPATE 15 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Clorazepate Dipotassium 3.75mg/1 500 TABLET BOTTLE, PLASTIC |
1 |
Tier 1 |
25% | 25% | None |
Clorazepate Dipotassium 7.5mg/1 500 TABLET BOTTLE, PLASTIC |
1 |
Tier 1 |
25% | 25% | None |
CLOTRIMAZOLE 1% CREAM |
1 |
Tier 1 |
25% | 25% | None |
CLOTRIMAZOLE 10MG TROCHE |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOTRIMAZOLE SOLUTION TOPICAL 1% 30ML BOTPL |
1 |
Tier 1 |
25% | 25% | None |
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION |
1 |
Tier 1 |
25% | 25% | None |
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE |
1 |
Tier 1 |
25% | 25% | None |
Clozapine 100mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
CLOZAPINE 200MG TABLET (500 CT) |
1 |
Tier 1 |
25% | 25% | None |
CLOZAPINE 25MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
CLOZAPINE 50MG TABLET (500 CT) |
1 |
Tier 1 |
25% | 25% | None |
CO-GESIC 5/500 TABLET |
1 |
Tier 1 |
25% | 25% | None |
COARTEM 20MG-120MG |
2 |
Tier 2 |
25% | 25% | None |
CODEINE SULFATE 30 MG TABLET 3100 |
1 |
Tier 1 |
25% | 25% | None |
Codeine sulfate 60mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CODEINE SULFATE TABLETS |
1 |
Tier 1 |
25% | 25% | None |
COGENTIN 2 MG/2 ML AMPULE |
2 |
Tier 2 |
25% | 25% | None |
COLCRYS 0.6 MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
COLESTIPOL HCL 1G TABLET |
1 |
Tier 1 |
25% | 25% | None |
COLESTIPOL HYDROCHLORIDE 5g/1 100 SUSPENSION in 1 BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
colistimethate 150mg/2mL 1 VIAL in 1 CARTON / 2 mL in 1 VIAL |
1 |
Tier 1 |
25% | 25% | P |
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE |
2 |
Tier 2 |
25% | 25% | None |
COLOCORT 100MG ENEMA |
1 |
Tier 1 |
25% | 25% | None |
COMBIGAN 0.2%-0.5% DROPS |
2 |
Tier 2 |
25% | 25% | None |
COMBIPATCH 0.05/0.14MG PTCH |
2 |
Tier 2 |
25% | 25% | None |
COMBIPATCH 0.05/0.25MG PTCH |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COMBIVENT INHALER |
2 |
Tier 2 |
25% | 25% | Q:30 /25Days |
COMBIVENT RESPIMAT INHAL SPRAY |
2 |
Tier 2 |
25% | 25% | Q:20 /90Days |
COMETRIQ 100 MG DAILY-DOSE PK |
4 |
Tier 4 |
25% | 25% | P |
COMETRIQ 140 MG DAILY-DOSE PK |
4 |
Tier 4 |
25% | 25% | P |
COMETRIQ 60 MG DAILY-DOSE PACK |
4 |
Tier 4 |
25% | 25% | P |
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1 |
4 |
Tier 4 |
25% | 25% | None |
COMPRO 25MG SUPPOSITORY |
1 |
Tier 1 |
25% | 25% | None |
COMTAN 200MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
COMVAX VACCINE VIAL |
2 |
Tier 2 |
25% | 25% | None |
CONCERTA 54mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Tier 3 |
25% | 25% | P |
CONCERTA ER TABLETS 18MG 100 TABLETS BOT |
3 |
Tier 3 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CONCERTA ER TABLETS 27MG 100 TABLETS BOT |
3 |
Tier 3 |
25% | 25% | P |
CONCERTA ER TABLETS 36MG 100 TABLETS BOT |
3 |
Tier 3 |
25% | 25% | P |
CONDYLOX GEL 0.5% 3.5 GM CRTN |
3 |
Tier 3 |
25% | 25% | None |
CONSTULOSE 10 GM/15 ML SOLN |
1 |
Tier 1 |
25% | 25% | None |
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN |
4 |
Tier 4 |
25% | 25% | None |
Cordran 0.5mg/mL 60 mL in 1 BOTTLE, PLASTIC |
3 |
Tier 3 |
25% | 25% | None |
CORDRAN TAPE 4MCG/SQCM 1 X 80 X 3 CTR |
3 |
Tier 3 |
25% | 25% | None |
COREG CR 10MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
25% | 25% | None |
COREG CR 20MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
25% | 25% | None |
COREG CR 40MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
25% | 25% | None |
COREG CR 80MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CORTIFOAM RECTAL FOAM |
3 |
Tier 3 |
25% | 25% | None |
CORTISONE ACETATE 25MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
COSMEGEN 0.5MG VIAL |
2 |
Tier 2 |
25% | 25% | None |
COUMADIN 10MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
COUMADIN 1MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
COUMADIN 2.5MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
COUMADIN 2MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
COUMADIN 3mg/1 1 BOTTLE in 1 CARTON / 100 TABLET BOTTLE |
2 |
Tier 2 |
25% | 25% | None |
COUMADIN 4mg/1 100 TABLET in 1 BLISTER PACK |
2 |
Tier 2 |
25% | 25% | None |
COUMADIN 5MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
COUMADIN 6MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COUMADIN 7.5MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
Creon 256.11mg/1 1 BOTTLE in 1 CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
2 |
Tier 2 |
25% | 25% | None |
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT |
2 |
Tier 2 |
25% | 25% | None |
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT |
2 |
Tier 2 |
25% | 25% | None |
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT |
2 |
Tier 2 |
25% | 25% | None |
CREON DR 36,000 UNITS CAPSULE |
2 |
Tier 2 |
25% | 25% | None |
CRESTOR 10MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
CRESTOR 20MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
CRESTOR 40mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Tier 2 |
25% | 25% | None |
CRESTOR 5MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
Crinone 45mg/1.125g 6 APPLICATOR in 1 CARTON / 1.125 g in 1 APPLICATOR |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Crinone 90mg/1.125g 15 APPLICATOR in 1 CARTON / 1.125 g in 1 APPLICATOR |
2 |
Tier 2 |
25% | 25% | P |
CRIXIVAN 200MG CAPSULE |
2 |
Tier 2 |
25% | 25% | None |
CRIXIVAN 400mg/1 90 CAPSULE in 1 BOTTLE |
2 |
Tier 2 |
25% | 25% | None |
CROMOLYN NEBULIZER SOLUTION |
1 |
Tier 1 |
25% | 25% | P Q:240 /25Days |
CROMOLYN SODIUM 100 MG/5 ML |
1 |
Tier 1 |
25% | 25% | None |
CROMOLYN SODIUM 4% 40MG 10ML BOT |
1 |
Tier 1 |
25% | 25% | None |
CUBICIN 500MG VIAL |
4 |
Tier 4 |
25% | 25% | P |
Cyclafem 1/35 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
1 |
Tier 1 |
25% | 25% | None |
Cyclafem 7/7/7 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
1 |
Tier 1 |
25% | 25% | None |
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT) |
1 |
Tier 1 |
25% | 25% | None |
Cyclobenzaprine Hydrochloride 5mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYCLOBENZAPRINE HYROCHLORIDE 7.5mg/1 |
1 |
Tier 1 |
25% | 25% | None |
CYCLOPHOSPHAMIDE 25MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
CYCLOPHOSPHAMIDE 50MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
CYCLOSPORINE 100MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P |
Cyclosporine 100mg/1 30 BLISTER PACK in 1 CARTON / 1 CAPSULE, LIQUID FILLED in 1 BLISTER PACK |
1 |
Tier 1 |
25% | 25% | P |
CYCLOSPORINE 25MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P |
Cyclosporine 25mg/1 30 BLISTER PACK in 1 CARTON / 1 CAPSULE, LIQUID FILLED in 1 BLISTER PACK |
1 |
Tier 1 |
25% | 25% | P |
Cyclosporine 50mg/1 30 BLISTER PACK in 1 CARTON / 1 CAPSULE, LIQUID FILLED in 1 BLISTER PACK |
1 |
Tier 1 |
25% | 25% | P |
Cyclosporine 50mg/mL 10 VIAL in 1 BOX / 5 mL in 1 VIAL |
1 |
Tier 1 |
25% | 25% | None |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT |
1 |
Tier 1 |
25% | 25% | P |
CYKLOKAPRON 100MG/ML AMPUL |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYMBALTA 20MG CAPSULE |
2 |
Tier 2 |
25% | 25% | None |
Cymbalta 60mg/1 1000 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
2 |
Tier 2 |
25% | 25% | None |
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT) |
2 |
Tier 2 |
25% | 25% | None |
CYSTADANE POWDER FOR ORAL SOLUTION 180GM |
2 |
Tier 2 |
25% | 25% | None |
CYSTAGON 150MG CAPSULE |
2 |
Tier 2 |
25% | 25% | None |
CYSTAGON 50MG CAPSULE |
2 |
Tier 2 |
25% | 25% | None |
CYSTARAN 0.44% EYE DROPS |
4 |
Tier 4 |
25% | 25% | None |
CYTARABINE 20MG/ML VIAL |
1 |
Tier 1 |
25% | 25% | None |
CYTARABINE 500MG VIAL |
1 |
Tier 1 |
25% | 25% | None |
CYTARABINE SOLUTION INJECTION 100MG 20ML VIALSD |
1 |
Tier 1 |
25% | 25% | None |
CYTOMEL 25MCG TABLET |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYTOMEL 50MCG TABLET |
2 |
Tier 2 |
25% | 25% | None |
CYTOMEL 5MCG TABLET |
2 |
Tier 2 |
25% | 25% | None |