2013 Medicare Part D Plan Formulary Information |
Presbyterian MediCare PPO Plan 2 with Rx (PPO) (H3206-001-0)
Benefit Details
|
The Presbyterian MediCare PPO Plan 2 with Rx (PPO) (H3206-001-0) Formulary Drugs Starting with the Letter C in QUAY County, NM: CMS MA Region 20 which includes: NM
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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 |
$8.00 | $16.00 | None |
CALCIPOTRIENE 0.005% CREAM |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CALCIPOTRIENE TOPICAL SOLUTION |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CALCITRIOL 0.25MCG CAPSULE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CALCITRIOL 0.5MCG CAPSULE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CALCITRIOL 1MCG/ML SOLUTION ORAL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CALCITRIOL INJ 1MCG/ML |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CALCIUM ACETATE CAPSULE 667 MG |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CAMILA 0.35MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAMPATH INJECTION 30 MG/ML |
5 |
Specialty Tier |
33% | N/A | P |
Campral 333mg/1 180 TABLET, DELAYED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | S Q:180 /30Days |
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
candesartan-hctz 16-12.5 mg tablet |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | S |
candesartan-hctz 32-12.5 mg tablet |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | S |
candesartan-hctz 32-25 mg |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | S |
CAPASTAT SULFATE 1g/1 1 INJECTION, POWDER, FOR SOLUTION in 1 CARTON |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
CAPRELSA 100mg/1 30 TABLET BOTTLE, PLASTIC |
5 |
Specialty Tier |
33% | N/A | P |
CAPRELSA 300mg/1 30 TABLET BOTTLE, PLASTIC |
5 |
Specialty Tier |
33% | N/A | P |
CAPTOPRIL 100MG TABLET |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
CAPTOPRIL 12.5MG TABLET |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAPTOPRIL 25MG TABLET |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
CAPTOPRIL 50MG TABLET |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
Captopril and Hydrochlorothiazide 25; 15mg 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Captopril and Hydrochlorothiazide 25; 25mg 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Captopril and Hydrochlorothiazide 50; 15mg 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Captopril and Hydrochlorothiazide 50; 25mg 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CARAC CRE 0.5% |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
CARAFATE SUS 1GM/10ML |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
CARBAMAZEPINE 100 MG/5 ML SUSP |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Carbamazepine 100mg, CHEWABLE 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Carbamazepine 100mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Carbamazepine 200mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Carbamazepine 300mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CARBAMAZEPINE TABLET USP 200MG (1000 CT) |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CARBAMAZEPINE XR 200 MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CARBAMAZEPINE XR 400 MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CARBIDOPA-LEVODOPA ER 25-100 TAB |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
CARBIDOPA-LEVODOPA ER 50-200 TAB |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
CARBIDOPA/LEVO 10/100 TABLET |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
CARBIDOPA/LEVO 25/100 TABLET |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
CARBIDOPA/LEVO 25/250 TABLET |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
CARIMUNE NF 3GM VIAL |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARISOPRODOL AND ASPIRIN TABLETS USP 325;200MG;MG 100 BOTPL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CARISOPRODOL ASPIRIN AND CODEINE PHOSPHATE TABLETS USP 325;200;16MG;MG;MG 100 BOTPL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CARISOPRODOL TABLET USP 350MG (100 CT) |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Carvedilol 12.5mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
Carvedilol 25mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
Carvedilol 3.125mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
Carvedilol 6.25mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
CEENU 100MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
CEENU 10MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
CEENU 40MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFACLOR CAPSULES |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CEFACLOR CAPSULES |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CEFACLOR ER 500MG TABLET SR 12HR |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
CEFADROXIL 1G TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Cefadroxil 500mg/1 100 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Cefadroxil 500mg/5mL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CEFADROXIL FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CEFAZOLIN 1 GM VIAL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CEFAZOLIN FOR INJECTION |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | 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 |
$8.00 | $16.00 | None |
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT) |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CEFEPIME HCL 2 GRAM VIAL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Cefotaxime 1g/1 25 INJECTION in 1 PACKAGE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CEFOTAXIME FOR INJECTION |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CEFOTAXIME FOR INJECTION 2GM 25 VIAL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CEFPODOXIME 100 MG/5 ML SUSP |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CEFPODOXIME 200 MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CEFPODOXIME 50 MG/5 ML SUSP |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT) |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
cefprozil 125 mg/5 ml susp |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
cefprozil 250 mg/5 ml susp |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Cefprozil 250mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CEFPROZIL TABLETS 500MG 100 BOT |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CEFTIN 250MG/5ML ORAL SUSP |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
CEFTRIAXONE 10GM VIAL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CEFTRIAXONE 250 MG VIAL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Ceftriaxone Sodium 500mg/1 |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
cefuroxime axetil 250mg/1 |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CEFUROXIME AXETIL 500 MG TAB |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CEFUROXIME FOR INJECTION |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFUROXIME FOR INJECTION |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CEFUROXIME FOR INJECTION |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CELEBREX 100MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
CELEBREX 200MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
CELEBREX 400MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
CELEBREX 50MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
CELLCEPT 200MG/ML ORAL SUSP |
5 |
Specialty Tier |
33% | N/A | P |
CELLCEPT 500MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
CELLCEPT CAPSULES 250MG (500 CT) |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | P |
CELLCEPT IV INJ 500MG |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | P |
CELONTIN 300MG KAPSEAL |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CENESTIN 0.3MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
CENESTIN 0.45MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
CENESTIN 0.625MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
CENESTIN 0.9MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
CENESTIN 1.25MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
Cephalexin 125mg/5mL 200 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CEPHALEXIN 250MG CAPSULE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CEPHALEXIN 250MG/5ML ORAL SUSP |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CEPHALEXIN CAPSULES 500MG (500 CT) |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CEREZYME INJ 200UNIT |
5 |
Specialty Tier |
33% | N/A | None |
CETIRIZINE HCL 5MG/5ML |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHANTIX 0.5MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | Q:360 /365Days |
CHANTIX 1 KIT in 1 CARTON |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | Q:106 /365Days |
CHANTIX 1MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | Q:360 /365Days |
CHLORAMPHEN NA SUCC 1GM VL |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
CHLORDIAZEPOXIDE HCL 10mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE in 1 BLISTER |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | Q:120 /30Days |
CHLORDIAZEPOXIDE HCL 25mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE in 1 BLISTER |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | Q:120 /30Days |
CHLORDIAZEPOXIDE HCL 5mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE in 1 BLISTER |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | Q:120 /30Days |
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CHLOROQUINE PH 500MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CHLOROQUINE PHOSPHATE 250MG TABLET (50 CT) |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CHLOROTHIAZIDE 250MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLOROTHIAZIDE 500MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CHLORPROMAZINE 10MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CHLORPROMAZINE 25MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CHLORPROMAZINE 25MG/ML AMP |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
CHLORPROMAZINE 50 MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CHLORPROMAZINE HCL 200MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Chlorpromazine Hydrochloride 100mg SUGAR COATED 1000 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CHLORTHALIDONE 25MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CHLORTHALIDONE 50MG TABLET (1000 CT) |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CHLORZOXAZONE 500 MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ciclopirox 1mL/100mL 1 BOTTLE in 1 CARTON / 120 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Ciclopirox 7.7mg/mL 60 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6ML BOT |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CICLOPIROX GEL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Ciclopirox Olamine 7.7mg/g 1 TUBE in 1 TUBE / 15 g in 1 TUBE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Cilostazol 50mg/1 60 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CILOSTAZOL TABLET 100MG (60 CT) |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CILOXAN 0.3% OINTMENT |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
Cimetidine 200mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Cimetidine 400mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Cimetidine 800mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIMETIDINE TABLETS |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Cinryze 500[iU]/5mL 1 VIAL in 1 CARTON / 5 mL in 1 VIAL |
5 |
Specialty Tier |
33% | N/A | P |
Cipro 1 KIT in 1 KIT |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
Cipro 1 KIT in 1 KIT |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
CIPRO HC OTIC SUSPENSION |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
CIPRODEX OTIC SUSPENSION |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
CIPROFLOXACIN 0.3% EYE DROP |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CIPROFLOXACIN 250MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Ciprofloxacin 400mg/40mL 1 VIAL in 1 CARTON / 40 mL in 1 VIAL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CIPROFLOXACIN 500MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Ciprofloxacin and Dextrose 2mg/mL 24 BAG in 1 CASE / 100 mL in 1 BAG |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIPROFLOXACIN HCL 100MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CIPROFLOXACIN TABLETS 750MG 100 BOT |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CITALOPRAM HBR 20 MG TABLET |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | Q:600 /30Days |
CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
CITOLOPRAM HBR 10MG TABLET (100 CT) |
1 |
Preferred Generic |
$2.00 | $4.00 | Q:60 /30Days |
CLADRIBINE 1MG/ML VIAL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CLARITHROMYCIN 250MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CLARITHROMYCIN 500MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CLARITHROMYCIN ER 500MG TABLET (60 CT) |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CLARITHROMYCIN FOR ORAL SUSPENSION |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLARITHROMYCIN FOR ORAL SUSPENSION |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CLEOCIN 300MG/D5W/GALAXY |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
CLEOCIN 600MG/D5W/GALAXY |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
CLEOCIN 900MG/D5W/GALAXY |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
CLIMARA 0.025MG/DAY PATCH |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
CLIMARA 0.0375MG/DAY PATCH |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
CLIMARA 0.05MG/24H PATCH |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
CLIMARA 0.06/MG DAY PATCH |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
CLIMARA 0.075MG/DAY PATCH |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
CLIMARA 0.1MG/24H PATCH |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
CLINDAMYCIN HCL 150MG CAPSULE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Clindamycin Hydrochloride 75mg/1 200 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CLINDAMYCIN HYDROCHLORIDE CAPSULES |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
clindamycin phosphate 10mg/mL 1 BOTTLE in 1 CARTON / 60 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Clindamycin Phosphate and Benzoyl Peroxide 1 KIT |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
clindamycin-d5w 300 mg/50 ml |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
clindamycin-d5w 600 mg/50 ml |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
clindamycin-d5w 900 mg/50 ml |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
CLINIMIX E 4.25/25 SOLUTION |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
CLOBETASOL 0.05% OINTMENT |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CLOBETASOL E 0.05% CREAM |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Clobetasol Propionate 0.4625mg/mL 1 BOTTLE in 1 CARTON / 50 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CLOMIPRAMINE HCL 25MG CAPSULE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CLOMIPRAMINE HCL 50MG CAPSULE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CLOMIPRAMINE HCL 75MG CAPSULE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Clonazepam 0.125mg/1 10 BLISTER PACK in 1 CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PAC |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Clonazepam 0.25mg/1 10 BLISTER PACK in 1 CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Clonazepam 0.5mg/1 10 BLISTER PACK in 1 CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Clonazepam 0.5mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Clonazepam 1mg/1 10 BLISTER PACK in 1 CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Clonazepam 1mg/1 90 TABLET BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Clonazepam 2mg/1 10 BLISTER PACK in 1 CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Clonazepam 2mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Clonidine 0.1mg/d 4 POUCH in 1 CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Clonidine 0.2mg/d 4 POUCH in 1 CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Clonidine 0.3mg/d 4 POUCH in 1 CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CLONIDINE HCL 0.2MG TABLET (500 CT) |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CLONIDINE HCL TABLET 0.1MG (500 CT) |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CLONIDINE HCL TABLET 0.3MG (100 CT) |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CLOPIDOGREL TAB 75MG |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CLORAZEPATE 15 MG TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Clorazepate Dipotassium 3.75mg/1 500 TABLET BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Clorazepate Dipotassium 7.5mg/1 500 TABLET BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CLOTRIMAZOLE 1% CREAM |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CLOTRIMAZOLE 10MG TROCHE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Clozapine 100mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CLOZAPINE 200MG TABLET (500 CT) |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CLOZAPINE 25MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CLOZAPINE 50MG TABLET (500 CT) |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CODEINE SULFATE 30 MG TABLET 3100 |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:180 /30Days |
Codeine sulfate 60mg/1 100 TABLET BOTTLE |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CODEINE SULFATE TABLETS |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:180 /30Days |
COLCRYS 0.6 MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
COLESTIPOL HCL 1G TABLET |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
COLESTIPOL HYDROCHLORIDE 5g/1 100 SUSPENSION in 1 BOTTLE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
colistimethate 150mg/2mL 1 VIAL in 1 CARTON / 2 mL in 1 VIAL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
COMBIGAN 0.2%-0.5% DROPS |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
COMBIPATCH 0.05/0.14MG PTCH |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
COMBIPATCH 0.05/0.25MG PTCH |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
COMBIVENT INHALER |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
COMBIVENT RESPIMAT INHAL SPRAY |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | Q:8 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COMETRIQ 100 MG DAILY-DOSE PK |
5 |
Specialty Tier |
33% | N/A | P |
COMETRIQ 140 MG DAILY-DOSE PK |
5 |
Specialty Tier |
33% | N/A | P |
COMETRIQ 60 MG DAILY-DOSE PACK |
5 |
Specialty Tier |
33% | N/A | P |
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1 |
5 |
Specialty Tier |
33% | N/A | None |
COMTAN 200MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
COMVAX VACCINE VIAL |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
CONCERTA 54mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:30 /30Days |
CONCERTA ER TABLETS 18MG 100 TABLETS BOT |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:30 /30Days |
CONCERTA ER TABLETS 27MG 100 TABLETS BOT |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:30 /30Days |
CONCERTA ER TABLETS 36MG 100 TABLETS BOT |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:60 /30Days |
CONSTULOSE 10 GM/15 ML SOLN |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN |
5 |
Specialty Tier |
33% | N/A | None |
CORTISONE ACETATE 25MG TABLET (100 CT) |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
COUMADIN 10MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
COUMADIN 1MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
COUMADIN 2.5MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
COUMADIN 2MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
COUMADIN 3mg/1 1 BOTTLE in 1 CARTON / 100 TABLET BOTTLE |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
COUMADIN 4mg/1 100 TABLET in 1 BLISTER PACK |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
COUMADIN 5MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
COUMADIN 6MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
COUMADIN 7.5MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Creon 256.11mg/1 1 BOTTLE in 1 CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
CREON DR 36,000 UNITS CAPSULE |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
CRESTOR 10MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | S |
CRESTOR 20MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | S |
CRESTOR 40mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Preferred Brand |
$40.00 | $100.00 | S |
CRESTOR 5MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | S |
CRIXIVAN 200MG CAPSULE |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
CRIXIVAN 400mg/1 90 CAPSULE in 1 BOTTLE |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CROMOLYN NEBULIZER SOLUTION |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CROMOLYN SODIUM 100 MG/5 ML |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CROMOLYN SODIUM 4% 40MG 10ML BOT |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CUBICIN 500MG VIAL |
5 |
Specialty Tier |
33% | N/A | None |
Cyclafem 1/35 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Cyclafem 7/7/7 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT) |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Cyclobenzaprine Hydrochloride 5mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CYCLOPHOSPHAMIDE 25MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
CYCLOPHOSPHAMIDE 50MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
CYCLOSPORINE 100MG CAPSULE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cyclosporine 100mg/1 30 BLISTER PACK in 1 CARTON / 1 CAPSULE, LIQUID FILLED in 1 BLISTER PACK |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | P |
CYCLOSPORINE 25MG CAPSULE |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | P |
Cyclosporine 25mg/1 30 BLISTER PACK in 1 CARTON / 1 CAPSULE, LIQUID FILLED in 1 BLISTER PACK |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | P |
Cyclosporine 50mg/1 30 BLISTER PACK in 1 CARTON / 1 CAPSULE, LIQUID FILLED in 1 BLISTER PACK |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | P |
Cyclosporine 50mg/mL 10 VIAL in 1 BOX / 5 mL in 1 VIAL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | P |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | P |
CYMBALTA 20MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | Q:60 /30Days |
Cymbalta 60mg/1 1000 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | Q:60 /30Days |
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT) |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | Q:60 /30Days |
CYPROHEPTADINE HCL 4 MG |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYSTADANE POWDER FOR ORAL SOLUTION 180GM |
5 |
Specialty Tier |
33% | N/A | None |
CYSTAGON 150MG CAPSULE |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
CYSTAGON 50MG CAPSULE |
3 |
Preferred Brand |
$40.00 | $100.00 | None |