2013 Medicare Part D Plan Formulary Information |
MCS Classicare Premium Health (HMO) (H4006-007-0)
Benefit Details
|
The MCS Classicare Premium Health (HMO) (H4006-007-0) Formulary Drugs Starting with the Letter P in MOROVIS County, PR: CMS MA Region 30 which includes: PR
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Drugs Starting with Letter P
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
PACERONE 100MG TABLET |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
PACERONE 200MG TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
PACLITAXEL INJECTION SOLUTION 6MG 50ML VIALMD |
1 |
Generic |
$5.00 | $10.00 | None |
PAMIDRONATE 60MG/10ML VIAL |
1 |
Generic |
$5.00 | $10.00 | P |
PAMIDRONATE DISODIUM INJECTION 3MG 10ML VIALSD |
1 |
Generic |
$5.00 | $10.00 | P |
PAMIDRONATE DISODIUM INJECTION 9MG 10ML VIALSD |
1 |
Generic |
$5.00 | $10.00 | P |
PANCREAZE 10,500 UNIT CAP DR |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
PANCREAZE 16,800 UNIT CAP DR |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
PANCREAZE 21,000 UNIT CAP DR |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
PANCREAZE 4,200 UNIT CAP DR |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PANRETIN 0.1% GEL 60GM TUBE |
4 |
Specialty Tier |
33% | N/A | P |
Pantoprazole 40mg/1 90 TABLET, DELAYED RELEASE in 1 BOTTLE |
1 |
Generic |
$5.00 | $10.00 | Q:30 /30Days |
PANTOPRAZOLE SODIUM 20MG TABLET DELAYED RELEASE |
1 |
Generic |
$5.00 | $10.00 | Q:30 /30Days |
pantoprazole sodium 40 mg vial |
1 |
Generic |
$5.00 | $10.00 | None |
PAROMOMYCIN 250MG CAPSULE |
1 |
Generic |
$5.00 | $10.00 | None |
Paroxetine 40mg/1 500 FILM COATED TABLETS in BOTTLE |
1 |
Generic |
$5.00 | $10.00 | None |
PAROXETINE FILM COATED 20MG TABLET (100 CT) |
1 |
Generic |
$5.00 | $10.00 | Q:30 /30Days |
PAROXETINE HCL TABLET 24 12.5MG |
1 |
Generic |
$5.00 | $10.00 | Q:30 /30Days |
PAROXETINE HCL TABLET 24 25MG |
1 |
Generic |
$5.00 | $10.00 | Q:60 /30Days |
Paroxetine Hydrochloride 37.5mg/1 30 BOTTLE in 1 BOTTLE / 30 TABLET, FILM COATED, EXTENDED RELEASE |
1 |
Generic |
$5.00 | $10.00 | Q:60 /30Days |
PAROXETINE HYDROCHLORIDE TABLETS 10 MG |
1 |
Generic |
$5.00 | $10.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAROXETINE TABLETS 30MG 90 BOT |
1 |
Generic |
$5.00 | $10.00 | Q:60 /30Days |
PASER GRANULES 4GM PACKET |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
PATADAY 0.2% DROPS |
2 |
Preferred Brand |
$25.00 | $50.00 | Q:10 /25Days |
PATANOL 0.1% EYE DROPS |
2 |
Preferred Brand |
$25.00 | $50.00 | Q:10 /25Days |
PAXIL ORAL SUSPENSION 10 MG/5ML |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | S |
PEDI-DRI TOPICAL POWDER |
1 |
Generic |
$5.00 | $10.00 | None |
PEDVAXHIB VACCINE VIAL |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
PEGANONE 250MG TABLET |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
PEGASYS 180MCG/0.5ML CONV.PK |
4 |
Specialty Tier |
33% | N/A | P |
PEGASYS INJECTION |
4 |
Specialty Tier |
33% | N/A | P |
PEGINTRON 1 KIT in 1 CARTON |
4 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PegIntron 120ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE |
4 |
Specialty Tier |
33% | N/A | P |
PegIntron 150ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE |
4 |
Specialty Tier |
33% | N/A | P |
PegIntron 50ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE |
4 |
Specialty Tier |
33% | N/A | P |
PegIntron 80ug/0.5mL 1 CARTRIDGE in 1 CARTON / 0.5 mL in 1 CARTRIDGE |
4 |
Specialty Tier |
33% | N/A | P |
PENICILLIN G POTASSIUM FOR INJECTION 5000000UNIT/VIAL |
1 |
Generic |
$5.00 | $10.00 | None |
PENICILLIN G PROCAINE 1200000UNT 2ML CTG |
1 |
Generic |
$5.00 | $10.00 | None |
Penicillin G Sodium 5000000[iU]/1 10 VIAL in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL |
1 |
Generic |
$5.00 | $10.00 | None |
Penicillin V Potassium 125mg/5mL 200 mL in 1 BOTTLE |
1 |
Generic |
$5.00 | $10.00 | None |
Penicillin V Potassium 250mg/1 1000 TABLET BOTTLE |
1 |
Generic |
$5.00 | $10.00 | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
1 |
Generic |
$5.00 | $10.00 | None |
PENICILLIN V POTASSIUM 500MG TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENTAM 300 INJ 300MG |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | None |
PENTASA 250MG CAPSULE SA |
2 |
Preferred Brand |
$25.00 | $50.00 | Q:240 /30Days |
PENTASA 500MG CAPSULE |
2 |
Preferred Brand |
$25.00 | $50.00 | Q:240 /30Days |
Pentazocine Hydrochloride and Naloxone Hydrochloride 0.5; 50mg/1; mg/1 100 TABLET BOTTLE |
1 |
Generic |
$5.00 | $10.00 | P |
PENTAZOCINE/ACETAMIN TABLET |
1 |
Generic |
$5.00 | $10.00 | P Q:180 /30Days |
PENTOSTATIN FOR INJECTION 10MG/VIAL |
4 |
Specialty Tier |
33% | N/A | None |
PENTOXIFYLLINE 400MG TABLET SA |
1 |
Generic |
$5.00 | $10.00 | None |
Perindopril Erbumine 2mg/1 100 TABLET BOTTLE |
1 |
Generic |
$5.00 | $10.00 | Q:60 /30Days |
Perindopril Erbumine 4mg/1 100 TABLET BOTTLE |
1 |
Generic |
$5.00 | $10.00 | Q:60 /30Days |
Perindopril Erbumine 8mg/1 100 TABLET BOTTLE |
1 |
Generic |
$5.00 | $10.00 | Q:60 /30Days |
PERIOGARD 0.12% ORAL RINSE |
1 |
Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PERJETA 420 MG/14 ML VIAL |
4 |
Specialty Tier |
33% | N/A | P |
Permethrin 50mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
1 |
Generic |
$5.00 | $10.00 | None |
Perphenazine 16mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Generic |
$5.00 | $10.00 | None |
PERPHENAZINE TABLETS 4MG 100 BOXUD |
1 |
Generic |
$5.00 | $10.00 | None |
PERPHENAZINE TABLETS 8MG 100 BOT |
1 |
Generic |
$5.00 | $10.00 | None |
PERPHENAZINE TABLETS USP 2MG 100 BOT |
1 |
Generic |
$5.00 | $10.00 | None |
PERTZYE DR 16,000 UNITS CAPS |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | None |
PERTZYE DR 8,000 UNITS CAPSULE |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | None |
PFIZERPEN 20MMU VIAL |
1 |
Generic |
$5.00 | $10.00 | None |
Phenadoz 12.5 mg Suppository |
1 |
Generic |
$5.00 | $10.00 | P |
PHENADOZ 25MG SUPPOSITORY |
1 |
Generic |
$5.00 | $10.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Phenelzine Sulfate 15mg/1 60 TABLET BOTTLE |
1 |
Generic |
$5.00 | $10.00 | None |
Phenobarbital 100mg/1 |
1 |
Generic |
$5.00 | $10.00 | Q:90 /30Days |
Phenobarbital 15mg/1 |
1 |
Generic |
$5.00 | $10.00 | Q:90 /30Days |
PHENOBARBITAL 16.2 MG TABLET |
1 |
Generic |
$5.00 | $10.00 | Q:90 /30Days |
PHENOBARBITAL 20 MG/5 ML ELIX |
1 |
Generic |
$5.00 | $10.00 | Q:2400 /30Days |
Phenobarbital 30mg/1 |
1 |
Generic |
$5.00 | $10.00 | Q:90 /30Days |
PHENOBARBITAL 32.4 MG TABLET |
1 |
Generic |
$5.00 | $10.00 | Q:30 /30Days |
Phenobarbital 60mg/1 |
1 |
Generic |
$5.00 | $10.00 | Q:90 /30Days |
PHENOBARBITAL 64.8 MG TABLET |
1 |
Generic |
$5.00 | $10.00 | Q:90 /30Days |
PHENOBARBITAL 97.2 MG TABLET |
1 |
Generic |
$5.00 | $10.00 | Q:90 /30Days |
phenytoin 50 mg tablet chew |
1 |
Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT |
1 |
Generic |
$5.00 | $10.00 | None |
PHENYTOIN SOD EXT 200 MG CAP |
1 |
Generic |
$5.00 | $10.00 | None |
PHENYTOIN SODIUM 50mg/mL 25 VIAL, SINGLE-DOSE in 1 CARTON / 2 mL in 1 VIAL, SINGLE-DOSE |
1 |
Generic |
$5.00 | $10.00 | None |
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT) |
1 |
Generic |
$5.00 | $10.00 | None |
PHOSPHOLINE IODIDE 0.125% |
1 |
Generic |
$5.00 | $10.00 | None |
PHYSIOLYTE SOLUTION FOR IRRIGATION |
1 |
Generic |
$5.00 | $10.00 | P |
PILOCARPINE HCL 5MG TABLET (100 CT) |
1 |
Generic |
$5.00 | $10.00 | None |
Pilocarpine Hydrochloride 7.5mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Generic |
$5.00 | $10.00 | None |
PILOPINE HS 4% EYE GEL |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | None |
PINDOLOL 10MG TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
PINDOLOL 5MG TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
pioglitaz-glimepir 30-2 mg tab |
1 |
Generic |
$5.00 | $10.00 | None |
pioglitaz-glimepir 30-4 mg tab |
1 |
Generic |
$5.00 | $10.00 | None |
pioglitazone hcl 15 mg tablet |
1 |
Generic |
$5.00 | $10.00 | Q:30 /30Days |
pioglitazone hcl 30 mg tablet |
1 |
Generic |
$5.00 | $10.00 | Q:30 /30Days |
pioglitazone hcl 45 mg tablet |
1 |
Generic |
$5.00 | $10.00 | Q:30 /30Days |
PIOGLITAZONE-METFORMIN 15-500 |
1 |
Generic |
$5.00 | $10.00 | Q:90 /30Days |
PIOGLITAZONE-METFORMIN 15-850 |
1 |
Generic |
$5.00 | $10.00 | Q:90 /30Days |
PIPERACILLIN 200 MG/ML / TAZOBACTAM 25 MG/ML INJECTABLE SOLUTION |
1 |
Generic |
$5.00 | $10.00 | None |
Piperacillin and Tazobactam 4; 0.5g/1; g/1 10 VIAL, SINGLE-USE in 1 CARTON / 1 INJECTION, POWDER, L |
1 |
Generic |
$5.00 | $10.00 | None |
PIROXICAM 10 MG CAPSULE |
1 |
Generic |
$5.00 | $10.00 | None |
Piroxicam 20mg/1 500 CAPSULE in 1 BOTTLE |
1 |
Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PLASMA-LYTE 148 IV SOLUTION |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
PLASMA-LYTE 56/DEXTROSE 5% |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
PLASMA-LYTE A PH 7.4 SOLUTION 37;368; MG/100ML; |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
PODOFILOX 0.5% TOPICAL TUBEX |
1 |
Generic |
$5.00 | $10.00 | None |
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT) |
1 |
Generic |
$5.00 | $10.00 | None |
POLYETHYLENE GLYCOL 3350 105 MG/ML / POTASSIUM CHLORIDE 0.00497 MEQ/ML / SODIUM BICARBONATE 1.43 MG/ |
1 |
Generic |
$5.00 | $10.00 | None |
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1% |
1 |
Generic |
$5.00 | $10.00 | None |
POLYMYXIN B SULFATE VIAL |
1 |
Generic |
$5.00 | $10.00 | None |
POMALYST 1 MG CAPSULE |
4 |
Specialty Tier |
33% | N/A | P |
POMALYST 2 MG CAPSULE |
4 |
Specialty Tier |
33% | N/A | P |
POMALYST 3 MG CAPSULE |
4 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POMALYST 4 MG CAPSULE |
4 |
Specialty Tier |
33% | N/A | P |
PORTIA 0.15-0.03 TABLET |
1 |
Generic |
$5.00 | $10.00 | Q:28 /28Days |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45% |
1 |
Generic |
$5.00 | $10.00 | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.9% 1000ML |
1 |
Generic |
$5.00 | $10.00 | None |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG |
1 |
Generic |
$5.00 | $10.00 | None |
POTASSIUM CHLORIDE 10MEQ/100ML SOL |
1 |
Generic |
$5.00 | $10.00 | None |
POTASSIUM CHLORIDE 149mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 5 mL in 1 VIAL, SINGLE-DOSE |
1 |
Generic |
$5.00 | $10.00 | None |
Potassium Chloride 20.000000meq/1 |
1 |
Generic |
$5.00 | $10.00 | None |
POTASSIUM CHLORIDE 20MEQ IN D5W/NACL 0.225% |
1 |
Generic |
$5.00 | $10.00 | None |
POTASSIUM CHLORIDE 20MEQ/50ML SOL |
1 |
Generic |
$5.00 | $10.00 | None |
POTASSIUM CHLORIDE 30MEQ/100ML SOL |
1 |
Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE 40MEQ/NS 1000ML IV SOLUTION |
1 |
Generic |
$5.00 | $10.00 | None |
POTASSIUM CHLORIDE ER CAPSULES 10MEQ |
1 |
Generic |
$5.00 | $10.00 | None |
POTASSIUM CHLORIDE ER CPCR 8MEQ |
1 |
Generic |
$5.00 | $10.00 | None |
POTASSIUM CHLORIDE EXTENDED RELEASE TABLETS |
1 |
Generic |
$5.00 | $10.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE |
1 |
Generic |
$5.00 | $10.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA |
1 |
Generic |
$5.00 | $10.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION |
1 |
Generic |
$5.00 | $10.00 | None |
POTASSIUM CHLORIDE IN DEXTROSE 5; 0.3g/100mL; g/100mL 12 CONTAINER in 1 CASE / 1000 mL in 1 CONTAIN |
1 |
Generic |
$5.00 | $10.00 | None |
Potassium Chloride in Dextrose 5; 150g/100mL; mg/100mL 1000 mL in 1 BAG |
1 |
Generic |
$5.00 | $10.00 | None |
Potassium Chloride in Dextrose and Sodium Chloride 5; 0.15; 0.33g/100mL; g/100mL; g/100mL 12 CONTAI |
1 |
Generic |
$5.00 | $10.00 | None |
Potassium Chloride in Dextrose and Sodium Chloride 5; 300; 900g/100mL; mg/100mL; mg/100mL 1000 mL i |
1 |
Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION |
1 |
Generic |
$5.00 | $10.00 | None |
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION 0.15%-0.9% 12 X 1000ML BAG |
1 |
Generic |
$5.00 | $10.00 | None |
POTASSIUM CITRATE ER 10 MEQ TB |
1 |
Generic |
$5.00 | $10.00 | None |
POTASSIUM CITRATE ER 5 MEQ TAB |
1 |
Generic |
$5.00 | $10.00 | None |
POTIGA 200 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
POTIGA 300 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
POTIGA 400 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
POTIGA 50 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
PRADAXA 150mg/1 1 BOTTLE in 1 CARTON / 60 CAPSULE in 1 BOTTLE |
2 |
Preferred Brand |
$25.00 | $50.00 | P Q:60 /30Days |
PRADAXA 75mg/1 1 BOTTLE in 1 CARTON / 60 CAPSULE in 1 BOTTLE |
2 |
Preferred Brand |
$25.00 | $50.00 | P Q:60 /30Days |
Pramipexole Dihydrochloride 0.125mg/1 500 TABLET BOTTLE, PLASTIC |
1 |
Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Pramipexole Dihydrochloride 0.25mg/1 500 TABLET BOTTLE, PLASTIC |
1 |
Generic |
$5.00 | $10.00 | None |
Pramipexole Dihydrochloride 0.5mg/1 500 TABLET BOTTLE, PLASTIC |
1 |
Generic |
$5.00 | $10.00 | None |
Pramipexole Dihydrochloride 1.5mg/1 500 TABLET BOTTLE, PLASTIC |
1 |
Generic |
$5.00 | $10.00 | None |
Pramipexole Dihydrochloride 1mg/1 500 TABLET BOTTLE, PLASTIC |
1 |
Generic |
$5.00 | $10.00 | None |
PRAMIPEXOLE DIHYDROCHLORIDE TABLETS |
1 |
Generic |
$5.00 | $10.00 | None |
Prandin 0.5mg/1 100 TABLET BOTTLE, PLASTIC |
2 |
Preferred Brand |
$25.00 | $50.00 | S Q:30 /30Days |
Prandin 1mg/1 100 TABLET BOTTLE, PLASTIC |
2 |
Preferred Brand |
$25.00 | $50.00 | S Q:120 /30Days |
Prandin 2mg/1 100 TABLET BOTTLE, PLASTIC |
2 |
Preferred Brand |
$25.00 | $50.00 | S Q:240 /30Days |
PRAVASTATIN SODIUM 20MG TABLET 500 BOT |
1 |
Generic |
$5.00 | $10.00 | Q:30 /30Days |
PRAVASTATIN SODIUM 40MG TABLET (500 CT) |
1 |
Generic |
$5.00 | $10.00 | Q:30 /30Days |
Pravastatin Sodium 80 mg tab |
1 |
Generic |
$5.00 | $10.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT |
1 |
Generic |
$5.00 | $10.00 | Q:30 /30Days |
PRAZOSIN 5MG CAPSULE |
1 |
Generic |
$5.00 | $10.00 | Q:120 /30Days |
PRAZOSIN HCL 1MG CAPSULE |
1 |
Generic |
$5.00 | $10.00 | Q:120 /30Days |
PRAZOSIN HCL 2MG CAPSULE |
1 |
Generic |
$5.00 | $10.00 | Q:240 /30Days |
PRED MILD 0.12% EYE DROPS |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | None |
PREDNICARBATE 0.1% OINTMENT |
1 |
Generic |
$5.00 | $10.00 | None |
PREDNICARBATE 1 MG/ML TOPICAL CREAM |
1 |
Generic |
$5.00 | $10.00 | None |
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR |
1 |
Generic |
$5.00 | $10.00 | None |
PREDNISOLONE SOD 1% EYE DROP |
1 |
Generic |
$5.00 | $10.00 | None |
PREDNISOLONE SOD PH 25 MG/5 ML |
1 |
Generic |
$5.00 | $10.00 | None |
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL |
1 |
Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION |
1 |
Generic |
$5.00 | $10.00 | None |
PREDNISONE 10MG TABLET (100 CT) |
1 |
Generic |
$5.00 | $10.00 | None |
PREDNISONE 1MG TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
PREDNISONE 2.5MG TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
PREDNISONE 20MG TABLET (1000 CT) |
1 |
Generic |
$5.00 | $10.00 | None |
PREDNISONE 5 MG TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
PREDNISONE 50MG TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
PREDNISONE 5MG/5ML SOLUTION |
1 |
Generic |
$5.00 | $10.00 | None |
PREDNISONE 5MG/ML SOLUTION |
1 |
Generic |
$5.00 | $10.00 | None |
Prefest 6 POUCH in 1 CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER PACK |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | None |
PREGNYL INJ 10000UNT |
1 |
Generic |
$5.00 | $10.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREMARIN 0.3MG (100 CT) |
2 |
Preferred Brand |
$25.00 | $50.00 | P |
PREMARIN 0.45MG TABLET |
2 |
Preferred Brand |
$25.00 | $50.00 | P |
PREMARIN 0.625MG (100 CT) |
2 |
Preferred Brand |
$25.00 | $50.00 | P |
Premarin 0.625mg/g |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
PREMARIN 0.9MG TABLET |
2 |
Preferred Brand |
$25.00 | $50.00 | P |
PREMARIN 1.25MG (100 CT) |
2 |
Preferred Brand |
$25.00 | $50.00 | P |
PREMARIN 25MG VIAL |
2 |
Preferred Brand |
$25.00 | $50.00 | P |
PREMASOL 6% IV SOLUTION |
1 |
Generic |
$5.00 | $10.00 | P |
PREMPHASE 0.625-5 MG TABLET |
2 |
Preferred Brand |
$25.00 | $50.00 | P Q:28 /28Days |
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA |
2 |
Preferred Brand |
$25.00 | $50.00 | P Q:28 /28Days |
PREMPRO 0.45-1.5 MG TABLET 28 EA |
2 |
Preferred Brand |
$25.00 | $50.00 | P Q:28 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREMPRO 0.625-5 MG TABLET |
2 |
Preferred Brand |
$25.00 | $50.00 | P Q:28 /28Days |
Prempro 0.625; 2.5mg/1; mg/1 1 BLISTER PACK in 1 CARTON / 28 TABLET, SUGAR COATED in 1 BLISTER PACK |
2 |
Preferred Brand |
$25.00 | $50.00 | P Q:28 /28Days |
PREVALITE POW 4GM |
1 |
Generic |
$5.00 | $10.00 | None |
Previfem 6 BLISTER PACK in 1 BLISTER PACK / 1 KIT in 1 BLISTER PACK |
1 |
Generic |
$5.00 | $10.00 | Q:28 /28Days |
PREVPAC (TRIPLE THERAPY) KIT 30;500;500MG;MG;MG; 14 PKGCOM |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
PREZISTA 100 MG/ML SUSPENSION |
4 |
Specialty Tier |
33% | N/A | None |
PREZISTA 800 MG TABLET |
4 |
Specialty Tier |
33% | N/A | None |
PREZISTA TABLET 600MG |
4 |
Specialty Tier |
33% | N/A | None |
PREZISTA TABLET 75MG |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | None |
PREZISTA TABLETS |
4 |
Specialty Tier |
33% | N/A | None |
PREZISTA TABLETS 400MG 60 TABLETS BOT |
4 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRIFTIN 150MG TABLET |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
Primidone 250mg/1 100 TABLET BOTTLE |
1 |
Generic |
$5.00 | $10.00 | None |
Primidone 50mg/1 500 TABLET BOTTLE |
1 |
Generic |
$5.00 | $10.00 | None |
PRISTIQ 100MG TABLET SR 24HR |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | S Q:120 /30Days |
Pristiq Extended-Release 50mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | S Q:30 /30Days |
PROAIR HFA 90 MCG INHALER |
2 |
Preferred Brand |
$25.00 | $50.00 | Q:26 /30Days |
PROBENECID 500MG TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
PROBENECID/COLCHICINE TABLET S |
1 |
Generic |
$5.00 | $10.00 | None |
ProcalAmine 0.21; 0.29; 0.026; 0.014; 3; 0.42; 0.085; 0.21; 0.27; 0.22; 0.054; 0.16; 0.17; 0.041; 0 |
2 |
Preferred Brand |
$25.00 | $50.00 | P |
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN |
1 |
Generic |
$5.00 | $10.00 | None |
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT) |
1 |
Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT) |
1 |
Generic |
$5.00 | $10.00 | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX |
1 |
Generic |
$5.00 | $10.00 | None |
PROCRIT 10000U/ML VIAL |
2 |
Preferred Brand |
$25.00 | $50.00 | P |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL |
2 |
Preferred Brand |
$25.00 | $50.00 | P |
PROCRIT 3000U/ML VIAL |
2 |
Preferred Brand |
$25.00 | $50.00 | P |
PROCRIT 40000U/ML VIAL PR |
4 |
Specialty Tier |
33% | N/A | P |
PROCRIT 4000U/ML VIAL 25 X 1ML VIAL |
2 |
Preferred Brand |
$25.00 | $50.00 | P |
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY |
4 |
Specialty Tier |
33% | N/A | P |
procto-pak 1% cream |
1 |
Generic |
$5.00 | $10.00 | None |
Proctocream HC 25mg/g |
1 |
Generic |
$5.00 | $10.00 | None |
proctozone-hc 2.5% cream |
1 |
Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROGESTERONE 100 MG CAPSULE |
1 |
Generic |
$5.00 | $10.00 | None |
PROGESTERONE 200 MG CAPSULE |
1 |
Generic |
$5.00 | $10.00 | None |
Proglycem 50mg/mL 1 BOTTLE, DROPPER in 1 BOX / 30 mL in 1 BOTTLE, DROPPER |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
PROLASTIN-C 1 KIT in 1 CARTON |
4 |
Specialty Tier |
33% | N/A | P |
PROLEUKIN 22 MILLION UNIT VIAL |
4 |
Specialty Tier |
33% | N/A | P |
PROLIA INJECTION |
2 |
Preferred Brand |
$25.00 | $50.00 | P |
PROMACTA 12.5 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
PROMACTA 25 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
PROMACTA 50 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
PROMACTA 75 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
PROMETHAZINE 50MG/ML VIAL |
1 |
Generic |
$5.00 | $10.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMETHAZINE HCL 25MG TABLET (1000 CT) |
1 |
Generic |
$5.00 | $10.00 | P |
PROMETHAZINE HCL 50MG TABLET (100 CT) |
1 |
Generic |
$5.00 | $10.00 | P |
PROMETHAZINE HCL 6.25MG/5ML SYRUP |
1 |
Generic |
$5.00 | $10.00 | P |
PROMETHAZINE HCL INJECTION 25MG 10 X 1ML VIAL |
1 |
Generic |
$5.00 | $10.00 | P |
Promethazine Hydrochloride 12.5mg/1 100 TABLET BOTTLE |
1 |
Generic |
$5.00 | $10.00 | P |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX |
1 |
Generic |
$5.00 | $10.00 | P |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX |
1 |
Generic |
$5.00 | $10.00 | P |
PROMETHEGAN 25MG SUPP |
1 |
Generic |
$5.00 | $10.00 | P |
PROMETHEGAN 50MG SUPPOS |
1 |
Generic |
$5.00 | $10.00 | P |
Propafenone HCl 150mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Generic |
$5.00 | $10.00 | None |
PROPAFENONE HCL 225MG TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPAFENONE HCL 300MG TABLET (100 CT) |
1 |
Generic |
$5.00 | $10.00 | None |
Propafenone Hydrochloride 225mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Generic |
$5.00 | $10.00 | None |
PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE |
1 |
Generic |
$5.00 | $10.00 | None |
PROPAFENONE HYDROCHLORIDE CAPSULES EXTENDED RELEASE |
1 |
Generic |
$5.00 | $10.00 | None |
PROPARACAINE 0.5% EYE DROPS |
1 |
Generic |
$5.00 | $10.00 | None |
Propranolol 1mg/mL 1 mL in 1 VIAL |
1 |
Generic |
$5.00 | $10.00 | None |
PROPRANOLOL 20MG/5ML TUBEX |
1 |
Generic |
$5.00 | $10.00 | None |
PROPRANOLOL 40MG/5ML TUBEX |
1 |
Generic |
$5.00 | $10.00 | None |
PROPRANOLOL 60MG TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
PROPRANOLOL 80 MG TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
PROPRANOLOL HCL 20MG TABLET (1000 CT) |
1 |
Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPRANOLOL HCL TABLET USP 10MG (1000 CT) |
1 |
Generic |
$5.00 | $10.00 | None |
PROPRANOLOL HCL TABLET USP 40MG (1000 CT) |
1 |
Generic |
$5.00 | $10.00 | None |
Propranolol Hydrochloride 120mg EXTENDED RELEASE 100 CAPSULE BOTTLE |
1 |
Generic |
$5.00 | $10.00 | None |
Propranolol Hydrochloride 160mg EXTENDED RELEASE 100 CAPSULE BOTTLE |
1 |
Generic |
$5.00 | $10.00 | None |
Propranolol Hydrochloride 60mg/1 1000 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
1 |
Generic |
$5.00 | $10.00 | None |
Propranolol Hydrochloride 80mg EXTENDED RELEASE 100 CAPSULE BOTTLE |
1 |
Generic |
$5.00 | $10.00 | None |
PROPRANOLOL/HCTZ 40/25 TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
PROPRANOLOL/HCTZ 80/25 TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
PROPYLTHIOURACIL 50MG TABLET |
1 |
Generic |
$5.00 | $10.00 | None |
PROQUAD VIAL |
2 |
Preferred Brand |
$25.00 | $50.00 | None |
Protonix I.V. 40mg/10mL 10 CARTON in 1 PACKAGE / 1 VIAL in 1 CARTON / 40 mL in 1 VIAL |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROTOPIC 0.03% OINTMENT 100GM TUBE |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | S |
PROTOPIC 0.1% OINTMENT 60GM TUBE |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | S |
PROTRIPTYLINE HYDROCHLORIDE TABLETS |
1 |
Generic |
$5.00 | $10.00 | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG |
1 |
Generic |
$5.00 | $10.00 | None |
PROVENTIL HFA INHALER 90MCG AE |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | Q:14 /25Days |
PULMICORT 1MG/2ML AMPUL FOR NEBULIZATION |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | P Q:120 /30Days |
PULMICORT FLEXHALER 180MCG AEROSOL POWDER BREATH ACTIVATED |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | Q:2 /25Days |
PULMICORT FLEXHALER 90MCG AEROSOL POWDER BREATH ACTIVATED |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | Q:4 /25Days |
PULMOZYME 1MG/ML AMPUL |
4 |
Specialty Tier |
33% | N/A | P |
pyridostigmine br 60 mg tablet |
1 |
Generic |
$5.00 | $10.00 | None |