2013 Medicare Part D Plan Formulary Information |
Windsor Medicare Extra Gold Plan (HMO) (H5698-028-0)
Benefit Details
|
The Windsor Medicare Extra Gold Plan (HMO) (H5698-028-0) Formulary Drugs Starting with the Letter A in YALOBUSHA County, MS: CMS MA Region 16 which includes: MS
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Drugs Starting with Letter A
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
A-HYDROCORT 100MG VIAL |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
ABACAVIR 300 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
ABILIFY 10MG TABLET |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | Q:30 /30Days |
ABILIFY 15MG TABLET |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | Q:30 /30Days |
ABILIFY 1MG/ML SOLUTION |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | Q:900 /30Days |
ABILIFY 20MG TABLET |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | Q:30 /30Days |
ABILIFY 2MG TABLET |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | Q:30 /30Days |
ABILIFY 30MG TABLET |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | Q:30 /30Days |
ABILIFY 5MG TABLET (OTSUKA) |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | Q:30 /30Days |
ABILIFY DISCMELT 10MG TABLET |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABILIFY DISCMELT 15MG TABLET |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | Q:60 /30Days |
ABILIFY INJ 9.75MG |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | Q:4 /1Days |
ABILIFY MAINTENA ER 300 MG VL |
5 |
Specialty Tier |
33% | 33% | None |
Acarbose 100mg/1 1000 TABLET BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
Acarbose 50mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
ACARBOSE TABLETS |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
ACEBUTOLOL 200MG CAPSULE |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
ACEBUTOLOL 400MG CAPSULE |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
Acetaminophen and Codeine Phosphate 300; 60mg/1; mg/1 500 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:390 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:5000 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:390 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:390 /30Days |
ACETASOL HC SOLUTION 10ML 10 ML BOT |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
ACETAZOLAMIDE 125MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
ACETIC ACID 2% SOLUTION NON-ORAL |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
ACETYLCYSTEINE 10% VIAL |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
ACTEMRA INJECTION 200MG/10ML |
5 |
Specialty Tier |
33% | 33% | None |
ACTHIB VACCINE VIAL 10-24UNT/5ML |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
ACTIMMUNE SOLUTION FOR INJECTION 100MCG |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTOS 15MG TABLET |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
Actos 30mg/90 Tablet Bottle |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
ACTOS 45MG TABLET |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
ACYCLOVIR 200 MG CAPSULE |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
Acyclovir 200mg/5mL 473 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
acyclovir 400mg/1 |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
acyclovir 5% ointment |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
ACYCLOVIR 800 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
ACYCLOVIR SODIUM 500MG VIAL |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
ADACEL VIAL 2UNT/5UNT |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
ADAGEN 250U/ML VIAL |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Adalat CC 30mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
Adalat CC 60mg/1 1000 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
ADALAT CC 90MG TABLET |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA] |
5 |
Specialty Tier |
33% | 33% | P Q:2 /28Days |
ADCIRCA TABLETS 20MG 60 BOT |
5 |
Specialty Tier |
33% | 33% | P |
ADVAIR DISKUS MIS 100/50 |
3 |
Preferred Brand |
$43.00 | $129.00 | Q:60 /30Days |
ADVAIR DISKUS MIS 250/50 |
3 |
Preferred Brand |
$43.00 | $129.00 | Q:60 /30Days |
ADVAIR DISKUS MIS 500/50 |
3 |
Preferred Brand |
$43.00 | $129.00 | Q:60 /30Days |
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$43.00 | $129.00 | Q:12 /30Days |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL |
3 |
Preferred Brand |
$43.00 | $129.00 | Q:12 /30Days |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
3 |
Preferred Brand |
$43.00 | $129.00 | Q:12 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AFEDITAB CR 30MG TABLET SA |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AFEDITAB CR 60MG TABLET SA |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Afinitor 7.5mg/1 28 BLISTER PACK in 1 CARTON / 1 TABLET in 1 BLISTER PACK |
5 |
Specialty Tier |
33% | 33% | Q:30 /30Days |
AFINITOR TABLETS 10 MG |
5 |
Specialty Tier |
33% | 33% | Q:30 /30Days |
AFINITOR TABLETS 2.5 MG |
5 |
Specialty Tier |
33% | 33% | Q:30 /30Days |
AFINITOR TABLETS 5 MG |
5 |
Specialty Tier |
33% | 33% | Q:30 /30Days |
AGGRENOX 25-200MG CAPSULE |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
AK-CON 0.1% EYE DROPS |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
AKNE-MYCIN 2% OINTMENT |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
ALBENZA 200 MG TABLET |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH in 1 CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P Q:360 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P Q:360 /30Days |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P Q:60 /30Days |
ALBUTEROL SULFATE SOLUTION FOR INHALATION |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P Q:360 /30Days |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
ALBUTEROL TABLET 4MG (500 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
ALDACTAZIDE 50/50 TABLET |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
ALDURAZYME 2.9MG/5ML VIAL |
5 |
Specialty Tier |
33% | 33% | None |
ALENDRONATE SODIUM 10MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALENDRONATE SODIUM 5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:240 /30Days |
ALENDRONATE SODIUM 70mg/1 |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:4 /28Days |
ALENDRONATE SODIUM TABLET 35MG 20 CRTN |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:4 /28Days |
ALFUZOSIN HYDROCHLORIDE 10mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:30 /30Days |
ALIMTA 500MG VIAL |
5 |
Specialty Tier |
33% | 33% | None |
ALINIA 100MG/5ML SUSPENSION |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
ALINIA 500 MG TABLET |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET in 1 BLISTER PACK |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
ALLOPURINOL TABLETS |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
ALPRAZOLAM 0.25 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:90 /30Days |
ALPRAZOLAM 0.5 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALPRAZOLAM 1 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:90 /30Days |
ALPRAZOLAM 2 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:150 /30Days |
ALREX 0.2% EYE DROPS |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
AMANTADINE 100MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Amantadine Hydrochloride 50mg/5mL 473 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
AMIFOSTINE 50mg/mL 3 VIAL, SINGLE-USE in 1 CARTON / 10 mL in 1 VIAL, SINGLE-USE |
5 |
Specialty Tier |
33% | 33% | None |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
Aminophylline 25mg/mL 5 TRAY in 1 CARTON / 5 AMPULE in 1 TRAY / 10 mL in 1 AMPULE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMINOSYN HBC INJECTION SULFITE FREE 7% |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | P |
AMINOSYN II 10% IV SOLUTION |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN II 7% IV SOLUTION |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | P |
AMINOSYN II 8.5% ELECTROLYT |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | P |
AMINOSYN II 8.5% IV SOLUTION |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | P |
Aminosyn II Sulfite-Free 1490; 1527; 1050; 1107; 750; 450; 990; 1500; 1575; 258; 405; 447; 1083; 79 |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | P |
AMINOSYN PF INJECTION |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | P |
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5% |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | P |
AMINOSYN-PF 7% IV SOLUTION |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | P |
AMIODARONE HCL 200MG 60 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMIODARONE HCL INJECTION |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMITIZA 8MCG CAPSULE |
3 |
Preferred Brand |
$43.00 | $129.00 | Q:60 /30Days |
AMITIZA CAPSULES 24MCG 60 CAP BOT |
3 |
Preferred Brand |
$43.00 | $129.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIP/CDP 25-10 TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMITRIP/PERPHEN 10-2 TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMITRIP/PERPHEN 10-4 TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMITRIP/PERPHEN 25-2 TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMITRIP/PERPHEN 25-4 TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMITRIP/PERPHEN 50-4 TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMITRIPTYLINE HCL 100MG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
AMITRIPTYLINE HCL 10MG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
AMITRIPTYLINE HCL 150 MG TAB |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
ammonium lactate 12% cream |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMMONIUM LACTATE 12% LOTION |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
amox tr-k clv 200-28.5/5 susp |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMOX TR-K CLV 500-125 MG TAB |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMOXAPINE 100MG TABLET |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
AMOXAPINE 150MG TABLET |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
AMOXAPINE 25MG TABLET |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
AMOXAPINE 50MG TABLET |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
AMOXICILLIN 125MG TABLET CHEW |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMOXICILLIN 250MG CAPSULE |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Amoxicillin 250mg/1 500 TABLET, CHEWABLE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
Amoxicillin 500mg/1 500 CAPSULE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
AMOXICILLIN 875MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPHETAMINE SALT COMBO 15MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
AMPHETAMINE SALT COMBO 30MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
AMPHETAMINE SALTS 20MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
AMPHETAMINE SALTS 5 MG TAB |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
amphotericin b 50mg/10mL 10 mL in 1 VIAL |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMPICILLIN CAPSULES 250MG 100 BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPYRA ER 10 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:60 /30Days |
Amturnide 150; 5; 12.5mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
Amturnide 300; 10; 12.5mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
Amturnide 300; 10; 25mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
Amturnide 300; 5; 12.5mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
Amturnide 300; 5; 25mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Anagrelide Hydrochloride 1mg/1 100 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Anastrozole 1mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
ANDROGEL 1%(50MG) GEL PACKET |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | P |
ANTARA CAPSULES |
3 |
Preferred Brand |
$43.00 | $129.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANTARA CAPSULES |
3 |
Preferred Brand |
$43.00 | $129.00 | Q:60 /30Days |
APOKYN 30 MG/3 ML CARTRIDGE |
5 |
Specialty Tier |
33% | 33% | None |
Apraclonidine Ophthalmic 5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 10 mL in 1 BOTTLE, DROPPER |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
APRI 0.15-0.03 TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:28 /28Days |
APRISO CP24 |
3 |
Preferred Brand |
$43.00 | $129.00 | Q:120 /30Days |
APTIVUS 250MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
5 |
Specialty Tier |
33% | 33% | None |
Aralast NP 1 KIT in 1 CARTON |
5 |
Specialty Tier |
33% | 33% | None |
ARANELLE 7-9-5 TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
ARCALYST INJECTION 220MG/VIAL |
5 |
Specialty Tier |
33% | 33% | P |
ARZERRA 20mg/mL 3 VIAL in 1 CARTON / 5 mL in 1 VIAL |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ASACOL 400mg/1 12 BOTTLE CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | Q:180 /30Days |
Ascomp with Codeine 325; 50; 40; 30mg/1; mg/1; mg/1; mg/1 500 CAPSULE in 1 BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | Q:360 /30Days |
ASTRAMORPH PF INJECTION 0.5MG/ML |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
ATENOLOL 100mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
Atenolol 25mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
ATENOLOL TABLET USP 50MG (100 CT) |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
ATGAM 50MG/ML AMPUL |
5 |
Specialty Tier |
33% | 33% | P |
ATORVASTATIN 10 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:30 /30Days |
ATORVASTATIN 20 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATORVASTATIN 40 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:30 /30Days |
ATORVASTATIN 80 MG TABLET |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | Q:30 /30Days |
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
5 |
Specialty Tier |
33% | 33% | None |
ATROVENT HFA AER 17MCG |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | Q:26 /30Days |
AVANDIA 2mg/1 60 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | S |
AVANDIA 4mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | S |
AVANDIA 8mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | S |
AVASTIN 100MG/4ML VIAL |
5 |
Specialty Tier |
33% | 33% | None |
AVELOX 400MG TABLET |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
AVODART 0.5MG SOFTGEL |
3 |
Preferred Brand |
$43.00 | $129.00 | Q:30 /30Days |
AVONEX ADMIN PACK 30MCG VL |
5 |
Specialty Tier |
33% | 33% | P Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZACTAM INJECTION 1GM/50ML |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
AZACTAM INJECTION 2GM/50ML |
5 |
Specialty Tier |
33% | 33% | None |
AZATHIOPRINE 50MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
AZATHIOPRINE SOD 100MG VIAL |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
AZELASTINE 137 MCG NASAL SPRAY |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | Q:30 /30Days |
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:120 /30Days |
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:120 /30Days |
AZITHROMYCIN 250 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:30 /30Days |
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION |
4 |
Non-Preferred Brand |
$67.00 | $201.00 | None |
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Azithromycin 600mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:30 /30Days |
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
AZOR 10MG-20MG TABLET |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
AZOR 10MG-40MG TABLET (30 CT) |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
AZOR 5MG-20MG TABLET (30 CT) |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
AZOR 5MG-40MG TABLET |
3 |
Preferred Brand |
$43.00 | $129.00 | None |
AZTREONAM FOR INJECTION |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |