2013 Medicare Part D Plan Formulary Information |
SCAN Classic (HMO) (H5811-001-0)
Benefit Details
|
The SCAN Classic (HMO) (H5811-001-0) Formulary Drugs Starting with the Letter A in SAN JOAQUIN County, CA: CMS MA Region 24 which includes: CA
|
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 |
ABACAVIR 300 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ABILIFY 10MG TABLET |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | S |
ABILIFY 15MG TABLET |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | S |
ABILIFY 1MG/ML SOLUTION |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | S |
ABILIFY 20MG TABLET |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | S |
ABILIFY 2MG TABLET |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | S |
ABILIFY 30MG TABLET |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | S |
ABILIFY 5MG TABLET (OTSUKA) |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | S |
ABILIFY DISCMELT 10MG TABLET |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | S |
ABILIFY DISCMELT 15MG TABLET |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABILIFY INJ 9.75MG |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | None |
ABILIFY MAINTENA ER 300 MG VL |
5 |
Specialty Tier |
33% | N/A | None |
Acarbose 100mg/1 1000 TABLET BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Acarbose 50mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ACARBOSE TABLETS |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ACEBUTOLOL 200MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ACEBUTOLOL 400MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
Acetaminophen and Codeine Phosphate 300; 60mg/1; mg/1 500 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:186 /31Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:4650 /31Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:372 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:372 /31Days |
ACETASOL HC SOLUTION 10ML 10 ML BOT |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ACETAZOLAMIDE 125MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ACTHIB VACCINE VIAL 10-24UNT/5ML |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ACTIMMUNE SOLUTION FOR INJECTION 100MCG |
5 |
Specialty Tier |
33% | N/A | None |
Actonel 150mg/1 36 DOSE PACK CASE / 1 TRAY DOSE PACK / 1 FILM COATED TABLETS in TRAY |
3 |
Preferred Brand |
$35.00 | $70.00 | S |
Actonel 30mg/1 12 BOTTLE CASE / 30 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$35.00 | $70.00 | S |
Actonel 35mg/1 36 DOSE PACK CASE / 1 TRAY DOSE PACK / 4 FILM COATED TABLETS in TRAY |
3 |
Preferred Brand |
$35.00 | $70.00 | S |
Actonel 5mg/1 12 BOTTLE CASE / 30 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$35.00 | $70.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACYCLOVIR 200 MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Acyclovir 200mg/5mL 473 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
acyclovir 400mg/1 |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ACYCLOVIR 800 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ACYCLOVIR SODIUM 500MG VIAL |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ADACEL VIAL 2UNT/5UNT |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ADAGEN 250U/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA] |
5 |
Specialty Tier |
33% | N/A | P |
ADCIRCA TABLETS 20MG 60 BOT |
5 |
Specialty Tier |
33% | N/A | P |
ADVAIR DISKUS MIS 100/50 |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ADVAIR DISKUS MIS 250/50 |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADVAIR DISKUS MIS 500/50 |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ADVICOR ER 20-750MG TABLET (90 CT) |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:31 /31Days |
ADVICOR EXTENDED RELEASE TABLETS 20;1000MG;MG 90 BOTPL |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:31 /31Days |
ADVICOR EXTENDED RELEASE TABLETS 20;500MG;MG 90 BOTPL |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:31 /31Days |
ADVICOR EXTENDED RELEASE TABLETS 40;1000MG;MG 90 BOTPL |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:31 /31Days |
AFEDITAB CR 30MG TABLET SA |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AFEDITAB CR 60MG TABLET SA |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Afinitor 7.5mg/1 28 BLISTER PACK in 1 CARTON / 1 TABLET in 1 BLISTER PACK |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AFINITOR TABLETS 10 MG |
5 |
Specialty Tier |
33% | N/A | P |
AFINITOR TABLETS 2.5 MG |
5 |
Specialty Tier |
33% | N/A | P |
AFINITOR TABLETS 5 MG |
5 |
Specialty Tier |
33% | N/A | P |
AGGRENOX 25-200MG CAPSULE |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | Q:62 /31Days |
ALBENZA 200 MG TABLET |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | 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 | $20.00 | P |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | P |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | P |
ALBUTEROL SULFATE SOLUTION FOR INHALATION |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ALBUTEROL TABLET 4MG (500 CT) |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ALCLOMETASONE DIPROPIONATE 0.05% CREAM |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Alclometasone Dipropionate 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ALDURAZYME 2.9MG/5ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
ALENDRONATE SODIUM 10MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
ALENDRONATE SODIUM 40MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
ALENDRONATE SODIUM 5MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
ALENDRONATE SODIUM 70mg/1 |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
ALENDRONATE SODIUM TABLET 35MG 20 CRTN |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALFUZOSIN HYDROCHLORIDE 10mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ALIMTA 500MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
ALINIA 100MG/5ML SUSPENSION |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | None |
ALINIA 500 MG TABLET |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | None |
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET in 1 BLISTER PACK |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
ALLOPURINOL TABLETS |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
ALORA 0.025MG PATCH |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ALORA 0.05MG PATCH |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ALORA 0.075MG PATCH |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ALORA 0.1MG PATCH |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ALPHAGAN P 0.1% DROPS |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:15 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALPRAZOLAM 0.25 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | P |
ALPRAZOLAM 0.5 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | P |
Alprazolam 0.5mg/1 60 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | P |
ALPRAZOLAM 1 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | P |
Alprazolam 1mg/mL 1 BOTTLE in 1 CONTAINER / 30 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | P |
ALPRAZOLAM 2 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | P |
ALPRAZOLAM ER 1 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | P |
ALPRAZOLAM ER 2 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | P |
ALPRAZOLAM ER 3 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | P |
AMANTADINE 100MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMANTADINE 100MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Amantadine Hydrochloride 50mg/5mL 473 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMIFOSTINE 50mg/mL 3 VIAL, SINGLE-USE in 1 CARTON / 10 mL in 1 VIAL, SINGLE-USE |
5 |
Specialty Tier |
33% | N/A | P |
AMIKACIN 50MG/ML VIAL |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMIKACIN Sulfate 1g/4mL 10 VIAL, SINGLE-DOSE in 1 CARTON / 4 mL in 1 VIAL, SINGLE-DOSE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | 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 | $20.00 | None |
AMINOSYN HBC INJECTION SULFITE FREE 7% |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
AMINOSYN II 10% IV SOLUTION |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
AMINOSYN II 7% IV SOLUTION |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
AMINOSYN II 8.5% ELECTROLYT |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN II 8.5% IV SOLUTION |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
Aminosyn II Sulfite-Free 1490; 1527; 1050; 1107; 750; 450; 990; 1500; 1575; 258; 405; 447; 1083; 79 |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
AMINOSYN M 3.5% IV SOLUTION |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
AMINOSYN PF INJECTION |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
AMINOSYN-PF 7% IV SOLUTION |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
AMIODARONE HCL 200MG 60 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMIODARONE HCL 400MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMITIZA 8MCG CAPSULE |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
AMITIZA CAPSULES 24MCG 60 CAP BOT |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
AMITRIP/PERPHEN 10-2 TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMITRIP/PERPHEN 10-4 TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIP/PERPHEN 25-2 TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMITRIP/PERPHEN 25-4 TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMITRIP/PERPHEN 50-4 TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMITRIPTYLINE HCL 100MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMITRIPTYLINE HCL 10MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMITRIPTYLINE HCL 150 MG TAB |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ammonium lactate 12% cream |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMMONIUM LACTATE 12% LOTION |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
amox tr-k clv 200-28.5/5 susp |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMOX TR-K CLV 500-125 MG TAB |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMOXAPINE 100MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMOXAPINE 150MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMOXAPINE 25MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMOXAPINE 50MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMOXICILLIN 125MG TABLET CHEW |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
AMOXICILLIN 250MG CAPSULE |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
Amoxicillin 250mg/1 500 TABLET, CHEWABLE in 1 BOTTLE |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN 500MG TABLET (100 CT) |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
Amoxicillin 500mg/1 500 CAPSULE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
AMOXICILLIN 875MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:62 /31Days |
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 | $20.00 | Q:62 /31Days |
AMPHETAMINE SALT COMBO 30MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:62 /31Days |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:62 /31Days |
AMPHETAMINE SALTS 20MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:62 /31Days |
AMPHETAMINE SALTS 5 MG TAB |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:62 /31Days |
amphotericin b 50mg/10mL 10 mL in 1 VIAL |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMPICILLIN CAPSULES 250MG 100 BOT |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMPICILLIN FOR INJECTION POWDER |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Anagrelide Hydrochloride 1mg/1 100 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Anastrozole 1mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ANDROGEL 1%(50MG) GEL PACKET |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
Androgel 16.2mg/g 1 BOTTLE, PUMP in 1 CARTON / 88 g in 1 BOTTLE, PUMP |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
APOKYN 30 MG/3 ML CARTRIDGE |
5 |
Specialty Tier |
33% | N/A | None |
APRI 0.15-0.03 TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
APRISO CP24 |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | Q:124 /31Days |
APTIVUS 250MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
5 |
Specialty Tier |
33% | N/A | None |
ARANELLE 7-9-5 TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ARCALYST INJECTION 220MG/VIAL |
5 |
Specialty Tier |
33% | N/A | P |
ASACOL 400mg/1 12 BOTTLE CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | Q:186 /31Days |
ASTEPRO 0.15% NASAL SPRAY 30 ML |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ATENOLOL 100mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
Atenolol 25mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
ATENOLOL TABLET USP 50MG (100 CT) |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT) |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
ATORVASTATIN 10 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATORVASTATIN 20 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ATORVASTATIN 40 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ATORVASTATIN 80 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Atovaquone and Proguanil Hydrochloride 250; 100mg/1; mg/1 |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
5 |
Specialty Tier |
33% | N/A | None |
ATROPINE 0.05MG/ML SYRINGE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ATROPINE 0.1MG/ML SYRINGE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
ATROVENT HFA AER 17MCG |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:26 /31Days |
AUGMENTED BETAMETHASONE DIPROPIONATE OINTMENT |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AUVI-Q 0.15 MG AUTO-INJECTOR |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
AUVI-Q 0.3 MG AUTO-INJECTOR |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVASTIN 100MG/4ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
AVELOX 400MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
AVIANE 0.1-0.02 TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AVODART 0.5MG SOFTGEL |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
AVONEX ADMIN PACK 30MCG SYR |
5 |
Specialty Tier |
33% | N/A | P |
AVONEX ADMIN PACK 30MCG VL |
5 |
Specialty Tier |
33% | N/A | P |
AZATHIOPRINE 50MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | P |
AZATHIOPRINE SOD 100MG VIAL |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AZELASTINE 137 MCG NASAL SPRAY |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AZILECT 0.5MG TABLET |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZILECT 1MG TABLET |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | None |
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AZITHROMYCIN 250 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Azithromycin 600mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
AZOR 10MG-20MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | S |
AZOR 10MG-40MG TABLET (30 CT) |
3 |
Preferred Brand |
$35.00 | $70.00 | S |
AZOR 5MG-20MG TABLET (30 CT) |
3 |
Preferred Brand |
$35.00 | $70.00 | S |
AZOR 5MG-40MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZTREONAM FOR INJECTION |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |