| 2013 Medicare Part D Plan Formulary Information |
|---|
Coventry Summit Ideal (HMO-POS) (H5850-012-0)
Benefit Details
 |
The Coventry Summit Ideal (HMO-POS) (H5850-012-0)
Formulary Drugs Starting with the Letter C
in MIAMI-DADE County, FL: CMS MA Region 9 which includes: FL
|
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  |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CALCIPOTRIENE 0.005% CREAM |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CALCIPOTRIENE TOPICAL SOLUTION |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CALCITONIN SALMON NASAL SPRAY 200IU/SPRY |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CALCITRIOL 0.25MCG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
| CALCITRIOL 0.5MCG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
| CALCITRIOL 1MCG/ML SOLUTION ORAL |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
| CALCITRIOL INJ 1MCG/ML |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
| CALCIUM ACETATE CAPSULE 667 MG |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CAMILA 0.35MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| CAMPATH INJECTION 30 MG/ML |
4 |
Specialty Tier |
33% | N/A | P |
| Campral 333mg/1 180 TABLET, DELAYED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | Q:180
/30Days |
| CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| CANCIDAS IV 50MG VIAL |
4 |
Specialty Tier |
33% | N/A | P |
| CANCIDAS IV 70MG VIAL |
4 |
Specialty Tier |
33% | N/A | P |
| candesartan-hctz 16-12.5 mg tablet |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30
/30Days |
| candesartan-hctz 32-12.5 mg tablet |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30
/30Days |
| candesartan-hctz 32-25 mg |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30
/30Days |
| CANTIL 25MG TABLET |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CAPASTAT SULFATE 1g/1 1 INJECTION, POWDER, FOR SOLUTION in 1 CARTON |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CAPEX SHA 0.01% |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| CAPITAL W/CODEINE ORAL SUSP |
2 |
Preferred Brand |
$0.00 | $0.00 | Q:4950
/30Days |
| CAPRELSA 100mg/1 30 TABLET BOTTLE, PLASTIC |
4 |
Specialty Tier |
33% | N/A | P Q:60
/30Days |
| CAPRELSA 300mg/1 30 TABLET BOTTLE, PLASTIC |
4 |
Specialty Tier |
33% | N/A | P Q:30
/30Days |
| CAPTOPRIL 100MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CAPTOPRIL 12.5MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CAPTOPRIL 25MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CAPTOPRIL 50MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Captopril and Hydrochlorothiazide 25; 15mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Captopril and Hydrochlorothiazide 25; 25mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Captopril and Hydrochlorothiazide 50; 15mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Captopril and Hydrochlorothiazide 50; 25mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| CARAC CRE 0.5% |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CARBAMAZEPINE 100 MG/5 ML SUSP |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Carbamazepine 100mg, CHEWABLE 100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Carbamazepine 100mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| Carbamazepine 200mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| Carbamazepine 300mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CARBAMAZEPINE TABLET USP 200MG (1000 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CARBAMAZEPINE XR 200 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CARBAMAZEPINE XR 400 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Carbatrol 100mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CARBATROL 200MG CAPSULE SA |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| CARBATROL 300MG CAPSULE SA |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;100MG;MG 100 BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;250MG;MG 100 BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CARBIDOPA-LEVODOPA ER 25-100 TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CARBIDOPA-LEVODOPA ER 50-200 TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CARBIDOPA/LEVO 10/100 TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CARBIDOPA/LEVO 25/100 TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CARBIDOPA/LEVO 25/250 TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Carbinoxamine Maleate 4mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Carbinoxamine Maleate 4mg/5mL 118 mL in 1 BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| CARIMUNE NF 3GM VIAL |
4 |
Specialty Tier |
33% | N/A | P |
| CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CARTIA XT 120MG CAPSULE SA |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CARTIA XT 180MG CAPSULE SA |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CARTIA XT 240MG CAPSULE SA |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CARTIA XT 300MG CAPSULE SR 24 HR |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Carvedilol 12.5mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Carvedilol 25mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Carvedilol 3.125mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Carvedilol 6.25mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CAYSTON KIT |
4 |
Specialty Tier |
33% | N/A | P |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| CEDAX 400mg/1 |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CEENU 100MG CAPSULE |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| CEENU 10MG CAPSULE |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| CEENU 40MG CAPSULE |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| CEFACLOR CAPSULES |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CEFACLOR CAPSULES |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CEFACLOR ER 500MG TABLET SR 12HR |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CEFADROXIL 1G TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Cefadroxil 500mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Cefadroxil 500mg/5mL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CEFADROXIL FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| CEFAZOLIN 1 GM VIAL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CEFAZOLIN 1GM/D5W BAG |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CEFAZOLIN FOR INJECTION |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CEFDINIR CAPSULES 300MG (60 CT) |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT) |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CEFEPIME HCL 2 GRAM VIAL |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CEFEPIME INJ 1GM 20ML APX 10x1G VIAL |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| Cefotaxime 1g/1 25 INJECTION in 1 PACKAGE |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CEFOTAXIME FOR INJECTION |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| CEFOTAXIME FOR INJECTION 2GM 25 VIAL |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CEFOTETAN 10 GM SOLR |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CEFOTETAN 1GM VIAL 1EA x 10 |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CEFOTETAN 2GM VIAL 1EA x 10 |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| Cefoxitin 1g/1 10 POWDER in 1 CARTON |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| Cefoxitin 2g/1 10 POWDER in 1 CARTON |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CEFOXITIN FOR INJECTION 1 GM/50ML |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CEFOXITIN FOR INJECTION 2MG/50ML 50 ML BOT |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CEFOXITIN FOR INJECTION SOLUTION |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CEFPODOXIME 100 MG/5 ML SUSP |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CEFPODOXIME 200 MG TABLET |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| CEFPODOXIME 50 MG/5 ML SUSP |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT) |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| cefprozil 125 mg/5 ml susp |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| cefprozil 250 mg/5 ml susp |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| Cefprozil 250mg/1 100 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CEFPROZIL TABLETS 500MG 100 BOT |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CEFTAZIDIME 1g/1 25 VIAL in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| Ceftazidime and Dextrose 1g/50mL 24 CONTAINER in 1 CASE / 50 mL in 1 CONTAINER |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| Ceftazidime and Dextrose 2g/50mL 24 CONTAINER in 1 CASE / 50 mL in 1 CONTAINER |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| CEFTRIAXONE 10GM VIAL |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CEFTRIAXONE 250 MG VIAL |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CEFTRIAXONE FOR INJECTION |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CEFTRIAXONE FOR INJECTION |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| Ceftriaxone Sodium 500mg/1 |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| cefuroxime axetil 250mg/1 |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CEFUROXIME AXETIL 500 MG TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CEFUROXIME FOR INJECTION |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CEFUROXIME FOR INJECTION |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CEFUROXIME FOR INJECTION |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CELEBREX 100MG CAPSULE |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | Q:30
/30Days |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| CELEBREX 200MG CAPSULE |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | Q:60
/30Days |
| CELEBREX 400MG CAPSULE |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | Q:60
/30Days |
| CELEBREX 50MG CAPSULE |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | Q:60
/30Days |
| CELESTONE 0.6MG/5ML SYRUP |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| CELLCEPT 200MG/ML ORAL SUSP |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | P |
| CELONTIN 300MG KAPSEAL |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| Cephalexin 125mg/5mL 200 mL in 1 BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CEPHALEXIN 250MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CEPHALEXIN 250MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CEPHALEXIN 250MG/5ML ORAL SUSP |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CEPHALEXIN 500MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| CEPHALEXIN CAPSULES 500MG (500 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CEREZYME INJ 200UNIT |
4 |
Specialty Tier |
33% | N/A | P |
| CEVIMELINE HCL 30 MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CHANTIX 0.5MG TABLET |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | P Q:60
/30Days |
| CHANTIX 1 KIT in 1 CARTON |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | P Q:53
/30Days |
| CHANTIX 1MG TABLET |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | P Q:60
/30Days |
| Chenodal 250mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Specialty Tier |
33% | N/A | P Q:90
/30Days |
| CHLORAMPHEN NA SUCC 1GM VL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CHLORDIAZEPOXIDE AND AMITRIPTYLINE HCL TABLET 12.5-5MG (500 CT) |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CHLOROQUINE PH 500MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| CHLOROQUINE PHOSPHATE 250MG TABLET (50 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CHLOROTHIAZIDE 250MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CHLOROTHIAZIDE 500MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CHLORPROMAZINE 10MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CHLORPROMAZINE 25MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CHLORPROMAZINE 25MG/ML AMP |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CHLORPROMAZINE 50 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CHLORPROMAZINE HCL 200MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Chlorpromazine Hydrochloride 100mg SUGAR COATED 1000 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CHLORTHALIDONE 25MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CHLORTHALIDONE 50MG TABLET (1000 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Ciclopirox 7.7mg/mL 60 mL in 1 BOTTLE |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6ML BOT |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| Ciclopirox Olamine 7.7mg/g 1 TUBE in 1 TUBE / 15 g in 1 TUBE |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| Cilostazol 50mg/1 60 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CILOSTAZOL TABLET 100MG (60 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CILOXAN 0.3% OINTMENT |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| CIMETIDINE 150MG/ML VIAL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Cimetidine 200mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Cimetidine 400mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Cimetidine 800mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| Cimetidine Hydrochloride Oral Solution 300mg/5mL 237 mL in 1 BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CIMETIDINE TABLETS |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Cimzia 2 KIT in 1 CARTON / 1 KIT in 1 KIT |
4 |
Specialty Tier |
33% | N/A | P Q:6
/28Days |
| CIMZIA 200 MG/ML SYRINGE KIT |
4 |
Specialty Tier |
33% | N/A | P Q:6
/28Days |
| Cinryze 500[iU]/5mL 1 VIAL in 1 CARTON / 5 mL in 1 VIAL |
4 |
Specialty Tier |
33% | N/A | P Q:20
/30Days |
| Cipro 1 KIT in 1 KIT |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| Cipro 1 KIT in 1 KIT |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| CIPRO HC OTIC SUSPENSION |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CIPRODEX OTIC SUSPENSION |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| CIPROFLOXACIN 0.3% EYE DROP |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CIPROFLOXACIN 250MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| Ciprofloxacin 400mg/40mL 1 VIAL in 1 CARTON / 40 mL in 1 VIAL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CIPROFLOXACIN 500MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Ciprofloxacin and Dextrose 2mg/mL 24 BAG in 1 CASE / 100 mL in 1 BAG |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Ciprofloxacin ER 212.6; 287.5mg/1; mg/1 50 TABLET, FILM COATED, in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:28
/30Days |
| Ciprofloxacin ER 425.2; 574.9mg/1; mg/1 50 TABLET, FILM COATED, in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:14
/30Days |
| CIPROFLOXACIN HCL 100MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CIPROFLOXACIN TABLETS 750MG 100 BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Cisplatin 100mg/100mL 1 VIAL in 1 CARTON / 100 mL in 1 VIAL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CITALOPRAM HBR 20 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| CITOLOPRAM HBR 10MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CLARAVIS 10MG CAPSULE |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CLARAVIS 20MG CAPSULE |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| Claravis 30mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CLARAVIS 40MG CAPSULE |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CLARITHROMYCIN 250MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CLARITHROMYCIN 500MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CLARITHROMYCIN ER 500MG TABLET (60 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:28
/14Days |
| CLARITHROMYCIN FOR ORAL SUSPENSION |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CLARITHROMYCIN FOR ORAL SUSPENSION |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CLEMASTINE FUM 2.68MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| Clemastine Fumarate 0.5mg/5mL 120 mL in 1 BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CLEOCIN 100MG VAGINAL OVULE |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| CLIMARA PRO DIS WEEKLY 4.40MG/1.39MG |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | Q:4
/28Days |
| CLINDAMYCIN 150MG/ML ADDVAN |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CLINDAMYCIN HCL 150MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Clindamycin Hydrochloride 75mg/1 200 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CLINDAMYCIN HYDROCHLORIDE CAPSULES |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CLINDAMYCIN PHOSP 1% LOTION |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| clindamycin phosphate 10mg/mL 1 BOTTLE in 1 CARTON / 60 mL in 1 BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Clindamycin Phosphate and Benzoyl Peroxide 1 KIT |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CLINDAMYCIN PHOSPHATE VAGINAL CREAM |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CLINIMIX 2.75%/5% INJECTION 1000ML BAG |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | P |
| CLINIMIX 4.25/10 SOLUTION |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | P |
| CLINIMIX 4.25/20 SOLUTION |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | P |
| CLINIMIX 4.25/25 SOLUTION |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | P |
| CLINIMIX 4.25/5 SOLUTION |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | P |
| CLINIMIX 5/15 SOLUTION |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | P |
| CLINIMIX 5/20 SOLUTION |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | P |
| CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | P |
| CLINIMIX E 2.75/10 SOLUTION |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | P |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| CLINIMIX E 2.75/5 SOLUTION |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | P |
| CLINIMIX E 4.25/25 SOLUTION |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | P |
| CLINIMIX E 4.25/5 SOLUTION |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | P |
| CLINIMIX E 5/20 SOLUTION |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | P |
| CLINIMIX E 5/25 SOLUTION |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | P |
| CLINIMIX E 5%/15% INJECTION 2000ML BAG |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | P |
| CLINISOL 15% SOLUTION |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | P |
| CLOBETASOL 0.05% OINTMENT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CLOBETASOL 0.05% SHAMPOO |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CLOBETASOL 0.05% TOPICAL LOTION |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CLOBETASOL E 0.05% CREAM |
1 |
Preferred Generic |
$0.00 | $0.00 | 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 |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CLOBEX 0.05% SPRAY NON-AEROSOL |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CLODERM 0.1% CREAM PUMP |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CLOMIPRAMINE HCL 25MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CLOMIPRAMINE HCL 50MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CLOMIPRAMINE HCL 75MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Clonazepam 0.125mg/1 10 BLISTER PACK in 1 CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PAC |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | Q:150
/30Days |
| Clonazepam 0.25mg/1 10 BLISTER PACK in 1 CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | Q:150
/30Days |
| Clonazepam 0.5mg/1 10 BLISTER PACK in 1 CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | Q:150
/30Days |
| Clonazepam 0.5mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:150
/30Days |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| Clonazepam 1mg/1 10 BLISTER PACK in 1 CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | Q:150
/30Days |
| Clonazepam 1mg/1 90 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:150
/30Days |
| Clonazepam 2mg/1 10 BLISTER PACK in 1 CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PACK |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | Q:300
/30Days |
| Clonazepam 2mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:300
/30Days |
| Clonidine 0.1mg/d 4 POUCH in 1 CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | S Q:5
/30Days |
| Clonidine 0.2mg/d 4 POUCH in 1 CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | S Q:5
/30Days |
| Clonidine 0.3mg/d 4 POUCH in 1 CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | S Q:5
/30Days |
| CLONIDINE HCL 0.2MG TABLET (500 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CLONIDINE HCL TABLET 0.1MG (500 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CLONIDINE HCL TABLET 0.3MG (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CLOPIDOGREL 300 MG tablet |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:1
/365Days |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| CLOPIDOGREL TAB 75MG |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30
/30Days |
| CLORAZEPATE 15 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:180
/30Days |
| Clorazepate Dipotassium 3.75mg/1 500 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:180
/30Days |
| Clorazepate Dipotassium 7.5mg/1 500 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:180
/30Days |
| CLORPRES 0.1-15 TABLET |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| CLORPRES 0.2-15 TABLET |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| CLORPRES 0.3-15 TABLET |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| CLOTRIMAZOLE 10MG TROCHE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CLOTRIMAZOLE SOLUTION TOPICAL 1% 30ML BOTPL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| Clozapine 100mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CLOZAPINE 200MG TABLET (500 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CLOZAPINE 25MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CLOZAPINE 50MG TABLET (500 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CODEINE SULFATE 30 MG TABLET 3100 |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| Codeine sulfate 60mg/1 100 TABLET BOTTLE |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CODEINE SULFATE TABLETS |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| COLCRYS 0.6 MG TABLET |
2 |
Preferred Brand |
$0.00 | $0.00 | Q:120
/30Days |
| COLESTIPOL HCL 1G TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| COLESTIPOL HYDROCHLORIDE 5g/1 100 SUSPENSION in 1 BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| colistimethate 150mg/2mL 1 VIAL in 1 CARTON / 2 mL in 1 VIAL |
4 |
Specialty Tier |
33% | N/A | P |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| COLY MYCIN S OTIC SUSPENSION 3;3.3;10MG/ML;MG/ 5 ML BOTDR |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| COMBIGAN 0.2%-0.5% DROPS |
2 |
Preferred Brand |
$0.00 | $0.00 | Q:10
/30Days |
| COMBIPATCH 0.05/0.14MG PTCH |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | Q:8
/28Days |
| COMBIPATCH 0.05/0.25MG PTCH |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | Q:8
/28Days |
| COMBIVENT INHALER |
2 |
Preferred Brand |
$0.00 | $0.00 | Q:29
/30Days |
| COMBIVENT RESPIMAT INHAL SPRAY |
2 |
Preferred Brand |
$0.00 | $0.00 | Q:8
/30Days |
| COMETRIQ 100 MG DAILY-DOSE PK |
4 |
Specialty Tier |
33% | N/A | P Q:1
/28Days |
| COMETRIQ 140 MG DAILY-DOSE PK |
4 |
Specialty Tier |
33% | N/A | P Q:1
/28Days |
| COMETRIQ 60 MG DAILY-DOSE PACK |
4 |
Specialty Tier |
33% | N/A | P Q:1
/28Days |
| COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1 |
4 |
Specialty Tier |
33% | N/A | Q:30
/30Days |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| COMPRO 25MG SUPPOSITORY |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| COMTAN 200MG TABLET |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| COMVAX VACCINE VIAL |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CONCERTA 54mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | S Q:30
/30Days |
| CONCERTA ER TABLETS 18MG 100 TABLETS BOT |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | S Q:30
/30Days |
| CONCERTA ER TABLETS 27MG 100 TABLETS BOT |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | S Q:30
/30Days |
| CONCERTA ER TABLETS 36MG 100 TABLETS BOT |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | S Q:60
/30Days |
| CONDYLOX GEL 0.5% 3.5 GM CRTN |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CONSTULOSE 10 GM/15 ML SOLN |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN |
4 |
Specialty Tier |
33% | N/A | P Q:30
/30Days |
| Cordran 0.5mg/mL 60 mL in 1 BOTTLE, PLASTIC |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| CORDRAN TAPE 4MCG/SQCM 1 X 80 X 3 CTR |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| COREG CR 10MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Preferred Brand |
$0.00 | $0.00 | Q:30
/30Days |
| COREG CR 20MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Preferred Brand |
$0.00 | $0.00 | Q:30
/30Days |
| COREG CR 40MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Preferred Brand |
$0.00 | $0.00 | Q:30
/30Days |
| COREG CR 80MG CAPSULE MULTIPHASIC RELEASE 24 HR |
2 |
Preferred Brand |
$0.00 | $0.00 | Q:30
/30Days |
| CORTIFOAM RECTAL FOAM |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| CORTISONE ACETATE 25MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CORTISPORIN TC OTIC SUSPENSION 3;3.3;0.5MG/ML; 10 ML BOTDR |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| COUMADIN 10MG TABLET |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| COUMADIN 1MG TABLET |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| COUMADIN 2.5MG TABLET |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| COUMADIN 2MG TABLET |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| COUMADIN 3mg/1 1 BOTTLE in 1 CARTON / 100 TABLET BOTTLE |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| COUMADIN 4mg/1 100 TABLET in 1 BLISTER PACK |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| COUMADIN 5MG TABLET |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| COUMADIN 6MG TABLET |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| COUMADIN 7.5MG TABLET |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| COVERA-HS 180MG SA TABLET |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| COVERA-HS 240MG SA TABLET |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| Creon 256.11mg/1 1 BOTTLE in 1 CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| CREON DR 36,000 UNITS CAPSULE |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| CRESTOR 10MG TABLET |
2 |
Preferred Brand |
$0.00 | $0.00 | Q:30
/30Days |
| CRESTOR 20MG TABLET |
2 |
Preferred Brand |
$0.00 | $0.00 | Q:30
/30Days |
| CRESTOR 40mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Preferred Brand |
$0.00 | $0.00 | Q:30
/30Days |
| CRESTOR 5MG TABLET |
2 |
Preferred Brand |
$0.00 | $0.00 | Q:30
/30Days |
| Crinone 90mg/1.125g 15 APPLICATOR in 1 CARTON / 1.125 g in 1 APPLICATOR |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CRIXIVAN 200MG CAPSULE |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| CRIXIVAN 400mg/1 90 CAPSULE in 1 BOTTLE |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| CROMOLYN NEBULIZER SOLUTION |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
| CROMOLYN SODIUM 100 MG/5 ML |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| CROMOLYN SODIUM 4% 40MG 10ML BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
| CUBICIN 500MG VIAL |
2 |
Preferred Brand |
$0.00 | $0.00 | P |
| CYCLOPHOSPHAMIDE 25MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
| CYCLOPHOSPHAMIDE 50MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
| CYCLOSPORINE 100MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
| Cyclosporine 100mg/1 30 BLISTER PACK in 1 CARTON / 1 CAPSULE, LIQUID FILLED in 1 BLISTER PACK |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
| CYCLOSPORINE 25MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
| Cyclosporine 25mg/1 30 BLISTER PACK in 1 CARTON / 1 CAPSULE, LIQUID FILLED in 1 BLISTER PACK |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
| Cyclosporine 50mg/1 30 BLISTER PACK in 1 CARTON / 1 CAPSULE, LIQUID FILLED in 1 BLISTER PACK |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
| CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
| CYKLOKAPRON 100MG/ML AMPUL |
2 |
Preferred Brand |
$0.00 | $0.00 | None |
| Drug Name |
Tier
Nbr. |
Tier
Description |
30-Day
Preferred
Pharm |
90-Day
Mail
Order |
Drug
Usage
Mgmt |
| CYMBALTA 20MG CAPSULE |
2 |
Preferred Brand |
$0.00 | $0.00 | Q:60
/30Days |
| Cymbalta 60mg/1 1000 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
2 |
Preferred Brand |
$0.00 | $0.00 | Q:60
/30Days |
| CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT) |
2 |
Preferred Brand |
$0.00 | $0.00 | Q:90
/30Days |
| CYSTADANE POWDER FOR ORAL SOLUTION 180GM |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | None |
| CYSTAGON 150MG CAPSULE |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | P |
| CYSTAGON 50MG CAPSULE |
3 |
Non-Preferred Brand |
$25.00 | $75.00 | P |