2014 Medicare Part D Plan Formulary Information |
Patriot Plus (PFFS) (H4268-002-0)
Benefit Details
|
The Patriot Plus (PFFS) (H4268-002-0) Formulary Drugs Starting with the Letter C in WAKE County, NC: CMS MA Region 7 which includes: NC Plan Monthly Premium: $61.00 Deductible: $0 |
Drugs Starting with Letter C
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
CABERGOLINE 0.5 MG TABLET |
2 |
Preferred Brand |
$45.00 | $112.50 | Q:20 /30Days |
CALCIPOTRIENE 0.005% CREAM |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
Calcipotriene 50ug/g 60 g per CARTON |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
CALCIPOTRIENE TOPICAL SOLUTION |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY |
2 |
Preferred Brand |
$45.00 | $112.50 | Q:4 /30Days |
CALCITRIOL 0.25MCG CAPSULE |
1 |
Preferred Generic |
$4.00 | $10.00 | P |
CALCITRIOL 0.5MCG CAPSULE |
1 |
Preferred Generic |
$4.00 | $10.00 | P |
CALCIUM ACETATE CAPSULE 667 MG |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
Campral 333mg/1 180 TABLET, DELAYED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Camptosar 20mg/mL 1 VIAL, SINGLE-DOSE per CARTON / 5 mL in 1 VIAL, SINGLE-DOSE |
2 |
Preferred Brand |
$45.00 | $112.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:30 /30Days |
CANCIDAS IV 50MG VIAL |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CANCIDAS IV 70MG VIAL |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CAPASTAT SULFATE 1g/1 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CAPRELSA 100mg/1 30 TABLET BOTTLE, PLASTIC |
4 |
Specialty Tier |
33% | 33% | Q:60 /30Days |
CAPRELSA 300mg/1 30 TABLET BOTTLE, PLASTIC |
4 |
Specialty Tier |
33% | 33% | Q:30 /30Days |
CAPTOPRIL 100MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CAPTOPRIL 12.5MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CAPTOPRIL 25MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CAPTOPRIL 50MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Captopril and Hydrochlorothiazide 25; 15mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Captopril and Hydrochlorothiazide 25; 25mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Captopril and Hydrochlorothiazide 50; 15mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Captopril and Hydrochlorothiazide 50; 25mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CARAC CREAM |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CARBAMAZEPINE 100 MG/5 ML SUSP |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Carbamazepine 100mg, CHEWABLE 100 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CARBAMAZEPINE TABLET USP 200MG (1000 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CARBAMAZEPINE XR 200 MG TABLET |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
CARBAMAZEPINE XR 400 MG TABLET |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
Carbatrol 100mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:90 /30Days |
CARBATROL 200MG CAPSULE SA |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:60 /30Days |
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 |
$95.00 | $237.50 | Q:150 /30Days |
CARBIDOPA-LEVO ER 25-100 TAB |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
CARBIDOPA-LEVO ER 50-200 TAB |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
CARBIDOPA/LEVO 10/100 TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CARBIDOPA/LEVO 25/100 TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CARBIDOPA/LEVO 25/250 TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Carboplatin 10mg/mL |
2 |
Preferred Brand |
$45.00 | $112.50 | P |
CARISOPRODOL TABLET USP 350MG (100 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | Q:120 /30Days |
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CARTIA XT 120MG CAPSULE SA |
2 |
Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
CARTIA XT 180MG CAPSULE SA |
2 |
Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARTIA XT 240MG CAPSULE SA |
2 |
Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
CARTIA XT 300MG CAPSULE SR 24 HR |
2 |
Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
Carvedilol 12.5mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$4.00 | $10.00 | Q:60 /30Days |
Carvedilol 25mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$4.00 | $10.00 | Q:60 /30Days |
Carvedilol 3.125mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$4.00 | $10.00 | Q:60 /30Days |
Carvedilol 6.25mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$4.00 | $10.00 | Q:60 /30Days |
CATAPRES-TTS DIS 0.3/24HR 7.5MG/UNT |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:5 /30Days |
CATAPRES-TTS-1 PATCH 2.52.5MG/UNT 1 X 4 CRTN |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:5 /30Days |
CATAPRES-TTS-2 PATCH 52.5MG/UNT 1 X 4 CRTN |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:5 /30Days |
CAYSTON KIT 75 MG/VIAL |
4 |
Specialty Tier |
33% | 33% | P Q:84 /28Days |
CEENU 10MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEENU 40MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
CEFACLOR 250 MG CAPSULES |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CEFACLOR 500 MG CAPSULES |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CEFACLOR ER 500MG TABLET SR 12HR |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CEFADROXIL 1G TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Cefadroxil 500mg/1 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Cefadroxil 500mg/5mL |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CEFADROXIL FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CEFAZOLIN 1GM/D5W BAG |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CEFDINIR CAPSULES 300MG (60 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CEFEPIME HCL 2 GRAM VIAL |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
CEFOTAXIME 10 mg vial FOR INJECTION |
1 |
Preferred Generic |
$4.00 | $10.00 | P |
Cefotaxime sodium 1 gm vial |
1 |
Preferred Generic |
$4.00 | $10.00 | P |
Cefotaxime sodium 2 gm vial |
1 |
Preferred Generic |
$4.00 | $10.00 | P |
Cefotaxime sodium 500 mg vial |
1 |
Preferred Generic |
$4.00 | $10.00 | P |
Cefoxitin 1g/1 10 POWDER per CARTON |
1 |
Preferred Generic |
$4.00 | $10.00 | P |
CEFPODOXIME 200 MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFTRIAXONE 10GM VIAL |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CEFTRIAXONE 250 MG VIAL |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CEFTRIAXONE FOR INJECTION |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CEFTRIAXONE FOR INJECTION |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Ceftriaxone Sodium 500mg/1 |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CEFUROXIME 750MG FOR INJECTION |
1 |
Preferred Generic |
$4.00 | $10.00 | P |
cefuroxime axetil 250mg/1 |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CEFUROXIME AXETIL 500 MG TAB |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CELEBREX 100MG CAPSULE |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:60 /30Days |
CELEBREX 200MG CAPSULE |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:60 /30Days |
CELEBREX 400MG CAPSULE |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CELLCEPT 200MG/ML ORAL SUSP |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
CELLCEPT 500MG TABLET |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
CELLCEPT CAPSULES 250MG (500 CT) |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
CELLCEPT IV INJ 500MG |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
CELONTIN 300MG KAPSEAL |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
Cephalexin 125mg/5mL 200 mL in 1 BOTTLE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CEPHALEXIN 250MG CAPSULE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CEPHALEXIN 250MG/5ML ORAL SUSP |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CEPHALEXIN CAPSULES 500MG (500 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CEREZYME INJ 200UNIT |
4 |
Specialty Tier |
33% | 33% | P |
CERVARIX VACCINE SYRINGE |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CESAMET 1MG CAPSULES |
4 |
Specialty Tier |
33% | 33% | P Q:180 /30Days |
CETIRIZINE HCL 1 MG/ML SYRUP |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CHANTIX 0.5MG TABLET |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:60 /30Days |
CHANTIX 1MG TABLET |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:60 /30Days |
CHLORAMPHEN NA SUCC 1GM VL |
1 |
Preferred Generic |
$4.00 | $10.00 | P |
CHLORDIAZEPOXIDE AND AMITRIPTYLINE HCL TABLET 12.5-5MG (500 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CHLORDIAZEPOXIDE HCL 10mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE in 1 BLISTER |
1 |
Preferred Generic |
$4.00 | $10.00 | P |
CHLORDIAZEPOXIDE HCL 25mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE in 1 BLISTER |
1 |
Preferred Generic |
$4.00 | $10.00 | P |
CHLORDIAZEPOXIDE HCL 5mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE in 1 BLISTER |
1 |
Preferred Generic |
$4.00 | $10.00 | P |
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CHLOROQUINE PH 500MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLOROTHIAZIDE 250 MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CHLOROTHIAZIDE 500MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CHLORPROMAZINE 10MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CHLORPROMAZINE 25MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CHLORPROMAZINE 25MG/ML AMP |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CHLORPROMAZINE 50 MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CHLORPROMAZINE HCL 200MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Chlorpromazine Hydrochloride 100mg SUGAR COATED 1000 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Chlorpropamide 100mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$4.00 | $10.00 | P |
Chlorpropamide 250mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$4.00 | $10.00 | P |
CHLORTHALIDONE 25MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLORTHALIDONE 50MG TABLET (1000 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CHLORZOXAZONE 500 MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CHORIONIC GONAD 10000U VIAL |
2 |
Preferred Brand |
$45.00 | $112.50 | P |
Cialis 2.5mg/1 2 BLISTER PACK per CARTON / 15 FILM COATED TABLETS in BLISTER PACK |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:30 /30Days |
Cialis 5mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:30 /30Days |
Ciclopirox 7.7mg/mL 60 mL in 1 BOTTLE |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6ML BOT |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
Ciclopirox Olamine 7.7mg/g 1 TUBE in 1 TUBE / 15 g in 1 TUBE |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
Cilostazol 50mg/1 60 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CILOSTAZOL TABLET 100MG (60 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIMETIDINE 300 MG TABLETS |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Cimetidine 400mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Cimetidine 800mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Cimetidine Hydrochloride Oral Solution 300mg/5mL 237 mL in 1 BOTTLE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Cimzia 2 KIT per CARTON / 1 KIT in 1 KIT |
4 |
Specialty Tier |
33% | 33% | P Q:6 /30Days |
CIMZIA 200 MG/ML SYRINGE KIT |
4 |
Specialty Tier |
33% | 33% | P Q:6 /30Days |
Cinryze 500[iU]/5mL 1 VIAL per CARTON / 5 mL in 1 VIAL |
4 |
Specialty Tier |
33% | 33% | P |
CIPRO HC OTIC SUSPENSION |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CIPRODEX OTIC SUSPENSION |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
CIPROFLOXACIN 0.3% EYE DROP |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CIPROFLOXACIN 250MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ciprofloxacin 400mg/40mL 1 VIAL per CARTON / 40 mL in 1 VIAL |
1 |
Preferred Generic |
$4.00 | $10.00 | P |
CIPROFLOXACIN HCL 500 MG TAB |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CIPROFLOXACIN TABLETS 750MG 100 BOT |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Cisplatin 100mg/100mL 1 VIAL per CARTON / 100 mL in 1 VIAL |
2 |
Preferred Brand |
$45.00 | $112.50 | P |
CITALOPRAM HBR 20 MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | Q:90 /30Days |
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL |
1 |
Preferred Generic |
$4.00 | $10.00 | Q:600 /30Days |
CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT |
1 |
Preferred Generic |
$4.00 | $10.00 | Q:60 /30Days |
CITOLOPRAM HBR 10MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | Q:60 /30Days |
cladribine 10 mg/10 ml vial |
1 |
Preferred Generic |
$4.00 | $10.00 | P |
CLARAVIS 10MG CAPSULE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CLARAVIS 20MG CAPSULE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Claravis 30mg/1 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CLARAVIS 40MG CAPSULE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CLARINEX-D 24 HOUR 5; 240mg/1; mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:30 /30Days |
CLARITHROMYCIN 125 MG/5ML FOR ORAL SUSPENSION |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CLARITHROMYCIN 250 MG/5MLFOR ORAL SUSPENSION |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CLARITHROMYCIN 250MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | Q:60 /30Days |
CLARITHROMYCIN 500MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | Q:60 /30Days |
CLEMASTINE FUM 2.68MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CLEOCIN 300MG/D5W/GALAXY |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
CLEOCIN 600MG/D5W/GALAXY |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
CLEOCIN 900MG/D5W/GALAXY |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINDAMYCIN HCL 150MG CAPSULE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CLINDAMYCIN HCL 300 MG CAPSULE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CLINDAMYCIN PHOSP 1% LOTION |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
clindamycin phosphate 10mg/mL 1 BOTTLE per CARTON / 60 mL in 1 BOTTLE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CLINIMIX 2.75%/5% INJECTION 1000ML BAG |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CLINIMIX 4.25/10 SOLUTION |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CLINIMIX 4.25/20 SOLUTION |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CLINIMIX 4.25/25 SOLUTION |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CLINIMIX 4.25/5 SOLUTION |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CLINIMIX 5/15 SOLUTION |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINIMIX 5/20 SOLUTION |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CLINIMIX E 2.75/10 SOLUTION |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CLINIMIX E 2.75/5 SOLUTION |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CLINIMIX E 4.25/25 SOLUTION |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CLINIMIX E 4.25/5 SOLUTION |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CLINIMIX E 5/20 SOLUTION |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CLINIMIX E 5/25 SOLUTION |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CLINIMIX E 5%/15% INJECTION 2000ML BAG |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CLINISOL 15% SOLUTION |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CLOBETASOL 0.05% OINTMENT |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOBETASOL E 0.05% CREAM |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
Clobetasol Propionate 0.4625mg/mL 1 BOTTLE per CARTON / 50 mL in 1 BOTTLE |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
CLOLAR 1MG/ML VIAL |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
CLOMIPRAMINE HCL 25MG CAPSULE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CLOMIPRAMINE HCL 50MG CAPSULE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CLOMIPRAMINE HCL 75MG CAPSULE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Clonazepam 0.125mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PAC |
2 |
Preferred Brand |
$45.00 | $112.50 | P |
Clonazepam 0.25mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
2 |
Preferred Brand |
$45.00 | $112.50 | P |
Clonazepam 0.5mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
2 |
Preferred Brand |
$45.00 | $112.50 | P |
Clonazepam 0.5mg/1 100 TABLET BOTTLE |
2 |
Preferred Brand |
$45.00 | $112.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Clonazepam 1mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
2 |
Preferred Brand |
$45.00 | $112.50 | P |
Clonazepam 1mg/1 90 TABLET BOTTLE, PLASTIC |
2 |
Preferred Brand |
$45.00 | $112.50 | P |
Clonazepam 2mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
2 |
Preferred Brand |
$45.00 | $112.50 | P |
Clonazepam 2mg/1 100 TABLET BOTTLE |
2 |
Preferred Brand |
$45.00 | $112.50 | P |
CLONIDINE HCL 0.2MG TABLET (500 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CLONIDINE HCL TABLET 0.1MG (500 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CLONIDINE HCL TABLET 0.3MG (100 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CLOPIDOGREL TAB 75MG |
1 |
Preferred Generic |
$4.00 | $10.00 | Q:30 /30Days |
CLORAZEPATE 15 MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | P |
Clorazepate Dipotassium 3.75mg/1 500 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$4.00 | $10.00 | P |
Clorazepate Dipotassium 7.5mg/1 500 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$4.00 | $10.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOTRIMAZOLE 1% CREAM |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CLOTRIMAZOLE 10MG TROCHE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CLOTRIMAZOLE SOLUTION TOPICAL 1% 30ML BOTPL |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Clozapine 100mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CLOZAPINE 200MG TABLET (500 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CLOZAPINE 25MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CLOZAPINE 50MG TABLET (500 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CODEINE SULFATE 15 MG TABLETS |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
CODEINE SULFATE 30 MG TABLET 3100 |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Codeine sulfate 60mg/1 100 TABLET BOTTLE |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
COGENTIN 2 MG/2 ML AMPULE |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
COLCRYS 0.6 MG TABLET |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
COLESTIPOL HCL 1G TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
colistimethate 150mg/2mL 1 VIAL per CARTON / 2 mL in 1 VIAL |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
COMBIVENT RESPIMAT INHAL SPRAY |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:30 /30Days |
COMBIVIR 150; 300mg/1; mg/1 120 FILM COATED TABLETS in DOSE PACK |
4 |
Specialty Tier |
33% | 33% | Q:60 /30Days |
COMETRIQ 100 MG DAILY-DOSE PK |
4 |
Specialty Tier |
33% | 33% | None |
COMETRIQ 140 MG DAILY-DOSE PK |
4 |
Specialty Tier |
33% | 33% | None |
COMETRIQ 60 MG DAILY-DOSE PACK |
4 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1 |
4 |
Specialty Tier |
33% | 33% | Q:30 /30Days |
COMVAX VACCINE VIAL |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
CONSTULOSE 10 GM/15 ML SOLN |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN |
4 |
Specialty Tier |
33% | 33% | P |
COPAXONE 40 MG/ML SYRINGE |
4 |
Specialty Tier |
33% | 33% | P |
COREG CR 10MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:30 /30Days |
COREG CR 20MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:30 /30Days |
COREG CR 40MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:30 /30Days |
COREG CR 80MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:30 /30Days |
CORTISONE ACETATE 25MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
COSMEGEN 0.5 MG VIAL |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COUMADIN 5MG VIAL |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Creon 256.11mg/1 1 BOTTLE per CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CREON DR 36,000 UNITS CAPSULE |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CRESTOR 10MG TABLET |
2 |
Preferred Brand |
$45.00 | $112.50 | S Q:30 /30Days |
CRESTOR 20MG TABLET |
2 |
Preferred Brand |
$45.00 | $112.50 | S Q:30 /30Days |
CRESTOR 40mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Preferred Brand |
$45.00 | $112.50 | S Q:30 /30Days |
CRESTOR 5MG TABLET |
2 |
Preferred Brand |
$45.00 | $112.50 | S Q:30 /30Days |
CRIXIVAN 200MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CRIXIVAN 400mg, 180 CAPSULE BOTTLE |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
CROMOLYN NEBULIZER SOLUTION 20MG/2ML |
1 |
Preferred Generic |
$4.00 | $10.00 | P |
CROMOLYN SODIUM 4% 40MG 10ML BOT |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CUBICIN 500MG VIAL |
4 |
Specialty Tier |
33% | 33% | P |
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | Q:90 /30Days |
Cyclobenzaprine Hydrochloride 5mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$4.00 | $10.00 | Q:90 /30Days |
CYCLOPHOSPHAMIDE 25MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | P |
CYCLOPHOSPHAMIDE 50MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | P |
CYCLOSET 0.8MG TABLETS |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
CYCLOSPORINE 100MG CAPSULE |
1 |
Preferred Generic |
$4.00 | $10.00 | P |
Cyclosporine 100mg/1 30 BLISTER PACK per CARTON / 1 CAPSULE, LIQUID FILLED per BLISTER PACK |
2 |
Preferred Brand |
$45.00 | $112.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYCLOSPORINE 25MG CAPSULE |
1 |
Preferred Generic |
$4.00 | $10.00 | P |
Cyclosporine 25mg/1 30 BLISTER PACK per CARTON / 1 CAPSULE, LIQUID FILLED per BLISTER PACK |
2 |
Preferred Brand |
$45.00 | $112.50 | P |
Cyclosporine 50mg/1 30 BLISTER PACK per CARTON / 1 CAPSULE, LIQUID FILLED per BLISTER PACK |
2 |
Preferred Brand |
$45.00 | $112.50 | P |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT |
1 |
Preferred Generic |
$4.00 | $10.00 | P |
CYKLOKAPRON 100MG/ML AMPUL |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
CYMBALTA 20MG CAPSULE |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:60 /30Days |
Cymbalta 60mg/1 1000 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:60 /30Days |
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT) |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:60 /30Days |
CYPROHEPTADINE HCL 4 MG |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
CYSTADANE POWDER FOR ORAL SOLUTION 180GM |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYTARABINE 20MG/ML VIAL |
1 |
Preferred Generic |
$4.00 | $10.00 | P |
CYTARABINE SOLUTION INJECTION 100MG 20ML VIALSD |
1 |
Preferred Generic |
$4.00 | $10.00 | P |
CYTOMEL 25MCG TABLET |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
CYTOMEL 50MCG TABLET |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
CYTOMEL 5MCG TABLET |
2 |
Preferred Brand |
$45.00 | $112.50 | None |