2014 Medicare Part D Plan Formulary Information |
Olympus - Constellation Health (PPO) (H4876-001-0)
Benefit Details
|
The Olympus - Constellation Health (PPO) (H4876-001-0) Formulary Drugs Starting with the Letter A in BAYAMON County, PR: CMS MA Region 30 which includes: PR Plan Monthly Premium: $51.00 Deductible: $0 |
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 |
1 |
Generic |
$5.00 | $15.00 | None |
ABACAVIR 300 MG TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir] |
4 |
Specialty Tier |
33% | 33% | None |
ABILIFY 10MG TABLET |
2 |
Preferred Brand |
$25.00 | $75.00 | Q:30 /30Days |
ABILIFY 15MG TABLET |
2 |
Preferred Brand |
$25.00 | $75.00 | Q:30 /30Days |
ABILIFY 1MG/ML SOLUTION |
2 |
Preferred Brand |
$25.00 | $75.00 | None |
ABILIFY 20MG TABLET |
2 |
Preferred Brand |
$25.00 | $75.00 | Q:30 /30Days |
ABILIFY 2MG TABLET |
2 |
Preferred Brand |
$25.00 | $75.00 | Q:30 /30Days |
ABILIFY 30MG TABLET |
2 |
Preferred Brand |
$25.00 | $75.00 | Q:30 /30Days |
ABILIFY 5MG TABLET (OTSUKA) |
2 |
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 |
ABILIFY DISCMELT 10MG TABLET |
2 |
Preferred Brand |
$25.00 | $75.00 | Q:90 /30Days |
ABILIFY DISCMELT 15MG TABLET |
2 |
Preferred Brand |
$25.00 | $75.00 | Q:60 /30Days |
ABILIFY INJ 9.75MG |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P |
ABILIFY MAINTENA ER 300 MG VL |
4 |
Specialty Tier |
33% | 33% | P |
Acamprosate Calcium DR 333 MG tablets [Campral] |
1 |
Generic |
$5.00 | $15.00 | None |
Acarbose 100mg/1 1000 TABLET BOTTLE, PLASTIC |
1 |
Generic |
$5.00 | $15.00 | Q:90 /30Days |
ACARBOSE 25 MG TABLETS |
1 |
Generic |
$5.00 | $15.00 | Q:90 /30Days |
Acarbose 50mg/1 100 TABLET BOTTLE |
1 |
Generic |
$5.00 | $15.00 | Q:90 /30Days |
ACCOLATE 10MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
ACCOLATE 20MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
ACCUPRIL 10MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACCUPRIL 20MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ACCUPRIL 40MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ACCUPRIL 5MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ACCURETIC 10-12.5MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ACCURETIC 20-12.5MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ACCURETIC 20-25MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ACEBUTOLOL 200MG CAPSULE |
1 |
Generic |
$5.00 | $15.00 | None |
ACEBUTOLOL 400MG CAPSULE |
1 |
Generic |
$5.00 | $15.00 | None |
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
Acetaminophen and Codeine Phosphate 300; 60mg/1; mg/1 500 TABLET BOTTLE |
1 |
Generic |
$5.00 | $15.00 | Q:180 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD |
1 |
Generic |
$5.00 | $15.00 | None |
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) |
1 |
Generic |
$5.00 | $15.00 | Q:360 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
1 |
Generic |
$5.00 | $15.00 | Q:360 /30Days |
ACETAZOLAMIDE 125MG TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
1 |
Generic |
$5.00 | $15.00 | None |
ACETIC ACID 2% SOLUTION NON-ORAL |
1 |
Generic |
$5.00 | $15.00 | None |
ACETYLCYSTEINE 10% VIAL |
1 |
Generic |
$5.00 | $15.00 | P |
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN |
1 |
Generic |
$5.00 | $15.00 | P |
ACITRETIN 10 MG CAPSULE [Soriatane] |
1 |
Generic |
$5.00 | $15.00 | Q:30 /30Days |
ACITRETIN 17.5 MG CAPSULE [Soriatane] |
1 |
Generic |
$5.00 | $15.00 | Q:30 /30Days |
ACITRETIN 25 MG CAPSULE [Soriatane] |
1 |
Generic |
$5.00 | $15.00 | Q:60 /30Days |
ACTEMRA 162 MG/0.9 ML SYRINGE |
4 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTEMRA INJECTION 200MG/10ML |
4 |
Specialty Tier |
33% | 33% | P |
ACTHIB VACCINE VIAL 10-24UNT/5ML |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ACTIGALL 300MG CAPSULE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ACTIMMUNE 100 MCG/0.5 ML VIAL |
4 |
Specialty Tier |
33% | 33% | P |
ACTIQ 1200MCG LOZENGE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P Q:120 /30Days |
ACTIQ 1600MCG LOZENGE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P Q:120 /30Days |
ACTIQ 200MCG LOZENGE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P Q:120 /30Days |
ACTIQ 400MCG LOZENGE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P Q:120 /30Days |
ACTIQ 600MCG LOZENGE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P Q:120 /30Days |
ACTIQ 800MCG LOZENGE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P Q:120 /30Days |
ACTOPLUS MET 15MG/500MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTOPLUS MET 15MG/850MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ACTOPLUS MET XR TABLETS EXTENDED RELEASE 15;1000 MG;MG |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
ACTOPLUS MET XR TABLETS EXTENDED RELEASE 30;1000 MG;MG |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
ACTOS 15 MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
Actos 30mg/90 Tablet Bottle |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
ACTOS 45MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
ACULAR 0.5% EYE DROPS |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ACULAR LS 0.4% OPHTH SOL |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ACYCLOVIR 200 MG CAPSULE |
1 |
Generic |
$5.00 | $15.00 | None |
Acyclovir 200mg/5mL 473 mL in 1 BOTTLE |
1 |
Generic |
$5.00 | $15.00 | None |
Acyclovir 400mg/1 |
1 |
Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACYCLOVIR 800 MG TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
ACYCLOVIR SODIUM 500MG VIAL |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P |
ADACEL VIAL 2UNT/5UNT |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ADAGEN 250U/ML VIAL |
4 |
Specialty Tier |
33% | 33% | P |
Adalat CC 30mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
Adalat CC 60mg/1 1000 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
Adalat CC 90mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA] |
4 |
Specialty Tier |
33% | 33% | P |
ADCIRCA TABLETS 20MG 60 BOT |
4 |
Specialty Tier |
33% | 33% | P |
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera] |
1 |
Generic |
$5.00 | $15.00 | P |
ADEMPAS 0.5 MG TABLET |
4 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADEMPAS 1 MG TABLET |
4 |
Specialty Tier |
33% | 33% | P |
ADEMPAS 1.5 MG TABLET |
4 |
Specialty Tier |
33% | 33% | P |
ADEMPAS 2 MG TABLET |
4 |
Specialty Tier |
33% | 33% | P |
ADEMPAS 2.5 MG TABLET |
4 |
Specialty Tier |
33% | 33% | P |
ADVAIR DISKUS MIS 100/50 |
2 |
Preferred Brand |
$25.00 | $75.00 | None |
ADVAIR DISKUS MIS 250/50 |
2 |
Preferred Brand |
$25.00 | $75.00 | None |
ADVAIR DISKUS MIS 500/50 |
2 |
Preferred Brand |
$25.00 | $75.00 | None |
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER |
2 |
Preferred Brand |
$25.00 | $75.00 | None |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL |
2 |
Preferred Brand |
$25.00 | $75.00 | None |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
2 |
Preferred Brand |
$25.00 | $75.00 | None |
AFEDITAB CR 30MG TABLET SA |
1 |
Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AFEDITAB CR 60MG TABLET SA |
1 |
Generic |
$5.00 | $15.00 | None |
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK |
4 |
Specialty Tier |
33% | 33% | P |
AFINITOR DISPERZ 2 MG TABLET |
4 |
Specialty Tier |
33% | 33% | P |
AFINITOR DISPERZ 3 MG TABLET |
4 |
Specialty Tier |
33% | 33% | P |
AFINITOR DISPERZ 5 MG TABLET |
4 |
Specialty Tier |
33% | 33% | P |
AFINITOR TABLETS 10 MG |
4 |
Specialty Tier |
33% | 33% | P |
AFINITOR TABLETS 2.5 MG |
4 |
Specialty Tier |
33% | 33% | P |
AFINITOR TABLETS 5 MG |
4 |
Specialty Tier |
33% | 33% | P |
AGGRENOX 25-200MG CAPSULE |
2 |
Preferred Brand |
$25.00 | $75.00 | None |
AGRYLIN 0.5MG CAPSULE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
AK-CON 0.1% EYE DROPS |
1 |
Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBENZA 200 MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
1 |
Generic |
$5.00 | $15.00 | P |
ALBUTEROL SULFATE SOLUTION FOR INHALATION |
1 |
Generic |
$5.00 | $15.00 | P |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
1 |
Generic |
$5.00 | $15.00 | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
1 |
Generic |
$5.00 | $15.00 | None |
ALBUTEROL TABLET 4MG (500 CT) |
1 |
Generic |
$5.00 | $15.00 | None |
ALCLOMETASONE DIPROPIONATE 0.05% CREAM |
1 |
Generic |
$5.00 | $15.00 | None |
Alclometasone Dipropionate 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
1 |
Generic |
$5.00 | $15.00 | None |
ALDACTAZIDE 25/25 TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ALDACTAZIDE 50/50 TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ALDACTONE 100MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALDACTONE 25MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ALDACTONE 50MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ALDARA 5% CREAM |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ALDURAZYME 2.9MG/5ML VIAL |
4 |
Specialty Tier |
33% | 33% | P |
ALENDRONATE SODIUM 10MG TABLET |
1 |
Generic |
$5.00 | $15.00 | Q:30 /30Days |
Alendronate Sodium 35mg, 4 BLISTER PACK in 1 BOX / 1 TABLET per BLISTER PACK |
1 |
Generic |
$5.00 | $15.00 | Q:4 /28Days |
ALENDRONATE SODIUM 40MG TABLET |
1 |
Generic |
$5.00 | $15.00 | Q:30 /30Days |
ALENDRONATE SODIUM 5MG TABLET |
1 |
Generic |
$5.00 | $15.00 | Q:30 /30Days |
Alendronate Sodium 70 mg tab |
1 |
Generic |
$5.00 | $15.00 | Q:4 /28Days |
ALIMTA 500MG VIAL |
4 |
Specialty Tier |
33% | 33% | P |
ALINIA 100MG/5ML SUSPENSION |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALINIA 500 MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ALLOPURINOL 100 MG TABLETS |
1 |
Generic |
$5.00 | $15.00 | None |
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET per BLISTER PACK |
1 |
Generic |
$5.00 | $15.00 | None |
ALPHAGAN P 0.1% DROPS |
2 |
Preferred Brand |
$25.00 | $75.00 | None |
ALPHAGAN P 0.15% EYE DROPS |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ALPRAZOLAM 0.25 MG TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
ALPRAZOLAM 0.5 MG TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
ALPRAZOLAM 1 MG TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
ALPRAZOLAM 2 MG TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
ALTACE 1.25MG CAPSULE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ALTACE 10MG CAPSULE (100 CT) |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALTACE 2.5 MG CAPSULE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ALTACE 5MG CAPSULE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
AMANTADINE 100MG CAPSULE |
1 |
Generic |
$5.00 | $15.00 | None |
AMARYL 1MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
AMARYL 2MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
AMARYL 4MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
AMBIEN 10MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
AMBIEN TABLETS 5MG 100 BOT |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
AMBISOME 50MG VIAL |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P |
AMERGE 1MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:9 /30Days |
AMERGE 2.5MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:9 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Amethia 2 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
1 |
Generic |
$5.00 | $15.00 | None |
Amethyst 20; 90ug/1; ug/1 1 BLISTER PACK per CARTON / 28 TABLET per BLISTER PACK |
1 |
Generic |
$5.00 | $15.00 | None |
AMIFOSTINE 50mg/mL 3 VIAL, SINGLE-USE per CARTON / 10 mL in 1 VIAL, SINGLE-USE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P |
AMIKACIN SULFATE 500 MG/2 ML VIAL |
1 |
Generic |
$5.00 | $15.00 | P |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT |
1 |
Generic |
$5.00 | $15.00 | None |
Aminophylline 25mg/mL 5 TRAY per CARTON / 5 AMPULE in 1 TRAY / 10 mL in 1 AMPULE |
1 |
Generic |
$5.00 | $15.00 | P |
AMINOSYN HBC INJECTION SULFITE FREE 7% |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P |
AMINOSYN II 10% IV SOLUTION |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P |
AMINOSYN II 7% IV SOLUTION |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P |
AMINOSYN II 8.5% ELECTROLYT |
1 |
Generic |
$5.00 | $15.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN II 8.5% IV SOLUTION |
1 |
Generic |
$5.00 | $15.00 | P |
Aminosyn II Sulfite-Free 1490; 1527; 1050; 1107; 750; 450; 990; 1500; 1575; 258; 405; 447; 1083; 79 |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P |
AMINOSYN M 3.5% IV SOLUTION |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P |
AMINOSYN PF INJECTION |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P |
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5% |
1 |
Generic |
$5.00 | $15.00 | P |
AMINOSYN-PF 7% IV SOLUTION |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P |
AMIODARONE HCL 200MG 60 TABLET BOTTLE |
1 |
Generic |
$5.00 | $15.00 | None |
AMIODARONE HCL 400MG TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
AMITIZA 8MCG CAPSULE |
2 |
Preferred Brand |
$25.00 | $75.00 | Q:60 /30Days |
AMITIZA CAPSULES 24MCG 60 CAP BOT |
2 |
Preferred Brand |
$25.00 | $75.00 | Q:60 /30Days |
AMITRIP/PERPHEN 10-2 TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIP/PERPHEN 10-4 TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
AMITRIP/PERPHEN 25-2 TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
AMITRIP/PERPHEN 25-4 TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
AMITRIP/PERPHEN 50-4 TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
AMITRIPTYLINE HCL 100MG TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
AMITRIPTYLINE HCL 10MG TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
AMITRIPTYLINE HCL 150 MG TAB |
1 |
Generic |
$5.00 | $15.00 | None |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
1 |
Generic |
$5.00 | $15.00 | None |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
1 |
Generic |
$5.00 | $15.00 | None |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
1 |
Generic |
$5.00 | $15.00 | None |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
1 |
Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1 |
Generic |
$5.00 | $15.00 | None |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
1 |
Generic |
$5.00 | $15.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE |
1 |
Generic |
$5.00 | $15.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE |
1 |
Generic |
$5.00 | $15.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE |
1 |
Generic |
$5.00 | $15.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE |
1 |
Generic |
$5.00 | $15.00 | None |
AMLODIPINE-BENAZEPRIL 10-40 MG |
1 |
Generic |
$5.00 | $15.00 | None |
AMLODIPINE-BENAZEPRIL 5-40 MG |
1 |
Generic |
$5.00 | $15.00 | None |
ammonium lactate 12% cream |
1 |
Generic |
$5.00 | $15.00 | None |
AMMONIUM LACTATE 12% LOTION |
1 |
Generic |
$5.00 | $15.00 | None |
Amnesteem 10mg/1 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
1 |
Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Amnesteem 20mg/1 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
1 |
Generic |
$5.00 | $15.00 | None |
Amnesteem 40mg/1 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
1 |
Generic |
$5.00 | $15.00 | None |
amox tr-k clv 200-28.5/5 susp |
1 |
Generic |
$5.00 | $15.00 | None |
AMOX TR-K CLV 500-125 MG TAB |
1 |
Generic |
$5.00 | $15.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
1 |
Generic |
$5.00 | $15.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
1 |
Generic |
$5.00 | $15.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Generic |
$5.00 | $15.00 | None |
AMOXAPINE 100MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
AMOXAPINE 150MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
AMOXAPINE 25MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXAPINE 50MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
AMOXICILLIN 125MG TABLET CHEW |
1 |
Generic |
$5.00 | $15.00 | None |
AMOXICILLIN 250MG CAPSULE |
1 |
Generic |
$5.00 | $15.00 | None |
Amoxicillin 250mg/1 500 TABLET, CHEWABLE in 1 BOTTLE |
1 |
Generic |
$5.00 | $15.00 | None |
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION |
1 |
Generic |
$5.00 | $15.00 | None |
AMOXICILLIN 500MG TABLET (100 CT) |
1 |
Generic |
$5.00 | $15.00 | None |
Amoxicillin 500mg/1 500 CAPSULE BOTTLE, PLASTIC |
1 |
Generic |
$5.00 | $15.00 | None |
AMOXICILLIN 875MG TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
1 |
Generic |
$5.00 | $15.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG |
1 |
Generic |
$5.00 | $15.00 | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
1 |
Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
1 |
Generic |
$5.00 | $15.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
1 |
Generic |
$5.00 | $15.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Generic |
$5.00 | $15.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
1 |
Generic |
$5.00 | $15.00 | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
1 |
Generic |
$5.00 | $15.00 | Q:60 /30Days |
AMPHETAMINE SALT COMBO 15MG TABLET |
1 |
Generic |
$5.00 | $15.00 | Q:60 /30Days |
AMPHETAMINE SALT COMBO 30MG TABLET |
1 |
Generic |
$5.00 | $15.00 | Q:60 /30Days |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
1 |
Generic |
$5.00 | $15.00 | Q:60 /30Days |
AMPHETAMINE SALTS 20MG TABLET |
1 |
Generic |
$5.00 | $15.00 | Q:60 /30Days |
AMPHETAMINE SALTS 5 MG TAB |
1 |
Generic |
$5.00 | $15.00 | Q:60 /30Days |
amphotericin b 50mg/10mL 10 mL in 1 VIAL |
1 |
Generic |
$5.00 | $15.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS |
1 |
Generic |
$5.00 | $15.00 | P |
AMPICILLIN CAPSULES 250MG 100 BOT |
1 |
Generic |
$5.00 | $15.00 | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
1 |
Generic |
$5.00 | $15.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
1 |
Generic |
$5.00 | $15.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
1 |
Generic |
$5.00 | $15.00 | None |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML |
1 |
Generic |
$5.00 | $15.00 | P |
AMPYRA ER 10 MG TABLET |
4 |
Specialty Tier |
33% | 33% | P |
Amturnide 150; 5; 12.5mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Preferred Brand |
$25.00 | $75.00 | Q:30 /30Days |
Amturnide 300; 10; 12.5mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Preferred Brand |
$25.00 | $75.00 | Q:30 /30Days |
Amturnide 300; 10; 25mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Preferred Brand |
$25.00 | $75.00 | Q:30 /30Days |
Amturnide 300; 5; 12.5mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
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 |
Amturnide 300; 5; 25mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Preferred Brand |
$25.00 | $75.00 | Q:30 /30Days |
ANAFRANIL 25mg/1 30 CAPSULE BOTTLE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ANAFRANIL 50mg/1 30 CAPSULE BOTTLE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ANAFRANIL 75mg/1 30 CAPSULE BOTTLE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE |
1 |
Generic |
$5.00 | $15.00 | None |
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE |
1 |
Generic |
$5.00 | $15.00 | None |
ANAPROX 275MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ANAPROX DS 550MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
Anastrozole 1mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Generic |
$5.00 | $15.00 | Q:30 /30Days |
ANCOBON 250MG CAPSULE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ANCOBON 500MG CAPSULE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANDRODERM 2 MG/24HR PATCH |
2 |
Preferred Brand |
$25.00 | $75.00 | None |
ANDRODERM 4 MG/24HR PATCH |
2 |
Preferred Brand |
$25.00 | $75.00 | None |
ANORO ELLIPTA 62.5-25 MCG INH |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P |
ANTABUSE 250MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ANTABUSE 500MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ANTIVERT 12.5MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ANTIVERT 25MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ANUSOL-HC 2.5% CREAM |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
APIDRA 100 UNITS/ML VIAL |
2 |
Preferred Brand |
$25.00 | $75.00 | Q:40 /30Days |
APIDRA SOLOSTAR 100 UNITS/ML |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:40 /30Days |
APOKYN 30 MG/3 ML CARTRIDGE |
4 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APRI 0.15-0.03 TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
APRISO CP24 |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
APTIOM 200 MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
APTIOM 400 MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
APTIOM 600 MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
APTIOM 800 MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
APTIVUS 250MG CAPSULE |
4 |
Specialty Tier |
33% | 33% | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
4 |
Specialty Tier |
33% | 33% | None |
Aralast NP 1 KIT per CARTON |
4 |
Specialty Tier |
33% | 33% | P |
ARANELLE 7-9-5 TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.5 mL in 1 SYRINGE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P |
ARANESP 200MCG/0.4ML SYRINGE |
4 |
Specialty Tier |
33% | 33% | P |
ARANESP 200MCG/ML VIAL |
4 |
Specialty Tier |
33% | 33% | P |
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.42 mL in 1 SYRING |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P |
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P |
ARANESP 300MCG/ML VIAL |
4 |
Specialty Tier |
33% | 33% | P |
ARANESP 500MCG/1ML SYRINGE |
4 |
Specialty Tier |
33% | 33% | P |
ARANESP 60MCG/ML VIAL |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P |
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.3 mL in 1 SYRINGE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P |
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR |
4 |
Specialty Tier |
33% | 33% | P |
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR |
4 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P |
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P |
ARAVA 10MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ARAVA 20MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ARCALYST INJECTION 220MG/VIAL |
4 |
Specialty Tier |
33% | 33% | P |
ARICEPT 10MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
ARICEPT 23 MG TABLETS |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
ARICEPT 5MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
ARICEPT ODT 10MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
ARICEPT ODT 5MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
ARIMIDEX 1MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARIXTRA 10MG SYRINGE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ARIXTRA 2.5MG SYRINGE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ARIXTRA 5MG SYRINGE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ARIXTRA 7.5MG SYRINGE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
AROMASIN 25MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ASACOL HD 800mg/1 12 BOTTLE CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE |
2 |
Preferred Brand |
$25.00 | $75.00 | None |
ASMANEX TWISTHALER 110 MCG #30 |
2 |
Preferred Brand |
$25.00 | $75.00 | None |
ASMANEX TWISTHALER 220MCG #120 |
2 |
Preferred Brand |
$25.00 | $75.00 | None |
ASMANEX TWISTHALER 220MCG #30 |
2 |
Preferred Brand |
$25.00 | $75.00 | None |
ASMANEX TWISTHALER 220MCG #60 |
2 |
Preferred Brand |
$25.00 | $75.00 | None |
ASTAGRAF XL 0.5 MG CAPSULE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ASTAGRAF XL 1 MG CAPSULE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P |
ASTAGRAF XL 5 MG CAPSULE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | P |
ASTEPRO 0.15% NASAL SPRAY 30 ML |
2 |
Preferred Brand |
$25.00 | $75.00 | None |
ATACAND 16MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
ATACAND 32MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
ATACAND 4MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
ATACAND 8MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
ATACAND HCT 16/12.5MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
ATACAND HCT 32/12.5MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
ATACAND HCT TABLETS 32;25MG;MG 90 TABLET BOTTLE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
ATENOLOL 100 MG TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Atenolol 25mg 100 TABLET BOTTLE |
1 |
Generic |
$5.00 | $15.00 | None |
ATENOLOL TABLET USP 50MG (100 CT) |
1 |
Generic |
$5.00 | $15.00 | None |
ATENOLOL-CHLORTHALIDONE 100-25 |
1 |
Generic |
$5.00 | $15.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
1 |
Generic |
$5.00 | $15.00 | None |
ATIVAN 0.5 MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:90 /30Days |
ATIVAN 1 MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:90 /30Days |
ATIVAN 2 MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:90 /30Days |
ATORVASTATIN 10 MG TABLET [Lipitor] |
1 |
Generic |
$5.00 | $15.00 | Q:30 /30Days |
ATORVASTATIN 20 MG TABLET [Lipitor] |
1 |
Generic |
$5.00 | $15.00 | Q:30 /30Days |
ATORVASTATIN 40 MG TABLET [Lipitor] |
1 |
Generic |
$5.00 | $15.00 | Q:30 /30Days |
ATORVASTATIN 80 MG TABLET [Lipitor] |
1 |
Generic |
$5.00 | $15.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATOVAQUONE 750 MG/5 ML SUSP [Mepron] |
4 |
Specialty Tier |
33% | 33% | None |
Atovaquone and Proguanil Hydrochloride 250; 100mg/1; mg/1 [Malarone] |
1 |
Generic |
$5.00 | $15.00 | None |
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Specialty Tier |
33% | 33% | None |
ATROVENT HFA AER 17MCG |
2 |
Preferred Brand |
$25.00 | $75.00 | None |
ATROVENT NASAL SPRAY 0.03% |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
ATROVENT NASAL SPRAY 0.06% |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
AUBAGIO 14 MG TABLET |
4 |
Specialty Tier |
33% | 33% | P |
AUBAGIO 7 MG TABLET |
4 |
Specialty Tier |
33% | 33% | P |
AUGMENTED BETAMETHASONE DIPROPIONATE OINTMENT |
1 |
Generic |
$5.00 | $15.00 | None |
AVALIDE 12.5; 150mg/1; mg/1 90 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
AVALIDE 12.5; 300mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVAPRO 150MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
AVAPRO 300MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
AVAPRO 75MG TABLET (30 CT) |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
AVASTIN 100MG/4ML VIAL |
4 |
Specialty Tier |
33% | 33% | P |
AVELOX 400MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
AVIANE 0.1-0.02 TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
AVODART 0.5MG SOFTGEL |
2 |
Preferred Brand |
$25.00 | $75.00 | Q:30 /30Days |
AVONEX ADMIN PACK 30MCG SYR |
4 |
Specialty Tier |
33% | 33% | P |
AVONEX ADMIN PACK 30MCG VL |
4 |
Specialty Tier |
33% | 33% | P |
AXIRON 30mg/1.5mL 1 BOTTLE, WITH APPLICATOR per CARTON / 90 mL in 1 BOTTLE, WITH APPLICATOR |
2 |
Preferred Brand |
$25.00 | $75.00 | None |
Aygestin 5mg/1 50 TABLET BOTTLE |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Azacitidine 100 mg vial [Vidaza] |
1 |
Generic |
$5.00 | $15.00 | P |
AZATHIOPRINE 50MG TABLET |
1 |
Generic |
$5.00 | $15.00 | P |
AZILECT 0.5MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
AZILECT 1MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
Azithromycin 100mg/5mL 15 mL in 1 BOTTLE |
1 |
Generic |
$5.00 | $15.00 | None |
Azithromycin 200mg/5mL 22.5 mL in 1 BOTTLE |
1 |
Generic |
$5.00 | $15.00 | None |
AZITHROMYCIN 250 MG TABLET |
1 |
Generic |
$5.00 | $15.00 | None |
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE |
1 |
Generic |
$5.00 | $15.00 | None |
Azithromycin 600mg/1 30 FILM COATED TABLETS in BOTTLE |
1 |
Generic |
$5.00 | $15.00 | None |
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT |
2 |
Preferred Brand |
$25.00 | $75.00 | None |
AZULFIDINE 500MG TABLET |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZULFIDINE EN TABLET S 500MG TABLET 6 X (300 CT)PL |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None |