2014 Medicare Part D Plan Formulary Information |
Blue Cross MedicareRx Basic (PDP) (S5715-014-0)
Benefit Details
|
The Blue Cross MedicareRx Basic (PDP) (S5715-014-0) Formulary Drugs Starting with the Letter A in CMS PDP Region 22 which includes: TX Plan Monthly Premium: $23.10 Deductible: $310 Qualifies for LIS: Yes |
Drugs Starting with Letter A
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
ABACAVIR 300 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | Q:60 /30Days |
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir] |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
ABILIFY 10MG TABLET |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:30 /30Days |
ABILIFY 15MG TABLET |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:30 /30Days |
ABILIFY 1MG/ML SOLUTION |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:750 /30Days |
ABILIFY 20MG TABLET |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:30 /30Days |
ABILIFY 2MG TABLET |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:30 /30Days |
ABILIFY 30MG TABLET |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:30 /30Days |
ABILIFY 5MG TABLET (OTSUKA) |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:30 /30Days |
ABILIFY DISCMELT 10MG TABLET |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABILIFY DISCMELT 15MG TABLET |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:60 /30Days |
ABILIFY INJ 9.75MG |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:117 /30Days |
ABILIFY MAINTENA ER 300 MG VL |
5 |
Specialty Tier |
25% | N/A | Q:1 /30Days |
ABRAXANE 100MG VIAL |
5 |
Specialty Tier |
25% | N/A | None |
Acarbose 100mg/1 1000 TABLET BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | Q:90 /30Days |
ACARBOSE 25 MG TABLETS |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | Q:360 /30Days |
Acarbose 50mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | Q:180 /30Days |
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | None |
Acetaminophen and Codeine Phosphate 300; 60mg/1; mg/1 500 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | Q:180 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | Q:2700 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | Q:360 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | Q:360 /30Days |
ACETASOL HC SOLUTION 10ML 10 ML BOT |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
ACETYLCYSTEINE 10% VIAL |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | P |
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | P |
ACITRETIN 10 MG CAPSULE [Soriatane] |
5 |
Specialty Tier |
25% | N/A | None |
ACITRETIN 17.5 MG CAPSULE [Soriatane] |
5 |
Specialty Tier |
25% | N/A | None |
ACITRETIN 25 MG CAPSULE [Soriatane] |
5 |
Specialty Tier |
25% | N/A | None |
ACTHIB VACCINE VIAL 10-24UNT/5ML |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | None |
ACTIMMUNE 100 MCG/0.5 ML VIAL |
5 |
Specialty Tier |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Actonel 150mg/1 36 DOSE PACK CASE / 1 TRAY DOSE PACK / 1 FILM COATED TABLETS in TRAY |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:1 /28Days |
Actonel 30mg/1 12 BOTTLE CASE / 30 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:30 /30Days |
Actonel 35mg/1 36 DOSE PACK CASE / 1 TRAY DOSE PACK / 4 FILM COATED TABLETS in TRAY |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:4 /28Days |
Actonel 5mg/1 12 BOTTLE CASE / 30 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:30 /30Days |
ACYCLOVIR 200 MG CAPSULE |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
Acyclovir 200mg/5mL 473 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
Acyclovir 400mg/1 |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
ACYCLOVIR 800 MG TABLET |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
ACYCLOVIR SODIUM 500MG VIAL |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | P |
ADACEL VIAL 2UNT/5UNT |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | None |
ADAGEN 250U/ML VIAL |
5 |
Specialty Tier |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA] |
5 |
Specialty Tier |
25% | N/A | P |
ADCIRCA TABLETS 20MG 60 BOT |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera] |
5 |
Specialty Tier |
25% | N/A | None |
ADVAIR DISKUS MIS 100/50 |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:60 /30Days |
ADVAIR DISKUS MIS 250/50 |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:60 /30Days |
ADVAIR DISKUS MIS 500/50 |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:60 /30Days |
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:12 /30Days |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:12 /30Days |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:12 /30Days |
AFEDITAB CR 30MG TABLET SA |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
AFEDITAB CR 60MG TABLET SA |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
AFINITOR DISPERZ 2 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
AFINITOR DISPERZ 3 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
AFINITOR DISPERZ 5 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
AFINITOR TABLETS 10 MG |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
AFINITOR TABLETS 2.5 MG |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
AFINITOR TABLETS 5 MG |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
AGGRENOX 25-200MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | None |
AK-CON 0.1% EYE DROPS |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | None |
ALA-CORT 1% CREAM |
1 |
Preferred Generic |
$1.00 | $15.00 | None |
ALBENZA 200 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH per CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | P |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | P |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | P |
ALBUTEROL SULFATE SOLUTION FOR INHALATION |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | P |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
1 |
Preferred Generic |
$1.00 | $15.00 | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
1 |
Preferred Generic |
$1.00 | $15.00 | None |
ALBUTEROL TABLET 4MG (500 CT) |
1 |
Preferred Generic |
$1.00 | $15.00 | None |
ALDURAZYME 2.9MG/5ML VIAL |
5 |
Specialty Tier |
25% | N/A | None |
ALENDRONATE SODIUM 10MG TABLET |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | Q:120 /30Days |
Alendronate Sodium 35mg, 4 BLISTER PACK in 1 BOX / 1 TABLET per BLISTER PACK |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | Q:4 /28Days |
ALENDRONATE SODIUM 5MG TABLET |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Alendronate Sodium 70 mg tab |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | Q:4 /28Days |
ALIMTA 500MG VIAL |
5 |
Specialty Tier |
25% | N/A | None |
ALINIA 100MG/5ML SUSPENSION |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | None |
ALINIA 500 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | None |
ALLOPURINOL 100 MG TABLETS |
1 |
Preferred Generic |
$1.00 | $15.00 | None |
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET per BLISTER PACK |
1 |
Preferred Generic |
$1.00 | $15.00 | None |
ALOXI 0.25 MG/5 ML |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | None |
AMANTADINE 100MG CAPSULE |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
Amantadine Hydrochloride 50mg/5mL 473 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
AMBISOME 50MG VIAL |
5 |
Specialty Tier |
25% | N/A | P |
Amethia 2 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMIFOSTINE 50mg/mL 3 VIAL, SINGLE-USE per CARTON / 10 mL in 1 VIAL, SINGLE-USE |
5 |
Specialty Tier |
25% | N/A | None |
AMIKACIN SULFATE 500 MG/2 ML VIAL |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
AMIODARONE HCL 200MG 60 TABLET BOTTLE |
1 |
Preferred Generic |
$1.00 | $15.00 | None |
AMIODARONE HCL 400MG TABLET |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
AMITIZA 8MCG CAPSULE |
3 |
Preferred Brand |
$39.00 | $112.50 | P |
AMITIZA CAPSULES 24MCG 60 CAP BOT |
3 |
Preferred Brand |
$39.00 | $112.50 | P |
AMITRIPTYLINE HCL 100MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | P |
AMITRIPTYLINE HCL 10MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | P |
AMITRIPTYLINE HCL 150 MG TAB |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | P |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | P |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | P |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
1 |
Preferred Generic |
$1.00 | $15.00 | None |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1 |
Preferred Generic |
$1.00 | $15.00 | None |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
1 |
Preferred Generic |
$1.00 | $15.00 | None |
ammonium lactate 12% cream |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
AMMONIUM LACTATE 12% LOTION |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
Amnesteem 10mg/1 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | None |
Amnesteem 20mg/1 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | None |
Amnesteem 40mg/1 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | None |
AMOX TR-K CLV 500-125 MG TAB |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
AMOXAPINE 100MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | None |
AMOXAPINE 150MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | None |
AMOXAPINE 25MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | None |
AMOXAPINE 50MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | None |
AMOXICILLIN 250MG CAPSULE |
1 |
Preferred Generic |
$1.00 | $15.00 | None |
AMOXICILLIN 500MG TABLET (100 CT) |
1 |
Preferred Generic |
$1.00 | $15.00 | None |
Amoxicillin 500mg/1 500 CAPSULE BOTTLE, PLASTIC |
1 |
Preferred Generic |
$1.00 | $15.00 | None |
AMOXICILLIN 875MG TABLET |
1 |
Preferred Generic |
$1.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
1 |
Preferred Generic |
$1.00 | $15.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
1 |
Preferred Generic |
$1.00 | $15.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Preferred Generic |
$1.00 | $15.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
1 |
Preferred Generic |
$1.00 | $15.00 | None |
amphotericin b 50mg/10mL 10 mL in 1 VIAL |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | P |
AMPICILLIN CAPSULES 250MG 100 BOT |
1 |
Preferred Generic |
$1.00 | $15.00 | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
1 |
Preferred Generic |
$1.00 | $15.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | None |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | None |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPYRA ER 10 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
Anastrozole 1mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
ANDRODERM 2 MG/24HR PATCH |
3 |
Preferred Brand |
$39.00 | $112.50 | P Q:30 /30Days |
ANDRODERM 4 MG/24HR PATCH |
3 |
Preferred Brand |
$39.00 | $112.50 | P Q:30 /30Days |
ANDROGEL 1%(50MG) GEL PACKET |
3 |
Preferred Brand |
$39.00 | $112.50 | P Q:300 /30Days |
Androgel 16.2mg/g 1 BOTTLE, PUMP per CARTON / 88 g in 1 BOTTLE, PUMP |
3 |
Preferred Brand |
$39.00 | $112.50 | P Q:150 /30Days |
ANDROID 10 MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | P |
ANORO ELLIPTA 62.5-25 MCG INH |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:60 /30Days |
APOKYN 30 MG/3 ML CARTRIDGE |
5 |
Specialty Tier |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APRI 0.15-0.03 TABLET |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
APRISO CP24 |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | None |
APTIOM 200 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | None |
APTIOM 400 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | None |
APTIOM 600 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | None |
APTIOM 800 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | None |
APTIVUS 250MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | Q:120 /30Days |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
5 |
Specialty Tier |
25% | N/A | Q:380 /30Days |
ARANELLE 7-9-5 TABLET |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
ARCALYST INJECTION 220MG/VIAL |
5 |
Specialty Tier |
25% | N/A | P |
ARRANON 250MG VIAL |
5 |
Specialty Tier |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARZERRA 20mg/mL 3 VIAL per CARTON / 5 mL in 1 VIAL |
5 |
Specialty Tier |
25% | N/A | None |
Ascomp with Codeine 325; 50; 40; 30mg/1; mg/1; mg/1; mg/1 500 CAPSULE BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | P Q:180 /30Days |
ASMANEX TWISTHALER 110 MCG #30 |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:1 /30Days |
ASMANEX TWISTHALER 220MCG #120 |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:1 /30Days |
ASMANEX TWISTHALER 220MCG #30 |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:1 /30Days |
ASMANEX TWISTHALER 220MCG #60 |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:1 /30Days |
ASTEPRO 0.15% NASAL SPRAY 30 ML |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:60 /30Days |
ATENOLOL 100 MG TABLET |
1 |
Preferred Generic |
$1.00 | $15.00 | None |
Atenolol 25mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
$1.00 | $15.00 | None |
ATENOLOL TABLET USP 50MG (100 CT) |
1 |
Preferred Generic |
$1.00 | $15.00 | None |
ATORVASTATIN 10 MG TABLET [Lipitor] |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | Q:45 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATORVASTATIN 20 MG TABLET [Lipitor] |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | Q:45 /30Days |
ATORVASTATIN 40 MG TABLET [Lipitor] |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | Q:45 /30Days |
ATORVASTATIN 80 MG TABLET [Lipitor] |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | Q:30 /30Days |
ATOVAQUONE 750 MG/5 ML SUSP [Mepron] |
5 |
Specialty Tier |
25% | N/A | None |
Atovaquone and Proguanil Hydrochloride 250; 100mg/1; mg/1 [Malarone] |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
ATROVENT HFA AER 17MCG |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | Q:26 /30Days |
AVASTIN 100MG/4ML VIAL |
5 |
Specialty Tier |
25% | N/A | None |
AVELOX IV 400MG/250ML |
4 |
Non-Preferred Brand |
$85.00 | $237.50 | None |
AVIANE 0.1-0.02 TABLET |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
AVODART 0.5MG SOFTGEL |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVONEX ADMIN PACK 30MCG SYR |
5 |
Specialty Tier |
25% | N/A | P Q:1 /28Days |
AVONEX ADMIN PACK 30MCG VL |
5 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
Azacitidine 100 mg vial [Vidaza] |
5 |
Specialty Tier |
25% | N/A | None |
AZATHIOPRINE 50MG TABLET |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | P |
AZELASTINE 0.15% NASAL SPRAY |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | Q:60 /30Days |
AZELASTINE 137 MCG NASAL SPRAY |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | Q:60 /30Days |
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
AZILECT 0.5MG TABLET |
3 |
Preferred Brand |
$39.00 | $112.50 | None |
AZILECT 1MG TABLET |
3 |
Preferred Brand |
$39.00 | $112.50 | None |
Azithromycin 100mg/5mL 15 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
Azithromycin 200mg/5mL 22.5 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZITHROMYCIN 250 MG TABLET |
1 |
Preferred Generic |
$1.00 | $15.00 | None |
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
Azithromycin 600mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |
AZOR 10MG-20MG TABLET |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:30 /30Days |
AZOR 10MG-40MG TABLET (30 CT) |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:30 /30Days |
AZOR 5MG-20MG TABLET (30 CT) |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:30 /30Days |
AZOR 5MG-40MG TABLET |
3 |
Preferred Brand |
$39.00 | $112.50 | Q:30 /30Days |
AZTREONAM FOR INJECTION |
2 |
Non-Preferred Generic |
$2.00 | $20.00 | None |