2015 Medicare Part D Plan Formulary Information |
Health Alliance Medicare PPO10 Rx (PPO) (H1417-002-0)
Benefit Details
|
The Health Alliance Medicare PPO10 Rx (PPO) (H1417-002-0) Formulary Drugs Starting with the Letter P in BOONE County, IL: CMS MA Region 14 which includes: IL Plan Monthly Premium: $141.00 Deductible: $200 |
Drugs Starting with Letter P
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
PACERONE 100MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PACERONE 200MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PACERONE 400MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PACLITAXEL INJECTION SOLUTION 6MG 50ML VIALMD |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PAMIDRONATE 60MG/10ML VIAL |
1* |
Preferred Generic |
$0.00 | $30.00 | P |
PAMIDRONATE DISODIUM INJECTION 3MG 10ML VIALSD |
1* |
Preferred Generic |
$0.00 | $30.00 | P |
PAMIDRONATE DISODIUM INJECTION 9MG 10ML VIALSD |
1* |
Preferred Generic |
$0.00 | $30.00 | P |
PANRETIN 0.1% GEL 60GM TUBE |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Pantoprazole 40mg/1 90 TABLET, DELAYED RELEASE in 1 BOTTLE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PANTOPRAZOLE SODIUM 20MG TABLET DELAYED RELEASE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PARICALCITOL 1 MCG CAPSULE [Zemplar] |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
PARICALCITOL 2 MCG CAPSULE [Zemplar] |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
PARICALCITOL 2 MCG/ML VIAL [Zemplar] |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
PARICALCITOL 4 MCG CAPSULE [Zemplar] |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
PARICALCITOL 5 MCG/ML VIAL [Zemplar] |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
PAROMOMYCIN 250MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Paroxetine 40mg/1 500 FILM COATED TABLETS in BOTTLE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PAROXETINE FILM COATED 20MG TABLET (100 CT) |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PAROXETINE HCL TABLET 24 12.5MG |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PAROXETINE HCL TABLET 24 25MG |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Paroxetine Hydrochloride 37.5mg/1 30 BOTTLE in 1 BOTTLE / 30 TABLET, FILM COATED, EXTENDED RELEASE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAROXETINE HYDROCHLORIDE TABLETS 10 MG |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PAROXETINE TABLETS 30MG 90 BOT |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PASER GRANULES 4GM PACKET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
PATADAY 0.2% DROPS |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
PATANOL 0.1% EYE DROPS |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
PAXIL ORAL SUSPENSION 10 MG/5ML |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
PAZEO 0.7% EYE DROPS |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
PCE 333 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
PCE 500 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
PEDVAXHIB VACCINE VIAL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
PEG-3350 and Electrolytes 236; 2.97; 6.74; 5.86; 22.74g/2L; g/2L; g/2L; g/2L; g/2L 4 L in 1 JUG |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEGANONE 250 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Pegasys 180ug/0.5mL 1 PACKET in 1 BOX / 4 SYRINGE, GLASS in 1 PACKET / 0.5 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
28% | 28% | P |
PEGASYS INJECTION |
5 |
Specialty Tier |
28% | 28% | P |
PEGASYS PROCLICK 135 MCG/0.5 |
5 |
Specialty Tier |
28% | 28% | P |
PEGASYS PROCLICK 180 MCG/0.5 |
5 |
Specialty Tier |
28% | 28% | P |
PEGINTRON 1 KIT per CARTON |
5 |
Specialty Tier |
28% | 28% | P |
PEGINTRON 120 MCG KIT |
5 |
Specialty Tier |
28% | 28% | P |
PegIntron 120ug/0.5mL 1 CARTRIDGE per CARTON / 0.5 mL in 1 CARTRIDGE |
5 |
Specialty Tier |
28% | 28% | P |
PEGINTRON 150 MCG KIT |
5 |
Specialty Tier |
28% | 28% | P |
PegIntron 150ug/0.5mL 1 CARTRIDGE per CARTON / 0.5 mL in 1 CARTRIDGE |
5 |
Specialty Tier |
28% | 28% | P |
PegIntron 50ug/0.5mL 1 CARTRIDGE per CARTON / 0.5 mL in 1 CARTRIDGE |
5 |
Specialty Tier |
28% | 28% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEGINTRON 80 MCG KIT |
5 |
Specialty Tier |
28% | 28% | P |
PegIntron 80ug/0.5mL 1 CARTRIDGE per CARTON / 0.5 mL in 1 CARTRIDGE |
5 |
Specialty Tier |
28% | 28% | P |
PENICILLIN G POTASSIUM 2MMUNITS/50ML ISO-OSM |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PENICILLIN G POTASSIUM 3MMUNITS/50ML ISO-OSM |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PENICILLIN G POTASSIUM FOR INJECTION 5000000UNIT/VIAL |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PENICILLIN G PROCAINE 1200000UNT 2ML CTG |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Penicillin V Potassium 125mg/5mL 200 mL in 1 BOTTLE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Penicillin V Potassium 250mg/1 1000 TABLET BOTTLE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PENICILLIN V POTASSIUM 500MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PENTAM 300 INJ 300MG |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENTOXIFYLLINE 400MG TABLET SA |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Perindopril Erbumine 2mg/1 100 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Perindopril Erbumine 4mg/1 100 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Perindopril Erbumine 8mg/1 100 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
PERIOGARD 0.12% ORAL RINSE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PERJETA 420 MG/14 ML VIAL |
5 |
Specialty Tier |
28% | 28% | P |
Permethrin 50mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Perphenazine 16mg/1 100 FILM COATED TABLETS in BOTTLE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PERPHENAZINE TABLETS 4MG 100 BOXUD |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PERPHENAZINE TABLETS 8MG 100 BOT |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PERPHENAZINE TABLETS USP 2MG 100 BOT |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEXEVA 10MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S |
PEXEVA 20MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S |
PEXEVA 30MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S |
PEXEVA 40MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S |
Pfizerpen 5000000[iU]/1 10 VIAL in 1 CARTON / 1 POWDER, FOR SOLUTION in 1 VIAL |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Phenelzine Sulfate 15mg/1 60 TABLET BOTTLE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Phenobarbital 100mg/1 |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Phenobarbital 15mg/1 |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
PHENOBARBITAL 16.2 MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
PHENOBARBITAL 20 MG/5 ML ELIX |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Phenobarbital 30mg/1 |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PHENOBARBITAL 32.4 MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Phenobarbital 60mg/1 |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
PHENOBARBITAL 64.8 MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
PHENOBARBITAL 97.2 MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
PHENYTEK 200 MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
PHENYTEK 300 MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
phenytoin 50 mg tablet chew |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PHENYTOIN SOD EXT 200 MG CAP |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PHENYTOIN SODIUM 100MG /2ML INJECTION |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT) |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Phoslyra 667mg/5mL 1 BOTTLE per CARTON / 473 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
PHOSPHOLINE IODIDE 0.125% 6.25MG |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
PILOCARPINE 1% EYE DROPS |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PILOCARPINE 2% EYE DROPS |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PILOCARPINE 4% EYE DROPS |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PILOCARPINE HCL 5MG TABLET (100 CT) |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Pilocarpine Hydrochloride 7.5mg/1 100 FILM COATED TABLETS in BOTTLE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PIMTREA 28 DAY TABLET |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
PINDOLOL 10MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PINDOLOL 5MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
pioglitaz-glimepir 30-2 mg tab |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
pioglitaz-glimepir 30-4 mg tab |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
pioglitazone hcl 15 mg tablet [Actos] |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
pioglitazone hcl 30 mg tablet [Actos] |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
pioglitazone hcl 45 mg tablet [Actos] |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
PIOGLITAZONE-METFORMIN 15-500 |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
PIOGLITAZONE-METFORMIN 15-850 |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
PIPERACILLIN 200 MG/ML / TAZOBACTAM 25 MG/ML INJECTABLE SOLUTION |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Piperacillin and Tazobactam 4; 0.5g/1; g/1 10 VIAL, SINGLE-USE per CARTON / 1 INJECTION, POWDER, L |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Pirmella 1-35-28 tablet |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
PIROXICAM 10 MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Piroxicam 20mg/1 500 CAPSULE BOTTLE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PLASMA-LYTE 148 IV SOLUTION |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
PLASMA-LYTE 56/DEXTROSE 5% |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
PLASMA-LYTE A PH 7.4 SOLUTION 37;368; MG/100ML; |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
PODOFILOX 0.5% TOPICAL TUBEX |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT) |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
polymyxin b 5000001/1 1 VIAL in 1 CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1% |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
POMALYST 1 MG CAPSULE |
5 |
Specialty Tier |
28% | 28% | P Q:21 /28Days |
POMALYST 2 MG CAPSULE |
5 |
Specialty Tier |
28% | 28% | P Q:21 /28Days |
POMALYST 3 MG CAPSULE |
5 |
Specialty Tier |
28% | 28% | P Q:21 /28Days |
POMALYST 4 MG CAPSULE |
5 |
Specialty Tier |
28% | 28% | P Q:21 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PORTIA 0.15-0.03 TABLET |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.9% 1000ML |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
POTASSIUM CHLORIDE 40MEQ/NS 1000ML IV SOLUTION |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
POTASSIUM CHLORIDE 750MG EXTENDED RELEASE TABLETS |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
POTASSIUM CHLORIDE ER CAPSULES 10MEQ |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
POTASSIUM CHLORIDE ER CPCR 8MEQ |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Potassium Chloride in Dextrose 5; 150g/100mL; mg/100mL 1000 mL in 1 BAG |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Potassium Chloride in Dextrose and Sodium Chloride 5; 0.15; 0.33g/100mL; g/100mL; g/100mL 12 CONTAI |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Potassium Chloride in Dextrose and Sodium Chloride 5; 0.15; 0.45g/100mL; g/100mL; g/100mL 12 CONTAI |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Potassium Chloride in Dextrose and Sodium Chloride 5; 300; 900g/100mL; mg/100mL; mg/100mL 1000 mL i |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Potassium Chloride in Lactated Ringers and Dextrose 20; 5; 179; 600; 310mg/100mL; g/100mL; mg/100mL |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
POTASSIUM CHLORIDE INJECTION 10MEQ/100ML |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
POTASSIUM CHLORIDE INJECTION 20 MEQ/100ML |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
POTASSIUM CHLORIDE INJECTION 40 MEQ/100ML |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
POTASSIUM CITRATE ER 10 MEQ TB |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
POTASSIUM CITRATE ER 15 MEQ TABLET |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
POTASSIUM CITRATE ER 5 MEQ TAB |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CITRATE ER 8 MEQ TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Potassium Cl 10% (20 MEQ/15 ML) |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Potassium cl 2 meq/ml vial |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Potassium Cl 20% (40 MEQ/15 ML) |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
POTASSIUM CL ER 20 MEQ TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
POTIGA 200 MG TABLET |
5 |
Specialty Tier |
28% | 28% | None |
POTIGA 300 MG TABLET |
5 |
Specialty Tier |
28% | 28% | None |
POTIGA 400 MG TABLET |
5 |
Specialty Tier |
28% | 28% | None |
POTIGA 50 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
PRADAXA 150mg/1 1 BOTTLE per CARTON / 60 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
PRADAXA 75mg/1 1 BOTTLE per CARTON / 60 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Pramipexole Dihydrochloride 0.125mg/1 500 TABLET BOTTLE, PLASTIC |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Pramipexole Dihydrochloride 0.25mg/1 500 TABLET BOTTLE, PLASTIC |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Pramipexole Dihydrochloride 0.5mg/1 500 TABLET BOTTLE, PLASTIC |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PRAMIPEXOLE DIHYDROCHLORIDE 0.75MG TABLETS |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Pramipexole Dihydrochloride 1.5mg/1 500 TABLET BOTTLE, PLASTIC |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Pramipexole Dihydrochloride 1mg/1 500 TABLET BOTTLE, PLASTIC |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PRANDIMET 1MG/500MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
PRANDIMET 2MG/500MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Prandin 0.5mg/1 100 TABLET BOTTLE, PLASTIC |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Prandin 1mg/1 100 TABLET BOTTLE, PLASTIC |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Prandin 2mg/1 100 TABLET BOTTLE, PLASTIC |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAVASTATIN SODIUM 20MG TABLET 500 BOT |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PRAVASTATIN SODIUM 40MG TABLET (500 CT) |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Pravastatin Sodium 80mg/1 1000 TABLET BOTTLE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PRAZOSIN 5MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PRAZOSIN HCL 1MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PRAZOSIN HCL 2MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PREDNICARBATE 0.1% OINTMENT |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
PREDNICARBATE 1 MG/ML TOPICAL CREAM |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Prednisolone odt 10 mg tablet |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Prednisolone odt 15 mg tablet |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Prednisolone odt 30 mg tablet |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
PREDNISOLONE SOD 1% EYE DROP |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PREDNISOLONE SOD PH 25 MG/5 ML |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PREDNISOLONE SODIUM PHOSPHATE 5MG /5ML ORAL SOLUTION |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PREDNISONE 10MG TABLET (100 CT) |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PREDNISONE 1MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PREDNISONE 2.5MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PREDNISONE 20MG TABLET (1000 CT) |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PREDNISONE 5 MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISONE 50MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PREDNISONE 5MG/5ML SOLUTION |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PREDNISONE 5MG/ML SOLUTION |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
PREGNYL INJ 10000UNT |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
Premarin 0.625mg/g |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
PREMARIN 25MG VIAL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
PREMASOL 10% IV SOLUTION |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
PREMASOL 6% IV SOLUTION |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
PREPOPIK POWDER PACKET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
PREVALITE POW 4GM |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Previfem 6 BLISTER PACK per BLISTER PACK / 1 KIT per BLISTER PACK |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREZCOBIX 800 MG-150 MG TABLET |
5 |
Specialty Tier |
28% | 28% | None |
PREZISTA 100 MG/ML SUSPENSION |
5 |
Specialty Tier |
28% | 28% | None |
PREZISTA 150MG TABLETS |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
PREZISTA 800 MG TABLET |
5 |
Specialty Tier |
28% | 28% | None |
PREZISTA TABLET 600MG |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
PREZISTA TABLET 75MG |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
PRIFTIN 150MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
PRIMAQUINE 26.3MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Primidone 250mg/1 100 TABLET BOTTLE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Primidone 50mg/1 500 TABLET BOTTLE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PRIMSOL 50MG/5ML ORAL SOLUTION |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRISTIQ 100MG TABLET SR 24HR |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S Q:31 /31Days |
PRISTIQ ER 25 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S Q:31 /31Days |
Pristiq Extended-Release 50mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S Q:31 /31Days |
PRIVIGEN 10% VIAL |
5 |
Specialty Tier |
28% | 28% | P |
PROBENECID 500MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PROBENECID/COLCHICINE 0.5MG/500MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PROCAINAMIDE 100MG/ML VIAL |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PROCAINAMIDE 500MG/ML VIAL |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
ProcalAmine 0.21; 0.29; 0.026; 0.014; 3; 0.42; 0.085; 0.21; 0.27; 0.22; 0.054; 0.16; 0.17; 0.041; 0 |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
PROCENTRA 5 MG/5 ML SOLUTION |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
Prochlorperazine 10 mg/2 ml vl |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT) |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Prochlorperazine Maleate 5mg/1 100 FILM COATED TABLETS in BOTTLE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PROCRIT 10000U/ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
PROCRIT 3,000 UNITS/ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
PROCRIT 4,000 UNITS/ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
PROCRIT 40000U/ML VIAL PR |
5 |
Specialty Tier |
28% | 28% | P |
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY |
5 |
Specialty Tier |
28% | 28% | P |
procto-pak 1% cream |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
PROCTOSOL-HC 2.5% CREAM |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
proctozone-hc 2.5% cream |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
PROCYSBI DR 25 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
PROCYSBI DR 75 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
PROGESTERONE 100 MG CAPSULE |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
PROGESTERONE 200 MG CAPSULE |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Proglycem 50mg/mL 1 BOTTLE, DROPPER in 1 BOX / 30 mL in 1 BOTTLE, DROPPER |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
PROLEUKIN 22 MILLION UNIT VIAL |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
PROLIA 60MG/ML INJECTION |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
PROMACTA 12.5 MG TABLET |
5 |
Specialty Tier |
28% | 28% | P |
PROMACTA 25 MG TABLET |
5 |
Specialty Tier |
28% | 28% | P |
PROMACTA 50 MG TABLET |
5 |
Specialty Tier |
28% | 28% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMACTA 75 MG TABLET |
5 |
Specialty Tier |
28% | 28% | P |
Propafenone HCl 150mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
PROPAFENONE HCL 225MG TABLET |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
PROPAFENONE HCL 300MG TABLET (100 CT) |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Propafenone Hydrochloride 225mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
PROPAFENONE HYDROCHLORIDE 325MG CAPSULES EXTENDED RELEASE |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
PROPAFENONE HYDROCHLORIDE 425MG CAPSULES EXTENDED RELEASE |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
Propantheline Bromide 15mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
2* |
Non-Preferred Generic |
$33.00 | $99.00 | None |
PROPARACAINE 0.5% EYE DROPS |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Propranolol 1mg/mL 1 mL in 1 VIAL |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PROPRANOLOL 20MG/5ML TUBEX |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPRANOLOL 40MG/5ML TUBEX |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PROPRANOLOL 60MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PROPRANOLOL 80 MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PROPRANOLOL ER 120 MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PROPRANOLOL ER 160 MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PROPRANOLOL HCL 20MG TABLET (1000 CT) |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PROPRANOLOL HCL TABLET USP 10MG (1000 CT) |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PROPRANOLOL HCL TABLET USP 40MG (1000 CT) |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Propranolol Hydrochloride 60mg/1 1000 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Propranolol Hydrochloride 80mg/1 500 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PROPRANOLOL/HCTZ 40/25 TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPRANOLOL/HCTZ 80/25 TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PROPYLTHIOURACIL 50MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PROQUAD 0.5 VIAL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
PROSOL 20% INJECTION |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
PROTRIPTYLINE HYDROCHLORIDE 10MG TABLETS |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Prudoxin 5% cream |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
PULMICORT 1MG/2ML AMPUL FOR NEBULIZATION |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
PULMICORT FLEXHALER 180MCG AEROSOL POWDER BREATH ACTIVATED |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
PULMICORT FLEXHALER 90MCG AEROSOL POWDER BREATH ACTIVATED |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
PULMOZYME 1MG/ML AMPUL |
5 |
Specialty Tier |
28% | 28% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PURIXAN 20 MG/ML ORAL SUSP |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
PYLERA CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
PYRAZINAMIDE 500 MG TABLET |
1* |
Preferred Generic |
$0.00 | $30.00 | None |
Pyridostigmine br 60 mg tablet |
1* |
Preferred Generic |
$0.00 | $30.00 | None |