2015 Medicare Part D Plan Formulary Information |
Meridian Prime (HMO) (H5779-002-0)
Benefit Details
|
The Meridian Prime (HMO) (H5779-002-0) Formulary Drugs Starting with the Letter A in BOONE County, IL: CMS MA Region 14 which includes: IL Plan Monthly Premium: $0.00 Deductible: $320 |
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 |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir] |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ABELCENT INJECTION SUSPENSION 5MG/ML |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P |
ABILIFY 10MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
ABILIFY 15MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
ABILIFY 20MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
ABILIFY 2MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
ABILIFY 30MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
ABILIFY 5MG TABLET (OTSUKA) |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
ABILIFY MAINTENA ER 300 MG SYR |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABILIFY MAINTENA ER 300 MG VL |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
ABILIFY MAINTENA ER 400 MG SYR |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
ABRAXANE 100MG VIAL |
5 |
Specialty Tier |
25% | 25% | P |
Acamprosate Calcium DR 333 MG tablets [Campral] |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ACARBOSE 100 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ACARBOSE 25 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Acarbose 50mg/1 100 TABLET BOTTLE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ACEBUTOLOL 200MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ACEBUTOLOL 400MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:5000 /30Days |
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* |
Preferred Generic |
$0.00 | $0.00 | Q:360 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:360 /30Days |
ACETAMINOPHEN-COD #4 TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:360 /30Days |
ACETAZOLAMIDE 125MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ACETAZOLAMIDE ER CAPSULES 500MG 100 BOT |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ACETIC ACID 2% SOLUTION NON-ORAL |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ACETYLCYSTEINE 10% VIAL |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | P |
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | P |
ACITRETIN 10 MG CAPSULE [Soriatane] |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ACITRETIN 17.5 MG CAPSULE [Soriatane] |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACITRETIN 25 MG CAPSULE [Soriatane] |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ACTEMRA INJECTION 200MG/10ML |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P |
ACTHIB VACCINE VIAL 10-24UNT/5ML |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
ACTIMMUNE 100 MCG/0.5 ML VIAL |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
Actonel 150mg 36 DOSE PACK CASE / 1 TRAY DOSE PACK / 1 FILM COATED TABLETS in TRAY |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | S |
Actonel 30mg 12 BOTTLE CASE / 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | S |
Actonel 5mg 12 BOTTLE CASE / 30 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$45.00 | $135.00 | S |
ACTOPLUS MET XR TABLETS ER 15;1000 MG;MG |
3 |
Preferred Brand |
$45.00 | $135.00 | S |
ACTOPLUS MET XR TABLETS ER 30;1000 MG;MG |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | S |
ACUVAIL 0.45% OPHTH SOLUTION #30X0.4 EA |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Acyclovir 200mg 100 CAPSULE BOTTLE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Acyclovir 200mg/5mL 473 mL BOTTLE |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
Acyclovir 400 MG |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Acyclovir 5% Ointment |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ACYCLOVIR 800 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Acyclovir sodium 500 mg vial |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ADACEL VIAL 2UNT/5UNT |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
ADAGEN 250U/ML VIAL |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA] |
5 |
Specialty Tier |
25% | 25% | P |
ADAPALENE 0.1% CREAM |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ADAPALENE 0.1% GEL |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Adapalene 0.3% gel |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADCIRCA TABLETS 20MG 60 BOTTLE |
5 |
Specialty Tier |
25% | 25% | P |
ADDERALL XR 25MG CAPSULE SA |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera] |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ADRUCIL 50mg/mL 10 VIAL in 1 TRAY / 10 mL in 1 VIAL |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK |
5 |
Specialty Tier |
25% | 25% | P |
AFINITOR DISPERZ 2 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
AFINITOR DISPERZ 3 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
AFINITOR DISPERZ 5 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
AFINITOR TABLETS 10 MG |
5 |
Specialty Tier |
25% | 25% | P |
AFINITOR TABLETS 2.5 MG |
5 |
Specialty Tier |
25% | 25% | P |
AFINITOR TABLETS 5 MG |
5 |
Specialty Tier |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AGGRENOX 25-200MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
ALBENZA 200 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH per CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL |
1* |
Preferred Generic |
$0.00 | $0.00 | P |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
1* |
Preferred Generic |
$0.00 | $0.00 | P |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
1* |
Preferred Generic |
$0.00 | $0.00 | P |
ALBUTEROL SULFATE SOLUTION FOR INHALATION |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | P |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ALBUTEROL TABLET 4MG (500 CT) |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALENDRONATE SODIUM 10MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Alendronate Sodium 35mg/1 12 TABLET in 1 BOX, UNIT-DOSE |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ALENDRONATE SODIUM 40MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ALENDRONATE SODIUM 5MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Alendronate Sodium 70mg/1 4 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ALFUZOSIN HYDROCHLORIDE 10mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ALIMTA 500MG VIAL |
5 |
Specialty Tier |
25% | 25% | P |
ALINIA 100MG/5ML SUSPENSION |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
ALINIA 500 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
ALKERAN 50 MG VIAL |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ALLOPURINOL 100 MG TABLETS |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET per BLISTER PACK |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ALOCRIL 2% EYE DROPS |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
ALOMIDE 0.1% EYE DROPS |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
ALOSETRON HCL 0.5 MG TABLET [Lotronex] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ALOSETRON HCL 1 MG TABLET [Lotronex] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ALOXI 0.25 MG/5 ML |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P |
ALPHAGAN P 0.1% DROPS |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
ALPRAZOLAM 0.25 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ALPRAZOLAM 0.5 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ALPRAZOLAM 1 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ALPRAZOLAM 2 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALTABAX 10mg/g 30 g in 1 TUBE |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
AMANTADINE 100MG CAPSULE |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
AMANTADINE 100MG TABLET |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
Amantadine Hydrochloride 50mg/5mL 473 mL in 1 BOTTLE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMBISOME 50MG VIAL |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P |
AMIFOSTINE 50mg/mL 3 VIAL, SINGLE-USE per CARTON / 10 mL in 1 VIAL, SINGLE-USE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMIKACIN SULFATE 500 MG/2 ML VIAL |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | P |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
Aminophylline 25mg/mL 5 TRAY per CARTON / 5 AMPULE in 1 TRAY / 10 mL in 1 AMPULE |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
AMINOSYN HBC INJECTION SULFITE FREE 7% |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN II 10% IV SOLUTION |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
AMINOSYN II 15% IV SOLUTION |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
AMINOSYN II 7% IV SOLUTION |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
AMINOSYN II 8.5% ELECTROLYT |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
AMINOSYN II 8.5% IV SOLUTION |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
AMINOSYN M 3.5% IV SOLUTION |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
AMINOSYN PF INJECTION |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5% |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
AMINOSYN-PF 7% IV SOLUTION |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
AMIODARONE HCL 200MG 60 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
AMIODARONE HCL 400MG TABLET |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITIZA 8MCG CAPSULE |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
AMITIZA CAPSULES 24MCG 60 CAP BOT |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
AMITRIP/CDP 25-10 TABLET |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
AMITRIP/PERPHEN 10-2 TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMITRIP/PERPHEN 10-4 TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMITRIP/PERPHEN 25-2 TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMITRIP/PERPHEN 25-4 TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMITRIP/PERPHEN 50-4 TABLET |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
AMITRIPTYLINE HCL 100MG TABLET |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
AMITRIPTYLINE HCL 10MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMITRIPTYLINE HCL 150 MG TAB |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMLOD-VALSA-HCTZ 10-160-12.5 MG [EXFORGE HCT] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMLOD-VALSA-HCTZ 10-160-25 MG [EXFORGE HCT] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMLOD-VALSA-HCTZ 10-320-25 MG [EXFORGE HCT] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMLOD-VALSA-HCTZ 5-160-12.5 MG [EXFORGE HCT] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMLOD-VALSA-HCTZ 5-160-25 MG [EXFORGE HCT] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMLODIPINE-BENAZEPRIL 10-40 MG |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMLODIPINE-BENAZEPRIL 5-40 MG |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMLODIPINE-VALSARTAN 10-160 MG |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMLODIPINE-VALSARTAN 10-320 MG |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMLODIPINE-VALSARTAN 5-160 MG |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMLODIPINE-VALSARTAN 5-320 MG |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMMONIUM LACTATE 12% LOTION |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Amnesteem 10mg/1 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
Amnesteem 20mg/1 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
Amnesteem 40mg/1 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
amox tr-k clv 200-28.5/5 susp |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
AMOX TR-K CLV 500-125 MG TAB |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
AMOXAPINE 100MG TABLET |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
AMOXAPINE 150MG TABLET |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXAPINE 25MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMOXAPINE 50MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMOXICILLIN 125MG TABLET CHEW |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMOXICILLIN 250MG 500 CHEWABLE TABLET in BOTTLE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMOXICILLIN 250MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
AMOXICILLIN 500MG 500 CAPSULE BOTTLE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMOXICILLIN 500MG TABLET (100 CT) |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMOXICILLIN 875MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
AMPHETAMINE SALT COMBO 15MG TABLET |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
AMPHETAMINE SALT COMBO 30MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
AMPHETAMINE SALTS 20MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMPHETAMINE SALTS 5 MG TAB |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
amphotericin b 50mg/10mL 10 mL in 1 VIAL |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
AMPICILLIN CAPSULES 250MG 100 BOT |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMPICILLIN FOR INJECTION POWDER |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
AMPICILLIN-SULBACTAM 15 GM VIAL |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
AMPICILLIN-SULBACTAM 3 GM VIAL |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
AMPICILLIN-SULBACTAM FOR INJECTION |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPYRA ER 10 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P |
ANAFRANIL 25 MG 30 CAPSULE BOTTLE |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ANAFRANIL 50 MG 30 CAPSULE BOTTLE |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ANAFRANIL 75 MG 30 CAPSULE BOTTLE |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Anastrozole 1mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ANDROGEL 1.62% (1.25G) GEL PCKT |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ANDROGEL 1.62% (2.5G) GEL PCKT |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ANDROGEL 1% (50MG) GEL PACKET |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
Androgel 10mg/g 2 BOTTLE, PUMP in 1 CARTON / 75 g in 1 BOTTLE, PUMP |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Androgel 10mg/g 30 PACKET in 1 CARTON / 2.5 g in 1 PACKET |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
Androgel 16.2mg/g 1 BOTTLE, PUMP per CARTON / 88 g in 1 BOTTLE, PUMP |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
ANDROID 10 MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P |
ANZEMET 100MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P |
ANZEMET 20MG/ML VIAL |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P |
ANZEMET 50MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P |
APIDRA 100 UNITS/ML VIAL |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
APIDRA SOLOSTAR 100 UNITS/ML |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
APLENZIN ER 174 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
APLENZIN ER 348 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
APLENZIN ER 522 MG TABLET |
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 |
APOKYN 30 MG/3 ML CARTRIDGE |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
Apraclonidine Ophthalmic 5mg/mL 1 BOTTLE, DROPPER per CARTON / 10 mL in 1 BOTTLE, DROPPER |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
APRISO CP24 |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
APTIOM 200 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
APTIOM 400 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
APTIOM 600 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
APTIOM 800 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
APTIVUS 250MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
ARALAST NP 500 MG VIAL |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
ARANELLE 7-9-5 TABLET |
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 |
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.5 mL in 1 SYRINGE |
5 |
Specialty Tier |
25% | 25% | P |
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
5 |
Specialty Tier |
25% | 25% | P |
ARANESP 200MCG/0.4ML SYRINGE |
5 |
Specialty Tier |
25% | 25% | P |
ARANESP 200MCG/ML VIAL |
5 |
Specialty Tier |
25% | 25% | P |
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.42 mL in 1 SYRING |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P |
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P |
ARANESP 300MCG/ML VIAL |
5 |
Specialty Tier |
25% | 25% | P |
ARANESP 500MCG/1ML SYRINGE |
5 |
Specialty Tier |
25% | 25% | P |
ARANESP 60MCG/ML VIAL |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P |
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.3 mL in 1 SYRINGE |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P |
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR |
5 |
Specialty Tier |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR |
5 |
Specialty Tier |
25% | 25% | P |
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P |
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P |
ARCALYST INJECTION 220MG/VIAL |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
ARIMIDEX 1MG TABLET |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ARIPIPRAZOLE 10 MG TABLET [Abilify] |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ARIPIPRAZOLE 15 MG TABLET [Abilify] |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ARIPIPRAZOLE 2 MG TABLET [Abilify] |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ARIPIPRAZOLE 20 MG TABLET [Abilify] |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ARIPIPRAZOLE 30 MG TABLET [Abilify] |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ARIPIPRAZOLE 5 MG TABLET [Abilify] |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AROMASIN 25MG TABLET |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ARRANON 250MG VIAL |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
ARZERRA 20mg/mL 3 VIAL per CARTON / 5 mL in 1 VIAL |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
ASACOL HD 800mg/1 12 BOTTLE CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
ASMANEX TWISTHALER 110 MCG #30 |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
ASMANEX TWISTHALER 220 MCG #30 |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
ASMANEX TWISTHALER 220MCG #120 |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
ASMANEX TWISTHALER 220MCG #60 |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
ASPIRIN/BUTALBITAL/CAFFEINE/CODEINE |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | Q:360 /30Days |
ASTAGRAF XL 0.5 MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
ASTAGRAF XL 1 MG CAPSULE |
3 |
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 5 MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P |
ATENOLOL 100 MG100 TABLET BOTTLE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ATENOLOL 25 MG 100 TABLET BOTTLE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ATENOLOL TABLET USP 50MG (100 CT) |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ATENOLOL-CHLORTHALIDONE 100-25 |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ATGAM 50MG/ML AMPUL |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
ATORVASTATIN 10 MG TABLET [Lipitor] |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ATORVASTATIN 20 MG TABLET [Lipitor] |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ATORVASTATIN 40 MG TABLET [Lipitor] |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
ATORVASTATIN 80 MG TABLET [Lipitor] |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATOVAQUONE 750 MG/5 ML SUSP [Mepron] |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone] |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
ATROVENT HFA AER 17MCG |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
AUBRA-28 TABLET |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
AUGMENTED BETAMETHASONE DIPROPIONATE OINTMENT |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AUVI-Q 0.3 MG AUTO-INJECTOR |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
AVANDAMET 1000; 2mg/1; mg/1 60 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
AVANDIA 2 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
AVANDIA 4 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
AVANDIA 8 MG TABLET |
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 |
AVASTIN 100MG/4ML VIAL |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
AVELOX 400MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
AVELOX ABC PACK 400MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
AVELOX IV 400MG/250ML |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
AVIANE 0.1-0.02 TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
AVODART 0.5MG SOFTGEL |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
AVONEX ADMIN PACK 30MCG SYR |
5 |
Specialty Tier |
25% | 25% | P |
AVONEX ADMIN PACK 30MCG VL |
5 |
Specialty Tier |
25% | 25% | P |
AVONEX PEN 30 MCG/0.5 ML KIT |
5 |
Specialty Tier |
25% | 25% | P |
AXIRON 30mg/1.5mL 1 BOTTLE, WITH APPLICATOR per CARTON / 90 mL in 1 BOTTLE, WITH APPLICATOR |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Azacitidine 100 mg vial [Vidaza] |
5 |
Specialty Tier |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZACTAM INJECTION 1GM/50ML |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
AZACTAM INJECTION 2GM/50ML |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
AZASAN 100MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
AZASAN 75MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
AZATHIOPRINE 50MG TABLET |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | P |
AZELASTINE 137 MCG NASAL SPRAY |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
AZILECT 0.5MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
AZILECT 1MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
Azithromycin 100mg/5mL 15 mL in 1 BOTTLE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Azithromycin 200mg/5mL 22.5 mL in 1 BOTTLE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZITHROMYCIN 250 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Azithromycin 600mg/1 30 FILM COATED TABLETS in BOTTLE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None |
AZOR 5MG-20MG TABLET (30 CT) |
3 |
Preferred Brand |
$45.00 | $135.00 | S |
AZOR 5MG-40MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | S |
AZTREONAM FOR INJECTION |
2* |
Non-Preferred Generic |
$5.00 | $15.00 | None |