2015 Medicare Part D Plan Formulary Information |
Gateway Health Medicare Assured Choice (HMO) (H9190-017-0)
Benefit Details
|
The Gateway Health Medicare Assured Choice (HMO) (H9190-017-0) Formulary Drugs Starting with the Letter A in WAYNE County, KY: CMS MA Region 13 which includes: KY Plan Monthly Premium: $57.90 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 |
ABACAVIR 300 MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir] |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
ABILIFY 10MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | Q:30 /30Days |
ABILIFY 15MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | Q:30 /30Days |
ABILIFY 20MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | Q:30 /30Days |
ABILIFY 2MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | Q:30 /30Days |
ABILIFY 30MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | Q:30 /30Days |
ABILIFY 5MG TABLET (OTSUKA) |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | Q:30 /30Days |
ABILIFY MAINTENA ER 300 MG SYR |
5 |
Specialty Tier |
33% | N/A | P Q:1 /30Days |
ABILIFY MAINTENA ER 300 MG VL |
5 |
Specialty Tier |
33% | N/A | P Q:1 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABILIFY MAINTENA ER 400 MG SYR |
5 |
Specialty Tier |
33% | N/A | P Q:1 /30Days |
Acamprosate Calcium DR 333 MG tablets [Campral] |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
ACARBOSE 100 MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:90 /30Days |
ACARBOSE 25 MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Acarbose 50mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:90 /30Days |
ACEBUTOLOL 200MG CAPSULE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
ACEBUTOLOL 400MG CAPSULE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | Q:2700 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | Q:180 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAMINOPHEN-COD #4 TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | Q:180 /30Days |
ACETAZOLAMIDE 125MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
ACETAZOLAMIDE ER CAPSULES 500MG 100 BOT |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
ACETIC ACID 2% SOLUTION NON-ORAL |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
ACETYLCYSTEINE 10% VIAL |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
ACITRETIN 10 MG CAPSULE [Soriatane] |
5 |
Specialty Tier |
33% | N/A | P |
ACITRETIN 17.5 MG CAPSULE [Soriatane] |
5 |
Specialty Tier |
33% | N/A | P |
ACITRETIN 25 MG CAPSULE [Soriatane] |
5 |
Specialty Tier |
33% | N/A | P |
ACTHIB VACCINE VIAL 10-24UNT/5ML |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTIMMUNE 100 MCG/0.5 ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
Actonel 30mg 12 BOTTLE CASE / 30 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days |
Actonel 35mg 36 DOSE PACK CASE / 1 TRAY DOSE PACK / 4 FILM COATED TABLETS in TRAY |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:4 /30Days |
Actonel 5mg 12 BOTTLE CASE / 30 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days |
Acyclovir 200mg 100 CAPSULE BOTTLE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Acyclovir 200mg/5mL 473 mL BOTTLE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Acyclovir 400 MG |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Acyclovir 5% Ointment |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
ACYCLOVIR 800 MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Acyclovir sodium 500 mg vial |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
ADACEL VIAL 2UNT/5UNT |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADAGEN 250U/ML VIAL |
3 |
Preferred Brand |
$45.00 | $90.00 | P |
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA] |
5 |
Specialty Tier |
33% | N/A | P Q:12 /28Days |
ADAPALENE 0.1% CREAM |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
ADAPALENE 0.1% GEL |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Adapalene 0.3% gel |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
ADCIRCA TABLETS 20MG 60 BOTTLE |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera] |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | Q:30 /30Days |
ADVAIR DISKUS MIS 100/50 |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days |
ADVAIR DISKUS MIS 250/50 |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days |
ADVAIR DISKUS MIS 500/50 |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days |
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days |
AFEDITAB CR 30MG TABLET SA |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AFEDITAB CR 60MG TABLET SA |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
AFINITOR DISPERZ 2 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
AFINITOR DISPERZ 3 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
AFINITOR DISPERZ 5 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
AFINITOR TABLETS 10 MG |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
AFINITOR TABLETS 2.5 MG |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
AFINITOR TABLETS 5 MG |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
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 | $90.00 | None |
AK-CON 0.1% EYE DROPS |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
ALBENZA 200 MG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | 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 |
$4.00 | $8.00 | P Q:375 /30Days |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
1 |
Preferred Generic |
$4.00 | $8.00 | P Q:375 /30Days |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
1 |
Preferred Generic |
$4.00 | $8.00 | P Q:80 /30Days |
ALBUTEROL SULFATE SOLUTION FOR INHALATION |
1 |
Preferred Generic |
$4.00 | $8.00 | P Q:375 /30Days |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL TABLET 4MG (500 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
ALDURAZYME 2.9MG/5ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
ALENDRONATE SODIUM 10MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | Q:30 /30Days |
Alendronate Sodium 35mg/1 12 TABLET in 1 BOX, UNIT-DOSE |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:4 /30Days |
ALENDRONATE SODIUM 40MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | Q:30 /30Days |
ALENDRONATE SODIUM 5MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | Q:30 /30Days |
Alendronate Sodium 70 mg/75 ml |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Alendronate Sodium 70mg/1 4 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
ALFUZOSIN HYDROCHLORIDE 10mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
ALIMTA 500MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
ALINIA 100MG/5ML SUSPENSION |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALINIA 500 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ALLOPURINOL 100 MG TABLETS |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET per BLISTER PACK |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
ALOSETRON HCL 0.5 MG TABLET [Lotronex] |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P |
ALOSETRON HCL 1 MG TABLET [Lotronex] |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P |
ALPHAGAN P 0.1% DROPS |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
ALPRAZOLAM 0.25 MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P Q:120 /30Days |
Alprazolam 0.25mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PAC |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P Q:120 /30Days |
ALPRAZOLAM 0.5 MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P Q:120 /30Days |
Alprazolam 0.5mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P Q:120 /30Days |
Alprazolam 0.5mg/1 60 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALPRAZOLAM 1 MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P Q:120 /30Days |
Alprazolam 1mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P Q:120 /30Days |
Alprazolam 1mg/mL 1 BOTTLE in 1 CONTAINER / 30 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P Q:300 /30Days |
ALPRAZOLAM 2 MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P Q:150 /30Days |
Alprazolam 2mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P Q:150 /30Days |
ALPRAZOLAM ER 1 MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P Q:90 /30Days |
ALPRAZOLAM ER 2 MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P Q:90 /30Days |
ALPRAZOLAM ER 3 MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P Q:90 /30Days |
AMANTADINE 100MG CAPSULE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMANTADINE 100MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Amantadine Hydrochloride 50mg/5mL 473 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMBISOME 50MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
AMIFOSTINE 50mg/mL 3 VIAL, SINGLE-USE per CARTON / 10 mL in 1 VIAL, SINGLE-USE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMIKACIN SULFATE 500 MG/2 ML VIAL |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Aminophylline 25mg/mL 5 TRAY per CARTON / 5 AMPULE in 1 TRAY / 10 mL in 1 AMPULE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMINOSYN II 10% IV SOLUTION |
3 |
Preferred Brand |
$45.00 | $90.00 | P |
AMINOSYN II 15% IV SOLUTION |
3 |
Preferred Brand |
$45.00 | $90.00 | P |
AMINOSYN II 7% IV SOLUTION |
3 |
Preferred Brand |
$45.00 | $90.00 | P |
AMINOSYN II 8.5% ELECTROLYT |
3 |
Preferred Brand |
$45.00 | $90.00 | P |
AMINOSYN II 8.5% IV SOLUTION |
3 |
Preferred Brand |
$45.00 | $90.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN PF INJECTION |
3 |
Preferred Brand |
$45.00 | $90.00 | P |
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5% |
3 |
Preferred Brand |
$45.00 | $90.00 | P |
AMINOSYN-PF 7% IV SOLUTION |
3 |
Preferred Brand |
$45.00 | $90.00 | P |
AMIODARONE HCL 200MG 60 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMIODARONE HCL 400MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMIODARONE HCL 50 MG INJECTION |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMITIZA 8MCG CAPSULE |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days |
AMITIZA CAPSULES 24MCG 60 CAP BOT |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days |
AMITRIPTYLINE HCL 100MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
AMITRIPTYLINE HCL 10MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
AMITRIPTYLINE HCL 150 MG TAB |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
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 |
$4.00 | $8.00 | P |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMLODIPINE-BENAZEPRIL 10-40 MG |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE-BENAZEPRIL 5-40 MG |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMMONIUM CHLORIDE 5 MEQ/ML |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
ammonium lactate 12% cream |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMMONIUM LACTATE 12% LOTION |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Amnesteem 10mg/1 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Amnesteem 20mg/1 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Amnesteem 40mg/1 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
amox tr-k clv 200-28.5/5 susp |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMOX TR-K CLV 500-125 MG TAB |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMOXAPINE 100MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMOXAPINE 150MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMOXAPINE 25MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMOXAPINE 50MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMOXICILLIN 125MG TABLET CHEW |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
AMOXICILLIN 250MG 500 CHEWABLE TABLET in BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
AMOXICILLIN 250MG CAPSULE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMOXICILLIN 500MG 500 CAPSULE BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN 500MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
AMOXICILLIN 875MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P Q:60 /30Days |
AMPHETAMINE SALT COMBO 15MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPHETAMINE SALT COMBO 30MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P Q:60 /30Days |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P Q:60 /30Days |
AMPHETAMINE SALTS 20MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P Q:60 /30Days |
AMPHETAMINE SALTS 5 MG TAB |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P Q:60 /30Days |
amphotericin b 50mg/10mL 10 mL in 1 VIAL |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | P |
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMPICILLIN CAPSULES 250MG 100 BOT |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
AMPICILLIN FOR INJECTION POWDER |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMPICILLIN-SULBACTAM 15 GM VIAL |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AMPICILLIN-SULBACTAM 3 GM VIAL |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Anastrozole 1mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | Q:30 /30Days |
APOKYN 30 MG/3 ML CARTRIDGE |
5 |
Specialty Tier |
33% | N/A | None |
Apraclonidine Ophthalmic 5mg/mL 1 BOTTLE, DROPPER per CARTON / 10 mL in 1 BOTTLE, DROPPER |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
APRI 0.15-0.03 TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
APTIOM 200 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | Q:30 /30Days |
APTIOM 400 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APTIOM 600 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | Q:60 /30Days |
APTIOM 800 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | Q:30 /30Days |
APTIVUS 250MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
ARCALYST INJECTION 220MG/VIAL |
5 |
Specialty Tier |
33% | N/A | P |
ARIPIPRAZOLE 10 MG TABLET [Abilify] |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:30 /30Days |
ARIPIPRAZOLE 15 MG TABLET [Abilify] |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:30 /30Days |
ARIPIPRAZOLE 2 MG TABLET [Abilify] |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:30 /30Days |
ARIPIPRAZOLE 20 MG TABLET [Abilify] |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:30 /30Days |
ARIPIPRAZOLE 30 MG TABLET [Abilify] |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:30 /30Days |
ARIPIPRAZOLE 5 MG TABLET [Abilify] |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARRANON 250MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
ARZERRA 20mg/mL 3 VIAL per CARTON / 5 mL in 1 VIAL |
5 |
Specialty Tier |
33% | N/A | P |
ASACOL HD 800mg/1 12 BOTTLE CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
ASMANEX HFA 100 MCG INHALER |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:13 /30Days |
ASMANEX HFA 200 MCG INHALER |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:13 /30Days |
ASMANEX TWISTHALER 110 MCG #30 |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days |
ASMANEX TWISTHALER 220 MCG #30 |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days |
ASMANEX TWISTHALER 220MCG #120 |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:120 /30Days |
ASMANEX TWISTHALER 220MCG #60 |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days |
ATENOLOL 100 MG100 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
ATENOLOL 25 MG 100 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATENOLOL TABLET USP 50MG (100 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
ATENOLOL-CHLORTHALIDONE 100-25 |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
ATGAM 50MG/ML AMPUL |
5 |
Specialty Tier |
33% | N/A | P |
ATORVASTATIN 10 MG TABLET [Lipitor] |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
ATORVASTATIN 20 MG TABLET [Lipitor] |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
ATORVASTATIN 40 MG TABLET [Lipitor] |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
ATORVASTATIN 80 MG TABLET [Lipitor] |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
ATOVAQUONE 750 MG/5 ML SUSP [Mepron] |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone] |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Atovaquone-Proguanil 62.5-25 [Malarone] |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
ATROVENT HFA AER 17MCG |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:52 /30Days |
AUBRA-28 TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AUGMENTED BETAMETHASONE DIPROPIONATE OINTMENT |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AUVI-Q 0.15 MG AUTO-INJECTOR |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
AUVI-Q 0.3 MG AUTO-INJECTOR |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
AVANDAMET 1000; 2mg/1; mg/1 60 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days |
AVANDIA 2 MG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days |
AVANDIA 4 MG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days |
AVANDIA 8 MG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days |
AVASTIN 100MG/4ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVELOX IV 400MG/250ML |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
AVIANE 0.1-0.02 TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AVODART 0.5MG SOFTGEL |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days |
AVONEX ADMIN PACK 30MCG SYR |
5 |
Specialty Tier |
33% | N/A | P Q:4 /30Days |
AVONEX ADMIN PACK 30MCG VL |
5 |
Specialty Tier |
33% | N/A | P Q:4 /30Days |
AVONEX PEN 30 MCG/0.5 ML KIT |
5 |
Specialty Tier |
33% | N/A | P Q:4 /30Days |
AXIRON 30mg/1.5mL 1 BOTTLE, WITH APPLICATOR per CARTON / 90 mL in 1 BOTTLE, WITH APPLICATOR |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:180 /30Days |
Azacitidine 100 mg vial [Vidaza] |
5 |
Specialty Tier |
33% | N/A | P |
AZACTAM 1g/1 10 VIAL, SINGLE-DOSE in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, SINGLE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
AZACTAM INJECTION 1GM/50ML |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
AZACTAM INJECTION 2GM/50ML |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZATHIOPRINE 50MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AZELASTINE 0.15% NASAL SPRAY |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
AZELASTINE 137 MCG NASAL SPRAY |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AZILECT 0.5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | Q:30 /30Days |
AZILECT 1MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | Q:30 /30Days |
Azithromycin 100mg/5mL 15 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Azithromycin 200mg/5mL 22.5 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
AZITHROMYCIN 250 MG TABLET |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Azithromycin 600mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZOR 10MG-20MG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
AZOR 10MG-40MG TABLET (30 CT) |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
AZOR 5MG-20MG TABLET (30 CT) |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
AZOR 5MG-40MG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
AZTREONAM FOR INJECTION |
1 |
Preferred Generic |
$4.00 | $8.00 | None |