2015 Medicare Part D Plan Formulary Information |
Blue Shield Medicare Enhanced Plan (PDP) (S2468-004-0)
Benefit Details
|
The Blue Shield Medicare Enhanced Plan (PDP) (S2468-004-0) Formulary Drugs Starting with the Letter P in CMS PDP Region 32 which includes: CA Plan Monthly Premium: $93.10 Deductible: $0 Qualifies for LIS: No |
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 |
PACLITAXEL INJECTION SOLUTION 6MG 50ML VIALMD |
5 |
Injectable Drugs |
25% | 25% | P |
PANCREAZE 10,500 UNIT CAP DR |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PANCREAZE 16,800 UNIT CAP DR |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PANCREAZE 21,000 UNIT CAP DR |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PANCREAZE 4,200 UNIT CAP DR |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
Pandel 1mg/g 45 g in 1 TUBE |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
PANRETIN 0.1% GEL 60GM TUBE |
6 |
Specialty Tier |
33% | 33% | P |
Pantoprazole 40mg/1 90 TABLET, DELAYED RELEASE in 1 BOTTLE |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
PANTOPRAZOLE SODIUM 20MG TABLET DELAYED RELEASE |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
PARICALCITOL 1 MCG CAPSULE [Zemplar] |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PARICALCITOL 2 MCG CAPSULE [Zemplar] |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PARICALCITOL 2 MCG/ML VIAL [Zemplar] |
5 |
Injectable Drugs |
25% | 25% | P |
PARICALCITOL 4 MCG CAPSULE [Zemplar] |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PARICALCITOL 5 MCG/ML VIAL [Zemplar] |
5 |
Injectable Drugs |
25% | 25% | P |
PAROMOMYCIN 250MG CAPSULE |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Paroxetine 40mg/1 500 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
PAROXETINE FILM COATED 20MG TABLET (100 CT) |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
PAROXETINE HCL TABLET 24 12.5MG |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PAROXETINE HCL TABLET 24 25MG |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
Paroxetine Hydrochloride 37.5mg/1 30 BOTTLE in 1 BOTTLE / 30 TABLET, FILM COATED, EXTENDED RELEASE |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PAROXETINE HYDROCHLORIDE TABLETS 10 MG |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAROXETINE TABLETS 30MG 90 BOT |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
PASER GRANULES 4GM PACKET |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
PATADAY 0.2% DROPS |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PATANOL 0.1% EYE DROPS |
3 |
Preferred Brand |
$40.00 | $80.00 | Q:10 /30Days |
PAXIL ORAL SUSPENSION 10 MG/5ML |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | Q:900 /30Days |
PAZEO 0.7% EYE DROPS |
3 |
Preferred Brand |
$40.00 | $80.00 | Q:3 /30Days |
PCE 333 MG TABLET |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PCE 500 MG TABLET |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PEDVAXHIB VACCINE VIAL |
5 |
Injectable Drugs |
25% | 25% | None |
PEGANONE 250 MG TABLET |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
Pegasys 180ug/0.5mL 1 PACKET in 1 BOX / 4 SYRINGE, GLASS in 1 PACKET / 0.5 mL in 1 SYRINGE, GLASS |
6 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEGASYS INJECTION |
6 |
Specialty Tier |
33% | 33% | P |
PEGASYS PROCLICK 135 MCG/0.5 |
6 |
Specialty Tier |
33% | 33% | P |
PEGASYS PROCLICK 180 MCG/0.5 |
6 |
Specialty Tier |
33% | 33% | P |
PEGINTRON 1 KIT per CARTON |
6 |
Specialty Tier |
33% | 33% | P |
PEGINTRON 120 MCG KIT |
6 |
Specialty Tier |
33% | 33% | P |
PegIntron 120ug/0.5mL 1 CARTRIDGE per CARTON / 0.5 mL in 1 CARTRIDGE |
6 |
Specialty Tier |
33% | 33% | P |
PEGINTRON 150 MCG KIT |
6 |
Specialty Tier |
33% | 33% | P |
PegIntron 150ug/0.5mL 1 CARTRIDGE per CARTON / 0.5 mL in 1 CARTRIDGE |
6 |
Specialty Tier |
33% | 33% | P |
PegIntron 50ug/0.5mL 1 CARTRIDGE per CARTON / 0.5 mL in 1 CARTRIDGE |
6 |
Specialty Tier |
33% | 33% | P |
PEGINTRON 80 MCG KIT |
6 |
Specialty Tier |
33% | 33% | P |
PegIntron 80ug/0.5mL 1 CARTRIDGE per CARTON / 0.5 mL in 1 CARTRIDGE |
6 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENICILLIN G POTASSIUM FOR INJECTION 5000000UNIT/VIAL |
5 |
Injectable Drugs |
25% | 25% | None |
PENICILLIN G PROCAINE 1200000UNT 2ML CTG |
5 |
Injectable Drugs |
25% | 25% | None |
Penicillin G Sodium 5000000[iU]/1 10 VIAL per CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL |
5 |
Injectable Drugs |
25% | 25% | None |
Penicillin V Potassium 125mg/5mL 200 mL in 1 BOTTLE |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
Penicillin V Potassium 250mg/1 1000 TABLET BOTTLE |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
PENICILLIN V POTASSIUM 500MG TABLET |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
PENTAM 300 INJ 300MG |
5 |
Injectable Drugs |
25% | 25% | P |
PENTOXIFYLLINE 400MG TABLET SA |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Perindopril Erbumine 2mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | Q:30 /30Days |
Perindopril Erbumine 4mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Perindopril Erbumine 8mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | Q:60 /30Days |
PERIOGARD 0.12% ORAL RINSE |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Permethrin 50mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Perphenazine 16mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PERPHENAZINE TABLETS 4MG 100 BOXUD |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PERPHENAZINE TABLETS 8MG 100 BOT |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PERPHENAZINE TABLETS USP 2MG 100 BOT |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PEXEVA 10MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | S Q:180 /30Days |
PEXEVA 20MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | S Q:90 /30Days |
PEXEVA 30MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | S Q:60 /30Days |
PEXEVA 40MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Phenelzine Sulfate 15mg/1 60 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Phenobarbital 100mg/1 |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Phenobarbital 15mg/1 |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PHENOBARBITAL 16.2 MG TABLET |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PHENOBARBITAL 20 MG/5 ML ELIX |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Phenobarbital 30mg/1 |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PHENOBARBITAL 32.4 MG TABLET |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Phenobarbital 60mg/1 |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PHENOBARBITAL 64.8 MG TABLET |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PHENOBARBITAL 97.2 MG TABLET |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
phenytoin 50 mg tablet chew |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PHENYTOIN SOD EXT 200 MG CAP |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT) |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PHOSPHOLINE IODIDE 0.125% 6.25MG |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
PHYSIOLYTE SOLUTION FOR IRRIGATION |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PHYSIOSOL IRRIGATION SOL |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PICATO 0.015% GEL |
3 |
Preferred Brand |
$40.00 | $80.00 | Q:3 /30Days |
PICATO 0.05% GEL |
3 |
Preferred Brand |
$40.00 | $80.00 | Q:2 /30Days |
PILOCARPINE 1% EYE DROPS |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PILOCARPINE 2% EYE DROPS |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PILOCARPINE 4% EYE DROPS |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PILOCARPINE HCL 5MG TABLET (100 CT) |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
Pilocarpine Hydrochloride 7.5mg/1 100 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PIMTREA 28 DAY TABLET |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PINDOLOL 10MG TABLET |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PINDOLOL 5MG TABLET |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
pioglitaz-glimepir 30-2 mg tab |
3 |
Preferred Brand |
$40.00 | $80.00 | S Q:30 /30Days |
pioglitaz-glimepir 30-4 mg tab |
3 |
Preferred Brand |
$40.00 | $80.00 | S Q:30 /30Days |
pioglitazone hcl 15 mg tablet [Actos] |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
pioglitazone hcl 30 mg tablet [Actos] |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
pioglitazone hcl 45 mg tablet [Actos] |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PIOGLITAZONE-METFORMIN 15-500 |
3 |
Preferred Brand |
$40.00 | $80.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PIOGLITAZONE-METFORMIN 15-850 |
3 |
Preferred Brand |
$40.00 | $80.00 | S |
PIPERACILLIN 200 MG/ML / TAZOBACTAM 25 MG/ML INJECTABLE SOLUTION |
5 |
Injectable Drugs |
25% | 25% | None |
Piperacillin and Tazobactam 4; 0.5g/1; g/1 10 VIAL, SINGLE-USE per CARTON / 1 INJECTION, POWDER, L |
5 |
Injectable Drugs |
25% | 25% | None |
Pirmella 1-35-28 tablet |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PIROXICAM 10 MG CAPSULE |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Piroxicam 20mg/1 500 CAPSULE BOTTLE |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PLEGRIDY 125 MCG/0.5 ML PEN |
6 |
Specialty Tier |
33% | 33% | P Q:1 /28Days |
PLEGRIDY 125 MCG/0.5 ML SYRING |
6 |
Specialty Tier |
33% | 33% | P Q:1 /28Days |
PLEGRIDY PEN INJ STARTER PACK |
6 |
Specialty Tier |
33% | 33% | P Q:1 /365Days |
PODOFILOX 0.5% TOPICAL TUBEX |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT) |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
polymyxin b 5000001/1 1 VIAL in 1 CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL |
5 |
Injectable Drugs |
25% | 25% | None |
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1% |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
POMALYST 1 MG CAPSULE |
6 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
POMALYST 2 MG CAPSULE |
6 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
POMALYST 3 MG CAPSULE |
6 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
POMALYST 4 MG CAPSULE |
6 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
PORTIA 0.15-0.03 TABLET |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
POTASSIUM CHLORIDE 750MG EXTENDED RELEASE TABLETS |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
POTASSIUM CHLORIDE ER CAPSULES 10MEQ |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
POTASSIUM CHLORIDE ER CPCR 8MEQ |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
Potassium Chloride in Dextrose and Sodium Chloride 5; 300; 900g/100mL; mg/100mL; mg/100mL 1000 mL i |
5 |
Injectable Drugs |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Potassium Chloride in Lactated Ringers and Dextrose 20; 5; 179; 600; 310mg/100mL; g/100mL; mg/100mL |
5 |
Injectable Drugs |
25% | 25% | None |
POTASSIUM CHLORIDE INJECTION 10MEQ/100ML |
5 |
Injectable Drugs |
25% | 25% | None |
POTASSIUM CHLORIDE INJECTION 20 MEQ/100ML |
5 |
Injectable Drugs |
25% | 25% | P |
POTASSIUM CHLORIDE INJECTION 40 MEQ/100ML |
5 |
Injectable Drugs |
25% | 25% | P |
POTASSIUM CITRATE ER 10 MEQ TB |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
POTASSIUM CITRATE ER 15 MEQ TABLET |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
POTASSIUM CITRATE ER 5 MEQ TAB |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
POTASSIUM CITRATE ER 8 MEQ TABLET |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
Potassium cl 2 meq/ml vial |
5 |
Injectable Drugs |
25% | 25% | None |
POTASSIUM CL ER 20 MEQ TABLET |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
POTIGA 200 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTIGA 300 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | Q:90 /30Days |
POTIGA 400 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | Q:90 /30Days |
POTIGA 50 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | Q:270 /30Days |
PRADAXA 150mg/1 1 BOTTLE per CARTON / 60 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | P |
PRADAXA 75mg/1 1 BOTTLE per CARTON / 60 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | P |
Pramipexole Dihydrochloride 0.125mg/1 500 TABLET BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Pramipexole Dihydrochloride 0.25mg/1 500 TABLET BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Pramipexole Dihydrochloride 0.5mg/1 500 TABLET BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PRAMIPEXOLE DIHYDROCHLORIDE 0.75MG TABLETS |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Pramipexole Dihydrochloride 1.5mg/1 500 TABLET BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Pramipexole Dihydrochloride 1mg/1 500 TABLET BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | 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 |
$3.00 | $6.00 | Q:60 /30Days |
PRAVASTATIN SODIUM 40MG TABLET (500 CT) |
1 |
Preferred Generic |
$3.00 | $6.00 | Q:60 /30Days |
Pravastatin Sodium 80mg/1 1000 TABLET BOTTLE |
1 |
Preferred Generic |
$3.00 | $6.00 | Q:30 /30Days |
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT |
1 |
Preferred Generic |
$3.00 | $6.00 | Q:60 /30Days |
PRAZOSIN 5MG CAPSULE |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PRAZOSIN HCL 1MG CAPSULE |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PRAZOSIN HCL 2MG CAPSULE |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PRED G OPHTHALMIC SUSPENSION 1;0.3%;% 5 ML BOTDR |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
PRED MILD 0.12% EYE DROPS |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PRED-G S.O.P. EYE OINTMENT |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
PREDNICARBATE 0.1% OINTMENT |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNICARBATE 1 MG/ML TOPICAL CREAM |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Prednisolone odt 10 mg tablet |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Prednisolone odt 15 mg tablet |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Prednisolone odt 30 mg tablet |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PREDNISOLONE SOD 1% EYE DROP |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PREDNISOLONE SOD PH 25 MG/5 ML |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PREDNISOLONE SODIUM PHOSPHATE 5MG /5ML ORAL SOLUTION |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PREDNISONE 10MG TABLET (100 CT) |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
PREDNISONE 1MG TABLET |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISONE 2.5MG TABLET |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
PREDNISONE 20MG TABLET (1000 CT) |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
PREDNISONE 5 MG TABLET |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
PREDNISONE 50MG TABLET |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
PREDNISONE 5MG/5ML SOLUTION |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PREDNISONE 5MG/ML SOLUTION |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Prefest 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | P |
Premarin 0.625mg/g |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PREMPHASE 0.625-5 MG TABLET |
3 |
Preferred Brand |
$40.00 | $80.00 | P Q:28 /28Days |
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA |
3 |
Preferred Brand |
$40.00 | $80.00 | P Q:28 /28Days |
PREMPRO 0.45-1.5 MG TABLET 28 EA |
3 |
Preferred Brand |
$40.00 | $80.00 | P Q:28 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREMPRO 0.625-5 MG TABLET |
3 |
Preferred Brand |
$40.00 | $80.00 | P Q:28 /28Days |
Prempro 0.625; 2.5mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, SUGAR COATED per BLISTER PACK |
3 |
Preferred Brand |
$40.00 | $80.00 | P Q:28 /28Days |
PREVALITE POW 4GM |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
Previfem 6 BLISTER PACK per BLISTER PACK / 1 KIT per BLISTER PACK |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PREZCOBIX 800 MG-150 MG TABLET |
6 |
Specialty Tier |
33% | 33% | None |
PREZISTA 100 MG/ML SUSPENSION |
6 |
Specialty Tier |
33% | 33% | None |
PREZISTA 150MG TABLETS |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
PREZISTA 800 MG TABLET |
6 |
Specialty Tier |
33% | 33% | None |
PREZISTA TABLET 600MG |
6 |
Specialty Tier |
33% | 33% | None |
PREZISTA TABLET 75MG |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
PRIFTIN 150MG TABLET |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRILOSEC 10mg/1 30 GRANULE, DELAYED RELEASE in 1 CARTON |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
PRILOSEC 2.5mg/1 30 GRANULE, DELAYED RELEASE in 1 CARTON |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
PRIMAQUINE 26.3MG TABLET |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Primidone 250mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Primidone 50mg/1 500 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PRIMSOL 50MG/5ML ORAL SOLUTION |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
PRISTIQ 100MG TABLET SR 24HR |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | S Q:120 /30Days |
PRISTIQ ER 25 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | S Q:30 /30Days |
Pristiq Extended-Release 50mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | S Q:30 /30Days |
PRIVIGEN 10% VIAL |
6 |
Specialty Tier |
33% | 33% | P |
PROAIR HFA 90 MCG INHALER |
3 |
Preferred Brand |
$40.00 | $80.00 | Q:17 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROAIR RESPICLICK INHAL POWDER |
3 |
Preferred Brand |
$40.00 | $80.00 | Q:2 /30Days |
PROBENECID 500MG TABLET |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PROBENECID/COLCHICINE 0.5MG/500MG TABLET |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Prochlorperazine 10 mg/2 ml vl |
5 |
Injectable Drugs |
25% | 25% | P |
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Prochlorperazine Maleate 5mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PROCRIT 10000U/ML VIAL |
5 |
Injectable Drugs |
25% | 25% | P |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL |
5 |
Injectable Drugs |
25% | 25% | P |
PROCRIT 3,000 UNITS/ML VIAL |
5 |
Injectable Drugs |
25% | 25% | P |
PROCRIT 4,000 UNITS/ML VIAL |
5 |
Injectable Drugs |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCRIT 40000U/ML VIAL PR |
6 |
Specialty Tier |
33% | 33% | P |
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY |
6 |
Specialty Tier |
33% | 33% | P |
proctozone-hc 2.5% cream |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PROCYSBI DR 25 MG CAPSULE |
6 |
Specialty Tier |
33% | 33% | P Q:120 /30Days |
PROCYSBI DR 75 MG CAPSULE |
6 |
Specialty Tier |
33% | 33% | P Q:780 /30Days |
PROGESTERONE 100 MG CAPSULE |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PROGESTERONE 200 MG CAPSULE |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Proglycem 50mg/mL 1 BOTTLE, DROPPER in 1 BOX / 30 mL in 1 BOTTLE, DROPPER |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
PROGRAF 5MG/ML AMPULE |
5 |
Injectable Drugs |
25% | 25% | P |
PROLASTIN-C |
6 |
Specialty Tier |
33% | 33% | P |
PROLEUKIN 22 MILLION UNIT VIAL |
6 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROLIA 60MG/ML INJECTION |
5 |
Injectable Drugs |
25% | 25% | P |
PROMACTA 12.5 MG TABLET |
6 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
PROMACTA 25 MG TABLET |
6 |
Specialty Tier |
33% | 33% | P Q:90 /30Days |
PROMACTA 50 MG TABLET |
6 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
PROMACTA 75 MG TABLET |
6 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
Propafenone HCl 150mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PROPAFENONE HCL 225MG TABLET |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PROPAFENONE HCL 300MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Propafenone Hydrochloride 225mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PROPAFENONE HYDROCHLORIDE 325MG CAPSULES EXTENDED RELEASE |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PROPAFENONE HYDROCHLORIDE 425MG CAPSULES EXTENDED RELEASE |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Propantheline Bromide 15mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Propranolol 1mg/mL 1 mL in 1 VIAL |
5 |
Injectable Drugs |
25% | 25% | None |
PROPRANOLOL 20MG/5ML TUBEX |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PROPRANOLOL 40MG/5ML TUBEX |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PROPRANOLOL 60MG TABLET |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
PROPRANOLOL 80 MG TABLET |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
PROPRANOLOL ER 120 MG CAPSULE |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PROPRANOLOL ER 160 MG CAPSULE |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PROPRANOLOL HCL 20MG TABLET (1000 CT) |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
PROPRANOLOL HCL TABLET USP 10MG (1000 CT) |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
PROPRANOLOL HCL TABLET USP 40MG (1000 CT) |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Propranolol Hydrochloride 60mg/1 1000 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Propranolol Hydrochloride 80mg/1 500 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PROPRANOLOL/HCTZ 40/25 TABLET |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PROPRANOLOL/HCTZ 80/25 TABLET |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PROPYLTHIOURACIL 50MG TABLET |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
PROQUAD 0.5 VIAL |
5 |
Injectable Drugs |
25% | 25% | None |
PROTONIX 40MG SUSP FOR RECON DELAYED REL. IN A PACKET |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
PROTRIPTYLINE HYDROCHLORIDE 10MG TABLETS |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
PULMICORT 1MG/2ML AMPUL FOR NEBULIZATION |
3 |
Preferred Brand |
$40.00 | $80.00 | P Q:60 /30Days |
PULMICORT FLEXHALER 180MCG AEROSOL POWDER BREATH ACTIVATED |
3 |
Preferred Brand |
$40.00 | $80.00 | Q:2 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PULMICORT FLEXHALER 90MCG AEROSOL POWDER BREATH ACTIVATED |
3 |
Preferred Brand |
$40.00 | $80.00 | Q:2 /30Days |
PULMOZYME 1MG/ML AMPUL |
6 |
Specialty Tier |
33% | 33% | P Q:150 /30Days |
PURIXAN 20 MG/ML ORAL SUSP |
6 |
Specialty Tier |
33% | 33% | P Q:100 /30Days |
PYRAZINAMIDE 500 MG TABLET |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |
Pyridostigmine br 60 mg tablet |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None |