2015 Medicare Part D Plan Formulary Information |
Aetna Medicare Rx Saver (PDP) (S5810-065-0)
Benefit Details
 |
The Aetna Medicare Rx Saver (PDP) (S5810-065-0) Formulary Drugs Starting with the Letter C in CMS PDP Region 31 which includes: ID UT Plan Monthly Premium: $31.40 Deductible: $320 Qualifies for LIS: Yes |
Drugs Starting with Letter C
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
CABERGOLINE 0.5 MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CALCIPOTRIENE 0.005% CREAM  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Calcipotriene 50ug/g 60 g per CARTON  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CALCIPOTRIENE TOPICAL SOLUTION  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
CALCITRIOL 0.25MCG CAPSULE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CALCITRIOL 0.5MCG CAPSULE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Calcitriol 1 mcg/ml ampul  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CALCITRIOL 1MCG/ML SOLUTION ORAL  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CALCIUM ACETATE CAPSULE 667 MG  |
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 |
CAMILA 0.35MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CANCIDAS IV 50MG VIAL  |
5 |
Specialty Tier |
25% | N/A | None |
CANCIDAS IV 70MG VIAL  |
5 |
Specialty Tier |
25% | N/A | None |
CANDESARTAN CILEXETIL 16 MG TABLET [Atacand] ![Compare how all Medicare Part D PDP plans in ID cover CANDESARTAN CILEXETIL 16 MG TABLET [Atacand].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | Q:30 /30Days |
CANDESARTAN CILEXETIL 32 MG TABLET [Atacand] ![Compare how all Medicare Part D PDP plans in ID cover CANDESARTAN CILEXETIL 32 MG TABLET [Atacand].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | Q:30 /30Days |
CANDESARTAN CILEXETIL 4 MG TABLET [Atacand] ![Compare how all Medicare Part D PDP plans in ID cover CANDESARTAN CILEXETIL 4 MG TABLET [Atacand].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | Q:30 /30Days |
CANDESARTAN CILEXETIL 8 MG TABLET [Atacand] ![Compare how all Medicare Part D PDP plans in ID cover CANDESARTAN CILEXETIL 8 MG TABLET [Atacand].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | Q:30 /30Days |
candesartan-hctz 16-12.5 mg tablet  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | Q:60 /30Days |
candesartan-hctz 32-12.5 mg tablet  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | Q:30 /30Days |
candesartan-hctz 32-25 mg  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | Q:30 /30Days |
CAPASTAT SULFATE 1g/1 1 INJECTION, POWDER, FOR SOLUTION per CARTON  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAPRELSA 100mg/1 30 TABLET BOTTLE  |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
CAPRELSA 300mg/1 30 TABLET BOTTLE  |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
CAPTOPRIL 100MG TABLET  |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CAPTOPRIL 12.5MG TABLET  |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CAPTOPRIL 25MG TABLET  |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CAPTOPRIL 50MG TABLET  |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Captopril and Hydrochlorothiazide 25; 15mg 100 TABLET BOTTLE  |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Captopril and Hydrochlorothiazide 25; 25mg 100 TABLET BOTTLE  |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Captopril and Hydrochlorothiazide 50; 15mg 100 TABLET BOTTLE  |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Captopril and Hydrochlorothiazide 50; 25mg 100 TABLET BOTTLE  |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CARBAMAZEPINE 100 MG/5 ML SUSP  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Carbamazepine 100mg, CHEWABLE 100 TABLET BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Carbamazepine 100mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Carbamazepine 200mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Carbamazepine 300mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CARBAMAZEPINE TABLET USP 200MG (1000 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CARBAMAZEPINE XR 200 MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CARBAMAZEPINE XR 400 MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CARBIDOPA 25 MG TABLET [Lodosyn] ![Compare how all Medicare Part D PDP plans in ID cover CARBIDOPA 25 MG TABLET [Lodosyn].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Carbidopa and Levodopa 25; 100mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Carbidopa and Levodopa 50; 200mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;100MG;MG 100 BOT  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;250MG;MG 100 BOT  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Carbidopa-Levodopa-Entacapone 100 MG [Stalevo] ![Compare how all Medicare Part D PDP plans in ID cover Carbidopa-Levodopa-Entacapone 100 MG [Stalevo].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
36% | 36% | None |
Carbidopa-Levodopa-Entacapone 125 MG [Stalevo] ![Compare how all Medicare Part D PDP plans in ID cover Carbidopa-Levodopa-Entacapone 125 MG [Stalevo].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
36% | 36% | None |
Carbidopa-Levodopa-Entacapone 150 MG [Stalevo] ![Compare how all Medicare Part D PDP plans in ID cover Carbidopa-Levodopa-Entacapone 150 MG [Stalevo].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
36% | 36% | None |
Carbidopa-Levodopa-Entacapone 200 MG [Stalevo] ![Compare how all Medicare Part D PDP plans in ID cover Carbidopa-Levodopa-Entacapone 200 MG [Stalevo].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
36% | 36% | None |
Carbidopa-Levodopa-Entacapone 50 MG [Stalevo] ![Compare how all Medicare Part D PDP plans in ID cover Carbidopa-Levodopa-Entacapone 50 MG [Stalevo].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
36% | 36% | None |
Carbidopa-Levodopa-Entacapone 75 MG [Stalevo] ![Compare how all Medicare Part D PDP plans in ID cover Carbidopa-Levodopa-Entacapone 75 MG [Stalevo].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
36% | 36% | None |
CARBIDOPA/LEVO 10/100 TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CARBIDOPA/LEVO 25/100 TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CARBIDOPA/LEVO 25/250 TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Carboplatin 10mg/mL  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CARTIA XT 120MG CAPSULE SA  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CARTIA XT 180MG CAPSULE SA  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CARTIA XT 240MG CAPSULE SA  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CARTIA XT 300MG CAPSULE SR 24 HR  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Carvedilol 12.5mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Carvedilol 25mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Carvedilol 3.125mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Carvedilol 6.25mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CAYSTON KIT 75 MG/VIAL  |
5 |
Specialty Tier |
25% | N/A | Q:84 /56Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFACLOR 125 MG/5 ML SUSP  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFACLOR 250 MG CAPSULES  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFACLOR 250 MG/5 ML SUSP  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFACLOR 375 MG/5 ML SUSPEN  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFACLOR 500 MG CAPSULES  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFACLOR ER 500MG TABLET SR 12HR  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFADROXIL 1G TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CEFADROXIL 250 MG/5 ML SUSP  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Cefadroxil 500mg/1 100 CAPSULE BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Cefadroxil 500mg/5mL  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CEFAZOLIN 1 GM VIAL  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFAZOLIN 1GM/D5W BAG  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFAZOLIN 500MG FOR INJECTION  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFDINIR CAPSULES 300MG (60 CT)  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT)  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Cefditoren Pivoxil 200 mg Tablet [Spectracef] ![Compare how all Medicare Part D PDP plans in ID cover Cefditoren Pivoxil 200 mg Tablet [Spectracef].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFEPIME HCL 2 GRAM VIAL  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFEPIME HYDROCHLORIDE AND DEXTROSE 1g/50mL 24 CONTAINER in 1 CASE / 50 mL in 1 CONTAINER  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFEPIME HYDROCHLORIDE AND DEXTROSE 2g/50mL 24 CONTAINER in 1 CASE / 50 mL in 1 CONTAINER  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFIXIME 100 MG/5 ML SUSP [Suprax] ![Compare how all Medicare Part D PDP plans in ID cover CEFIXIME 100 MG/5 ML SUSP [Suprax].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFIXIME 200 MG/5 ML SUSP [Suprax] ![Compare how all Medicare Part D PDP plans in ID cover CEFIXIME 200 MG/5 ML SUSP [Suprax].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
36% | 36% | None |
Cefotaxime sodium 1 gm vial  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Cefotaxime sodium 2 gm vial  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Cefotaxime sodium 500 mg vial  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFOTETAN 10 GM SOLR  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFOTETAN 1GM VIAL 1EA x 10  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFOTETAN 2GM VIAL 1EA x 10  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Cefoxitin 1g/1 10 POWDER per CARTON  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Cefoxitin 2g/1 10 POWDER per CARTON  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFOXITIN FOR INJECTION 1 GM/50ML  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFOXITIN FOR INJECTION 2MG/50ML 50 ML BOT  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFOXITIN FOR INJECTION SOLUTION  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFPODOXIME 100 MG/5 ML SUSP  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFPODOXIME 200 MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFPODOXIME 50 MG/5 ML SUSP  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT)  |
4 |
Non-Preferred Brand |
36% | 36% | None |
cefprozil 125 mg/5 ml susp  |
4 |
Non-Preferred Brand |
36% | 36% | None |
cefprozil 250 mg/5 ml susp  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Cefprozil 250mg 100 FILM COATED TABLETS in BOTTLE  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFPROZIL TABLETS 500MG 100 BOT  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFTAZIDIME 1g 25 VIAL per CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ceftazidime and Dextrose 1g/50mL 24 CONTAINER in 1 CASE / 50 mL in 1 CONTAINER  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Ceftazidime and Dextrose 2g/50mL 24 CONTAINER in 1 CASE / 50 mL in 1 CONTAINER  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFTRIAXONE 10GM VIAL  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFTRIAXONE 250 MG VIAL  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFTRIAXONE FOR INJECTION  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFTRIAXONE FOR INJECTION  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Ceftriaxone Sodium 500mg  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFUROXIME 1.5 GM/VIAL FOR INJECTION  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEFUROXIME 7.5 GM FOR INJECTION  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFUROXIME 750 MG FOR INJECTION  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Cefuroxime Axetil 250 MG  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Cefuroxime Axetil 500mg  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CELECOXIB 100 MG CAPSULE [Celebrex] ![Compare how all Medicare Part D PDP plans in ID cover CELECOXIB 100 MG CAPSULE [Celebrex].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
36% | 36% | Q:60 /30Days |
CELECOXIB 200 MG CAPSULE [Celebrex] ![Compare how all Medicare Part D PDP plans in ID cover CELECOXIB 200 MG CAPSULE [Celebrex].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
36% | 36% | Q:60 /30Days |
CELECOXIB 400 MG CAPSULE [Celebrex] ![Compare how all Medicare Part D PDP plans in ID cover CELECOXIB 400 MG CAPSULE [Celebrex].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
36% | 36% | Q:30 /30Days |
CELECOXIB 50 MG CAPSULE [Celebrex] ![Compare how all Medicare Part D PDP plans in ID cover CELECOXIB 50 MG CAPSULE [Celebrex].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
36% | 36% | Q:60 /30Days |
CELLCEPT 200 MG/ML ORAL SUSP  |
5 |
Specialty Tier |
25% | N/A | P |
CELLCEPT IV INJ 500 MG  |
4 |
Non-Preferred Brand |
36% | 36% | P |
CELONTIN 300 MG KAPSEAL  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Cephalexin 125mg/5mL 200 mL in 1 BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEPHALEXIN 250 MG CAPSULE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CEPHALEXIN 250 MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CEPHALEXIN 250 MG/5ML ORAL SUSP  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CEPHALEXIN 500 MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CEPHALEXIN 750 MG CAPSULE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CEPHALEXIN CAPSULES 500 MG (500 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CEREBYX 500 MG PE/10 ML VIAL  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CEREZYME 400 UNITS VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
CERVARIX VACCINE SYRINGE  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CHANTIX 0.5 MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | Q:336 /365Days |
CHANTIX 1 KIT per CARTON  |
4 |
Non-Preferred Brand |
36% | 36% | Q:106 /365Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHANTIX 1 MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | Q:336 /365Days |
Chantix 1.0mg/1 56 FILM COATED TABLETS in BOX  |
4 |
Non-Preferred Brand |
36% | 36% | Q:336 /365Days |
CHLORAMPHEN NA SUCC 1GM VL  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CHLORDIAZEPOXIDE AND AMITRIPTYLINE HCL TABLET 12.5-5MG (500 CT)  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CHLOROQUINE PH 500 MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CHLOROQUINE PHOSPHATE 250 MG TABLET (50 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CHLOROTHIAZIDE 250 MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Chlorothiazide 500mg 100 TABLET BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CHLORPROMAZINE 10 MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CHLORPROMAZINE 25 MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLORPROMAZINE 25 MG/ML AMP  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CHLORPROMAZINE 50 MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CHLORPROMAZINE HCL 200 MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Chlorpromazine Hydrochloride 100mg SUGAR COATED 1000 TABLET BOTTLE  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CHLORTHALIDONE 25 MG TABLET (100 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CHLORTHALIDONE 50 MG TABLET (1000 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CHLORZOXAZONE 500 MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | P Q:180 /30Days |
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CICLOPIROX 1% SHAMPOO  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Ciclopirox 7.7mg/mL 60 mL in 1 BOTTLE  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6 ML BOT  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CICLOPIROX GEL  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Ciclopirox Olamine 7.7mg/g 1 TUBE in 1 TUBE / 15 g in 1 TUBE  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Cilostazol 50mg/1 60 TABLET BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CILOSTAZOL TABLET 100MG (60 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Cimetidine 200mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CIMETIDINE 300 MG TABLETS  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Cimetidine 400mg/1 100 FILM COATED TABLETS in BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Cimetidine 800mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Cimetidine Hydrochloride Oral Solution 300mg/5mL 237 mL in 1 BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Cimzia 2 KIT per CARTON / 1 KIT in 1 KIT  |
5 |
Specialty Tier |
25% | N/A | P Q:6 /28Days |
CIMZIA 200 MG/ML SYRINGE KIT  |
5 |
Specialty Tier |
25% | N/A | P Q:6 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cinryze 500[iU]/5mL 1 VIAL per CARTON / 5 mL in 1 VIAL ![Compare how all Medicare Part D PDP plans in ID cover Cinryze 500[iU]/5mL 1 VIAL per CARTON / 5 mL in 1 VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P |
CIPROFLOXACIN 0.3% EYE DROP  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CIPROFLOXACIN 250 MG TABLET (100 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CIPROFLOXACIN 250 MG/5 ML SUSP  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Ciprofloxacin 400mg/40mL 1 VIAL per CARTON / 40 mL in 1 VIAL  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CIPROFLOXACIN 500 MG/5 ML SUSP  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Ciprofloxacin and Dextrose 2mg/mL 24 BAG in 1 CASE / 100 mL in 1 BAG  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Ciprofloxacin ER 212.6; 287.5mg/1; mg/1 50 TABLET, FILM COATED, in 1 BOTTLE, PLASTIC  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Ciprofloxacin ER 425.2; 574.9mg/1; mg/1 50 TABLET, FILM COATED, in 1 BOTTLE, PLASTIC  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CIPROFLOXACIN HCL 100 MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CIPROFLOXACIN HCL 500 MG TAB  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIPROFLOXACIN TABLETS 750 MG 100 BOT  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Cisplatin 100mg/100mL 1 VIAL per CARTON / 100 mL in 1 VIAL  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CITALOPRAM HBR 20 MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | Q:60 /30Days |
CITALOPRAM HBR ORAL SOLUTION 10MG 240 ML BOTPL  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | Q:600 /30Days |
CITALOPRAM HYDROBROMIDE TABLETS 40 MG 30 BOT  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | Q:30 /30Days |
CITOLOPRAM HBR 10 MG TABLET (100 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | Q:120 /30Days |
Cladribine 10 mg/10 ml vial  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | P |
CLARAVIS 10 MG CAPSULE  |
4 |
Non-Preferred Brand |
36% | 36% | P |
CLARAVIS 20 MG CAPSULE  |
4 |
Non-Preferred Brand |
36% | 36% | P |
Claravis 30mg 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK  |
4 |
Non-Preferred Brand |
36% | 36% | P |
CLARAVIS 40MG CAPSULE  |
4 |
Non-Preferred Brand |
36% | 36% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLARITHROMYCIN 125 MG/5ML FOR ORAL SUSPENSION  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
CLARITHROMYCIN 250 MG TABLET  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
CLARITHROMYCIN 250 MG/5MLFOR ORAL SUSPENSION  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
CLARITHROMYCIN 500 MG TABLET  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
CLEMASTINE FUM 2.68 MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | P |
Clemastine Fumarate 0.5mg/5mL 120 mL in 1 BOTTLE  |
4 |
Non-Preferred Brand |
36% | 36% | P |
CLINDAMYCIN 150MG/ML ADDVAN  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CLINDAMYCIN HCL 150 MG CAPSULE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CLINDAMYCIN HCL 300 MG 100 CAPSULE in 1 BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CLINDAMYCIN HCL 75 MG 200 CAPSULE BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CLINDAMYCIN PEDIATR 75 MG/5 ML  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINDAMYCIN PHOSP 1% LOTION  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CLINDAMYCIN PHOSPHATE 1% FOAM  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
clindamycin phosphate 10mg/mL 1 BOTTLE per CARTON / 60 mL in 1 BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Clindamycin Phosphate and Benzoyl Peroxide 1 KIT  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CLINDAMYCIN PHOSPHATE VAGINAL CREAM  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
clindamycin-d5w 300 mg/50 ml  |
4 |
Non-Preferred Brand |
36% | 36% | None |
clindamycin-d5w 600 mg/50 ml  |
4 |
Non-Preferred Brand |
36% | 36% | None |
clindamycin-d5w 900 mg/50 ml  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CLINISOL 15% SOLUTION  |
4 |
Non-Preferred Brand |
36% | 36% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOBETASOL 0.05% OINTMENT  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CLOBETASOL 0.05% SHAMPOO  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CLOBETASOL 0.05% TOPICAL LOTION  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CLOBETASOL E 0.05% CREAM  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CLOBETASOL PROP 0.05% SPRAY  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Clobetasol Propionate 0.4625mg/mL 1 BOTTLE per CARTON / 50 mL in 1 BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Clobetasol Propionate 0.5mg/g 1 CAN per CARTON / 100 g in 1 CAN  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CLOLAR 20 MG/20 ML VIAL  |
5 |
Specialty Tier |
25% | N/A | None |
CLOMIPRAMINE HCL 25MG CAPSULE  |
4 |
Non-Preferred Brand |
36% | 36% | P |
CLOMIPRAMINE HCL 50MG CAPSULE  |
4 |
Non-Preferred Brand |
36% | 36% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOMIPRAMINE HCL 75MG CAPSULE  |
4 |
Non-Preferred Brand |
36% | 36% | P |
Clonazepam 0.125mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PAC  |
4 |
Non-Preferred Brand |
36% | 36% | Q:90 /30Days |
Clonazepam 0.25mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK  |
4 |
Non-Preferred Brand |
36% | 36% | Q:90 /30Days |
Clonazepam 0.5mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK  |
4 |
Non-Preferred Brand |
36% | 36% | Q:90 /30Days |
Clonazepam 0.5mg/1 100 TABLET BOTTLE  |
4 |
Non-Preferred Brand |
36% | 36% | Q:90 /30Days |
Clonazepam 1mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK  |
4 |
Non-Preferred Brand |
36% | 36% | Q:120 /30Days |
Clonazepam 1mg/1 90 TABLET BOTTLE, PLASTIC  |
4 |
Non-Preferred Brand |
36% | 36% | Q:120 /30Days |
Clonazepam 2mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK  |
4 |
Non-Preferred Brand |
36% | 36% | Q:300 /30Days |
Clonazepam 2mg/1 100 TABLET BOTTLE  |
4 |
Non-Preferred Brand |
36% | 36% | Q:300 /30Days |
Clonidine 0.1mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH  |
4 |
Non-Preferred Brand |
36% | 36% | Q:8 /28Days |
Clonidine 0.2mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH  |
4 |
Non-Preferred Brand |
36% | 36% | Q:8 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Clonidine 0.3mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH  |
4 |
Non-Preferred Brand |
36% | 36% | Q:8 /28Days |
CLONIDINE HCL 0.2MG TABLET (500 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CLONIDINE HCL TABLET 0.1MG (500 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CLONIDINE HCL TABLET 0.3MG (100 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CLOPIDOGREL 300 MG TABLET [Plavix] ![Compare how all Medicare Part D PDP plans in ID cover CLOPIDOGREL 300 MG TABLET [Plavix].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | Q:2 /365Days |
CLOPIDOGREL 75 MG TABLET [Plavix] ![Compare how all Medicare Part D PDP plans in ID cover CLOPIDOGREL 75 MG TABLET [Plavix].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | Q:30 /30Days |
CLORAZEPATE 15 MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | Q:180 /30Days |
Clorazepate Dipotassium 3.75mg/1 500 TABLET BOTTLE, PLASTIC  |
4 |
Non-Preferred Brand |
36% | 36% | Q:90 /30Days |
Clorazepate Dipotassium 7.5mg/1 500 TABLET BOTTLE, PLASTIC  |
4 |
Non-Preferred Brand |
36% | 36% | Q:90 /30Days |
CLOTRIMAZOLE 10MG TROCHE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CLOTRIMAZOLE SOLUTION TOPICAL 1% 30ML BOTPL  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Clozapine 100mg/1 100 TABLET BOTTLE  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
CLOZAPINE 200MG TABLET (500 CT)  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
CLOZAPINE 25MG TABLET (100 CT)  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
CLOZAPINE 50MG TABLET (500 CT)  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
CLOZAPINE ODT 100 MG TABLET  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
CLOZAPINE ODT 12.5 MG TABLET  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
CLOZAPINE ODT 150 MG TABLET  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
CLOZAPINE ODT 200 MG TABLET  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
CLOZAPINE ODT 25 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 |
COARTEM 20MG-120MG  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CODEINE SULFATE 15 MG TABLETS  |
4 |
Non-Preferred Brand |
36% | 36% | Q:180 /30Days |
CODEINE SULFATE 30 MG TABLET 3100  |
4 |
Non-Preferred Brand |
36% | 36% | Q:180 /30Days |
Codeine sulfate 60mg/1 100 TABLET BOTTLE  |
4 |
Non-Preferred Brand |
36% | 36% | Q:180 /30Days |
COLCHICINE 0.6 MG CAPSULE  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
COLCHICINE 0.6 MG TABLET  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
COLCRYS 0.6 MG TABLET  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
COLESTIPOL HCL 1G TABLET  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
COLESTIPOL HYDROCHLORIDE 5g/1 100 SUSPENSION in 1 BOTTLE  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
colistimethate 150mg/2mL 1 VIAL per CARTON / 2 mL in 1 VIAL  |
4 |
Non-Preferred Brand |
36% | 36% | P |
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE  |
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 |
COLOCORT 100MG ENEMA  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
COMBIGAN 0.2%-0.5% DROPS  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
COMBIVENT RESPIMAT INHAL SPRAY  |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:8 /30Days |
COMETRIQ 100 MG DAILY-DOSE PK  |
5 |
Specialty Tier |
25% | N/A | P |
COMETRIQ 140 MG DAILY-DOSE PK  |
5 |
Specialty Tier |
25% | N/A | P |
COMETRIQ 60 MG DAILY-DOSE PACK  |
5 |
Specialty Tier |
25% | N/A | P |
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1  |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
COMPRO 25MG SUPPOSITORY  |
4 |
Non-Preferred Brand |
36% | 36% | None |
COMVAX VACCINE VIAL  |
4 |
Non-Preferred Brand |
36% | 36% | None |
CONSTULOSE 10 GM/15 ML SOLN  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN  |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COPAXONE 40 MG/ML SYRINGE  |
5 |
Specialty Tier |
25% | N/A | P Q:12 /28Days |
CORLANOR 5 MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | P |
CORLANOR 7.5 MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | P |
CORMAX 0.05% SOLUTION  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Cortisone 25 MG Tablet  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
COSMEGEN 0.5 MG VIAL  |
5 |
Specialty Tier |
25% | N/A | None |
Creon 256.11mg/1 1 BOTTLE per CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
CREON DR 36,000 UNITS CAPSULE  |
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 |
CRESTOR 10MG TABLET  |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
CRESTOR 20MG TABLET  |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
CRESTOR 40mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC  |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
CRESTOR 5MG TABLET  |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
CRIXIVAN 200MG CAPSULE  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
CRIXIVAN 400mg, 180 CAPSULE BOTTLE  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
CROMOLYN NEBULIZER SOLUTION 20MG/2ML  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | P |
CROMOLYN SODIUM 100 MG/5 ML  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CROMOLYN SODIUM 4% 40MG 10ML BOT  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
CUBICIN 500MG VIAL  |
5 |
Specialty Tier |
25% | N/A | None |
CUPRIMINE 250 MG CAPSULE  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cyclafem 1/35 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Cyclafem 7/7/7 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Cyclobenzaprine 7.5 mg tablet  |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:90 /30Days |
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT)  |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:90 /30Days |
Cyclobenzaprine Hydrochloride 5mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC  |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:90 /30Days |
CYCLOPHOSPHAMIDE 25 MG CAPSULE  |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
CYCLOPHOSPHAMIDE 50 MG CAPSULE  |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
Cyclosporine 100mg 30 BLISTER PACK per CARTON / 1 CAPSULE, LIQUID FILLED per BLISTER PACK  |
4 |
Non-Preferred Brand |
36% | 36% | P |
CYCLOSPORINE 100MG CAPSULE  |
4 |
Non-Preferred Brand |
36% | 36% | P |
Cyclosporine 25mg 30 BLISTER PACK per CARTON / 1 CAPSULE, LIQUID FILLED per BLISTER PACK  |
4 |
Non-Preferred Brand |
36% | 36% | P |
CYCLOSPORINE 25MG CAPSULE  |
4 |
Non-Preferred Brand |
36% | 36% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cyclosporine 50 mg/ml vial  |
4 |
Non-Preferred Brand |
36% | 36% | P |
Cyclosporine 50mg 30 BLISTER PACK per CARTON / 1 CAPSULE, LIQUID FILLED per BLISTER PACK  |
4 |
Non-Preferred Brand |
36% | 36% | P |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT  |
4 |
Non-Preferred Brand |
36% | 36% | P |
CYSTADANE POWDER FOR ORAL SOLUTION 180GM  |
5 |
Specialty Tier |
25% | N/A | None |
CYSTAGON 150MG CAPSULE  |
4 |
Non-Preferred Brand |
36% | 36% | P |
CYSTAGON 50MG CAPSULE  |
4 |
Non-Preferred Brand |
36% | 36% | P |
CYSTARAN 0.44% EYE DROPS  |
5 |
Specialty Tier |
25% | N/A | Q:60 /28Days |
CYTARABINE 20MG/ML VIAL  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | P |
CYTARABINE SOLUTION INJECTION 100MG 20ML VIALSD  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | P |