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 P in CMS PDP Region 31 which includes: ID UT Plan Monthly Premium: $31.40 Deductible: $320 Qualifies for LIS: Yes |
Drugs Starting with Letter P
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
PACERONE 100MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PACERONE 200MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PACERONE 400MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PACLITAXEL INJECTION SOLUTION 6MG 50ML VIALMD  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PAMIDRONATE 60MG/10ML VIAL  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PAMIDRONATE DISODIUM INJECTION 3MG 10ML VIALSD  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PAMIDRONATE DISODIUM INJECTION 9MG 10ML VIALSD  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PANRETIN 0.1% GEL 60GM TUBE  |
5 |
Specialty Tier |
25% | N/A | None |
Pantoprazole 40mg/1 90 TABLET, DELAYED RELEASE in 1 BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | Q:60 /30Days |
PANTOPRAZOLE SODIUM 20MG TABLET DELAYED RELEASE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PARICALCITOL 1 MCG CAPSULE [Zemplar] ![Compare how all Medicare Part D PDP plans in ID cover PARICALCITOL 1 MCG CAPSULE [Zemplar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PARICALCITOL 2 MCG CAPSULE [Zemplar] ![Compare how all Medicare Part D PDP plans in ID cover PARICALCITOL 2 MCG CAPSULE [Zemplar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PARICALCITOL 2 MCG/ML VIAL [Zemplar] ![Compare how all Medicare Part D PDP plans in ID cover PARICALCITOL 2 MCG/ML VIAL [Zemplar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PARICALCITOL 4 MCG CAPSULE [Zemplar] ![Compare how all Medicare Part D PDP plans in ID cover PARICALCITOL 4 MCG CAPSULE [Zemplar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PARICALCITOL 5 MCG/ML VIAL [Zemplar] ![Compare how all Medicare Part D PDP plans in ID cover PARICALCITOL 5 MCG/ML VIAL [Zemplar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PAROMOMYCIN 250MG CAPSULE  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Paroxetine 40mg/1 500 FILM COATED TABLETS in BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PAROXETINE FILM COATED 20MG TABLET (100 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PAROXETINE HYDROCHLORIDE TABLETS 10 MG  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PAROXETINE TABLETS 30MG 90 BOT  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PASER GRANULES 4GM PACKET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PATADAY 0.2% DROPS  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PATANOL 0.1% EYE DROPS  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PAXIL ORAL SUSPENSION 10 MG/5ML  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PAZEO 0.7% EYE DROPS  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PEDVAXHIB VACCINE VIAL  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PEG-3350 and Electrolytes 236; 2.97; 6.74; 5.86; 22.74g/2L; g/2L; g/2L; g/2L; g/2L 4 L in 1 JUG  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PEGANONE 250 MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PEGINTRON 1 KIT per CARTON  |
5 |
Specialty Tier |
25% | N/A | P |
PEGINTRON 120 MCG KIT  |
5 |
Specialty Tier |
25% | N/A | P |
PegIntron 120ug/0.5mL 1 CARTRIDGE per CARTON / 0.5 mL in 1 CARTRIDGE  |
5 |
Specialty Tier |
25% | N/A | P |
PEGINTRON 150 MCG KIT  |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PegIntron 150ug/0.5mL 1 CARTRIDGE per CARTON / 0.5 mL in 1 CARTRIDGE  |
5 |
Specialty Tier |
25% | N/A | P |
PegIntron 50ug/0.5mL 1 CARTRIDGE per CARTON / 0.5 mL in 1 CARTRIDGE  |
5 |
Specialty Tier |
25% | N/A | P |
PEGINTRON 80 MCG KIT  |
5 |
Specialty Tier |
25% | N/A | P |
PegIntron 80ug/0.5mL 1 CARTRIDGE per CARTON / 0.5 mL in 1 CARTRIDGE  |
5 |
Specialty Tier |
25% | N/A | P |
PENICILLIN G POTASSIUM FOR INJECTION 5000000UNIT/VIAL  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PENICILLIN G PROCAINE 1200000UNT 2ML CTG  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Penicillin G Sodium 5000000[iU]/1 10 VIAL per CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL ![Compare how all Medicare Part D PDP plans in ID cover Penicillin G Sodium 5000000[iU]/1 10 VIAL per CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
36% | 36% | None |
Penicillin V Potassium 125mg/5mL 200 mL in 1 BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Penicillin V Potassium 250mg/1 1000 TABLET BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PENICILLIN V POTASSIUM 500MG 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 |
PENTAM 300 INJ 300MG  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PENTOXIFYLLINE 400MG TABLET SA  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Perindopril Erbumine 2mg/1 100 TABLET BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Perindopril Erbumine 4mg/1 100 TABLET BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Perindopril Erbumine 8mg/1 100 TABLET BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PERIOGARD 0.12% ORAL RINSE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PERJETA 420 MG/14 ML VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
Permethrin 50mg/g 1 TUBE per CARTON / 60 g in 1 TUBE  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Perphenazine 16mg/1 100 FILM COATED TABLETS in BOTTLE  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PERPHENAZINE TABLETS 4MG 100 BOXUD  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PERPHENAZINE TABLETS 8MG 100 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 |
PERPHENAZINE TABLETS USP 2MG 100 BOT  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Phenadoz 12.5 mg Suppository  |
4 |
Non-Preferred Brand |
36% | 36% | P |
Phenelzine Sulfate 15mg/1 60 TABLET BOTTLE  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Phenergan 12.5 mg suppository  |
4 |
Non-Preferred Brand |
36% | 36% | P |
Phenergan 25 mg suppository  |
4 |
Non-Preferred Brand |
36% | 36% | P |
Phenergan 50 mg suppository  |
4 |
Non-Preferred Brand |
36% | 36% | P |
Phenobarbital 100mg/1  |
4 |
Non-Preferred Brand |
36% | 36% | P Q:120 /30Days |
Phenobarbital 15mg/1  |
4 |
Non-Preferred Brand |
36% | 36% | P Q:120 /30Days |
PHENOBARBITAL 16.2 MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | P Q:120 /30Days |
PHENOBARBITAL 20 MG/5 ML ELIX  |
4 |
Non-Preferred Brand |
36% | 36% | P Q:1500 /30Days |
Phenobarbital 30mg/1  |
4 |
Non-Preferred Brand |
36% | 36% | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PHENOBARBITAL 32.4 MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | P Q:120 /30Days |
Phenobarbital 60mg/1  |
4 |
Non-Preferred Brand |
36% | 36% | P Q:120 /30Days |
PHENOBARBITAL 64.8 MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | P Q:120 /30Days |
PHENOBARBITAL 97.2 MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | P Q:120 /30Days |
phenytoin 50 mg tablet chew  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PHENYTOIN SOD EXT 200 MG CAP  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PHENYTOIN SODIUM 100MG /2ML INJECTION  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PHOSPHOLINE IODIDE 0.125% 6.25MG  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PILOCARPINE 1% EYE DROPS  |
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 |
PILOCARPINE 2% EYE DROPS  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PILOCARPINE 4% EYE DROPS  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PILOCARPINE HCL 5MG TABLET (100 CT)  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Pilocarpine Hydrochloride 7.5mg/1 100 FILM COATED TABLETS in BOTTLE  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
PIMTREA 28 DAY TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PINDOLOL 10MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PINDOLOL 5MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
pioglitaz-glimepir 30-2 mg tab  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | Q:30 /30Days |
pioglitaz-glimepir 30-4 mg tab  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | Q:30 /30Days |
pioglitazone hcl 15 mg tablet [Actos] ![Compare how all Medicare Part D PDP plans in ID cover pioglitazone hcl 15 mg tablet [Actos].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | Q:30 /30Days |
pioglitazone hcl 30 mg tablet [Actos] ![Compare how all Medicare Part D PDP plans in ID cover pioglitazone hcl 30 mg tablet [Actos].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
pioglitazone hcl 45 mg tablet [Actos] ![Compare how all Medicare Part D PDP plans in ID cover pioglitazone hcl 45 mg tablet [Actos].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | Q:30 /30Days |
PIOGLITAZONE-METFORMIN 15-500  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | Q:90 /30Days |
PIOGLITAZONE-METFORMIN 15-850  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | Q:90 /30Days |
PIPERACILLIN 200 MG/ML / TAZOBACTAM 25 MG/ML INJECTABLE SOLUTION  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Piperacillin and Tazobactam 4; 0.5g/1; g/1 10 VIAL, SINGLE-USE per CARTON / 1 INJECTION, POWDER, L  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Pirmella 1-35-28 tablet  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PIROXICAM 10 MG CAPSULE  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Piroxicam 20mg/1 500 CAPSULE BOTTLE  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
PODOFILOX 0.5% TOPICAL TUBEX  |
4 |
Non-Preferred Brand |
36% | 36% | None |
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1%  |
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 |
POMALYST 1 MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P Q:21 /28Days |
POMALYST 2 MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P Q:21 /28Days |
POMALYST 3 MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P Q:21 /28Days |
POMALYST 4 MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P Q:21 /28Days |
PORTIA 0.15-0.03 TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.9% 1000ML  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
POTASSIUM CHLORIDE 20MEQ IN D5W/NACL 0.225%  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
POTASSIUM CHLORIDE 40MEQ/NS 1000ML IV SOLUTION  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
POTASSIUM CHLORIDE 750MG EXTENDED RELEASE TABLETS  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
POTASSIUM CHLORIDE ER CAPSULES 10MEQ  |
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 |
POTASSIUM CHLORIDE ER CPCR 8MEQ  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Potassium Chloride in Dextrose 5; 150g/100mL; mg/100mL 1000 mL in 1 BAG  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Potassium Chloride in Dextrose and Sodium Chloride 5; 0.15; 0.33g/100mL; g/100mL; g/100mL 12 CONTAI  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Potassium Chloride in Dextrose and Sodium Chloride 5; 0.15; 0.45g/100mL; g/100mL; g/100mL 12 CONTAI  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Potassium Chloride in Dextrose and Sodium Chloride 5; 300; 900g/100mL; mg/100mL; mg/100mL 1000 mL i  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Potassium Chloride in Lactated Ringers and Dextrose 20; 5; 179; 600; 310mg/100mL; g/100mL; mg/100mL  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
POTASSIUM CHLORIDE INJECTION 10MEQ/100ML  |
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 |
POTASSIUM CHLORIDE INJECTION 20 MEQ/100ML  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
POTASSIUM CHLORIDE INJECTION 40 MEQ/100ML  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
POTASSIUM CITRATE ER 10 MEQ TB  |
4 |
Non-Preferred Brand |
36% | 36% | None |
POTASSIUM CITRATE ER 15 MEQ TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
POTASSIUM CITRATE ER 5 MEQ TAB  |
4 |
Non-Preferred Brand |
36% | 36% | None |
POTASSIUM CITRATE ER 8 MEQ TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Potassium Cl 10% (20 MEQ/15 ML)  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Potassium cl 2 meq/ml vial  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Potassium Cl 20% (40 MEQ/15 ML)  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
POTASSIUM CL ER 20 MEQ TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
POTIGA 200 MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | P 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 |
36% | 36% | P Q:90 /30Days |
POTIGA 400 MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | P Q:90 /30Days |
POTIGA 50 MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | P Q:270 /30Days |
PRADAXA 150mg/1 1 BOTTLE per CARTON / 60 CAPSULE BOTTLE  |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
PRADAXA 75mg/1 1 BOTTLE per CARTON / 60 CAPSULE BOTTLE  |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
Pramipexole Dihydrochloride 0.125mg/1 500 TABLET BOTTLE, PLASTIC  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Pramipexole Dihydrochloride 0.25mg/1 500 TABLET BOTTLE, PLASTIC  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Pramipexole Dihydrochloride 0.5mg/1 500 TABLET BOTTLE, PLASTIC  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PRAMIPEXOLE DIHYDROCHLORIDE 0.75MG TABLETS  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Pramipexole Dihydrochloride 1.5mg/1 500 TABLET BOTTLE, PLASTIC  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Pramipexole Dihydrochloride 1mg/1 500 TABLET BOTTLE, PLASTIC  |
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 |
PRAVASTATIN SODIUM 20MG TABLET 500 BOT  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PRAVASTATIN SODIUM 40MG TABLET (500 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Pravastatin Sodium 80mg/1 1000 TABLET BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PRAZOSIN 5MG CAPSULE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PRAZOSIN HCL 1MG CAPSULE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PRAZOSIN HCL 2MG CAPSULE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PREDNICARBATE 0.1% OINTMENT  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PREDNICARBATE 1 MG/ML TOPICAL CREAM  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PREDNISOLONE SOD 1% EYE DROP  |
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 |
PREDNISOLONE SOD PH 25 MG/5 ML  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PREDNISOLONE SODIUM PHOSPHATE 5MG /5ML ORAL SOLUTION  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PREDNISONE 10MG TABLET (100 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PREDNISONE 1MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PREDNISONE 2.5MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PREDNISONE 20MG TABLET (1000 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PREDNISONE 5 MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PREDNISONE 50MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PREDNISONE 5MG/5ML SOLUTION  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PREDNISONE 5MG/ML SOLUTION  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREMASOL 10% IV SOLUTION  |
4 |
Non-Preferred Brand |
36% | 36% | P |
PREMASOL 6% IV SOLUTION  |
4 |
Non-Preferred Brand |
36% | 36% | P |
PREVALITE POW 4GM  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Previfem 6 BLISTER PACK per BLISTER PACK / 1 KIT per BLISTER PACK  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PREZCOBIX 800 MG-150 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
PREZISTA 100 MG/ML SUSPENSION  |
5 |
Specialty Tier |
25% | N/A | None |
PREZISTA 150MG TABLETS  |
5 |
Specialty Tier |
25% | N/A | None |
PREZISTA 800 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | None |
PREZISTA TABLET 600MG  |
5 |
Specialty Tier |
25% | N/A | None |
PREZISTA TABLET 75MG  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PRIFTIN 150MG 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 |
PRIMAQUINE 26.3MG TABLET  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Primidone 250mg/1 100 TABLET BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Primidone 50mg/1 500 TABLET BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PRISTIQ 100MG TABLET SR 24HR  |
4 |
Non-Preferred Brand |
36% | 36% | S Q:30 /30Days |
PRISTIQ ER 25 MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | S Q:30 /30Days |
Pristiq Extended-Release 50mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC  |
4 |
Non-Preferred Brand |
36% | 36% | S Q:30 /30Days |
PROAIR HFA 90 MCG INHALER  |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:17 /30Days |
PROAIR RESPICLICK INHAL POWDER  |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:2 /30Days |
PROBENECID 500MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PROBENECID/COLCHICINE 0.5MG/500MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Prochlorperazine 10 mg/2 ml vl  |
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 |
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Prochlorperazine Maleate 5mg/1 100 FILM COATED TABLETS in BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PROCRIT 10000U/ML VIAL  |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:12 /28Days |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL  |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:12 /28Days |
PROCRIT 3,000 UNITS/ML VIAL  |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:12 /28Days |
PROCRIT 4,000 UNITS/ML VIAL  |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:12 /28Days |
PROCRIT 40000U/ML VIAL PR  |
5 |
Specialty Tier |
25% | N/A | P Q:8 /28Days |
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY  |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:12 /28Days |
PROCTOSOL-HC 2.5% CREAM  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
proctozone-hc 2.5% cream  |
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 |
PROGESTERONE 100 MG CAPSULE  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PROGESTERONE 200 MG CAPSULE  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Proglycem 50mg/mL 1 BOTTLE, DROPPER in 1 BOX / 30 mL in 1 BOTTLE, DROPPER  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PROGRAF 5MG/ML AMPULE  |
4 |
Non-Preferred Brand |
36% | 36% | P |
PROLASTIN-C  |
5 |
Specialty Tier |
25% | N/A | P |
PROLENSA 0.07% EYE DROPS  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PROLEUKIN 22 MILLION UNIT VIAL  |
5 |
Specialty Tier |
25% | N/A | None |
PROLIA 60MG/ML INJECTION  |
4 |
Non-Preferred Brand |
36% | 36% | P Q:1 /180Days |
PROMACTA 12.5 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
PROMACTA 25 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
PROMACTA 50 MG TABLET  |
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 |
PROMACTA 75 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
PROMETHAZINE 50 MG SUPPOSITORY  |
4 |
Non-Preferred Brand |
36% | 36% | P |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX  |
4 |
Non-Preferred Brand |
36% | 36% | P |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX  |
4 |
Non-Preferred Brand |
36% | 36% | P |
PROMETHEGAN 25MG SUPP  |
4 |
Non-Preferred Brand |
36% | 36% | P |
PROMETHEGAN 50MG SUPPOS  |
4 |
Non-Preferred Brand |
36% | 36% | P |
Propafenone HCl 150mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PROPAFENONE HCL 225MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PROPAFENONE HCL 300MG TABLET (100 CT)  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Propafenone Hydrochloride 225mg/1 60 CAPSULE, EXTENDED RELEASE in 1 BOTTLE, PLASTIC  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PROPAFENONE HYDROCHLORIDE 325MG CAPSULES EXTENDED RELEASE  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPAFENONE HYDROCHLORIDE 425MG CAPSULES EXTENDED RELEASE  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PROPARACAINE 0.5% EYE DROPS  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Propranolol 1mg/mL 1 mL in 1 VIAL  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PROPRANOLOL 20MG/5ML TUBEX  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PROPRANOLOL 40MG/5ML TUBEX  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PROPRANOLOL 60MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PROPRANOLOL 80 MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PROPRANOLOL ER 120 MG CAPSULE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PROPRANOLOL ER 160 MG CAPSULE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PROPRANOLOL HCL 20MG TABLET (1000 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PROPRANOLOL HCL TABLET USP 10MG (1000 CT)  |
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 |
PROPRANOLOL HCL TABLET USP 40MG (1000 CT)  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Propranolol Hydrochloride 60mg/1 1000 CAPSULE, EXTENDED RELEASE in 1 BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
Propranolol Hydrochloride 80mg/1 500 CAPSULE, EXTENDED RELEASE in 1 BOTTLE  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PROPRANOLOL/HCTZ 40/25 TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PROPRANOLOL/HCTZ 80/25 TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PROPYLTHIOURACIL 50MG TABLET  |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | None |
PROQUAD 0.5 VIAL  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PROTRIPTYLINE HYDROCHLORIDE 10MG TABLETS  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG  |
4 |
Non-Preferred Brand |
36% | 36% | None |
PULMOZYME 1MG/ML AMPUL  |
5 |
Specialty Tier |
25% | N/A | P |
PURIXAN 20 MG/ML ORAL SUSP  |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PYRAZINAMIDE 500 MG TABLET  |
4 |
Non-Preferred Brand |
36% | 36% | None |
Pyridostigmine br 60 mg tablet  |
3 |
Preferred Brand |
$45.00 | $135.00 | None |