2015 Medicare Part D Plan Formulary Information |
FHCP's Medvantage Rx Plus (HMO-POS) (H1035-002-0)
Benefit Details
|
The FHCP's Medvantage Rx Plus (HMO-POS) (H1035-002-0) Formulary Drugs Starting with the Letter A in FLAGLER County, FL: CMS MA Region 9 which includes: FL Plan Monthly Premium: $46.00 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 |
A-HYDROCORT 100MG VIAL |
6 |
Injectable Drugs |
25% | 25% | None |
ABACAVIR 300 MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir] |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
ABILIFY 10MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | P |
ABILIFY 15MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | P |
ABILIFY 20MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | P |
ABILIFY 2MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | P |
ABILIFY 30MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | P |
ABILIFY 5MG TABLET (OTSUKA) |
4 |
Non-Preferred Brand |
50% | 50% | P |
ABILIFY MAINTENA ER 300 MG SYR |
6 |
Injectable Drugs |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABILIFY MAINTENA ER 300 MG VL |
6 |
Injectable Drugs |
25% | 25% | P |
ABILIFY MAINTENA ER 400 MG SYR |
6 |
Injectable Drugs |
25% | 25% | P |
Acamprosate Calcium DR 333 MG tablets [Campral] |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
ACARBOSE 100 MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
ACARBOSE 25 MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
Acarbose 50mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
ACEBUTOLOL 200MG CAPSULE |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
ACEBUTOLOL 400MG CAPSULE |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE |
6 |
Injectable Drugs |
25% | 25% | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
ACETAMINOPHEN-COD #4 TABLET |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
ACETAZOLAMIDE 125MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
ACETAZOLAMIDE ER CAPSULES 500MG 100 BOT |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
ACETIC ACID 2% SOLUTION NON-ORAL |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | Q:15 /3Days |
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 |
6 |
Injectable Drugs |
25% | 25% | None |
ACTIMMUNE 100 MCG/0.5 ML 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 |
Acyclovir 200mg 100 CAPSULE BOTTLE |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
Acyclovir 200mg/5mL 473 mL BOTTLE |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
Acyclovir 400 MG |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
Acyclovir 5% Ointment |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
ACYCLOVIR 800 MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
Acyclovir sodium 500 mg vial |
6 |
Injectable Drugs |
25% | 25% | None |
ADACEL VIAL 2UNT/5UNT |
6 |
Injectable Drugs |
25% | 25% | None |
ADAGEN 250U/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera] |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | P |
ADVAIR DISKUS MIS 100/50 |
4 |
Non-Preferred Brand |
50% | 50% | Q:60 /3Days |
ADVAIR DISKUS MIS 250/50 |
4 |
Non-Preferred Brand |
50% | 50% | Q:60 /3Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADVAIR DISKUS MIS 500/50 |
4 |
Non-Preferred Brand |
50% | 50% | Q:60 /3Days |
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER |
4 |
Non-Preferred Brand |
50% | 50% | Q:12 /3Days |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL |
4 |
Non-Preferred Brand |
50% | 50% | Q:12 /3Days |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
4 |
Non-Preferred Brand |
50% | 50% | Q:12 /3Days |
AFEDITAB CR 30MG TABLET SA |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
AFEDITAB CR 60MG TABLET SA |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK |
5 |
Specialty Tier |
33% | N/A | None |
AFINITOR DISPERZ 2 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
AFINITOR DISPERZ 3 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
AFINITOR DISPERZ 5 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
AFINITOR TABLETS 10 MG |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AFINITOR TABLETS 2.5 MG |
5 |
Specialty Tier |
33% | N/A | None |
AFINITOR TABLETS 5 MG |
5 |
Specialty Tier |
33% | N/A | None |
AGGRENOX 25-200MG CAPSULE |
3 |
Preferred Brand |
25% | 25% | None |
ALBENZA 200 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH per CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | P |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | P |
ALBUTEROL SULFATE SOLUTION FOR INHALATION |
6 |
Injectable Drugs |
25% | 25% | P |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
ALBUTEROL TABLET 4MG (500 CT) |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
ALDURAZYME 2.9MG/5ML 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 |
ALENDRONATE SODIUM 10MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | Q:4 /3Days |
Alendronate Sodium 35mg/1 12 TABLET in 1 BOX, UNIT-DOSE |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
ALENDRONATE SODIUM 5MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
Alendronate Sodium 70mg/1 4 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ALFUZOSIN HYDROCHLORIDE 10mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
ALIMTA 500MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
ALINIA 500 MG TABLET |
3 |
Preferred Brand |
25% | 25% | None |
ALLOPURINOL 100 MG TABLETS |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET per BLISTER PACK |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ALOMIDE 0.1% EYE DROPS |
3 |
Preferred Brand |
25% | 25% | Q:10 /3Days |
ALOSETRON HCL 0.5 MG TABLET [Lotronex] |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALOSETRON HCL 1 MG TABLET [Lotronex] |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | P |
ALOXI 0.25 MG/5 ML |
6 |
Injectable Drugs |
25% | 25% | P |
ALPRAZOLAM 0.25 MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
ALPRAZOLAM 0.5 MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
ALPRAZOLAM 1 MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
ALPRAZOLAM 2 MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
ALREX 0.2% EYE DROPS |
4 |
Non-Preferred Brand |
50% | 50% | Q:5 /3Days |
AMANTADINE 100MG CAPSULE |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
AMBISOME 50MG VIAL |
6 |
Injectable Drugs |
25% | 25% | P |
AMIFOSTINE 50mg/mL 3 VIAL, SINGLE-USE per CARTON / 10 mL in 1 VIAL, SINGLE-USE |
6 |
Injectable Drugs |
25% | 25% | P |
AMIKACIN SULFATE 500 MG/2 ML VIAL |
6 |
Injectable Drugs |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
Aminophylline 25mg/mL 5 TRAY per CARTON / 5 AMPULE in 1 TRAY / 10 mL in 1 AMPULE |
6 |
Injectable Drugs |
25% | 25% | None |
AMIODARONE HCL 200MG 60 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
AMIODARONE HCL 50 MG INJECTION |
6 |
Injectable Drugs |
25% | 25% | None |
AMITIZA 8MCG CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | P |
AMITIZA CAPSULES 24MCG 60 CAP BOT |
4 |
Non-Preferred Brand |
50% | 50% | P |
AMITRIPTYLINE HCL 100MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
AMITRIPTYLINE HCL 10MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
AMITRIPTYLINE HCL 150 MG TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
Amnesteem 20mg/1 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | P |
amox tr-k clv 200-28.5/5 susp |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | Q:100 /3Days |
AMOX TR-K CLV 500-125 MG TAB |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | Q:100 /3Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXAPINE 100MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
AMOXAPINE 150MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
AMOXAPINE 25MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
AMOXAPINE 50MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
AMOXICILLIN 125MG TABLET CHEW |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
AMOXICILLIN 250MG 500 CHEWABLE TABLET in BOTTLE |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
AMOXICILLIN 250MG CAPSULE |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | Q:150 /3Days |
AMOXICILLIN 500MG 500 CAPSULE BOTTLE |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
AMOXICILLIN 875MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | Q:200 /3Days |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | Q:150 /3Days |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | Q:100 /3Days |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | Q:150 /3Days |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | Q:100 /3Days |
amphotericin b 50mg/10mL 10 mL in 1 VIAL |
6 |
Injectable Drugs |
25% | 25% | None |
AMPICILLIN CAPSULES 250MG 100 BOT |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | Q:200 /3Days |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | Q:200 /3Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML |
6 |
Injectable Drugs |
25% | 25% | None |
AMPICILLIN-SULBACTAM 3 GM VIAL |
6 |
Injectable Drugs |
25% | 25% | None |
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
Anastrozole 1mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
ANDROGEL 1.62% (1.25G) GEL PCKT |
4 |
Non-Preferred Brand |
50% | 50% | Q:150 /30Days |
ANDROGEL 1.62% (2.5G) GEL PCKT |
4 |
Non-Preferred Brand |
50% | 50% | Q:150 /30Days |
ANDROGEL 1% (50MG) GEL PACKET |
4 |
Non-Preferred Brand |
50% | 50% | Q:300 /30Days |
Androgel 10mg/g 2 BOTTLE, PUMP in 1 CARTON / 75 g in 1 BOTTLE, PUMP |
4 |
Non-Preferred Brand |
50% | 50% | Q:300 /30Days |
Androgel 10mg/g 30 PACKET in 1 CARTON / 2.5 g in 1 PACKET |
4 |
Non-Preferred Brand |
50% | 50% | Q:75 /30Days |
Androgel 16.2mg/g 1 BOTTLE, PUMP per CARTON / 88 g in 1 BOTTLE, PUMP |
4 |
Non-Preferred Brand |
50% | 50% | Q:150 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANZEMET 20MG/ML VIAL |
6 |
Injectable Drugs |
25% | 25% | None |
APOKYN 30 MG/3 ML CARTRIDGE |
5 |
Specialty Tier |
33% | N/A | P |
Apraclonidine Ophthalmic 5mg/mL 1 BOTTLE, DROPPER per CARTON / 10 mL in 1 BOTTLE, DROPPER |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | Q:5 /3Days |
APRI 0.15-0.03 TABLET |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
APTIOM 200 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | P |
APTIOM 400 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | P |
APTIOM 600 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | P |
APTIOM 800 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | P |
APTIVUS 250MG CAPSULE |
3 |
Preferred Brand |
25% | 25% | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
3 |
Preferred Brand |
25% | 25% | None |
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.5 mL in 1 SYRINGE |
6 |
Injectable Drugs |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
6 |
Injectable Drugs |
25% | 25% | P |
ARANESP 200MCG/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
6 |
Injectable Drugs |
25% | 25% | P |
ARANESP 60MCG/ML VIAL |
6 |
Injectable Drugs |
25% | 25% | P |
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.3 mL in 1 SYRINGE |
6 |
Injectable Drugs |
25% | 25% | P |
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR |
5 |
Specialty Tier |
33% | N/A | P |
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR |
6 |
Injectable Drugs |
25% | 25% | P |
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD |
6 |
Injectable Drugs |
25% | 25% | P |
ARCALYST INJECTION 220MG/VIAL |
5 |
Specialty Tier |
33% | N/A | P |
ARIPIPRAZOLE 10 MG TABLET [Abilify] |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | P |
ARIPIPRAZOLE 15 MG TABLET [Abilify] |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARIPIPRAZOLE 2 MG TABLET [Abilify] |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | P |
ARIPIPRAZOLE 20 MG TABLET [Abilify] |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | P |
ARIPIPRAZOLE 30 MG TABLET [Abilify] |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | P |
ARIPIPRAZOLE 5 MG TABLET [Abilify] |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | P |
ARNUITY ELLIPTA 100 MCG INH |
3 |
Preferred Brand |
25% | 25% | None |
ARNUITY ELLIPTA 200 MCG INH |
3 |
Preferred Brand |
25% | 25% | None |
ASACOL HD 800mg/1 12 BOTTLE CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE |
3 |
Preferred Brand |
25% | 25% | None |
ASMANEX HFA 100 MCG INHALER |
3 |
Preferred Brand |
25% | 25% | Q:13 /30Days |
ASMANEX HFA 200 MCG INHALER |
3 |
Preferred Brand |
25% | 25% | Q:13 /30Days |
ASMANEX TWISTHALER 110 MCG #30 |
3 |
Preferred Brand |
25% | 25% | Q:1 /30Days |
ASMANEX TWISTHALER 220 MCG #30 |
3 |
Preferred Brand |
25% | 25% | Q:1 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ASMANEX TWISTHALER 220MCG #120 |
3 |
Preferred Brand |
25% | 25% | Q:1 /30Days |
ASMANEX TWISTHALER 220MCG #60 |
3 |
Preferred Brand |
25% | 25% | Q:1 /30Days |
ATENOLOL 100 MG100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ATENOLOL 25 MG 100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ATENOLOL TABLET USP 50MG (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ATGAM 50MG/ML AMPUL |
6 |
Injectable Drugs |
25% | 25% | P |
ATORVASTATIN 10 MG TABLET [Lipitor] |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
ATORVASTATIN 20 MG TABLET [Lipitor] |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
ATORVASTATIN 40 MG TABLET [Lipitor] |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
ATORVASTATIN 80 MG TABLET [Lipitor] |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
ATOVAQUONE 750 MG/5 ML SUSP [Mepron] |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone] |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
Atovaquone-Proguanil 62.5-25 [Malarone] |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Preferred Brand |
25% | 25% | None |
ATROPINE 0.1MG/ML SYRINGE |
6 |
Injectable Drugs |
25% | 25% | None |
Atropine 1% Eye Drops |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | Q:5 /3Days |
ATROVENT HFA AER 17MCG |
3 |
Preferred Brand |
25% | 25% | Q:12 /3Days |
AVASTIN 100MG/4ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
AVIANE 0.1-0.02 TABLET |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
AVODART 0.5MG SOFTGEL |
3 |
Preferred Brand |
25% | 25% | None |
AVONEX ADMIN PACK 30MCG SYR |
5 |
Specialty Tier |
33% | N/A | None |
AVONEX ADMIN PACK 30MCG VL |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVONEX PEN 30 MCG/0.5 ML KIT |
5 |
Specialty Tier |
33% | N/A | None |
Azacitidine 100 mg vial [Vidaza] |
6 |
Injectable Drugs |
25% | 25% | P |
AZATHIOPRINE 50MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | P |
AZELASTINE 137 MCG NASAL SPRAY |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | Q:30 /3Days |
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | Q:6 /3Days |
AZILECT 0.5MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | P |
AZILECT 1MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | P |
Azithromycin 100mg/5mL 15 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | Q:15 /3Days |
Azithromycin 200mg/5mL 22.5 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | Q:30 /3Days |
AZITHROMYCIN 250 MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION |
6 |
Injectable Drugs |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
Azithromycin 600mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$4.00 | $9.00 | None |
AZTREONAM FOR INJECTION |
6 |
Injectable Drugs |
25% | 25% | None |