2015 Medicare Part D Plan Formulary Information |
PHP (HMO SNP) (H3132-001-0)
Benefit Details
|
The PHP (HMO SNP) (H3132-001-0) Formulary Drugs Starting with the Letter P in MIAMI-DADE County, FL: CMS MA Region 9 which includes: FL Plan Monthly Premium: $0.00 Deductible: $320 |
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 |
Preferred Brand |
25% | N/A | None |
PACERONE 200MG TABLET |
2 |
Preferred Brand |
25% | N/A | None |
PACERONE 400MG TABLET |
2 |
Preferred Brand |
25% | N/A | None |
PANCREAZE 10,500 UNIT CAP DR |
2 |
Preferred Brand |
25% | N/A | None |
PANCREAZE 16,800 UNIT CAP DR |
2 |
Preferred Brand |
25% | N/A | None |
PANCREAZE 21,000 UNIT CAP DR |
2 |
Preferred Brand |
25% | N/A | None |
PANCREAZE 4,200 UNIT CAP DR |
2 |
Preferred Brand |
25% | N/A | None |
PANRETIN 0.1% GEL 60GM TUBE |
1 |
Preferred Generic |
25% | N/A | P |
Pantoprazole 40mg/1 90 TABLET, DELAYED RELEASE in 1 BOTTLE |
1 |
Preferred Generic |
25% | N/A | None |
PANTOPRAZOLE SODIUM 20MG TABLET DELAYED RELEASE |
1 |
Preferred Generic |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAROMOMYCIN 250MG CAPSULE |
2 |
Preferred Brand |
25% | N/A | None |
Paroxetine 40mg/1 500 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
25% | N/A | None |
PAROXETINE FILM COATED 20MG TABLET (100 CT) |
1 |
Preferred Generic |
25% | N/A | None |
PAROXETINE HCL TABLET 24 12.5MG |
1 |
Preferred Generic |
25% | N/A | None |
PAROXETINE HCL TABLET 24 25MG |
1 |
Preferred Generic |
25% | N/A | None |
Paroxetine Hydrochloride 37.5mg/1 30 BOTTLE in 1 BOTTLE / 30 TABLET, FILM COATED, EXTENDED RELEASE |
1 |
Preferred Generic |
25% | N/A | None |
PAROXETINE HYDROCHLORIDE TABLETS 10 MG |
1 |
Preferred Generic |
25% | N/A | None |
PAROXETINE TABLETS 30MG 90 BOT |
1 |
Preferred Generic |
25% | N/A | None |
PASER GRANULES 4GM PACKET |
2 |
Preferred Brand |
25% | N/A | None |
PAXIL ORAL SUSPENSION 10 MG/5ML |
2 |
Preferred Brand |
25% | N/A | None |
PCE 333 MG TABLET |
1 |
Preferred Generic |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PCE 500 MG TABLET |
1 |
Preferred Generic |
25% | N/A | None |
PEDVAXHIB VACCINE VIAL |
2 |
Preferred Brand |
25% | N/A | 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 |
1 |
Preferred Generic |
25% | N/A | None |
PEGANONE 250 MG TABLET |
2 |
Preferred Brand |
25% | N/A | None |
Pegasys 180ug/0.5mL 1 PACKET in 1 BOX / 4 SYRINGE, GLASS in 1 PACKET / 0.5 mL in 1 SYRINGE, GLASS |
2 |
Preferred Brand |
25% | N/A | P Q:2 /28Days |
PEGASYS INJECTION |
2 |
Preferred Brand |
25% | N/A | P Q:4 /28Days |
PEGASYS PROCLICK 135 MCG/0.5 |
2 |
Preferred Brand |
25% | N/A | P Q:2 /28Days |
PEGASYS PROCLICK 180 MCG/0.5 |
2 |
Preferred Brand |
25% | N/A | P Q:2 /28Days |
PEGINTRON 1 KIT per CARTON |
3 |
Non-Preferred Brand |
25% | N/A | P Q:2 /28Days |
PEGINTRON 120 MCG KIT |
3 |
Non-Preferred Brand |
25% | N/A | P Q:2 /28Days |
PegIntron 120ug/0.5mL 1 CARTRIDGE per CARTON / 0.5 mL in 1 CARTRIDGE |
3 |
Non-Preferred Brand |
25% | N/A | P Q:2 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEGINTRON 150 MCG KIT |
3 |
Non-Preferred Brand |
25% | N/A | P Q:2 /28Days |
PegIntron 150ug/0.5mL 1 CARTRIDGE per CARTON / 0.5 mL in 1 CARTRIDGE |
3 |
Non-Preferred Brand |
25% | N/A | P Q:2 /28Days |
PegIntron 50ug/0.5mL 1 CARTRIDGE per CARTON / 0.5 mL in 1 CARTRIDGE |
3 |
Non-Preferred Brand |
25% | N/A | P Q:2 /28Days |
PEGINTRON 80 MCG KIT |
3 |
Non-Preferred Brand |
25% | N/A | P Q:2 /28Days |
PegIntron 80ug/0.5mL 1 CARTRIDGE per CARTON / 0.5 mL in 1 CARTRIDGE |
3 |
Non-Preferred Brand |
25% | N/A | P Q:2 /28Days |
PENICILLIN G POTASSIUM FOR INJECTION 5000000UNIT/VIAL |
1 |
Preferred Generic |
25% | N/A | None |
Penicillin G Sodium 5000000[iU]/1 10 VIAL per CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL |
1 |
Preferred Generic |
25% | N/A | None |
Penicillin V Potassium 250mg/1 1000 TABLET BOTTLE |
1 |
Preferred Generic |
25% | N/A | None |
PENICILLIN V POTASSIUM 500MG TABLET |
1 |
Preferred Generic |
25% | N/A | None |
PENTAM 300 INJ 300MG |
3 |
Non-Preferred Brand |
25% | N/A | None |
PENTASA 250MG CAPSULE SA |
2 |
Preferred Brand |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENTASA 500MG CAPSULE |
2 |
Preferred Brand |
25% | N/A | None |
PENTOXIFYLLINE 400MG TABLET SA |
1 |
Preferred Generic |
25% | N/A | None |
PERIOGARD 0.12% ORAL RINSE |
2 |
Preferred Brand |
25% | N/A | None |
PERJETA 420 MG/14 ML VIAL |
3 |
Non-Preferred Brand |
25% | N/A | P |
Permethrin 50mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
1 |
Preferred Generic |
25% | N/A | None |
Perphenazine 16mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
25% | N/A | None |
PERPHENAZINE TABLETS 4MG 100 BOXUD |
1 |
Preferred Generic |
25% | N/A | None |
PERPHENAZINE TABLETS 8MG 100 BOT |
1 |
Preferred Generic |
25% | N/A | None |
PERPHENAZINE TABLETS USP 2MG 100 BOT |
1 |
Preferred Generic |
25% | N/A | None |
Pfizerpen 5000000[iU]/1 10 VIAL in 1 CARTON / 1 POWDER, FOR SOLUTION in 1 VIAL |
1 |
Preferred Generic |
25% | N/A | None |
Phenadoz 12.5 mg Suppository |
2 |
Preferred Brand |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Phenelzine Sulfate 15mg/1 60 TABLET BOTTLE |
1 |
Preferred Generic |
25% | N/A | None |
Phenobarbital 100mg/1 |
2 |
Preferred Brand |
25% | N/A | P |
Phenobarbital 15mg/1 |
2 |
Preferred Brand |
25% | N/A | P |
PHENOBARBITAL 20 MG/5 ML ELIX |
2 |
Preferred Brand |
25% | N/A | P |
Phenobarbital 30mg/1 |
2 |
Preferred Brand |
25% | N/A | P |
Phenobarbital 60mg/1 |
2 |
Preferred Brand |
25% | N/A | P |
PHENOBARBITAL 64.8 MG TABLET |
2 |
Preferred Brand |
25% | N/A | None |
PHENOBARBITAL 97.2 MG TABLET |
2 |
Preferred Brand |
25% | N/A | None |
PHENYTEK 200 MG CAPSULE |
1 |
Preferred Generic |
25% | N/A | None |
PHENYTEK 300 MG CAPSULE |
1 |
Preferred Generic |
25% | N/A | None |
phenytoin 50 mg tablet chew |
1 |
Preferred Generic |
25% | N/A | 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 |
1 |
Preferred Generic |
25% | N/A | None |
PHENYTOIN SOD EXT 200 MG CAP |
1 |
Preferred Generic |
25% | N/A | None |
PHENYTOIN SODIUM 100MG /2ML INJECTION |
1 |
Preferred Generic |
25% | N/A | P |
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT) |
1 |
Preferred Generic |
25% | N/A | None |
PHOSPHOLINE IODIDE 0.125% 6.25MG |
2 |
Preferred Brand |
25% | N/A | None |
PILOCARPINE HCL 5MG TABLET (100 CT) |
1 |
Preferred Generic |
25% | N/A | None |
Pilocarpine Hydrochloride 7.5mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
25% | N/A | None |
PIMTREA 28 DAY TABLET |
1 |
Preferred Generic |
25% | N/A | None |
PINDOLOL 10MG TABLET |
1 |
Preferred Generic |
25% | N/A | None |
PINDOLOL 5MG TABLET |
1 |
Preferred Generic |
25% | N/A | None |
pioglitazone hcl 15 mg tablet [Actos] |
1 |
Preferred Generic |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
pioglitazone hcl 30 mg tablet [Actos] |
1 |
Preferred Generic |
25% | N/A | None |
pioglitazone hcl 45 mg tablet [Actos] |
1 |
Preferred Generic |
25% | N/A | None |
PIOGLITAZONE-METFORMIN 15-500 |
1 |
Preferred Generic |
25% | N/A | None |
PIOGLITAZONE-METFORMIN 15-850 |
1 |
Preferred Generic |
25% | N/A | None |
PIPERACILLIN 200 MG/ML / TAZOBACTAM 25 MG/ML INJECTABLE SOLUTION |
2 |
Preferred Brand |
25% | N/A | None |
Piperacillin and Tazobactam 4; 0.5g/1; g/1 10 VIAL, SINGLE-USE per CARTON / 1 INJECTION, POWDER, L |
2 |
Preferred Brand |
25% | N/A | None |
Pirmella 1-35-28 tablet |
1 |
Preferred Generic |
25% | N/A | None |
PODOFILOX 0.5% TOPICAL TUBEX |
1 |
Preferred Generic |
25% | N/A | None |
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT) |
1 |
Preferred Generic |
25% | N/A | None |
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1% |
1 |
Preferred Generic |
25% | N/A | None |
POMALYST 1 MG CAPSULE |
3 |
Non-Preferred Brand |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POMALYST 2 MG CAPSULE |
3 |
Non-Preferred Brand |
25% | N/A | P |
POMALYST 3 MG CAPSULE |
3 |
Non-Preferred Brand |
25% | N/A | P |
POMALYST 4 MG CAPSULE |
3 |
Non-Preferred Brand |
25% | N/A | P |
PORTIA 0.15-0.03 TABLET |
1 |
Preferred Generic |
25% | N/A | None |
POTASSIUM CHLORIDE 750MG EXTENDED RELEASE TABLETS |
1 |
Preferred Generic |
25% | N/A | None |
POTASSIUM CHLORIDE ER CAPSULES 10MEQ |
1 |
Preferred Generic |
25% | N/A | None |
POTASSIUM CHLORIDE ER CPCR 8MEQ |
1 |
Preferred Generic |
25% | N/A | None |
Potassium Chloride in Lactated Ringers and Dextrose 20; 5; 179; 600; 310mg/100mL; g/100mL; mg/100mL |
1 |
Preferred Generic |
25% | N/A | None |
POTASSIUM CITRATE ER 10 MEQ TB |
1 |
Preferred Generic |
25% | N/A | None |
POTASSIUM CITRATE ER 15 MEQ TABLET |
1 |
Preferred Generic |
25% | N/A | None |
POTASSIUM CITRATE ER 5 MEQ TAB |
1 |
Preferred Generic |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CITRATE ER 8 MEQ TABLET |
1 |
Preferred Generic |
25% | N/A | None |
Potassium cl 2 meq/ml vial |
1 |
Preferred Generic |
25% | N/A | None |
POTASSIUM CL ER 20 MEQ TABLET |
1 |
Preferred Generic |
25% | N/A | None |
POTIGA 200 MG TABLET |
2 |
Preferred Brand |
25% | N/A | P |
POTIGA 300 MG TABLET |
2 |
Preferred Brand |
25% | N/A | P |
POTIGA 400 MG TABLET |
2 |
Preferred Brand |
25% | N/A | P |
POTIGA 50 MG TABLET |
2 |
Preferred Brand |
25% | N/A | P |
PRADAXA 150mg/1 1 BOTTLE per CARTON / 60 CAPSULE BOTTLE |
2 |
Preferred Brand |
25% | N/A | P |
PRADAXA 75mg/1 1 BOTTLE per CARTON / 60 CAPSULE BOTTLE |
2 |
Preferred Brand |
25% | N/A | P |
Pramipexole Dihydrochloride 0.125mg/1 500 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
25% | N/A | None |
Pramipexole Dihydrochloride 0.25mg/1 500 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Pramipexole Dihydrochloride 0.5mg/1 500 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
25% | N/A | None |
PRAMIPEXOLE DIHYDROCHLORIDE 0.75MG TABLETS |
1 |
Preferred Generic |
25% | N/A | None |
Pramipexole Dihydrochloride 1.5mg/1 500 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
25% | N/A | None |
Pramipexole Dihydrochloride 1mg/1 500 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
25% | N/A | None |
PRAVASTATIN SODIUM 20MG TABLET 500 BOT |
1 |
Preferred Generic |
25% | N/A | None |
PRAVASTATIN SODIUM 40MG TABLET (500 CT) |
1 |
Preferred Generic |
25% | N/A | None |
Pravastatin Sodium 80mg/1 1000 TABLET BOTTLE |
1 |
Preferred Generic |
25% | N/A | None |
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT |
1 |
Preferred Generic |
25% | N/A | None |
PRAZOSIN 5MG CAPSULE |
1 |
Preferred Generic |
25% | N/A | None |
PRAZOSIN HCL 1MG CAPSULE |
1 |
Preferred Generic |
25% | N/A | None |
PRAZOSIN HCL 2MG CAPSULE |
1 |
Preferred Generic |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRED MILD 0.12% EYE DROPS |
2 |
Preferred Brand |
25% | N/A | None |
PRED-G S.O.P. EYE OINTMENT |
2 |
Preferred Brand |
25% | N/A | None |
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR |
1 |
Preferred Generic |
25% | N/A | None |
Prednisolone odt 10 mg tablet |
1 |
Preferred Generic |
25% | N/A | None |
Prednisolone odt 15 mg tablet |
1 |
Preferred Generic |
25% | N/A | None |
Prednisolone odt 30 mg tablet |
1 |
Preferred Generic |
25% | N/A | None |
PREDNISOLONE SOD 1% EYE DROP |
1 |
Preferred Generic |
25% | N/A | None |
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL |
1 |
Preferred Generic |
25% | N/A | None |
PREDNISONE 10MG TABLET (100 CT) |
1 |
Preferred Generic |
25% | N/A | None |
PREDNISONE 1MG TABLET |
1 |
Preferred Generic |
25% | N/A | None |
PREDNISONE 2.5MG TABLET |
1 |
Preferred Generic |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISONE 20MG TABLET (1000 CT) |
1 |
Preferred Generic |
25% | N/A | None |
PREDNISONE 5 MG TABLET |
1 |
Preferred Generic |
25% | N/A | None |
PREDNISONE 50MG TABLET |
1 |
Preferred Generic |
25% | N/A | None |
PREDNISONE 5MG/5ML SOLUTION |
1 |
Preferred Generic |
25% | N/A | None |
PREDNISONE 5MG/ML SOLUTION |
1 |
Preferred Generic |
25% | N/A | None |
PREGNYL INJ 10000UNT |
3 |
Non-Preferred Brand |
25% | N/A | P |
Premarin 0.3mg/1 1000 FILM COATED TABLETS in BOTTLE |
2 |
Preferred Brand |
25% | N/A | None |
PREMARIN 0.45MG TABLET |
2 |
Preferred Brand |
25% | N/A | None |
Premarin 0.625mg/1 1000 FILM COATED TABLETS in BOTTLE |
2 |
Preferred Brand |
25% | N/A | None |
PREMARIN 0.9MG TABLET |
2 |
Preferred Brand |
25% | N/A | None |
Premarin 1.25mg/1 1000 FILM COATED TABLETS in BOTTLE |
2 |
Preferred Brand |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREVALITE POW 4GM |
2 |
Preferred Brand |
25% | N/A | None |
Previfem 6 BLISTER PACK per BLISTER PACK / 1 KIT per BLISTER PACK |
1 |
Preferred Generic |
25% | N/A | None |
PREZCOBIX 800 MG-150 MG TABLET |
2 |
Preferred Brand |
25% | N/A | None |
PREZISTA 100 MG/ML SUSPENSION |
1 |
Preferred Generic |
25% | N/A | None |
PREZISTA 150MG TABLETS |
1 |
Preferred Generic |
25% | N/A | None |
PREZISTA 800 MG TABLET |
1 |
Preferred Generic |
25% | N/A | None |
PREZISTA TABLET 600MG |
1 |
Preferred Generic |
25% | N/A | None |
PREZISTA TABLET 75MG |
1 |
Preferred Generic |
25% | N/A | None |
PRIFTIN 150MG TABLET |
3 |
Non-Preferred Brand |
25% | N/A | P |
PRIMAQUINE 26.3MG TABLET |
3 |
Non-Preferred Brand |
25% | N/A | P |
Primidone 250mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Primidone 50mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic |
25% | N/A | None |
PRIVIGEN 10% VIAL |
2 |
Preferred Brand |
25% | N/A | P |
PROAIR HFA 90 MCG INHALER |
1 |
Preferred Generic |
25% | N/A | None |
PROBENECID 500MG TABLET |
1 |
Preferred Generic |
25% | N/A | None |
PROBENECID/COLCHICINE 0.5MG/500MG TABLET |
1 |
Preferred Generic |
25% | N/A | None |
PROCAINAMIDE 100MG/ML VIAL |
1 |
Preferred Generic |
25% | N/A | None |
PROCAINAMIDE 500MG/ML VIAL |
1 |
Preferred Generic |
25% | N/A | None |
Prochlorperazine 10 mg/2 ml vl |
1 |
Preferred Generic |
25% | N/A | None |
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT) |
1 |
Preferred Generic |
25% | N/A | None |
Prochlorperazine Maleate 5mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
25% | N/A | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX |
1 |
Preferred Generic |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCRIT 10000U/ML VIAL |
2 |
Preferred Brand |
25% | N/A | P |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL |
2 |
Preferred Brand |
25% | N/A | P |
PROCRIT 3,000 UNITS/ML VIAL |
2 |
Preferred Brand |
25% | N/A | P |
PROCRIT 4,000 UNITS/ML VIAL |
2 |
Preferred Brand |
25% | N/A | P |
PROCRIT 40000U/ML VIAL PR |
2 |
Preferred Brand |
25% | N/A | P |
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY |
2 |
Preferred Brand |
25% | N/A | P |
PROCTOSOL-HC 2.5% CREAM |
2 |
Preferred Brand |
25% | N/A | None |
proctozone-hc 2.5% cream |
1 |
Preferred Generic |
25% | N/A | None |
Proglycem 50mg/mL 1 BOTTLE, DROPPER in 1 BOX / 30 mL in 1 BOTTLE, DROPPER |
2 |
Preferred Brand |
25% | N/A | None |
PROLEUKIN 22 MILLION UNIT VIAL |
3 |
Non-Preferred Brand |
25% | N/A | P |
PROLIA 60MG/ML INJECTION |
3 |
Non-Preferred Brand |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMACTA 12.5 MG TABLET |
3 |
Non-Preferred Brand |
25% | N/A | P Q:30 /30Days |
PROMACTA 25 MG TABLET |
3 |
Non-Preferred Brand |
25% | N/A | P Q:30 /30Days |
PROMACTA 50 MG TABLET |
3 |
Non-Preferred Brand |
25% | N/A | P Q:30 /30Days |
PROMACTA 75 MG TABLET |
3 |
Non-Preferred Brand |
25% | N/A | P Q:30 /30Days |
PROMETHAZINE 50 MG SUPPOSITORY |
1 |
Preferred Generic |
25% | N/A | None |
PROMETHAZINE 50MG/ML VIAL |
1 |
Preferred Generic |
25% | N/A | None |
PROMETHAZINE HCL 25MG TABLET (1000 CT) |
1 |
Preferred Generic |
25% | N/A | P |
PROMETHAZINE HCL 50MG TABLET (100 CT) |
1 |
Preferred Generic |
25% | N/A | P |
PROMETHAZINE HYDROCHLORIDE 12.5mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
25% | N/A | P |
PROMETHAZINE HYDROCHLORIDE 25mg/mL 25 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
1 |
Preferred Generic |
25% | N/A | None |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX |
1 |
Preferred Generic |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX |
1 |
Preferred Generic |
25% | N/A | None |
PROMETHAZINE VC SYRUP |
1 |
Preferred Generic |
25% | N/A | None |
PROMETHEGAN 25MG SUPP |
2 |
Preferred Brand |
25% | N/A | None |
PROMETHEGAN 50MG SUPPOS |
2 |
Preferred Brand |
25% | N/A | None |
Propafenone HCl 150mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
25% | N/A | None |
PROPAFENONE HCL 225MG TABLET |
1 |
Preferred Generic |
25% | N/A | None |
PROPAFENONE HCL 300MG TABLET (100 CT) |
1 |
Preferred Generic |
25% | N/A | None |
PROPRANOLOL 20MG/5ML TUBEX |
1 |
Preferred Generic |
25% | N/A | None |
PROPRANOLOL 40MG/5ML TUBEX |
1 |
Preferred Generic |
25% | N/A | None |
PROPRANOLOL 60MG TABLET |
1 |
Preferred Generic |
25% | N/A | None |
PROPRANOLOL 80 MG TABLET |
1 |
Preferred Generic |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPRANOLOL ER 120 MG CAPSULE |
1 |
Preferred Generic |
25% | N/A | None |
PROPRANOLOL ER 160 MG CAPSULE |
1 |
Preferred Generic |
25% | N/A | None |
PROPRANOLOL HCL 20MG TABLET (1000 CT) |
1 |
Preferred Generic |
25% | N/A | None |
PROPRANOLOL HCL TABLET USP 10MG (1000 CT) |
1 |
Preferred Generic |
25% | N/A | None |
PROPRANOLOL HCL TABLET USP 40MG (1000 CT) |
1 |
Preferred Generic |
25% | N/A | None |
Propranolol Hydrochloride 60mg/1 1000 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
1 |
Preferred Generic |
25% | N/A | None |
Propranolol Hydrochloride 80mg/1 500 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
1 |
Preferred Generic |
25% | N/A | None |
PROPRANOLOL/HCTZ 40/25 TABLET |
1 |
Preferred Generic |
25% | N/A | None |
PROPRANOLOL/HCTZ 80/25 TABLET |
1 |
Preferred Generic |
25% | N/A | None |
PROPYLTHIOURACIL 50MG TABLET |
1 |
Preferred Generic |
25% | N/A | None |
PROQUAD 0.5 VIAL |
2 |
Preferred Brand |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROTOPIC 0.03% OINTMENT 100GM TUBE |
2 |
Preferred Brand |
25% | N/A | P |
PROTOPIC 0.1% OINTMENT 60GM TUBE |
2 |
Preferred Brand |
25% | N/A | P |
PROTRIPTYLINE HYDROCHLORIDE 10MG TABLETS |
1 |
Preferred Generic |
25% | N/A | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG |
1 |
Preferred Generic |
25% | N/A | None |
PULMICORT FLEXHALER 180MCG AEROSOL POWDER BREATH ACTIVATED |
2 |
Preferred Brand |
25% | N/A | None |
PULMICORT FLEXHALER 90MCG AEROSOL POWDER BREATH ACTIVATED |
2 |
Preferred Brand |
25% | N/A | None |
PULMOZYME 1MG/ML AMPUL |
2 |
Preferred Brand |
25% | N/A | None |
PURIXAN 20 MG/ML ORAL SUSP |
3 |
Non-Preferred Brand |
25% | N/A | P |
PYRAZINAMIDE 500 MG TABLET |
1 |
Preferred Generic |
25% | N/A | None |
Pyridostigmine br 60 mg tablet |
1 |
Preferred Generic |
25% | N/A | None |