2016 Medicare Part D Plan Formulary Information |
EnvisionRxPlus Silver (PDP) (S7694-025-0)
Benefit Details
|
The EnvisionRxPlus Silver (PDP) (S7694-025-0) Formulary Drugs Starting with the Letter C in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY Plan Monthly Premium: $33.20 Deductible: $360 Qualifies for LIS: No |
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 |
2 |
Preferred Brand |
14% | 14% | None |
CABOMETYX 20 MG TABLET |
4 |
Specialty Tier |
25% | N/A | P |
CABOMETYX 40 MG TABLET |
4 |
Specialty Tier |
25% | N/A | P |
CABOMETYX 60 MG TABLET |
4 |
Specialty Tier |
25% | N/A | P |
CAFERGOT TABLET |
3 |
Non-Preferred Brand |
40% | 40% | None |
CALCIPOTRIENE TOPICAL SOLUTION |
3 |
Non-Preferred Brand |
40% | 40% | Q:60 /30Days |
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY |
3 |
Non-Preferred Brand |
40% | 40% | P Q:4 /28Days |
CALCITRIOL 0.25MCG CAPSULE |
1 |
Generic |
$2.00 | $6.00 | P |
CALCITRIOL 0.5MCG CAPSULE |
1 |
Generic |
$2.00 | $6.00 | P |
Calcitriol 1 mcg/ml ampul |
1 |
Generic |
$2.00 | $6.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CALCITRIOL 1MCG/ML SOLUTION ORAL |
1 |
Generic |
$2.00 | $6.00 | P |
CALCIUM ACETATE CAPSULE 667 MG |
2 |
Preferred Brand |
14% | 14% | None |
CANCIDAS IV 50MG VIAL |
4 |
Specialty Tier |
25% | N/A | P |
CANCIDAS IV 70MG VIAL |
4 |
Specialty Tier |
25% | N/A | P |
CANDESARTAN CILEXETIL 16 MG TABLET [Atacand] |
1 |
Generic |
$2.00 | $6.00 | Q:60 /30Days |
CANDESARTAN CILEXETIL 32 MG TABLET [Atacand] |
2 |
Preferred Brand |
14% | 14% | Q:30 /30Days |
CANDESARTAN CILEXETIL 4 MG TABLET [Atacand] |
1 |
Generic |
$2.00 | $6.00 | Q:60 /30Days |
CANDESARTAN CILEXETIL 8 MG TABLET [Atacand] |
1 |
Generic |
$2.00 | $6.00 | Q:60 /30Days |
candesartan-hctz 16-12.5 mg tablet |
1 |
Generic |
$2.00 | $6.00 | Q:30 /30Days |
candesartan-hctz 32-12.5 mg tablet |
1 |
Generic |
$2.00 | $6.00 | Q:30 /30Days |
candesartan-hctz 32-25 mg |
2 |
Preferred Brand |
14% | 14% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAPASTAT SULFATE 1g/1 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
3 |
Non-Preferred Brand |
40% | 40% | P |
CAPRELSA 100mg/1 30 TABLET BOTTLE |
4 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
CAPRELSA 300mg/1 30 TABLET BOTTLE |
4 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
CAPTOPRIL 100MG TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
CAPTOPRIL 12.5MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | None |
CAPTOPRIL 25MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | None |
CAPTOPRIL 50MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | None |
Captopril and Hydrochlorothiazide 25; 15mg 100 TABLET BOTTLE |
1 |
Generic |
$2.00 | $6.00 | None |
Captopril and Hydrochlorothiazide 25; 25mg 100 TABLET BOTTLE |
1 |
Generic |
$2.00 | $6.00 | None |
Captopril and Hydrochlorothiazide 50; 15mg 100 TABLET BOTTLE |
1 |
Generic |
$2.00 | $6.00 | None |
Captopril and Hydrochlorothiazide 50; 25mg 100 TABLET BOTTLE |
1 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Carbaglu 200mg/1 5 TABLET BOTTLE |
4 |
Specialty Tier |
25% | N/A | None |
CARBAMAZEPINE 100 MG/5 ML SUSP |
3 |
Non-Preferred Brand |
40% | 40% | None |
Carbamazepine 100mg, CHEWABLE 100 TABLET BOTTLE |
3 |
Non-Preferred Brand |
40% | 40% | None |
Carbamazepine 100mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
2 |
Preferred Brand |
14% | 14% | None |
Carbamazepine 200mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand |
40% | 40% | None |
Carbamazepine 300mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand |
40% | 40% | None |
CARBAMAZEPINE ER 100 MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | None |
CARBAMAZEPINE TABLET USP 200MG (1000 CT) |
3 |
Non-Preferred Brand |
40% | 40% | None |
CARBAMAZEPINE XR 200 MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | None |
CARBAMAZEPINE XR 400 MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | None |
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT |
1 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Carbidopa and Levodopa 25; 100mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED |
1 |
Generic |
$2.00 | $6.00 | None |
Carbidopa and Levodopa 50; 200mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED |
1 |
Generic |
$2.00 | $6.00 | None |
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;100MG;MG 100 BOT |
1 |
Generic |
$2.00 | $6.00 | None |
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;250MG;MG 100 BOT |
1 |
Generic |
$2.00 | $6.00 | None |
Carbidopa-Levodopa-Entacapone 100 MG [Stalevo] |
3 |
Non-Preferred Brand |
40% | 40% | S |
Carbidopa-Levodopa-Entacapone 125 MG [Stalevo] |
2 |
Preferred Brand |
14% | 14% | S |
Carbidopa-Levodopa-Entacapone 150 MG [Stalevo] |
2 |
Preferred Brand |
14% | 14% | S |
Carbidopa-Levodopa-Entacapone 200 MG [Stalevo] |
3 |
Non-Preferred Brand |
40% | 40% | S |
Carbidopa-Levodopa-Entacapone 50 MG [Stalevo] |
3 |
Non-Preferred Brand |
40% | 40% | S |
Carbidopa-Levodopa-Entacapone 75 MG [Stalevo] |
3 |
Non-Preferred Brand |
40% | 40% | S |
CARBIDOPA/LEVO 10/100 TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARBIDOPA/LEVO 25/100 TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
CARBIDOPA/LEVO 25/250 TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
Carboplatin 10mg/mL |
1 |
Generic |
$2.00 | $6.00 | P |
CARISOPRODOL 250 MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | P Q:120 /30Days |
CARISOPRODOL AND ASPIRIN TABLETS USP 325;200MG;MG 100 BOTPL |
2 |
Preferred Brand |
14% | 14% | P Q:240 /30Days |
CARISOPRODOL ASPIRIN AND CODEINE PHOSPHATE TABLETS USP 325;200;16MG;MG;MG 100 BOTPL |
2 |
Preferred Brand |
14% | 14% | P Q:240 /30Days |
CARISOPRODOL TABLET USP 350MG (100 CT) |
3 |
Non-Preferred Brand |
40% | 40% | P Q:120 /30Days |
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT |
1 |
Generic |
$2.00 | $6.00 | None |
CARTIA XT 120MG CAPSULE SA |
1 |
Generic |
$2.00 | $6.00 | Q:60 /30Days |
CARTIA XT 180MG CAPSULE SA |
1 |
Generic |
$2.00 | $6.00 | Q:60 /30Days |
CARTIA XT 240MG CAPSULE SA |
1 |
Generic |
$2.00 | $6.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARTIA XT 300MG CAPSULE SR 24 HR |
1 |
Generic |
$2.00 | $6.00 | Q:30 /30Days |
Carvedilol 12.5mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Generic |
$2.00 | $6.00 | None |
Carvedilol 25mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Generic |
$2.00 | $6.00 | None |
Carvedilol 3.125mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Generic |
$2.00 | $6.00 | None |
Carvedilol 6.25mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Generic |
$2.00 | $6.00 | None |
CAYSTON KIT 75 MG/VIAL |
4 |
Specialty Tier |
25% | N/A | P Q:84 /28Days |
CEFACLOR 250 MG CAPSULES |
1 |
Generic |
$2.00 | $6.00 | None |
CEFACLOR 500 MG CAPSULES |
1 |
Generic |
$2.00 | $6.00 | None |
CEFAZOLIN 1 GM VIAL |
1 |
Generic |
$2.00 | $6.00 | None |
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE |
1 |
Generic |
$2.00 | $6.00 | None |
CEFAZOLIN 500MG FOR INJECTION |
1 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Preferred Brand |
14% | 14% | None |
CEFDINIR CAPSULES 300MG (60 CT) |
1 |
Generic |
$2.00 | $6.00 | None |
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT) |
1 |
Generic |
$2.00 | $6.00 | None |
CEFEPIME HCL 2 GRAM VIAL |
2 |
Preferred Brand |
14% | 14% | None |
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL |
2 |
Preferred Brand |
14% | 14% | None |
CEFOTETAN 10 GM SOLR |
3 |
Non-Preferred Brand |
40% | 40% | None |
CEFOTETAN 1GM VIAL 1EA x 10 |
2 |
Preferred Brand |
14% | 14% | None |
CEFOTETAN 2GM VIAL 1EA x 10 |
3 |
Non-Preferred Brand |
40% | 40% | None |
CEFOXITIN FOR INJECTION SOLUTION |
1 |
Generic |
$2.00 | $6.00 | None |
CEFPODOXIME 200 MG TABLET |
2 |
Preferred Brand |
14% | 14% | None |
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT) |
1 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFTRIAXONE 250 MG VIAL |
1 |
Generic |
$2.00 | $6.00 | None |
Ceftriaxone Sodium 500mg |
1 |
Generic |
$2.00 | $6.00 | None |
CEFUROXIME 1.5 GM/VIAL FOR INJECTION |
3 |
Non-Preferred Brand |
40% | 40% | None |
CEFUROXIME 7.5 GM FOR INJECTION |
1 |
Generic |
$2.00 | $6.00 | None |
CEFUROXIME 750 MG FOR INJECTION |
1 |
Generic |
$2.00 | $6.00 | None |
Cefuroxime Axetil 250 MG |
1 |
Generic |
$2.00 | $6.00 | None |
CEFUROXIME AXETIL 500 MG TAB |
1 |
Generic |
$2.00 | $6.00 | None |
CELECOXIB 100 MG CAPSULE [Celebrex] |
1 |
Generic |
$2.00 | $6.00 | None |
CELECOXIB 200 MG CAPSULE [Celebrex] |
1 |
Generic |
$2.00 | $6.00 | None |
CELECOXIB 400 MG CAPSULE [Celebrex] |
1 |
Generic |
$2.00 | $6.00 | None |
CELECOXIB 50 MG CAPSULE [Celebrex] |
1 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CELLCEPT IV INJ 500 MG |
4 |
Specialty Tier |
25% | N/A | P |
CELONTIN 300 MG KAPSEAL |
3 |
Non-Preferred Brand |
40% | 40% | S |
Cephalexin 125mg/5mL 200 mL in 1 BOTTLE |
1 |
Generic |
$2.00 | $6.00 | None |
CEPHALEXIN 250 MG CAPSULE |
1 |
Generic |
$2.00 | $6.00 | None |
CEPHALEXIN 250 MG TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
CEPHALEXIN 250 MG/5ML ORAL SUSP |
1 |
Generic |
$2.00 | $6.00 | None |
CEPHALEXIN 500 MG TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
CEPHALEXIN CAPSULES 500 MG (500 CT) |
1 |
Generic |
$2.00 | $6.00 | None |
CEREZYME 400 UNITS VIAL |
4 |
Specialty Tier |
25% | N/A | P |
CERVARIX VACCINE SYRINGE |
3 |
Non-Preferred Brand |
40% | 40% | None |
Cetirizine Hydrochloride 1mg/mL 120 mL in 1 BOTTLE |
1 |
Generic |
$2.00 | $6.00 | Q:300 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHANTIX 0.5 MG TABLET |
2 |
Preferred Brand |
14% | 14% | None |
CHANTIX 1 MG TABLET |
2 |
Preferred Brand |
14% | 14% | P Q:168 /84Days |
Chantix 1.0mg/1 56 FILM COATED TABLETS in BOX |
2 |
Preferred Brand |
14% | 14% | P Q:168 /84Days |
CHANTIX STARTING MONTH BOX |
2 |
Preferred Brand |
14% | 14% | P Q:53 /28Days |
CHLORAMPHEN NA SUCC 1GM VL |
1 |
Generic |
$2.00 | $6.00 | None |
CHLORDIAZEPOXIDE HCL 10mg 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE in 1 BLISTER |
1 |
Generic |
$2.00 | $6.00 | Q:120 /30Days |
CHLORDIAZEPOXIDE HCL 25mg 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE in 1 BLISTER |
1 |
Generic |
$2.00 | $6.00 | Q:120 /30Days |
CHLORDIAZEPOXIDE HCL 5mg 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE in 1 BLISTER |
1 |
Generic |
$2.00 | $6.00 | Q:120 /30Days |
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH |
1 |
Generic |
$2.00 | $6.00 | None |
CHLOROQUINE PH 500 MG TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
CHLOROQUINE PHOSPHATE 250 MG TABLET (50 CT) |
1 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLOROTHIAZIDE 250 MG TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
Chlorothiazide 500mg 100 TABLET BOTTLE |
1 |
Generic |
$2.00 | $6.00 | None |
CHLORPROMAZINE 10 MG TABLET |
1 |
Generic |
$2.00 | $6.00 | P |
CHLORPROMAZINE 25 MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | P |
CHLORPROMAZINE 25 MG/ML AMP |
2 |
Preferred Brand |
14% | 14% | P |
CHLORPROMAZINE 50 MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | None |
CHLORPROMAZINE HCL 200 MG TABLET |
2 |
Preferred Brand |
14% | 14% | None |
Chlorpromazine Hydrochloride 100mg SUGAR COATED 1000 TABLET BOTTLE |
3 |
Non-Preferred Brand |
40% | 40% | None |
Chlorpropamide 100mg 100 TABLET BOTTLE, PLASTIC |
1 |
Generic |
$2.00 | $6.00 | None |
Chlorpropamide 250mg 100 TABLET BOTTLE, PLASTIC |
1 |
Generic |
$2.00 | $6.00 | None |
CHLORTHALIDONE 25 MG TABLET (100 CT) |
3 |
Non-Preferred Brand |
40% | 40% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLORTHALIDONE 50 MG TABLET (1000 CT) |
3 |
Non-Preferred Brand |
40% | 40% | None |
CHLORZOXAZONE 500 MG TABLET |
1 |
Generic |
$2.00 | $6.00 | P Q:180 /30Days |
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION |
3 |
Non-Preferred Brand |
40% | 40% | None |
CHORIONIC GONAD 10000U VIAL |
3 |
Non-Preferred Brand |
40% | 40% | None |
Cialis 2.5mg/1 2 BLISTER PACK per CARTON / 15 FILM COATED TABLETS in BLISTER PACK |
3 |
Non-Preferred Brand |
40% | 40% | P Q:30 /30Days |
Cialis 5mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Brand |
40% | 40% | P Q:30 /30Days |
CICLOPIROX 0.77% TOPICAL SUSP |
1 |
Generic |
$2.00 | $6.00 | None |
CICLOPIROX 8% SOLUTION |
1 |
Generic |
$2.00 | $6.00 | None |
Ciclopirox Olamine 7.7mg/g 1 TUBE in 1 TUBE / 15 g in 1 TUBE |
1 |
Generic |
$2.00 | $6.00 | None |
cidofovir 375 mg/5 ml vial [Vistide] |
4 |
Specialty Tier |
25% | N/A | None |
Cilostazol 50mg/1 60 TABLET BOTTLE |
1 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CILOSTAZOL TABLET 100MG (60 CT) |
1 |
Generic |
$2.00 | $6.00 | None |
Cimzia 2 KIT per CARTON / 1 KIT in 1 KIT |
4 |
Specialty Tier |
25% | N/A | S |
CIMZIA 200 MG/ML SYRINGE KIT |
4 |
Specialty Tier |
25% | N/A | S |
Cinryze 500[iU]/5mL 1 VIAL per CARTON / 5 mL in 1 VIAL |
4 |
Specialty Tier |
25% | N/A | P Q:100 /30Days |
CIPROFLOXACIN 0.3% EYE DROP |
1 |
Generic |
$2.00 | $6.00 | None |
CIPROFLOXACIN 250 MG TABLET (100 CT) |
1 |
Generic |
$2.00 | $6.00 | None |
CIPROFLOXACIN 250 MG/5 ML SUSP |
1 |
Generic |
$2.00 | $6.00 | None |
Ciprofloxacin 400mg/40mL 1 VIAL per CARTON / 40 mL in 1 VIAL |
1 |
Generic |
$2.00 | $6.00 | None |
CIPROFLOXACIN 500 MG/5 ML SUSP |
1 |
Generic |
$2.00 | $6.00 | None |
CIPROFLOXACIN HCL 500 MG TAB |
1 |
Generic |
$2.00 | $6.00 | None |
CIPROFLOXACIN TABLETS 750 MG 100 BOT |
1 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cisplatin 100mg/100mL 1 VIAL per CARTON / 100 mL in 1 VIAL |
1 |
Generic |
$2.00 | $6.00 | P |
CITALOPRAM HBR 20 MG TABLET |
1 |
Generic |
$2.00 | $6.00 | Q:60 /30Days |
CITALOPRAM HBR ORAL SOLUTION 10MG 240 ML BOTPL |
1 |
Generic |
$2.00 | $6.00 | None |
CITALOPRAM HYDROBROMIDE TABLETS 40 MG 30 BOT |
1 |
Generic |
$2.00 | $6.00 | Q:30 /30Days |
CITOLOPRAM HBR 10 MG TABLET (100 CT) |
3 |
Non-Preferred Brand |
40% | 40% | Q:30 /30Days |
Cladribine 10 mg/10 ml vial |
1 |
Generic |
$2.00 | $6.00 | P |
CLARAVIS 10 MG CAPSULE |
3 |
Non-Preferred Brand |
40% | 40% | None |
CLARAVIS 20 MG CAPSULE |
2 |
Preferred Brand |
14% | 14% | None |
Claravis 30mg 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
3 |
Non-Preferred Brand |
40% | 40% | None |
CLARAVIS 40MG CAPSULE |
3 |
Non-Preferred Brand |
40% | 40% | None |
CLARITHROMYCIN 250 MG TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLARITHROMYCIN 500 MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | None |
CLINDAMYCIN 600 MG/4 ML ADDVAN |
1 |
Generic |
$2.00 | $6.00 | None |
CLINDAMYCIN HCL 150 MG CAPSULE |
1 |
Generic |
$2.00 | $6.00 | None |
CLINDAMYCIN HCL 300 MG 100 CAPSULE in 1 BOTTLE |
1 |
Generic |
$2.00 | $6.00 | None |
CLINDAMYCIN PHOSP 1% LOTION |
3 |
Non-Preferred Brand |
40% | 40% | None |
clindamycin phosphate 10mg/mL 1 BOTTLE per CARTON / 60 mL in 1 BOTTLE |
3 |
Non-Preferred Brand |
40% | 40% | None |
Clindamycin Phosphate and Benzoyl Peroxide 1 KIT |
3 |
Non-Preferred Brand |
40% | 40% | None |
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE |
3 |
Non-Preferred Brand |
40% | 40% | None |
CLINDAMYCIN PHOSPHATE VAGINAL CREAM |
1 |
Generic |
$2.00 | $6.00 | None |
CLINIMIX 4.25/10 SOLUTION |
1 |
Generic |
$2.00 | $6.00 | P |
CLINIMIX 5/15 SOLUTION |
3 |
Non-Preferred Brand |
40% | 40% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINIMIX E 2.75/5 SOLUTION |
3 |
Non-Preferred Brand |
40% | 40% | P |
CLINIMIX E 4.25/25 SOLUTION |
3 |
Non-Preferred Brand |
40% | 40% | P |
CLINIMIX E 4.25%-10% SOLUTION |
3 |
Non-Preferred Brand |
40% | 40% | P |
CLINIMIX E 5%/15% INJECTION 2000ML BAG |
3 |
Non-Preferred Brand |
40% | 40% | P |
CLOBETASOL 0.05% OINTMENT |
3 |
Non-Preferred Brand |
40% | 40% | None |
CLOBETASOL E 0.05% CREAM |
3 |
Non-Preferred Brand |
40% | 40% | None |
Clobetasol Propionate 0.4625mg/mL 1 BOTTLE per CARTON / 50 mL in 1 BOTTLE |
3 |
Non-Preferred Brand |
40% | 40% | None |
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE |
1 |
Generic |
$2.00 | $6.00 | None |
CLOMIPRAMINE HCL 25MG CAPSULE |
3 |
Non-Preferred Brand |
40% | 40% | P S |
CLOMIPRAMINE HCL 50MG CAPSULE |
3 |
Non-Preferred Brand |
40% | 40% | P S |
CLOMIPRAMINE HCL 75MG CAPSULE |
3 |
Non-Preferred Brand |
40% | 40% | P S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Clonazepam 0.125mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PAC |
1 |
Generic |
$2.00 | $6.00 | None |
Clonazepam 0.25mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
3 |
Non-Preferred Brand |
40% | 40% | None |
Clonazepam 0.5mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
1 |
Generic |
$2.00 | $6.00 | None |
Clonazepam 0.5mg/1 100 TABLET BOTTLE |
1 |
Generic |
$2.00 | $6.00 | None |
Clonazepam 1mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
1 |
Generic |
$2.00 | $6.00 | None |
Clonazepam 1mg/1 90 TABLET BOTTLE, PLASTIC |
1 |
Generic |
$2.00 | $6.00 | None |
Clonazepam 2mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
1 |
Generic |
$2.00 | $6.00 | None |
Clonazepam 2mg/1 100 TABLET BOTTLE |
3 |
Non-Preferred Brand |
40% | 40% | None |
Clonidine 0.1mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
3 |
Non-Preferred Brand |
40% | 40% | S Q:4 /28Days |
Clonidine 0.2mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
3 |
Non-Preferred Brand |
40% | 40% | S Q:4 /28Days |
Clonidine 0.3mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
3 |
Non-Preferred Brand |
40% | 40% | S Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLONIDINE HCL 0.1 MG TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
CLONIDINE HCL 0.2MG TABLET (500 CT) |
1 |
Generic |
$2.00 | $6.00 | None |
CLONIDINE HCL TABLET 0.3MG (100 CT) |
1 |
Generic |
$2.00 | $6.00 | None |
CLOPIDOGREL 75 MG TABLET [Plavix] |
1 |
Generic |
$2.00 | $6.00 | Q:30 /30Days |
Clorazepate Dipotassium 3.75mg/1 500 TABLET BOTTLE, PLASTIC |
1 |
Generic |
$2.00 | $6.00 | None |
CLOTRIMAZOLE 1% CREAM |
3 |
Non-Preferred Brand |
40% | 40% | None |
CLOTRIMAZOLE 10MG TROCHE |
3 |
Non-Preferred Brand |
40% | 40% | None |
CLOTRIMAZOLE SOLUTION TOPICAL 1% 30ML BOTPL |
3 |
Non-Preferred Brand |
40% | 40% | None |
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION |
3 |
Non-Preferred Brand |
40% | 40% | None |
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE |
1 |
Generic |
$2.00 | $6.00 | None |
Clozapine 100mg/1 100 TABLET BOTTLE |
3 |
Non-Preferred Brand |
40% | 40% | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOZAPINE 200MG TABLET (500 CT) |
3 |
Non-Preferred Brand |
40% | 40% | S |
CLOZAPINE 25MG TABLET (100 CT) |
1 |
Generic |
$2.00 | $6.00 | None |
CLOZAPINE 50MG TABLET (500 CT) |
1 |
Generic |
$2.00 | $6.00 | S |
CLOZAPINE ODT 100 MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | S |
CLOZAPINE ODT 12.5 MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | S |
CLOZAPINE ODT 150 MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | S |
CLOZAPINE ODT 200 MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | S |
CLOZAPINE ODT 25 MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | S |
COARTEM 20MG-120MG |
3 |
Non-Preferred Brand |
40% | 40% | Q:24 /30Days |
COLCHICINE 0.6 MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | None |
COLESTIPOL HCL 1G TABLET |
3 |
Non-Preferred Brand |
40% | 40% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COLESTIPOL HYDROCHLORIDE 5g/1 100 SUSPENSION in 1 BOTTLE |
1 |
Generic |
$2.00 | $6.00 | None |
colistimethate 150mg/2mL 1 VIAL per CARTON / 2 mL in 1 VIAL |
3 |
Non-Preferred Brand |
40% | 40% | P |
COMBIGAN 0.2%-0.5% DROPS |
3 |
Non-Preferred Brand |
40% | 40% | None |
COMBIVENT RESPIMAT INHAL SPRAY |
3 |
Non-Preferred Brand |
40% | 40% | Q:4 /20Days |
COMETRIQ 100 MG DAILY-DOSE PK |
4 |
Specialty Tier |
25% | N/A | P Q:56 /28Days |
COMETRIQ 140 MG DAILY-DOSE PK |
4 |
Specialty Tier |
25% | N/A | P Q:112 /28Days |
COMETRIQ 60 MG DAILY-DOSE PACK |
4 |
Specialty Tier |
25% | N/A | P Q:84 /28Days |
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1 |
3 |
Non-Preferred Brand |
40% | 40% | Q:30 /30Days |
COMPRO 25MG SUPPOSITORY |
1 |
Generic |
$2.00 | $6.00 | None |
CONSTULOSE 10 GM/15 ML SOLN |
1 |
Generic |
$2.00 | $6.00 | None |
CONZIP 100 MG CAPSULE |
3 |
Non-Preferred Brand |
40% | 40% | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CONZIP 200 MG CAPSULE |
3 |
Non-Preferred Brand |
40% | 40% | S Q:30 /30Days |
CONZIP 300 MG CAPSULE |
3 |
Non-Preferred Brand |
40% | 40% | S Q:30 /30Days |
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN |
4 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
COPAXONE 40 MG/ML SYRINGE |
4 |
Specialty Tier |
25% | N/A | Q:12 /28Days |
COTELLIC 20 MG TABLET |
4 |
Specialty Tier |
25% | N/A | P |
Creon 256.11mg/1 1 BOTTLE per CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
2 |
Preferred Brand |
14% | 14% | None |
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT |
2 |
Preferred Brand |
14% | 14% | None |
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT |
2 |
Preferred Brand |
14% | 14% | None |
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT |
2 |
Preferred Brand |
14% | 14% | None |
CREON DR 36,000 UNITS CAPSULE |
2 |
Preferred Brand |
14% | 14% | None |
CRESTOR 10MG TABLET |
2 |
Preferred Brand |
14% | 14% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CRESTOR 20MG TABLET |
2 |
Preferred Brand |
14% | 14% | Q:30 /30Days |
CRESTOR 40mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Preferred Brand |
14% | 14% | Q:30 /30Days |
CRESTOR 5MG TABLET |
2 |
Preferred Brand |
14% | 14% | Q:30 /30Days |
CRIXIVAN 200MG CAPSULE |
3 |
Non-Preferred Brand |
40% | 40% | Q:450 /30Days |
CRIXIVAN 400mg, 180 CAPSULE BOTTLE |
3 |
Non-Preferred Brand |
40% | 40% | Q:270 /30Days |
CROMOLYN 20 MG/2 ML NEB SOLN |
2 |
Preferred Brand |
14% | 14% | P |
CROMOLYN SODIUM 4% 40MG 10ML BOT |
3 |
Non-Preferred Brand |
40% | 40% | None |
CUBICIN 500MG VIAL |
4 |
Specialty Tier |
25% | N/A | None |
Cyclobenzaprine 7.5 mg tablet |
3 |
Non-Preferred Brand |
40% | 40% | P Q:120 /30Days |
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT) |
3 |
Non-Preferred Brand |
40% | 40% | P |
Cyclobenzaprine Hydrochloride 5mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Non-Preferred Brand |
40% | 40% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYCLOPHOSPHAMIDE 25 MG CAPSULE |
3 |
Non-Preferred Brand |
40% | 40% | P |
CYCLOPHOSPHAMIDE 50 MG CAPSULE |
3 |
Non-Preferred Brand |
40% | 40% | P |
Cyclosporine 100mg 30 BLISTER PACK per CARTON / 1 CAPSULE, LIQUID FILLED per BLISTER PACK |
2 |
Preferred Brand |
14% | 14% | P |
CYCLOSPORINE 100MG CAPSULE |
3 |
Non-Preferred Brand |
40% | 40% | P |
Cyclosporine 25mg 30 BLISTER PACK per CARTON / 1 CAPSULE, LIQUID FILLED per BLISTER PACK |
1 |
Generic |
$2.00 | $6.00 | P |
CYCLOSPORINE 25MG CAPSULE |
2 |
Preferred Brand |
14% | 14% | P |
Cyclosporine 50 mg/ml vial |
1 |
Generic |
$2.00 | $6.00 | P |
Cyclosporine 50mg 30 BLISTER PACK per CARTON / 1 CAPSULE, LIQUID FILLED per BLISTER PACK |
2 |
Preferred Brand |
14% | 14% | P |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT |
3 |
Non-Preferred Brand |
40% | 40% | P |
CYPROHEPTADINE HCL 4 MG |
1 |
Generic |
$2.00 | $6.00 | P |
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL |
1 |
Generic |
$2.00 | $6.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYRAMZA 100 MG/10 ML VIAL |
4 |
Specialty Tier |
25% | N/A | P |
CYRAMZA 500 MG/50 ML VIAL |
4 |
Specialty Tier |
25% | N/A | P |
CYSTAGON 150MG CAPSULE |
3 |
Non-Preferred Brand |
40% | 40% | None |
CYSTAGON 50MG CAPSULE |
3 |
Non-Preferred Brand |
40% | 40% | None |
CYTARABINE 20MG/ML VIAL |
1 |
Generic |
$2.00 | $6.00 | P |
CYTARABINE SOLUTION INJECTION 100MG 20ML VIALSD |
1 |
Generic |
$2.00 | $6.00 | P |