2016 Medicare Part D Plan Formulary Information |
EnvisionRxPlus Silver (PDP) (S7694-030-0)
Benefit Details
|
The EnvisionRxPlus Silver (PDP) (S7694-030-0) Formulary Drugs Starting with the Letter P in CMS PDP Region 30 which includes: OR WA Plan Monthly Premium: $30.70 Deductible: $360 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 |
Preferred Brand |
10% | 10% | None |
PACERONE 200MG TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
PACLITAXEL INJECTION SOLUTION 6MG 50ML VIALMD |
3 |
Non-Preferred Brand |
40% | 40% | P |
PALIPERIDONE ER 1.5 MG TABLET [INVEGA] |
3 |
Non-Preferred Brand |
40% | 40% | Q:30 /30Days |
PALIPERIDONE ER 3 MG TABLET [INVEGA] |
3 |
Non-Preferred Brand |
40% | 40% | Q:30 /30Days |
PALIPERIDONE ER 6 MG TABLET [INVEGA] |
3 |
Non-Preferred Brand |
40% | 40% | Q:60 /30Days |
PALIPERIDONE ER 9 MG TABLET [INVEGA] |
3 |
Non-Preferred Brand |
40% | 40% | Q:30 /30Days |
PAMIDRONATE 60MG/10ML VIAL |
1 |
Generic |
$2.00 | $6.00 | None |
PAMIDRONATE DISODIUM INJECTION 3MG 10ML VIALSD |
1 |
Generic |
$2.00 | $6.00 | None |
PAMIDRONATE DISODIUM INJECTION 9MG 10ML VIALSD |
1 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PANRETIN 0.1% GEL 60GM TUBE |
4 |
Specialty Tier |
25% | N/A | P |
Pantoprazole 40mg/1 90 TABLET, DELAYED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand |
40% | 40% | None |
PANTOPRAZOLE SODIUM 20 MG TABLET DELAYED RELEASE |
3 |
Non-Preferred Brand |
40% | 40% | None |
PARICALCITOL 1 MCG CAPSULE [Zemplar] |
3 |
Non-Preferred Brand |
40% | 40% | P |
PARICALCITOL 2 MCG CAPSULE [Zemplar] |
3 |
Non-Preferred Brand |
40% | 40% | P |
PARICALCITOL 4 MCG CAPSULE [Zemplar] |
3 |
Non-Preferred Brand |
40% | 40% | P |
PARICALCITOL 5 MCG/ML VIAL [Zemplar] |
3 |
Non-Preferred Brand |
40% | 40% | P |
PAROMOMYCIN 250MG CAPSULE |
3 |
Non-Preferred Brand |
40% | 40% | None |
Paroxetine 40mg/1 500 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Brand |
40% | 40% | Q:60 /30Days |
PAROXETINE FILM COATED 20MG TABLET (100 CT) |
3 |
Non-Preferred Brand |
40% | 40% | Q:30 /30Days |
PAROXETINE HCL TABLET 24 12.5MG |
3 |
Non-Preferred Brand |
40% | 40% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAROXETINE HCL TABLET 24 25MG |
3 |
Non-Preferred Brand |
40% | 40% | Q:90 /30Days |
Paroxetine Hydrochloride 37.5mg/1 30 BOTTLE in 1 BOTTLE / 30 TABLET, FILM COATED, EXTENDED RELEASE |
3 |
Non-Preferred Brand |
40% | 40% | Q:60 /30Days |
PAROXETINE HYDROCHLORIDE TABLETS 10 MG |
3 |
Non-Preferred Brand |
40% | 40% | Q:30 /30Days |
PAROXETINE TABLETS 30MG 90 BOT |
3 |
Non-Preferred Brand |
40% | 40% | Q:60 /30Days |
PASER GRANULES 4GM PACKET |
3 |
Non-Preferred Brand |
40% | 40% | None |
PATADAY 0.2% DROPS |
2 |
Preferred Brand |
10% | 10% | None |
PAXIL ORAL SUSPENSION 10 MG/5ML |
3 |
Non-Preferred Brand |
40% | 40% | None |
PAZEO 0.7% EYE DROPS |
3 |
Non-Preferred Brand |
40% | 40% | None |
PEDVAXHIB VACCINE VIAL |
3 |
Non-Preferred Brand |
40% | 40% | None |
PEGANONE 250 MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | S |
Pegasys 180ug/0.5mL 1 PACKET in 1 BOX / 4 SYRINGE, GLASS in 1 PACKET / 0.5 mL in 1 SYRINGE, GLASS |
4 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEGASYS INJECTION |
4 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
PEGASYS PROCLICK 135 MCG/0.5 |
4 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
PEGASYS PROCLICK 180 MCG/0.5 |
4 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
PENICILLIN G POTASSIUM FOR INJECTION 5000000UNIT/VIAL |
3 |
Non-Preferred Brand |
40% | 40% | None |
Penicillin V Potassium 125mg/5mL 200 mL in 1 BOTTLE |
1 |
Generic |
$2.00 | $6.00 | None |
Penicillin V Potassium 250mg/1 1000 TABLET BOTTLE |
1 |
Generic |
$2.00 | $6.00 | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
1 |
Generic |
$2.00 | $6.00 | None |
PENICILLIN V POTASSIUM 500MG TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
PENTAM 300 INJ 300MG |
3 |
Non-Preferred Brand |
40% | 40% | None |
Pentazocine Hydrochloride and Naloxone Hydrochloride 0.5; 50mg/1; mg/1 100 TABLET BOTTLE |
2 |
Preferred Brand |
10% | 10% | P Q:360 /30Days |
PENTOXIFYLLINE 400MG TABLET SA |
1 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Perindopril Erbumine 2mg/1 100 TABLET BOTTLE |
1 |
Generic |
$2.00 | $6.00 | None |
Perindopril Erbumine 4mg/1 100 TABLET BOTTLE |
1 |
Generic |
$2.00 | $6.00 | None |
Perindopril Erbumine 8mg/1 100 TABLET BOTTLE |
1 |
Generic |
$2.00 | $6.00 | None |
PERIOGARD 0.12% ORAL RINSE |
1 |
Generic |
$2.00 | $6.00 | None |
Permethrin 50mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
3 |
Non-Preferred Brand |
40% | 40% | None |
Perphenazine 16mg/1 100 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Brand |
40% | 40% | None |
PERPHENAZINE TABLETS 4MG 100 BOXUD |
3 |
Non-Preferred Brand |
40% | 40% | None |
PERPHENAZINE TABLETS 8MG 100 BOT |
3 |
Non-Preferred Brand |
40% | 40% | None |
PERPHENAZINE TABLETS USP 2MG 100 BOT |
3 |
Non-Preferred Brand |
40% | 40% | None |
PEXEVA 10MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | None |
PEXEVA 20MG 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 |
PEXEVA 30MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | None |
PEXEVA 40MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | None |
Phenelzine Sulfate 15mg/1 60 TABLET BOTTLE |
1 |
Generic |
$2.00 | $6.00 | None |
Phenobarbital 100mg/1 |
1 |
Generic |
$2.00 | $6.00 | P Q:90 /30Days |
Phenobarbital 15mg/1 |
1 |
Generic |
$2.00 | $6.00 | P Q:120 /30Days |
PHENOBARBITAL 16.2 MG TABLET |
1 |
Generic |
$2.00 | $6.00 | P Q:90 /30Days |
PHENOBARBITAL 20 MG/5 ML ELIX |
1 |
Generic |
$2.00 | $6.00 | P Q:1500 /30Days |
Phenobarbital 30mg/1 |
1 |
Generic |
$2.00 | $6.00 | P Q:300 /30Days |
PHENOBARBITAL 32.4 MG TABLET |
1 |
Generic |
$2.00 | $6.00 | P Q:90 /30Days |
Phenobarbital 60mg/1 |
1 |
Generic |
$2.00 | $6.00 | P Q:120 /30Days |
PHENOBARBITAL 64.8 MG TABLET |
1 |
Generic |
$2.00 | $6.00 | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PHENOBARBITAL 97.2 MG TABLET |
1 |
Generic |
$2.00 | $6.00 | P Q:90 /30Days |
phenytoin 50 mg tablet chew |
2 |
Preferred Brand |
10% | 10% | None |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT |
3 |
Non-Preferred Brand |
40% | 40% | None |
PHENYTOIN SODIUM 100MG /2ML INJECTION |
1 |
Generic |
$2.00 | $6.00 | None |
PHENYTOIN SODIUM EXT 200 MG CAP |
1 |
Generic |
$2.00 | $6.00 | None |
PHENYTOIN SODIUM EXT 300 MG CAP |
1 |
Generic |
$2.00 | $6.00 | None |
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT) |
3 |
Non-Preferred Brand |
40% | 40% | None |
PICATO 0.015% GEL |
3 |
Non-Preferred Brand |
40% | 40% | Q:3 /30Days |
PICATO 0.05% GEL |
3 |
Non-Preferred Brand |
40% | 40% | Q:2 /30Days |
PILOCARPINE 1% EYE DROPS |
1 |
Generic |
$2.00 | $6.00 | None |
PILOCARPINE 2% EYE DROPS |
1 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PILOCARPINE 4% EYE DROPS |
1 |
Generic |
$2.00 | $6.00 | None |
PILOCARPINE HCL 5 MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | None |
PILOCARPINE HCL 7.5 MG 100 FILM COATED TABLETS in BOTTLE |
1 |
Generic |
$2.00 | $6.00 | None |
PIMOZIDE 1 MG TABLET [Orap] |
3 |
Non-Preferred Brand |
40% | 40% | None |
PIMOZIDE 2 MG TABLET [Orap] |
3 |
Non-Preferred Brand |
40% | 40% | None |
PINDOLOL 10MG TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
PINDOLOL 5MG TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
pioglitazone hcl 15 mg tablet [Actos] |
1 |
Generic |
$2.00 | $6.00 | Q:30 /30Days |
pioglitazone hcl 30 mg tablet [Actos] |
1 |
Generic |
$2.00 | $6.00 | Q:30 /30Days |
pioglitazone hcl 45 mg tablet [Actos] |
1 |
Generic |
$2.00 | $6.00 | Q:30 /30Days |
Piperacillin and Tazobactam 4; 0.5g/1; g/1 10 VIAL, SINGLE-USE per CARTON / 1 INJECTION, POWDER, L |
1 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PLEGRIDY 125 MCG/0.5 ML PEN |
4 |
Specialty Tier |
25% | N/A | Q:2 /28Days |
PLEGRIDY 125 MCG/0.5 ML SYRING |
4 |
Specialty Tier |
25% | N/A | Q:2 /28Days |
PLEGRIDY PEN INJ STARTER PACK |
4 |
Specialty Tier |
25% | N/A | Q:2 /28Days |
PLEGRIDY SYRINGE STARTER PACK |
4 |
Specialty Tier |
25% | N/A | Q:2 /28Days |
PODOFILOX 0.5% TOPICAL TUBEX |
1 |
Generic |
$2.00 | $6.00 | None |
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT) |
3 |
Non-Preferred Brand |
40% | 40% | None |
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1% |
3 |
Non-Preferred Brand |
40% | 40% | None |
POMALYST 1 MG CAPSULE |
4 |
Specialty Tier |
25% | N/A | P Q:21 /28Days |
POMALYST 2 MG CAPSULE |
4 |
Specialty Tier |
25% | N/A | P Q:21 /28Days |
POMALYST 3 MG CAPSULE |
4 |
Specialty Tier |
25% | N/A | P Q:21 /28Days |
POMALYST 4 MG CAPSULE |
4 |
Specialty Tier |
25% | N/A | P Q:21 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.9% 1000ML |
1 |
Generic |
$2.00 | $6.00 | None |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG |
1 |
Generic |
$2.00 | $6.00 | None |
POTASSIUM CHLORIDE 20MEQ IN D5W/NACL 0.225% |
1 |
Generic |
$2.00 | $6.00 | None |
POTASSIUM CHLORIDE 750MG EXTENDED RELEASE TABLETS |
1 |
Generic |
$2.00 | $6.00 | None |
POTASSIUM CHLORIDE ER CAPSULES 10MEQ |
3 |
Non-Preferred Brand |
40% | 40% | None |
POTASSIUM CHLORIDE ER CPCR 8MEQ |
3 |
Non-Preferred Brand |
40% | 40% | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE |
1 |
Generic |
$2.00 | $6.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA |
1 |
Generic |
$2.00 | $6.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION |
1 |
Generic |
$2.00 | $6.00 | None |
Potassium Chloride in Dextrose 5; 150g/100mL; mg/100mL 1000 mL in 1 BAG |
1 |
Generic |
$2.00 | $6.00 | None |
Potassium Chloride in Dextrose and Sodium Chloride 5; 0.15; 0.33g/100mL; g/100mL; g/100mL 12 CONTAI |
1 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Potassium Chloride in Dextrose and Sodium Chloride 5; 0.15; 0.45g/100mL; g/100mL; g/100mL 12 CONTAI |
1 |
Generic |
$2.00 | $6.00 | None |
Potassium Chloride in Dextrose and Sodium Chloride 5; 300; 900g/100mL; mg/100mL; mg/100mL 1000 mL i |
1 |
Generic |
$2.00 | $6.00 | None |
Potassium Chloride in Lactated Ringers and Dextrose 20; 5; 179; 600; 310mg/100mL; g/100mL; mg/100mL |
1 |
Generic |
$2.00 | $6.00 | None |
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION |
1 |
Generic |
$2.00 | $6.00 | None |
POTASSIUM CHLORIDE INJECTION 20 MEQ/100ML |
1 |
Generic |
$2.00 | $6.00 | None |
POTASSIUM CITRATE ER 10 MEQ TB |
3 |
Non-Preferred Brand |
40% | 40% | None |
POTASSIUM CITRATE ER 15 MEQ TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
POTASSIUM CITRATE ER 5 MEQ TAB |
1 |
Generic |
$2.00 | $6.00 | None |
POTASSIUM CITRATE ER 8 MEQ TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
Potassium Cl 10% (20 MEQ/15 ML) |
3 |
Non-Preferred Brand |
40% | 40% | None |
Potassium cl 2 meq/ml vial |
1 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Potassium Cl 20% (40 MEQ/15 ML) |
3 |
Non-Preferred Brand |
40% | 40% | None |
POTASSIUM CL ER 20 MEQ TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
POTIGA 200 MG TABLET |
2 |
Preferred Brand |
10% | 10% | S |
POTIGA 300 MG TABLET |
2 |
Preferred Brand |
10% | 10% | S |
POTIGA 400 MG TABLET |
2 |
Preferred Brand |
10% | 10% | S |
POTIGA 50 MG TABLET |
2 |
Preferred Brand |
10% | 10% | S |
PRADAXA 110 MG CAPSULE |
3 |
Non-Preferred Brand |
40% | 40% | None |
PRADAXA 150 MG 1 BOTTLE per CARTON / 60 CAPSULE BOTTLE |
3 |
Non-Preferred Brand |
40% | 40% | None |
PRADAXA 75 MG 1 BOTTLE per CARTON / 60 CAPSULE BOTTLE |
3 |
Non-Preferred Brand |
40% | 40% | None |
PRALUENT 150 MG/ML PEN |
4 |
Specialty Tier |
25% | N/A | P |
PRALUENT 150 MG/ML SYRINGE |
4 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRALUENT 75 MG/ML PEN |
4 |
Specialty Tier |
25% | N/A | P |
PRALUENT 75 MG/ML SYRINGE |
4 |
Specialty Tier |
25% | N/A | P |
PRAMIPEXOLE 0.75 MG TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
Pramipexole Dihydrochloride 0.125mg 500 TABLET BOTTLE, PLASTIC |
1 |
Generic |
$2.00 | $6.00 | None |
Pramipexole Dihydrochloride 0.25mg 500 TABLET BOTTLE, PLASTIC |
1 |
Generic |
$2.00 | $6.00 | None |
Pramipexole Dihydrochloride 0.5mg 500 TABLET BOTTLE, PLASTIC |
1 |
Generic |
$2.00 | $6.00 | None |
Pramipexole Dihydrochloride 1.5mg 500 TABLET BOTTLE, PLASTIC |
1 |
Generic |
$2.00 | $6.00 | None |
Pramipexole Dihydrochloride 1mg 500 TABLET BOTTLE, PLASTIC |
1 |
Generic |
$2.00 | $6.00 | None |
PRAVASTATIN SODIUM 20MG TABLET 500 BOT |
3 |
Non-Preferred Brand |
40% | 40% | S Q:30 /30Days |
PRAVASTATIN SODIUM 40MG TABLET (500 CT) |
3 |
Non-Preferred Brand |
40% | 40% | S Q:30 /30Days |
Pravastatin Sodium 80mg/1 1000 TABLET BOTTLE |
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 |
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT |
3 |
Non-Preferred Brand |
40% | 40% | S Q:30 /30Days |
PRAZOSIN 5MG CAPSULE |
1 |
Generic |
$2.00 | $6.00 | None |
PRAZOSIN HCL 1MG CAPSULE |
1 |
Generic |
$2.00 | $6.00 | None |
PRAZOSIN HCL 2MG CAPSULE |
1 |
Generic |
$2.00 | $6.00 | None |
PREDNICARBATE 0.1% OINTMENT |
1 |
Generic |
$2.00 | $6.00 | None |
PREDNICARBATE 1 MG/ML TOPICAL CREAM |
1 |
Generic |
$2.00 | $6.00 | None |
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR |
3 |
Non-Preferred Brand |
40% | 40% | None |
Prednisolone odt 10 mg tablet |
1 |
Generic |
$2.00 | $6.00 | None |
Prednisolone odt 15 mg tablet |
1 |
Generic |
$2.00 | $6.00 | None |
Prednisolone odt 30 mg tablet |
1 |
Generic |
$2.00 | $6.00 | None |
PREDNISOLONE SOD 1% EYE DROP |
1 |
Generic |
$2.00 | $6.00 | 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 |
1 |
Generic |
$2.00 | $6.00 | None |
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL |
1 |
Generic |
$2.00 | $6.00 | None |
PREDNISOLONE SODIUM PHOSPHATE 5MG /5ML ORAL SOLUTION |
1 |
Generic |
$2.00 | $6.00 | None |
PREDNISONE 10MG TABLET (100 CT) |
1 |
Generic |
$2.00 | $6.00 | None |
PREDNISONE 1MG TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
PREDNISONE 2.5MG TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
PREDNISONE 20MG TABLET (1000 CT) |
1 |
Generic |
$2.00 | $6.00 | None |
PREDNISONE 5 MG TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
PREDNISONE 50MG TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
PREDNISONE 5MG/5ML SOLUTION |
1 |
Generic |
$2.00 | $6.00 | None |
Premarin 0.3mg/1 1000 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Brand |
40% | 40% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREMARIN 0.45MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | P |
Premarin 0.625mg/1 1000 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Brand |
40% | 40% | P |
PREMARIN 0.9MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | P |
Premarin 1.25mg/1 1000 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Brand |
40% | 40% | P |
PREMARIN 25MG VIAL |
3 |
Non-Preferred Brand |
40% | 40% | P |
PREMPHASE 0.625-5 MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | P |
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA |
3 |
Non-Preferred Brand |
40% | 40% | P |
PREMPRO 0.45-1.5 MG TABLET 28 EA |
3 |
Non-Preferred Brand |
40% | 40% | P |
PREMPRO 0.625-5 MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | P |
Prempro 0.625; 2.5mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, SUGAR COATED per BLISTER PACK |
3 |
Non-Preferred Brand |
40% | 40% | P |
PREPOPIK POWDER PACKET |
3 |
Non-Preferred Brand |
40% | 40% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREVALITE POW 4GM |
1 |
Generic |
$2.00 | $6.00 | None |
PREZCOBIX 800 MG-150 MG TABLET |
4 |
Specialty Tier |
25% | N/A | None |
PREZISTA 100 MG/ML SUSPENSION |
3 |
Non-Preferred Brand |
40% | 40% | Q:360 /30Days |
PREZISTA 150MG TABLETS |
3 |
Non-Preferred Brand |
40% | 40% | Q:240 /30Days |
PREZISTA 800 MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | Q:30 /30Days |
PREZISTA TABLET 600MG |
3 |
Non-Preferred Brand |
40% | 40% | Q:60 /30Days |
PREZISTA TABLET 75MG |
3 |
Non-Preferred Brand |
40% | 40% | Q:480 /30Days |
PRIMAQUINE 26.3MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | None |
Primidone 250mg/1 100 TABLET BOTTLE |
3 |
Non-Preferred Brand |
40% | 40% | None |
Primidone 50mg/1 500 TABLET BOTTLE |
3 |
Non-Preferred Brand |
40% | 40% | None |
PRISTIQ 100MG TABLET SR 24HR |
3 |
Non-Preferred Brand |
40% | 40% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRISTIQ ER 25 MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | None |
Pristiq Extended-Release 50mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
3 |
Non-Preferred Brand |
40% | 40% | None |
PROAIR HFA 90 MCG INHALER |
2 |
Preferred Brand |
10% | 10% | Q:27 /30Days |
PROAIR RESPICLICK INHAL POWDER |
2 |
Preferred Brand |
10% | 10% | Q:3 /30Days |
PROBENECID 500MG TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
PROBENECID/COLCHICINE 0.5MG/500MG TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
PROCAINAMIDE 100MG/ML VIAL |
1 |
Generic |
$2.00 | $6.00 | None |
PROCAINAMIDE 500MG/ML VIAL |
1 |
Generic |
$2.00 | $6.00 | None |
Prochlorperazine 10 mg/2 ml vl |
1 |
Generic |
$2.00 | $6.00 | None |
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT) |
1 |
Generic |
$2.00 | $6.00 | None |
Prochlorperazine Maleate 5mg/1 100 FILM COATED TABLETS in 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 |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX |
2 |
Preferred Brand |
10% | 10% | None |
PROCRIT 10000U/ML VIAL |
3 |
Non-Preferred Brand |
40% | 40% | P Q:12 /28Days |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL |
2 |
Preferred Brand |
10% | 10% | P Q:23 /30Days |
PROCRIT 3,000 UNITS/ML VIAL |
2 |
Preferred Brand |
10% | 10% | P Q:16 /30Days |
PROCRIT 4,000 UNITS/ML VIAL |
2 |
Preferred Brand |
10% | 10% | P Q:12 /28Days |
PROCRIT 40000U/ML VIAL PR |
4 |
Specialty Tier |
25% | N/A | P Q:12 /30Days |
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY |
4 |
Specialty Tier |
25% | N/A | P Q:12 /28Days |
PROCTO-MED HC 2.5% CREAM |
1 |
Generic |
$2.00 | $6.00 | None |
procto-pak 1% cream |
1 |
Generic |
$2.00 | $6.00 | None |
proctozone-hc 2.5% cream |
1 |
Generic |
$2.00 | $6.00 | None |
PROGESTERONE 100 MG CAPSULE |
1 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROGESTERONE 200 MG CAPSULE |
1 |
Generic |
$2.00 | $6.00 | None |
Proglycem 50mg/mL 1 BOTTLE, DROPPER in 1 BOX / 30 mL in 1 BOTTLE, DROPPER |
4 |
Specialty Tier |
25% | N/A | None |
PROGRAF 5MG/ML AMPULE |
3 |
Non-Preferred Brand |
40% | 40% | P |
PROLASTIN-C |
4 |
Specialty Tier |
25% | N/A | None |
PROLENSA 0.07% EYE DROPS |
3 |
Non-Preferred Brand |
40% | 40% | None |
PROLEUKIN 22 MILLION UNIT VIAL |
4 |
Specialty Tier |
25% | N/A | P |
PROLIA 60MG/ML INJECTION |
3 |
Non-Preferred Brand |
40% | 40% | Q:1 /180Days |
PROMACTA 12.5 MG TABLET |
4 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
PROMACTA 25 MG TABLET |
4 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
PROMACTA 50 MG TABLET |
4 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
PROMETHAZINE HCL 25MG TABLET (1000 CT) |
3 |
Non-Preferred Brand |
40% | 40% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMETHAZINE HCL 50MG TABLET (100 CT) |
1 |
Generic |
$2.00 | $6.00 | P |
PROMETHAZINE HYDROCHLORIDE 12.5mg 100 TABLET BOTTLE, PLASTIC |
1 |
Generic |
$2.00 | $6.00 | P |
Propafenone HCl 150mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Non-Preferred Brand |
40% | 40% | None |
PROPAFENONE HCL 225MG TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
PROPAFENONE HCL 300MG TABLET (100 CT) |
1 |
Generic |
$2.00 | $6.00 | None |
PROPAFENONE HCL ER 225 MG CAP |
3 |
Non-Preferred Brand |
40% | 40% | None |
PROPAFENONE HYDROCHLORIDE 325MG CAPSULES EXTENDED RELEASE |
3 |
Non-Preferred Brand |
40% | 40% | None |
PROPAFENONE HYDROCHLORIDE 425MG CAPSULES EXTENDED RELEASE |
3 |
Non-Preferred Brand |
40% | 40% | None |
Propranolol 1mg/mL 1 mL in 1 VIAL |
1 |
Generic |
$2.00 | $6.00 | None |
PROPRANOLOL 20MG/5ML TUBEX |
1 |
Generic |
$2.00 | $6.00 | None |
PROPRANOLOL 40MG/5ML TUBEX |
1 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPRANOLOL 60MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | None |
PROPRANOLOL 80 MG TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
PROPRANOLOL ER 120 MG CAPSULE |
3 |
Non-Preferred Brand |
40% | 40% | None |
PROPRANOLOL ER 160 MG CAPSULE |
3 |
Non-Preferred Brand |
40% | 40% | None |
PROPRANOLOL ER 80 MG CAPSULE |
3 |
Non-Preferred Brand |
40% | 40% | None |
PROPRANOLOL HCL 20MG TABLET (1000 CT) |
1 |
Generic |
$2.00 | $6.00 | None |
PROPRANOLOL HCL TABLET USP 10MG (1000 CT) |
1 |
Generic |
$2.00 | $6.00 | None |
PROPRANOLOL HCL TABLET USP 40MG (1000 CT) |
1 |
Generic |
$2.00 | $6.00 | None |
Propranolol Hydrochloride 60mg/1 1000 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand |
40% | 40% | None |
PROPRANOLOL/HCTZ 40/25 TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
PROPRANOLOL/HCTZ 80/25 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 |
PROPYLTHIOURACIL 50MG TABLET |
3 |
Non-Preferred Brand |
40% | 40% | None |
PROQUAD 0.5 VIAL |
3 |
Non-Preferred Brand |
40% | 40% | None |
PROSOL 20% INJECTION |
3 |
Non-Preferred Brand |
40% | 40% | P |
PROTRIPTYLINE HYDROCHLORIDE 10MG TABLETS |
1 |
Generic |
$2.00 | $6.00 | P |
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG |
1 |
Generic |
$2.00 | $6.00 | P |
PULMICORT FLEXHALER 180MCG AEROSOL POWDER BREATH ACTIVATED |
2 |
Preferred Brand |
10% | 10% | Q:1 /30Days |
PULMICORT FLEXHALER 90MCG AEROSOL POWDER BREATH ACTIVATED |
2 |
Preferred Brand |
10% | 10% | Q:2 /30Days |
PULMOZYME 1MG/ML AMPUL |
4 |
Specialty Tier |
25% | N/A | P Q:150 /30Days |
PURIXAN 20 MG/ML ORAL SUSP |
3 |
Non-Preferred Brand |
40% | 40% | None |
PYRAZINAMIDE 500 MG TABLET |
1 |
Generic |
$2.00 | $6.00 | None |
Pyridostigmine br 60 mg tablet |
1 |
Generic |
$2.00 | $6.00 | None |