2016 Medicare Part D Plan Formulary Information |
FHCP's Premier Plus Plan (HMO-POS) (H1035-011-0)
Benefit Details
|
The FHCP's Premier Plus Plan (HMO-POS) (H1035-011-0) Formulary Drugs Starting with the Letter C in Brevard County, FL: CMS MA Region 9 which includes: FL Plan Monthly Premium: $17.00 Deductible: $0 |
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 |
Tier 2 |
$7.00 | $18.00 | None |
CABOMETYX 20 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
CABOMETYX 40 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
CABOMETYX 60 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
CALCIPOTRIENE 0.005% CREAM |
2 |
Tier 2 |
$7.00 | $18.00 | Q:60 /30Days |
Calcipotriene 50ug/g 60 g per CARTON |
2 |
Tier 2 |
$7.00 | $18.00 | Q:60 /30Days |
CALCIPOTRIENE TOPICAL SOLUTION |
2 |
Tier 2 |
$7.00 | $18.00 | Q:60 /30Days |
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CALCITRIOL 0.25MCG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CALCITRIOL 0.5MCG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CALCITRIOL 1MCG/ML SOLUTION ORAL |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CALCIUM ACETATE CAPSULE 667 MG |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CAMILA 0.35MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX |
3 |
Tier 3 |
$40.00 | $117.00 | Q:30 /30Days |
CANCIDAS IV 50MG VIAL |
6 |
Tier 6 |
25% | N/A | None |
CAPASTAT SULFATE 1g/1 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
6 |
Tier 6 |
25% | N/A | P |
CAPRELSA 100mg/1 30 TABLET BOTTLE |
5 |
Tier 5 |
33% | N/A | None |
CAPRELSA 300mg/1 30 TABLET BOTTLE |
5 |
Tier 5 |
33% | N/A | None |
CARAFATE SUS 1GM/10ML |
3 |
Tier 3 |
$40.00 | $117.00 | None |
Carbaglu 200mg/1 5 TABLET BOTTLE |
5 |
Tier 5 |
33% | N/A | P |
CARBAMAZEPINE 100 MG/5 ML SUSP |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Carbamazepine 100mg, CHEWABLE 100 TABLET BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CARBAMAZEPINE TABLET USP 200MG (1000 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Carbidopa and Levodopa 25; 100mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Carbidopa and Levodopa 50; 200mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CARBIDOPA/LEVO 10/100 TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CARBIDOPA/LEVO 25/100 TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CARBIDOPA/LEVO 25/250 TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Carboplatin 10mg/mL |
6 |
Tier 6 |
25% | N/A | None |
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT |
2 |
Tier 2 |
$7.00 | $18.00 | Q:10 /30Days |
CARTIA XT 120MG CAPSULE SA |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CARTIA XT 180MG CAPSULE SA |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARTIA XT 240MG CAPSULE SA |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CARTIA XT 300MG CAPSULE SR 24 HR |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Carvedilol 12.5mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Carvedilol 25mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Carvedilol 3.125mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Carvedilol 6.25mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Tier 1 |
$0.00 | $0.00 | None |
CAYSTON KIT 75 MG/VIAL |
5 |
Tier 5 |
33% | N/A | None |
CEFACLOR 250 MG CAPSULES |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CEFACLOR 500 MG CAPSULES |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CEFADROXIL 250 MG/5 ML SUSP |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Cefadroxil 500mg/5mL |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFAZOLIN 1 GM VIAL |
6 |
Tier 6 |
25% | N/A | P |
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CEFDINIR CAPSULES 300MG (60 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL |
6 |
Tier 6 |
25% | N/A | P |
CEFIXIME 100 MG/5 ML SUSP [Suprax] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CEFIXIME 200 MG/5 ML SUSP [Suprax] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CEFOXITIN FOR INJECTION SOLUTION |
6 |
Tier 6 |
25% | N/A | P |
cefprozil 125 mg/5 ml susp |
2 |
Tier 2 |
$7.00 | $18.00 | None |
cefprozil 250 mg/5 ml susp |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Cefprozil 250mg 100 FILM COATED TABLETS in BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFPROZIL TABLETS 500MG 100 BOT |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CEFTRIAXONE 250 MG VIAL |
6 |
Tier 6 |
25% | N/A | P |
Ceftriaxone Sodium 500mg |
6 |
Tier 6 |
25% | N/A | P |
CEFUROXIME 1.5 GM/VIAL FOR INJECTION |
6 |
Tier 6 |
25% | N/A | P |
Cefuroxime Axetil 250 MG |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CEFUROXIME AXETIL 500 MG TAB |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CELONTIN 300 MG KAPSEAL |
4 |
Tier 4 |
$80.00 | $237.00 | None |
Cephalexin 125mg/5mL 200 mL in 1 BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CEPHALEXIN 250 MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CEPHALEXIN 250 MG/5ML ORAL SUSP |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CEPHALEXIN CAPSULES 500 MG (500 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEREBYX 500 MG PE/10 ML VIAL |
6 |
Tier 6 |
25% | N/A | P |
CEREZYME 400 UNITS VIAL |
5 |
Tier 5 |
33% | N/A | P |
CERVARIX VACCINE SYRINGE |
6 |
Tier 6 |
25% | N/A | None |
CHANTIX 0.5 MG TABLET |
4 |
Tier 4 |
$80.00 | $237.00 | None |
CHANTIX 1 MG TABLET |
4 |
Tier 4 |
$80.00 | $237.00 | None |
CHEMET 100 MG CAPSULE |
3 |
Tier 3 |
$40.00 | $117.00 | None |
CHLORAMPHEN NA SUCC 1GM VL |
6 |
Tier 6 |
25% | N/A | None |
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CHLOROQUINE PH 500 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CHLOROTHIAZIDE 250 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Chlorothiazide 500mg 100 TABLET BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLORPROMAZINE 10 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CHLORPROMAZINE 25 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CHLORPROMAZINE 25 MG/ML AMP |
6 |
Tier 6 |
25% | N/A | P |
CHLORPROMAZINE 50 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CHLORPROMAZINE HCL 200 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Chlorpromazine Hydrochloride 100mg SUGAR COATED 1000 TABLET BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Chlorpropamide 100mg 100 TABLET BOTTLE, PLASTIC |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Chlorpropamide 250mg 100 TABLET BOTTLE, PLASTIC |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CHLORTHALIDONE 25 MG TABLET (100 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CHLORTHALIDONE 50 MG TABLET (1000 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHORIONIC GONAD 10000U VIAL |
6 |
Tier 6 |
25% | N/A | None |
CICLOPIROX 0.77% TOPICAL SUSP |
2 |
Tier 2 |
$7.00 | $18.00 | Q:60 /30Days |
CICLOPIROX 8% SOLUTION |
2 |
Tier 2 |
$7.00 | $18.00 | Q:7 /30Days |
CICLOPIROX GEL |
2 |
Tier 2 |
$7.00 | $18.00 | Q:120 /30Days |
Ciclopirox Olamine 7.7mg/g 1 TUBE in 1 TUBE / 15 g in 1 TUBE |
2 |
Tier 2 |
$7.00 | $18.00 | Q:120 /30Days |
Cilostazol 50mg/1 60 TABLET BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CILOSTAZOL TABLET 100MG (60 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CILOXAN 0.3% OINTMENT |
3 |
Tier 3 |
$40.00 | $117.00 | None |
CIMETIDINE 300 MG TABLETS |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Cimetidine 400mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Cimetidine 800mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cimetidine Hydrochloride Oral Solution 300mg/5mL 237 mL in 1 BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Cinryze 500[iU]/5mL 1 VIAL per CARTON / 5 mL in 1 VIAL |
5 |
Tier 5 |
33% | N/A | P |
Cipro 2mg/mL 200 mL in 1 BOTTLE, PLASTIC |
6 |
Tier 6 |
25% | N/A | None |
CIPRODEX OTIC SUSPENSION |
3 |
Tier 3 |
$40.00 | $117.00 | Q:7 /7Days |
CIPROFLOXACIN 0.3% EYE DROP |
2 |
Tier 2 |
$7.00 | $18.00 | Q:15 /30Days |
CIPROFLOXACIN 250 MG TABLET (100 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CIPROFLOXACIN HCL 500 MG TAB |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CIPROFLOXACIN TABLETS 750 MG 100 BOT |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Cisplatin 100mg/100mL 1 VIAL per CARTON / 100 mL in 1 VIAL |
6 |
Tier 6 |
25% | N/A | None |
CITALOPRAM HBR 20 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
CITALOPRAM HBR ORAL SOLUTION 10MG 240 ML BOTPL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CITALOPRAM HYDROBROMIDE TABLETS 40 MG 30 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
CITOLOPRAM HBR 10 MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Claravis 30mg 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
5 |
Tier 5 |
33% | N/A | P |
CLARITHROMYCIN 125 MG/5ML FOR ORAL SUSPENSION |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CLARITHROMYCIN 250 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CLARITHROMYCIN 250 MG/5MLFOR ORAL SUSPENSION |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CLARITHROMYCIN 500 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CLEOCIN PHOS 150 MG/ML VIAL |
6 |
Tier 6 |
25% | N/A | P |
CLINDAMYCIN 600 MG/4 ML ADDVAN |
6 |
Tier 6 |
25% | N/A | None |
CLINDAMYCIN HCL 150 MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CLINDAMYCIN PEDIATR 75 MG/5 ML |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX |
2 |
Tier 2 |
$7.00 | $18.00 | Q:60 /15Days |
CLINDAMYCIN PHOSPHATE VAGINAL CREAM |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CLOBETASOL 0.05% OINTMENT |
2 |
Tier 2 |
$7.00 | $18.00 | Q:120 /30Days |
CLOBETASOL E 0.05% CREAM |
2 |
Tier 2 |
$7.00 | $18.00 | Q:120 /30Days |
Clobetasol Propionate 0.4625mg/mL 1 BOTTLE per CARTON / 50 mL in 1 BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | Q:60 /30Days |
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE |
2 |
Tier 2 |
$7.00 | $18.00 | Q:120 /30Days |
CLOMIPRAMINE HCL 25MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CLOMIPRAMINE HCL 50MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CLOMIPRAMINE HCL 75MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Clonazepam 0.125mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PAC |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Clonazepam 0.25mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Clonazepam 0.5mg/1 100 TABLET BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Clonazepam 1mg/1 90 TABLET BOTTLE, PLASTIC |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Clonazepam 2mg/1 100 TABLET BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CLONIDINE HCL 0.1 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
CLONIDINE HCL 0.2MG TABLET (500 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
CLONIDINE HCL TABLET 0.3MG (100 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CLOPIDOGREL 300 MG TABLET [Plavix] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CLOPIDOGREL 75 MG TABLET [Plavix] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CLORAZEPATE 15 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | P |
Clorazepate Dipotassium 3.75mg/1 500 TABLET BOTTLE, PLASTIC |
2 |
Tier 2 |
$7.00 | $18.00 | P |
Clorazepate Dipotassium 7.5mg/1 500 TABLET BOTTLE, PLASTIC |
2 |
Tier 2 |
$7.00 | $18.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOTRIMAZOLE 10MG TROCHE |
2 |
Tier 2 |
$7.00 | $18.00 | P Q:70 /14Days |
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION |
2 |
Tier 2 |
$7.00 | $18.00 | Q:60 /30Days |
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE |
2 |
Tier 2 |
$7.00 | $18.00 | Q:120 /30Days |
Clozapine 100mg/1 100 TABLET BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CLOZAPINE 25MG TABLET (100 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CLOZAPINE 50MG TABLET (500 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CLOZAPINE ODT 100 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CLOZAPINE ODT 12.5 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CLOZAPINE ODT 150 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CLOZAPINE ODT 200 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CLOZAPINE ODT 25 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COARTEM 20MG-120MG |
4 |
Tier 4 |
$80.00 | $237.00 | None |
COLCHICINE 0.6 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | Q:120 /30Days |
colistimethate 150mg/2mL 1 VIAL per CARTON / 2 mL in 1 VIAL |
6 |
Tier 6 |
25% | N/A | P |
COLOCORT 100MG ENEMA |
2 |
Tier 2 |
$7.00 | $18.00 | Q:420 /7Days |
COMETRIQ 100 MG DAILY-DOSE PK |
5 |
Tier 5 |
33% | N/A | P |
COMETRIQ 140 MG DAILY-DOSE PK |
5 |
Tier 5 |
33% | N/A | P |
COMETRIQ 60 MG DAILY-DOSE PACK |
5 |
Tier 5 |
33% | N/A | P |
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1 |
3 |
Tier 3 |
$40.00 | $117.00 | None |
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN |
5 |
Tier 5 |
33% | N/A | None |
CORDRAN TAPE 4MCG/SQCM 1 X 80 X 3 CTR |
3 |
Tier 3 |
$40.00 | $117.00 | None |
Cortisone 25 MG Tablet |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CORTISPORIN CRE 0.5% |
3 |
Tier 3 |
$40.00 | $117.00 | None |
CORTISPORIN OINTMENT |
3 |
Tier 3 |
$40.00 | $117.00 | Q:15 /7Days |
COTELLIC 20 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
Creon 256.11mg/1 1 BOTTLE per CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
3 |
Tier 3 |
$40.00 | $117.00 | None |
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT |
3 |
Tier 3 |
$40.00 | $117.00 | None |
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT |
3 |
Tier 3 |
$40.00 | $117.00 | None |
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT |
3 |
Tier 3 |
$40.00 | $117.00 | None |
CREON DR 36,000 UNITS CAPSULE |
3 |
Tier 3 |
$40.00 | $117.00 | None |
CRESTOR 10MG TABLET |
3 |
Tier 3 |
$40.00 | $117.00 | None |
CRESTOR 20MG TABLET |
3 |
Tier 3 |
$40.00 | $117.00 | None |
CRESTOR 40mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Tier 3 |
$40.00 | $117.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CRESTOR 5MG TABLET |
3 |
Tier 3 |
$40.00 | $117.00 | None |
CRIXIVAN 200MG CAPSULE |
3 |
Tier 3 |
$40.00 | $117.00 | None |
CRIXIVAN 400mg, 180 CAPSULE BOTTLE |
3 |
Tier 3 |
$40.00 | $117.00 | None |
CROMOLYN 20 MG/2 ML NEB SOLN |
2 |
Tier 2 |
$7.00 | $18.00 | P |
CROMOLYN SODIUM 100 MG/5 ML |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CROMOLYN SODIUM 4% 40MG 10ML BOT |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CUBICIN 500MG VIAL |
6 |
Tier 6 |
25% | N/A | P |
CUPRIMINE 250 MG CAPSULE |
3 |
Tier 3 |
$40.00 | $117.00 | None |
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | P |
CYCLOPHOSPHAMIDE 25 MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | P |
CYCLOPHOSPHAMIDE 50 MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cyclosporine 100mg 30 BLISTER PACK per CARTON / 1 CAPSULE, LIQUID FILLED per BLISTER PACK |
2 |
Tier 2 |
$7.00 | $18.00 | P |
CYCLOSPORINE 100MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | P |
Cyclosporine 25mg 30 BLISTER PACK per CARTON / 1 CAPSULE, LIQUID FILLED per BLISTER PACK |
2 |
Tier 2 |
$7.00 | $18.00 | P |
CYCLOSPORINE 25MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | P |
Cyclosporine 50mg 30 BLISTER PACK per CARTON / 1 CAPSULE, LIQUID FILLED per BLISTER PACK |
2 |
Tier 2 |
$7.00 | $18.00 | P |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT |
2 |
Tier 2 |
$7.00 | $18.00 | P |
CYPROHEPTADINE HCL 4 MG |
2 |
Tier 2 |
$7.00 | $18.00 | None |
CYRAMZA 100 MG/10 ML VIAL |
5 |
Tier 5 |
33% | N/A | P |
CYRAMZA 500 MG/50 ML VIAL |
5 |
Tier 5 |
33% | N/A | P |
CYSTADANE POWDER FOR ORAL SOLUTION 180GM |
4 |
Tier 4 |
$80.00 | $237.00 | None |
CYSTAGON 150MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | None |