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 P in Brevard County, FL: CMS MA Region 9 which includes: FL Plan Monthly Premium: $17.00 Deductible: $0 |
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 |
PACLITAXEL INJECTION SOLUTION 6MG 50ML VIALMD |
6 |
Tier 6 |
25% | N/A | None |
PALIPERIDONE ER 1.5 MG TABLET [INVEGA] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PALIPERIDONE ER 3 MG TABLET [INVEGA] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PALIPERIDONE ER 6 MG TABLET [INVEGA] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PALIPERIDONE ER 9 MG TABLET [INVEGA] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PAMIDRONATE 60MG/10ML VIAL |
6 |
Tier 6 |
25% | N/A | P |
PANRETIN 0.1% GEL 60GM TUBE |
5 |
Tier 5 |
33% | N/A | None |
Pantoprazole 40mg/1 90 TABLET, DELAYED RELEASE in 1 BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PANTOPRAZOLE SODIUM 20 MG TABLET DELAYED RELEASE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PARICALCITOL 1 MCG CAPSULE [Zemplar] |
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 |
PARICALCITOL 2 MCG CAPSULE [Zemplar] |
2 |
Tier 2 |
$7.00 | $18.00 | P |
PARICALCITOL 2 MCG/ML VIAL [Zemplar] |
6 |
Tier 6 |
25% | N/A | P |
PARICALCITOL 4 MCG CAPSULE [Zemplar] |
2 |
Tier 2 |
$7.00 | $18.00 | P |
PAROMOMYCIN 250MG CAPSULE |
3 |
Tier 3 |
$40.00 | $117.00 | None |
Paroxetine 40mg/1 500 FILM COATED TABLETS in BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PAROXETINE FILM COATED 20MG TABLET (100 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PAROXETINE HCL TABLET 24 12.5MG |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PAROXETINE HCL TABLET 24 25MG |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Paroxetine Hydrochloride 37.5mg/1 30 BOTTLE in 1 BOTTLE / 30 TABLET, FILM COATED, EXTENDED RELEASE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PAROXETINE HYDROCHLORIDE TABLETS 10 MG |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PAROXETINE TABLETS 30MG 90 BOT |
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 |
PASER GRANULES 4GM PACKET |
4 |
Tier 4 |
$80.00 | $237.00 | None |
PAXIL ORAL SUSPENSION 10 MG/5ML |
4 |
Tier 4 |
$80.00 | $237.00 | None |
PEDVAXHIB VACCINE VIAL |
6 |
Tier 6 |
25% | N/A | None |
PEGANONE 250 MG TABLET |
4 |
Tier 4 |
$80.00 | $237.00 | None |
Pegasys 180ug/0.5mL 1 PACKET in 1 BOX / 4 SYRINGE, GLASS in 1 PACKET / 0.5 mL in 1 SYRINGE, GLASS |
5 |
Tier 5 |
33% | N/A | P |
PENICILLIN G POTASSIUM FOR INJECTION 5000000UNIT/VIAL |
6 |
Tier 6 |
25% | N/A | P |
PENICILLIN G PROCAINE 1200000UNT 2ML CTG |
6 |
Tier 6 |
25% | N/A | None |
Penicillin V Potassium 125mg/5mL 200 mL in 1 BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Penicillin V Potassium 250mg/1 1000 TABLET BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PENICILLIN V POTASSIUM 500MG 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 |
PENTAM 300 INJ 300MG |
6 |
Tier 6 |
25% | N/A | P |
PENTOXIFYLLINE 400MG TABLET SA |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PERJETA 420 MG/14 ML VIAL |
6 |
Tier 6 |
25% | N/A | P |
Permethrin 50mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2 |
Tier 2 |
$7.00 | $18.00 | Q:60 /30Days |
Perphenazine 16mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PERPHENAZINE TABLETS 4MG 100 BOXUD |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PERPHENAZINE TABLETS 8MG 100 BOT |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PERPHENAZINE TABLETS USP 2MG 100 BOT |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PHENADOZ 12.5 MG SUPPOSITORY |
2 |
Tier 2 |
$7.00 | $18.00 | Q:12 /2Days |
Phenelzine Sulfate 15mg/1 60 TABLET BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PHENOBARBITAL 16.2 MG TABLET |
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 |
PHENOBARBITAL 20 MG/5 ML ELIX |
2 |
Tier 2 |
$7.00 | $18.00 | P |
PHENOBARBITAL 32.4 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | P |
PHENOBARBITAL 64.8 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | P |
PHENOBARBITAL 97.2 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | P |
phenytoin 50 mg tablet chew |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PHENYTOIN SODIUM 100MG /2ML INJECTION |
6 |
Tier 6 |
25% | N/A | P |
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PHOSPHOLINE IODIDE 0.125% 6.25MG |
3 |
Tier 3 |
$40.00 | $117.00 | None |
PILOCARPINE HCL 5 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PIMOZIDE 1 MG TABLET [Orap] |
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 |
PIMOZIDE 2 MG TABLET [Orap] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
pioglitazone hcl 15 mg tablet [Actos] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
pioglitazone hcl 30 mg tablet [Actos] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
pioglitazone hcl 45 mg tablet [Actos] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PIPERACILLIN 200 MG/ML / TAZOBACTAM 25 MG/ML INJECTABLE SOLUTION |
6 |
Tier 6 |
25% | N/A | None |
PIROXICAM 10 MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Piroxicam 20mg/1 500 CAPSULE BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PODOFILOX 0.5% TOPICAL TUBEX |
2 |
Tier 2 |
$7.00 | $18.00 | Q:14 /28Days |
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | Q:527 /31Days |
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1% |
2 |
Tier 2 |
$7.00 | $18.00 | Q:10 /7Days |
POMALYST 1 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POMALYST 2 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P |
POMALYST 3 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P |
POMALYST 4 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P |
PORTIA 0.15-0.03 TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Potassium Chloride in Dextrose and Sodium Chloride 5; 0.15; 0.45g/100mL; g/100mL; g/100mL 12 CONTAI |
6 |
Tier 6 |
25% | N/A | None |
Potassium Chloride in Lactated Ringers and Dextrose 20; 5; 179; 600; 310mg/100mL; g/100mL; mg/100mL |
6 |
Tier 6 |
25% | N/A | None |
POTASSIUM CITRATE ER 10 MEQ TB |
2 |
Tier 2 |
$7.00 | $18.00 | None |
POTASSIUM CITRATE ER 15 MEQ TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
POTASSIUM CITRATE ER 5 MEQ TAB |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Potassium cl 2 meq/ml vial |
6 |
Tier 6 |
25% | N/A | None |
POTIGA 200 MG TABLET |
4 |
Tier 4 |
$80.00 | $237.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTIGA 300 MG TABLET |
4 |
Tier 4 |
$80.00 | $237.00 | None |
POTIGA 400 MG TABLET |
4 |
Tier 4 |
$80.00 | $237.00 | None |
POTIGA 50 MG TABLET |
4 |
Tier 4 |
$80.00 | $237.00 | None |
PRADAXA 110 MG CAPSULE |
3 |
Tier 3 |
$40.00 | $117.00 | None |
PRADAXA 150 MG 1 BOTTLE per CARTON / 60 CAPSULE BOTTLE |
3 |
Tier 3 |
$40.00 | $117.00 | None |
PRADAXA 75 MG 1 BOTTLE per CARTON / 60 CAPSULE BOTTLE |
3 |
Tier 3 |
$40.00 | $117.00 | None |
PRAMIPEXOLE 0.75 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Pramipexole Dihydrochloride 0.125mg 500 TABLET BOTTLE, PLASTIC |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Pramipexole Dihydrochloride 0.25mg 500 TABLET BOTTLE, PLASTIC |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Pramipexole Dihydrochloride 0.5mg 500 TABLET BOTTLE, PLASTIC |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Pramipexole Dihydrochloride 1.5mg 500 TABLET 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 |
Pramipexole Dihydrochloride 1mg 500 TABLET BOTTLE, PLASTIC |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PRAVASTATIN SODIUM 20MG TABLET 500 BOT |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PRAVASTATIN SODIUM 40MG TABLET (500 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Pravastatin Sodium 80mg/1 1000 TABLET BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PRAZOSIN 5MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PRAZOSIN HCL 1MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PRAZOSIN HCL 2MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PRED G OPHTHALMIC SUSPENSION 1;0.3%;% 5 ML BOTDR |
3 |
Tier 3 |
$40.00 | $117.00 | Q:15 /30Days |
PRED MILD 0.12% EYE DROPS |
3 |
Tier 3 |
$40.00 | $117.00 | Q:10 /15Days |
PRED-G S.O.P. EYE OINTMENT |
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 |
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PREDNISOLONE SOD 1% EYE DROP |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PREDNISOLONE SODIUM PHOSPHATE 5MG /5ML ORAL SOLUTION |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PREDNISONE 10MG TABLET (100 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PREDNISONE 1MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PREDNISONE 2.5MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PREDNISONE 20MG TABLET (1000 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PREDNISONE 5 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PREDNISONE 50MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PREDNISONE 5MG/5ML SOLUTION |
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 |
Premarin 0.3mg/1 1000 FILM COATED TABLETS in BOTTLE |
3 |
Tier 3 |
$40.00 | $117.00 | None |
PREMARIN 0.45MG TABLET |
3 |
Tier 3 |
$40.00 | $117.00 | None |
Premarin 0.625mg/1 1000 FILM COATED TABLETS in BOTTLE |
3 |
Tier 3 |
$40.00 | $117.00 | None |
Premarin 0.625mg/g |
3 |
Tier 3 |
$40.00 | $117.00 | Q:42 /28Days |
PREMARIN 0.9MG TABLET |
3 |
Tier 3 |
$40.00 | $117.00 | None |
Premarin 1.25mg/1 1000 FILM COATED TABLETS in BOTTLE |
3 |
Tier 3 |
$40.00 | $117.00 | None |
PREMPHASE 0.625-5 MG TABLET |
3 |
Tier 3 |
$40.00 | $117.00 | None |
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA |
3 |
Tier 3 |
$40.00 | $117.00 | None |
PREMPRO 0.45-1.5 MG TABLET 28 EA |
3 |
Tier 3 |
$40.00 | $117.00 | None |
PREMPRO 0.625-5 MG TABLET |
3 |
Tier 3 |
$40.00 | $117.00 | None |
Prempro 0.625; 2.5mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, SUGAR COATED per BLISTER PACK |
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 |
PREZCOBIX 800 MG-150 MG TABLET |
3 |
Tier 3 |
$40.00 | $117.00 | None |
PREZISTA 100 MG/ML SUSPENSION |
3 |
Tier 3 |
$40.00 | $117.00 | None |
PREZISTA 150MG TABLETS |
3 |
Tier 3 |
$40.00 | $117.00 | None |
PREZISTA 800 MG TABLET |
3 |
Tier 3 |
$40.00 | $117.00 | None |
PREZISTA TABLET 600MG |
3 |
Tier 3 |
$40.00 | $117.00 | None |
PREZISTA TABLET 75MG |
3 |
Tier 3 |
$40.00 | $117.00 | None |
PRIFTIN 150MG TABLET |
4 |
Tier 4 |
$80.00 | $237.00 | None |
PRIMAQUINE 26.3MG TABLET |
3 |
Tier 3 |
$40.00 | $117.00 | None |
Primidone 250mg/1 100 TABLET BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Primidone 50mg/1 500 TABLET BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PRISTIQ 100MG TABLET SR 24HR |
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 |
PRISTIQ ER 25 MG TABLET |
3 |
Tier 3 |
$40.00 | $117.00 | None |
Pristiq Extended-Release 50mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
3 |
Tier 3 |
$40.00 | $117.00 | None |
PROBENECID 500MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PROBENECID/COLCHICINE 0.5MG/500MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PROCAINAMIDE 500MG/ML VIAL |
6 |
Tier 6 |
25% | N/A | P |
Prochlorperazine 10 mg/2 ml vl |
6 |
Tier 6 |
25% | N/A | P |
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Prochlorperazine Maleate 5mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX |
2 |
Tier 2 |
$7.00 | $18.00 | Q:12 /6Days |
PROCRIT 10000U/ML VIAL |
6 |
Tier 6 |
25% | N/A | P |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL |
6 |
Tier 6 |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCRIT 3,000 UNITS/ML VIAL |
6 |
Tier 6 |
25% | N/A | P |
PROCRIT 4,000 UNITS/ML VIAL |
6 |
Tier 6 |
25% | N/A | P |
PROCRIT 40000U/ML VIAL PR |
6 |
Tier 6 |
25% | N/A | P |
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY |
6 |
Tier 6 |
25% | N/A | P |
PROCTOSOL-HC 2.5% CREAM |
2 |
Tier 2 |
$7.00 | $18.00 | Q:28 /30Days |
proctozone-hc 2.5% cream |
2 |
Tier 2 |
$7.00 | $18.00 | Q:30 /30Days |
Proglycem 50mg/mL 1 BOTTLE, DROPPER in 1 BOX / 30 mL in 1 BOTTLE, DROPPER |
4 |
Tier 4 |
$80.00 | $237.00 | None |
PROLASTIN-C |
5 |
Tier 5 |
33% | N/A | P |
PROLEUKIN 22 MILLION UNIT VIAL |
5 |
Tier 5 |
33% | N/A | None |
PROLIA 60MG/ML INJECTION |
6 |
Tier 6 |
25% | N/A | P |
PROMACTA 12.5 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMACTA 25 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
PROMACTA 50 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
PROMETHAZINE 50 MG SUPPOSITORY |
2 |
Tier 2 |
$7.00 | $18.00 | Q:12 /2Days |
PROMETHAZINE 50MG/ML VIAL |
6 |
Tier 6 |
25% | N/A | P |
PROMETHAZINE HCL 25MG TABLET (1000 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | P |
PROMETHAZINE HYDROCHLORIDE 25mg/mL 25 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
6 |
Tier 6 |
25% | N/A | P |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX |
2 |
Tier 2 |
$7.00 | $18.00 | Q:12 /2Days |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX |
2 |
Tier 2 |
$7.00 | $18.00 | Q:12 /2Days |
PROMETHEGAN 25MG SUPP |
2 |
Tier 2 |
$7.00 | $18.00 | Q:12 /2Days |
PROMETHEGAN 50MG SUPPOS |
2 |
Tier 2 |
$7.00 | $18.00 | Q:12 /2Days |
Propafenone HCl 150mg/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 |
PROPAFENONE HCL 225MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PROPAFENONE HCL 300MG TABLET (100 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PROPARACAINE 0.5% EYE DROPS |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Propranolol 1mg/mL 1 mL in 1 VIAL |
6 |
Tier 6 |
25% | N/A | None |
PROPRANOLOL 20MG/5ML TUBEX |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PROPRANOLOL 40MG/5ML TUBEX |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PROPRANOLOL 60MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PROPRANOLOL 80 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PROPRANOLOL HCL 20MG TABLET (1000 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PROPRANOLOL HCL TABLET USP 10MG (1000 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PROPRANOLOL HCL TABLET USP 40MG (1000 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 |
PROPYLTHIOURACIL 50MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PROQUAD 0.5 VIAL |
6 |
Tier 6 |
25% | N/A | None |
Protonix I.V. 40mg/10mL 10 CARTON in 1 PACKAGE / 1 VIAL per CARTON / 40 mL in 1 VIAL |
6 |
Tier 6 |
25% | N/A | P |
PROTRIPTYLINE HYDROCHLORIDE 10MG TABLETS |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PULMOZYME 1MG/ML AMPUL |
5 |
Tier 5 |
33% | N/A | P Q:150 /28Days |
PURIXAN 20 MG/ML ORAL SUSP |
5 |
Tier 5 |
33% | N/A | None |
PYRAZINAMIDE 500 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Pyridostigmine br 60 mg tablet |
2 |
Tier 2 |
$7.00 | $18.00 | None |
PYRIDOSTIGMINE BR ER 180 MG TAB |
2 |
Tier 2 |
$7.00 | $18.00 | None |