2016 Medicare Part D Plan Formulary Information |
Platinum Blue Complete Plan with Rx (Cost) (H2461-010-0)
Benefit Details
|
The Platinum Blue Complete Plan with Rx (Cost) (H2461-010-0) Formulary Drugs Starting with the Letter A in Roseau County, MN: CMS MA Region 19 which includes: MN Plan Monthly Premium: $164.50 Deductible: $360 |
Drugs Starting with Letter A
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
ABACAVIR 300 MG TABLET |
2* |
Generic |
$10.00 | $20.00 | Q:60 /30Days |
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir] |
5 |
Specialty Tier |
25% | 25% | Q:60 /30Days |
ABILIFY MAINTENA ER 300 MG SYR |
5 |
Specialty Tier |
25% | 25% | P Q:1 /30Days |
ABILIFY MAINTENA ER 300 MG VL |
5 |
Specialty Tier |
25% | 25% | P Q:1 /30Days |
ABILIFY MAINTENA ER 400 MG SYR |
5 |
Specialty Tier |
25% | 25% | P Q:1 /30Days |
ABRAXANE 100MG VIAL |
5 |
Specialty Tier |
25% | 25% | None |
ABSTRAL 100 MCG TAB SUBLINGUAL |
5 |
Specialty Tier |
25% | 25% | P Q:120 /30Days |
ABSTRAL 200 MCG TAB SUBLINGUAL |
5 |
Specialty Tier |
25% | 25% | P Q:120 /30Days |
ABSTRAL 300 MCG TAB SUBLINGUAL |
5 |
Specialty Tier |
25% | 25% | P Q:120 /30Days |
ABSTRAL 400 MCG TAB SUBLINGUAL |
5 |
Specialty Tier |
25% | 25% | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABSTRAL 600 MCG TAB SUBLINGUAL |
5 |
Specialty Tier |
25% | 25% | P Q:120 /30Days |
ABSTRAL 800 MCG TAB SUBLINGUAL |
5 |
Specialty Tier |
25% | 25% | P Q:120 /30Days |
Acamprosate Calcium DR 333 MG tablets [Campral] |
2* |
Generic |
$10.00 | $20.00 | None |
ACARBOSE 100 MG TABLET |
2* |
Generic |
$10.00 | $20.00 | Q:90 /30Days |
ACARBOSE 25 MG TABLET |
2* |
Generic |
$10.00 | $20.00 | Q:360 /30Days |
Acarbose 50mg/1 100 TABLET BOTTLE |
2* |
Generic |
$10.00 | $20.00 | Q:180 /30Days |
ACEBUTOLOL 200MG CAPSULE |
2* |
Generic |
$10.00 | $20.00 | None |
ACEBUTOLOL 400MG CAPSULE |
2* |
Generic |
$10.00 | $20.00 | None |
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE |
4 |
Non-Preferred Brand |
50% | 50% | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD |
1* |
Preferred Generic |
$3.00 | $6.00 | Q:2700 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) |
1* |
Preferred Generic |
$3.00 | $6.00 | Q:360 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
1* |
Preferred Generic |
$3.00 | $6.00 | Q:360 /30Days |
ACETAMINOPHEN-COD #4 TABLET |
1* |
Preferred Generic |
$3.00 | $6.00 | Q:180 /30Days |
ACETASOL HC SOLUTION 10ML 10 ML BOT |
2* |
Generic |
$10.00 | $20.00 | None |
ACETAZOLAMIDE 125MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
2* |
Generic |
$10.00 | $20.00 | None |
ACETAZOLAMIDE ER CAPSULES 500MG 100 BOT |
2* |
Generic |
$10.00 | $20.00 | None |
ACETIC ACID 2% EAR SOLUTION |
2* |
Generic |
$10.00 | $20.00 | None |
ACETYLCYSTEINE 10% VIAL |
2* |
Generic |
$10.00 | $20.00 | P |
ACETYLCYSTEINE 20% VIAL |
2* |
Generic |
$10.00 | $20.00 | P |
ACITRETIN 10 MG CAPSULE [Soriatane] |
5 |
Specialty Tier |
25% | 25% | None |
ACITRETIN 17.5 MG CAPSULE [Soriatane] |
5 |
Specialty Tier |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACITRETIN 25 MG CAPSULE [Soriatane] |
5 |
Specialty Tier |
25% | 25% | None |
ACTHIB VACCINE WITH DILUENT |
4 |
Non-Preferred Brand |
50% | 50% | None |
ACTIMMUNE 100 MCG/0.5 ML VIAL |
5 |
Specialty Tier |
25% | 25% | None |
Acyclovir 200mg 100 CAPSULE BOTTLE |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
Acyclovir 200mg/5mL 473 mL BOTTLE |
2* |
Generic |
$10.00 | $20.00 | None |
Acyclovir 400mg/1 |
2* |
Generic |
$10.00 | $20.00 | None |
Acyclovir 5% Ointment |
2* |
Generic |
$10.00 | $20.00 | None |
ACYCLOVIR 800 MG TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
Acyclovir sodium 500 mg vial |
2* |
Generic |
$10.00 | $20.00 | P |
ADACEL VIAL 2UNT/5UNT |
4 |
Non-Preferred Brand |
50% | 50% | None |
ADAGEN 250U/ML VIAL |
5 |
Specialty Tier |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA] |
5 |
Specialty Tier |
25% | 25% | P |
ADCIRCA TABLETS 20MG 60 BOTTLE |
5 |
Specialty Tier |
25% | 25% | P Q:60 /30Days |
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera] |
5 |
Specialty Tier |
25% | 25% | None |
ADEMPAS 0.5 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:90 /30Days |
ADEMPAS 1 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:90 /30Days |
ADEMPAS 1.5 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:90 /30Days |
ADEMPAS 2 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:90 /30Days |
ADEMPAS 2.5 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:90 /30Days |
ADRUCIL 50mg/mL 10 VIAL in 1 TRAY / 10 mL in 1 VIAL |
2* |
Generic |
$10.00 | $20.00 | P |
ADVAIR DISKUS MIS 100/50 |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:60 /30Days |
ADVAIR DISKUS MIS 250/50 |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADVAIR DISKUS MIS 500/50 |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:60 /30Days |
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:12 /30Days |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:12 /30Days |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:12 /30Days |
AFEDITAB CR 30MG TABLET SA |
2* |
Generic |
$10.00 | $20.00 | None |
AFEDITAB CR 60MG TABLET SA |
2* |
Generic |
$10.00 | $20.00 | None |
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
AFINITOR DISPERZ 2 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:60 /30Days |
AFINITOR DISPERZ 3 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:90 /30Days |
AFINITOR DISPERZ 5 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:60 /30Days |
AFINITOR TABLETS 10 MG |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AFINITOR TABLETS 2.5 MG |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
AFINITOR TABLETS 5 MG |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
AGGRENOX 25-200MG CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | None |
AK-CON 0.1% EYE DROPS |
4 |
Non-Preferred Brand |
50% | 50% | None |
ALA-CORT 1% CREAM |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
ALBENZA 200 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH per CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL |
2* |
Generic |
$10.00 | $20.00 | P |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
2* |
Generic |
$10.00 | $20.00 | P |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
2* |
Generic |
$10.00 | $20.00 | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
2* |
Generic |
$10.00 | $20.00 | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
2* |
Generic |
$10.00 | $20.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL SULFATE SOLUTION FOR INHALATION |
2* |
Generic |
$10.00 | $20.00 | P |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
2* |
Generic |
$10.00 | $20.00 | None |
ALBUTEROL TABLET 4MG (500 CT) |
2* |
Generic |
$10.00 | $20.00 | None |
ALCLOMETASONE DIPROPIONATE 0.05% CREAM |
2* |
Generic |
$10.00 | $20.00 | None |
Alclometasone Dipropionate 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2* |
Generic |
$10.00 | $20.00 | None |
ALDURAZYME 2.9MG/5ML VIAL |
5 |
Specialty Tier |
25% | 25% | None |
ALECENSA 150 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P Q:240 /30Days |
ALENDRONATE SODIUM 10MG TABLET |
1* |
Preferred Generic |
$3.00 | $6.00 | Q:120 /30Days |
ALENDRONATE SODIUM 35 MG TABLET |
1* |
Preferred Generic |
$3.00 | $6.00 | Q:4 /28Days |
ALENDRONATE SODIUM 5MG TABLET |
1* |
Preferred Generic |
$3.00 | $6.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Alendronate Sodium 70mg/1 4 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK |
1* |
Preferred Generic |
$3.00 | $6.00 | Q:4 /28Days |
ALFUZOSIN HYDROCHLORIDE 10mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2* |
Generic |
$10.00 | $20.00 | Q:30 /30Days |
ALIMTA 500MG VIAL |
5 |
Specialty Tier |
25% | 25% | None |
ALINIA 100MG/5ML SUSPENSION |
4 |
Non-Preferred Brand |
50% | 50% | None |
ALINIA 500 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
ALLOPURINOL 100 MG TABLETS |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET per BLISTER PACK |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
ALOPRIM SOLUTION FOR INJECTION 500MG/VIAL 30 ML VIALGL |
4 |
Non-Preferred Brand |
50% | 50% | None |
ALOSETRON HCL 0.5 MG TABLET [Lotronex] |
5 |
Specialty Tier |
25% | 25% | None |
ALOSETRON HCL 1 MG TABLET [Lotronex] |
5 |
Specialty Tier |
25% | 25% | None |
ALOXI 0.25 MG/5 ML |
4 |
Non-Preferred Brand |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALPHAGAN P 0.1% DROPS |
4 |
Non-Preferred Brand |
50% | 50% | None |
AMANTADINE 100MG CAPSULE |
2* |
Generic |
$10.00 | $20.00 | None |
AMANTADINE 100MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
Amantadine Hydrochloride 50mg/5mL 473 mL in 1 BOTTLE |
2* |
Generic |
$10.00 | $20.00 | None |
AMBISOME 50MG VIAL |
5 |
Specialty Tier |
25% | 25% | P |
Amethia 2 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2* |
Generic |
$10.00 | $20.00 | None |
Amethyst 20; 90ug/1; ug/1 1 BLISTER PACK per CARTON / 28 TABLET per BLISTER PACK |
2* |
Generic |
$10.00 | $20.00 | None |
AMIFOSTINE 50mg/mL 3 VIAL, SINGLE-USE per CARTON / 10 mL in 1 VIAL, SINGLE-USE |
5 |
Specialty Tier |
25% | 25% | None |
AMIKACIN SULFATE 500 MG/2 ML VIAL |
2* |
Generic |
$10.00 | $20.00 | None |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT |
2* |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Amino Acids 15% Solution |
2* |
Generic |
$10.00 | $20.00 | P |
AMIODARONE HCL 200MG 60 TABLET BOTTLE |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
AMIODARONE HCL 400MG TABLET |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
AMITIZA 8MCG CAPSULE |
3 |
Preferred Brand |
$35.00 | $70.00 | P |
AMITIZA CAPSULES 24MCG 60 CAP BOT |
3 |
Preferred Brand |
$35.00 | $70.00 | P |
AMITRIPTYLINE HCL 100MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | P |
AMITRIPTYLINE HCL 10MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | P |
AMITRIPTYLINE HCL 150 MG TAB |
4 |
Non-Preferred Brand |
50% | 50% | P |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
4 |
Non-Preferred Brand |
50% | 50% | P |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
4 |
Non-Preferred Brand |
50% | 50% | P |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
4 |
Non-Preferred Brand |
50% | 50% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLOD-VALSA-HCTZ 10-160-12.5 MG [EXFORGE HCT] |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days |
AMLOD-VALSA-HCTZ 10-160-25 MG [EXFORGE HCT] |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days |
AMLOD-VALSA-HCTZ 10-320-25 MG [EXFORGE HCT] |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days |
AMLOD-VALSA-HCTZ 5-160-12.5 MG [EXFORGE HCT] |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days |
AMLOD-VALSA-HCTZ 5-160-25 MG [EXFORGE HCT] |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE |
6* |
Select Care Drugs |
$0.00 | $0.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE |
6* |
Select Care Drugs |
$0.00 | $0.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE |
6* |
Select Care Drugs |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE |
6* |
Select Care Drugs |
$0.00 | $0.00 | None |
Amlodipine-Atorvastatin 10-10 mg [Caduet] |
6* |
Select Care Drugs |
$0.00 | $0.00 | None |
Amlodipine-Atorvastatin 10-20 mg [Caduet] |
6* |
Select Care Drugs |
$0.00 | $0.00 | None |
Amlodipine-Atorvastatin 10-40 mg [Caduet] |
6* |
Select Care Drugs |
$0.00 | $0.00 | None |
Amlodipine-Atorvastatin 10-80 mg [Caduet] |
6* |
Select Care Drugs |
$0.00 | $0.00 | None |
Amlodipine-Atorvastatin 2.5-10 mg [Caduet] |
6* |
Select Care Drugs |
$0.00 | $0.00 | None |
Amlodipine-Atorvastatin 2.5-20 mg [Caduet] |
6* |
Select Care Drugs |
$0.00 | $0.00 | None |
Amlodipine-Atorvastatin 2.5-40 mg [Caduet] |
6* |
Select Care Drugs |
$0.00 | $0.00 | None |
Amlodipine-Atorvastatin 5-10 mg [Caduet] |
6* |
Select Care Drugs |
$0.00 | $0.00 | None |
Amlodipine-Atorvastatin 5-20 mg [Caduet] |
6* |
Select Care Drugs |
$0.00 | $0.00 | None |
Amlodipine-Atorvastatin 5-40 mg [Caduet] |
6* |
Select Care Drugs |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Amlodipine-Atorvastatin 5-80 mg [Caduet] |
6* |
Select Care Drugs |
$0.00 | $0.00 | None |
AMLODIPINE-BENAZEPRIL 10-40 MG |
6* |
Select Care Drugs |
$0.00 | $0.00 | None |
AMLODIPINE-BENAZEPRIL 5-40 MG |
6* |
Select Care Drugs |
$0.00 | $0.00 | None |
AMLODIPINE-VALSARTAN 10-160 MG |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days |
AMLODIPINE-VALSARTAN 10-320 MG |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days |
AMLODIPINE-VALSARTAN 5-160 MG |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days |
AMLODIPINE-VALSARTAN 5-320 MG |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days |
AMMONIUM LACTATE 12% CREAM |
2* |
Generic |
$10.00 | $20.00 | None |
AMMONIUM LACTATE 12% LOTION |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
AMOX TR-K CLV 500-125 MG TAB |
2* |
Generic |
$10.00 | $20.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
2* |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
2* |
Generic |
$10.00 | $20.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
2* |
Generic |
$10.00 | $20.00 | None |
AMOX-CLAV 200-28.5 MG/5 ML SUSPENSION |
2* |
Generic |
$10.00 | $20.00 | None |
AMOXAPINE 100MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
AMOXAPINE 150MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
AMOXAPINE 25MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
AMOXAPINE 50MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
AMOXICILLIN 250MG CAPSULE |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
AMOXICILLIN 500MG 500 CAPSULE BOTTLE |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
AMOXICILLIN 500MG TABLET (100 CT) |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN 875MG TABLET |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
2* |
Generic |
$10.00 | $20.00 | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
2* |
Generic |
$10.00 | $20.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
amphotericin b 50mg/10mL 10 mL in 1 VIAL |
4 |
Non-Preferred Brand |
50% | 50% | P |
AMPICILLIN CAPSULES 250MG 100 BOT |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
AMPICILLIN FOR INJECTION POWDER |
2* |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
4 |
Non-Preferred Brand |
50% | 50% | None |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
4 |
Non-Preferred Brand |
50% | 50% | None |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML |
2* |
Generic |
$10.00 | $20.00 | None |
AMPICILLIN-SULBACTAM 3 GM VIAL |
2* |
Generic |
$10.00 | $20.00 | None |
AMPYRA ER 10 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
ANADROL-50 TABLET |
5 |
Specialty Tier |
25% | 25% | P |
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE |
2* |
Generic |
$10.00 | $20.00 | None |
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE |
2* |
Generic |
$10.00 | $20.00 | None |
Anastrozole 1mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
ANDRODERM 2 MG/24HR PATCH |
3 |
Preferred Brand |
$35.00 | $70.00 | P Q:30 /30Days |
ANDRODERM 4 MG/24HR PATCH |
3 |
Preferred Brand |
$35.00 | $70.00 | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANDROGEL 1.62% (1.25G) GEL PCKT |
3 |
Preferred Brand |
$35.00 | $70.00 | P Q:38 /30Days |
ANDROGEL 1.62% (2.5G) GEL PCKT |
3 |
Preferred Brand |
$35.00 | $70.00 | P Q:150 /30Days |
ANDROGEL 1% (50MG) GEL PACKET |
3 |
Preferred Brand |
$35.00 | $70.00 | P Q:300 /30Days |
Androgel 10mg/g 30 PACKET in 1 CARTON / 2.5 g in 1 PACKET |
3 |
Preferred Brand |
$35.00 | $70.00 | P Q:225 /30Days |
Androgel 16.2mg/g 1 BOTTLE, PUMP per CARTON / 88 g in 1 BOTTLE, PUMP |
3 |
Preferred Brand |
$35.00 | $70.00 | P Q:150 /30Days |
ANDROID 10 MG CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | P |
ANORO ELLIPTA 62.5-25 MCG INH |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:60 /30Days |
APOKYN 30 MG/3 ML CARTRIDGE |
5 |
Specialty Tier |
25% | 25% | None |
APRI 0.15-0.03 TABLET |
2* |
Generic |
$10.00 | $20.00 | None |
APRISO CP24 |
4 |
Non-Preferred Brand |
50% | 50% | None |
APTIOM 200 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APTIOM 400 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
APTIOM 600 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
APTIOM 800 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
APTIVUS 250MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | Q:120 /30Days |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
5 |
Specialty Tier |
25% | 25% | Q:380 /30Days |
ARANELLE 7-9-5 TABLET |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
ARANESP 10 MCG/0.4 ML SYRINGE |
4 |
Non-Preferred Brand |
50% | 50% | P |
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.5 mL in 1 SYRINGE |
5 |
Specialty Tier |
25% | 25% | P |
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
5 |
Specialty Tier |
25% | 25% | P |
ARANESP 200MCG/0.4ML SYRINGE |
5 |
Specialty Tier |
25% | 25% | P |
ARANESP 200MCG/ML VIAL |
5 |
Specialty Tier |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.42 mL in 1 SYRING |
4 |
Non-Preferred Brand |
50% | 50% | P |
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
4 |
Non-Preferred Brand |
50% | 50% | P |
ARANESP 300MCG/ML VIAL |
5 |
Specialty Tier |
25% | 25% | P |
ARANESP 500MCG/1ML SYRINGE |
5 |
Specialty Tier |
25% | 25% | P |
ARANESP 60MCG/ML VIAL |
4 |
Non-Preferred Brand |
50% | 50% | P |
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.3 mL in 1 SYRINGE |
4 |
Non-Preferred Brand |
50% | 50% | P |
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR |
5 |
Specialty Tier |
25% | 25% | P |
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR |
5 |
Specialty Tier |
25% | 25% | P |
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR |
4 |
Non-Preferred Brand |
50% | 50% | P |
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD |
4 |
Non-Preferred Brand |
50% | 50% | P |
ARCALYST INJECTION 220MG/VIAL |
5 |
Specialty Tier |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARIPIPRAZOLE 10 MG TABLET [Abilify] |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
ARIPIPRAZOLE 15 MG TABLET [Abilify] |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
ARIPIPRAZOLE 2 MG TABLET [Abilify] |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
ARIPIPRAZOLE 20 MG TABLET [Abilify] |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
ARIPIPRAZOLE 30 MG TABLET [Abilify] |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
ARIPIPRAZOLE 5 MG TABLET [Abilify] |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
ARIPIPRAZOLE ODT 10 MG TABLET [Abilify] |
5 |
Specialty Tier |
25% | 25% | P Q:60 /30Days |
ARIPIPRAZOLE ODT 15 MG TABLET [Abilify] |
5 |
Specialty Tier |
25% | 25% | P Q:60 /30Days |
Armodafinil 150 MG TABLET [NUVIGIL] |
2* |
Generic |
$10.00 | $20.00 | P Q:30 /30Days |
Armodafinil 250 MG TABLET [NUVIGIL] |
2* |
Generic |
$10.00 | $20.00 | P Q:30 /30Days |
Armodafinil 50 MG TABLET [NUVIGIL] |
2* |
Generic |
$10.00 | $20.00 | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARNUITY ELLIPTA 100 MCG INH |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:30 /30Days |
ARNUITY ELLIPTA 200 MCG INH |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:30 /30Days |
ARRANON 250MG VIAL |
5 |
Specialty Tier |
25% | 25% | None |
ASACOL HD 800mg/1 12 BOTTLE CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ASCOMP WITH CODEINE CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | P Q:180 /30Days |
Ashlyna 0.15-0.03-0.01 mg tablet |
2* |
Generic |
$10.00 | $20.00 | None |
ASMANEX HFA 100 MCG INHALER |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:13 /30Days |
ASMANEX HFA 200 MCG INHALER |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:13 /30Days |
ASMANEX TWISTHALER 110 MCG #30 |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:1 /30Days |
ASMANEX TWISTHALER 220 MCG #30 |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:1 /30Days |
ASMANEX TWISTHALER 220MCG #120 |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:1 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ASMANEX TWISTHALER 220MCG #60 |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:1 /30Days |
ASPIRIN/BUTALBITAL/CAFFEINE/CODEINE |
4 |
Non-Preferred Brand |
50% | 50% | P Q:180 /30Days |
ATENOLOL 100 MG100 TABLET BOTTLE |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
ATENOLOL 25 MG 100 TABLET BOTTLE |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
ATENOLOL TABLET USP 50MG (100 CT) |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
ATENOLOL-CHLORTHALIDONE 100-25 |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
ATGAM 50MG/ML AMPUL |
5 |
Specialty Tier |
25% | 25% | P |
ATORVASTATIN 10 MG TABLET [Lipitor] |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:45 /30Days |
ATORVASTATIN 20 MG TABLET [Lipitor] |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:45 /30Days |
ATORVASTATIN 40 MG TABLET [Lipitor] |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:45 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATORVASTATIN 80 MG TABLET [Lipitor] |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days |
ATOVAQUONE 750 MG/5 ML SUSP [Mepron] |
5 |
Specialty Tier |
25% | 25% | None |
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone] |
2* |
Generic |
$10.00 | $20.00 | None |
Atovaquone-Proguanil 62.5-25 [Malarone] |
2* |
Generic |
$10.00 | $20.00 | None |
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
5 |
Specialty Tier |
25% | 25% | Q:30 /30Days |
ATROVENT HFA AER 17MCG |
4 |
Non-Preferred Brand |
50% | 50% | Q:26 /30Days |
AUBRA-28 TABLET |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
AVASTIN 100MG/4ML VIAL |
5 |
Specialty Tier |
25% | 25% | None |
AVASTIN 400 MG/16 ML VIAL |
5 |
Specialty Tier |
25% | 25% | None |
AVELOX IV 400MG/250ML |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
AVIANE 0.1-0.02 TABLET |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVITA 0.025% CREAM |
2* |
Generic |
$10.00 | $20.00 | None |
Avita 0.25mg/g 45 g in 1 TUBE |
2* |
Generic |
$10.00 | $20.00 | None |
AVONEX ADMIN PACK 30 MCG VL |
5 |
Specialty Tier |
25% | 25% | P Q:4 /28Days |
AVONEX PEN 30 MCG/0.5 ML KIT |
5 |
Specialty Tier |
25% | 25% | P Q:1 /28Days |
AVONEX PREFILLED SYR 30 MCG KT |
5 |
Specialty Tier |
25% | 25% | P Q:1 /28Days |
AXIRON 30mg/1.5mL 1 BOTTLE, WITH APPLICATOR per CARTON / 90 mL in 1 BOTTLE, WITH APPLICATOR |
4 |
Non-Preferred Brand |
50% | 50% | P Q:180 /30Days |
Azacitidine 100 mg vial [Vidaza] |
5 |
Specialty Tier |
25% | 25% | None |
AZACTAM INJECTION 1GM/50ML |
4 |
Non-Preferred Brand |
50% | 50% | None |
AZACTAM INJECTION 2GM/50ML |
4 |
Non-Preferred Brand |
50% | 50% | None |
AZASAN 100MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | P |
AZASAN 75MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZATHIOPRINE 50 MG TABLET |
2* |
Generic |
$10.00 | $20.00 | P |
AZATHIOPRINE SODIUM 100 MG VIAL |
4 |
Non-Preferred Brand |
50% | 50% | P |
AZELASTINE 0.15% NASAL SPRAY |
2* |
Generic |
$10.00 | $20.00 | Q:60 /30Days |
AZELASTINE 137 MCG NASAL SPRAY |
2* |
Generic |
$10.00 | $20.00 | Q:60 /30Days |
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION |
2* |
Generic |
$10.00 | $20.00 | None |
AZELEX 20% CREAM 30GM TUBE |
4 |
Non-Preferred Brand |
50% | 50% | None |
AZILECT 0.5MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
AZILECT 1MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
AZITHROMYCIN 1 GM PWD PACKET |
4 |
Non-Preferred Brand |
50% | 50% | None |
AZITHROMYCIN 100 MG/5 ML SUSP |
2* |
Generic |
$10.00 | $20.00 | None |
Azithromycin 200mg/5mL 22.5 mL in 1 BOTTLE |
2* |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZITHROMYCIN 250 MG TABLET |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
AZITHROMYCIN 250 MG TABLET |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION |
2* |
Generic |
$10.00 | $20.00 | None |
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
Azithromycin 600mg/1 30 FILM COATED TABLETS in BOTTLE |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
Azithromycin i.v. 500 mg vial |
2* |
Generic |
$10.00 | $20.00 | None |
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT |
4 |
Non-Preferred Brand |
50% | 50% | None |
AZTREONAM FOR INJECTION |
2* |
Generic |
$10.00 | $20.00 | None |