2016 Medicare Part D Plan Formulary Information |
Advantra Northern Pennsylvania Gold (HMO) (H3959-037-0)
Benefit Details
|
The Advantra Northern Pennsylvania Gold (HMO) (H3959-037-0) Formulary Drugs Starting with the Letter C in Monroe County, PA: CMS MA Region 6 which includes: PA Plan Monthly Premium: $0.00 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 |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CABOMETYX 20 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
CABOMETYX 40 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
CABOMETYX 60 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
Caduet 10; 10mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | S |
Caduet 10; 20mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | S |
CADUET 10MG/40MG TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | S |
CADUET 10MG/80MG TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | S |
CADUET 2.5MG/10MG TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | S |
CADUET 2.5MG/20MG TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CADUET 2.5MG/40MG TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | S |
CADUET 5MG/10MG TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | S |
CADUET 5MG/20MG TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | S |
CADUET 5MG/40MG TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | S |
CADUET 5MG/80MG TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | S |
CAFERGOT TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:40 /28Days |
CALCIPOTRIENE 0.005% CREAM |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Calcipotriene 50ug/g 60 g per CARTON |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CALCIPOTRIENE TOPICAL SOLUTION |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY |
1 |
Generic |
$10.00 | $37.50 | None |
CALCITRIOL 0.25MCG CAPSULE |
1 |
Generic |
$10.00 | $37.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CALCITRIOL 0.5MCG CAPSULE |
1 |
Generic |
$10.00 | $37.50 | None |
Calcitriol 1 mcg/ml ampul |
1 |
Generic |
$10.00 | $37.50 | None |
CALCITRIOL 1MCG/ML SOLUTION ORAL |
1 |
Generic |
$10.00 | $37.50 | None |
CALCIUM ACETATE CAPSULE 667 MG |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CAMILA 0.35MG TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CANCIDAS IV 50MG VIAL |
4 |
Specialty Tier |
33% | N/A | None |
CANCIDAS IV 70MG VIAL |
4 |
Specialty Tier |
33% | N/A | None |
CANDESARTAN CILEXETIL 16 MG TABLET [Atacand] |
1 |
Generic |
$10.00 | $37.50 | Q:30 /30Days |
CANDESARTAN CILEXETIL 32 MG TABLET [Atacand] |
1 |
Generic |
$10.00 | $37.50 | Q:30 /30Days |
CANDESARTAN CILEXETIL 4 MG TABLET [Atacand] |
1 |
Generic |
$10.00 | $37.50 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CANDESARTAN CILEXETIL 8 MG TABLET [Atacand] |
1 |
Generic |
$10.00 | $37.50 | Q:30 /30Days |
candesartan-hctz 16-12.5 mg tablet |
1 |
Generic |
$10.00 | $37.50 | Q:60 /30Days |
candesartan-hctz 32-12.5 mg tablet |
1 |
Generic |
$10.00 | $37.50 | Q:30 /30Days |
candesartan-hctz 32-25 mg |
1 |
Generic |
$10.00 | $37.50 | Q:30 /30Days |
CAPASTAT SULFATE 1g/1 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CAPEX SHA 0.01% |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CAPRELSA 100mg/1 30 TABLET BOTTLE |
4 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
CAPRELSA 300mg/1 30 TABLET BOTTLE |
4 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
CAPTOPRIL 100MG TABLET |
1 |
Generic |
$10.00 | $37.50 | None |
CAPTOPRIL 12.5MG TABLET |
1 |
Generic |
$10.00 | $37.50 | None |
CAPTOPRIL 25MG TABLET |
1 |
Generic |
$10.00 | $37.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAPTOPRIL 50MG TABLET |
1 |
Generic |
$10.00 | $37.50 | None |
Captopril and Hydrochlorothiazide 25; 15mg 100 TABLET BOTTLE |
1 |
Generic |
$10.00 | $37.50 | None |
Captopril and Hydrochlorothiazide 25; 25mg 100 TABLET BOTTLE |
1 |
Generic |
$10.00 | $37.50 | None |
Captopril and Hydrochlorothiazide 50; 15mg 100 TABLET BOTTLE |
1 |
Generic |
$10.00 | $37.50 | None |
Captopril and Hydrochlorothiazide 50; 25mg 100 TABLET BOTTLE |
1 |
Generic |
$10.00 | $37.50 | None |
Carbaglu 200mg/1 5 TABLET BOTTLE |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CARBAMAZEPINE 100 MG/5 ML SUSP |
1 |
Generic |
$10.00 | $37.50 | None |
Carbamazepine 100mg, CHEWABLE 100 TABLET BOTTLE |
1 |
Generic |
$10.00 | $37.50 | None |
Carbamazepine 100mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Carbamazepine 200mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Carbamazepine 300mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARBAMAZEPINE ER 100 MG TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CARBAMAZEPINE TABLET USP 200MG (1000 CT) |
1 |
Generic |
$10.00 | $37.50 | None |
CARBAMAZEPINE XR 200 MG TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CARBAMAZEPINE XR 400 MG TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CARBIDOPA 25 MG TABLET [Lodosyn] |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT |
1 |
Generic |
$10.00 | $37.50 | None |
Carbidopa and Levodopa 25; 100mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
Carbidopa and Levodopa 50; 200mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;100MG;MG 100 BOT |
1 |
Generic |
$10.00 | $37.50 | None |
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;250MG;MG 100 BOT |
1 |
Generic |
$10.00 | $37.50 | None |
Carbidopa-Levodopa-Entacapone 100 MG [Stalevo] |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Carbidopa-Levodopa-Entacapone 125 MG [Stalevo] |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Carbidopa-Levodopa-Entacapone 150 MG [Stalevo] |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Carbidopa-Levodopa-Entacapone 200 MG [Stalevo] |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Carbidopa-Levodopa-Entacapone 50 MG [Stalevo] |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Carbidopa-Levodopa-Entacapone 75 MG [Stalevo] |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CARBIDOPA/LEVO 10/100 TABLET |
1 |
Generic |
$10.00 | $37.50 | None |
CARBIDOPA/LEVO 25/100 TABLET |
1 |
Generic |
$10.00 | $37.50 | None |
CARBIDOPA/LEVO 25/250 TABLET |
1 |
Generic |
$10.00 | $37.50 | None |
Carboplatin 10mg/mL |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT |
1 |
Generic |
$10.00 | $37.50 | None |
CARTIA XT 120MG CAPSULE SA |
1 |
Generic |
$10.00 | $37.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARTIA XT 180MG CAPSULE SA |
1 |
Generic |
$10.00 | $37.50 | None |
CARTIA XT 240MG CAPSULE SA |
1 |
Generic |
$10.00 | $37.50 | None |
CARTIA XT 300MG CAPSULE SR 24 HR |
1 |
Generic |
$10.00 | $37.50 | None |
Carvedilol 12.5mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Generic |
$10.00 | $37.50 | None |
Carvedilol 25mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Generic |
$10.00 | $37.50 | None |
Carvedilol 3.125mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Generic |
$10.00 | $37.50 | None |
Carvedilol 6.25mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Generic |
$10.00 | $37.50 | None |
CATAPRES-TTS DIS 0.3/24HR 7.5MG/UNT |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:8 /28Days |
CATAPRES-TTS-1 PATCH 2.52.5MG/UNT 1 X 4 CRTN |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:8 /28Days |
CATAPRES-TTS-2 PATCH 52.5MG/UNT 1 X 4 CRTN |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:8 /28Days |
CAYSTON KIT 75 MG/VIAL |
4 |
Specialty Tier |
33% | N/A | Q:84 /56Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFACLOR 250 MG CAPSULES |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CEFACLOR 250 MG/5 ML SUSP |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
Cefaclor 375 mg/5 ml suspen |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CEFACLOR 500 MG CAPSULES |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CEFACLOR ER 500MG TABLET SR 12HR |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CEFACLOR SUS 125 MG/5ML |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CEFADROXIL 1G TABLET |
1 |
Generic |
$10.00 | $37.50 | None |
CEFADROXIL 250 MG/5 ML SUSP |
1 |
Generic |
$10.00 | $37.50 | None |
CEFADROXIL 500 MG CAPSULE |
1 |
Generic |
$10.00 | $37.50 | None |
Cefadroxil 500mg/5mL |
1 |
Generic |
$10.00 | $37.50 | None |
CEFAZOLIN 1 GM VIAL |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFAZOLIN 1GM/D5W BAG |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFAZOLIN 500MG FOR INJECTION |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFDINIR CAPSULES 300MG (60 CT) |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT) |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFEPIME HCL 2 GRAM VIAL |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFEPIME HYDROCHLORIDE AND DEXTROSE 1g/50mL 24 CONTAINER in 1 CASE / 50 mL in 1 CONTAINER |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFEPIME HYDROCHLORIDE AND DEXTROSE 2g/50mL 24 CONTAINER in 1 CASE / 50 mL in 1 CONTAINER |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFIXIME 100 MG/5 ML SUSP [Suprax] |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFIXIME 200 MG/5 ML SUSP [Suprax] |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Cefotaxime sodium 1 gm vial |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Cefotaxime sodium 2 gm vial |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Cefotaxime sodium 500 mg vial |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFOTETAN 10 GM SOLR |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFOTETAN 1GM VIAL 1EA x 10 |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFOTETAN 2GM VIAL 1EA x 10 |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Cefoxitin 1g/1 10 POWDER per CARTON |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Cefoxitin 2g/1 10 POWDER per CARTON |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFOXITIN FOR INJECTION 1 GM/50ML |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFOXITIN FOR INJECTION 2MG/50ML 50 ML BOT |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFOXITIN FOR INJECTION SOLUTION |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFPODOXIME 100 MG/5 ML SUSP |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFPODOXIME 200 MG TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFPODOXIME 50 MG/5 ML SUSP |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT) |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
cefprozil 125 mg/5 ml susp |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
cefprozil 250 mg/5 ml susp |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Cefprozil 250mg 100 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFPROZIL TABLETS 500MG 100 BOT |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFTAZIDIME 1g 25 VIAL per CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Ceftazidime and Dextrose 1g/50mL 24 CONTAINER in 1 CASE / 50 mL in 1 CONTAINER |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ceftazidime and Dextrose 2g/50mL 24 CONTAINER in 1 CASE / 50 mL in 1 CONTAINER |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFTRIAXONE 10GM VIAL |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFTRIAXONE 250 MG VIAL |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFTRIAXONE FOR INJECTION |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFTRIAXONE FOR INJECTION |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Ceftriaxone Sodium 500mg |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFUROXIME 1.5 GM/VIAL FOR INJECTION |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFUROXIME 7.5 GM FOR INJECTION |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CEFUROXIME 750 MG FOR INJECTION |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cefuroxime Axetil 250 MG |
1 |
Generic |
$10.00 | $37.50 | None |
CEFUROXIME AXETIL 500 MG TAB |
1 |
Generic |
$10.00 | $37.50 | None |
CELEBREX 100 MG CAPSULE |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | S Q:60 /30Days |
CELEBREX 200 MG CAPSULE |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | S Q:60 /30Days |
CELEBREX 400 MG CAPSULE |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | S Q:30 /30Days |
CELEBREX 50 MG CAPSULE |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | S Q:60 /30Days |
CELECOXIB 100 MG CAPSULE [Celebrex] |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:60 /30Days |
CELECOXIB 200 MG CAPSULE [Celebrex] |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:60 /30Days |
CELECOXIB 400 MG CAPSULE [Celebrex] |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:30 /30Days |
CELECOXIB 50 MG CAPSULE [Celebrex] |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:60 /30Days |
CELLCEPT 200 MG/ML ORAL SUSP |
4 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CELLCEPT IV INJ 500 MG |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
CELONTIN 300 MG KAPSEAL |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Cephalexin 125mg/5mL 200 mL in 1 BOTTLE |
1 |
Generic |
$10.00 | $37.50 | None |
CEPHALEXIN 250 MG CAPSULE |
1 |
Generic |
$10.00 | $37.50 | None |
CEPHALEXIN 250 MG TABLET |
1 |
Generic |
$10.00 | $37.50 | None |
CEPHALEXIN 250 MG/5ML ORAL SUSP |
1 |
Generic |
$10.00 | $37.50 | None |
CEPHALEXIN 500 MG TABLET |
1 |
Generic |
$10.00 | $37.50 | None |
CEPHALEXIN 750 MG CAPSULE |
1 |
Generic |
$10.00 | $37.50 | None |
CEPHALEXIN CAPSULES 500 MG (500 CT) |
1 |
Generic |
$10.00 | $37.50 | None |
CEREZYME 400 UNITS VIAL |
4 |
Specialty Tier |
33% | N/A | P |
CERVARIX VACCINE SYRINGE |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEVIMELINE HCL 30 MG CAPSULE [Evoxac] |
1 |
Generic |
$10.00 | $37.50 | None |
CHANTIX 0.5 MG TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:336 /365Days |
CHANTIX 1 MG TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:336 /365Days |
Chantix 1.0mg/1 56 FILM COATED TABLETS in BOX |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:336 /365Days |
CHANTIX STARTING MONTH BOX |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:106 /365Days |
CHLORAMPHEN NA SUCC 1GM VL |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH |
1 |
Generic |
$10.00 | $37.50 | None |
CHLOROQUINE PH 500 MG TABLET |
1 |
Generic |
$10.00 | $37.50 | None |
CHLOROQUINE PHOSPHATE 250 MG TABLET (50 CT) |
1 |
Generic |
$10.00 | $37.50 | None |
CHLOROTHIAZIDE 250 MG TABLET |
1 |
Generic |
$10.00 | $37.50 | None |
Chlorothiazide 500mg 100 TABLET BOTTLE |
1 |
Generic |
$10.00 | $37.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLORPROMAZINE 10 MG TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CHLORPROMAZINE 25 MG TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CHLORPROMAZINE 25 MG/ML AMP |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CHLORPROMAZINE 50 MG TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CHLORPROMAZINE HCL 200 MG TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Chlorpromazine Hydrochloride 100mg SUGAR COATED 1000 TABLET BOTTLE |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CHLORTHALIDONE 25 MG TABLET (100 CT) |
1 |
Generic |
$10.00 | $37.50 | None |
CHLORTHALIDONE 50 MG TABLET (1000 CT) |
1 |
Generic |
$10.00 | $37.50 | None |
CHLORZOXAZONE 500 MG TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P Q:180 /30Days |
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION |
1 |
Generic |
$10.00 | $37.50 | None |
Cialis 2.5mg/1 2 BLISTER PACK per CARTON / 15 FILM COATED TABLETS in BLISTER PACK |
1 |
Generic |
$10.00 | $37.50 | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cialis 5mg/1 30 FILM COATED TABLETS in BOTTLE |
1 |
Generic |
$10.00 | $37.50 | P Q:30 /30Days |
CICLOPIROX 0.77% TOPICAL SUSP |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CICLOPIROX 1% SHAMPOO |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CICLOPIROX 8% SOLUTION |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CICLOPIROX GEL |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Ciclopirox Olamine 7.7mg/g 1 TUBE in 1 TUBE / 15 g in 1 TUBE |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Cilostazol 50mg/1 60 TABLET BOTTLE |
1 |
Generic |
$10.00 | $37.50 | None |
CILOSTAZOL TABLET 100MG (60 CT) |
1 |
Generic |
$10.00 | $37.50 | None |
CILOXAN 0.3% OINTMENT |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Cimetidine 200mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CIMETIDINE 300 MG TABLETS |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cimetidine 400mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
Cimetidine 800mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
Cimetidine Hydrochloride Oral Solution 300mg/5mL 237 mL in 1 BOTTLE |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
Cimzia 2 KIT per CARTON / 1 KIT in 1 KIT |
4 |
Specialty Tier |
33% | N/A | P Q:6 /28Days |
CIMZIA 200 MG/ML SYRINGE KIT |
4 |
Specialty Tier |
33% | N/A | P Q:6 /28Days |
Cinryze 500[iU]/5mL 1 VIAL per CARTON / 5 mL in 1 VIAL |
4 |
Specialty Tier |
33% | N/A | P |
CIPRO HC OTIC SUSPENSION |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CIPRODEX OTIC SUSPENSION |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CIPROFLOXACIN 0.3% EYE DROP |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CIPROFLOXACIN 250 MG TABLET (100 CT) |
1 |
Generic |
$10.00 | $37.50 | None |
CIPROFLOXACIN 250 MG/5 ML SUSP |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ciprofloxacin 400mg/40mL 1 VIAL per CARTON / 40 mL in 1 VIAL |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CIPROFLOXACIN 500 MG/5 ML SUSP |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
Ciprofloxacin and Dextrose 2mg/mL 24 BAG in 1 CASE / 100 mL in 1 BAG |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Ciprofloxacin ER 212.6; 287.5mg/1; mg/1 50 TABLET, FILM COATED, in 1 BOTTLE, PLASTIC |
1 |
Generic |
$10.00 | $37.50 | None |
Ciprofloxacin ER 425.2; 574.9mg/1; mg/1 50 TABLET, FILM COATED, in 1 BOTTLE, PLASTIC |
1 |
Generic |
$10.00 | $37.50 | None |
CIPROFLOXACIN HCL 100 MG TABLET |
1 |
Generic |
$10.00 | $37.50 | None |
CIPROFLOXACIN HCL 500 MG TAB |
1 |
Generic |
$10.00 | $37.50 | None |
CIPROFLOXACIN TABLETS 750 MG 100 BOT |
1 |
Generic |
$10.00 | $37.50 | None |
Cisplatin 100mg/100mL 1 VIAL per CARTON / 100 mL in 1 VIAL |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CITALOPRAM HBR 20 MG TABLET |
1 |
Generic |
$10.00 | $37.50 | Q:60 /30Days |
CITALOPRAM HBR ORAL SOLUTION 10MG 240 ML BOTPL |
1 |
Generic |
$10.00 | $37.50 | Q:600 /30Days |
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 |
Generic |
$10.00 | $37.50 | Q:30 /30Days |
CITOLOPRAM HBR 10 MG TABLET (100 CT) |
1 |
Generic |
$10.00 | $37.50 | Q:120 /30Days |
Cladribine 10 mg/10 ml vial |
1 |
Generic |
$10.00 | $37.50 | P |
CLARAVIS 10 MG CAPSULE |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CLARAVIS 20 MG CAPSULE |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Claravis 30mg 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CLARAVIS 40MG CAPSULE |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CLARITHROMYCIN 125 MG/5ML FOR ORAL SUSPENSION |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CLARITHROMYCIN 250 MG TABLET |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CLARITHROMYCIN 250 MG/5MLFOR ORAL SUSPENSION |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CLARITHROMYCIN 500 MG TABLET |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLARITHROMYCIN ER 500 MG TABLET (60 CT) |
1 |
Generic |
$10.00 | $37.50 | None |
CLEMASTINE FUM 2.68 MG TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
CLINDAMAX 1% GEL |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CLINDAMYCIN 600 MG/4 ML ADDVAN |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CLINDAMYCIN HCL 150 MG CAPSULE |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CLINDAMYCIN HCL 300 MG 100 CAPSULE in 1 BOTTLE |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CLINDAMYCIN HCL 75 MG 200 CAPSULE BOTTLE |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CLINDAMYCIN PEDIATR 75 MG/5 ML |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CLINDAMYCIN PHOSP 1% LOTION |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CLINDAMYCIN PHOSPHATE 1% FOAM |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
clindamycin phosphate 10mg/mL 1 BOTTLE per CARTON / 60 mL in 1 BOTTLE |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Clindamycin Phosphate and Benzoyl Peroxide 1 KIT |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CLINDAMYCIN PHOSPHATE VAGINAL CREAM |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
clindamycin-d5w 300 mg/50 ml |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
clindamycin-d5w 600 mg/50 ml |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
clindamycin-d5w 900 mg/50 ml |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CLINIMIX 2.75%/5% INJECTION 1000ML BAG |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
CLINIMIX 4.25/10 SOLUTION |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
CLINIMIX 4.25/20 SOLUTION |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
CLINIMIX 4.25/25 SOLUTION |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINIMIX 4.25/5 SOLUTION |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
CLINIMIX 5/15 SOLUTION |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
CLINIMIX 5/20 SOLUTION |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
CLINIMIX E 2.75/10 SOLUTION |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
CLINIMIX E 2.75/5 SOLUTION |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
CLINIMIX E 4.25/25 SOLUTION |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
CLINIMIX E 4.25/5 SOLUTION |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
CLINIMIX E 4.25%-10% SOLUTION |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
CLINIMIX E 5/20 SOLUTION |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
CLINIMIX E 5/25 SOLUTION |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINIMIX E 5%/15% INJECTION 2000ML BAG |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
CLINISOL 15% SOLUTION |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
CLOBETASOL 0.05% OINTMENT |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CLOBETASOL 0.05% SHAMPOO |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CLOBETASOL 0.05% TOPICAL LOTION |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CLOBETASOL E 0.05% CREAM |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CLOBETASOL PROP 0.05% SPRAY |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
Clobetasol Propionate 0.4625mg/mL 1 BOTTLE per CARTON / 50 mL in 1 BOTTLE |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
Clobetasol Propionate 0.5mg/g 1 CAN per CARTON / 100 g in 1 CAN |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CLOLAR 20 MG/20 ML VIAL |
4 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOMIPRAMINE HCL 25MG CAPSULE |
2 |
Preferred Brand |
$47.00 | $117.50 | P |
CLOMIPRAMINE HCL 50MG CAPSULE |
2 |
Preferred Brand |
$47.00 | $117.50 | P |
CLOMIPRAMINE HCL 75MG CAPSULE |
2 |
Preferred Brand |
$47.00 | $117.50 | P |
Clonazepam 0.125mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PAC |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:90 /30Days |
Clonazepam 0.25mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:90 /30Days |
Clonazepam 0.5mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:90 /30Days |
Clonazepam 0.5mg/1 100 TABLET BOTTLE |
2 |
Preferred Brand |
$47.00 | $117.50 | Q:90 /30Days |
Clonazepam 1mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:120 /30Days |
Clonazepam 1mg/1 90 TABLET BOTTLE, PLASTIC |
2 |
Preferred Brand |
$47.00 | $117.50 | Q:120 /30Days |
Clonazepam 2mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:300 /30Days |
Clonazepam 2mg/1 100 TABLET BOTTLE |
2 |
Preferred Brand |
$47.00 | $117.50 | Q:300 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Clonidine 0.1mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:8 /28Days |
Clonidine 0.2mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:8 /28Days |
Clonidine 0.3mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:8 /28Days |
CLONIDINE HCL 0.1 MG TABLET |
1 |
Generic |
$10.00 | $37.50 | None |
CLONIDINE HCL 0.2MG TABLET (500 CT) |
1 |
Generic |
$10.00 | $37.50 | None |
CLONIDINE HCL TABLET 0.3MG (100 CT) |
1 |
Generic |
$10.00 | $37.50 | None |
CLOPIDOGREL 300 MG TABLET [Plavix] |
1 |
Generic |
$10.00 | $37.50 | Q:2 /365Days |
CLOPIDOGREL 75 MG TABLET [Plavix] |
1 |
Generic |
$10.00 | $37.50 | Q:30 /30Days |
CLORAZEPATE 15 MG TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:180 /30Days |
Clorazepate Dipotassium 3.75mg/1 500 TABLET BOTTLE, PLASTIC |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:90 /30Days |
Clorazepate Dipotassium 7.5mg/1 500 TABLET BOTTLE, PLASTIC |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLORPRES 0.1-15 TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CLORPRES 0.2-15 TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CLORPRES 0.3-15 TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CLOTRIMAZOLE 1% CREAM |
1 |
Generic |
$10.00 | $37.50 | None |
CLOTRIMAZOLE 10MG TROCHE |
1 |
Generic |
$10.00 | $37.50 | None |
CLOTRIMAZOLE SOLUTION TOPICAL 1% 30ML BOTPL |
1 |
Generic |
$10.00 | $37.50 | None |
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION |
1 |
Generic |
$10.00 | $37.50 | None |
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE |
1 |
Generic |
$10.00 | $37.50 | None |
Clozapine 100mg/1 100 TABLET BOTTLE |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CLOZAPINE 200MG TABLET (500 CT) |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CLOZAPINE 25MG TABLET (100 CT) |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOZAPINE 50MG TABLET (500 CT) |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CLOZAPINE ODT 100 MG TABLET |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CLOZAPINE ODT 12.5 MG TABLET |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CLOZAPINE ODT 150 MG TABLET |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CLOZAPINE ODT 200 MG TABLET |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CLOZAPINE ODT 25 MG TABLET |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
COARTEM 20MG-120MG |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CODEINE SULFATE 15 MG TABLETS |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:180 /30Days |
CODEINE SULFATE 30 MG TABLET 3100 |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:180 /30Days |
Codeine sulfate 60mg/1 100 TABLET BOTTLE |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:180 /30Days |
COLCHICINE 0.6 MG CAPSULE |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COLCHICINE 0.6 MG TABLET |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
COLCRYS 0.6 MG TABLET |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
COLESTIPOL HCL 1G TABLET |
1 |
Generic |
$10.00 | $37.50 | None |
COLESTIPOL HYDROCHLORIDE 5g/1 100 SUSPENSION in 1 BOTTLE |
1 |
Generic |
$10.00 | $37.50 | None |
colistimethate 150mg/2mL 1 VIAL per CARTON / 2 mL in 1 VIAL |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
COLOCORT 100MG ENEMA |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
COLY-MYCIN S OTIC SUSP DROP |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
COMBIGAN 0.2%-0.5% DROPS |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
COMBIVENT RESPIMAT INHAL SPRAY |
2 |
Preferred Brand |
$47.00 | $117.50 | Q:8 /30Days |
COMETRIQ 100 MG DAILY-DOSE PK |
4 |
Specialty Tier |
33% | N/A | P |
COMETRIQ 140 MG DAILY-DOSE PK |
4 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COMETRIQ 60 MG DAILY-DOSE PACK |
4 |
Specialty Tier |
33% | N/A | P |
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1 |
4 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
COMPRO 25MG SUPPOSITORY |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
CONSTULOSE 10 GM/15 ML SOLN |
1 |
Generic |
$10.00 | $37.50 | None |
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN |
4 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
COPAXONE 40 MG/ML SYRINGE |
4 |
Specialty Tier |
33% | N/A | P Q:12 /28Days |
CORDRAN TAPE 4MCG/SQCM 1 X 80 X 3 CTR |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
COREG CR 10MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:30 /30Days |
COREG CR 20MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:30 /30Days |
COREG CR 40MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:30 /30Days |
COREG CR 80MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CORLANOR 5 MG TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
CORLANOR 7.5 MG TABLET |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
CORMAX 0.05% SOLUTION |
1 |
Generic |
$10.00 | $37.50 | None |
Cortisone 25 MG Tablet |
1 |
Generic |
$10.00 | $37.50 | None |
COSMEGEN 0.5 MG VIAL |
4 |
Specialty Tier |
33% | N/A | None |
COTELLIC 20 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P Q:63 /28Days |
Creon 256.11mg/1 1 BOTTLE per CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CREON DR 36,000 UNITS CAPSULE |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CRESTOR 10MG TABLET |
2 |
Preferred Brand |
$47.00 | $117.50 | Q:30 /30Days |
CRESTOR 20MG TABLET |
2 |
Preferred Brand |
$47.00 | $117.50 | Q:30 /30Days |
CRESTOR 40mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Preferred Brand |
$47.00 | $117.50 | Q:30 /30Days |
CRESTOR 5MG TABLET |
2 |
Preferred Brand |
$47.00 | $117.50 | Q:30 /30Days |
CRIXIVAN 200MG CAPSULE |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CRIXIVAN 400mg, 180 CAPSULE BOTTLE |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CROMOLYN 20 MG/2 ML NEB SOLN |
2 |
Preferred Brand |
$47.00 | $117.50 | P |
CROMOLYN SODIUM 100 MG/5 ML |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CROMOLYN SODIUM 4% 40MG 10ML BOT |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CUBICIN 500MG VIAL |
4 |
Specialty Tier |
33% | N/A | None |
CUPRIMINE 250 MG CAPSULE |
4 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cyclafem 1/35 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Cyclafem 7/7/7 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | None |
Cyclobenzaprine 7.5 mg tablet |
2 |
Preferred Brand |
$47.00 | $117.50 | P Q:90 /30Days |
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT) |
2 |
Preferred Brand |
$47.00 | $117.50 | P Q:90 /30Days |
Cyclobenzaprine Hydrochloride 5mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Preferred Brand |
$47.00 | $117.50 | P Q:90 /30Days |
CYCLOPHOSPHAMIDE 25 MG CAPSULE |
2 |
Preferred Brand |
$47.00 | $117.50 | P |
CYCLOPHOSPHAMIDE 50 MG CAPSULE |
2 |
Preferred Brand |
$47.00 | $117.50 | P |
Cyclosporine 100mg 30 BLISTER PACK per CARTON / 1 CAPSULE, LIQUID FILLED per BLISTER PACK |
2 |
Preferred Brand |
$47.00 | $117.50 | P |
CYCLOSPORINE 100MG CAPSULE |
2 |
Preferred Brand |
$47.00 | $117.50 | P |
Cyclosporine 25mg 30 BLISTER PACK per CARTON / 1 CAPSULE, LIQUID FILLED per BLISTER PACK |
2 |
Preferred Brand |
$47.00 | $117.50 | P |
CYCLOSPORINE 25MG CAPSULE |
2 |
Preferred Brand |
$47.00 | $117.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cyclosporine 50 mg/ml vial |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
Cyclosporine 50mg 30 BLISTER PACK per CARTON / 1 CAPSULE, LIQUID FILLED per BLISTER PACK |
2 |
Preferred Brand |
$47.00 | $117.50 | P |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT |
2 |
Preferred Brand |
$47.00 | $117.50 | P |
CYKLOKAPRON 100MG/ML AMPUL |
2 |
Preferred Brand |
$47.00 | $117.50 | None |
CYMBALTA 20MG CAPSULE |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | S Q:60 /30Days |
Cymbalta 60mg/1 1000 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | S Q:60 /30Days |
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT) |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | S Q:90 /30Days |
CYRAMZA 100 MG/10 ML VIAL |
4 |
Specialty Tier |
33% | N/A | P |
CYRAMZA 500 MG/50 ML VIAL |
4 |
Specialty Tier |
33% | N/A | P |
CYSTADANE POWDER FOR ORAL SOLUTION 180GM |
4 |
Specialty Tier |
33% | N/A | None |
CYSTAGON 150MG CAPSULE |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYSTAGON 50MG CAPSULE |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
CYSTARAN 0.44% EYE DROPS |
4 |
Specialty Tier |
33% | N/A | Q:60 /28Days |
CYTARABINE 20MG/ML VIAL |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P |
CYTARABINE SOLUTION INJECTION 100MG 20ML VIALSD |
3 |
Non-Preferred Brand |
$100.00 | $300.00 | P |