2016 Medicare Part D Plan Formulary Information |
Peach State Health Plan Advantage (HMO SNP) (H7173-001-0)
Benefit Details
|
The Peach State Health Plan Advantage (HMO SNP) (H7173-001-0) Formulary Drugs Starting with the Letter A in Rabun County, GA: CMS MA Region 8 which includes: GA Plan Monthly Premium: $25.70 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 |
A-HYDROCORT 100MG VIAL |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | None |
ABACAVIR 300 MG TABLET |
2 |
Generic |
$20.00 | $20.00 | None |
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir] |
2 |
Generic |
$20.00 | $20.00 | None |
ABELCENT INJECTION SUSPENSION 5MG/ML |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | None |
ABILIFY MAINTENA ER 300 MG SYR |
5 |
Specialty Tier |
25% | 25% | Q:1 /30Days |
ABILIFY MAINTENA ER 300 MG VL |
5 |
Specialty Tier |
25% | 25% | Q:2 /28Days |
ABILIFY MAINTENA ER 400 MG SYR |
5 |
Specialty Tier |
25% | 25% | Q:1 /30Days |
ABRAXANE 100MG VIAL |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | None |
Acamprosate Calcium DR 333 MG tablets [Campral] |
2 |
Generic |
$20.00 | $20.00 | None |
ACARBOSE 100 MG TABLET |
2 |
Generic |
$20.00 | $20.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACARBOSE 25 MG TABLET |
2 |
Generic |
$20.00 | $20.00 | Q:90 /30Days |
Acarbose 50mg/1 100 TABLET BOTTLE |
2 |
Generic |
$20.00 | $20.00 | Q:90 /30Days |
ACEBUTOLOL 200MG CAPSULE |
2 |
Generic |
$20.00 | $20.00 | None |
ACEBUTOLOL 400MG CAPSULE |
2 |
Generic |
$20.00 | $20.00 | None |
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) |
2 |
Generic |
$20.00 | $20.00 | Q:390 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
2 |
Generic |
$20.00 | $20.00 | Q:390 /30Days |
ACETAMINOPHEN-COD #4 TABLET |
2 |
Generic |
$20.00 | $20.00 | Q:390 /30Days |
ACETASOL HC SOLUTION 10ML 10 ML BOT |
2 |
Generic |
$20.00 | $20.00 | None |
ACETAZOLAMIDE 125MG TABLET |
2 |
Generic |
$20.00 | $20.00 | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
2 |
Generic |
$20.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Acetazolamide 500mg/5mL 1 VIAL in 1 CARTON / 5 mL in 1 VIAL |
2 |
Generic |
$20.00 | $20.00 | None |
ACETAZOLAMIDE ER CAPSULES 500MG 100 BOT |
2 |
Generic |
$20.00 | $20.00 | None |
ACETIC ACID 2% EAR SOLUTION |
2 |
Generic |
$20.00 | $20.00 | None |
ACETYLCYSTEINE 10% VIAL |
2 |
Generic |
$20.00 | $20.00 | P |
ACETYLCYSTEINE 20% VIAL |
2 |
Generic |
$20.00 | $20.00 | P |
ACTHIB VACCINE WITH DILUENT |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | None |
ACTIMMUNE 100 MCG/0.5 ML VIAL |
5 |
Specialty Tier |
25% | 25% | None |
Acyclovir 200mg 100 CAPSULE BOTTLE |
2 |
Generic |
$20.00 | $20.00 | None |
Acyclovir 200mg/5mL 473 mL BOTTLE |
2 |
Generic |
$20.00 | $20.00 | None |
Acyclovir 400mg/1 |
2 |
Generic |
$20.00 | $20.00 | None |
ACYCLOVIR 800 MG TABLET |
2 |
Generic |
$20.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Acyclovir sodium 500 mg vial |
2 |
Generic |
$20.00 | $20.00 | None |
ADACEL VIAL 2UNT/5UNT |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | None |
ADAGEN 250U/ML VIAL |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | None |
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA] |
5 |
Specialty Tier |
25% | 25% | P |
ADAPALENE 0.1% CREAM |
2 |
Generic |
$20.00 | $20.00 | None |
ADAPALENE 0.1% GEL |
2 |
Generic |
$20.00 | $20.00 | None |
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera] |
2 |
Generic |
$20.00 | $20.00 | 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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
$20.00 | $20.00 | None |
ADVAIR DISKUS MIS 100/50 |
3 |
Preferred Brand |
$47.00 | $47.00 | Q:60 /30Days |
ADVAIR DISKUS MIS 250/50 |
3 |
Preferred Brand |
$47.00 | $47.00 | Q:60 /30Days |
ADVAIR DISKUS MIS 500/50 |
3 |
Preferred Brand |
$47.00 | $47.00 | Q:60 /30Days |
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$47.00 | $47.00 | Q:12 /30Days |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL |
3 |
Preferred Brand |
$47.00 | $47.00 | None |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
3 |
Preferred Brand |
$47.00 | $47.00 | None |
AFEDITAB CR 30MG TABLET SA |
2 |
Generic |
$20.00 | $20.00 | Q:30 /30Days |
AFEDITAB CR 60MG TABLET SA |
2 |
Generic |
$20.00 | $20.00 | Q:30 /30Days |
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK |
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 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:60 /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 |
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 |
3 |
Preferred Brand |
$47.00 | $47.00 | Q:60 /30Days |
AK-CON 0.1% EYE DROPS |
2 |
Generic |
$20.00 | $20.00 | None |
ALBENZA 200 MG TABLET |
3 |
Preferred Brand |
$47.00 | $47.00 | None |
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH per CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL |
2 |
Generic |
$20.00 | $20.00 | P Q:1200 /30Days |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
2 |
Generic |
$20.00 | $20.00 | P Q:1200 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
2 |
Generic |
$20.00 | $20.00 | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
2 |
Generic |
$20.00 | $20.00 | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
2 |
Generic |
$20.00 | $20.00 | P Q:200 /30Days |
ALBUTEROL SULFATE SOLUTION FOR INHALATION |
2 |
Generic |
$20.00 | $20.00 | P Q:1170 /30Days |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
2 |
Generic |
$20.00 | $20.00 | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
2 |
Generic |
$20.00 | $20.00 | None |
ALBUTEROL TABLET 4MG (500 CT) |
2 |
Generic |
$20.00 | $20.00 | None |
ALCLOMETASONE DIPROPIONATE 0.05% CREAM |
2 |
Generic |
$20.00 | $20.00 | None |
Alclometasone Dipropionate 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2 |
Generic |
$20.00 | $20.00 | None |
ALDURAZYME 2.9MG/5ML VIAL |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | None |
ALECENSA 150 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | P Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALENDRONATE SODIUM 10MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
ALENDRONATE SODIUM 35 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:8 /28Days |
ALENDRONATE SODIUM 40MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
ALENDRONATE SODIUM 5MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
Alendronate Sodium 70mg/1 4 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:4 /28Days |
ALFUZOSIN HYDROCHLORIDE 10mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2 |
Generic |
$20.00 | $20.00 | Q:30 /30Days |
ALIMTA 500MG VIAL |
5 |
Specialty Tier |
25% | 25% | None |
ALINIA 100MG/5ML SUSPENSION |
3 |
Preferred Brand |
$47.00 | $47.00 | None |
ALINIA 500 MG TABLET |
3 |
Preferred Brand |
$47.00 | $47.00 | None |
ALKERAN 50 MG VIAL |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | P |
ALLOPURINOL 100 MG TABLETS |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET per BLISTER PACK |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ALLZITAL 25-325 MG TABLET |
2 |
Generic |
$20.00 | $20.00 | None |
ALOPRIM SOLUTION FOR INJECTION 500MG/VIAL 30 ML VIALGL |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | None |
ALORA 0.025 MG PATCH |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | P Q:8 /28Days |
ALORA 0.05 MG PATCH |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | P Q:8 /28Days |
ALORA 0.075 MG PATCH |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | P Q:8 /28Days |
ALORA 0.1 MG PATCH |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | P Q:8 /28Days |
ALOSETRON HCL 0.5 MG TABLET [Lotronex] |
5 |
Specialty Tier |
25% | 25% | P Q:60 /30Days |
ALOSETRON HCL 1 MG TABLET [Lotronex] |
5 |
Specialty Tier |
25% | 25% | P Q:60 /30Days |
ALPHAGAN P 0.1% DROPS |
3 |
Preferred Brand |
$47.00 | $47.00 | None |
ALPRAZOLAM 0.25 MG TABLET |
2 |
Generic |
$20.00 | $20.00 | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALPRAZOLAM 0.5 MG TABLET |
2 |
Generic |
$20.00 | $20.00 | Q:150 /30Days |
ALPRAZOLAM 1 MG TABLET |
2 |
Generic |
$20.00 | $20.00 | Q:150 /30Days |
Alprazolam 1mg/mL 1 BOTTLE in 1 CONTAINER / 30 mL in 1 BOTTLE |
2 |
Generic |
$20.00 | $20.00 | None |
ALPRAZOLAM 2 MG TABLET |
2 |
Generic |
$20.00 | $20.00 | Q:150 /30Days |
AMANTADINE 100MG CAPSULE |
2 |
Generic |
$20.00 | $20.00 | None |
AMANTADINE 100MG TABLET |
2 |
Generic |
$20.00 | $20.00 | None |
Amantadine Hydrochloride 50mg/5mL 473 mL in 1 BOTTLE |
2 |
Generic |
$20.00 | $20.00 | None |
AMBISOME 50MG VIAL |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | None |
AMCINONIDE 0.1% CREAM |
2 |
Generic |
$20.00 | $20.00 | None |
AMCINONIDE 0.1% LOTION |
2 |
Generic |
$20.00 | $20.00 | None |
AMCINONIDE 0.1% OINTMENT 60GM TUBE |
2 |
Generic |
$20.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMIFOSTINE 50mg/mL 3 VIAL, SINGLE-USE per CARTON / 10 mL in 1 VIAL, SINGLE-USE |
2 |
Generic |
$20.00 | $20.00 | None |
AMIKACIN SULFATE 500 MG/2 ML VIAL |
2 |
Generic |
$20.00 | $20.00 | None |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
2 |
Generic |
$20.00 | $20.00 | None |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT |
2 |
Generic |
$20.00 | $20.00 | None |
Amino Acids 15% Solution |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | P |
Aminophylline 25mg/mL 5 TRAY per CARTON / 5 AMPULE in 1 TRAY / 10 mL in 1 AMPULE |
2 |
Generic |
$20.00 | $20.00 | None |
AMINOSYN 7%-ELECTROLYTE SOL |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | P |
AMINOSYN HBC INJECTION SULFITE FREE 7% |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | P |
AMINOSYN II 10% IV SOLUTION |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | P |
AMINOSYN II 15% IV SOLUTION |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | P |
AMINOSYN II 7% IV SOLUTION |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN II 8.5% ELECTROLYT |
2 |
Generic |
$20.00 | $20.00 | P |
AMINOSYN II 8.5% IV SOLUTION |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | P |
AMINOSYN M 3.5% IV SOLUTION |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | P |
AMINOSYN PF INJECTION |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | P |
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5% |
2 |
Generic |
$20.00 | $20.00 | P |
AMINOSYN-PF 7% IV SOLUTION |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | P |
AMINOSYN-RF 5.2% IV SOLUTION |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | P |
AMIODARONE HCL 200MG 60 TABLET BOTTLE |
2 |
Generic |
$20.00 | $20.00 | None |
AMIODARONE HCL 400MG TABLET |
2 |
Generic |
$20.00 | $20.00 | None |
AMIODARONE HCL 50 MG INJECTION |
2 |
Generic |
$20.00 | $20.00 | None |
AMITIZA 8MCG CAPSULE |
3 |
Preferred Brand |
$47.00 | $47.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITIZA CAPSULES 24MCG 60 CAP BOT |
3 |
Preferred Brand |
$47.00 | $47.00 | None |
AMITRIP/CDP 25-10 TABLET |
2 |
Generic |
$20.00 | $20.00 | None |
AMITRIP/PERPHEN 10-2 TABLET |
2 |
Generic |
$20.00 | $20.00 | None |
AMITRIP/PERPHEN 10-4 TABLET |
2 |
Generic |
$20.00 | $20.00 | None |
AMITRIP/PERPHEN 25-2 TABLET |
2 |
Generic |
$20.00 | $20.00 | None |
AMITRIP/PERPHEN 25-4 TABLET |
2 |
Generic |
$20.00 | $20.00 | None |
AMITRIP/PERPHEN 50-4 TABLET |
2 |
Generic |
$20.00 | $20.00 | None |
AMITRIPTYLINE HCL 100MG TABLET |
2 |
Generic |
$20.00 | $20.00 | None |
AMITRIPTYLINE HCL 10MG TABLET |
2 |
Generic |
$20.00 | $20.00 | None |
AMITRIPTYLINE HCL 150 MG TAB |
2 |
Generic |
$20.00 | $20.00 | None |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
2 |
Generic |
$20.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
2 |
Generic |
$20.00 | $20.00 | None |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
2 |
Generic |
$20.00 | $20.00 | None |
AMLOD-VALSA-HCTZ 10-160-12.5 MG [EXFORGE HCT] |
2 |
Generic |
$20.00 | $20.00 | Q:30 /30Days |
AMLOD-VALSA-HCTZ 10-160-25 MG [EXFORGE HCT] |
2 |
Generic |
$20.00 | $20.00 | Q:30 /30Days |
AMLOD-VALSA-HCTZ 10-320-25 MG [EXFORGE HCT] |
2 |
Generic |
$20.00 | $20.00 | Q:30 /30Days |
AMLOD-VALSA-HCTZ 5-160-12.5 MG [EXFORGE HCT] |
2 |
Generic |
$20.00 | $20.00 | Q:30 /30Days |
AMLOD-VALSA-HCTZ 5-160-25 MG [EXFORGE HCT] |
2 |
Generic |
$20.00 | $20.00 | Q:30 /30Days |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
AMLODIPINE-BENAZEPRIL 10-40 MG |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
AMLODIPINE-BENAZEPRIL 5-40 MG |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
AMLODIPINE-VALSARTAN 10-160 MG |
2 |
Generic |
$20.00 | $20.00 | Q:30 /30Days |
AMLODIPINE-VALSARTAN 10-320 MG |
2 |
Generic |
$20.00 | $20.00 | Q:30 /30Days |
AMLODIPINE-VALSARTAN 5-160 MG |
2 |
Generic |
$20.00 | $20.00 | Q:30 /30Days |
AMLODIPINE-VALSARTAN 5-320 MG |
2 |
Generic |
$20.00 | $20.00 | Q:30 /30Days |
AMMONIUM CHLORIDE 5 MEQ/ML |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | None |
AMMONIUM LACTATE 12% CREAM |
2 |
Generic |
$20.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMMONIUM LACTATE 12% LOTION |
2 |
Generic |
$20.00 | $20.00 | None |
AMOX TR-K CLV 500-125 MG TAB |
2 |
Generic |
$20.00 | $20.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
2 |
Generic |
$20.00 | $20.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
2 |
Generic |
$20.00 | $20.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
2 |
Generic |
$20.00 | $20.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
2 |
Generic |
$20.00 | $20.00 | None |
AMOX-CLAV 200-28.5 MG/5 ML SUSPENSION |
2 |
Generic |
$20.00 | $20.00 | None |
AMOXAPINE 100MG TABLET |
2 |
Generic |
$20.00 | $20.00 | None |
AMOXAPINE 150MG TABLET |
2 |
Generic |
$20.00 | $20.00 | None |
AMOXAPINE 25MG TABLET |
2 |
Generic |
$20.00 | $20.00 | None |
AMOXAPINE 50MG TABLET |
2 |
Generic |
$20.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN 125MG TABLET CHEW |
2 |
Generic |
$20.00 | $20.00 | None |
AMOXICILLIN 250MG 500 CHEWABLE TABLET in BOTTLE |
2 |
Generic |
$20.00 | $20.00 | None |
AMOXICILLIN 250MG CAPSULE |
2 |
Generic |
$20.00 | $20.00 | None |
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION |
2 |
Generic |
$20.00 | $20.00 | None |
AMOXICILLIN 500MG 500 CAPSULE BOTTLE |
2 |
Generic |
$20.00 | $20.00 | None |
AMOXICILLIN 500MG TABLET (100 CT) |
2 |
Generic |
$20.00 | $20.00 | None |
AMOXICILLIN 875MG TABLET |
2 |
Generic |
$20.00 | $20.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
2 |
Generic |
$20.00 | $20.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG |
2 |
Generic |
$20.00 | $20.00 | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
2 |
Generic |
$20.00 | $20.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
2 |
Generic |
$20.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
2 |
Generic |
$20.00 | $20.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
2 |
Generic |
$20.00 | $20.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
2 |
Generic |
$20.00 | $20.00 | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
2 |
Generic |
$20.00 | $20.00 | Q:90 /30Days |
AMPHETAMINE SALT COMBO 15MG TABLET |
2 |
Generic |
$20.00 | $20.00 | Q:90 /30Days |
AMPHETAMINE SALT COMBO 30MG TABLET |
2 |
Generic |
$20.00 | $20.00 | Q:60 /30Days |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
2 |
Generic |
$20.00 | $20.00 | Q:90 /30Days |
AMPHETAMINE SALTS 20MG TABLET |
2 |
Generic |
$20.00 | $20.00 | Q:60 /30Days |
AMPHETAMINE SALTS 5 MG TAB |
2 |
Generic |
$20.00 | $20.00 | Q:90 /30Days |
amphotericin b 50mg/10mL 10 mL in 1 VIAL |
2 |
Generic |
$20.00 | $20.00 | None |
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS |
2 |
Generic |
$20.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN CAPSULES 250MG 100 BOT |
2 |
Generic |
$20.00 | $20.00 | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
2 |
Generic |
$20.00 | $20.00 | None |
AMPICILLIN FOR INJECTION POWDER |
2 |
Generic |
$20.00 | $20.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
2 |
Generic |
$20.00 | $20.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
2 |
Generic |
$20.00 | $20.00 | None |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML |
2 |
Generic |
$20.00 | $20.00 | None |
AMPICILLIN-SULBACTAM 15 GM VIAL |
2 |
Generic |
$20.00 | $20.00 | None |
AMPICILLIN-SULBACTAM 3 GM VIAL |
2 |
Generic |
$20.00 | $20.00 | None |
AMPICILLIN-SULBACTAM FOR INJECTION |
2 |
Generic |
$20.00 | $20.00 | None |
AMPYRA ER 10 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:60 /30Days |
ANADROL-50 TABLET |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE |
2 |
Generic |
$20.00 | $20.00 | None |
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE |
2 |
Generic |
$20.00 | $20.00 | None |
Anastrozole 1mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Generic |
$20.00 | $20.00 | Q:30 /30Days |
ANDRODERM 2 MG/24HR PATCH |
3 |
Preferred Brand |
$47.00 | $47.00 | None |
ANDRODERM 4 MG/24HR PATCH |
3 |
Preferred Brand |
$47.00 | $47.00 | None |
APIDRA 100 UNITS/ML VIAL |
3 |
Preferred Brand |
$47.00 | $47.00 | Q:40 /30Days |
APIDRA SOLOSTAR 100 UNITS/ML |
3 |
Preferred Brand |
$47.00 | $47.00 | Q:45 /30Days |
APOKYN 30 MG/3 ML CARTRIDGE |
5 |
Specialty Tier |
25% | 25% | None |
APRI 0.15-0.03 TABLET |
2 |
Generic |
$20.00 | $20.00 | None |
APTIOM 200 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | Q:30 /30Days |
APTIOM 400 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APTIOM 600 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | Q:60 /30Days |
APTIOM 800 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | Q:30 /30Days |
APTIVUS 250MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
5 |
Specialty Tier |
25% | 25% | None |
ARALAST NP 500 MG VIAL |
5 |
Specialty Tier |
25% | 25% | None |
ARANELLE 7-9-5 TABLET |
2 |
Generic |
$20.00 | $20.00 | None |
ARANESP 10 MCG/0.4 ML SYRINGE |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | 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 |
$100.00 | $100.00 | P |
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | 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 |
5 |
Specialty Tier |
25% | 25% | P |
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.3 mL in 1 SYRINGE |
5 |
Specialty Tier |
25% | 25% | 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 |
$100.00 | $100.00 | P |
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD |
5 |
Specialty Tier |
25% | 25% | P |
ARCALYST INJECTION 220MG/VIAL |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARIPIPRAZOLE 10 MG TABLET [Abilify] |
2 |
Generic |
$20.00 | $20.00 | Q:30 /30Days |
ARIPIPRAZOLE 15 MG TABLET [Abilify] |
2 |
Generic |
$20.00 | $20.00 | Q:30 /30Days |
ARIPIPRAZOLE 2 MG TABLET [Abilify] |
2 |
Generic |
$20.00 | $20.00 | Q:30 /30Days |
ARIPIPRAZOLE 20 MG TABLET [Abilify] |
2 |
Generic |
$20.00 | $20.00 | Q:30 /30Days |
ARIPIPRAZOLE 30 MG TABLET [Abilify] |
2 |
Generic |
$20.00 | $20.00 | Q:30 /30Days |
ARIPIPRAZOLE 5 MG TABLET [Abilify] |
2 |
Generic |
$20.00 | $20.00 | Q:30 /30Days |
ARIPIPRAZOLE ODT 10 MG TABLET [Abilify] |
2 |
Generic |
$20.00 | $20.00 | Q:60 /30Days |
ARIPIPRAZOLE ODT 15 MG TABLET [Abilify] |
2 |
Generic |
$20.00 | $20.00 | Q:60 /30Days |
ARISTADA ER 441 MG/1.6 ML SYRN |
5 |
Specialty Tier |
25% | 25% | Q:2 /30Days |
ARISTADA ER 662 MG/2.4 ML SYRN |
5 |
Specialty Tier |
25% | 25% | Q:2 /30Days |
ARISTADA ER 882 MG/3.2 ML SYRN |
5 |
Specialty Tier |
25% | 25% | Q:3 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARRANON 250MG VIAL |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | None |
ASCOMP WITH CODEINE CAPSULE |
2 |
Generic |
$20.00 | $20.00 | Q:180 /30Days |
ASMANEX HFA 100 MCG INHALER |
3 |
Preferred Brand |
$47.00 | $47.00 | None |
ASMANEX HFA 200 MCG INHALER |
3 |
Preferred Brand |
$47.00 | $47.00 | None |
ASMANEX TWISTHALER 110 MCG #30 |
3 |
Preferred Brand |
$47.00 | $47.00 | None |
ASMANEX TWISTHALER 220 MCG #30 |
3 |
Preferred Brand |
$47.00 | $47.00 | None |
ASMANEX TWISTHALER 220MCG #120 |
3 |
Preferred Brand |
$47.00 | $47.00 | None |
ASMANEX TWISTHALER 220MCG #60 |
3 |
Preferred Brand |
$47.00 | $47.00 | None |
ASPIRIN-DIPYRIDAM ER 25-200 MG [Aggrenox] |
2 |
Generic |
$20.00 | $20.00 | Q:60 /30Days |
ATENOLOL 100 MG100 TABLET BOTTLE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ATENOLOL 25 MG 100 TABLET BOTTLE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATENOLOL TABLET USP 50MG (100 CT) |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ATENOLOL-CHLORTHALIDONE 100-25 |
2 |
Generic |
$20.00 | $20.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
2 |
Generic |
$20.00 | $20.00 | None |
ATORVASTATIN 10 MG TABLET [Lipitor] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
ATORVASTATIN 20 MG TABLET [Lipitor] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
ATORVASTATIN 40 MG TABLET [Lipitor] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
ATORVASTATIN 80 MG TABLET [Lipitor] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
ATOVAQUONE 750 MG/5 ML SUSP [Mepron] |
2 |
Generic |
$20.00 | $20.00 | None |
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone] |
2 |
Generic |
$20.00 | $20.00 | None |
Atovaquone-Proguanil 62.5-25 [Malarone] |
2 |
Generic |
$20.00 | $20.00 | None |
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
5 |
Specialty Tier |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATROPINE 0.05MG/ML SYRINGE |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | None |
ATROPINE 0.1MG/ML SYRINGE |
2 |
Generic |
$20.00 | $20.00 | None |
ATROVENT HFA AER 17MCG |
3 |
Preferred Brand |
$47.00 | $47.00 | Q:39 /30Days |
AUBAGIO 14 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
AUBAGIO 7 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
AUBRA-28 TABLET |
2 |
Generic |
$20.00 | $20.00 | None |
AVASTIN 100MG/4ML VIAL |
5 |
Specialty Tier |
25% | 25% | P |
AVASTIN 400 MG/16 ML VIAL |
5 |
Specialty Tier |
25% | 25% | P |
AVELOX IV 400MG/250ML |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | None |
AVIANE 0.1-0.02 TABLET |
2 |
Generic |
$20.00 | $20.00 | None |
AVODART 0.5MG SOFTGEL |
3 |
Preferred Brand |
$47.00 | $47.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVONEX ADMIN PACK 30 MCG VL |
5 |
Specialty Tier |
25% | 25% | P |
AVONEX PEN 30 MCG/0.5 ML KIT |
5 |
Specialty Tier |
25% | 25% | P |
AVONEX PREFILLED SYR 30 MCG KT |
5 |
Specialty Tier |
25% | 25% | P |
Azacitidine 100 mg vial [Vidaza] |
2 |
Generic |
$20.00 | $20.00 | None |
AZACTAM 1g/1 10 VIAL, SINGLE-DOSE in 1 CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, SINGLE |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | None |
AZACTAM INJECTION 1GM/50ML |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | None |
AZACTAM INJECTION 2GM/50ML |
4 |
Non-Preferred Brand |
$100.00 | $100.00 | None |
AZATHIOPRINE 50 MG TABLET |
2 |
Generic |
$20.00 | $20.00 | P |
AZATHIOPRINE SODIUM 100 MG VIAL |
2 |
Generic |
$20.00 | $20.00 | None |
AZELASTINE 0.15% NASAL SPRAY |
2 |
Generic |
$20.00 | $20.00 | None |
AZELASTINE 137 MCG NASAL SPRAY |
2 |
Generic |
$20.00 | $20.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZILECT 0.5MG TABLET |
3 |
Preferred Brand |
$47.00 | $47.00 | Q:30 /30Days |
AZILECT 1MG TABLET |
3 |
Preferred Brand |
$47.00 | $47.00 | Q:30 /30Days |
AZITHROMYCIN 100 MG/5 ML SUSP |
2 |
Generic |
$20.00 | $20.00 | Q:15 /5Days |
Azithromycin 200mg/5mL 22.5 mL in 1 BOTTLE |
2 |
Generic |
$20.00 | $20.00 | Q:23 /5Days |
AZITHROMYCIN 250 MG TABLET |
2 |
Generic |
$20.00 | $20.00 | Q:6 /5Days |
AZITHROMYCIN 250 MG TABLET |
2 |
Generic |
$20.00 | $20.00 | Q:6 /5Days |
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION |
2 |
Generic |
$20.00 | $20.00 | None |
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Generic |
$20.00 | $20.00 | Q:3 /3Days |
Azithromycin 600mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Generic |
$20.00 | $20.00 | Q:8 /28Days |
AZTREONAM FOR INJECTION |
2 |
Generic |
$20.00 | $20.00 | None |