2016 Medicare Part D Plan Formulary Information |
FHCP's Premier Plus Plan (HMO-POS) (H1035-011-0)
Benefit Details
|
The FHCP's Premier Plus Plan (HMO-POS) (H1035-011-0) Formulary Drugs Starting with the Letter A in Brevard County, FL: CMS MA Region 9 which includes: FL Plan Monthly Premium: $17.00 Deductible: $0 |
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 |
6 |
Tier 6 |
25% | N/A | P |
ABACAVIR 300 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ABILIFY MAINTENA ER 300 MG SYR |
6 |
Tier 6 |
25% | N/A | P |
ABILIFY MAINTENA ER 300 MG VL |
6 |
Tier 6 |
25% | N/A | P |
ABILIFY MAINTENA ER 400 MG SYR |
6 |
Tier 6 |
25% | N/A | P |
ABRAXANE 100MG VIAL |
6 |
Tier 6 |
25% | N/A | P |
Acamprosate Calcium DR 333 MG tablets [Campral] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ACARBOSE 100 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ACARBOSE 25 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Acarbose 50mg/1 100 TABLET BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ACEBUTOLOL 200MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ACEBUTOLOL 400MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE |
6 |
Tier 6 |
25% | N/A | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ACETAMINOPHEN-COD #4 TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ACETAZOLAMIDE 125MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ACETAZOLAMIDE ER CAPSULES 500MG 100 BOT |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETIC ACID 2% EAR SOLUTION |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ACETYLCYSTEINE 10% VIAL |
2 |
Tier 2 |
$7.00 | $18.00 | P |
ACITRETIN 10 MG CAPSULE [Soriatane] |
5 |
Tier 5 |
33% | N/A | P |
ACITRETIN 17.5 MG CAPSULE [Soriatane] |
5 |
Tier 5 |
33% | N/A | P |
ACITRETIN 25 MG CAPSULE [Soriatane] |
5 |
Tier 5 |
33% | N/A | P |
ACTHIB VACCINE WITH DILUENT |
6 |
Tier 6 |
25% | N/A | None |
ACTIMMUNE 100 MCG/0.5 ML VIAL |
5 |
Tier 5 |
33% | N/A | P |
Acyclovir 200mg 100 CAPSULE BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Acyclovir 200mg/5mL 473 mL BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Acyclovir 400mg/1 |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Acyclovir 5% Ointment |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACYCLOVIR 800 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Acyclovir sodium 500 mg vial |
6 |
Tier 6 |
25% | N/A | None |
ADACEL VIAL 2UNT/5UNT |
6 |
Tier 6 |
25% | N/A | None |
ADAGEN 250U/ML VIAL |
5 |
Tier 5 |
33% | N/A | P |
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA] |
5 |
Tier 5 |
33% | N/A | P |
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera] |
2 |
Tier 2 |
$7.00 | $18.00 | P |
ADEMPAS 0.5 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
ADEMPAS 1 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
ADEMPAS 1.5 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
ADEMPAS 2 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
ADEMPAS 2.5 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADVAIR DISKUS MIS 100/50 |
4 |
Tier 4 |
$80.00 | $237.00 | Q:60 /30Days |
ADVAIR DISKUS MIS 250/50 |
4 |
Tier 4 |
$80.00 | $237.00 | Q:60 /30Days |
ADVAIR DISKUS MIS 500/50 |
4 |
Tier 4 |
$80.00 | $237.00 | Q:60 /30Days |
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER |
4 |
Tier 4 |
$80.00 | $237.00 | Q:12 /30Days |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL |
4 |
Tier 4 |
$80.00 | $237.00 | Q:12 /30Days |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
4 |
Tier 4 |
$80.00 | $237.00 | Q:12 /30Days |
AFEDITAB CR 30MG TABLET SA |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AFEDITAB CR 60MG TABLET SA |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK |
5 |
Tier 5 |
33% | N/A | None |
AFINITOR DISPERZ 2 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
AFINITOR DISPERZ 3 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AFINITOR DISPERZ 5 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
AFINITOR TABLETS 10 MG |
5 |
Tier 5 |
33% | N/A | None |
AFINITOR TABLETS 2.5 MG |
5 |
Tier 5 |
33% | N/A | None |
AFINITOR TABLETS 5 MG |
5 |
Tier 5 |
33% | N/A | None |
AGGRENOX 25-200MG CAPSULE |
3 |
Tier 3 |
$40.00 | $117.00 | None |
ALBENZA 200 MG TABLET |
4 |
Tier 4 |
$80.00 | $237.00 | None |
ALBUTEROL SULFATE SOLUTION FOR INHALATION |
2 |
Tier 2 |
$7.00 | $18.00 | P |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ALBUTEROL TABLET 4MG (500 CT) |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ALDURAZYME 2.9MG/5ML VIAL |
5 |
Tier 5 |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALECENSA 150 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P |
ALENDRONATE SODIUM 10MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ALENDRONATE SODIUM 35 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ALENDRONATE SODIUM 5MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Alendronate Sodium 70mg/1 4 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALFUZOSIN HYDROCHLORIDE 10mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ALIMTA 500MG VIAL |
5 |
Tier 5 |
33% | N/A | P |
ALINIA 500 MG TABLET |
3 |
Tier 3 |
$40.00 | $117.00 | None |
ALLOPURINOL 100 MG TABLETS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET per BLISTER PACK |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALOMIDE 0.1% EYE DROPS |
3 |
Tier 3 |
$40.00 | $117.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALOSETRON HCL 0.5 MG TABLET [Lotronex] |
2 |
Tier 2 |
$7.00 | $18.00 | P |
ALOSETRON HCL 1 MG TABLET [Lotronex] |
2 |
Tier 2 |
$7.00 | $18.00 | P |
ALOXI 0.25 MG/5 ML |
6 |
Tier 6 |
25% | N/A | P |
ALPRAZOLAM 0.25 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ALPRAZOLAM 0.5 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ALPRAZOLAM 1 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ALPRAZOLAM 2 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ALREX 0.2% EYE DROPS |
4 |
Tier 4 |
$80.00 | $237.00 | Q:5 /12Days |
AMANTADINE 100MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMBISOME 50MG VIAL |
6 |
Tier 6 |
25% | N/A | P |
AMIFOSTINE 50mg/mL 3 VIAL, SINGLE-USE per CARTON / 10 mL in 1 VIAL, SINGLE-USE |
6 |
Tier 6 |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMIKACIN SULFATE 500 MG/2 ML VIAL |
6 |
Tier 6 |
25% | N/A | P |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Aminophylline 25mg/mL 5 TRAY per CARTON / 5 AMPULE in 1 TRAY / 10 mL in 1 AMPULE |
6 |
Tier 6 |
25% | N/A | None |
AMIODARONE HCL 200MG 60 TABLET BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMIODARONE HCL 50 MG INJECTION |
6 |
Tier 6 |
25% | N/A | None |
AMITIZA 8MCG CAPSULE |
4 |
Tier 4 |
$80.00 | $237.00 | P |
AMITIZA CAPSULES 24MCG 60 CAP BOT |
4 |
Tier 4 |
$80.00 | $237.00 | P |
AMITRIPTYLINE HCL 100MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P |
AMITRIPTYLINE HCL 10MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P |
AMITRIPTYLINE HCL 150 MG TAB |
1 |
Tier 1 |
$0.00 | $0.00 | P |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | P |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | P |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
AMOX TR-K CLV 500-125 MG TAB |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOX-CLAV 200-28.5 MG/5 ML SUSPENSION |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXAPINE 100MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOXAPINE 150MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOXAPINE 25MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOXAPINE 50MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOXICILLIN 125MG TABLET CHEW |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOXICILLIN 250MG 500 CHEWABLE TABLET in BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOXICILLIN 250MG CAPSULE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOXICILLIN 500MG 500 CAPSULE BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOXICILLIN 875MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
2 |
Tier 2 |
$7.00 | $18.00 | None |
amphotericin b 50mg/10mL 10 mL in 1 VIAL |
6 |
Tier 6 |
25% | N/A | P |
AMPICILLIN CAPSULES 250MG 100 BOT |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML |
6 |
Tier 6 |
25% | N/A | P |
AMPICILLIN-SULBACTAM 3 GM VIAL |
6 |
Tier 6 |
25% | N/A | P |
AMPYRA ER 10 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Anastrozole 1mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ANDROGEL 1.62% (1.25G) GEL PCKT |
4 |
Tier 4 |
$80.00 | $237.00 | Q:38 /30Days |
ANDROGEL 1.62% (2.5G) GEL PCKT |
4 |
Tier 4 |
$80.00 | $237.00 | Q:75 /30Days |
Androgel 16.2mg/g 1 BOTTLE, PUMP per CARTON / 88 g in 1 BOTTLE, PUMP |
4 |
Tier 4 |
$80.00 | $237.00 | Q:150 /30Days |
ANORO ELLIPTA 62.5-25 MCG INH |
3 |
Tier 3 |
$40.00 | $117.00 | Q:60 /30Days |
ANZEMET 20MG/ML VIAL |
6 |
Tier 6 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APOKYN 30 MG/3 ML CARTRIDGE |
5 |
Tier 5 |
33% | N/A | P |
Apraclonidine Ophthalmic 5mg/mL 1 BOTTLE, DROPPER per CARTON / 10 mL in 1 BOTTLE, DROPPER |
2 |
Tier 2 |
$7.00 | $18.00 | None |
APRI 0.15-0.03 TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
APTIOM 200 MG TABLET |
4 |
Tier 4 |
$80.00 | $237.00 | P |
APTIOM 400 MG TABLET |
4 |
Tier 4 |
$80.00 | $237.00 | P |
APTIOM 600 MG TABLET |
4 |
Tier 4 |
$80.00 | $237.00 | P |
APTIOM 800 MG TABLET |
4 |
Tier 4 |
$80.00 | $237.00 | P |
APTIVUS 250MG CAPSULE |
3 |
Tier 3 |
$40.00 | $117.00 | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
3 |
Tier 3 |
$40.00 | $117.00 | None |
ARANESP 10 MCG/0.4 ML SYRINGE |
6 |
Tier 6 |
25% | N/A | P |
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.5 mL in 1 SYRINGE |
6 |
Tier 6 |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
6 |
Tier 6 |
25% | N/A | P |
ARANESP 200MCG/ML VIAL |
5 |
Tier 5 |
33% | N/A | P |
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
6 |
Tier 6 |
25% | N/A | P |
ARANESP 60MCG/ML VIAL |
6 |
Tier 6 |
25% | N/A | P |
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.3 mL in 1 SYRINGE |
6 |
Tier 6 |
25% | N/A | P |
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR |
5 |
Tier 5 |
33% | N/A | P |
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR |
6 |
Tier 6 |
25% | N/A | P |
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD |
6 |
Tier 6 |
25% | N/A | P |
ARCALYST INJECTION 220MG/VIAL |
5 |
Tier 5 |
33% | N/A | P |
ARIPIPRAZOLE 10 MG TABLET [Abilify] |
2 |
Tier 2 |
$7.00 | $18.00 | P |
ARIPIPRAZOLE 15 MG TABLET [Abilify] |
2 |
Tier 2 |
$7.00 | $18.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARIPIPRAZOLE 2 MG TABLET [Abilify] |
2 |
Tier 2 |
$7.00 | $18.00 | P |
ARIPIPRAZOLE 20 MG TABLET [Abilify] |
2 |
Tier 2 |
$7.00 | $18.00 | P |
ARIPIPRAZOLE 30 MG TABLET [Abilify] |
2 |
Tier 2 |
$7.00 | $18.00 | P |
ARIPIPRAZOLE 5 MG TABLET [Abilify] |
2 |
Tier 2 |
$7.00 | $18.00 | P |
ARIPIPRAZOLE ODT 10 MG TABLET [Abilify] |
2 |
Tier 2 |
$7.00 | $18.00 | P |
ARIPIPRAZOLE ODT 15 MG TABLET [Abilify] |
2 |
Tier 2 |
$7.00 | $18.00 | P |
ARISTADA ER 441 MG/1.6 ML SYRN |
6 |
Tier 6 |
25% | N/A | P |
ARISTADA ER 662 MG/2.4 ML SYRN |
6 |
Tier 6 |
25% | N/A | P |
ARISTADA ER 882 MG/3.2 ML SYRN |
6 |
Tier 6 |
25% | N/A | P |
ARNUITY ELLIPTA 100 MCG INH |
3 |
Tier 3 |
$40.00 | $117.00 | Q:30 /30Days |
ARNUITY ELLIPTA 200 MCG INH |
3 |
Tier 3 |
$40.00 | $117.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ASACOL HD 800mg/1 12 BOTTLE CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE |
3 |
Tier 3 |
$40.00 | $117.00 | None |
ASMANEX HFA 100 MCG INHALER |
3 |
Tier 3 |
$40.00 | $117.00 | Q:13 /30Days |
ASMANEX HFA 200 MCG INHALER |
3 |
Tier 3 |
$40.00 | $117.00 | Q:13 /30Days |
ASMANEX TWISTHALER 110 MCG #30 |
3 |
Tier 3 |
$40.00 | $117.00 | Q:1 /30Days |
ASMANEX TWISTHALER 220 MCG #30 |
3 |
Tier 3 |
$40.00 | $117.00 | Q:1 /30Days |
ASMANEX TWISTHALER 220MCG #120 |
3 |
Tier 3 |
$40.00 | $117.00 | Q:1 /30Days |
ASMANEX TWISTHALER 220MCG #60 |
3 |
Tier 3 |
$40.00 | $117.00 | Q:1 /30Days |
ASPIRIN-DIPYRIDAM ER 25-200 MG [Aggrenox] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ATENOLOL 100 MG100 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ATENOLOL 25 MG 100 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ATENOLOL TABLET USP 50MG (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATGAM 50MG/ML AMPUL |
6 |
Tier 6 |
25% | N/A | P |
ATORVASTATIN 10 MG TABLET [Lipitor] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ATORVASTATIN 20 MG TABLET [Lipitor] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ATORVASTATIN 40 MG TABLET [Lipitor] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ATORVASTATIN 80 MG TABLET [Lipitor] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
ATOVAQUONE 750 MG/5 ML SUSP [Mepron] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Atovaquone-Proguanil 62.5-25 [Malarone] |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Tier 3 |
$40.00 | $117.00 | None |
ATROPINE 0.1MG/ML SYRINGE |
6 |
Tier 6 |
25% | N/A | P |
Atropine 1% Eye Drops |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATROVENT HFA AER 17MCG |
3 |
Tier 3 |
$40.00 | $117.00 | Q:26 /30Days |
AVASTIN 100MG/4ML VIAL |
5 |
Tier 5 |
33% | N/A | P |
AVASTIN 400 MG/16 ML VIAL |
5 |
Tier 5 |
33% | N/A | P |
AVIANE 0.1-0.02 TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AVODART 0.5MG SOFTGEL |
3 |
Tier 3 |
$40.00 | $117.00 | None |
AVONEX ADMIN PACK 30 MCG VL |
5 |
Tier 5 |
33% | N/A | None |
AVONEX PEN 30 MCG/0.5 ML KIT |
5 |
Tier 5 |
33% | N/A | None |
AVONEX PREFILLED SYR 30 MCG KT |
5 |
Tier 5 |
33% | N/A | None |
Azacitidine 100 mg vial [Vidaza] |
6 |
Tier 6 |
25% | N/A | P |
AZATHIOPRINE 50 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | P |
AZELASTINE 137 MCG NASAL SPRAY |
2 |
Tier 2 |
$7.00 | $18.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION |
2 |
Tier 2 |
$7.00 | $18.00 | Q:6 /30Days |
AZILECT 0.5MG TABLET |
4 |
Tier 4 |
$80.00 | $237.00 | P |
AZILECT 1MG TABLET |
4 |
Tier 4 |
$80.00 | $237.00 | P |
AZITHROMYCIN 100 MG/5 ML SUSP |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Azithromycin 200mg/5mL 22.5 mL in 1 BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AZITHROMYCIN 250 MG TABLET |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION |
6 |
Tier 6 |
25% | N/A | None |
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
Azithromycin 600mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Tier 2 |
$7.00 | $18.00 | None |
AZTREONAM FOR INJECTION |
6 |
Tier 6 |
25% | N/A | P |