2017 Medicare Part D Plan Formulary Information |
GoldValue with Part D (HMO-POS) (H3305-022-0)
Benefit Details
|
The GoldValue with Part D (HMO-POS) (H3305-022-0) Formulary Drugs Starting with the Letter C in Albany County, NY: CMS MA Region 3 which includes: NY Plan Monthly Premium: $98.80 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 |
2 |
Generic |
$15.00 | $30.00 | None |
CABOMETYX 20 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
CABOMETYX 40 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
CABOMETYX 60 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
CAFERGOT TABLET |
4 |
Non-Preferred Drug |
50% | 50% | Q:43 /30Days |
CALCIPOTRIENE 0.005% CREAM |
4 |
Non-Preferred Drug |
50% | 50% | None |
Calcipotriene 50ug/g 60 g per CARTON |
4 |
Non-Preferred Drug |
50% | 50% | None |
CALCIPOTRIENE TOPICAL SOLUTION |
4 |
Non-Preferred Drug |
50% | 50% | None |
Calcipotriene-Betamethasone Dipropionate Ointment [Taclonex] |
4 |
Non-Preferred Drug |
50% | 50% | None |
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CALCITRIOL 0.25MCG CAPSULE |
2 |
Generic |
$15.00 | $30.00 | None |
CALCITRIOL 0.5 MCG CAPSULE |
2 |
Generic |
$15.00 | $30.00 | None |
Calcitriol 1 mcg/ml ampul |
2 |
Generic |
$15.00 | $30.00 | None |
CALCITRIOL 1MCG/ML SOLUTION ORAL |
2 |
Generic |
$15.00 | $30.00 | None |
CALCITRIOL 3 MCG/G OINTMENT |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Calcium Acetate 667 mg tablet |
2 |
Generic |
$15.00 | $30.00 | None |
CALCIUM ACETATE CAPSULE 667 MG |
2 |
Generic |
$15.00 | $30.00 | None |
CAMILA 0.35 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
Camrese Lo tablet |
2 |
Generic |
$15.00 | $30.00 | None |
CANASA 1,000 MG SUPPOSITORY |
4 |
Non-Preferred Drug |
50% | 50% | None |
CANCIDAS IV 50MG VIAL |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CANCIDAS IV 70MG VIAL |
5 |
Specialty Tier |
33% | N/A | None |
CANDESARTAN CILEXETIL 16 MG TABLET [Atacand] |
2 |
Generic |
$15.00 | $30.00 | None |
CANDESARTAN CILEXETIL 32 MG TABLET [Atacand] |
2 |
Generic |
$15.00 | $30.00 | None |
CANDESARTAN CILEXETIL 4 MG TABLET [Atacand] |
2 |
Generic |
$15.00 | $30.00 | None |
CANDESARTAN CILEXETIL 8 MG TABLET [Atacand] |
2 |
Generic |
$15.00 | $30.00 | None |
candesartan-hctz 16-12.5 mg tablet |
2 |
Generic |
$15.00 | $30.00 | None |
candesartan-hctz 32-12.5 mg tablet |
2 |
Generic |
$15.00 | $30.00 | None |
candesartan-hctz 32-25 mg |
2 |
Generic |
$15.00 | $30.00 | None |
CAPASTAT SULFATE 1g/1 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
4 |
Non-Preferred Drug |
50% | 50% | None |
CAPRELSA 100mg/1 30 TABLET BOTTLE |
3 |
Preferred Brand |
$45.00 | $90.00 | P Q:60 /30Days |
CAPRELSA 300mg/1 30 TABLET BOTTLE |
3 |
Preferred Brand |
$45.00 | $90.00 | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAPTOPRIL 100MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
CAPTOPRIL 12.5MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
CAPTOPRIL 25MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
CAPTOPRIL 50MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
Captopril and Hydrochlorothiazide 25; 15mg 100 TABLET BOTTLE |
2 |
Generic |
$15.00 | $30.00 | None |
Captopril and Hydrochlorothiazide 25; 25mg 100 TABLET BOTTLE |
2 |
Generic |
$15.00 | $30.00 | None |
Captopril and Hydrochlorothiazide 50; 15mg 100 TABLET BOTTLE |
2 |
Generic |
$15.00 | $30.00 | None |
Captopril and Hydrochlorothiazide 50; 25mg 100 TABLET BOTTLE |
2 |
Generic |
$15.00 | $30.00 | None |
CARAFATE SUS 1GM/10ML |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Carbaglu 200mg/1 5 TABLET BOTTLE |
5 |
Specialty Tier |
33% | N/A | None |
CARBAMAZEPINE 100 MG/5 ML SUSP |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Carbamazepine 100mg, CHEWABLE 100 TABLET BOTTLE |
2 |
Generic |
$15.00 | $30.00 | None |
Carbamazepine 100mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
2 |
Generic |
$15.00 | $30.00 | None |
Carbamazepine 200mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
2 |
Generic |
$15.00 | $30.00 | None |
Carbamazepine 300mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
2 |
Generic |
$15.00 | $30.00 | None |
CARBAMAZEPINE ER 100 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
CARBAMAZEPINE TABLET USP 200MG (1000 CT) |
2 |
Generic |
$15.00 | $30.00 | None |
CARBAMAZEPINE XR 200 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
CARBAMAZEPINE XR 400 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
CARBIDOPA 25 MG TABLET [Lodosyn] |
4 |
Non-Preferred Drug |
50% | 50% | None |
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT |
2 |
Generic |
$15.00 | $30.00 | None |
Carbidopa and Levodopa 25; 100mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Carbidopa and Levodopa 50; 200mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED |
2 |
Generic |
$15.00 | $30.00 | None |
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;100MG;MG 100 BOT |
2 |
Generic |
$15.00 | $30.00 | None |
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;250MG;MG 100 BOT |
2 |
Generic |
$15.00 | $30.00 | None |
CARBIDOPA-LEVODOPA 10-100 TAB |
2 |
Generic |
$15.00 | $30.00 | None |
CARBIDOPA-LEVODOPA 25-100 TAB |
2 |
Generic |
$15.00 | $30.00 | None |
CARBIDOPA-LEVODOPA 25-250 TAB |
2 |
Generic |
$15.00 | $30.00 | None |
Carbidopa-Levodopa-Entacapone 100 MG [Stalevo] |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Carbidopa-Levodopa-Entacapone 125 MG [Stalevo] |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Carbidopa-Levodopa-Entacapone 150 MG [Stalevo] |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Carbidopa-Levodopa-Entacapone 200 MG [Stalevo] |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Carbidopa-Levodopa-Entacapone 50 MG [Stalevo] |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Carbidopa-Levodopa-Entacapone 75 MG [Stalevo] |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Carboplatin 10mg/mL |
2 |
Generic |
$15.00 | $30.00 | None |
CARDIZEM CD 360 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | None |
CARIMUNE NF 6GM VIAL |
5 |
Specialty Tier |
33% | N/A | P |
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT |
2 |
Generic |
$15.00 | $30.00 | None |
CARTIA XT 120MG CAPSULE SA |
2 |
Generic |
$15.00 | $30.00 | None |
CARTIA XT 180MG CAPSULE SA |
2 |
Generic |
$15.00 | $30.00 | None |
CARTIA XT 240MG CAPSULE SA |
2 |
Generic |
$15.00 | $30.00 | None |
CARTIA XT 300MG CAPSULE SR 24 HR |
2 |
Generic |
$15.00 | $30.00 | None |
Carvedilol 12.5mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Carvedilol 25mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
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 |
Carvedilol 3.125mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Carvedilol 6.25mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CAYSTON KIT 75 MG/VIAL |
5 |
Specialty Tier |
33% | N/A | P |
CAZIANT 28 DAY TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
CEDAX 400mg/1 |
4 |
Non-Preferred Drug |
50% | 50% | None |
CEFACLOR 250 MG CAPSULES |
2 |
Generic |
$15.00 | $30.00 | None |
CEFACLOR 500 MG CAPSULES |
2 |
Generic |
$15.00 | $30.00 | None |
CEFACLOR ER 500MG TABLET SR 12HR |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
CEFADROXIL 1G TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
CEFADROXIL 250 MG/5 ML SUSP |
2 |
Generic |
$15.00 | $30.00 | None |
CEFADROXIL 500 MG CAPSULE |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cefadroxil 500mg/5mL |
2 |
Generic |
$15.00 | $30.00 | None |
Cefazolin 1 gm vial |
2 |
Generic |
$15.00 | $30.00 | None |
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE |
4 |
Non-Preferred Drug |
50% | 50% | None |
CEFAZOLIN 500MG FOR INJECTION |
2 |
Generic |
$15.00 | $30.00 | None |
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Generic |
$15.00 | $30.00 | None |
CEFDINIR CAPSULES 300MG (60 CT) |
2 |
Generic |
$15.00 | $30.00 | None |
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT) |
2 |
Generic |
$15.00 | $30.00 | None |
CEFEPIME HCL 2 GRAM VIAL |
2 |
Generic |
$15.00 | $30.00 | None |
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL |
2 |
Generic |
$15.00 | $30.00 | None |
CEFIXIME 100 MG/5 ML SUSP [Suprax] |
2 |
Generic |
$15.00 | $30.00 | None |
CEFIXIME 200 MG/5 ML SUSP [Suprax] |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cefotaxime sodium 1 gm vial |
2 |
Generic |
$15.00 | $30.00 | None |
Cefotaxime sodium 2 gm vial |
2 |
Generic |
$15.00 | $30.00 | None |
Cefotaxime sodium 500 mg vial |
2 |
Generic |
$15.00 | $30.00 | None |
CEFOTETAN 1GM VIAL 1EA x 10 |
2 |
Generic |
$15.00 | $30.00 | None |
CEFOTETAN 2GM VIAL 1EA x 10 |
2 |
Generic |
$15.00 | $30.00 | None |
Cefoxitin 1g/1 10 POWDER per CARTON |
2 |
Generic |
$15.00 | $30.00 | None |
Cefoxitin 2g/1 10 POWDER per CARTON |
2 |
Generic |
$15.00 | $30.00 | None |
CEFOXITIN FOR INJECTION SOLUTION |
2 |
Generic |
$15.00 | $30.00 | None |
CEFPODOXIME 100 MG/5 ML SUSP |
2 |
Generic |
$15.00 | $30.00 | None |
CEFPODOXIME 200 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
CEFPODOXIME 50 MG/5 ML SUSP |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT) |
2 |
Generic |
$15.00 | $30.00 | None |
CEFPROZIL 125 MG/5 ML SUSP |
2 |
Generic |
$15.00 | $30.00 | None |
cefprozil 250 mg/5 ml susp |
2 |
Generic |
$15.00 | $30.00 | None |
Cefprozil 250mg 100 FILM COATED TABLETS in BOTTLE |
2 |
Generic |
$15.00 | $30.00 | None |
CEFPROZIL TABLETS 500MG 100 BOT |
2 |
Generic |
$15.00 | $30.00 | None |
CEFTAZIDIME 1g 25 VIAL per CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL |
2 |
Generic |
$15.00 | $30.00 | None |
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN |
2 |
Generic |
$15.00 | $30.00 | None |
CEFTRIAXONE 10GM VIAL |
2 |
Generic |
$15.00 | $30.00 | None |
CEFTRIAXONE 250 MG VIAL |
2 |
Generic |
$15.00 | $30.00 | None |
CEFTRIAXONE FOR INJECTION |
2 |
Generic |
$15.00 | $30.00 | None |
CEFTRIAXONE FOR INJECTION |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ceftriaxone Sodium 500mg |
2 |
Generic |
$15.00 | $30.00 | None |
CEFUROXIME 1.5 GM/VIAL FOR INJECTION |
2 |
Generic |
$15.00 | $30.00 | None |
CEFUROXIME 7.5 GM FOR INJECTION |
2 |
Generic |
$15.00 | $30.00 | None |
CEFUROXIME 750 MG FOR INJECTION |
2 |
Generic |
$15.00 | $30.00 | None |
Cefuroxime Axetil 250 MG |
2 |
Generic |
$15.00 | $30.00 | None |
CEFUROXIME AXETIL 500 MG TAB |
2 |
Generic |
$15.00 | $30.00 | None |
CELECOXIB 100 MG CAPSULE [Celebrex] |
2 |
Generic |
$15.00 | $30.00 | None |
CELECOXIB 200 MG CAPSULE [Celebrex] |
2 |
Generic |
$15.00 | $30.00 | None |
CELECOXIB 400 MG CAPSULE [Celebrex] |
2 |
Generic |
$15.00 | $30.00 | None |
CELECOXIB 50 MG CAPSULE [Celebrex] |
2 |
Generic |
$15.00 | $30.00 | None |
CELLCEPT 200 MG/ML ORAL SUSP |
3 |
Preferred Brand |
$45.00 | $90.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CELLCEPT IV INJ 500 MG |
4 |
Non-Preferred Drug |
50% | 50% | P |
CELONTIN 300 MG KAPSEAL |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Cephalexin 125mg/5mL 200 mL in 1 BOTTLE |
2 |
Generic |
$15.00 | $30.00 | None |
CEPHALEXIN 250 MG CAPSULE |
2 |
Generic |
$15.00 | $30.00 | None |
CEPHALEXIN 250 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
CEPHALEXIN 250 MG/5ML ORAL SUSP |
2 |
Generic |
$15.00 | $30.00 | None |
CEPHALEXIN 500 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
CEPHALEXIN CAPSULES 500 MG (500 CT) |
2 |
Generic |
$15.00 | $30.00 | None |
CEREZYME 400 UNITS VIAL |
5 |
Specialty Tier |
33% | N/A | P |
CESAMET 1 MG CAPSULES |
4 |
Non-Preferred Drug |
50% | 50% | P |
CETIRIZINE HCL 1 MG/ML SOLN |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEVIMELINE HCL 30 MG CAPSULE [Evoxac] |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
CHANTIX 0.5 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
CHANTIX 1 MG CONT MONTH BOX |
4 |
Non-Preferred Drug |
50% | 50% | None |
CHANTIX 1 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
CHANTIX STARTING MONTH BOX |
4 |
Non-Preferred Drug |
50% | 50% | None |
CHEMET 100 MG CAPSULE |
4 |
Non-Preferred Drug |
50% | 50% | None |
CHLORAMPHEN NA SUCC 1GM VL |
2 |
Generic |
$15.00 | $30.00 | None |
CHLORDIAZEPOXIDE HCL 10mg 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE in 1 BLISTER |
2 |
Generic |
$15.00 | $30.00 | None |
CHLORDIAZEPOXIDE HCL 25mg 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE in 1 BLISTER |
2 |
Generic |
$15.00 | $30.00 | None |
CHLORDIAZEPOXIDE HCL 5mg 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE in 1 BLISTER |
2 |
Generic |
$15.00 | $30.00 | None |
CHLORHEXIDINE GLUCONATE 0.12% RINSE |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLOROQUINE PH 250 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
CHLOROQUINE PH 500 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
CHLOROTHIAZIDE 250 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Chlorothiazide 500mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CHLORPROMAZINE 10 MG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
CHLORPROMAZINE 25 MG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
CHLORPROMAZINE 25 MG/ML AMP |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
CHLORPROMAZINE 50 MG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
CHLORPROMAZINE HCL 200 MG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Chlorpromazine Hydrochloride 100mg SUGAR COATED 1000 TABLET BOTTLE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
CHLORTHALIDONE 25 MG TABLET (100 CT) |
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 |
CHLORTHALIDONE 50 MG TABLET (1000 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CHOLESTYRAMINE LIGHT POWDER |
2 |
Generic |
$15.00 | $30.00 | None |
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION |
2 |
Generic |
$15.00 | $30.00 | None |
Cialis 2.5mg/1 2 BLISTER PACK per CARTON / 15 FILM COATED TABLETS in BLISTER PACK |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days |
Cialis 5mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days |
CICLOPIROX 0.77% TOPICAL SUSP |
2 |
Generic |
$15.00 | $30.00 | None |
CICLOPIROX 1% SHAMPOO |
2 |
Generic |
$15.00 | $30.00 | None |
CICLOPIROX 8% SOLUTION |
2 |
Generic |
$15.00 | $30.00 | P |
CICLOPIROX GEL |
2 |
Generic |
$15.00 | $30.00 | None |
Ciclopirox Olamine 7.7mg/g 1 TUBE in 1 TUBE / 15 g in 1 TUBE |
2 |
Generic |
$15.00 | $30.00 | None |
cidofovir 375 mg/5 ml vial [Vistide] |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cilostazol 50mg/1 60 TABLET BOTTLE |
2 |
Generic |
$15.00 | $30.00 | None |
CILOSTAZOL TABLET 100MG (60 CT) |
2 |
Generic |
$15.00 | $30.00 | None |
CILOXAN 0.3% OINTMENT |
4 |
Non-Preferred Drug |
50% | 50% | None |
Cimzia 2 KIT per CARTON / 1 KIT in 1 KIT |
5 |
Specialty Tier |
33% | N/A | P |
CIMZIA 200 MG/ML SYRINGE KIT |
5 |
Specialty Tier |
33% | N/A | P |
Cinryze 500[iU]/5mL 1 VIAL per CARTON / 5 mL in 1 VIAL |
5 |
Specialty Tier |
33% | N/A | P |
CIPRO HC OTIC SUSPENSION |
4 |
Non-Preferred Drug |
50% | 50% | None |
CIPRODEX OTIC SUSPENSION |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
CIPROFLOXACIN 0.3% EYE DROP |
2 |
Generic |
$15.00 | $30.00 | None |
CIPROFLOXACIN 250 MG TABLET (100 CT) |
2 |
Generic |
$15.00 | $30.00 | None |
CIPROFLOXACIN 250 MG/5 ML SUSP |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ciprofloxacin 400 mg/40 ml vl |
2 |
Generic |
$15.00 | $30.00 | P |
CIPROFLOXACIN 500 MG/5 ML SUSP |
2 |
Generic |
$15.00 | $30.00 | None |
Ciprofloxacin and Dextrose 2mg/mL 24 BAG in 1 CASE / 100 mL in 1 BAG |
2 |
Generic |
$15.00 | $30.00 | None |
CIPROFLOXACIN HCL 100 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
CIPROFLOXACIN HCL 500 MG TAB |
2 |
Generic |
$15.00 | $30.00 | None |
CIPROFLOXACIN TABLETS 750 MG 100 BOT |
2 |
Generic |
$15.00 | $30.00 | None |
Cisplatin 100mg/100mL 1 VIAL per CARTON / 100 mL in 1 VIAL |
2 |
Generic |
$15.00 | $30.00 | None |
CITALOPRAM HBR 10 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CITALOPRAM HBR 10 MG/5 ML SOLN |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CITALOPRAM HBR 20 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
CITALOPRAM HYDROBROMIDE TABLETS 40 MG 30 BOT |
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 |
Cladribine 10 mg/10 ml vial |
4 |
Non-Preferred Drug |
50% | 50% | None |
CLARITHROMYCIN 125 MG/5ML FOR ORAL SUSPENSION |
2 |
Generic |
$15.00 | $30.00 | None |
CLARITHROMYCIN 250 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
CLARITHROMYCIN 250 MG/5MLFOR ORAL SUSPENSION |
2 |
Generic |
$15.00 | $30.00 | None |
CLARITHROMYCIN 500 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
CLARITHROMYCIN ER 500 MG TAB |
2 |
Generic |
$15.00 | $30.00 | None |
CLEOCIN 100 MG VAGINAL OVULE |
4 |
Non-Preferred Drug |
50% | 50% | None |
CLINDAMAX 1% GEL |
2 |
Generic |
$15.00 | $30.00 | None |
Clindamycin 150 MG/ML 2ml |
2 |
Generic |
$15.00 | $30.00 | None |
Clindamycin 150 MG/ML 6ml |
2 |
Generic |
$15.00 | $30.00 | None |
CLINDAMYCIN 600 MG/4 ML ADDVAN |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINDAMYCIN HCL 150 MG CAPSULE |
2 |
Generic |
$15.00 | $30.00 | None |
CLINDAMYCIN HCL 300 MG 100 CAPSULE in 1 BOTTLE |
2 |
Generic |
$15.00 | $30.00 | None |
CLINDAMYCIN HCL 75 MG 200 CAPSULE BOTTLE |
2 |
Generic |
$15.00 | $30.00 | None |
CLINDAMYCIN PEDIATR 75 MG/5 ML |
2 |
Generic |
$15.00 | $30.00 | None |
CLINDAMYCIN PHOSP 1% LOTION |
2 |
Generic |
$15.00 | $30.00 | None |
CLINDAMYCIN PHOSPHATE 1% FOAM |
2 |
Generic |
$15.00 | $30.00 | None |
clindamycin phosphate 10mg/mL 1 BOTTLE per CARTON / 60 mL in 1 BOTTLE |
2 |
Generic |
$15.00 | $30.00 | None |
Clindamycin Phosphate and Benzoyl Peroxide 1 KIT |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE |
2 |
Generic |
$15.00 | $30.00 | None |
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX |
2 |
Generic |
$15.00 | $30.00 | None |
CLINDAMYCIN PHOSPHATE VAGINAL CREAM |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Clindamycin Phosphate-Benzoyl Peroxide 1.2-5% [Benzaclin] |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
clindamycin-d5w 300 mg/50 ml |
2 |
Generic |
$15.00 | $30.00 | None |
clindamycin-d5w 600 mg/50 ml |
2 |
Generic |
$15.00 | $30.00 | None |
clindamycin-d5w 900 mg/50 ml |
2 |
Generic |
$15.00 | $30.00 | None |
CLOBETASOL 0.05% OINTMENT |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
CLOBETASOL 0.05% SHAMPOO |
2 |
Generic |
$15.00 | $30.00 | None |
CLOBETASOL 0.05% TOPICAL LOTION |
4 |
Non-Preferred Drug |
50% | 50% | None |
CLOBETASOL E 0.05% CREAM |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
CLOBETASOL PROP 0.05% SPRAY |
4 |
Non-Preferred Drug |
50% | 50% | None |
Clobetasol Propionate 0.4625mg/mL 1 BOTTLE per CARTON / 50 mL in 1 BOTTLE |
2 |
Generic |
$15.00 | $30.00 | None |
Clobetasol Propionate 0.5mg/g 1 CAN per CARTON / 100 g in 1 CAN |
4 |
Non-Preferred Drug |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
Clodan 0.05% shampoo |
2 |
Generic |
$15.00 | $30.00 | None |
Clofarabine 20 mg/20 ml vial [Clolar] |
5 |
Specialty Tier |
33% | N/A | None |
CLOMIPRAMINE HCL 25MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
CLOMIPRAMINE HCL 50MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
CLOMIPRAMINE HCL 75MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Clonazepam 0.125mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PAC |
2 |
Generic |
$15.00 | $30.00 | None |
Clonazepam 0.25mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
2 |
Generic |
$15.00 | $30.00 | None |
Clonazepam 0.5mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
2 |
Generic |
$15.00 | $30.00 | None |
Clonazepam 0.5mg/1 100 TABLET BOTTLE |
2 |
Generic |
$15.00 | $30.00 | None |
CLONAZEPAM 1 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Clonazepam 1mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
2 |
Generic |
$15.00 | $30.00 | None |
Clonazepam 2mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
2 |
Generic |
$15.00 | $30.00 | None |
Clonazepam 2mg/1 100 TABLET BOTTLE |
2 |
Generic |
$15.00 | $30.00 | None |
Clonidine 0.1mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
2 |
Generic |
$15.00 | $30.00 | None |
Clonidine 0.2mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
2 |
Generic |
$15.00 | $30.00 | None |
Clonidine 0.3mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
2 |
Generic |
$15.00 | $30.00 | None |
CLONIDINE HCL 0.1 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
CLONIDINE HCL 0.2MG TABLET (500 CT) |
2 |
Generic |
$15.00 | $30.00 | None |
CLONIDINE HCL TABLET 0.3MG (100 CT) |
2 |
Generic |
$15.00 | $30.00 | None |
CLOPIDOGREL 300 MG TABLET [Plavix] |
2 |
Generic |
$15.00 | $30.00 | None |
CLOPIDOGREL 75 MG TABLET [Plavix] |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLORAZEPATE 15 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
Clorazepate Dipotassium 3.75mg/1 500 TABLET BOTTLE, PLASTIC |
2 |
Generic |
$15.00 | $30.00 | None |
Clorazepate Dipotassium 7.5mg/1 500 TABLET BOTTLE, PLASTIC |
2 |
Generic |
$15.00 | $30.00 | None |
CLOTRIMAZOLE 1% CREAM |
2 |
Generic |
$15.00 | $30.00 | None |
CLOTRIMAZOLE 10MG TROCHE |
2 |
Generic |
$15.00 | $30.00 | None |
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION |
2 |
Generic |
$15.00 | $30.00 | None |
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE |
2 |
Generic |
$15.00 | $30.00 | None |
Clozapine 100 MG Disintegrating Oral Tablet |
2 |
Generic |
$15.00 | $30.00 | None |
Clozapine 100mg/1 100 TABLET BOTTLE |
2 |
Generic |
$15.00 | $30.00 | None |
CLOZAPINE 200MG TABLET (500 CT) |
2 |
Generic |
$15.00 | $30.00 | None |
Clozapine 25 MG Disintegrating Oral Tablet |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOZAPINE 25MG TABLET (100 CT) |
2 |
Generic |
$15.00 | $30.00 | None |
CLOZAPINE 50MG TABLET (500 CT) |
2 |
Generic |
$15.00 | $30.00 | None |
CLOZAPINE ODT 12.5 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
CLOZAPINE ODT 150 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
CLOZAPINE ODT 200 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
COARTEM 20MG-120MG |
4 |
Non-Preferred Drug |
50% | 50% | None |
CODEINE SULFATE 15 mg tablet |
2 |
Generic |
$15.00 | $30.00 | None |
CODEINE SULFATE 30 mg tablet |
2 |
Generic |
$15.00 | $30.00 | None |
CODEINE SULFATE 60 mg tablet |
2 |
Generic |
$15.00 | $30.00 | None |
COLCHICINE 0.6 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | Q:60 /30Days |
COLESTIPOL HCL 1G TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COLESTIPOL HYDROCHLORIDE 5g/1 100 SUSPENSION in 1 BOTTLE |
2 |
Generic |
$15.00 | $30.00 | None |
colistimethate 150mg/2mL 1 VIAL per CARTON / 2 mL in 1 VIAL |
4 |
Non-Preferred Drug |
50% | 50% | None |
COLOCORT 100MG ENEMA |
2 |
Generic |
$15.00 | $30.00 | None |
COMBIGAN 0.2%-0.5% DROPS |
4 |
Non-Preferred Drug |
50% | 50% | None |
COMBIVENT RESPIMAT INHAL SPRAY |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
COMETRIQ 100 MG DAILY-DOSE PK |
5 |
Specialty Tier |
33% | N/A | P |
COMETRIQ 140 MG DAILY-DOSE PK |
5 |
Specialty Tier |
33% | N/A | P |
COMETRIQ 60 MG DAILY-DOSE PACK |
5 |
Specialty Tier |
33% | N/A | P |
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1 |
5 |
Specialty Tier |
33% | N/A | None |
COMPRO 25MG SUPPOSITORY |
2 |
Generic |
$15.00 | $30.00 | None |
CONSTULOSE 10 GM/15 ML SOLN |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN |
5 |
Specialty Tier |
33% | N/A | None |
COPAXONE 40 MG/ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | None |
COREG CR 10MG CAPSULE MULTIPHASIC RELEASE 24 HR |
4 |
Non-Preferred Drug |
50% | 50% | None |
COREG CR 20MG CAPSULE MULTIPHASIC RELEASE 24 HR |
4 |
Non-Preferred Drug |
50% | 50% | None |
COREG CR 40MG CAPSULE MULTIPHASIC RELEASE 24 HR |
4 |
Non-Preferred Drug |
50% | 50% | None |
COREG CR 80MG CAPSULE MULTIPHASIC RELEASE 24 HR |
4 |
Non-Preferred Drug |
50% | 50% | None |
CORMAX 0.05% SOLUTION |
2 |
Generic |
$15.00 | $30.00 | None |
Cortisone 25 MG Tablet |
2 |
Generic |
$15.00 | $30.00 | None |
COSENTYX 150 MG/ML PEN INJECT |
5 |
Specialty Tier |
33% | N/A | P |
COTELLIC 20 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
COUMADIN 1 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COUMADIN 10MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
COUMADIN 2.5MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
COUMADIN 2MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
COUMADIN 3mg/1 1 BOTTLE per CARTON / 100 TABLET BOTTLE |
4 |
Non-Preferred Drug |
50% | 50% | None |
COUMADIN 4mg/1 1 BOTTLE in 1 CARTON / 100 TABLET BOTTLE |
4 |
Non-Preferred Drug |
50% | 50% | None |
COUMADIN 5MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
COUMADIN 6MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
COUMADIN 7.5MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
Creon 256.11mg/1 1 BOTTLE per CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
CREON DR 36,000 UNITS CAPSULE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
CRESTOR 10MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
CRESTOR 20MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
CRESTOR 40mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Drug |
50% | 50% | None |
CRESTOR 5MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
CRIXIVAN 200MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
CRIXIVAN 400mg, 180 CAPSULE BOTTLE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
CROMOLYN 20 MG/2 ML NEB SOLN |
2 |
Generic |
$15.00 | $30.00 | P |
CROMOLYN SODIUM 100 MG/5 ML |
2 |
Generic |
$15.00 | $30.00 | None |
CROMOLYN SODIUM 4% 40MG 10ML BOT |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CUBICIN 500MG VIAL |
5 |
Specialty Tier |
33% | N/A | None |
Cyclafem 1/35 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2 |
Generic |
$15.00 | $30.00 | None |
Cyclafem 7/7/7 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2 |
Generic |
$15.00 | $30.00 | None |
CYCLOPHOSPHAMIDE 25 MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $90.00 | P |
CYCLOPHOSPHAMIDE 50 MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $90.00 | P |
CYCLOSPORINE 100MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $90.00 | P |
CYCLOSPORINE 25MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $90.00 | P |
Cyclosporine 50 mg/ml vial |
2 |
Generic |
$15.00 | $30.00 | P |
CYCLOSPORINE MODIFIED 100 MG |
2 |
Generic |
$15.00 | $30.00 | P |
CYCLOSPORINE MODIFIED 25 MG |
2 |
Generic |
$15.00 | $30.00 | P |
CYCLOSPORINE MODIFIED 50 MG |
2 |
Generic |
$15.00 | $30.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT |
2 |
Generic |
$15.00 | $30.00 | P |
CYPROHEPTADINE HCL 4 MG |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
CYRAMZA 100 MG/10 ML VIAL |
5 |
Specialty Tier |
33% | N/A | None |
CYRAMZA 500 MG/50 ML VIAL |
5 |
Specialty Tier |
33% | N/A | None |
CYSTADANE 1 GRAM/1.7 ML POWDER |
4 |
Non-Preferred Drug |
50% | 50% | None |
CYSTAGON 150MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
CYSTAGON 50MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
CYSTARAN 0.44% EYE DROPS |
5 |
Specialty Tier |
33% | N/A | P |
CYTARABINE 20MG/ML VIAL |
2 |
Generic |
$15.00 | $30.00 | None |
CYTARABINE SOLUTION INJECTION 100MG 20ML VIALSD |
2 |
Generic |
$15.00 | $30.00 | None |