2017 Medicare Part D Plan Formulary Information |
The Health Plan SecureCare SNP (HMO SNP) (H3672-017-0)
Benefit Details
|
The The Health Plan SecureCare SNP (HMO SNP) (H3672-017-0) Formulary Drugs Starting with the Letter A in Jackson County, OH: CMS MA Region 12 which includes: OH Plan Monthly Premium: $32.30 Deductible: $400 |
Drugs Starting with Letter A
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
ABACAVIR 300 MG TABLET |
2 |
Tier 2 |
15% | N/A | None |
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir] |
5 |
Tier 5 |
15% | N/A | None |
ABACAVIR-LAMIVUDINE 600-300 MG [Epzicom] |
5 |
Tier 5 |
15% | N/A | None |
ABELCENT INJECTION SUSPENSION 5MG/ML |
5 |
Tier 5 |
15% | N/A | P |
ABILIFY MAINTENA ER 300 MG SYR |
5 |
Tier 5 |
15% | N/A | None |
ABILIFY MAINTENA ER 300 MG VL |
5 |
Tier 5 |
15% | N/A | None |
ABILIFY MAINTENA ER 400 MG SYR |
5 |
Tier 5 |
15% | N/A | None |
ABRAXANE 100MG VIAL |
5 |
Tier 5 |
15% | N/A | None |
Acamprosate Calcium DR 333 MG tablets [Campral] |
2 |
Tier 2 |
15% | N/A | None |
ACARBOSE 100 MG TABLET |
2 |
Tier 2 |
15% | N/A | 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 |
Tier 2 |
15% | N/A | Q:360 /30Days |
Acarbose 50mg/1 100 TABLET BOTTLE |
2 |
Tier 2 |
15% | N/A | Q:180 /30Days |
ACEBUTOLOL 200MG CAPSULE |
2 |
Tier 2 |
15% | N/A | None |
ACEBUTOLOL 400MG CAPSULE |
2 |
Tier 2 |
15% | N/A | None |
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE |
3 |
Tier 3 |
15% | N/A | None |
ACETAMINOP-CODEINE 120-12 MG/5 |
2 |
Tier 2 |
15% | N/A | Q:4500 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
2 |
Tier 2 |
15% | N/A | Q:360 /30Days |
ACETAMINOPHEN-COD #3 TABLET |
2 |
Tier 2 |
15% | N/A | Q:360 /30Days |
ACETAMINOPHEN-COD #4 TABLET |
2 |
Tier 2 |
15% | N/A | Q:180 /30Days |
ACETASOL HC SOLUTION 10ML 10 ML BOT |
2 |
Tier 2 |
15% | N/A | None |
ACETAZOLAMIDE 125MG TABLET |
2 |
Tier 2 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
2 |
Tier 2 |
15% | N/A | None |
Acetazolamide 500mg/5mL 1 VIAL in 1 CARTON / 5 mL in 1 VIAL |
2 |
Tier 2 |
15% | N/A | None |
ACETAZOLAMIDE ER CAPSULES 500MG 100 BOT |
2 |
Tier 2 |
15% | N/A | None |
ACETIC ACID 2% EAR SOLUTION |
2 |
Tier 2 |
15% | N/A | None |
ACETYLCYSTEINE 10% VIAL |
2 |
Tier 2 |
15% | N/A | P |
ACETYLCYSTEINE 20% VIAL |
2 |
Tier 2 |
15% | N/A | P |
ACITRETIN 10 MG CAPSULE [Soriatane] |
2 |
Tier 2 |
15% | N/A | None |
ACITRETIN 17.5 MG CAPSULE [Soriatane] |
5 |
Tier 5 |
15% | N/A | None |
ACITRETIN 25 MG CAPSULE [Soriatane] |
5 |
Tier 5 |
15% | N/A | None |
ACTEMRA 162 MG/0.9 ML SYRINGE |
5 |
Tier 5 |
15% | N/A | P |
ACTEMRA 400 MG/20 ML VIAL |
5 |
Tier 5 |
15% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTEMRA 80 MG/4 ML VIAL |
5 |
Tier 5 |
15% | N/A | P |
ACTEMRA INJECTION 200MG/10ML |
5 |
Tier 5 |
15% | N/A | P |
ACTHIB VACCINE WITH DILUENT |
3 |
Tier 3 |
15% | N/A | None |
ACTIMMUNE 100 MCG/0.5 ML VIAL |
5 |
Tier 5 |
15% | N/A | None |
Acyclovir 200mg 100 CAPSULE BOTTLE |
2 |
Tier 2 |
15% | N/A | None |
Acyclovir 200mg/5mL 473 mL BOTTLE |
2 |
Tier 2 |
15% | N/A | None |
Acyclovir 400mg/1 |
2 |
Tier 2 |
15% | N/A | None |
Acyclovir 5% Ointment |
4 |
Tier 4 |
15% | N/A | None |
ACYCLOVIR 800 MG TABLET |
2 |
Tier 2 |
15% | N/A | None |
Acyclovir sodium 500 mg vial |
2 |
Tier 2 |
15% | N/A | P |
ADACEL VIAL 2UNT/5UNT |
3 |
Tier 3 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADAGEN 250U/ML VIAL |
5 |
Tier 5 |
15% | N/A | None |
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA] |
5 |
Tier 5 |
15% | N/A | P Q:2 /28Days |
ADAPALENE 0.1% CREAM |
2 |
Tier 2 |
15% | N/A | P |
ADAPALENE 0.1% GEL |
2 |
Tier 2 |
15% | N/A | P |
Adapalene 0.3% gel |
4 |
Tier 4 |
15% | N/A | P |
ADCIRCA TABLETS 20MG 60 BOTTLE |
5 |
Tier 5 |
15% | N/A | P Q:60 /30Days |
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera] |
5 |
Tier 5 |
15% | N/A | None |
ADEMPAS 0.5 MG TABLET |
5 |
Tier 5 |
15% | N/A | P |
ADEMPAS 1 MG TABLET |
5 |
Tier 5 |
15% | N/A | P |
ADEMPAS 1.5 MG TABLET |
5 |
Tier 5 |
15% | N/A | P |
ADEMPAS 2 MG TABLET |
5 |
Tier 5 |
15% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADEMPAS 2.5 MG TABLET |
5 |
Tier 5 |
15% | N/A | P |
Adrenalin 1 mg/ml vial |
2 |
Tier 2 |
15% | N/A | None |
Adriamycin 20 mg/10 ml vial |
2 |
Tier 2 |
15% | N/A | None |
ADRUCIL 50mg/mL 10 VIAL in 1 TRAY / 10 mL in 1 VIAL |
2 |
Tier 2 |
15% | N/A | P |
AFEDITAB CR 30MG TABLET SA |
2 |
Tier 2 |
15% | N/A | None |
AFEDITAB CR 60MG TABLET SA |
2 |
Tier 2 |
15% | N/A | None |
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK |
5 |
Tier 5 |
15% | N/A | P |
AFINITOR DISPERZ 2 MG TABLET |
5 |
Tier 5 |
15% | N/A | P |
AFINITOR DISPERZ 3 MG TABLET |
5 |
Tier 5 |
15% | N/A | P |
AFINITOR DISPERZ 5 MG TABLET |
5 |
Tier 5 |
15% | N/A | P |
AFINITOR TABLETS 10 MG |
5 |
Tier 5 |
15% | N/A | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AFINITOR TABLETS 2.5 MG |
5 |
Tier 5 |
15% | N/A | P |
AFINITOR TABLETS 5 MG |
5 |
Tier 5 |
15% | N/A | P |
AKYNZEO 300-0.5 MG CAPSULE |
3 |
Tier 3 |
15% | N/A | P |
ALA-CORT 1% CREAM |
2 |
Tier 2 |
15% | N/A | None |
Ala-cort 2.5% cream |
2 |
Tier 2 |
15% | N/A | None |
ALBENZA 200 MG TABLET |
3 |
Tier 3 |
15% | N/A | None |
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH per CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL |
2 |
Tier 2 |
15% | N/A | P |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
2 |
Tier 2 |
15% | N/A | P |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
2 |
Tier 2 |
15% | N/A | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
2 |
Tier 2 |
15% | N/A | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
2 |
Tier 2 |
15% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL SULFATE SOLUTION FOR INHALATION |
2 |
Tier 2 |
15% | N/A | P |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
2 |
Tier 2 |
15% | N/A | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
2 |
Tier 2 |
15% | N/A | None |
ALBUTEROL TABLET 4MG (500 CT) |
4 |
Tier 4 |
15% | N/A | None |
ALCLOMETASONE DIPROPIONATE 0.05% CREAM |
2 |
Tier 2 |
15% | N/A | None |
Alclometasone Dipropionate 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2 |
Tier 2 |
15% | N/A | None |
ALDURAZYME 2.9MG/5ML VIAL |
5 |
Tier 5 |
15% | N/A | None |
ALECENSA 150 MG CAPSULE |
5 |
Tier 5 |
15% | N/A | P Q:240 /30Days |
ALENDRONATE SODIUM 10 MG TABLET |
1 |
Tier 1 |
15% | N/A | Q:30 /30Days |
ALENDRONATE SODIUM 35 MG TABLET |
1 |
Tier 1 |
15% | N/A | Q:4 /28Days |
ALENDRONATE SODIUM 40 MG TABLET |
1 |
Tier 1 |
15% | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALENDRONATE SODIUM 5 MG TABLET |
1 |
Tier 1 |
15% | N/A | Q:30 /30Days |
ALENDRONATE SODIUM 70 MG TAB |
1 |
Tier 1 |
15% | N/A | Q:4 /28Days |
ALENDRONATE SODIUM 70 mg/75 ml |
2 |
Tier 2 |
15% | N/A | Q:1286 /30Days |
ALFUZOSIN HYDROCHLORIDE 10mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2 |
Tier 2 |
15% | N/A | None |
ALIMTA 500MG VIAL |
5 |
Tier 5 |
15% | N/A | None |
ALINIA 100 MG/5 ML SUSPENSION |
3 |
Tier 3 |
15% | N/A | None |
ALINIA 500 MG TABLET |
3 |
Tier 3 |
15% | N/A | None |
Aliskiren 150 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT] |
3 |
Tier 3 |
15% | N/A | None |
Aliskiren 150 MG / Hydrochlorothiazide 25 MG Oral Tablet [Tekturna HCT] |
3 |
Tier 3 |
15% | N/A | None |
Aliskiren 300 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT] |
3 |
Tier 3 |
15% | N/A | None |
ALLOPURINOL 100 MG TABLETS |
1 |
Tier 1 |
15% | N/A | 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 |
Tier 1 |
15% | N/A | None |
Allopurinol sodium 500 mg vial |
2 |
Tier 2 |
15% | N/A | None |
ALMOTRIPTAN MALATE 12.5 MG TAB [Axert] |
2 |
Tier 2 |
15% | N/A | Q:24 /28Days |
ALMOTRIPTAN MALATE 6.25 MG TAB [Axert] |
2 |
Tier 2 |
15% | N/A | Q:18 /28Days |
ALOPRIM SOLUTION FOR INJECTION 500MG/VIAL 30 ML VIALGL |
2 |
Tier 2 |
15% | N/A | None |
ALOSETRON HCL 0.5 MG TABLET [Lotronex] |
5 |
Tier 5 |
15% | N/A | None |
ALOSETRON HCL 1 MG TABLET [Lotronex] |
5 |
Tier 5 |
15% | N/A | None |
ALOXI 0.25 MG/5 ML |
5 |
Tier 5 |
15% | N/A | None |
ALPHAGAN P 0.1% DROPS |
3 |
Tier 3 |
15% | N/A | None |
ALUNBRIG 30 MG TABLET |
5 |
Tier 5 |
15% | N/A | P Q:180 /30Days |
Alyacen 1-35-28 tablet |
2 |
Tier 2 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Amabelz 0.5 mg-0.1 mg tablet |
2 |
Tier 2 |
15% | N/A | None |
Amabelz 1 mg-0.5 mg tablet |
2 |
Tier 2 |
15% | N/A | None |
AMANTADINE 100MG CAPSULE |
2 |
Tier 2 |
15% | N/A | None |
AMANTADINE 100MG TABLET |
2 |
Tier 2 |
15% | N/A | None |
Amantadine Hydrochloride 50mg/5mL 473 mL in 1 BOTTLE |
2 |
Tier 2 |
15% | N/A | None |
AMBISOME 50MG VIAL |
5 |
Tier 5 |
15% | N/A | P |
AMCINONIDE 0.1% CREAM |
4 |
Tier 4 |
15% | N/A | None |
AMCINONIDE 0.1% LOTION |
4 |
Tier 4 |
15% | N/A | None |
AMCINONIDE 0.1% OINTMENT 60GM TUBE |
4 |
Tier 4 |
15% | N/A | None |
Amethia 0.15-0.03-0.01 mg tab |
2 |
Tier 2 |
15% | N/A | None |
Amethia lo tablet |
2 |
Tier 2 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMIKACIN SULFATE 500 MG/2 ML VIAL |
2 |
Tier 2 |
15% | N/A | None |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
1 |
Tier 1 |
15% | N/A | None |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT |
2 |
Tier 2 |
15% | N/A | None |
Amino Acids 15% Solution |
2 |
Tier 2 |
15% | N/A | P |
Aminophylline 25mg/mL 5 TRAY per CARTON / 5 AMPULE in 1 TRAY / 10 mL in 1 AMPULE |
2 |
Tier 2 |
15% | N/A | None |
AMINOSYN 7%-ELECTROLYTE SOL |
3 |
Tier 3 |
15% | N/A | P |
AMINOSYN HBC INJECTION SULFITE FREE 7% |
3 |
Tier 3 |
15% | N/A | P |
AMINOSYN II 10% IV SOLUTION |
3 |
Tier 3 |
15% | N/A | P |
AMINOSYN II 15% IV SOLUTION |
3 |
Tier 3 |
15% | N/A | P |
AMINOSYN II 8.5% ELECTROLYT |
3 |
Tier 3 |
15% | N/A | P |
AMINOSYN II 8.5% ELECTROLYT |
3 |
Tier 3 |
15% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN PF INJECTION |
3 |
Tier 3 |
15% | N/A | P |
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5% |
3 |
Tier 3 |
15% | N/A | P |
AMINOSYN-PF 7% IV SOLUTION |
3 |
Tier 3 |
15% | N/A | P |
AMINOSYN-RF 5.2% IV SOLUTION |
3 |
Tier 3 |
15% | N/A | P |
Amiodarone 150 mg/3 ml ampule |
2 |
Tier 2 |
15% | N/A | P |
Amiodarone hcl 100 mg tablet |
2 |
Tier 2 |
15% | N/A | None |
AMIODARONE HCL 200 MG TABLET |
2 |
Tier 2 |
15% | N/A | None |
AMIODARONE HCL 400MG TABLET |
2 |
Tier 2 |
15% | N/A | None |
AMITRIPTYLINE HCL 100MG TABLET |
2 |
Tier 2 |
15% | N/A | P |
AMITRIPTYLINE HCL 10MG TABLET |
2 |
Tier 2 |
15% | N/A | P |
AMITRIPTYLINE HCL 150 MG TAB |
2 |
Tier 2 |
15% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
2 |
Tier 2 |
15% | N/A | P |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
2 |
Tier 2 |
15% | N/A | P |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
2 |
Tier 2 |
15% | N/A | P |
AMLOD-VALSA-HCTZ 10-160-12.5 MG [EXFORGE HCT] |
4 |
Tier 4 |
15% | N/A | None |
AMLOD-VALSA-HCTZ 10-160-25 MG [EXFORGE HCT] |
4 |
Tier 4 |
15% | N/A | None |
AMLOD-VALSA-HCTZ 10-320-25 MG [EXFORGE HCT] |
4 |
Tier 4 |
15% | N/A | None |
AMLOD-VALSA-HCTZ 5-160-12.5 MG [EXFORGE HCT] |
2 |
Tier 2 |
15% | N/A | None |
AMLOD-VALSA-HCTZ 5-160-25 MG [EXFORGE HCT] |
2 |
Tier 2 |
15% | N/A | None |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
1 |
Tier 1 |
15% | N/A | None |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1 |
Tier 1 |
15% | N/A | None |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
1 |
Tier 1 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE |
2 |
Tier 2 |
15% | N/A | None |
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE |
2 |
Tier 2 |
15% | N/A | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE |
2 |
Tier 2 |
15% | N/A | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE |
2 |
Tier 2 |
15% | N/A | None |
Amlodipine-Atorvastatin 10-10 mg [Caduet] |
4 |
Tier 4 |
15% | N/A | Q:30 /30Days |
Amlodipine-Atorvastatin 10-20 mg [Caduet] |
4 |
Tier 4 |
15% | N/A | Q:30 /30Days |
Amlodipine-Atorvastatin 10-40 mg [Caduet] |
4 |
Tier 4 |
15% | N/A | Q:30 /30Days |
Amlodipine-Atorvastatin 10-80 mg [Caduet] |
4 |
Tier 4 |
15% | N/A | Q:30 /30Days |
Amlodipine-Atorvastatin 2.5-10 mg [Caduet] |
2 |
Tier 2 |
15% | N/A | Q:30 /30Days |
Amlodipine-Atorvastatin 2.5-20 mg [Caduet] |
4 |
Tier 4 |
15% | N/A | Q:30 /30Days |
Amlodipine-Atorvastatin 2.5-40 mg [Caduet] |
2 |
Tier 2 |
15% | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Amlodipine-Atorvastatin 5-10 mg [Caduet] |
4 |
Tier 4 |
15% | N/A | Q:30 /30Days |
Amlodipine-Atorvastatin 5-20 mg [Caduet] |
4 |
Tier 4 |
15% | N/A | Q:30 /30Days |
Amlodipine-Atorvastatin 5-40 mg [Caduet] |
4 |
Tier 4 |
15% | N/A | Q:30 /30Days |
Amlodipine-Atorvastatin 5-80 mg [Caduet] |
4 |
Tier 4 |
15% | N/A | Q:30 /30Days |
AMLODIPINE-BENAZEPRIL 10-40 MG |
2 |
Tier 2 |
15% | N/A | None |
AMLODIPINE-BENAZEPRIL 5-40 MG |
2 |
Tier 2 |
15% | N/A | None |
AMLODIPINE-OLMESARTAN 5-40 MG [Azor] |
2 |
Tier 2 |
15% | N/A | None |
Amlodipine-Olmesartan medoxomil 10 MG / 20 MG Oral Tablet [Azor] |
2 |
Tier 2 |
15% | N/A | None |
Amlodipine-Olmesartan medoxomil 10 MG / 40 MG Oral Tablet [Azor] |
2 |
Tier 2 |
15% | N/A | None |
Amlodipine-Olmesartan medoxomil 5 MG / 20 MG Oral Tablet [Azor] |
2 |
Tier 2 |
15% | N/A | None |
AMLODIPINE-VALSARTAN 10-160 MG |
2 |
Tier 2 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE-VALSARTAN 10-320 MG |
2 |
Tier 2 |
15% | N/A | None |
AMLODIPINE-VALSARTAN 5-160 MG |
2 |
Tier 2 |
15% | N/A | None |
AMLODIPINE-VALSARTAN 5-320 MG |
2 |
Tier 2 |
15% | N/A | None |
AMMONIUM LACTATE 12% CREAM |
2 |
Tier 2 |
15% | N/A | None |
AMMONIUM LACTATE 12% LOTION |
2 |
Tier 2 |
15% | N/A | None |
AMOX TR-K CLV 500-125 MG TAB |
2 |
Tier 2 |
15% | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
2 |
Tier 2 |
15% | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
2 |
Tier 2 |
15% | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
2 |
Tier 2 |
15% | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
2 |
Tier 2 |
15% | N/A | None |
AMOX-CLAV 200-28.5 MG/5 ML SUS |
2 |
Tier 2 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXAPINE 100MG TABLET |
2 |
Tier 2 |
15% | N/A | None |
AMOXAPINE 150MG TABLET |
2 |
Tier 2 |
15% | N/A | None |
AMOXAPINE 25MG TABLET |
2 |
Tier 2 |
15% | N/A | None |
AMOXAPINE 50MG TABLET |
2 |
Tier 2 |
15% | N/A | None |
AMOXICILLIN 125MG TABLET CHEW |
2 |
Tier 2 |
15% | N/A | None |
AMOXICILLIN 250MG 500 CHEWABLE TABLET in BOTTLE |
2 |
Tier 2 |
15% | N/A | None |
AMOXICILLIN 250MG CAPSULE |
2 |
Tier 2 |
15% | N/A | None |
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION |
2 |
Tier 2 |
15% | N/A | None |
AMOXICILLIN 500MG 500 CAPSULE BOTTLE |
2 |
Tier 2 |
15% | N/A | None |
AMOXICILLIN 500MG TABLET (100 CT) |
2 |
Tier 2 |
15% | N/A | None |
AMOXICILLIN 875MG TABLET |
2 |
Tier 2 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
2 |
Tier 2 |
15% | N/A | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG |
2 |
Tier 2 |
15% | N/A | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
2 |
Tier 2 |
15% | N/A | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
2 |
Tier 2 |
15% | N/A | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
2 |
Tier 2 |
15% | N/A | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
2 |
Tier 2 |
15% | N/A | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
2 |
Tier 2 |
15% | N/A | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
2 |
Tier 2 |
15% | N/A | None |
AMPHETAMINE SALT COMBO 15MG TABLET |
2 |
Tier 2 |
15% | N/A | None |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
2 |
Tier 2 |
15% | N/A | None |
AMPHETAMINE SALTS 5 MG TAB |
2 |
Tier 2 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
amphotericin b 50mg/10mL 10 mL in 1 VIAL |
4 |
Tier 4 |
15% | N/A | P |
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS |
2 |
Tier 2 |
15% | N/A | None |
AMPICILLIN CAPSULES 250MG 100 BOT |
2 |
Tier 2 |
15% | N/A | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
2 |
Tier 2 |
15% | N/A | None |
AMPICILLIN FOR INJECTION POWDER |
2 |
Tier 2 |
15% | N/A | None |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
2 |
Tier 2 |
15% | N/A | None |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
2 |
Tier 2 |
15% | N/A | None |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML |
2 |
Tier 2 |
15% | N/A | None |
ampicillin-sulbactam 1.5 gm vl |
2 |
Tier 2 |
15% | N/A | None |
AMPICILLIN-SULBACTAM 15 GM VIAL |
2 |
Tier 2 |
15% | N/A | None |
AMPICILLIN-SULBACTAM 3 GM VIAL |
2 |
Tier 2 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPYRA ER 10 MG TABLET |
5 |
Tier 5 |
15% | N/A | P |
ANADROL-50 TABLET |
5 |
Tier 5 |
15% | N/A | P |
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE |
2 |
Tier 2 |
15% | N/A | None |
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE |
2 |
Tier 2 |
15% | N/A | None |
Anastrozole 1mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Tier 2 |
15% | N/A | None |
ANDROGEL 1.62% (1.25G) GEL PCKT |
3 |
Tier 3 |
15% | N/A | P |
ANDROGEL 1.62% (2.5G) GEL PCKT |
3 |
Tier 3 |
15% | N/A | P |
Androgel 16.2mg/g 1 BOTTLE, PUMP per CARTON / 88 g in 1 BOTTLE, PUMP |
3 |
Tier 3 |
15% | N/A | P |
Apexicon E 0.05% Cream |
2 |
Tier 2 |
15% | N/A | None |
APOKYN 30 MG/3 ML CARTRIDGE |
5 |
Tier 5 |
15% | N/A | None |
Apraclonidine Ophthalmic 5mg/mL 1 BOTTLE, DROPPER per CARTON / 10 mL in 1 BOTTLE, DROPPER |
2 |
Tier 2 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APREPITANT 125 MG CAPSULE [Emend] |
2 |
Tier 2 |
15% | N/A | P |
APREPITANT 125-80-80 MG PACK [Emend] |
2 |
Tier 2 |
15% | N/A | P |
APREPITANT 40 MG CAPSULE [Emend] |
2 |
Tier 2 |
15% | N/A | P |
APREPITANT 80 MG CAPSULE [Emend] |
2 |
Tier 2 |
15% | N/A | P |
APRI 0.15-0.03 TABLET |
2 |
Tier 2 |
15% | N/A | None |
APTIOM 200 MG TABLET |
4 |
Tier 4 |
15% | N/A | None |
APTIOM 400 MG TABLET |
4 |
Tier 4 |
15% | N/A | None |
APTIOM 600 MG TABLET |
5 |
Tier 5 |
15% | N/A | None |
APTIOM 800 MG TABLET |
4 |
Tier 4 |
15% | N/A | None |
APTIVUS 250MG CAPSULE |
5 |
Tier 5 |
15% | N/A | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
5 |
Tier 5 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARALAST NP 500 MG VIAL |
5 |
Tier 5 |
15% | N/A | None |
ARANELLE 7-9-5 TABLET |
2 |
Tier 2 |
15% | N/A | None |
ARCALYST INJECTION 220MG/VIAL |
5 |
Tier 5 |
15% | N/A | P |
Arcapta Neohaler 75ug/1 30 BLISTER PACK in 1 BOX / 1 CAPSULE per BLISTER PACK |
3 |
Tier 3 |
15% | N/A | Q:30 /30Days |
ARIPIPRAZOLE 10 MG TABLET [Abilify] |
2 |
Tier 2 |
15% | N/A | Q:90 /30Days |
ARIPIPRAZOLE 15 MG TABLET [Abilify] |
2 |
Tier 2 |
15% | N/A | Q:60 /30Days |
ARIPIPRAZOLE 2 MG TABLET [Abilify] |
2 |
Tier 2 |
15% | N/A | Q:450 /30Days |
ARIPIPRAZOLE 20 MG TABLET [Abilify] |
5 |
Tier 5 |
15% | N/A | Q:60 /30Days |
ARIPIPRAZOLE 30 MG TABLET [Abilify] |
5 |
Tier 5 |
15% | N/A | Q:30 /30Days |
ARIPIPRAZOLE 5 MG TABLET [Abilify] |
2 |
Tier 2 |
15% | N/A | Q:180 /30Days |
ARIPIPRAZOLE ODT 10 MG TABLET [Abilify] |
5 |
Tier 5 |
15% | N/A | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARIPIPRAZOLE ODT 15 MG TABLET [Abilify] |
5 |
Tier 5 |
15% | N/A | Q:60 /30Days |
ARISTADA ER 1064 MG/3.9 ML SYR |
5 |
Tier 5 |
15% | N/A | None |
ARISTADA ER 441 MG/1.6 ML SYRN |
5 |
Tier 5 |
15% | N/A | None |
ARISTADA ER 662 MG/2.4 ML SYRN |
5 |
Tier 5 |
15% | N/A | None |
ARISTADA ER 882 MG/3.2 ML SYRN |
5 |
Tier 5 |
15% | N/A | None |
Armodafinil 150 MG TABLET [NUVIGIL] |
2 |
Tier 2 |
15% | N/A | P |
Armodafinil 200 MG Oral Tablet [NUVIGIL] |
2 |
Tier 2 |
15% | N/A | P |
Armodafinil 250 MG TABLET [NUVIGIL] |
2 |
Tier 2 |
15% | N/A | P |
Armodafinil 50 MG TABLET [NUVIGIL] |
2 |
Tier 2 |
15% | N/A | P |
ARRANON 250 MG VIAL |
5 |
Tier 5 |
15% | N/A | None |
Ashlyna 0.15-0.03-0.01 mg tablet |
2 |
Tier 2 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ASMANEX HFA 100 MCG INHALER |
3 |
Tier 3 |
15% | N/A | Q:13 /30Days |
ASMANEX HFA 200 MCG INHALER |
3 |
Tier 3 |
15% | N/A | Q:13 /30Days |
ASMANEX TWISTHALER 110 MCG #30 |
3 |
Tier 3 |
15% | N/A | Q:30 /30Days |
ASMANEX TWISTHALER 220 MCG #30 |
3 |
Tier 3 |
15% | N/A | Q:30 /30Days |
ASMANEX TWISTHALER 220MCG #120 |
3 |
Tier 3 |
15% | N/A | Q:240 /30Days |
ASMANEX TWISTHALER 220MCG #60 |
3 |
Tier 3 |
15% | N/A | Q:60 /30Days |
Aspirin-Diphenhydramine ER 25-200 MG |
2 |
Tier 2 |
15% | N/A | None |
ATENOLOL 100 MG100 TABLET BOTTLE |
1 |
Tier 1 |
15% | N/A | None |
ATENOLOL 25 MG 100 TABLET BOTTLE |
1 |
Tier 1 |
15% | N/A | None |
ATENOLOL TABLET USP 50MG (100 CT) |
1 |
Tier 1 |
15% | N/A | None |
ATENOLOL-CHLORTHALIDONE 100-25 |
1 |
Tier 1 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
1 |
Tier 1 |
15% | N/A | None |
Atomoxetine 10 MG Oral Capsule [Strattera] |
2 |
Tier 2 |
15% | N/A | None |
Atomoxetine 100 MG Oral Capsule [Strattera] |
2 |
Tier 2 |
15% | N/A | None |
Atomoxetine 18 MG Oral Capsule [Strattera] |
2 |
Tier 2 |
15% | N/A | None |
Atomoxetine 25 MG Oral Capsule [Strattera] |
2 |
Tier 2 |
15% | N/A | None |
Atomoxetine 40 MG Oral Capsule [Strattera] |
2 |
Tier 2 |
15% | N/A | None |
Atomoxetine 60 MG Oral Capsule [Strattera] |
2 |
Tier 2 |
15% | N/A | None |
Atomoxetine 80 MG Oral Capsule [Strattera] |
2 |
Tier 2 |
15% | N/A | None |
ATORVASTATIN 10 MG TABLET [Lipitor] |
1 |
Tier 1 |
15% | N/A | Q:30 /30Days |
ATORVASTATIN 20 MG TABLET [Lipitor] |
1 |
Tier 1 |
15% | N/A | Q:30 /30Days |
ATORVASTATIN 40 MG TABLET [Lipitor] |
1 |
Tier 1 |
15% | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATORVASTATIN 80 MG TABLET [Lipitor] |
1 |
Tier 1 |
15% | N/A | Q:30 /30Days |
ATOVAQUONE 750 MG/5 ML SUSP [Mepron] |
5 |
Tier 5 |
15% | N/A | None |
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone] |
2 |
Tier 2 |
15% | N/A | None |
Atovaquone-Proguanil 62.5-25 [Malarone] |
2 |
Tier 2 |
15% | N/A | None |
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
5 |
Tier 5 |
15% | N/A | None |
ATROPINE 0.05MG/ML SYRINGE |
2 |
Tier 2 |
15% | N/A | None |
Atropine 1% Eye Drops |
2 |
Tier 2 |
15% | N/A | None |
ATROVENT HFA AER 17MCG |
3 |
Tier 3 |
15% | N/A | Q:26 /30Days |
AUBRA-28 TABLET |
2 |
Tier 2 |
15% | N/A | None |
AUGMENTIN 125; 31.25mg/5mL; mg/5mL 100 mL in 1 BOTTLE |
3 |
Tier 3 |
15% | N/A | None |
AVASTIN 100MG/4ML VIAL |
5 |
Tier 5 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVASTIN 400 MG/16 ML VIAL |
5 |
Tier 5 |
15% | N/A | None |
AVIANE 0.1-0.02 TABLET |
2 |
Tier 2 |
15% | N/A | None |
AVITA 0.025% CREAM |
2 |
Tier 2 |
15% | N/A | P |
AVONEX ADMIN PACK 30 MCG VL |
5 |
Tier 5 |
15% | N/A | P Q:4 /28Days |
AVONEX PEN 30 MCG/0.5 ML KIT |
5 |
Tier 5 |
15% | N/A | P Q:4 /28Days |
AVONEX PREFILLED SYR 30 MCG KT |
5 |
Tier 5 |
15% | N/A | P Q:4 /28Days |
Azacitidine 100 mg vial [Vidaza] |
5 |
Tier 5 |
15% | N/A | None |
AZATHIOPRINE 50 MG TABLET |
2 |
Tier 2 |
15% | N/A | P |
AZATHIOPRINE SODIUM 100 MG VIAL |
2 |
Tier 2 |
15% | N/A | P |
AZELASTINE 0.15% NASAL SPRAY |
2 |
Tier 2 |
15% | N/A | Q:60 /30Days |
AZELASTINE 137 MCG NASAL SPRAY |
2 |
Tier 2 |
15% | N/A | Q:60 /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 |
15% | N/A | None |
AZILECT 0.5MG TABLET |
3 |
Tier 3 |
15% | N/A | None |
AZILECT 1MG TABLET |
3 |
Tier 3 |
15% | N/A | None |
AZITHROMYCIN 1 GM PWD PACKET |
2 |
Tier 2 |
15% | N/A | None |
AZITHROMYCIN 100 MG/5 ML SUSP |
2 |
Tier 2 |
15% | N/A | None |
Azithromycin 200mg/5mL 22.5 mL in 1 BOTTLE |
2 |
Tier 2 |
15% | N/A | None |
AZITHROMYCIN 250 MG TABLET |
2 |
Tier 2 |
15% | N/A | None |
AZITHROMYCIN 250 MG TABLET |
2 |
Tier 2 |
15% | N/A | None |
Azithromycin 500 mg tablet |
2 |
Tier 2 |
15% | N/A | None |
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION |
2 |
Tier 2 |
15% | N/A | None |
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Tier 2 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Azithromycin 600mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Tier 2 |
15% | N/A | None |
AZTREONAM FOR INJECTION |
2 |
Tier 2 |
15% | N/A | None |