2017 Medicare Part D Plan Formulary Information |
PriorityMedicare Merit (PPO) (H4875-016-1)
Benefit Details
|
The PriorityMedicare Merit (PPO) (H4875-016-1) Formulary Drugs Starting with the Letter A in Leelanau County, MI: CMS MA Region 11 which includes: MI Plan Monthly Premium: $87.00 Deductible: $75 |
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* |
Generic |
$10.00 | N/A | None |
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir] |
5 |
Specialty Tier |
31% | N/A | None |
ABACAVIR-LAMIVUDINE 600-300 MG [Epzicom] |
5 |
Specialty Tier |
31% | N/A | None |
ABELCENT INJECTION SUSPENSION 5MG/ML |
5 |
Specialty Tier |
31% | N/A | P |
ABILIFY MAINTENA ER 300 MG SYR |
5 |
Specialty Tier |
31% | N/A | None |
ABILIFY MAINTENA ER 300 MG VL |
5 |
Specialty Tier |
31% | N/A | None |
ABILIFY MAINTENA ER 400 MG SYR |
5 |
Specialty Tier |
31% | N/A | None |
ABRAXANE 100MG VIAL |
5 |
Specialty Tier |
31% | N/A | None |
ABSTRAL 100 MCG TAB SUBLINGUAL |
5 |
Specialty Tier |
31% | N/A | P Q:120 /30Days |
ABSTRAL 200 MCG TAB SUBLINGUAL |
5 |
Specialty Tier |
31% | N/A | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABSTRAL 300 MCG TAB SUBLINGUAL |
5 |
Specialty Tier |
31% | N/A | P Q:120 /30Days |
ABSTRAL 400 MCG TAB SUBLINGUAL |
5 |
Specialty Tier |
31% | N/A | P Q:116 /30Days |
ABSTRAL 600 MCG TAB SUBLINGUAL |
5 |
Specialty Tier |
31% | N/A | P Q:77 /30Days |
ABSTRAL 800 MCG TAB SUBLINGUAL |
5 |
Specialty Tier |
31% | N/A | P Q:58 /30Days |
Acamprosate Calcium DR 333 MG tablets [Campral] |
2* |
Generic |
$10.00 | N/A | None |
ACARBOSE 100 MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
ACARBOSE 25 MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
Acarbose 50mg/1 100 TABLET BOTTLE |
2* |
Generic |
$10.00 | N/A | None |
ACEBUTOLOL 200MG CAPSULE |
2* |
Generic |
$10.00 | N/A | None |
ACEBUTOLOL 400MG CAPSULE |
2* |
Generic |
$10.00 | N/A | None |
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE |
3 |
Preferred Brand |
$42.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAMINOP-CODEINE 120-12 MG/5 |
2* |
Generic |
$10.00 | N/A | Q:4500 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
2* |
Generic |
$10.00 | N/A | Q:360 /30Days |
ACETAMINOPHEN-COD #3 TABLET |
2* |
Generic |
$10.00 | N/A | Q:360 /30Days |
ACETAMINOPHEN-COD #4 TABLET |
2* |
Generic |
$10.00 | N/A | Q:180 /30Days |
ACETAZOLAMIDE 125MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
2* |
Generic |
$10.00 | N/A | None |
Acetazolamide 500mg/5mL 1 VIAL in 1 CARTON / 5 mL in 1 VIAL |
2* |
Generic |
$10.00 | N/A | None |
ACETAZOLAMIDE ER CAPSULES 500MG 100 BOT |
1* |
Preferred Generic |
$2.00 | N/A | None |
ACETIC ACID 2% EAR SOLUTION |
2* |
Generic |
$10.00 | N/A | None |
ACETYLCYSTEINE 10% VIAL |
2* |
Generic |
$10.00 | N/A | P |
ACETYLCYSTEINE 20% VIAL |
2* |
Generic |
$10.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACITRETIN 10 MG CAPSULE [Soriatane] |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
ACITRETIN 17.5 MG CAPSULE [Soriatane] |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
ACITRETIN 25 MG CAPSULE [Soriatane] |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
ACTEMRA 162 MG/0.9 ML SYRINGE |
5 |
Specialty Tier |
31% | N/A | P Q:4 /28Days |
ACTEMRA 400 MG/20 ML VIAL |
5 |
Specialty Tier |
31% | N/A | P |
ACTEMRA 80 MG/4 ML VIAL |
5 |
Specialty Tier |
31% | N/A | P |
ACTEMRA INJECTION 200MG/10ML |
5 |
Specialty Tier |
31% | N/A | P |
ACTHIB VACCINE WITH DILUENT |
3 |
Preferred Brand |
$42.00 | N/A | None |
ACTIMMUNE 100 MCG/0.5 ML VIAL |
5 |
Specialty Tier |
31% | N/A | P |
ACTOPLUS MET XR TABLETS ER 15;1000 MG;MG |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
ACTOPLUS MET XR TABLETS ER 30;1000 MG;MG |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Acyclovir 200mg 100 CAPSULE BOTTLE |
2* |
Generic |
$10.00 | N/A | None |
Acyclovir 200mg/5mL 473 mL BOTTLE |
2* |
Generic |
$10.00 | N/A | None |
Acyclovir 400mg/1 |
2* |
Generic |
$10.00 | N/A | None |
Acyclovir 5% Ointment |
2* |
Generic |
$10.00 | N/A | Q:30 /30Days |
ACYCLOVIR 800 MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
Acyclovir sodium 500 mg vial |
2* |
Generic |
$10.00 | N/A | P |
ADACEL VIAL 2UNT/5UNT |
3 |
Preferred Brand |
$42.00 | N/A | None |
ADAGEN 250U/ML VIAL |
5 |
Specialty Tier |
31% | N/A | None |
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA] |
5 |
Specialty Tier |
31% | N/A | P Q:2 /28Days |
ADAPALENE 0.1% CREAM |
2* |
Generic |
$10.00 | N/A | None |
ADAPALENE 0.1% GEL |
2* |
Generic |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Adapalene 0.3% gel |
2* |
Generic |
$10.00 | N/A | None |
ADCIRCA TABLETS 20MG 60 BOTTLE |
5 |
Specialty Tier |
31% | N/A | P |
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera] |
5 |
Specialty Tier |
31% | N/A | None |
ADEMPAS 0.5 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P Q:90 /30Days |
ADEMPAS 1 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P Q:90 /30Days |
ADEMPAS 1.5 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P Q:90 /30Days |
ADEMPAS 2 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P Q:90 /30Days |
ADEMPAS 2.5 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P Q:90 /30Days |
ADLYXIN 10-20 MCG STARTER PACK |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
ADLYXIN 20 MCG MAINTENANCE PK |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
Adriamycin 20 mg/10 ml vial |
2* |
Generic |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADRUCIL 50mg/mL 10 VIAL in 1 TRAY / 10 mL in 1 VIAL |
3 |
Preferred Brand |
$42.00 | N/A | P |
AFEDITAB CR 30MG TABLET SA |
2* |
Generic |
$10.00 | N/A | None |
AFEDITAB CR 60MG TABLET SA |
2* |
Generic |
$10.00 | N/A | None |
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK |
5 |
Specialty Tier |
31% | N/A | P |
AFINITOR DISPERZ 2 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P |
AFINITOR DISPERZ 3 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P |
AFINITOR DISPERZ 5 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P |
AFINITOR TABLETS 10 MG |
5 |
Specialty Tier |
31% | N/A | P |
AFINITOR TABLETS 2.5 MG |
5 |
Specialty Tier |
31% | N/A | P |
AFINITOR TABLETS 5 MG |
5 |
Specialty Tier |
31% | N/A | P |
AFREZZA 30-4 UNIT + 60-8 UNIT |
4 |
Non-Preferred Drug |
$95.00 | N/A | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AFREZZA 4 UNIT/8 UNIT/12 UNIT |
4 |
Non-Preferred Drug |
$95.00 | N/A | S |
AFREZZA 4 UNITS CARTRIDGE INH |
4 |
Non-Preferred Drug |
$95.00 | N/A | S |
AFREZZA 60-4 UNIT + 30-8 UNIT |
4 |
Non-Preferred Drug |
$95.00 | N/A | S |
AFREZZA 60-8 UNIT + 30-12 UNIT |
4 |
Non-Preferred Drug |
$95.00 | N/A | S |
AFREZZA 90-4 UNIT / 90-8 UNIT |
4 |
Non-Preferred Drug |
$95.00 | N/A | S |
AKYNZEO 300-0.5 MG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | N/A | P Q:2 /30Days |
ALA-CORT 1% CREAM |
2* |
Generic |
$10.00 | N/A | None |
ALA-SCALP HP 2% LOTION |
3 |
Preferred Brand |
$42.00 | N/A | None |
ALBENZA 200 MG TABLET |
3 |
Preferred Brand |
$42.00 | 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* |
Generic |
$10.00 | N/A | P |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
2* |
Generic |
$10.00 | N/A | P |
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 |
$10.00 | N/A | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
2* |
Generic |
$10.00 | N/A | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
2* |
Generic |
$10.00 | N/A | P |
ALBUTEROL SULFATE SOLUTION FOR INHALATION |
2* |
Generic |
$10.00 | N/A | P |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
2* |
Generic |
$10.00 | N/A | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
2* |
Generic |
$10.00 | N/A | None |
ALBUTEROL TABLET 4MG (500 CT) |
2* |
Generic |
$10.00 | N/A | None |
ALCLOMETASONE DIPROPIONATE 0.05% CREAM |
2* |
Generic |
$10.00 | N/A | None |
Alclometasone Dipropionate 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2* |
Generic |
$10.00 | N/A | None |
ALDURAZYME 2.9MG/5ML VIAL |
5 |
Specialty Tier |
31% | N/A | None |
ALECENSA 150 MG CAPSULE |
5 |
Specialty Tier |
31% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALENDRONATE SODIUM 10 MG TABLET |
1* |
Preferred Generic |
$2.00 | N/A | None |
ALENDRONATE SODIUM 35 MG TABLET |
1* |
Preferred Generic |
$2.00 | N/A | None |
ALENDRONATE SODIUM 40 MG TABLET |
1* |
Preferred Generic |
$2.00 | N/A | None |
ALENDRONATE SODIUM 5 MG TABLET |
1* |
Preferred Generic |
$2.00 | N/A | None |
ALENDRONATE SODIUM 70 MG TAB |
1* |
Preferred Generic |
$2.00 | N/A | None |
ALENDRONATE SODIUM 70 mg/75 ml |
1* |
Preferred Generic |
$2.00 | N/A | None |
ALFUZOSIN HYDROCHLORIDE 10mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2* |
Generic |
$10.00 | N/A | None |
ALIMTA 500MG VIAL |
5 |
Specialty Tier |
31% | N/A | None |
ALINIA 100 MG/5 ML SUSPENSION |
3 |
Preferred Brand |
$42.00 | N/A | None |
ALINIA 500 MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | None |
Aliskiren 150 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT] |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Aliskiren 150 MG / Hydrochlorothiazide 25 MG Oral Tablet [Tekturna HCT] |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
Aliskiren 300 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT] |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
ALLOPURINOL 100 MG TABLETS |
1* |
Preferred Generic |
$2.00 | N/A | None |
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET per BLISTER PACK |
1* |
Preferred Generic |
$2.00 | N/A | None |
ALMOTRIPTAN MALATE 12.5 MG TAB [Axert] |
2* |
Generic |
$10.00 | N/A | Q:12 /30Days |
ALMOTRIPTAN MALATE 6.25 MG TAB [Axert] |
2* |
Generic |
$10.00 | N/A | Q:12 /30Days |
ALOCRIL 2% EYE DROPS |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
ALOMIDE 0.1% EYE DROPS |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
ALORA 0.025 MG PATCH |
3 |
Preferred Brand |
$42.00 | N/A | None |
ALORA 0.05 MG PATCH |
3 |
Preferred Brand |
$42.00 | N/A | None |
ALORA 0.075 MG PATCH |
3 |
Preferred Brand |
$42.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALORA 0.1 MG PATCH |
3 |
Preferred Brand |
$42.00 | N/A | None |
ALOSETRON HCL 0.5 MG TABLET [Lotronex] |
5 |
Specialty Tier |
31% | N/A | None |
ALOSETRON HCL 1 MG TABLET [Lotronex] |
5 |
Specialty Tier |
31% | N/A | None |
ALPHAGAN P 0.1% DROPS |
3 |
Preferred Brand |
$42.00 | N/A | None |
ALPRAZOLAM 0.25 MG TABLET |
1* |
Preferred Generic |
$2.00 | N/A | None |
Alprazolam 0.25mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PAC |
2* |
Generic |
$10.00 | N/A | None |
ALPRAZOLAM 0.5 MG TABLET |
1* |
Preferred Generic |
$2.00 | N/A | None |
Alprazolam 0.5mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
2* |
Generic |
$10.00 | N/A | None |
ALPRAZOLAM 1 MG TABLET |
1* |
Preferred Generic |
$2.00 | N/A | None |
Alprazolam 1mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
2* |
Generic |
$10.00 | N/A | None |
Alprazolam 1mg/mL 1 BOTTLE in 1 CONTAINER / 30 mL in 1 BOTTLE |
2* |
Generic |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALPRAZOLAM 2 MG TABLET |
1* |
Preferred Generic |
$2.00 | N/A | None |
Alprazolam 2mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
2* |
Generic |
$10.00 | N/A | None |
ALPRAZOLAM ER 0.5 MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
ALPRAZOLAM ER 1 MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
ALPRAZOLAM ER 2 MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
ALPRAZOLAM ER 3 MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
ALTOPREV 20 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
ALTOPREV 40MG TABLET SR 24HR |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
ALUNBRIG 30 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P |
AMANTADINE 100MG CAPSULE |
2* |
Generic |
$10.00 | N/A | None |
AMANTADINE 100MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Amantadine Hydrochloride 50mg/5mL 473 mL in 1 BOTTLE |
2* |
Generic |
$10.00 | N/A | None |
AMBISOME 50MG VIAL |
5 |
Specialty Tier |
31% | N/A | P |
AMCINONIDE 0.1% CREAM |
2* |
Generic |
$10.00 | N/A | None |
AMCINONIDE 0.1% LOTION |
2* |
Generic |
$10.00 | N/A | None |
AMCINONIDE 0.1% OINTMENT 60GM TUBE |
2* |
Generic |
$10.00 | N/A | None |
Amethia 0.15-0.03-0.01 mg tab |
2* |
Generic |
$10.00 | N/A | None |
AMIKACIN SULFATE 500 MG/2 ML VIAL |
2* |
Generic |
$10.00 | N/A | None |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT |
2* |
Generic |
$10.00 | N/A | None |
Aminophylline 25mg/mL 5 TRAY per CARTON / 5 AMPULE in 1 TRAY / 10 mL in 1 AMPULE |
2* |
Generic |
$10.00 | N/A | None |
AMINOSYN 7%-ELECTROLYTE SOL |
3 |
Preferred Brand |
$42.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN II 15% IV SOLUTION |
2* |
Generic |
$10.00 | N/A | P |
AMINOSYN II 8.5% ELECTROLYT |
3 |
Preferred Brand |
$42.00 | N/A | P |
AMINOSYN II 8.5% ELECTROLYT |
3 |
Preferred Brand |
$42.00 | N/A | P |
AMINOSYN PF INJECTION |
3 |
Preferred Brand |
$42.00 | N/A | P |
AMINOSYN-PF 7% IV SOLUTION |
3 |
Preferred Brand |
$42.00 | N/A | P |
Amiodarone 150 mg/3 ml ampule |
2* |
Generic |
$10.00 | N/A | None |
AMIODARONE HCL 200 MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
AMIODARONE HCL 400MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
AMITIZA 8MCG CAPSULE |
3 |
Preferred Brand |
$42.00 | N/A | None |
AMITIZA CAPSULES 24MCG 60 CAP BOT |
3 |
Preferred Brand |
$42.00 | N/A | None |
AMITRIPTYLINE HCL 100MG TABLET |
2* |
Generic |
$10.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIPTYLINE HCL 10MG TABLET |
2* |
Generic |
$10.00 | N/A | P |
AMITRIPTYLINE HCL 150 MG TAB |
2* |
Generic |
$10.00 | N/A | P |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
2* |
Generic |
$10.00 | N/A | P |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
2* |
Generic |
$10.00 | N/A | P |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
2* |
Generic |
$10.00 | N/A | P |
AMLOD-VALSA-HCTZ 10-160-12.5 MG [EXFORGE HCT] |
2* |
Generic |
$10.00 | N/A | None |
AMLOD-VALSA-HCTZ 10-160-25 MG [EXFORGE HCT] |
2* |
Generic |
$10.00 | N/A | None |
AMLOD-VALSA-HCTZ 10-320-25 MG [EXFORGE HCT] |
2* |
Generic |
$10.00 | N/A | None |
AMLOD-VALSA-HCTZ 5-160-12.5 MG [EXFORGE HCT] |
2* |
Generic |
$10.00 | N/A | None |
AMLOD-VALSA-HCTZ 5-160-25 MG [EXFORGE HCT] |
2* |
Generic |
$10.00 | N/A | None |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
1* |
Preferred Generic |
$2.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1* |
Preferred Generic |
$2.00 | N/A | None |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
1* |
Preferred Generic |
$2.00 | N/A | None |
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE |
2* |
Generic |
$10.00 | N/A | None |
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE |
2* |
Generic |
$10.00 | N/A | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE |
2* |
Generic |
$10.00 | N/A | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE |
2* |
Generic |
$10.00 | N/A | None |
Amlodipine-Atorvastatin 10-10 mg [Caduet] |
2* |
Generic |
$10.00 | N/A | None |
Amlodipine-Atorvastatin 10-20 mg [Caduet] |
2* |
Generic |
$10.00 | N/A | None |
Amlodipine-Atorvastatin 10-40 mg [Caduet] |
2* |
Generic |
$10.00 | N/A | None |
Amlodipine-Atorvastatin 10-80 mg [Caduet] |
2* |
Generic |
$10.00 | N/A | None |
Amlodipine-Atorvastatin 2.5-10 mg [Caduet] |
2* |
Generic |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Amlodipine-Atorvastatin 2.5-20 mg [Caduet] |
2* |
Generic |
$10.00 | N/A | None |
Amlodipine-Atorvastatin 2.5-40 mg [Caduet] |
2* |
Generic |
$10.00 | N/A | None |
Amlodipine-Atorvastatin 5-10 mg [Caduet] |
2* |
Generic |
$10.00 | N/A | None |
Amlodipine-Atorvastatin 5-20 mg [Caduet] |
2* |
Generic |
$10.00 | N/A | None |
Amlodipine-Atorvastatin 5-40 mg [Caduet] |
2* |
Generic |
$10.00 | N/A | None |
Amlodipine-Atorvastatin 5-80 mg [Caduet] |
2* |
Generic |
$10.00 | N/A | None |
AMLODIPINE-BENAZEPRIL 10-40 MG |
2* |
Generic |
$10.00 | N/A | None |
AMLODIPINE-BENAZEPRIL 5-40 MG |
2* |
Generic |
$10.00 | N/A | None |
AMLODIPINE-OLMESARTAN 5-40 MG [Azor] |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
Amlodipine-Olmesartan medoxomil 10 MG / 20 MG Oral Tablet [Azor] |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
Amlodipine-Olmesartan medoxomil 10 MG / 40 MG Oral Tablet [Azor] |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Amlodipine-Olmesartan medoxomil 5 MG / 20 MG Oral Tablet [Azor] |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
AMLODIPINE-VALSARTAN 10-160 MG |
2* |
Generic |
$10.00 | N/A | None |
AMLODIPINE-VALSARTAN 10-320 MG |
2* |
Generic |
$10.00 | N/A | None |
AMLODIPINE-VALSARTAN 5-160 MG |
2* |
Generic |
$10.00 | N/A | None |
AMLODIPINE-VALSARTAN 5-320 MG |
2* |
Generic |
$10.00 | N/A | None |
AMMONIUM LACTATE 12% CREAM |
2* |
Generic |
$10.00 | N/A | None |
AMMONIUM LACTATE 12% LOTION |
2* |
Generic |
$10.00 | N/A | None |
AMOX TR-K CLV 500-125 MG TAB |
2* |
Generic |
$10.00 | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
2* |
Generic |
$10.00 | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
2* |
Generic |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
2* |
Generic |
$10.00 | N/A | None |
AMOX-CLAV 200-28.5 MG/5 ML SUS |
2* |
Generic |
$10.00 | N/A | None |
AMOXAPINE 100MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
AMOXAPINE 150MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
AMOXAPINE 25MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
AMOXAPINE 50MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
AMOXICILLIN 125MG TABLET CHEW |
2* |
Generic |
$10.00 | N/A | None |
AMOXICILLIN 250MG 500 CHEWABLE TABLET in BOTTLE |
2* |
Generic |
$10.00 | N/A | None |
AMOXICILLIN 250MG CAPSULE |
2* |
Generic |
$10.00 | N/A | None |
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION |
2* |
Generic |
$10.00 | N/A | None |
AMOXICILLIN 500MG 500 CAPSULE BOTTLE |
2* |
Generic |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN 500MG TABLET (100 CT) |
2* |
Generic |
$10.00 | N/A | None |
AMOXICILLIN 875MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
2* |
Generic |
$10.00 | N/A | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG |
2* |
Generic |
$10.00 | N/A | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
2* |
Generic |
$10.00 | N/A | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
2* |
Generic |
$10.00 | N/A | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
2* |
Generic |
$10.00 | N/A | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
2* |
Generic |
$10.00 | N/A | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
2* |
Generic |
$10.00 | N/A | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | Q:120 /30Days |
AMPHETAMINE SALT COMBO 15MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | Q:120 /30Days |
AMPHETAMINE SALTS 5 MG TAB |
4 |
Non-Preferred Drug |
$95.00 | N/A | Q:120 /30Days |
amphotericin b 50mg/10mL 10 mL in 1 VIAL |
2* |
Generic |
$10.00 | N/A | P |
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS |
2* |
Generic |
$10.00 | N/A | None |
AMPICILLIN CAPSULES 250MG 100 BOT |
1* |
Preferred Generic |
$2.00 | N/A | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
2* |
Generic |
$10.00 | N/A | None |
AMPICILLIN FOR INJECTION POWDER |
2* |
Generic |
$10.00 | N/A | None |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
2* |
Generic |
$10.00 | N/A | None |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
2* |
Generic |
$10.00 | N/A | None |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML |
2* |
Generic |
$10.00 | N/A | None |
AMPICILLIN-SULBACTAM 15 GM VIAL |
2* |
Generic |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN-SULBACTAM 3 GM VIAL |
2* |
Generic |
$10.00 | N/A | None |
AMPYRA ER 10 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P |
ANADROL-50 TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE |
2* |
Generic |
$10.00 | N/A | None |
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE |
2* |
Generic |
$10.00 | N/A | None |
Anastrozole 1mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC |
2* |
Generic |
$10.00 | N/A | None |
ANCOBON 250MG CAPSULE |
5 |
Specialty Tier |
31% | N/A | None |
ANCOBON 500MG CAPSULE |
5 |
Specialty Tier |
31% | N/A | None |
ANDRODERM 2 MG/24HR PATCH |
3 |
Preferred Brand |
$42.00 | N/A | P Q:30 /30Days |
ANDRODERM 4 MG/24HR PATCH |
3 |
Preferred Brand |
$42.00 | N/A | P Q:30 /30Days |
ANDROGEL 1.62% (1.25G) GEL PCKT |
3 |
Preferred Brand |
$42.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANDROGEL 1.62% (2.5G) GEL PCKT |
3 |
Preferred Brand |
$42.00 | N/A | P |
ANDROGEL 1% (50MG) GEL PACKET |
3 |
Preferred Brand |
$42.00 | N/A | P |
Androgel 16.2mg/g 1 BOTTLE, PUMP per CARTON / 88 g in 1 BOTTLE, PUMP |
3 |
Preferred Brand |
$42.00 | N/A | P |
ANORO ELLIPTA 62.5-25 MCG INH |
4 |
Non-Preferred Drug |
$95.00 | N/A | Q:60 /30Days |
ANZEMET 100 MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | P Q:20 /30Days |
ANZEMET 50 MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | P Q:20 /30Days |
APIDRA 100 UNITS/ML VIAL |
4 |
Non-Preferred Drug |
$95.00 | N/A | S |
APIDRA SOLOSTAR 100 UNITS/ML |
4 |
Non-Preferred Drug |
$95.00 | N/A | S |
APLENZIN ER 174 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
APLENZIN ER 348 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
APLENZIN ER 522 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | 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 |
Specialty Tier |
31% | N/A | None |
Apraclonidine Ophthalmic 5mg/mL 1 BOTTLE, DROPPER per CARTON / 10 mL in 1 BOTTLE, DROPPER |
2* |
Generic |
$10.00 | N/A | None |
APREPITANT 125 MG CAPSULE [Emend] |
4 |
Non-Preferred Drug |
$95.00 | N/A | P Q:6 /30Days |
APREPITANT 125-80-80 MG PACK [Emend] |
4 |
Non-Preferred Drug |
$95.00 | N/A | P Q:6 /30Days |
APREPITANT 40 MG CAPSULE [Emend] |
4 |
Non-Preferred Drug |
$95.00 | N/A | P Q:6 /30Days |
APREPITANT 80 MG CAPSULE [Emend] |
4 |
Non-Preferred Drug |
$95.00 | N/A | P Q:6 /30Days |
APRI 0.15-0.03 TABLET |
2* |
Generic |
$10.00 | N/A | None |
APRISO CP24 |
3 |
Preferred Brand |
$42.00 | N/A | None |
APTIOM 200 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | Q:30 /30Days |
APTIOM 400 MG TABLET |
5 |
Specialty Tier |
31% | N/A | Q:30 /30Days |
APTIOM 600 MG TABLET |
5 |
Specialty Tier |
31% | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APTIOM 800 MG TABLET |
5 |
Specialty Tier |
31% | N/A | Q:30 /30Days |
APTIVUS 250MG CAPSULE |
5 |
Specialty Tier |
31% | N/A | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
ARALAST NP 500 MG VIAL |
5 |
Specialty Tier |
31% | N/A | P |
ARANELLE 7-9-5 TABLET |
2* |
Generic |
$10.00 | N/A | None |
ARANESP 10 MCG/0.4 ML SYRINGE |
4 |
Non-Preferred Drug |
$95.00 | N/A | 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 |
31% | N/A | P |
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
4 |
Non-Preferred Drug |
$95.00 | N/A | P |
ARANESP 200MCG/0.4ML SYRINGE |
5 |
Specialty Tier |
31% | N/A | P |
ARANESP 200MCG/ML VIAL |
5 |
Specialty Tier |
31% | N/A | P |
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.42 mL in 1 SYRING |
4 |
Non-Preferred Drug |
$95.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
4 |
Non-Preferred Drug |
$95.00 | N/A | P |
ARANESP 300MCG/ML VIAL |
5 |
Specialty Tier |
31% | N/A | P |
ARANESP 500MCG/1ML SYRINGE |
5 |
Specialty Tier |
31% | N/A | P |
ARANESP 60MCG/ML VIAL |
4 |
Non-Preferred Drug |
$95.00 | N/A | P |
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.3 mL in 1 SYRINGE |
4 |
Non-Preferred Drug |
$95.00 | N/A | P |
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR |
5 |
Specialty Tier |
31% | N/A | P |
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR |
5 |
Specialty Tier |
31% | N/A | P |
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR |
4 |
Non-Preferred Drug |
$95.00 | N/A | P |
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD |
4 |
Non-Preferred Drug |
$95.00 | N/A | P |
ARCALYST INJECTION 220MG/VIAL |
5 |
Specialty Tier |
31% | N/A | None |
Arcapta Neohaler 75ug/1 30 BLISTER PACK in 1 BOX / 1 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Drug |
$95.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARIPIPRAZOLE 10 MG TABLET [Abilify] |
2* |
Generic |
$10.00 | N/A | P Q:30 /30Days |
ARIPIPRAZOLE 15 MG TABLET [Abilify] |
2* |
Generic |
$10.00 | N/A | P Q:30 /30Days |
ARIPIPRAZOLE 2 MG TABLET [Abilify] |
2* |
Generic |
$10.00 | N/A | P Q:30 /30Days |
ARIPIPRAZOLE 20 MG TABLET [Abilify] |
2* |
Generic |
$10.00 | N/A | P Q:30 /30Days |
ARIPIPRAZOLE 30 MG TABLET [Abilify] |
2* |
Generic |
$10.00 | N/A | P Q:30 /30Days |
ARIPIPRAZOLE 5 MG TABLET [Abilify] |
2* |
Generic |
$10.00 | N/A | P Q:30 /30Days |
ARIPIPRAZOLE ODT 10 MG TABLET [Abilify] |
4 |
Non-Preferred Drug |
$95.00 | N/A | P Q:60 /30Days |
ARIPIPRAZOLE ODT 15 MG TABLET [Abilify] |
4 |
Non-Preferred Drug |
$95.00 | N/A | P Q:60 /30Days |
ARISTADA ER 1064 MG/3.9 ML SYR |
5 |
Specialty Tier |
31% | N/A | None |
ARISTADA ER 441 MG/1.6 ML SYRN |
5 |
Specialty Tier |
31% | N/A | None |
ARISTADA ER 662 MG/2.4 ML SYRN |
5 |
Specialty Tier |
31% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARISTADA ER 882 MG/3.2 ML SYRN |
5 |
Specialty Tier |
31% | N/A | None |
Armodafinil 150 MG TABLET [NUVIGIL] |
4 |
Non-Preferred Drug |
$95.00 | N/A | P Q:30 /30Days |
Armodafinil 200 MG Oral Tablet [NUVIGIL] |
4 |
Non-Preferred Drug |
$95.00 | N/A | P Q:30 /30Days |
Armodafinil 250 MG TABLET [NUVIGIL] |
4 |
Non-Preferred Drug |
$95.00 | N/A | P Q:30 /30Days |
Armodafinil 50 MG TABLET [NUVIGIL] |
4 |
Non-Preferred Drug |
$95.00 | N/A | P Q:30 /30Days |
ARNUITY ELLIPTA 100 MCG INH |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
ARNUITY ELLIPTA 200 MCG INH |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
ARRANON 250 MG VIAL |
5 |
Specialty Tier |
31% | N/A | None |
ASACOL HD DR 800 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | S |
Aspirin-Diphenhydramine ER 25-200 MG |
2* |
Generic |
$10.00 | N/A | None |
ASTAGRAF XL 0.5 MG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ASTAGRAF XL 1 MG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | N/A | P |
ASTAGRAF XL 5 MG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | N/A | P |
ATENOLOL 100 MG100 TABLET BOTTLE |
1* |
Preferred Generic |
$2.00 | N/A | None |
ATENOLOL 25 MG 100 TABLET BOTTLE |
1* |
Preferred Generic |
$2.00 | N/A | None |
ATENOLOL TABLET USP 50MG (100 CT) |
1* |
Preferred Generic |
$2.00 | N/A | None |
ATENOLOL-CHLORTHALIDONE 100-25 |
1* |
Preferred Generic |
$2.00 | N/A | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
1* |
Preferred Generic |
$2.00 | N/A | None |
ATGAM 50MG/ML AMPUL |
5 |
Specialty Tier |
31% | N/A | P |
Atomoxetine 10 MG Oral Capsule [Strattera] |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
Atomoxetine 100 MG Oral Capsule [Strattera] |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
Atomoxetine 18 MG Oral Capsule [Strattera] |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Atomoxetine 25 MG Oral Capsule [Strattera] |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
Atomoxetine 40 MG Oral Capsule [Strattera] |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
Atomoxetine 60 MG Oral Capsule [Strattera] |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
Atomoxetine 80 MG Oral Capsule [Strattera] |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
ATORVASTATIN 10 MG TABLET [Lipitor] |
1* |
Preferred Generic |
$2.00 | N/A | None |
ATORVASTATIN 20 MG TABLET [Lipitor] |
2* |
Generic |
$10.00 | N/A | None |
ATORVASTATIN 40 MG TABLET [Lipitor] |
2* |
Generic |
$10.00 | N/A | None |
ATORVASTATIN 80 MG TABLET [Lipitor] |
2* |
Generic |
$10.00 | N/A | None |
ATOVAQUONE 750 MG/5 ML SUSP [Mepron] |
5 |
Specialty Tier |
31% | N/A | None |
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone] |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
Atovaquone-Proguanil 62.5-25 [Malarone] |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
5 |
Specialty Tier |
31% | N/A | None |
Atropine 1% Eye Drops |
2* |
Generic |
$10.00 | N/A | None |
ATROVENT HFA AER 17MCG |
3 |
Preferred Brand |
$42.00 | N/A | None |
AUBAGIO 14 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P |
AUBAGIO 7 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P |
AURYXIA 210 MG TABLET |
5 |
Specialty Tier |
31% | N/A | S |
AUSTEDO 12 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P Q:120 /30Days |
AUSTEDO 6 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P Q:240 /30Days |
AUSTEDO 9 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P Q:150 /30Days |
AUVI-Q 0.15 MG AUTO-INJECTOR |
5 |
Specialty Tier |
31% | N/A | P Q:2 /30Days |
AUVI-Q 0.3 MG AUTO-INJECTOR |
5 |
Specialty Tier |
31% | N/A | P Q:2 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVANDIA 2 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
AVANDIA 4 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
AVASTIN 100MG/4ML VIAL |
5 |
Specialty Tier |
31% | N/A | None |
AVASTIN 400 MG/16 ML VIAL |
5 |
Specialty Tier |
31% | N/A | None |
AVEED 750 MG/3 ML VIAL |
4 |
Non-Preferred Drug |
$95.00 | N/A | P |
AVIANE 0.1-0.02 TABLET |
2* |
Generic |
$10.00 | N/A | None |
AVONEX ADMIN PACK 30 MCG VL |
5 |
Specialty Tier |
31% | N/A | None |
AVONEX PEN 30 MCG/0.5 ML KIT |
5 |
Specialty Tier |
31% | N/A | None |
AVONEX PREFILLED SYR 30 MCG KT |
5 |
Specialty Tier |
31% | N/A | None |
AVYCAZ 2.5 GRAM VIAL |
5 |
Specialty Tier |
31% | N/A | None |
AXIRON 30mg/1.5mL 1 BOTTLE, WITH APPLICATOR per CARTON / 90 mL in 1 BOTTLE, WITH APPLICATOR |
3 |
Preferred Brand |
$42.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Azacitidine 100 mg vial [Vidaza] |
5 |
Specialty Tier |
31% | N/A | None |
AZACTAM INJECTION 1GM/50ML |
3 |
Preferred Brand |
$42.00 | N/A | None |
AZACTAM INJECTION 2GM/50ML |
3 |
Preferred Brand |
$42.00 | N/A | None |
AZASAN 100MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | P |
AZASAN 75MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | P |
AZASITE 1% EYE DROPS |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
AZATHIOPRINE 50 MG TABLET |
2* |
Generic |
$10.00 | N/A | P |
AZATHIOPRINE SODIUM 100 MG VIAL |
5 |
Specialty Tier |
31% | N/A | P |
AZELASTINE 0.15% NASAL SPRAY |
2* |
Generic |
$10.00 | N/A | None |
AZELASTINE 137 MCG NASAL SPRAY |
2* |
Generic |
$10.00 | N/A | None |
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION |
2* |
Generic |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZELEX 20% CREAM 30GM TUBE |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
AZILECT 0.5MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | None |
AZILECT 1MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | None |
AZITHROMYCIN 1 GM PWD PACKET |
2* |
Generic |
$10.00 | N/A | None |
AZITHROMYCIN 100 MG/5 ML SUSP |
2* |
Generic |
$10.00 | N/A | None |
Azithromycin 200mg/5mL 22.5 mL in 1 BOTTLE |
2* |
Generic |
$10.00 | N/A | None |
AZITHROMYCIN 250 MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
AZITHROMYCIN 250 MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION |
2* |
Generic |
$10.00 | N/A | None |
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE |
2* |
Generic |
$10.00 | N/A | None |
Azithromycin 600mg/1 30 FILM COATED TABLETS in BOTTLE |
2* |
Generic |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT |
3 |
Preferred Brand |
$42.00 | N/A | None |
AZOR 10-20 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
AZOR 10MG-40MG TABLET (30 CT) |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
AZOR 5-40 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
AZOR 5MG-20MG TABLET (30 CT) |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |