2017 Medicare Part D Plan Formulary Information |
SilverScript Plus (PDP) (S5601-023-0)
Benefit Details
|
The SilverScript Plus (PDP) (S5601-023-0) Formulary Drugs Starting with the Letter A in CMS PDP Region 11 which includes: FL Plan Monthly Premium: $75.00 Deductible: $0 Qualifies for LIS: No |
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 |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir] |
5 |
Specialty Tier |
33% | N/A | None |
ABACAVIR-LAMIVUDINE 600-300 MG [Epzicom] |
5 |
Specialty Tier |
33% | N/A | None |
ABELCENT INJECTION SUSPENSION 5MG/ML |
5 |
Specialty Tier |
33% | N/A | P |
ABILIFY MAINTENA ER 300 MG SYR |
4 |
Non-Preferred Drug |
40% | 40% | Q:1 /28Days |
ABILIFY MAINTENA ER 300 MG VL |
4 |
Non-Preferred Drug |
40% | 40% | Q:1 /28Days |
ABILIFY MAINTENA ER 400 MG SYR |
4 |
Non-Preferred Drug |
40% | 40% | Q:1 /28Days |
ABRAXANE 100MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
Acamprosate Calcium DR 333 MG tablets [Campral] |
4 |
Non-Preferred Drug |
40% | 40% | None |
ACARBOSE 100 MG TABLET |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACARBOSE 25 MG TABLET |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
Acarbose 50mg/1 100 TABLET BOTTLE |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
ACEBUTOLOL 200MG CAPSULE |
2 |
Generic |
$3.00 | $0.00 | None |
ACEBUTOLOL 400MG CAPSULE |
2 |
Generic |
$3.00 | $0.00 | None |
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
ACETAMINOP-CODEINE 120-12 MG/5 |
2 |
Generic |
$3.00 | $0.00 | Q:5000 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
2 |
Generic |
$3.00 | $0.00 | Q:400 /30Days |
ACETAMINOPHEN-COD #3 TABLET |
2 |
Generic |
$3.00 | $0.00 | Q:400 /30Days |
ACETAMINOPHEN-COD #4 TABLET |
2 |
Generic |
$3.00 | $0.00 | Q:400 /30Days |
ACETAZOLAMIDE 125MG TABLET |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAZOLAMIDE ER CAPSULES 500MG 100 BOT |
4 |
Non-Preferred Drug |
40% | 40% | None |
ACETIC ACID 2% EAR SOLUTION |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
ACETYLCYSTEINE 10% VIAL |
3 |
Preferred Brand |
$27.00 | $67.50 | P |
ACETYLCYSTEINE 20% VIAL |
3 |
Preferred Brand |
$27.00 | $67.50 | P |
ACITRETIN 10 MG CAPSULE [Soriatane] |
5 |
Specialty Tier |
33% | N/A | P |
ACITRETIN 17.5 MG CAPSULE [Soriatane] |
5 |
Specialty Tier |
33% | N/A | P |
ACITRETIN 25 MG CAPSULE [Soriatane] |
5 |
Specialty Tier |
33% | N/A | P |
ACTHIB VACCINE WITH DILUENT |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
ACTIMMUNE 100 MCG/0.5 ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
Acyclovir 200mg 100 CAPSULE BOTTLE |
2 |
Generic |
$3.00 | $0.00 | None |
Acyclovir 200mg/5mL 473 mL BOTTLE |
4 |
Non-Preferred Drug |
40% | 40% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Acyclovir 400mg/1 |
2 |
Generic |
$3.00 | $0.00 | None |
ACYCLOVIR 800 MG TABLET |
2 |
Generic |
$3.00 | $0.00 | None |
Acyclovir sodium 500 mg vial |
4 |
Non-Preferred Drug |
40% | 40% | P |
ADACEL VIAL 2UNT/5UNT |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
ADAGEN 250U/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA] |
5 |
Specialty Tier |
33% | N/A | P Q:2 /28Days |
ADCIRCA TABLETS 20MG 60 BOTTLE |
5 |
Specialty Tier |
33% | N/A | P |
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera] |
5 |
Specialty Tier |
33% | N/A | None |
ADEMPAS 0.5 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:90 /30Days |
ADEMPAS 1 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:90 /30Days |
ADEMPAS 1.5 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADEMPAS 2 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:90 /30Days |
ADEMPAS 2.5 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:90 /30Days |
Adriamycin 20 mg/10 ml vial |
4 |
Non-Preferred Drug |
40% | 40% | P |
ADRUCIL 50mg/mL 10 VIAL in 1 TRAY / 10 mL in 1 VIAL |
4 |
Non-Preferred Drug |
40% | 40% | P |
ADVAIR DISKUS MIS 100/50 |
4 |
Non-Preferred Drug |
40% | 40% | Q:60 /30Days |
ADVAIR DISKUS MIS 250/50 |
4 |
Non-Preferred Drug |
40% | 40% | Q:60 /30Days |
ADVAIR DISKUS MIS 500/50 |
4 |
Non-Preferred Drug |
40% | 40% | Q:60 /30Days |
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER |
4 |
Non-Preferred Drug |
40% | 40% | Q:12 /30Days |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL |
4 |
Non-Preferred Drug |
40% | 40% | Q:12 /30Days |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
4 |
Non-Preferred Drug |
40% | 40% | Q:12 /30Days |
AFEDITAB CR 30MG TABLET SA |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AFEDITAB CR 60MG TABLET SA |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK |
5 |
Specialty Tier |
33% | N/A | P |
AFINITOR DISPERZ 2 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
AFINITOR DISPERZ 3 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
AFINITOR DISPERZ 5 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
AFINITOR TABLETS 10 MG |
5 |
Specialty Tier |
33% | N/A | P |
AFINITOR TABLETS 2.5 MG |
5 |
Specialty Tier |
33% | N/A | P |
AFINITOR TABLETS 5 MG |
5 |
Specialty Tier |
33% | N/A | P |
AGGRENOX 25-200MG CAPSULE |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
ALA-CORT 1% CREAM |
2 |
Generic |
$3.00 | $0.00 | None |
Ala-cort 2.5% cream |
2 |
Generic |
$3.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBENZA 200 MG TABLET |
5 |
Specialty Tier |
33% | 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 |
$3.00 | $0.00 | P |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
2 |
Generic |
$3.00 | $0.00 | P |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
2 |
Generic |
$3.00 | $0.00 | P |
ALBUTEROL SULFATE SOLUTION FOR INHALATION |
2 |
Generic |
$3.00 | $0.00 | P |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
2 |
Generic |
$3.00 | $0.00 | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
4 |
Non-Preferred Drug |
40% | 40% | None |
ALBUTEROL TABLET 4MG (500 CT) |
4 |
Non-Preferred Drug |
40% | 40% | None |
ALCLOMETASONE DIPROPIONATE 0.05% CREAM |
4 |
Non-Preferred Drug |
40% | 40% | None |
Alclometasone Dipropionate 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
ALDURAZYME 2.9MG/5ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALECENSA 150 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
ALENDRONATE SODIUM 10 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ALENDRONATE SODIUM 35 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ALENDRONATE SODIUM 40 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ALENDRONATE SODIUM 5 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ALENDRONATE SODIUM 70 MG TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ALFUZOSIN HYDROCHLORIDE 10mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2 |
Generic |
$3.00 | $0.00 | None |
ALIMTA 500MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
ALINIA 100 MG/5 ML SUSPENSION |
4 |
Non-Preferred Drug |
40% | 40% | None |
ALINIA 500 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
ALLOPURINOL 100 MG TABLETS |
2 |
Generic |
$3.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET per BLISTER PACK |
2 |
Generic |
$3.00 | $0.00 | None |
ALOSETRON HCL 0.5 MG TABLET [Lotronex] |
5 |
Specialty Tier |
33% | N/A | P |
ALOSETRON HCL 1 MG TABLET [Lotronex] |
5 |
Specialty Tier |
33% | N/A | P |
ALPHAGAN P 0.1% DROPS |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
ALPHAGAN P 0.15% EYE DROPS |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
ALPRAZOLAM 0.25 MG TABLET |
2 |
Generic |
$3.00 | $0.00 | Q:480 /30Days |
ALPRAZOLAM 0.5 MG TABLET |
2 |
Generic |
$3.00 | $0.00 | Q:240 /30Days |
ALPRAZOLAM 1 MG TABLET |
2 |
Generic |
$3.00 | $0.00 | Q:120 /30Days |
ALPRAZOLAM 2 MG TABLET |
2 |
Generic |
$3.00 | $0.00 | Q:150 /30Days |
ALREX 0.2% EYE DROPS |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
ALUNBRIG 30 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Alyacen 1-35-28 tablet |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
AMANTADINE 100MG CAPSULE |
4 |
Non-Preferred Drug |
40% | 40% | Q:120 /30Days |
AMANTADINE 100MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
Amantadine Hydrochloride 50mg/5mL 473 mL in 1 BOTTLE |
2 |
Generic |
$3.00 | $0.00 | None |
AMBISOME 50MG VIAL |
4 |
Non-Preferred Drug |
40% | 40% | P |
AMIKACIN SULFATE 500 MG/2 ML VIAL |
4 |
Non-Preferred Drug |
40% | 40% | None |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
2 |
Generic |
$3.00 | $0.00 | None |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
Aminophylline 25mg/mL 5 TRAY per CARTON / 5 AMPULE in 1 TRAY / 10 mL in 1 AMPULE |
4 |
Non-Preferred Drug |
40% | 40% | None |
AMINOSYN 7%-ELECTROLYTE SOL |
4 |
Non-Preferred Drug |
40% | 40% | P |
AMINOSYN HBC INJECTION SULFITE FREE 7% |
4 |
Non-Preferred Drug |
40% | 40% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN II 10% IV SOLUTION |
4 |
Non-Preferred Drug |
40% | 40% | P |
AMINOSYN II 8.5% ELECTROLYT |
4 |
Non-Preferred Drug |
40% | 40% | P |
AMINOSYN II 8.5% ELECTROLYT |
4 |
Non-Preferred Drug |
40% | 40% | P |
AMINOSYN PF INJECTION |
4 |
Non-Preferred Drug |
40% | 40% | P |
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5% |
4 |
Non-Preferred Drug |
40% | 40% | P |
AMINOSYN-PF 7% IV SOLUTION |
4 |
Non-Preferred Drug |
40% | 40% | P |
AMINOSYN-RF 5.2% IV SOLUTION |
4 |
Non-Preferred Drug |
40% | 40% | P |
Amiodarone 150 mg/3 ml ampule |
4 |
Non-Preferred Drug |
40% | 40% | None |
Amiodarone hcl 100 mg tablet |
4 |
Non-Preferred Drug |
40% | 40% | None |
AMIODARONE HCL 200 MG TABLET |
2 |
Generic |
$3.00 | $0.00 | None |
AMIODARONE HCL 400MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITIZA 8MCG CAPSULE |
3 |
Preferred Brand |
$27.00 | $67.50 | Q:60 /30Days |
AMITIZA CAPSULES 24MCG 60 CAP BOT |
3 |
Preferred Brand |
$27.00 | $67.50 | Q:60 /30Days |
AMITRIPTYLINE HCL 100MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
AMITRIPTYLINE HCL 10MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
AMITRIPTYLINE HCL 150 MG TAB |
4 |
Non-Preferred Drug |
40% | 40% | None |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
4 |
Non-Preferred Drug |
40% | 40% | None |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
4 |
Non-Preferred Drug |
40% | 40% | None |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
4 |
Non-Preferred Drug |
40% | 40% | None |
AMLOD-VALSA-HCTZ 10-160-12.5 MG [EXFORGE HCT] |
2 |
Generic |
$3.00 | $0.00 | None |
AMLOD-VALSA-HCTZ 10-160-25 MG [EXFORGE HCT] |
2 |
Generic |
$3.00 | $0.00 | None |
AMLOD-VALSA-HCTZ 10-320-25 MG [EXFORGE HCT] |
2 |
Generic |
$3.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLOD-VALSA-HCTZ 5-160-12.5 MG [EXFORGE HCT] |
2 |
Generic |
$3.00 | $0.00 | None |
AMLOD-VALSA-HCTZ 5-160-25 MG [EXFORGE HCT] |
2 |
Generic |
$3.00 | $0.00 | None |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE |
2 |
Generic |
$3.00 | $0.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE |
2 |
Generic |
$3.00 | $0.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE |
2 |
Generic |
$3.00 | $0.00 | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE |
2 |
Generic |
$3.00 | $0.00 | None |
AMLODIPINE-BENAZEPRIL 10-40 MG |
2 |
Generic |
$3.00 | $0.00 | None |
AMLODIPINE-BENAZEPRIL 5-40 MG |
2 |
Generic |
$3.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE-OLMESARTAN 5-40 MG [Azor] |
2 |
Generic |
$3.00 | $0.00 | None |
Amlodipine-Olmesartan medoxomil 10 MG / 20 MG Oral Tablet [Azor] |
2 |
Generic |
$3.00 | $0.00 | None |
Amlodipine-Olmesartan medoxomil 10 MG / 40 MG Oral Tablet [Azor] |
2 |
Generic |
$3.00 | $0.00 | None |
Amlodipine-Olmesartan medoxomil 5 MG / 20 MG Oral Tablet [Azor] |
2 |
Generic |
$3.00 | $0.00 | None |
AMLODIPINE-VALSARTAN 10-160 MG |
2 |
Generic |
$3.00 | $0.00 | None |
AMLODIPINE-VALSARTAN 10-320 MG |
2 |
Generic |
$3.00 | $0.00 | None |
AMLODIPINE-VALSARTAN 5-160 MG |
2 |
Generic |
$3.00 | $0.00 | None |
AMLODIPINE-VALSARTAN 5-320 MG |
2 |
Generic |
$3.00 | $0.00 | None |
AMMONIUM LACTATE 12% CREAM |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
AMMONIUM LACTATE 12% LOTION |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
AMOX TR-K CLV 500-125 MG TAB |
2 |
Generic |
$3.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
2 |
Generic |
$3.00 | $0.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
AMOX-CLAV 200-28.5 MG/5 ML SUS |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
AMOXAPINE 100MG TABLET |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
AMOXAPINE 150MG TABLET |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
AMOXAPINE 25MG TABLET |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
AMOXAPINE 50MG TABLET |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
AMOXICILLIN 125MG TABLET CHEW |
2 |
Generic |
$3.00 | $0.00 | None |
AMOXICILLIN 250MG 500 CHEWABLE TABLET in BOTTLE |
2 |
Generic |
$3.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN 250MG CAPSULE |
2 |
Generic |
$3.00 | $0.00 | None |
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
AMOXICILLIN 500MG 500 CAPSULE BOTTLE |
2 |
Generic |
$3.00 | $0.00 | None |
AMOXICILLIN 500MG TABLET (100 CT) |
2 |
Generic |
$3.00 | $0.00 | None |
AMOXICILLIN 875MG TABLET |
2 |
Generic |
$3.00 | $0.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
2 |
Generic |
$3.00 | $0.00 | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG |
4 |
Non-Preferred Drug |
40% | 40% | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
2 |
Generic |
$3.00 | $0.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
2 |
Generic |
$3.00 | $0.00 | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
2 |
Generic |
$3.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
2 |
Generic |
$3.00 | $0.00 | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
3 |
Preferred Brand |
$27.00 | $67.50 | Q:144 /30Days |
AMPHETAMINE SALT COMBO 15MG TABLET |
3 |
Preferred Brand |
$27.00 | $67.50 | Q:120 /30Days |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
3 |
Preferred Brand |
$27.00 | $67.50 | Q:240 /30Days |
AMPHETAMINE SALTS 5 MG TAB |
3 |
Preferred Brand |
$27.00 | $67.50 | Q:360 /30Days |
amphotericin b 50mg/10mL 10 mL in 1 VIAL |
4 |
Non-Preferred Drug |
40% | 40% | P |
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS |
4 |
Non-Preferred Drug |
40% | 40% | None |
AMPICILLIN CAPSULES 250MG 100 BOT |
2 |
Generic |
$3.00 | $0.00 | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
2 |
Generic |
$3.00 | $0.00 | None |
AMPICILLIN FOR INJECTION POWDER |
4 |
Non-Preferred Drug |
40% | 40% | None |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML |
4 |
Non-Preferred Drug |
40% | 40% | None |
ampicillin-sulbactam 1.5 gm vl |
4 |
Non-Preferred Drug |
40% | 40% | None |
AMPICILLIN-SULBACTAM 15 GM VIAL |
4 |
Non-Preferred Drug |
40% | 40% | None |
AMPICILLIN-SULBACTAM 3 GM VIAL |
4 |
Non-Preferred Drug |
40% | 40% | None |
AMPYRA ER 10 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
ANADROL-50 TABLET |
5 |
Specialty Tier |
33% | N/A | P |
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE |
4 |
Non-Preferred Drug |
40% | 40% | None |
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE |
4 |
Non-Preferred Drug |
40% | 40% | None |
Anastrozole 1mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Generic |
$3.00 | $0.00 | None |
ANDRODERM 2 MG/24HR PATCH |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANDRODERM 4 MG/24HR PATCH |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
ANORO ELLIPTA 62.5-25 MCG INH |
3 |
Preferred Brand |
$27.00 | $67.50 | Q:60 /30Days |
APOKYN 30 MG/3 ML CARTRIDGE |
5 |
Specialty Tier |
33% | N/A | P |
APREPITANT 125 MG CAPSULE [Emend] |
4 |
Non-Preferred Drug |
40% | 40% | P |
APREPITANT 125-80-80 MG PACK [Emend] |
4 |
Non-Preferred Drug |
40% | 40% | P |
APREPITANT 40 MG CAPSULE [Emend] |
4 |
Non-Preferred Drug |
40% | 40% | P |
APREPITANT 80 MG CAPSULE [Emend] |
4 |
Non-Preferred Drug |
40% | 40% | P |
APRI 0.15-0.03 TABLET |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
APRISO CP24 |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
APTIOM 200 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | Q:180 /30Days |
APTIOM 400 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APTIOM 600 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | Q:60 /30Days |
APTIOM 800 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | Q:60 /30Days |
APTIVUS 250MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
5 |
Specialty Tier |
33% | N/A | None |
ARALAST NP 500 MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
ARANELLE 7-9-5 TABLET |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
ARCALYST INJECTION 220MG/VIAL |
5 |
Specialty Tier |
33% | N/A | P |
ARIPIPRAZOLE 10 MG TABLET [Abilify] |
4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days |
ARIPIPRAZOLE 15 MG TABLET [Abilify] |
4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days |
ARIPIPRAZOLE 2 MG TABLET [Abilify] |
4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days |
ARIPIPRAZOLE 20 MG TABLET [Abilify] |
4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARIPIPRAZOLE 30 MG TABLET [Abilify] |
4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days |
ARIPIPRAZOLE 5 MG TABLET [Abilify] |
4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days |
ARIPIPRAZOLE ODT 10 MG TABLET [Abilify] |
5 |
Specialty Tier |
33% | N/A | Q:60 /30Days |
ARIPIPRAZOLE ODT 15 MG TABLET [Abilify] |
5 |
Specialty Tier |
33% | N/A | Q:60 /30Days |
ARISTADA ER 1064 MG/3.9 ML SYR |
4 |
Non-Preferred Drug |
40% | 40% | Q:4 /56Days |
ARISTADA ER 441 MG/1.6 ML SYRN |
4 |
Non-Preferred Drug |
40% | 40% | Q:2 /28Days |
ARISTADA ER 662 MG/2.4 ML SYRN |
4 |
Non-Preferred Drug |
40% | 40% | Q:2 /28Days |
ARISTADA ER 882 MG/3.2 ML SYRN |
4 |
Non-Preferred Drug |
40% | 40% | Q:3 /28Days |
Armodafinil 150 MG TABLET [NUVIGIL] |
3 |
Preferred Brand |
$27.00 | $67.50 | P Q:60 /30Days |
Armodafinil 200 MG Oral Tablet [NUVIGIL] |
3 |
Preferred Brand |
$27.00 | $67.50 | P Q:30 /30Days |
Armodafinil 250 MG TABLET [NUVIGIL] |
3 |
Preferred Brand |
$27.00 | $67.50 | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Armodafinil 50 MG TABLET [NUVIGIL] |
3 |
Preferred Brand |
$27.00 | $67.50 | P Q:150 /30Days |
ARNUITY ELLIPTA 100 MCG INH |
4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days |
ARNUITY ELLIPTA 200 MCG INH |
4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days |
ASACOL HD DR 800 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
ATENOLOL 100 MG100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ATENOLOL 25 MG 100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ATENOLOL TABLET USP 50MG (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ATENOLOL-CHLORTHALIDONE 100-25 |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
Atomoxetine 10 MG Oral Capsule [Strattera] |
4 |
Non-Preferred Drug |
40% | 40% | Q:120 /30Days |
Atomoxetine 100 MG Oral Capsule [Strattera] |
4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Atomoxetine 18 MG Oral Capsule [Strattera] |
4 |
Non-Preferred Drug |
40% | 40% | Q:120 /30Days |
Atomoxetine 25 MG Oral Capsule [Strattera] |
4 |
Non-Preferred Drug |
40% | 40% | Q:120 /30Days |
Atomoxetine 40 MG Oral Capsule [Strattera] |
4 |
Non-Preferred Drug |
40% | 40% | Q:60 /30Days |
Atomoxetine 60 MG Oral Capsule [Strattera] |
4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days |
Atomoxetine 80 MG Oral Capsule [Strattera] |
4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days |
ATORVASTATIN 10 MG TABLET [Lipitor] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ATORVASTATIN 20 MG TABLET [Lipitor] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ATORVASTATIN 40 MG TABLET [Lipitor] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ATORVASTATIN 80 MG TABLET [Lipitor] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ATOVAQUONE 750 MG/5 ML SUSP [Mepron] |
5 |
Specialty Tier |
33% | N/A | None |
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone] |
4 |
Non-Preferred Drug |
40% | 40% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Atovaquone-Proguanil 62.5-25 [Malarone] |
4 |
Non-Preferred Drug |
40% | 40% | None |
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
5 |
Specialty Tier |
33% | N/A | None |
ATROVENT HFA AER 17MCG |
4 |
Non-Preferred Drug |
40% | 40% | Q:26 /30Days |
AUBRA-28 TABLET |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
AURYXIA 210 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
AVASTIN 100MG/4ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
AVASTIN 400 MG/16 ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
AVIANE 0.1-0.02 TABLET |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
AVITA 0.025% CREAM |
4 |
Non-Preferred Drug |
40% | 40% | P |
Avita 0.25mg/g 45 g in 1 TUBE |
4 |
Non-Preferred Drug |
40% | 40% | P |
AXIRON 30mg/1.5mL 1 BOTTLE, WITH APPLICATOR per CARTON / 90 mL in 1 BOTTLE, WITH APPLICATOR |
3 |
Preferred Brand |
$27.00 | $67.50 | P Q:440 /30Days |
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 |
33% | N/A | P |
AZACTAM INJECTION 1GM/50ML |
4 |
Non-Preferred Drug |
40% | 40% | None |
AZACTAM INJECTION 2GM/50ML |
4 |
Non-Preferred Drug |
40% | 40% | None |
AZATHIOPRINE 50 MG TABLET |
3 |
Preferred Brand |
$27.00 | $67.50 | P |
AZATHIOPRINE SODIUM 100 MG VIAL |
4 |
Non-Preferred Drug |
40% | 40% | P |
AZELASTINE 0.15% NASAL SPRAY |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
AZELASTINE 137 MCG NASAL SPRAY |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
AZITHROMYCIN 1 GM PWD PACKET |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
AZITHROMYCIN 100 MG/5 ML SUSP |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
Azithromycin 200mg/5mL 22.5 mL in 1 BOTTLE |
3 |
Preferred Brand |
$27.00 | $67.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZITHROMYCIN 250 MG TABLET |
2 |
Generic |
$3.00 | $0.00 | None |
AZITHROMYCIN 250 MG TABLET |
2 |
Generic |
$3.00 | $0.00 | None |
Azithromycin 500 mg tablet |
2 |
Generic |
$3.00 | $0.00 | None |
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION |
4 |
Non-Preferred Drug |
40% | 40% | None |
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Generic |
$3.00 | $0.00 | None |
Azithromycin 600mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Generic |
$3.00 | $0.00 | None |
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT |
4 |
Non-Preferred Drug |
40% | 40% | None |
AZTREONAM FOR INJECTION |
3 |
Preferred Brand |
$27.00 | $67.50 | None |