2017 Medicare Part D Plan Formulary Information |
First Health Part D Premier Plus (PDP) (S5768-188-0)
Benefit Details
|
The First Health Part D Premier Plus (PDP) (S5768-188-0) Formulary Drugs Starting with the Letter C in CMS PDP Region 11 which includes: FL Plan Monthly Premium: $99.10 Deductible: $0 Qualifies for LIS: No |
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 |
4 |
Non-Preferred Drug |
50% | 50% | None |
CABOMETYX 20 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
CABOMETYX 40 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
CABOMETYX 60 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
CAFERGOT TABLET |
4 |
Non-Preferred Drug |
50% | 50% | Q:40 /28Days |
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% | Q:400 /28Days |
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CALCITRIOL 0.25MCG CAPSULE |
2 |
Generic |
$2.00 | $6.00 | None |
CALCITRIOL 0.5 MCG CAPSULE |
2 |
Generic |
$2.00 | $6.00 | None |
Calcitriol 1 mcg/ml ampul |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CALCITRIOL 1MCG/ML SOLUTION ORAL |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
Calcium Acetate 667 mg tablet |
4 |
Non-Preferred Drug |
50% | 50% | None |
CALCIUM ACETATE CAPSULE 667 MG |
4 |
Non-Preferred Drug |
50% | 50% | None |
CAMILA 0.35 MG TABLET |
2 |
Generic |
$2.00 | $6.00 | None |
Camrese Lo tablet |
2 |
Generic |
$2.00 | $6.00 | None |
CANCIDAS IV 50MG VIAL |
5 |
Specialty Tier |
33% | N/A | None |
CANCIDAS IV 70MG VIAL |
5 |
Specialty Tier |
33% | N/A | None |
CANDESARTAN CILEXETIL 16 MG TABLET [Atacand] |
3 |
Preferred Brand |
$34.00 | $102.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CANDESARTAN CILEXETIL 32 MG TABLET [Atacand] |
3 |
Preferred Brand |
$34.00 | $102.00 | Q:30 /30Days |
CANDESARTAN CILEXETIL 4 MG TABLET [Atacand] |
3 |
Preferred Brand |
$34.00 | $102.00 | Q:30 /30Days |
CANDESARTAN CILEXETIL 8 MG TABLET [Atacand] |
3 |
Preferred Brand |
$34.00 | $102.00 | Q:30 /30Days |
candesartan-hctz 16-12.5 mg tablet |
3 |
Preferred Brand |
$34.00 | $102.00 | Q:60 /30Days |
candesartan-hctz 32-12.5 mg tablet |
3 |
Preferred Brand |
$34.00 | $102.00 | Q:30 /30Days |
candesartan-hctz 32-25 mg |
3 |
Preferred Brand |
$34.00 | $102.00 | Q:30 /30Days |
CAPASTAT SULFATE 1g/1 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
4 |
Non-Preferred Drug |
50% | 50% | None |
CAPEX SHA 0.01% |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CAPRELSA 100mg/1 30 TABLET BOTTLE |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
CAPRELSA 300mg/1 30 TABLET BOTTLE |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
CAPTOPRIL 100MG TABLET |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAPTOPRIL 12.5MG TABLET |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CAPTOPRIL 25MG TABLET |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CAPTOPRIL 50MG TABLET |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
Captopril and Hydrochlorothiazide 25; 15mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
Captopril and Hydrochlorothiazide 25; 25mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
Captopril and Hydrochlorothiazide 50; 15mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
Captopril and Hydrochlorothiazide 50; 25mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
CARAC CREAM |
5 |
Specialty Tier |
33% | N/A | None |
Carbaglu 200mg/1 5 TABLET BOTTLE |
4 |
Non-Preferred Drug |
50% | 50% | None |
CARBAMAZEPINE 100 MG/5 ML SUSP |
2 |
Generic |
$2.00 | $6.00 | None |
Carbamazepine 100mg, CHEWABLE 100 TABLET BOTTLE |
2 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Carbamazepine 100mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Drug |
50% | 50% | None |
Carbamazepine 200mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Drug |
50% | 50% | None |
Carbamazepine 300mg/1 120 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Drug |
50% | 50% | None |
CARBAMAZEPINE ER 100 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
CARBAMAZEPINE TABLET USP 200MG (1000 CT) |
2 |
Generic |
$2.00 | $6.00 | None |
CARBAMAZEPINE XR 200 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
CARBAMAZEPINE XR 400 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
CARBIDOPA 25 MG TABLET [Lodosyn] |
5 |
Specialty Tier |
33% | N/A | None |
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
Carbidopa and Levodopa 25; 100mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
Carbidopa and Levodopa 50; 200mg/1; mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, EXTENDED |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;100MG;MG 100 BOT |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;250MG;MG 100 BOT |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CARBIDOPA-LEVODOPA 10-100 TAB |
2 |
Generic |
$2.00 | $6.00 | None |
CARBIDOPA-LEVODOPA 25-100 TAB |
2 |
Generic |
$2.00 | $6.00 | None |
CARBIDOPA-LEVODOPA 25-250 TAB |
2 |
Generic |
$2.00 | $6.00 | None |
Carbidopa-Levodopa-Entacapone 100 MG [Stalevo] |
2 |
Generic |
$2.00 | $6.00 | None |
Carbidopa-Levodopa-Entacapone 125 MG [Stalevo] |
2 |
Generic |
$2.00 | $6.00 | None |
Carbidopa-Levodopa-Entacapone 150 MG [Stalevo] |
2 |
Generic |
$2.00 | $6.00 | None |
Carbidopa-Levodopa-Entacapone 200 MG [Stalevo] |
2 |
Generic |
$2.00 | $6.00 | None |
Carbidopa-Levodopa-Entacapone 50 MG [Stalevo] |
2 |
Generic |
$2.00 | $6.00 | None |
Carbidopa-Levodopa-Entacapone 75 MG [Stalevo] |
2 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Carboplatin 10mg/mL |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
CARTIA XT 120MG CAPSULE SA |
2 |
Generic |
$2.00 | $6.00 | None |
CARTIA XT 180MG CAPSULE SA |
2 |
Generic |
$2.00 | $6.00 | None |
CARTIA XT 240MG CAPSULE SA |
2 |
Generic |
$2.00 | $6.00 | None |
CARTIA XT 300MG CAPSULE SR 24 HR |
2 |
Generic |
$2.00 | $6.00 | None |
Carvedilol 12.5mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
Carvedilol 25mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
Carvedilol 3.125mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
Carvedilol 6.25mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
CAYSTON KIT 75 MG/VIAL |
5 |
Specialty Tier |
33% | N/A | Q:84 /42Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAZIANT 28 DAY TABLET |
2 |
Generic |
$2.00 | $6.00 | None |
CEFACLOR 250 MG CAPSULES |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CEFACLOR 250 MG/5 ML SUSP |
2 |
Generic |
$2.00 | $6.00 | None |
Cefaclor 375 mg/5 ml suspen |
2 |
Generic |
$2.00 | $6.00 | None |
CEFACLOR 500 MG CAPSULES |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CEFACLOR ER 500MG TABLET SR 12HR |
2 |
Generic |
$2.00 | $6.00 | None |
CEFACLOR SUS 125 MG/5ML |
2 |
Generic |
$2.00 | $6.00 | None |
CEFADROXIL 1G TABLET |
2 |
Generic |
$2.00 | $6.00 | None |
CEFADROXIL 250 MG/5 ML SUSP |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
CEFADROXIL 500 MG CAPSULE |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
Cefadroxil 500mg/5mL |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cefazolin 1 gm vial |
2 |
Generic |
$2.00 | $6.00 | None |
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE |
2 |
Generic |
$2.00 | $6.00 | None |
CEFAZOLIN 500MG FOR INJECTION |
2 |
Generic |
$2.00 | $6.00 | None |
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CEFDINIR CAPSULES 300MG (60 CT) |
2 |
Generic |
$2.00 | $6.00 | None |
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT) |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CEFEPIME HCL 2 GRAM VIAL |
4 |
Non-Preferred Drug |
50% | 50% | None |
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL |
4 |
Non-Preferred Drug |
50% | 50% | None |
CEFIXIME 100 MG/5 ML SUSP [Suprax] |
2 |
Generic |
$2.00 | $6.00 | None |
CEFIXIME 200 MG/5 ML SUSP [Suprax] |
2 |
Generic |
$2.00 | $6.00 | None |
Cefotaxime sodium 1 gm vial |
2 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cefotaxime sodium 2 gm vial |
2 |
Generic |
$2.00 | $6.00 | None |
Cefotaxime sodium 500 mg vial |
2 |
Generic |
$2.00 | $6.00 | None |
CEFOTETAN 1GM VIAL 1EA x 10 |
2 |
Generic |
$2.00 | $6.00 | None |
CEFOTETAN 2GM VIAL 1EA x 10 |
2 |
Generic |
$2.00 | $6.00 | None |
Cefoxitin 1g/1 10 POWDER per CARTON |
4 |
Non-Preferred Drug |
50% | 50% | None |
Cefoxitin 2g/1 10 POWDER per CARTON |
4 |
Non-Preferred Drug |
50% | 50% | None |
CEFOXITIN FOR INJECTION SOLUTION |
4 |
Non-Preferred Drug |
50% | 50% | None |
CEFPODOXIME 100 MG/5 ML SUSP |
4 |
Non-Preferred Drug |
50% | 50% | None |
CEFPODOXIME 200 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
CEFPODOXIME 50 MG/5 ML SUSP |
4 |
Non-Preferred Drug |
50% | 50% | None |
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT) |
4 |
Non-Preferred Drug |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFPROZIL 125 MG/5 ML SUSP |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
cefprozil 250 mg/5 ml susp |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
Cefprozil 250mg 100 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CEFPROZIL TABLETS 500MG 100 BOT |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CEFTAZIDIME 1g 25 VIAL per CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL |
2 |
Generic |
$2.00 | $6.00 | None |
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN |
2 |
Generic |
$2.00 | $6.00 | None |
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN |
2 |
Generic |
$2.00 | $6.00 | None |
CEFTRIAXONE 10GM VIAL |
4 |
Non-Preferred Drug |
50% | 50% | None |
CEFTRIAXONE 250 MG VIAL |
4 |
Non-Preferred Drug |
50% | 50% | None |
CEFTRIAXONE FOR INJECTION |
4 |
Non-Preferred Drug |
50% | 50% | None |
CEFTRIAXONE FOR INJECTION |
4 |
Non-Preferred Drug |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ceftriaxone Sodium 500mg |
4 |
Non-Preferred Drug |
50% | 50% | None |
CEFUROXIME 1.5 GM/VIAL FOR INJECTION |
2 |
Generic |
$2.00 | $6.00 | None |
CEFUROXIME 7.5 GM FOR INJECTION |
2 |
Generic |
$2.00 | $6.00 | None |
CEFUROXIME 750 MG FOR INJECTION |
2 |
Generic |
$2.00 | $6.00 | None |
Cefuroxime Axetil 250 MG |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CEFUROXIME AXETIL 500 MG TAB |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CELEBREX 100 MG CAPSULE |
4 |
Non-Preferred Drug |
50% | 50% | S Q:60 /30Days |
CELEBREX 200 MG CAPSULE |
4 |
Non-Preferred Drug |
50% | 50% | S Q:60 /30Days |
CELEBREX 400 MG CAPSULE |
4 |
Non-Preferred Drug |
50% | 50% | S Q:30 /30Days |
CELEBREX 50 MG CAPSULE |
4 |
Non-Preferred Drug |
50% | 50% | S Q:60 /30Days |
CELECOXIB 100 MG CAPSULE [Celebrex] |
3 |
Preferred Brand |
$34.00 | $102.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CELECOXIB 200 MG CAPSULE [Celebrex] |
3 |
Preferred Brand |
$34.00 | $102.00 | Q:60 /30Days |
CELECOXIB 400 MG CAPSULE [Celebrex] |
3 |
Preferred Brand |
$34.00 | $102.00 | Q:30 /30Days |
CELECOXIB 50 MG CAPSULE [Celebrex] |
3 |
Preferred Brand |
$34.00 | $102.00 | Q:60 /30Days |
CELLCEPT IV INJ 500 MG |
4 |
Non-Preferred Drug |
50% | 50% | P |
CELONTIN 300 MG KAPSEAL |
4 |
Non-Preferred Drug |
50% | 50% | None |
Cephalexin 125mg/5mL 200 mL in 1 BOTTLE |
2 |
Generic |
$2.00 | $6.00 | None |
CEPHALEXIN 250 MG CAPSULE |
2 |
Generic |
$2.00 | $6.00 | None |
CEPHALEXIN 250 MG TABLET |
2 |
Generic |
$2.00 | $6.00 | None |
CEPHALEXIN 250 MG/5ML ORAL SUSP |
2 |
Generic |
$2.00 | $6.00 | None |
CEPHALEXIN 500 MG TABLET |
2 |
Generic |
$2.00 | $6.00 | None |
CEPHALEXIN 750 MG CAPSULE |
2 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEPHALEXIN CAPSULES 500 MG (500 CT) |
2 |
Generic |
$2.00 | $6.00 | None |
CEREZYME 400 UNITS VIAL |
5 |
Specialty Tier |
33% | N/A | P |
CHANTIX 0.5 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | Q:336 /365Days |
CHANTIX 1 MG CONT MONTH BOX |
4 |
Non-Preferred Drug |
50% | 50% | Q:336 /365Days |
CHANTIX 1 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | Q:336 /365Days |
CHANTIX STARTING MONTH BOX |
4 |
Non-Preferred Drug |
50% | 50% | Q:106 /365Days |
CHLORAMPHEN NA SUCC 1GM VL |
2 |
Generic |
$2.00 | $6.00 | None |
CHLORDIAZEPOXIDE AND AMITRIPTYLINE HCL TABLET 12.5-5MG (500 CT) |
4 |
Non-Preferred Drug |
50% | 50% | None |
CHLORHEXIDINE GLUCONATE 0.12% RINSE |
2 |
Generic |
$2.00 | $6.00 | None |
CHLOROQUINE PH 250 MG TABLET |
2 |
Generic |
$2.00 | $6.00 | None |
CHLOROQUINE PH 500 MG TABLET |
2 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLOROTHIAZIDE 250 MG TABLET |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
Chlorothiazide 500mg 100 TABLET BOTTLE |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CHLORPROMAZINE 10 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
CHLORPROMAZINE 25 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
CHLORPROMAZINE 25 MG/ML AMP |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CHLORPROMAZINE 50 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
CHLORPROMAZINE HCL 200 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
Chlorpromazine Hydrochloride 100mg SUGAR COATED 1000 TABLET BOTTLE |
4 |
Non-Preferred Drug |
50% | 50% | None |
CHLORTHALIDONE 25 MG TABLET (100 CT) |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
CHLORTHALIDONE 50 MG TABLET (1000 CT) |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
CHLORZOXAZONE 500 MG TABLET |
2 |
Generic |
$2.00 | $6.00 | P Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHOLESTYRAMINE LIGHT POWDER |
4 |
Non-Preferred Drug |
50% | 50% | None |
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION |
4 |
Non-Preferred Drug |
50% | 50% | None |
CICLOPIROX 0.77% TOPICAL SUSP |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CICLOPIROX 1% SHAMPOO |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CICLOPIROX 8% SOLUTION |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CICLOPIROX GEL |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
Ciclopirox Olamine 7.7mg/g 1 TUBE in 1 TUBE / 15 g in 1 TUBE |
2 |
Generic |
$2.00 | $6.00 | None |
Cilostazol 50mg/1 60 TABLET BOTTLE |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
CILOSTAZOL TABLET 100MG (60 CT) |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
CILOXAN 0.3% OINTMENT |
4 |
Non-Preferred Drug |
50% | 50% | None |
Cimetidine 200mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIMETIDINE 300 MG TABLETS |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
Cimetidine 400mg/1 100 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
Cimetidine 800mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
Cimetidine Hydrochloride Oral Solution 300mg/5mL 237 mL in 1 BOTTLE |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
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 |
4 |
Non-Preferred Drug |
50% | 50% | None |
CIPROFLOXACIN 0.3% EYE DROP |
2 |
Generic |
$2.00 | $6.00 | None |
CIPROFLOXACIN 250 MG TABLET (100 CT) |
2 |
Generic |
$2.00 | $6.00 | None |
CIPROFLOXACIN 250 MG/5 ML SUSP |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
Ciprofloxacin 400 mg/40 ml vl |
2 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIPROFLOXACIN 500 MG/5 ML SUSP |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
Ciprofloxacin and Dextrose 2mg/mL 24 BAG in 1 CASE / 100 mL in 1 BAG |
2 |
Generic |
$2.00 | $6.00 | None |
Ciprofloxacin ER 212.6; 287.5mg/1; mg/1 50 TABLET, FILM COATED, in 1 BOTTLE, PLASTIC |
2 |
Generic |
$2.00 | $6.00 | None |
Ciprofloxacin ER 425.2; 574.9mg/1; mg/1 50 TABLET, FILM COATED, in 1 BOTTLE, PLASTIC |
2 |
Generic |
$2.00 | $6.00 | None |
CIPROFLOXACIN HCL 100 MG TABLET |
2 |
Generic |
$2.00 | $6.00 | None |
CIPROFLOXACIN HCL 500 MG TAB |
2 |
Generic |
$2.00 | $6.00 | None |
CIPROFLOXACIN TABLETS 750 MG 100 BOT |
2 |
Generic |
$2.00 | $6.00 | None |
Cisplatin 100mg/100mL 1 VIAL per CARTON / 100 mL in 1 VIAL |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CITALOPRAM HBR 10 MG TABLET |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:120 /30Days |
CITALOPRAM HBR 10 MG/5 ML SOLN |
3 |
Preferred Brand |
$34.00 | $102.00 | Q:600 /30Days |
CITALOPRAM HBR 20 MG TABLET |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CITALOPRAM HYDROBROMIDE TABLETS 40 MG 30 BOT |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
Cladribine 10 mg/10 ml vial |
2 |
Generic |
$2.00 | $6.00 | P |
CLARAVIS 10 MG CAPSULE |
4 |
Non-Preferred Drug |
50% | 50% | None |
CLARAVIS 20 MG CAPSULE |
4 |
Non-Preferred Drug |
50% | 50% | None |
Claravis 30mg 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Drug |
50% | 50% | None |
CLARAVIS 40MG CAPSULE |
4 |
Non-Preferred Drug |
50% | 50% | None |
CLARITHROMYCIN 125 MG/5ML FOR ORAL SUSPENSION |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CLARITHROMYCIN 250 MG TABLET |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CLARITHROMYCIN 250 MG/5MLFOR ORAL SUSPENSION |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CLARITHROMYCIN 500 MG TABLET |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
Clemastine fum 2.68 mg tab |
3 |
Preferred Brand |
$34.00 | $102.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLEOCIN HCL 150 MG CAPSULE |
4 |
Non-Preferred Drug |
50% | 50% | None |
CLEOCIN HCL 300 MG CAPSULE |
4 |
Non-Preferred Drug |
50% | 50% | None |
CLEOCIN HCL 75 MG CAPSULE |
4 |
Non-Preferred Drug |
50% | 50% | None |
CLINDACIN PAC KIT |
2 |
Generic |
$2.00 | $6.00 | None |
CLINDAMAX 1% GEL |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
Clindamycin 150 MG/ML 2ml |
2 |
Generic |
$2.00 | $6.00 | None |
Clindamycin 150 MG/ML 6ml |
2 |
Generic |
$2.00 | $6.00 | None |
CLINDAMYCIN 600 MG/4 ML ADDVAN |
2 |
Generic |
$2.00 | $6.00 | None |
CLINDAMYCIN HCL 150 MG CAPSULE |
2 |
Generic |
$2.00 | $6.00 | None |
CLINDAMYCIN HCL 300 MG 100 CAPSULE in 1 BOTTLE |
2 |
Generic |
$2.00 | $6.00 | None |
CLINDAMYCIN HCL 75 MG 200 CAPSULE BOTTLE |
2 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINDAMYCIN PEDIATR 75 MG/5 ML |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CLINDAMYCIN PHOSP 1% LOTION |
4 |
Non-Preferred Drug |
50% | 50% | None |
CLINDAMYCIN PHOSPHATE 1% FOAM |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
clindamycin phosphate 10mg/mL 1 BOTTLE per CARTON / 60 mL in 1 BOTTLE |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
Clindamycin Phosphate and Benzoyl Peroxide 1 KIT |
4 |
Non-Preferred Drug |
50% | 50% | None |
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX |
2 |
Generic |
$2.00 | $6.00 | None |
CLINDAMYCIN PHOSPHATE VAGINAL CREAM |
4 |
Non-Preferred Drug |
50% | 50% | None |
Clindamycin Phosphate-Benzoyl Peroxide 1.2-5% [Benzaclin] |
4 |
Non-Preferred Drug |
50% | 50% | None |
clindamycin-d5w 300 mg/50 ml |
2 |
Generic |
$2.00 | $6.00 | None |
clindamycin-d5w 600 mg/50 ml |
2 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
clindamycin-d5w 900 mg/50 ml |
2 |
Generic |
$2.00 | $6.00 | None |
CLINIMIX 2.75%/5% INJECTION 1000ML BAG |
4 |
Non-Preferred Drug |
50% | 50% | P |
CLINIMIX 4.25/10 SOLUTION |
4 |
Non-Preferred Drug |
50% | 50% | P |
CLINIMIX 4.25/20 SOLUTION |
4 |
Non-Preferred Drug |
50% | 50% | P |
CLINIMIX 4.25/25 SOLUTION |
4 |
Non-Preferred Drug |
50% | 50% | P |
CLINIMIX 4.25/5 SOLUTION |
4 |
Non-Preferred Drug |
50% | 50% | P |
CLINIMIX 5/15 SOLUTION |
4 |
Non-Preferred Drug |
50% | 50% | P |
CLINIMIX 5/20 SOLUTION |
4 |
Non-Preferred Drug |
50% | 50% | P |
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG |
4 |
Non-Preferred Drug |
50% | 50% | P |
CLINIMIX E 2.75/10 SOLUTION |
4 |
Non-Preferred Drug |
50% | 50% | P |
CLINIMIX E 2.75/5 SOLUTION |
4 |
Non-Preferred Drug |
50% | 50% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINIMIX E 4.25/25 SOLUTION |
4 |
Non-Preferred Drug |
50% | 50% | P |
CLINIMIX E 4.25/5 SOLUTION |
4 |
Non-Preferred Drug |
50% | 50% | P |
CLINIMIX E 4.25%-10% SOLUTION |
4 |
Non-Preferred Drug |
50% | 50% | P |
CLINIMIX E 5/20 SOLUTION |
4 |
Non-Preferred Drug |
50% | 50% | P |
CLINIMIX E 5/25 SOLUTION |
4 |
Non-Preferred Drug |
50% | 50% | P |
CLINIMIX E 5%/15% INJECTION 2000ML BAG |
4 |
Non-Preferred Drug |
50% | 50% | P |
CLINISOL 15% SOLUTION |
2 |
Generic |
$2.00 | $6.00 | P |
CLOBETASOL 0.05% OINTMENT |
4 |
Non-Preferred Drug |
50% | 50% | None |
CLOBETASOL 0.05% SHAMPOO |
4 |
Non-Preferred Drug |
50% | 50% | None |
CLOBETASOL 0.05% TOPICAL LOTION |
4 |
Non-Preferred Drug |
50% | 50% | None |
CLOBETASOL E 0.05% CREAM |
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 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 |
4 |
Non-Preferred Drug |
50% | 50% | None |
Clobetasol Propionate 0.5mg/g 1 CAN per CARTON / 100 g in 1 CAN |
4 |
Non-Preferred Drug |
50% | 50% | None |
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE |
4 |
Non-Preferred Drug |
50% | 50% | None |
Clodan 0.05% shampoo |
4 |
Non-Preferred Drug |
50% | 50% | None |
Clofarabine 20 mg/20 ml vial [Clolar] |
5 |
Specialty Tier |
33% | N/A | None |
CLOLAR 20 MG/20 ML VIAL |
5 |
Specialty Tier |
33% | N/A | None |
CLOMIPRAMINE HCL 25MG CAPSULE |
4 |
Non-Preferred Drug |
50% | 50% | P |
CLOMIPRAMINE HCL 50MG CAPSULE |
4 |
Non-Preferred Drug |
50% | 50% | P |
CLOMIPRAMINE HCL 75MG CAPSULE |
4 |
Non-Preferred Drug |
50% | 50% | P |
Clonazepam 0.125mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PAC |
3 |
Preferred Brand |
$34.00 | $102.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Clonazepam 0.25mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
3 |
Preferred Brand |
$34.00 | $102.00 | Q:90 /30Days |
Clonazepam 0.5mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
3 |
Preferred Brand |
$34.00 | $102.00 | Q:90 /30Days |
Clonazepam 0.5mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:90 /30Days |
CLONAZEPAM 1 MG TABLET |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:120 /30Days |
Clonazepam 1mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
3 |
Preferred Brand |
$34.00 | $102.00 | Q:120 /30Days |
Clonazepam 2mg/1 10 BLISTER PACK per CARTON / 6 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
3 |
Preferred Brand |
$34.00 | $102.00 | Q:300 /30Days |
Clonazepam 2mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:300 /30Days |
Clonidine 0.1mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
3 |
Preferred Brand |
$34.00 | $102.00 | Q:8 /28Days |
Clonidine 0.2mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
3 |
Preferred Brand |
$34.00 | $102.00 | Q:8 /28Days |
Clonidine 0.3mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
3 |
Preferred Brand |
$34.00 | $102.00 | Q:8 /28Days |
CLONIDINE HCL 0.1 MG TABLET |
2 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLONIDINE HCL 0.2MG TABLET (500 CT) |
2 |
Generic |
$2.00 | $6.00 | None |
CLONIDINE HCL TABLET 0.3MG (100 CT) |
2 |
Generic |
$2.00 | $6.00 | None |
CLOPIDOGREL 300 MG TABLET [Plavix] |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:2 /365Days |
CLOPIDOGREL 75 MG TABLET [Plavix] |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
CLORAZEPATE 15 MG TABLET |
3 |
Preferred Brand |
$34.00 | $102.00 | Q:180 /30Days |
Clorazepate Dipotassium 3.75mg/1 500 TABLET BOTTLE, PLASTIC |
3 |
Preferred Brand |
$34.00 | $102.00 | Q:90 /30Days |
Clorazepate Dipotassium 7.5mg/1 500 TABLET BOTTLE, PLASTIC |
3 |
Preferred Brand |
$34.00 | $102.00 | Q:90 /30Days |
CLORPRES 0.1-15 TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
CLORPRES 0.2-15 TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
CLORPRES 0.3-15 TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
CLOTRIMAZOLE 1% CREAM |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOTRIMAZOLE 1% SOLUTION |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CLOTRIMAZOLE 10MG TROCHE |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION |
4 |
Non-Preferred Drug |
50% | 50% | None |
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
Clozapine 100 MG Disintegrating Oral Tablet |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
Clozapine 100mg/1 100 TABLET BOTTLE |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CLOZAPINE 200MG TABLET (500 CT) |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
Clozapine 25 MG Disintegrating Oral Tablet |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CLOZAPINE 25MG TABLET (100 CT) |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CLOZAPINE 50MG TABLET (500 CT) |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CLOZAPINE ODT 12.5 MG TABLET |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOZAPINE ODT 150 MG TABLET |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CLOZAPINE ODT 200 MG TABLET |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
COARTEM 20MG-120MG |
4 |
Non-Preferred Drug |
50% | 50% | None |
CODEINE SULFATE 15 mg tablet |
3 |
Preferred Brand |
$34.00 | $102.00 | Q:180 /30Days |
CODEINE SULFATE 30 mg tablet |
3 |
Preferred Brand |
$34.00 | $102.00 | Q:180 /30Days |
CODEINE SULFATE 60 mg tablet |
3 |
Preferred Brand |
$34.00 | $102.00 | Q:180 /30Days |
COGENTIN 2 MG/2 ML AMPULE |
4 |
Non-Preferred Drug |
50% | 50% | P |
COLCHICINE 0.6 MG CAPSULE |
2 |
Generic |
$2.00 | $6.00 | None |
COLCHICINE 0.6 MG TABLET |
2 |
Generic |
$2.00 | $6.00 | None |
COLCRYS 0.6 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | S |
COLESTIPOL HCL 1G 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 |
COLESTIPOL HYDROCHLORIDE 5g/1 100 SUSPENSION in 1 BOTTLE |
4 |
Non-Preferred Drug |
50% | 50% | None |
colistimethate 150mg/2mL 1 VIAL per CARTON / 2 mL in 1 VIAL |
4 |
Non-Preferred Drug |
50% | 50% | P |
COLOCORT 100MG ENEMA |
2 |
Generic |
$2.00 | $6.00 | None |
COLY-MYCIN S OTIC SUSP DROP |
4 |
Non-Preferred Drug |
50% | 50% | None |
COMBIGAN 0.2%-0.5% DROPS |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
COMBIVENT RESPIMAT INHAL SPRAY |
4 |
Non-Preferred Drug |
50% | 50% | Q:8 /30Days |
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 | Q:30 /30Days |
COMPRO 25MG SUPPOSITORY |
2 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COMTAN 200MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
CONSTULOSE 10 GM/15 ML SOLN |
2 |
Generic |
$2.00 | $6.00 | None |
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
COPAXONE 40 MG/ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | P Q:12 /28Days |
CORDRAN 4 MCG/SQ CM TAPE LARGE |
4 |
Non-Preferred Drug |
50% | 50% | None |
COREG CR 10MG CAPSULE MULTIPHASIC RELEASE 24 HR |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
COREG CR 20MG CAPSULE MULTIPHASIC RELEASE 24 HR |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
COREG CR 40MG CAPSULE MULTIPHASIC RELEASE 24 HR |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
COREG CR 80MG CAPSULE MULTIPHASIC RELEASE 24 HR |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
CORLANOR 5 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | P |
CORLANOR 7.5 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CORMAX 0.05% SOLUTION |
4 |
Non-Preferred Drug |
50% | 50% | None |
Cortisone 25 MG Tablet |
2 |
Generic |
$2.00 | $6.00 | None |
COSMEGEN 0.5 MG VIAL |
5 |
Specialty Tier |
33% | N/A | None |
COSOPT EYE DROPS |
4 |
Non-Preferred Drug |
50% | 50% | None |
COTELLIC 20 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:63 /28Days |
Creon 256.11mg/1 1 BOTTLE per CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CREON DR 36,000 UNITS CAPSULE |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CRESTOR 10MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CRESTOR 20MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | S Q:30 /30Days |
CRESTOR 40mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Drug |
50% | 50% | S Q:30 /30Days |
CRESTOR 5MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | S Q:30 /30Days |
CRIXIVAN 200MG CAPSULE |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CRIXIVAN 400mg, 180 CAPSULE BOTTLE |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CROMOLYN 20 MG/2 ML NEB SOLN |
2 |
Generic |
$2.00 | $6.00 | P |
CROMOLYN SODIUM 100 MG/5 ML |
4 |
Non-Preferred Drug |
50% | 50% | None |
CROMOLYN SODIUM 4% 40MG 10ML BOT |
4 |
Non-Preferred Drug |
50% | 50% | None |
CUBICIN 500MG VIAL |
5 |
Specialty Tier |
33% | N/A | None |
CUPRIMINE 250 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | None |
Cyclafem 1/35 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2 |
Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cyclafem 7/7/7 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2 |
Generic |
$2.00 | $6.00 | None |
Cyclobenzaprine 7.5 mg tablet |
2 |
Generic |
$2.00 | $6.00 | P Q:90 /30Days |
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT) |
2 |
Generic |
$2.00 | $6.00 | P Q:90 /30Days |
Cyclobenzaprine Hydrochloride 5mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Generic |
$2.00 | $6.00 | P Q:90 /30Days |
CYCLOPHOSPHAMIDE 25 MG CAPSULE |
3 |
Preferred Brand |
$34.00 | $102.00 | P |
CYCLOPHOSPHAMIDE 50 MG CAPSULE |
3 |
Preferred Brand |
$34.00 | $102.00 | P |
CYCLOSET 0.8MG TABLETS |
4 |
Non-Preferred Drug |
50% | 50% | P Q:180 /30Days |
CYCLOSPORINE 100MG CAPSULE |
4 |
Non-Preferred Drug |
50% | 50% | P |
CYCLOSPORINE 25MG CAPSULE |
4 |
Non-Preferred Drug |
50% | 50% | P |
Cyclosporine 50 mg/ml vial |
3 |
Preferred Brand |
$34.00 | $102.00 | P |
CYCLOSPORINE MODIFIED 100 MG |
4 |
Non-Preferred Drug |
50% | 50% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYCLOSPORINE MODIFIED 25 MG |
4 |
Non-Preferred Drug |
50% | 50% | P |
CYCLOSPORINE MODIFIED 50 MG |
4 |
Non-Preferred Drug |
50% | 50% | P |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT |
4 |
Non-Preferred Drug |
50% | 50% | P |
CYKLOKAPRON 100MG/ML AMPUL |
3 |
Preferred Brand |
$34.00 | $102.00 | None |
CYMBALTA 20MG CAPSULE |
4 |
Non-Preferred Drug |
50% | 50% | S Q:60 /30Days |
Cymbalta 60mg/1 1000 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Drug |
50% | 50% | S Q:60 /30Days |
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT) |
4 |
Non-Preferred Drug |
50% | 50% | S Q:90 /30Days |
CYPROHEPTADINE HCL 4 MG |
4 |
Non-Preferred Drug |
50% | 50% | P |
CYRAMZA 100 MG/10 ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
CYRAMZA 500 MG/50 ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
CYSTADANE 1 GRAM/1.7 ML POWDER |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYSTAGON 150MG CAPSULE |
4 |
Non-Preferred Drug |
50% | 50% | P |
CYSTAGON 50MG CAPSULE |
4 |
Non-Preferred Drug |
50% | 50% | P |
CYSTARAN 0.44% EYE DROPS |
5 |
Specialty Tier |
33% | N/A | Q:60 /28Days |
CYTARABINE 20MG/ML VIAL |
3 |
Preferred Brand |
$34.00 | $102.00 | P |
CYTARABINE SOLUTION INJECTION 100MG 20ML VIALSD |
3 |
Preferred Brand |
$34.00 | $102.00 | P |