2018 Medicare Part D Plan Formulary Information |
FHCP's Premier Plan (HMO) (H1035-010-0)
Benefit Details
|
The FHCP's Premier Plan (HMO) (H1035-010-0) Formulary Drugs Starting with the Letter C in Seminole County, FL: CMS MA Region 9 which includes: FL Plan Monthly Premium: $0.00 Deductible: $0 |
Drugs Starting with Letter C
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
CABERGOLINE 0.5 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
CABOMETYX 20 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P |
CABOMETYX 40 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P |
CABOMETYX 60 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P |
CALCIPOTRIENE 0.005% CREAM |
2 |
Generic |
$7.00 | N/A | Q:60 /30Days |
CALCIPOTRIENE 0.005% SOLUTION |
2 |
Generic |
$7.00 | N/A | Q:60 /30Days |
Calcipotriene 50ug/g 60 g per CARTON |
2 |
Generic |
$7.00 | N/A | Q:60 /30Days |
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY |
2 |
Generic |
$7.00 | N/A | None |
CALCITRIOL 0.25 MCG CAPSULE [Rocaltrol] |
2 |
Generic |
$7.00 | N/A | None |
CALCITRIOL 0.5 MCG CAPSULE [Rocaltrol] |
2 |
Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Calcitriol 1 MCG per 1 ML Injection |
5 |
Injectable Drugs |
25% | N/A | P |
CALCITRIOL 1MCG/ML SOLUTION ORAL |
2 |
Generic |
$7.00 | N/A | None |
CALCIUM ACETATE CAPSULE 667 MG |
2 |
Generic |
$7.00 | N/A | None |
CALQUENCE 100 MG CAPSULE |
6 |
Specialty Tier |
33% | N/A | P |
CANASA 1,000 MG SUPPOSITORY |
3 |
Preferred Brand |
$42.00 | N/A | Q:30 /30Days |
CANCIDAS IV 50MG VIAL |
5 |
Injectable Drugs |
25% | N/A | P |
CANCIDAS IV 70MG VIAL |
5 |
Injectable Drugs |
25% | N/A | P |
CAPASTAT SULFATE 1g/1 1 INJECTION, POWDER, FOR SOLUTION per CARTON |
5 |
Injectable Drugs |
25% | N/A | P |
CAPRELSA 100 MG TABLET |
6 |
Specialty Tier |
33% | N/A | None |
CAPRELSA 300 MG TABLET |
6 |
Specialty Tier |
33% | N/A | None |
CARAFATE SUS 1GM/10ML |
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 |
CARBAGLU 200 MG DISPER TABLET |
6 |
Specialty Tier |
33% | N/A | P |
CARBAMAZEPINE 100 MG TAB CHEW |
2 |
Generic |
$7.00 | N/A | None |
CARBAMAZEPINE 100 MG/5 ML SUSP |
2 |
Generic |
$7.00 | N/A | None |
CARBAMAZEPINE 200 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
Carbidopa 25mg Tab 100 [Lodosyn] |
6 |
Specialty Tier |
33% | N/A | None |
CARBIDOPA-LEVO ER 25-100 TAB |
2 |
Generic |
$7.00 | N/A | None |
CARBIDOPA-LEVO ER 50-200 TAB |
2 |
Generic |
$7.00 | N/A | None |
CARBIDOPA-LEVODOPA 10-100 TAB |
2 |
Generic |
$7.00 | N/A | None |
CARBIDOPA-LEVODOPA 25-100 TAB |
2 |
Generic |
$7.00 | N/A | None |
CARBIDOPA-LEVODOPA 25-250 TAB |
2 |
Generic |
$7.00 | N/A | None |
Carboplatin 10 MG/ML Injectable Solution |
5 |
Injectable Drugs |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARTEOLOL HCL 1% EYE DROPS |
2 |
Generic |
$7.00 | N/A | None |
CARTIA XT 180MG CAPSULE SA |
2 |
Generic |
$7.00 | N/A | None |
CARVEDILOL 12.5 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
CARVEDILOL 25 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
CARVEDILOL 3.125 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
CARVEDILOL 6.25 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
CAYSTON KIT 75 MG/VIAL |
6 |
Specialty Tier |
33% | N/A | None |
CEFACLOR 250 MG CAPSULES |
2 |
Generic |
$7.00 | N/A | None |
CEFACLOR 500 MG CAPSULES |
2 |
Generic |
$7.00 | N/A | None |
CEFADROXIL 250 MG/5 ML SUSP |
2 |
Generic |
$7.00 | N/A | None |
CEFADROXIL 500 MG/5 ML SUSP |
2 |
Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFAZOLIN 1 GM VIAL 25/Box |
5 |
Injectable Drugs |
25% | N/A | P |
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE |
5 |
Injectable Drugs |
25% | N/A | P |
CEFAZOLIN 500 MG VIAL |
5 |
Injectable Drugs |
25% | N/A | P |
CEFDINIR 125 MG/5 ML SUSP |
2 |
Generic |
$7.00 | N/A | None |
CEFDINIR 250 MG/5 ML SUSP |
2 |
Generic |
$7.00 | N/A | None |
CEFDINIR 300 MG CAPSULE |
2 |
Generic |
$7.00 | N/A | None |
CEFEPIME HCL 1 GM VIAL |
5 |
Injectable Drugs |
25% | N/A | None |
CEFEPIME HCL 2 GRAM VIAL |
5 |
Injectable Drugs |
25% | N/A | None |
CEFIXIME 100 MG/5 ML SUSP [Suprax] |
2 |
Generic |
$7.00 | N/A | None |
CEFIXIME 200 MG/5 ML SUSP [Suprax] |
2 |
Generic |
$7.00 | N/A | None |
Cefotaxime 500 MG Injection |
5 |
Injectable Drugs |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Cefotaxime sodium 1 gm vial |
5 |
Injectable Drugs |
25% | N/A | None |
Cefotaxime sodium 2 gm vial |
5 |
Injectable Drugs |
25% | N/A | None |
CEFOXITIN 1 GM VIAL |
5 |
Injectable Drugs |
25% | N/A | None |
CEFOXITIN 10 GM VIAL |
5 |
Injectable Drugs |
25% | N/A | P |
CEFOXITIN 2 GM VIAL |
5 |
Injectable Drugs |
25% | N/A | None |
CEFPODOXIME 100 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
CEFPODOXIME 100 MG/5 ML SUSP |
2 |
Generic |
$7.00 | N/A | None |
CEFPODOXIME 200 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
CEFPODOXIME 50 MG/5 ML SUSP |
2 |
Generic |
$7.00 | N/A | None |
CEFPROZIL 125 MG/5 ML SUSP |
2 |
Generic |
$7.00 | N/A | None |
CEFPROZIL 250 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFPROZIL 250 MG/5 ML SUSP |
2 |
Generic |
$7.00 | N/A | None |
CEFPROZIL 500 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
CEFTAZIDIME 1 GM VIAL |
5 |
Injectable Drugs |
25% | N/A | None |
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN |
5 |
Injectable Drugs |
25% | N/A | None |
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN |
5 |
Injectable Drugs |
25% | N/A | None |
CEFTRIAXONE 250 MG VIAL |
5 |
Injectable Drugs |
25% | N/A | None |
CEFTRIAXONE 500 MG VIAL |
5 |
Injectable Drugs |
25% | N/A | None |
CEFUROXIME 1.5 GM/VIAL FOR INJECTION |
5 |
Injectable Drugs |
25% | N/A | P |
CEFUROXIME 750 MG FOR INJECTION |
5 |
Injectable Drugs |
25% | N/A | P |
Cefuroxime 95 MG/ML Injectable Solution |
5 |
Injectable Drugs |
25% | N/A | P |
CEFUROXIME AXETIL 250 MG TAB |
2 |
Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFUROXIME AXETIL 500 MG TAB |
2 |
Generic |
$7.00 | N/A | None |
CELECOXIB 100 MG CAPSULE [Celebrex] |
2 |
Generic |
$7.00 | N/A | None |
CELECOXIB 200 MG CAPSULE [Celebrex] |
2 |
Generic |
$7.00 | N/A | None |
CELECOXIB 400 MG CAPSULE [Celebrex] |
2 |
Generic |
$7.00 | N/A | None |
CELECOXIB 50 MG CAPSULE [Celebrex] |
2 |
Generic |
$7.00 | N/A | None |
CELONTIN 300 MG KAPSEAL |
4 |
Non-Preferred Brand |
$90.00 | N/A | None |
CEPHALEXIN 125 MG/5 ML SUSP |
2 |
Generic |
$7.00 | N/A | None |
CEPHALEXIN 250 MG CAPSULE |
2 |
Generic |
$7.00 | N/A | None |
CEPHALEXIN 250 MG/5 ML SUSP |
2 |
Generic |
$7.00 | N/A | None |
CEPHALEXIN 500 MG CAPSULE |
2 |
Generic |
$7.00 | N/A | None |
CEREZYME 400 UNITS VIAL |
5 |
Injectable Drugs |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHANTIX 0.5 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | N/A | None |
CHANTIX 1 MG CONT MONTH BOX |
4 |
Non-Preferred Brand |
$90.00 | N/A | None |
CHANTIX 1 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | N/A | None |
CHANTIX STARTING MONTH BOX |
4 |
Non-Preferred Brand |
$90.00 | N/A | None |
CHEMET 100 MG CAPSULE |
3 |
Preferred Brand |
$42.00 | N/A | None |
CHLORAMPHEN NA SUCC 1GM VL |
5 |
Injectable Drugs |
25% | N/A | None |
CHLORHEXIDINE GLUCONATE 0.12% RINSE |
2 |
Generic |
$7.00 | N/A | None |
CHLOROQUINE PH 500 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
CHLOROTHIAZIDE 250 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
Chlorothiazide 500 MG Injection |
5 |
Injectable Drugs |
25% | N/A | P |
Chlorothiazide 500mg 100 TABLET BOTTLE |
2 |
Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLORPROMAZINE 10 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
CHLORPROMAZINE 100 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
CHLORPROMAZINE 200 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
CHLORPROMAZINE 25 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
CHLORPROMAZINE 25 MG/ML AMP |
5 |
Injectable Drugs |
25% | N/A | P |
CHLORPROMAZINE 50 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
Chlorpropamide 100mg 100 TABLET BOTTLE, PLASTIC |
2 |
Generic |
$7.00 | N/A | None |
Chlorpropamide 250mg 100 TABLET BOTTLE, PLASTIC |
2 |
Generic |
$7.00 | N/A | None |
CHLORTHALIDONE 25 MG TABLET (100 CT) |
2 |
Generic |
$7.00 | N/A | None |
CHLORTHALIDONE 50 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
CHOLESTYRAMINE LIGHT POWDER |
2 |
Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHOLESTYRAMINE PACKET |
2 |
Generic |
$7.00 | N/A | None |
CHORIONIC GONAD 10000U VIAL |
5 |
Injectable Drugs |
25% | N/A | P |
CICLOPIROX 0.77% CREAM |
2 |
Generic |
$7.00 | N/A | Q:120 /30Days |
CICLOPIROX 0.77% GEL |
2 |
Generic |
$7.00 | N/A | Q:120 /30Days |
CICLOPIROX 0.77% TOPICAL SUSP |
2 |
Generic |
$7.00 | N/A | Q:60 /30Days |
CICLOPIROX 8% SOLUTION |
2 |
Generic |
$7.00 | N/A | None |
CIDOFOVIR 375 MG/5 ML VIAL [Vistide] |
5 |
Injectable Drugs |
25% | N/A | P |
Cilastatin 250 MG / Imipenem 250 MG Injection |
5 |
Injectable Drugs |
25% | N/A | None |
Cilastatin 500 MG / Imipenem 500 MG Injection |
5 |
Injectable Drugs |
25% | N/A | None |
CILOSTAZOL 100 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
CILOSTAZOL 50 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CILOXAN 0.3% OINTMENT |
3 |
Preferred Brand |
$42.00 | N/A | None |
Cimetidine 300 MG Oral Tablet |
2 |
Generic |
$7.00 | N/A | None |
Cimetidine 400mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Generic |
$7.00 | N/A | None |
Cimetidine 800mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Generic |
$7.00 | N/A | None |
Cimetidine Hydrochloride Oral Solution 300mg/5mL 237 mL in 1 BOTTLE |
2 |
Generic |
$7.00 | N/A | None |
Cinryze 500[iU]/5mL 1 VIAL per CARTON / 5 mL in 1 VIAL |
5 |
Injectable Drugs |
25% | N/A | P |
CIPRODEX OTIC SUSPENSION |
3 |
Preferred Brand |
$42.00 | N/A | None |
CIPROFLOXACIN 0.3% EYE DROP [Ciloxan] |
2 |
Generic |
$7.00 | N/A | None |
CIPROFLOXACIN 250 MG TABLET (100 CT) [Cipro] |
2 |
Generic |
$7.00 | N/A | None |
CIPROFLOXACIN HCL 500 MG Tablet [Cipro] |
2 |
Generic |
$7.00 | N/A | None |
CIPROFLOXACIN HCL 750 MG Tablet [Cipro] |
2 |
Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIPROFLOXACIN-D5W 200 MG/100 ML PIGGYBACK [Cipro] |
5 |
Injectable Drugs |
25% | N/A | P |
CISPLATIN 50MG/50ML MDV |
5 |
Injectable Drugs |
25% | N/A | P |
CITALOPRAM HBR 10 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
CITALOPRAM HBR 10 MG/5 ML SOLN |
1 |
Preferred Generic |
$0.00 | N/A | None |
CITALOPRAM HBR 20 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
CITALOPRAM HBR 40 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
Cladribine 1 MG/ML in 10 ML Injection |
5 |
Injectable Drugs |
25% | N/A | P |
CLARITHROMYCIN 125 MG/5ML FOR ORAL SUSPENSION |
2 |
Generic |
$7.00 | N/A | None |
CLARITHROMYCIN 250 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
CLARITHROMYCIN 250 MG/5MLFOR ORAL SUSPENSION |
2 |
Generic |
$7.00 | N/A | None |
CLARITHROMYCIN 500 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINDAMYCIN 75 MG/5 ML SOLN |
2 |
Generic |
$7.00 | N/A | None |
CLINDAMYCIN HCL 150 MG CAPSULE |
2 |
Generic |
$7.00 | N/A | None |
CLINDAMYCIN PH 600 MG/4 ML VL |
5 |
Injectable Drugs |
25% | N/A | P |
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX |
2 |
Generic |
$7.00 | N/A | Q:60 /15Days |
CLINDAMYCIN PHOSPHATE VAGINAL CREAM |
2 |
Generic |
$7.00 | N/A | None |
CLOBETASOL 0.05% OINTMENT |
2 |
Generic |
$7.00 | N/A | Q:120 /30Days |
CLOBETASOL 0.05% SOLUTION |
2 |
Generic |
$7.00 | N/A | Q:60 /30Days |
CLOBETASOL EMOLLIENT 0.05% CRM |
2 |
Generic |
$7.00 | N/A | Q:120 /30Days |
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE |
2 |
Generic |
$7.00 | N/A | Q:120 /30Days |
CLOFARABINE 20 MG/20 ML VIAL [Clolar] |
5 |
Injectable Drugs |
25% | N/A | P |
CLOMIPRAMINE 25 MG CAPSULE |
2 |
Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOMIPRAMINE 50 MG CAPSULE |
2 |
Generic |
$7.00 | N/A | None |
CLOMIPRAMINE 75 MG CAPSULE |
2 |
Generic |
$7.00 | N/A | None |
CLONAZEPAM 0.125 MG DIS TAB RAPDIS [Klonopin] |
2 |
Generic |
$7.00 | N/A | None |
CLONAZEPAM 0.25 MG ODT TAB RAPDIS [Klonopin] |
2 |
Generic |
$7.00 | N/A | None |
CLONAZEPAM 0.5 MG DIS TABLET RAPDIS [Klonopin] |
2 |
Generic |
$7.00 | N/A | None |
CLONAZEPAM 0.5 MG TABLET [Klonopin] |
2 |
Generic |
$7.00 | N/A | None |
CLONAZEPAM 1 MG TABLET [Klonopin] |
2 |
Generic |
$7.00 | N/A | None |
CLONAZEPAM 2 MG TABLET [Klonopin] |
2 |
Generic |
$7.00 | N/A | None |
Clonidine 0.1mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
2 |
Generic |
$7.00 | N/A | None |
Clonidine 0.2mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
2 |
Generic |
$7.00 | N/A | None |
Clonidine 0.3mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
2 |
Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLONIDINE HCL 0.1 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
CLONIDINE HCL 0.2 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
CLONIDINE HCL 0.3 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
CLOPIDOGREL 75 MG TABLET [Plavix] |
1 |
Preferred Generic |
$0.00 | N/A | None |
CLORAZEPATE 15 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
CLORAZEPATE 3.75 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
CLORAZEPATE 7.5 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
CLOTRIMAZOLE 10 MG TROCHE |
2 |
Generic |
$7.00 | N/A | None |
CLOTRIMAZOLE-BETAMETHASONE LOT |
2 |
Generic |
$7.00 | N/A | Q:60 /30Days |
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE |
2 |
Generic |
$7.00 | N/A | Q:120 /30Days |
CLOZAPINE 100 MG TABLET [Clozaril] |
2 |
Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOZAPINE 200 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
CLOZAPINE 25 MG TABLET [Clozaril] |
2 |
Generic |
$7.00 | N/A | None |
CLOZAPINE 50 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
CLOZAPINE ODT 100 MG TABLET RAPDIS [Fazaclo] |
2 |
Generic |
$7.00 | N/A | None |
CLOZAPINE ODT 12.5 MG TABLET RAPDIS [Fazaclo] |
2 |
Generic |
$7.00 | N/A | None |
CLOZAPINE ODT 150 MG TABLET RAPDIS [Fazaclo] |
2 |
Generic |
$7.00 | N/A | None |
CLOZAPINE ODT 200 MG TABLET RAPDIS [Fazaclo] |
2 |
Generic |
$7.00 | N/A | None |
CLOZAPINE ODT 25 MG TABLET RAPDIS [Fazaclo] |
2 |
Generic |
$7.00 | N/A | None |
COARTEM 20MG-120MG |
4 |
Non-Preferred Brand |
$90.00 | N/A | None |
COLCHICINE 0.6 MG TABLET [Colcrys] |
2 |
Generic |
$7.00 | N/A | Q:120 /30Days |
COLESEVELAM 625 MG TABLET [WelChol] |
4 |
Non-Preferred Brand |
$90.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COLISTIMETHATE 150 MG VIAL |
5 |
Injectable Drugs |
25% | N/A | None |
COMETRIQ 100 MG DAILY-DOSE PK |
6 |
Specialty Tier |
33% | N/A | P |
COMETRIQ 140 MG DAILY-DOSE PK |
6 |
Specialty Tier |
33% | N/A | P |
COMETRIQ 60 MG DAILY-DOSE PACK |
6 |
Specialty Tier |
33% | N/A | P |
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1 |
3 |
Preferred Brand |
$42.00 | N/A | None |
CORDRAN 4 MCG/SQ CM TAPE LARGE |
3 |
Preferred Brand |
$42.00 | N/A | None |
CORLANOR 5 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | N/A | P |
CORLANOR 7.5 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | N/A | P |
Cortisone 25 MG Tablet |
2 |
Generic |
$7.00 | N/A | None |
CORTISPORIN CRE 0.5% |
3 |
Preferred Brand |
$42.00 | N/A | Q:15 /7Days |
CORTISPORIN OINTMENT |
3 |
Preferred Brand |
$42.00 | N/A | Q:15 /7Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COSMEGEN 0.5 MG VIAL |
5 |
Injectable Drugs |
25% | N/A | P |
COTELLIC 20 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P |
Creon 256.11mg/1 1 BOTTLE per CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
3 |
Preferred Brand |
$42.00 | N/A | None |
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT |
3 |
Preferred Brand |
$42.00 | N/A | None |
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT |
3 |
Preferred Brand |
$42.00 | N/A | None |
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT |
3 |
Preferred Brand |
$42.00 | N/A | None |
CREON DR 36,000 UNITS CAPSULE |
3 |
Preferred Brand |
$42.00 | N/A | None |
CRESEMBA 372 MG VIAL |
5 |
Injectable Drugs |
25% | N/A | P |
CRIXIVAN 200MG CAPSULE |
3 |
Preferred Brand |
$42.00 | N/A | None |
CRIXIVAN 400mg, 180 CAPSULE BOTTLE |
3 |
Preferred Brand |
$42.00 | N/A | None |
CROMOLYN 20 MG/2 ML NEB SOLN |
2 |
Generic |
$7.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CROMOLYN SODIUM 100 MG/5 ML |
2 |
Generic |
$7.00 | N/A | None |
CROMOLYN SODIUM 4% 40MG 10ML BOT |
2 |
Generic |
$7.00 | N/A | None |
CUPRIMINE 250 MG CAPSULE |
6 |
Specialty Tier |
33% | N/A | P |
CYCLOBENZAPRINE 10 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
CYCLOPHOSPHAMIDE 25 MG CAPSULE |
2 |
Generic |
$7.00 | N/A | P |
CYCLOPHOSPHAMIDE 50 MG CAPSULE |
2 |
Generic |
$7.00 | N/A | P |
CYCLOSPORINE 100MG CAPSULE |
2 |
Generic |
$7.00 | N/A | P |
CYCLOSPORINE 25MG CAPSULE |
2 |
Generic |
$7.00 | N/A | P |
Cyclosporine 50 mg/ml vial |
5 |
Injectable Drugs |
25% | N/A | P |
CYCLOSPORINE MODIFIED 100 MG |
2 |
Generic |
$7.00 | N/A | P |
CYCLOSPORINE MODIFIED 25 MG |
2 |
Generic |
$7.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYCLOSPORINE MODIFIED 50 MG |
2 |
Generic |
$7.00 | N/A | P |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT |
2 |
Generic |
$7.00 | N/A | P |
CYPROHEPTADINE 4 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
CYRAMZA 100 MG/10 ML VIAL |
5 |
Injectable Drugs |
25% | N/A | P |
CYRAMZA 500 MG/50 ML VIAL |
5 |
Injectable Drugs |
25% | N/A | P |
CYSTADANE 1 GRAM/1.7 ML POWDER |
4 |
Non-Preferred Brand |
$90.00 | N/A | None |
CYSTAGON 150MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | N/A | None |
CYSTAGON 50MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | N/A | None |
CYSTARAN 0.44% EYE DROPS |
6 |
Specialty Tier |
33% | N/A | None |
CYTARABINE 20MG/ML VIAL |
5 |
Injectable Drugs |
25% | N/A | P |