2018 Medicare Part D Plan Formulary Information |
Kaiser Permanente Senior Advantage Basic (HMO) (H1170-009-0)
Benefit Details
|
The Kaiser Permanente Senior Advantage Basic (HMO) (H1170-009-0) Formulary Drugs Starting with the Letter A in Clayton County, GA: CMS MA Region 8 which includes: GA Plan Monthly Premium: $0.00 Deductible: $0 |
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 20 MG/ML SOLUTION |
2 |
Generic |
$20.00 | N/A | None |
ABACAVIR 300 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir] |
2 |
Generic |
$20.00 | N/A | None |
ABACAVIR-LAMIVUDINE 600-300 MG |
2 |
Generic |
$20.00 | N/A | None |
ABELCET INJECTION SUSPENSION 5MG/ML |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ABILIFY 10MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ABILIFY 15MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ABILIFY 20MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ABILIFY 2MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ABILIFY 30MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABILIFY 5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ABILIFY MAINTENA ER 300 MG SYR |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ABILIFY MAINTENA ER 300 MG VL |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ABILIFY MAINTENA ER 400 MG SUSER VIAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ABILIFY MAINTENA ER 400 MG SYR |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ABRAXANE 100MG VIAL |
3 |
Preferred Brand |
$47.00 | N/A | None |
ABSORICA 10 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ABSORICA 20 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ABSORICA 25 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ABSORICA 30 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ABSORICA 35 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABSORICA 40 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ABSTRAL 100 MCG TAB SUBLINGUAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
ABSTRAL 200 MCG TAB SUBLINGUAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
ABSTRAL 300 MCG TAB SUBLINGUAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
ABSTRAL 400 MCG TAB SUBLINGUAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
ABSTRAL 600 MCG TAB SUBLINGUAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
ABSTRAL 800 MCG TAB SUBLINGUAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
Acamprosate Calcium DR 333 MG tablets [Campral] |
2 |
Generic |
$20.00 | N/A | None |
ACANYA 25; 10mg/g; mg/g 1 BOTTLE, PUMP per CARTON / 50 g in 1 BOTTLE, PUMP |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACARBOSE 100 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
ACARBOSE 25 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACARBOSE 50 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
ACCOLATE 10 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACCOLATE 20 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACCUPRIL 10MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACCUPRIL 20MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACCUPRIL 40MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACCUPRIL 5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACCURETIC 10-12.5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACCURETIC 20-12.5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACCURETIC 20-25MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACEBUTOLOL 200 MG CAPSULE |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACEBUTOLOL 400 MG CAPSULE |
2 |
Generic |
$20.00 | N/A | None |
ACETAMINOP-CODEINE 120-12 MG/5 |
2 |
Generic |
$20.00 | N/A | None |
Acetaminophen 325 MG / Hydrocodone Bitartrate 5 MG Oral Tablet [Lorcet] |
2 |
Generic |
$20.00 | N/A | None |
ACETAMINOPHEN-COD #2 TABLET |
2 |
Generic |
$20.00 | N/A | None |
ACETAMINOPHEN-COD #3 TABLET |
2 |
Generic |
$20.00 | N/A | None |
ACETAMINOPHEN-COD #4 TABLET |
2 |
Generic |
$20.00 | N/A | None |
ACETAZOLAMIDE 125MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
2 |
Generic |
$20.00 | N/A | None |
Acetazolamide 500mg/5mL 1 VIAL in 1 CARTON / 5 mL in 1 VIAL |
2 |
Generic |
$20.00 | N/A | None |
ACETAZOLAMIDE ER 500 MG CAP |
2 |
Generic |
$20.00 | N/A | None |
ACETIC ACID 2% EAR SOLUTION |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETYLCYSTEINE 10% VIAL |
2 |
Generic |
$20.00 | N/A | P |
Acetylcysteine 200 MG/ML Inhalant Solution |
2 |
Generic |
$20.00 | N/A | P |
ACIPHEX 20MG TABLET EC |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACIPHEX SPRINKLE DR 10 MG CAP |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACIPHEX SPRINKLE DR 5 MG CAP |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACITRETIN 10 MG CAPSULE [Soriatane] |
2 |
Generic |
$20.00 | N/A | None |
ACITRETIN 17.5 MG CAPSULE [Soriatane] |
2 |
Generic |
$20.00 | N/A | None |
ACITRETIN 25 MG CAPSULE [Soriatane] |
2 |
Generic |
$20.00 | N/A | None |
ACTEMRA 162 MG/0.9 ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | None |
ACTEMRA 400 MG/20 ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACTEMRA 80 MG/4 ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTEMRA INJECTION 200MG/10ML |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACTHIB VACCINE WITH DILUENT |
6 |
Vaccines |
$0.00 | N/A | None |
ACTIGALL 300MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACTIMMUNE 100 MCG/0.5 ML VIAL |
5 |
Specialty Tier |
33% | N/A | None |
ACTIQ 1200MCG LOZENGE |
5 |
Specialty Tier |
33% | N/A | P |
ACTIQ 1600MCG LOZENGE |
5 |
Specialty Tier |
33% | N/A | P |
ACTIQ 200MCG LOZENGE |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
ACTIQ 400MCG LOZENGE |
5 |
Specialty Tier |
33% | N/A | P |
ACTIQ 600MCG LOZENGE |
5 |
Specialty Tier |
33% | N/A | P |
ACTIQ 800MCG LOZENGE |
5 |
Specialty Tier |
33% | N/A | P |
ACTIVELLA 0.5-0.1 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTIVELLA 1 MG-0.5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACTONEL 150 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACTONEL 30 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACTONEL 35 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACTONEL 5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACTOPLUS MET 15MG/500MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACTOPLUS MET 15MG/850MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACTOPLUS MET XR TABLETS ER 15;1000 MG;MG |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACTOPLUS MET XR TABLETS ER 30;1000 MG;MG |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACTOS 15 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACTOS 30 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTOS 45 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACULAR 0.5% EYE DROPS |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACULAR LS 0.4% OPHTH SOL |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACUVAIL 0.45% OPHTH SOLUTION #30X0.4 EA |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ACYCLOVIR 200 MG CAPSULE |
2 |
Generic |
$20.00 | N/A | None |
ACYCLOVIR 200 MG/5 ML SUSP |
2 |
Generic |
$20.00 | N/A | None |
ACYCLOVIR 400 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
Acyclovir 5% Ointment |
2 |
Generic |
$20.00 | N/A | None |
ACYCLOVIR 800 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
Acyclovir sodium 500 mg vial |
2 |
Generic |
$20.00 | N/A | None |
ACZONE 5% GEL |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADACEL TDAP SYRINGE |
6 |
Vaccines |
$0.00 | N/A | None |
ADACEL VIAL 2UNT/5UNT |
6 |
Vaccines |
$0.00 | N/A | None |
ADAGEN 250U/ML VIAL |
3 |
Preferred Brand |
$47.00 | N/A | None |
ADALAT CC 30 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ADALAT CC 60 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ADALAT CC 90 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA] |
5 |
Specialty Tier |
33% | N/A | None |
ADAPALENE 0.1% CREAM |
2 |
Generic |
$20.00 | N/A | None |
ADAPALENE 0.1% GEL |
2 |
Generic |
$20.00 | N/A | None |
Adapalene 0.3% gel |
2 |
Generic |
$20.00 | N/A | None |
ADAPALENE-BNZYL PEROX 0.1-2.5% [EPIDUO] |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADCIRCA TABLETS 20MG 60 BOTTLE |
5 |
Specialty Tier |
33% | N/A | P |
ADDERALL 20 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
ADDERALL 5 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
ADDERALL 7.5 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
ADDERALL XR 10MG CAPSULE SA |
3 |
Preferred Brand |
$47.00 | N/A | None |
ADDERALL XR 15MG CAPSULE SA |
3 |
Preferred Brand |
$47.00 | N/A | None |
ADDERALL XR 20MG CAPSULE SA |
3 |
Preferred Brand |
$47.00 | N/A | None |
ADDERALL XR 25MG CAPSULE SA |
3 |
Preferred Brand |
$47.00 | N/A | None |
ADDERALL XR 30MG CAPSULE SA |
3 |
Preferred Brand |
$47.00 | N/A | None |
ADDERALL XR 5MG CAPSULE SA |
3 |
Preferred Brand |
$47.00 | N/A | None |
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera] |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADEMPAS 0.5 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
ADEMPAS 1 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
ADEMPAS 1.5 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
ADEMPAS 2 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
ADEMPAS 2.5 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
ADLYXIN 10-20 MCG STARTER PACK |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ADLYXIN 20 MCG MAINTENANCE PK |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ADMELOG 100 UNIT/ML VIAL [Humalog] |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ADMELOG SOLOSTAR 100 UNIT/ML INSULN PEN [Humalog KwikPen] |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Adrenalin 1 mg/ml vial |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Adriamycin 20 mg/10 ml vial |
2 |
Generic |
$20.00 | 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 |
2 |
Generic |
$20.00 | N/A | None |
ADVAIR DISKUS MIS 100/50 |
3 |
Preferred Brand |
$47.00 | N/A | None |
ADVAIR DISKUS MIS 250/50 |
3 |
Preferred Brand |
$47.00 | N/A | None |
ADVAIR DISKUS MIS 500/50 |
3 |
Preferred Brand |
$47.00 | N/A | None |
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$47.00 | N/A | None |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL |
3 |
Preferred Brand |
$47.00 | N/A | None |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
3 |
Preferred Brand |
$47.00 | N/A | None |
ADZENYS ER 1.25 MG/ML SUSP BP 24H |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ADZENYS XR-ODT 12.5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ADZENYS XR-ODT 15.7 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ADZENYS XR-ODT 18.8 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADZENYS XR-ODT 3.1 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ADZENYS XR-ODT 6.3 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ADZENYS XR-ODT 9.4 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AFEDITAB CR 30MG TABLET SA |
2 |
Generic |
$20.00 | N/A | None |
AFEDITAB CR 60MG TABLET SA |
2 |
Generic |
$20.00 | N/A | None |
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK |
5 |
Specialty Tier |
33% | N/A | None |
AFINITOR DISPERZ 2 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
AFINITOR DISPERZ 3 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
AFINITOR DISPERZ 5 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
AFINITOR TABLETS 10 MG |
5 |
Specialty Tier |
33% | N/A | None |
AFINITOR TABLETS 2.5 MG |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AFINITOR TABLETS 5 MG |
5 |
Specialty Tier |
33% | N/A | None |
AFREZZA 12 UNIT CARTRIDGE CART INHAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AFREZZA 30-4 UNIT + 60-8 UNIT |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AFREZZA 4 UNIT/8 UNIT/12 UNIT |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AFREZZA 4 UNITS CARTRIDGE INH |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AFREZZA 60-8 UNIT + 30-12 UNIT |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AFREZZA 8 UNIT CARTRIDGE CART INHAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AFREZZA 90-4 UNIT / 90-8 UNIT |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AGGRENOX 25-200MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | None |
AGRYLIN 0.5MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AIMOVIG 140 MG DOSE-2 AUTO INJCT |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AIRDUO RESPICLICK 113-14 MCG |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AIRDUO RESPICLICK 232-14 MCG |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AIRDUO RESPICLICK 55-14 MCG |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AKTIPAK 3%-5% GEL POUCH |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Ala-cort 2.5% cream |
2 |
Generic |
$20.00 | N/A | None |
ALA-SCALP HP 2% LOTION |
2 |
Generic |
$20.00 | N/A | None |
ALBENZA 200 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
ALBUTEROL SUL 2.5 MG/3 ML SOLN |
1 |
Preferred Generic |
$2.00 | N/A | P |
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH per CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL |
2 |
Generic |
$20.00 | N/A | P |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
2 |
Generic |
$20.00 | N/A | P |
ALBUTEROL SULFATE 2 MG TAB |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL SULFATE 4 MG TAB |
2 |
Generic |
$20.00 | N/A | None |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
2 |
Generic |
$20.00 | N/A | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
2 |
Generic |
$20.00 | N/A | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
1 |
Preferred Generic |
$2.00 | N/A | P |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
2 |
Generic |
$20.00 | N/A | None |
ALCLOMETASONE DIPR 0.05% OINT |
2 |
Generic |
$20.00 | N/A | None |
ALCLOMETASONE DIPRO 0.05% CRM |
2 |
Generic |
$20.00 | N/A | None |
ALDACTAZIDE 25/25 TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ALDACTAZIDE 50/50 TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ALDACTONE 100MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ALDACTONE 25MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALDACTONE 50MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ALDARA 5% CREAM |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ALDURAZYME 2.9MG/5ML VIAL |
3 |
Preferred Brand |
$47.00 | N/A | None |
ALECENSA 150 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | None |
ALENDRONATE SODIUM 10 MG TAB |
1 |
Preferred Generic |
$2.00 | N/A | None |
ALENDRONATE SODIUM 35 MG TAB |
2 |
Generic |
$20.00 | N/A | None |
ALENDRONATE SODIUM 40 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
ALENDRONATE SODIUM 5 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
ALENDRONATE SODIUM 70 MG TAB |
1 |
Preferred Generic |
$2.00 | N/A | None |
ALENDRONATE SODIUM 70 MG/75 ML |
2 |
Generic |
$20.00 | N/A | None |
ALFUZOSIN HCL ER 10 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALIMTA 100 MG VIAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ALIMTA 500 MG VIAL |
3 |
Preferred Brand |
$47.00 | N/A | None |
ALINIA 100 MG/5 ML SUSPENSION |
3 |
Preferred Brand |
$47.00 | N/A | None |
ALINIA 500 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
ALIQOPA 60 MG VIAL |
5 |
Specialty Tier |
33% | N/A | None |
Aliskiren 150 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT] |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Aliskiren 150 MG / Hydrochlorothiazide 25 MG Oral Tablet [Tekturna HCT] |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Aliskiren 300 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT] |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ALKERAN 50 MG VIAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ALLOPURINOL 100 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
ALLOPURINOL 300 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Allopurinol sodium 500 mg vial |
2 |
Generic |
$20.00 | N/A | None |
ALLZITAL 25-325 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
ALMOTRIPTAN MALATE 12.5 MG TAB [Axert] |
2 |
Generic |
$20.00 | N/A | None |
ALMOTRIPTAN MALATE 6.25 MG TAB [Axert] |
2 |
Generic |
$20.00 | N/A | None |
ALOCRIL 2% EYE DROPS |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ALOGLIPTIN 12.5 MG TABLET [Nesina] |
2 |
Generic |
$20.00 | N/A | None |
ALOGLIPTIN 25 MG TABLET [Nesina] |
2 |
Generic |
$20.00 | N/A | None |
ALOGLIPTIN 6.25 MG TABLET [Nesina] |
2 |
Generic |
$20.00 | N/A | None |
ALOGLIPTIN-METFORMIN 12.5-1000 [Kazano] |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ALOGLIPTIN-METFORMIN 12.5-500 [Kazano] |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ALOGLIPTIN-PIOGLIT 12.5-15 MG [Oseni] |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALOGLIPTIN-PIOGLIT 12.5-30 MG [Oseni] |
2 |
Generic |
$20.00 | N/A | None |
ALOGLIPTIN-PIOGLIT 12.5-45 MG [Oseni] |
2 |
Generic |
$20.00 | N/A | None |
ALOGLIPTIN-PIOGLIT 25-15 MG TABLET [Oseni] |
2 |
Generic |
$20.00 | N/A | None |
ALOGLIPTIN-PIOGLIT 25-30 MG TABLET [Oseni] |
2 |
Generic |
$20.00 | N/A | None |
ALOGLIPTIN-PIOGLIT 25-45 MG TABLET [Oseni] |
2 |
Generic |
$20.00 | N/A | None |
ALOMIDE 0.1% EYE DROPS |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ALOPRIM SOLUTION FOR INJECTION 500MG/VIAL 30 ML VIALGL |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ALORA 0.025 MG PATCH |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ALORA 0.05 MG PATCH |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ALORA 0.075 MG PATCH |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ALORA 0.1 MG PATCH |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALOSETRON HCL 0.5 MG TABLET [Lotronex] |
2 |
Generic |
$20.00 | N/A | None |
ALOSETRON HCL 1 MG TABLET [Lotronex] |
2 |
Generic |
$20.00 | N/A | None |
ALOXI 0.25 MG/5 ML |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ALPHAGAN P 0.1% DROPS |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ALPHAGAN P 0.15% EYE DROPS |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ALPRAZOLAM 0.25 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
ALPRAZOLAM 0.5 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
ALPRAZOLAM 1 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
Alprazolam 1mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
2 |
Generic |
$20.00 | N/A | None |
Alprazolam 1mg/mL 1 BOTTLE in 1 CONTAINER / 30 mL in 1 BOTTLE |
2 |
Generic |
$20.00 | N/A | None |
ALPRAZOLAM 2 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Alprazolam 2mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
2 |
Generic |
$20.00 | N/A | None |
ALPRAZOLAM ER 0.5 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
ALPRAZOLAM ER 1 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
ALPRAZOLAM ER 2 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
ALPRAZOLAM ER 3 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
ALPRAZOLAM ODT 0.25 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
ALPRAZOLAM ODT 0.5 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
ALREX 0.2% EYE DROPS |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ALTACE 1.25MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ALTACE 10MG CAPSULE (100 CT) |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ALTACE 2.5 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALTACE 5MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ALTAVERA-28 TABLET |
2 |
Generic |
$20.00 | N/A | None |
ALTOPREV 20 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ALTOPREV 60 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ALUNBRIG 180 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
ALUNBRIG 30 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
ALUNBRIG 90 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
ALUNBRIG 90 MG-180 MG TABLET PACK |
5 |
Specialty Tier |
33% | N/A | None |
ALVESCO 160MCG/ACT AERS |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ALVESCO 80MCG/ACT AERS |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ALYACEN 1-35-28 TABLET |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Amabelz 0.5 MG/0.1 MG 28 TABLET/BLISTER PACK 3 PER CARTON |
2 |
Generic |
$20.00 | N/A | None |
Amabelz 1 MG/0.5 MG 28 TABLET/BLISTER PACK 3 PER CARTON |
2 |
Generic |
$20.00 | N/A | None |
AMANTADINE 100 MG CAPSULE |
2 |
Generic |
$20.00 | N/A | None |
AMANTADINE 100 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
AMANTADINE 50 MG/5 ML SOLUTION |
2 |
Generic |
$20.00 | N/A | None |
AMARYL 1MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AMARYL 2MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AMARYL 4MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AMBIEN 10 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AMBIEN CR 12.5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AMBIEN CR 6.25MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMBIEN TABLETS 5MG 100 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AMBISOME 50MG VIAL |
5 |
Specialty Tier |
33% | N/A | None |
AMCINONIDE 0.1% CREAM |
2 |
Generic |
$20.00 | N/A | None |
AMCINONIDE 0.1% LOTION |
2 |
Generic |
$20.00 | N/A | None |
AMCINONIDE 0.1% OINTMENT 60GM TUBE |
2 |
Generic |
$20.00 | N/A | None |
AMERGE 1MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AMERGE 2.5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AMETHIA 0.15-0.03-0.01 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
AMETHIA LO TABLET |
2 |
Generic |
$20.00 | N/A | None |
AMIKACIN SULF 500 MG/2 ML VIAL |
2 |
Generic |
$20.00 | N/A | None |
AMILORIDE HCL 5 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMILORIDE HCL-HCTZ 5-50 MG TABLET |
1 |
Preferred Generic |
$2.00 | N/A | None |
Amino Acids 15% Solution |
2 |
Generic |
$20.00 | N/A | None |
Amino acids 4.25% in dextrose 10% Injectable Solution [Clinimix 4.25/10] |
3 |
Preferred Brand |
$47.00 | N/A | None |
Amino acids 4.25% in dextrose 20% Injectable Solution [Clinimix 4.25/20] |
3 |
Preferred Brand |
$47.00 | N/A | None |
Amino acids 4.25% in dextrose 5% Injectable Solution [Clinimix 4.25/5] |
3 |
Preferred Brand |
$47.00 | N/A | None |
Amino acids 4.25% with electrolytes in dextrose 10% Injectable Solution [Clinimix E 4.25/10] |
3 |
Preferred Brand |
$47.00 | N/A | None |
Aminophylline 25 MG/ML 10 ML Injection |
2 |
Generic |
$20.00 | N/A | None |
AMINOSYN 7%-ELECTROLYTE SOL |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AMINOSYN HBC INJECTION SULFITE FREE 7% |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AMINOSYN II 10% SOL 6X2000 ML |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AMINOSYN II 15% IV SOLUTION |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN II 8.5% ELECTROLYT |
2 |
Generic |
$20.00 | N/A | None |
AMINOSYN II 8.5% ELECTROLYT |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AMINOSYN PF INJECTION |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5% |
2 |
Generic |
$20.00 | N/A | None |
AMINOSYN-PF 7% IV SOLUTION |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AMINOSYN-RF 5.2% IV SOLUTION |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AMIODARONE HCL 100 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
AMIODARONE HCL 200 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
AMIODARONE HCL 400 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
AMIODARONE HCL 50 MG/ML in 3 ML Injection |
2 |
Generic |
$20.00 | N/A | None |
AMITIZA 8MCG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITIZA CAPSULES 24MCG 60 CAP BOT |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AMITRIP/CDP 25-10 TABLET |
2 |
Generic |
$20.00 | N/A | None |
AMITRIP/PERPHEN 10-4 TABLET |
2 |
Generic |
$20.00 | N/A | None |
AMITRIP/PERPHEN 50-4 TABLET |
2 |
Generic |
$20.00 | N/A | None |
AMITRIPTYLINE HCL 10 MG TAB |
2 |
Generic |
$20.00 | N/A | None |
AMITRIPTYLINE HCL 100 MG TAB |
2 |
Generic |
$20.00 | N/A | None |
AMITRIPTYLINE HCL 150 MG TAB |
2 |
Generic |
$20.00 | N/A | None |
AMITRIPTYLINE HCL 25 MG TAB |
2 |
Generic |
$20.00 | N/A | None |
AMITRIPTYLINE HCL 50 MG TAB |
2 |
Generic |
$20.00 | N/A | None |
AMITRIPTYLINE HCL 75 MG TAB |
2 |
Generic |
$20.00 | N/A | None |
AMLOD-VALSA-HCTZ 10-160-12.5MG [Exforge HCT] |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLOD-VALSA-HCTZ 10-160-25 MG [Exforge HCT] |
2 |
Generic |
$20.00 | N/A | None |
AMLOD-VALSA-HCTZ 10-320-25 MG [Exforge HCT] |
2 |
Generic |
$20.00 | N/A | None |
AMLOD-VALSA-HCTZ 5-160-12.5 MG [Exforge HCT] |
2 |
Generic |
$20.00 | N/A | None |
AMLOD-VALSA-HCTZ 5-160-25 MG [Exforge HCT] |
2 |
Generic |
$20.00 | N/A | None |
AMLODIPINE BESYLATE 10 MG TAB |
1 |
Preferred Generic |
$2.00 | N/A | None |
AMLODIPINE BESYLATE 2.5 MG TAB |
1 |
Preferred Generic |
$2.00 | N/A | None |
AMLODIPINE BESYLATE 5 MG TAB |
1 |
Preferred Generic |
$2.00 | N/A | None |
AMLODIPINE-ATORVAST 10-20 MG [Caduet] |
2 |
Generic |
$20.00 | N/A | None |
AMLODIPINE-ATORVAST 10-40 MG [Caduet] |
2 |
Generic |
$20.00 | N/A | None |
Amlodipine-Atorvastatin 10-10 mg [Caduet] |
2 |
Generic |
$20.00 | N/A | None |
Amlodipine-Atorvastatin 10-80 mg [Caduet] |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Amlodipine-Atorvastatin 2.5-10 mg [Caduet] |
2 |
Generic |
$20.00 | N/A | None |
Amlodipine-Atorvastatin 2.5-20 mg [Caduet] |
2 |
Generic |
$20.00 | N/A | None |
Amlodipine-Atorvastatin 2.5-40 mg [Caduet] |
2 |
Generic |
$20.00 | N/A | None |
Amlodipine-Atorvastatin 5-10 mg [Caduet] |
2 |
Generic |
$20.00 | N/A | None |
Amlodipine-Atorvastatin 5-20 mg [Caduet] |
2 |
Generic |
$20.00 | N/A | None |
Amlodipine-Atorvastatin 5-40 mg [Caduet] |
2 |
Generic |
$20.00 | N/A | None |
Amlodipine-Atorvastatin 5-80 mg [Caduet] |
2 |
Generic |
$20.00 | N/A | None |
AMLODIPINE-BENAZEPRIL 10-20 MG Capsule [Lotrel] |
2 |
Generic |
$20.00 | N/A | None |
AMLODIPINE-BENAZEPRIL 10-40 MG Capsule [Lotrel] |
2 |
Generic |
$20.00 | N/A | None |
AMLODIPINE-BENAZEPRIL 2.5-10 Capsule [Lotrel] |
2 |
Generic |
$20.00 | N/A | None |
AMLODIPINE-BENAZEPRIL 5-10 MG Capsule [Lotrel] |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE-BENAZEPRIL 5-20 MG Capsule [Lotrel] |
2 |
Generic |
$20.00 | N/A | None |
AMLODIPINE-BENAZEPRIL 5-40 MG Capsule [Lotrel] |
2 |
Generic |
$20.00 | N/A | None |
AMLODIPINE-OLMESARTAN 10-20 MG [Azor] |
2 |
Generic |
$20.00 | N/A | None |
AMLODIPINE-OLMESARTAN 10-40 MG [Azor] |
2 |
Generic |
$20.00 | N/A | None |
AMLODIPINE-OLMESARTAN 5-20 MG [Azor] |
2 |
Generic |
$20.00 | N/A | None |
AMLODIPINE-OLMESARTAN 5-40 MG [Azor] |
2 |
Generic |
$20.00 | N/A | None |
AMLODIPINE-VALSARTAN 10-160 MG |
2 |
Generic |
$20.00 | N/A | None |
AMLODIPINE-VALSARTAN 10-320 MG |
2 |
Generic |
$20.00 | N/A | None |
AMLODIPINE-VALSARTAN 5-160 MG |
2 |
Generic |
$20.00 | N/A | None |
AMLODIPINE-VALSARTAN 5-320 MG |
2 |
Generic |
$20.00 | N/A | None |
AMMONIUM LACTATE 12% CREAM |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMMONIUM LACTATE 12% LOTION |
2 |
Generic |
$20.00 | N/A | None |
AMNESTEEM 10 MG CAPSULE |
2 |
Generic |
$20.00 | N/A | None |
AMNESTEEM 20 MG CAPSULE |
2 |
Generic |
$20.00 | N/A | None |
AMNESTEEM 40 MG CAPSULE |
2 |
Generic |
$20.00 | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE [Augmentin] |
2 |
Generic |
$20.00 | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin] |
2 |
Generic |
$20.00 | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE [Augmentin] |
2 |
Generic |
$20.00 | N/A | None |
AMOX-CLAV 200-28.5 MG/5 ML SUS |
2 |
Generic |
$20.00 | N/A | None |
AMOX-CLAV 250-62.5 MG/5 ML SUS |
2 |
Generic |
$20.00 | N/A | None |
AMOX-CLAV 400-57 MG/5 ML SUSP |
2 |
Generic |
$20.00 | N/A | None |
AMOX-CLAV 500-125 MG TABLET [Augmentin] |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOX-CLAV 600-42.9 MG/5 ML SUS |
2 |
Generic |
$20.00 | N/A | None |
AMOX-CLAV 875-125 MG TABLET [Augmentin] |
2 |
Generic |
$20.00 | N/A | None |
AMOX-CLAV ER 1,000-62.5 MG TABLET [Augmentin] |
2 |
Generic |
$20.00 | N/A | None |
AMOXAPINE 100MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
AMOXAPINE 150MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
AMOXAPINE 25MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
AMOXAPINE 50MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
AMOXICILLIN 125 MG/5 ML SUSP |
2 |
Generic |
$20.00 | N/A | None |
AMOXICILLIN 125MG TABLET CHEW |
2 |
Generic |
$20.00 | N/A | None |
AMOXICILLIN 200 MG/5 ML SUSP |
2 |
Generic |
$20.00 | N/A | None |
AMOXICILLIN 250 MG CAPSULE |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN 250 MG TAB CHEW |
2 |
Generic |
$20.00 | N/A | None |
AMOXICILLIN 250 MG/5 ML SUSP |
2 |
Generic |
$20.00 | N/A | None |
AMOXICILLIN 400 MG/5 ML SUSP |
2 |
Generic |
$20.00 | N/A | None |
AMOXICILLIN 500 MG CAPSULE |
2 |
Generic |
$20.00 | N/A | None |
AMOXICILLIN 500 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
AMOXICILLIN 875 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
AMPHETAMINE SALT COMBO 15MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
AMPHETAMINE SALTS 5 MG TAB |
2 |
Generic |
$20.00 | N/A | None |
amphotericin b 50mg/10mL 10 mL in 1 VIAL |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN 10 GM VIAL |
2 |
Generic |
$20.00 | N/A | None |
Ampicillin 1000 MG / Sulbactam 500 MG Injection |
2 |
Generic |
$20.00 | N/A | None |
Ampicillin 1000 MG Injection |
2 |
Generic |
$20.00 | N/A | None |
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS |
2 |
Generic |
$20.00 | N/A | None |
Ampicillin 2000 MG / Sulbactam 1000 MG Injection |
2 |
Generic |
$20.00 | N/A | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
2 |
Generic |
$20.00 | N/A | None |
AMPICILLIN-SULBACTAM 15 GM VL |
2 |
Generic |
$20.00 | N/A | None |
AMPYRA ER 10 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
AMRIX 30 MG |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
AMRIX CAPSULES EXTENDED RELEASE 15MG 60 CAPSULES BOT |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
ANADROL-50 TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANAFRANIL 25 MG 30 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ANAFRANIL 50 MG 30 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ANAFRANIL 75 MG 30 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE |
2 |
Generic |
$20.00 | N/A | None |
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE |
2 |
Generic |
$20.00 | N/A | None |
ANASTROZOLE 1 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
ANCOBON 250MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | None |
ANCOBON 500MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | None |
ANDRODERM 2 MG/24HR PATCH |
3 |
Preferred Brand |
$47.00 | N/A | None |
ANDRODERM 4 MG/24HR PATCH |
3 |
Preferred Brand |
$47.00 | N/A | None |
ANDROGEL 1.62% (1.25G) GEL PCKT |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANDROGEL 1.62% (2.5G) GEL PCKT |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ANDROGEL 1% (50MG) GEL PACKET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Androgel 10mg/g 30 PACKET in 1 CARTON / 2.5 g in 1 PACKET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Androgel 16.2mg/g 1 BOTTLE, PUMP per CARTON / 88 g in 1 BOTTLE, PUMP |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ANDROID 10 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Angeliq 0.25/0.5 28 Day Pack |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ANGELIQ 1-0.5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ANORO ELLIPTA 62.5-25 MCG INH |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ANTABUSE 250MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
ANTABUSE 500MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
ANTARA 30 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANTARA 90 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Antineoplastic Agent Etoposide 20 mg / mL Intravenous Injection Multiple Dose Vial 5 mL |
2 |
Generic |
$20.00 | N/A | None |
ANUSOL-HC 2.5% CREAM |
2 |
Generic |
$20.00 | N/A | None |
ANZEMET 100 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
ANZEMET 50 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
APEXICON E 0.05% CREAM |
2 |
Generic |
$20.00 | N/A | None |
APIDRA 100 UNITS/ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
APIDRA SOLOSTAR 100 UNITS/ML |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
APLENZIN ER 174 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
APLENZIN ER 348 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
APLENZIN ER 522 MG TABLET |
4 |
Non-Preferred Brand |
$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 |
33% | N/A | None |
Apraclonidine 5 MG/ML Ophthalmic Solution |
2 |
Generic |
$20.00 | N/A | None |
APREPITANT 125 MG CAPSULE [Emend] |
2 |
Generic |
$20.00 | N/A | P |
APREPITANT 125-80-80 MG PACK [Emend] |
2 |
Generic |
$20.00 | N/A | P |
APREPITANT 40 MG CAPSULE [Emend] |
2 |
Generic |
$20.00 | N/A | P |
APREPITANT 80 MG CAPSULE [Emend] |
2 |
Generic |
$20.00 | N/A | P |
APRI 0.15-0.03 TABLET |
2 |
Generic |
$20.00 | N/A | None |
APRISO CP24 |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
APTENSIO XR 10 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | None |
APTENSIO XR 15 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | None |
APTENSIO XR 20 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APTENSIO XR 30 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | None |
APTENSIO XR 40 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | None |
APTENSIO XR 50 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | None |
APTENSIO XR 60 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | None |
APTIOM 200 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
APTIOM 400 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
APTIOM 600 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
APTIOM 800 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
APTIVUS 250MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
3 |
Preferred Brand |
$47.00 | N/A | None |
ARALAST NP 1,000 MG VIAL |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANELLE 7-9-5 TABLET |
2 |
Generic |
$20.00 | N/A | None |
ARANESP 10 MCG/0.4 ML SYRINGE |
4 |
Non-Preferred Brand |
$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 |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
ARANESP 200MCG/0.4ML SYRINGE |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
ARANESP 200MCG/ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | 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 Brand |
$95.00 | N/A | P |
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
ARANESP 300MCG/ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
ARANESP 500MCG/1ML SYRINGE |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
ARANESP 60MCG/ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.3 mL in 1 SYRINGE |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
ARAVA 10MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ARAVA 20MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ARCALYST INJECTION 220MG/VIAL |
5 |
Specialty Tier |
33% | N/A | None |
ARCAPTA NEOHALER 75 MCG CAP |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Argatroban 125mg/125mL 2 VIAL, SINGLE-USE per CARTON / 125 mL in 1 VIAL, SINGLE-USE |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ARGATROBAN 250 MG VL 2.5 ML |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARICEPT 10MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ARICEPT 23 MG TABLETS |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ARICEPT 5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ARIMIDEX 1MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ARIPIPRAZOLE 1 MG/ML SOLUTION [Abilify] |
2 |
Generic |
$20.00 | N/A | None |
ARIPIPRAZOLE 10 MG TABLET [Abilify] |
2 |
Generic |
$20.00 | N/A | None |
ARIPIPRAZOLE 15 MG TABLET [Abilify] |
2 |
Generic |
$20.00 | N/A | None |
ARIPIPRAZOLE 2 MG TABLET [Abilify] |
2 |
Generic |
$20.00 | N/A | None |
ARIPIPRAZOLE 20 MG TABLET [Abilify] |
2 |
Generic |
$20.00 | N/A | None |
ARIPIPRAZOLE 30 MG TABLET [Abilify] |
2 |
Generic |
$20.00 | N/A | None |
ARIPIPRAZOLE 5 MG TABLET [Abilify] |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARIPIPRAZOLE ODT 10 MG TABLET [Abilify] |
2 |
Generic |
$20.00 | N/A | None |
ARIPIPRAZOLE ODT 15 MG TABLET [Abilify] |
2 |
Generic |
$20.00 | N/A | None |
ARISTADA ER 1064 MG/3.9 ML SYR |
5 |
Specialty Tier |
33% | N/A | None |
ARISTADA ER 441 MG/1.6 ML SYRN |
5 |
Specialty Tier |
33% | N/A | None |
ARISTADA ER 662 MG/2.4 ML SYRN |
5 |
Specialty Tier |
33% | N/A | None |
ARISTADA ER 882 MG/3.2 ML SYRN |
5 |
Specialty Tier |
33% | N/A | None |
ARIXTRA 7.5 MG/0.6 ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | None |
Armodafinil 150 MG TABLET [NUVIGIL] |
2 |
Generic |
$20.00 | N/A | P |
Armodafinil 200 MG Oral Tablet [NUVIGIL] |
2 |
Generic |
$20.00 | N/A | P |
Armodafinil 250 MG TABLET [NUVIGIL] |
2 |
Generic |
$20.00 | N/A | P |
Armodafinil 50 MG TABLET [NUVIGIL] |
2 |
Generic |
$20.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARMONAIR RESPICLICK 113 MCG |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ARMONAIR RESPICLICK 232 MCG |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ARMONAIR RESPICLICK 55 MCG |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ARNUITY ELLIPTA 100 MCG INH |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ARNUITY ELLIPTA 200 MCG INH |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ARNUITY ELLIPTA 50 MCG INH BLST W/DEV |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AROMASIN 25MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ARRANON 250 MG VIAL |
3 |
Preferred Brand |
$47.00 | N/A | None |
ARTHROTEC 50 50MG TABLET -200MCG (60 CT) |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ARTHROTEC 75 TABLET EC |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ASACOL HD DR 800 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ASCOMP WITH CODEINE CAPSULE |
2 |
Generic |
$20.00 | N/A | None |
ASHLYNA 0.15-0.03-0.01 MG TAB |
2 |
Generic |
$20.00 | N/A | None |
ASMANEX HFA 100 MCG INHALER |
3 |
Preferred Brand |
$47.00 | N/A | None |
ASMANEX HFA 200 MCG INHALER |
3 |
Preferred Brand |
$47.00 | N/A | None |
ASMANEX TWISTHALER 110 MCG #30 |
3 |
Preferred Brand |
$47.00 | N/A | None |
ASMANEX TWISTHALER 220 MCG #30 |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ASMANEX TWISTHALER 220MCG #120 |
3 |
Preferred Brand |
$47.00 | N/A | None |
ASMANEX TWISTHALER 220MCG #60 |
3 |
Preferred Brand |
$47.00 | N/A | None |
Aspirin-Diphenhydramine ER 25-200 MG |
2 |
Generic |
$20.00 | N/A | None |
ASPIRIN/BUTALBITAL/CAFFEINE/CODEINE |
2 |
Generic |
$20.00 | N/A | None |
ASTAGRAF XL 0.5 MG CAPSULE |
4 |
Non-Preferred Brand |
$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 Brand |
$95.00 | N/A | P |
ASTAGRAF XL 5 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
ASTEPRO 0.15% NASAL SPRAY 30 ML |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ATACAND 16MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ATACAND 32 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ATACAND 4MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ATACAND 8MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ATACAND HCT 16/12.5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ATACAND HCT 32/12.5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ATACAND HCT TABLETS 32;25MG;MG 90 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ATAZANAVIR SULFATE 150 MG CAP [Reyataz] |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATAZANAVIR SULFATE 200 MG CAP [Reyataz] |
2 |
Generic |
$20.00 | N/A | None |
ATAZANAVIR SULFATE 300 MG CAP [Reyataz] |
2 |
Generic |
$20.00 | N/A | None |
Atelvia 35mg/1 36 DOSE PACK CASE / 4 TABLET, DELAYED RELEASE in 1 DOSE PACK |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ATENOLOL 100 MG TABLET |
1 |
Preferred Generic |
$2.00 | N/A | None |
ATENOLOL 25 MG TABLET |
1 |
Preferred Generic |
$2.00 | N/A | None |
ATENOLOL 50 MG TABLET |
1 |
Preferred Generic |
$2.00 | N/A | None |
ATENOLOL-CHLORTHALIDONE 100-25 |
2 |
Generic |
$20.00 | N/A | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
2 |
Generic |
$20.00 | N/A | None |
ATGAM 50MG/ML AMPUL |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ATIVAN 0.5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ATIVAN 1 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATIVAN 1 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ATIVAN 2 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ATOMOXETINE HCL 10 MG CAPSULE [Strattera] |
2 |
Generic |
$20.00 | N/A | None |
ATOMOXETINE HCL 100 MG CAPSULE [Strattera] |
2 |
Generic |
$20.00 | N/A | None |
ATOMOXETINE HCL 18 MG CAPSULE [Strattera] |
2 |
Generic |
$20.00 | N/A | None |
ATOMOXETINE HCL 25 MG CAPSULE [Strattera] |
2 |
Generic |
$20.00 | N/A | None |
ATOMOXETINE HCL 40 MG CAPSULE [Strattera] |
2 |
Generic |
$20.00 | N/A | None |
ATOMOXETINE HCL 60 MG CAPSULE [Strattera] |
2 |
Generic |
$20.00 | N/A | None |
ATOMOXETINE HCL 80 MG CAPSULE [Strattera] |
2 |
Generic |
$20.00 | N/A | None |
ATORVASTATIN 10 MG TABLET [Lipitor] |
1 |
Preferred Generic |
$2.00 | N/A | None |
ATORVASTATIN 20 MG TABLET [Lipitor] |
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 |
ATORVASTATIN 40 MG TABLET [Lipitor] |
1 |
Preferred Generic |
$2.00 | N/A | None |
ATORVASTATIN 80 MG TABLET [Lipitor] |
1 |
Preferred Generic |
$2.00 | N/A | None |
ATOVAQUONE 750 MG/5 ML SUSP [Mepron] |
2 |
Generic |
$20.00 | N/A | None |
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone] |
2 |
Generic |
$20.00 | N/A | None |
ATOVAQUONE-PROGUANIL 62.5-25 [Malarone] |
2 |
Generic |
$20.00 | N/A | None |
ATRALIN 0.05% GEL |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Preferred Brand |
$47.00 | N/A | None |
ATROPINE 0.05MG/ML SYRINGE |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ATROPINE 1% EYE DROPS |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
ATROVENT HFA AER 17MCG |
3 |
Preferred Brand |
$47.00 | N/A | None |
AUBAGIO 14 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 |
AUBAGIO 7 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
AUBRA-28 TABLET |
2 |
Generic |
$20.00 | N/A | None |
AUGMENTIN 125-31.25 MG/5 ML |
3 |
Preferred Brand |
$47.00 | N/A | None |
AURYXIA 210 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AUSTEDO 12 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
AUSTEDO 6 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
AUSTEDO 9 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
AUVI-Q 0.1 MG AUTO-INJECTOR |
5 |
Specialty Tier |
33% | N/A | None |
AUVI-Q 0.15 MG AUTO-INJECTOR |
5 |
Specialty Tier |
33% | N/A | None |
AUVI-Q 0.3 MG AUTO-INJECTOR |
5 |
Specialty Tier |
33% | N/A | None |
AVALIDE 150-12.5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVALIDE 300-12.5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AVANDIA 2 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AVANDIA 4 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AVAPRO 150 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AVAPRO 300 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AVAPRO 75 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AVASTIN 100MG/4ML VIAL |
3 |
Preferred Brand |
$47.00 | N/A | None |
AVASTIN 400 MG/16 ML VIAL |
3 |
Preferred Brand |
$47.00 | N/A | None |
AVC 15% CREAM |
3 |
Preferred Brand |
$47.00 | N/A | None |
AVEED 750 MG/3 ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AVELOX 400 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVELOX IV 400 MG/250 ML |
3 |
Preferred Brand |
$47.00 | N/A | None |
AVIANE 0.1-0.02 TABLET |
2 |
Generic |
$20.00 | N/A | None |
AVITA 0.025% CREAM |
2 |
Generic |
$20.00 | N/A | P |
Avita 0.25mg/g 45 g in 1 TUBE |
2 |
Generic |
$20.00 | N/A | P |
AVODART 0.5 MG SOFTGEL |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AVONEX ADMIN PACK 30 MCG VL |
5 |
Specialty Tier |
33% | N/A | None |
AVONEX PEN 30 MCG/0.5 ML KIT |
5 |
Specialty Tier |
33% | N/A | None |
AVONEX PREFILLED SYR 30 MCG KT |
5 |
Specialty Tier |
33% | N/A | None |
AVYCAZ 2.5 GRAM VIAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AXERT 12.5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Aygestin 5mg/1 50 TABLET BOTTLE |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Azacitidine 100 mg vial [Vidaza] |
2 |
Generic |
$20.00 | N/A | None |
AZASAN 100MG TABLET |
2 |
Generic |
$20.00 | N/A | P |
AZASAN 75MG TABLET |
2 |
Generic |
$20.00 | N/A | P |
AZASITE 1% EYE DROPS |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AZATHIOPRINE 50 MG TABLET |
2 |
Generic |
$20.00 | N/A | P |
AZATHIOPRINE SODIUM 100 MG VIAL |
2 |
Generic |
$20.00 | N/A | None |
AZELASTINE 0.15% NASAL SPRAY |
2 |
Generic |
$20.00 | N/A | None |
AZELASTINE 137 MCG NASAL SPRAY |
2 |
Generic |
$20.00 | N/A | None |
AZELASTINE HCL 0.05% DROPS |
2 |
Generic |
$20.00 | N/A | None |
AZELEX 20% CREAM 30GM TUBE |
3 |
Preferred Brand |
$47.00 | N/A | None |
AZILECT 0.5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZILECT 1MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AZITHROMYCIN 1 GM PWD PACKET |
3 |
Preferred Brand |
$47.00 | N/A | None |
AZITHROMYCIN 100 MG/5 ML SUSP |
2 |
Generic |
$20.00 | N/A | None |
AZITHROMYCIN 200 MG/5 ML SUSP |
2 |
Generic |
$20.00 | N/A | None |
AZITHROMYCIN 250 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
AZITHROMYCIN 250 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
AZITHROMYCIN 500 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Generic |
$20.00 | N/A | None |
AZITHROMYCIN 600 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
AZITHROMYCIN I.V. 500 MG VIAL |
2 |
Generic |
$20.00 | N/A | None |
AZOPT 1% EYE DROPS |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZOR 10-20 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AZOR 10MG-40MG TABLET (30 CT) |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AZOR 5-40 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AZOR 5MG-20MG TABLET (30 CT) |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Aztreonam 1000 MG Injection [Azactam] |
3 |
Preferred Brand |
$47.00 | N/A | None |
Aztreonam 2000 MG Injection [Azactam] |
3 |
Preferred Brand |
$47.00 | N/A | None |
AZTREONAM FOR INJECTION |
2 |
Generic |
$20.00 | N/A | None |
AZULFIDINE 500 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
AZULFIDINE ENTAB 500 MG |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |