2018 Medicare Part D Plan Formulary Information |
Assurance Rx (HMO-POS) (H5211-007-0)
Benefit Details
|
The Assurance Rx (HMO-POS) (H5211-007-0) Formulary Drugs Starting with the Letter P in Green Lake County, WI: CMS MA Region 14 which includes: WI Plan Monthly Premium: $0.00 Deductible: $375 |
Drugs Starting with Letter P
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
PACERONE 100MG TABLET |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PACERONE 200 MG TABLET |
1* |
Preferred Generic |
$5.00 | N/A | None |
PACERONE 400MG TABLET |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PACLITAXEL 100 MG/16.7 ML VIAL |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PALIPERIDONE ER 1.5 MG TABLET [INVEGA] |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
PALIPERIDONE ER 3 MG TABLET [INVEGA] |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
PALIPERIDONE ER 6 MG TABLET [INVEGA] |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
PALIPERIDONE ER 9 MG TABLET [INVEGA] |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
PAMIDRONATE 30 MG/10 ML VIAL |
3 |
Preferred Brand |
$45.00 | N/A | None |
PAMIDRONATE 60MG/10ML VIAL |
3 |
Preferred Brand |
$45.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAMIDRONATE 90 MG/10 ML VIAL |
3 |
Preferred Brand |
$45.00 | N/A | None |
PANCREAZE 10,500 UNIT CAP DR |
3 |
Preferred Brand |
$45.00 | N/A | None |
PANCREAZE 16,800 UNIT CAP DR |
3 |
Preferred Brand |
$45.00 | N/A | None |
PANCREAZE 21,000 UNIT CAP DR |
3 |
Preferred Brand |
$45.00 | N/A | None |
PANCREAZE 4,200 UNIT CAP DR |
3 |
Preferred Brand |
$45.00 | N/A | None |
PANCREAZE DR 2,600 UNIT CAP |
3 |
Preferred Brand |
$45.00 | N/A | None |
PANRETIN 0.1% GEL 60GM TUBE |
5 |
Specialty Tier |
25% | N/A | None |
PANTOPRAZOLE SOD DR 20 MG TAB |
1* |
Preferred Generic |
$5.00 | N/A | Q:60 /30Days |
PANTOPRAZOLE SOD DR 40 MG TAB |
1* |
Preferred Generic |
$5.00 | N/A | Q:60 /30Days |
PARICALCITOL 1 MCG CAPSULE [Zemplar] |
3 |
Preferred Brand |
$45.00 | N/A | None |
PARICALCITOL 10 MCG/2 ML VIAL [Zemplar] |
3 |
Preferred Brand |
$45.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PARICALCITOL 2 MCG CAPSULE [Zemplar] |
3 |
Preferred Brand |
$45.00 | N/A | None |
PARICALCITOL 2 MCG/ML VIAL [Zemplar] |
3 |
Preferred Brand |
$45.00 | N/A | None |
PARICALCITOL 4 MCG CAPSULE [Zemplar] |
3 |
Preferred Brand |
$45.00 | N/A | None |
PAROMOMYCIN 250 MG CAPSULE |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PAROXETINE HCL 10 MG TABLET |
1* |
Preferred Generic |
$5.00 | N/A | Q:30 /30Days |
PAROXETINE HCL 20 MG TABLET |
1* |
Preferred Generic |
$5.00 | N/A | Q:30 /30Days |
PAROXETINE HCL 30 MG TABLET |
1* |
Preferred Generic |
$5.00 | N/A | Q:60 /30Days |
PAROXETINE HCL 40 MG TABLET |
1* |
Preferred Generic |
$5.00 | N/A | Q:60 /30Days |
PASER GRANULES 4GM PACKET |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PATADAY 0.2% DROPS |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PAXIL ORAL SUSPENSION 10 MG/5ML |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEDVAXHIB VACCINE VIAL |
3 |
Preferred Brand |
$45.00 | N/A | None |
PEG 3350 ELECTROLYTE SOLN SOLN RECON [GaviLyte-C] |
2* |
Generic |
$13.00 | N/A | None |
PEG 3350-ELECTROLYTE SOLUTION SOLN RECON |
2* |
Generic |
$13.00 | N/A | None |
PEG-3350 AND ELECTROLYTES SOLN SOLN RECON |
2* |
Generic |
$13.00 | N/A | None |
PEGANONE 250 MG TABLET |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
Pegasys 180ug/0.5mL 1 PACKET in 1 BOX / 4 SYRINGE, GLASS in 1 PACKET / 0.5 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
25% | N/A | P Q:2 /28Days |
PEGASYS INJECTION |
5 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
PEGASYS PROCLICK 135 MCG/0.5 |
5 |
Specialty Tier |
25% | N/A | P Q:2 /28Days |
PEGASYS PROCLICK 180 MCG/0.5 |
5 |
Specialty Tier |
25% | N/A | P Q:2 /28Days |
PENICILLIN G POTASSIUM 2MMUNITS/50ML ISO-OSM |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PENICILLIN G POTASSIUM 3MMUNITS/50ML ISO-OSM |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENICILLIN GK 20 MILLION UNIT |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
2* |
Generic |
$13.00 | N/A | None |
PENICILLIN V POTASSIUM 500MG TABLET |
2* |
Generic |
$13.00 | N/A | None |
PENICILLIN VK 125 MG/5 ML SOLN |
2* |
Generic |
$13.00 | N/A | None |
PENICILLIN VK 250 MG TABLET |
2* |
Generic |
$13.00 | N/A | None |
PENTAM 300 INJ 300MG |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PENTASA 250MG CAPSULE SA |
4 |
Non-Preferred Drug |
$98.00 | N/A | Q:150 /30Days |
PENTASA 500MG CAPSULE |
4 |
Non-Preferred Drug |
$98.00 | N/A | Q:300 /30Days |
PENTOXIFYLLINE 400MG TABLET SA |
2* |
Generic |
$13.00 | N/A | None |
PERFOROMIST 20MCG/2ML VIAL NEBULIZER |
4 |
Non-Preferred Drug |
$98.00 | N/A | P Q:120 /30Days |
PERINDOPRIL ERBUMINE 2 MG TAB |
2* |
Generic |
$13.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PERINDOPRIL ERBUMINE 4 MG TAB |
2* |
Generic |
$13.00 | N/A | None |
PERINDOPRIL ERBUMINE 8 MG TAB |
2* |
Generic |
$13.00 | N/A | None |
PERIOGARD 0.12% ORAL RINSE |
1* |
Preferred Generic |
$5.00 | N/A | None |
PERJETA 420 MG/14 ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
Permethrin 50mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
3 |
Preferred Brand |
$45.00 | N/A | None |
PERPHEN-AMITRIP 2 MG-10 MG TAB |
3 |
Preferred Brand |
$45.00 | N/A | None |
PERPHEN-AMITRIP 2 MG-25 MG TAB |
3 |
Preferred Brand |
$45.00 | N/A | None |
PERPHEN-AMITRIP 4 MG-25 MG TAB |
3 |
Preferred Brand |
$45.00 | N/A | None |
Perphenazine 16mg/1 100 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$45.00 | N/A | None |
PERPHENAZINE 4 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | None |
PERPHENAZINE 8 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PERPHENAZINE TABLETS USP 2MG 100 BOT |
3 |
Preferred Brand |
$45.00 | N/A | None |
PHENADOZ 12.5 MG SUPPOSITORY |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
Phenelzine Sulfate 15mg/1 60 TABLET BOTTLE |
3 |
Preferred Brand |
$45.00 | N/A | None |
Phenobarbital 100mg/1 |
3 |
Preferred Brand |
$45.00 | N/A | Q:90 /30Days |
Phenobarbital 15mg/1 |
3 |
Preferred Brand |
$45.00 | N/A | Q:120 /30Days |
PHENOBARBITAL 16.2 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:90 /30Days |
PHENOBARBITAL 20 MG/5 ML ELIX |
4 |
Non-Preferred Drug |
$98.00 | N/A | Q:1500 /30Days |
Phenobarbital 30mg/1 |
3 |
Preferred Brand |
$45.00 | N/A | Q:300 /30Days |
PHENOBARBITAL 32.4 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:90 /30Days |
Phenobarbital 60mg/1 |
3 |
Preferred Brand |
$45.00 | N/A | Q:120 /30Days |
PHENOBARBITAL 64.8 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PHENOBARBITAL 97.2 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:90 /30Days |
PHENOXYBENZAMINE HCL 10 MG Capsule [Dibenzyline] |
5 |
Specialty Tier |
25% | N/A | None |
PHENYTEK 200 MG CAPSULE |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PHENYTEK 300 MG CAPSULE |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
Phenytoin 50 MG Chewable Tablet |
2* |
Generic |
$13.00 | N/A | None |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT |
2* |
Generic |
$13.00 | N/A | None |
PHENYTOIN SOD EXT 100 MG CAP |
2* |
Generic |
$13.00 | N/A | None |
PHENYTOIN SOD EXT 200 MG CAP |
2* |
Generic |
$13.00 | N/A | None |
PHENYTOIN SOD EXT 300 MG CAP |
2* |
Generic |
$13.00 | N/A | None |
PHENYTOIN SODIUM 100MG /2ML INJECTION |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
Phoslyra 667mg/5mL 1 BOTTLE per CARTON / 473 mL in 1 BOTTLE |
3 |
Preferred Brand |
$45.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PHOSPHOLINE IODIDE 0.125% 6.25MG |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PHRENILIN FORTE 50-300-40 MG |
4 |
Non-Preferred Drug |
$98.00 | N/A | Q:180 /30Days |
PICATO 0.015% GEL |
4 |
Non-Preferred Drug |
$98.00 | N/A | Q:3 /30Days |
PICATO 0.05% GEL |
4 |
Non-Preferred Drug |
$98.00 | N/A | Q:2 /30Days |
PILOCARPINE 1% EYE DROPS [Pilocar] |
2* |
Generic |
$13.00 | N/A | None |
PILOCARPINE 2% EYE DROPS [Pilocar] |
2* |
Generic |
$13.00 | N/A | None |
PILOCARPINE 4% EYE DROPS [Pilocar] |
2* |
Generic |
$13.00 | N/A | None |
PILOCARPINE HCL 5 MG TABLET [Salagen] |
3 |
Preferred Brand |
$45.00 | N/A | None |
PILOCARPINE HCL 7.5 MG TABLET [Salagen] |
3 |
Preferred Brand |
$45.00 | N/A | None |
PIMOZIDE 1 MG TABLET [Orap] |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PIMOZIDE 2 MG TABLET [Orap] |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PIMTREA 28 DAY TABLET |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PINDOLOL 10 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | None |
PINDOLOL 5 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | None |
pioglitaz-glimepir 30-2 mg tab |
4 |
Non-Preferred Drug |
$98.00 | N/A | Q:30 /30Days |
PIOGLITAZONE HCL 15 MG TABLET [Actos] |
1* |
Preferred Generic |
$5.00 | N/A | Q:30 /30Days |
PIOGLITAZONE HCL 30 MG TABLET [Actos] |
1* |
Preferred Generic |
$5.00 | N/A | Q:30 /30Days |
PIOGLITAZONE HCL 45 MG TABLET [Actos] |
1* |
Preferred Generic |
$5.00 | N/A | Q:30 /30Days |
PIOGLITAZONE-GLIMEPIRIDE 30-4 Tablet [Duetact] |
4 |
Non-Preferred Drug |
$98.00 | N/A | Q:30 /30Days |
PIOGLITAZONE-METFORMIN 15-500 |
4 |
Non-Preferred Drug |
$98.00 | N/A | Q:90 /30Days |
PIOGLITAZONE-METFORMIN 15-850 |
4 |
Non-Preferred Drug |
$98.00 | N/A | Q:90 /30Days |
PIPERACIL-TAZOBACT 2.25 GM VIAL |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PIPERACIL-TAZOBACT 3.375 GM VIAL |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PIPERACIL-TAZOBACT 4.5 GM VIAL |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PIPERACIL-TAZOBACT 40.5 GM VIAL |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
Pirmella 1-35-28 tablet |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PIROXICAM 10 MG CAPSULE |
3 |
Preferred Brand |
$45.00 | N/A | None |
PIROXICAM 20 MG CAPSULE |
3 |
Preferred Brand |
$45.00 | N/A | None |
PLEGRIDY 125 MCG/0.5 ML PEN |
5 |
Specialty Tier |
25% | N/A | P |
PLEGRIDY 125 MCG/0.5 ML SYRING |
5 |
Specialty Tier |
25% | N/A | P |
PLEGRIDY PEN INJ STARTER PACK |
5 |
Specialty Tier |
25% | N/A | P |
PLEGRIDY SYRINGE STARTER PACK |
5 |
Specialty Tier |
25% | N/A | P |
PODOFILOX 0.5% TOPICAL TUBEX |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POLYETHYLENE GLYCOL 3350 POWD |
2* |
Generic |
$13.00 | N/A | None |
POLYMYXIN B SULFATE VIAL |
3 |
Preferred Brand |
$45.00 | N/A | None |
POLYMYXIN B-TMP EYE DROPS |
1* |
Preferred Generic |
$5.00 | N/A | None |
POMALYST 1 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:21 /28Days |
POMALYST 2 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:21 /28Days |
POMALYST 3 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:21 /28Days |
POMALYST 4 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:21 /28Days |
PORTIA 0.15-0.03 TABLET |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
POT CHL/SWFI P-B 40 MEQ 24X100 ML |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
Potassium Chloride 2 MEQ/ML Injectable Solution |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
Potassium Chloride 200 meq/1000mL 24 POUCH in 1 CASE |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Potassium Chloride 8 MEQ Extended Release Oral Tablet |
2* |
Generic |
$13.00 | N/A | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
Potassium Chloride in Dextrose and Sodium Chloride 5; 0.15; 0.33g/100mL; g/100mL; g/100mL 12 CONTAI |
2* |
Generic |
$13.00 | N/A | None |
POTASSIUM CITRATE ER 10 MEQ TB |
3 |
Preferred Brand |
$45.00 | N/A | None |
POTASSIUM CITRATE ER 15 MEQ TABLET |
3 |
Preferred Brand |
$45.00 | N/A | None |
POTASSIUM CITRATE ER 5 MEQ TAB |
3 |
Preferred Brand |
$45.00 | N/A | None |
Potassium cl 10% (20 meq/15 ml) |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
Potassium cl 20% (40 meq/15 ml) |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
POTASSIUM CL 40 MEQ/20 ML CONC |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
POTASSIUM CL ER 10 MEQ CAPSULE |
2* |
Generic |
$13.00 | N/A | None |
POTASSIUM CL ER 10 MEQ TABLET |
2* |
Generic |
$13.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CL ER 10 MEQ TABLET |
2* |
Generic |
$13.00 | N/A | None |
POTASSIUM CL ER 20 MEQ TABLET |
2* |
Generic |
$13.00 | N/A | None |
Potassium cl er 20 meq tablet |
2* |
Generic |
$13.00 | N/A | None |
POTASSIUM CL ER 8 MEQ CAPSULE |
2* |
Generic |
$13.00 | N/A | None |
PRADAXA 110 MG CAPSULE |
4 |
Non-Preferred Drug |
$98.00 | N/A | Q:60 /30Days |
PRADAXA 150 MG CAPSULE |
4 |
Non-Preferred Drug |
$98.00 | N/A | Q:60 /30Days |
PRADAXA 75 MG CAPSULE |
4 |
Non-Preferred Drug |
$98.00 | N/A | Q:60 /30Days |
PRALUENT 150 MG/ML PEN |
5 |
Specialty Tier |
25% | N/A | P |
PRALUENT 75 MG/ML PEN |
5 |
Specialty Tier |
25% | N/A | P |
PRAMIPEXOLE 0.125 MG TABLET |
2* |
Generic |
$13.00 | N/A | None |
PRAMIPEXOLE 0.25 MG TABLET |
2* |
Generic |
$13.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAMIPEXOLE 0.5 MG TABLET |
2* |
Generic |
$13.00 | N/A | None |
PRAMIPEXOLE 0.75 MG TABLET |
2* |
Generic |
$13.00 | N/A | None |
PRAMIPEXOLE 1 MG TABLET |
2* |
Generic |
$13.00 | N/A | None |
PRAMIPEXOLE 1.5 MG TABLET |
2* |
Generic |
$13.00 | N/A | None |
PRAMIPEXOLE ER 0.375 MG TABLET |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PRAMIPEXOLE ER 0.75 MG TABLET |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PRAMIPEXOLE ER 1.5 MG TABLET |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PRAMIPEXOLE ER 2.25 MG TABLET |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PRAMIPEXOLE ER 3 MG TABLET |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PRAMIPEXOLE ER 3.75 MG TABLET |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PRAMIPEXOLE ER 4.5 MG TABLET |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRASUGREL 10 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | None |
PRASUGREL 5 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | None |
PRAVASTATIN SODIUM 10 MG TAB |
2* |
Generic |
$13.00 | N/A | Q:60 /30Days |
PRAVASTATIN SODIUM 20 MG TAB |
2* |
Generic |
$13.00 | N/A | Q:60 /30Days |
PRAVASTATIN SODIUM 40 MG TAB |
2* |
Generic |
$13.00 | N/A | Q:60 /30Days |
PRAVASTATIN SODIUM 80 MG TAB |
2* |
Generic |
$13.00 | N/A | Q:60 /30Days |
PRAZOSIN 1 MG CAPSULE |
2* |
Generic |
$13.00 | N/A | None |
PRAZOSIN 2 MG CAPSULE |
2* |
Generic |
$13.00 | N/A | None |
PRAZOSIN 5MG CAPSULE |
2* |
Generic |
$13.00 | N/A | None |
PRED MILD 0.12% EYE DROPS |
3 |
Preferred Brand |
$45.00 | N/A | None |
Prednicarbate 0.1% cream |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNICARBATE 0.1% OINTMENT |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PREDNISOLONE 15 MG/5 ML SOLN |
2* |
Generic |
$13.00 | N/A | None |
PREDNISOLONE AC 1% EYE DROP |
3 |
Preferred Brand |
$45.00 | N/A | None |
PREDNISOLONE SOD 1% EYE DROP |
3 |
Preferred Brand |
$45.00 | N/A | None |
PREDNISOLONE SOD PH 25 MG/5 ML |
3 |
Preferred Brand |
$45.00 | N/A | None |
PREDNISOLONE SODIUM PHOSPHATE 5MG /5ML ORAL SOLUTION |
3 |
Preferred Brand |
$45.00 | N/A | None |
PREDNISONE 1 MG TABLET |
1* |
Preferred Generic |
$5.00 | N/A | None |
Prednisone 10 MG Oral Tablet |
1* |
Preferred Generic |
$5.00 | N/A | None |
PREDNISONE 2.5 MG TABLET |
1* |
Preferred Generic |
$5.00 | N/A | None |
Prednisone 20 MG Oral Tablet |
1* |
Preferred Generic |
$5.00 | N/A | None |
PREDNISONE 5 MG TABLET |
1* |
Preferred Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISONE 5 MG/5 ML SOLUTION |
3 |
Preferred Brand |
$45.00 | N/A | None |
PREDNISONE 50MG TABLET |
1* |
Preferred Generic |
$5.00 | N/A | None |
PREMARIN 0.3 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | None |
PREMARIN 0.45MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | None |
PREMARIN 0.625 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | None |
Premarin 0.625mg/g |
3 |
Preferred Brand |
$45.00 | N/A | None |
PREMARIN 0.9MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | None |
PREMARIN 1.25 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | None |
PREMASOL 10% IV SOLUTION |
1* |
Preferred Generic |
$5.00 | N/A | P |
PREMASOL 6% IV SOLUTION |
1* |
Preferred Generic |
$5.00 | N/A | P |
PREMPHASE 0.625-5 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA |
3 |
Preferred Brand |
$45.00 | N/A | None |
PREMPRO 0.45-1.5 MG TABLET 28 EA |
3 |
Preferred Brand |
$45.00 | N/A | None |
PREMPRO 0.625-5 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | None |
Prempro 0.625; 2.5mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, SUGAR COATED per BLISTER PACK |
3 |
Preferred Brand |
$45.00 | N/A | None |
PREVALITE PACKET |
3 |
Preferred Brand |
$45.00 | N/A | None |
Previfem 6 BLISTER PACK per BLISTER PACK / 1 KIT per BLISTER PACK |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PREZCOBIX 800 MG-150 MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
PREZISTA 100 MG/ML SUSPENSION |
5 |
Specialty Tier |
25% | N/A | Q:360 /30Days |
PREZISTA 150MG TABLETS |
4 |
Non-Preferred Drug |
$98.00 | N/A | Q:240 /30Days |
PREZISTA 800 MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
PREZISTA TABLET 600MG |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREZISTA TABLET 75MG |
4 |
Non-Preferred Drug |
$98.00 | N/A | Q:480 /30Days |
PRIFTIN 150 MG TABLET |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
Primaquine Phosphate 26.3 MG Oral Tablet |
3 |
Preferred Brand |
$45.00 | N/A | None |
PRIMIDONE 250 MG TABLET |
2* |
Generic |
$13.00 | N/A | None |
PRIMIDONE 50 MG TABLET |
2* |
Generic |
$13.00 | N/A | None |
PRIVIGEN 10% VIAL |
5 |
Specialty Tier |
25% | N/A | P |
PROAIR HFA 90 MCG INHALER |
3 |
Preferred Brand |
$45.00 | N/A | None |
PROAIR RESPICLICK INHAL POWDER |
3 |
Preferred Brand |
$45.00 | N/A | None |
PROBENECID 500 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | None |
PROBENECID/COLCHICINE 0.5MG/500MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | None |
PROCHLORPERAZINE 10 MG TAB |
1* |
Preferred Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Prochlorperazine 10 mg/2 ml vl |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PROCHLORPERAZINE 5 MG TABLET |
1* |
Preferred Generic |
$5.00 | N/A | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX |
3 |
Preferred Brand |
$45.00 | N/A | None |
PROCRIT 10000U/ML VIAL |
4 |
Non-Preferred Drug |
$98.00 | N/A | Q:14 /30Days |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL |
4 |
Non-Preferred Drug |
$98.00 | N/A | Q:14 /30Days |
PROCRIT 3,000 UNITS/ML VIAL |
4 |
Non-Preferred Drug |
$98.00 | N/A | Q:14 /30Days |
PROCRIT 4,000 UNITS/ML VIAL |
4 |
Non-Preferred Drug |
$98.00 | N/A | Q:14 /30Days |
PROCRIT 40000U/ML VIAL PR |
5 |
Specialty Tier |
25% | N/A | Q:14 /30Days |
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY |
5 |
Specialty Tier |
25% | N/A | Q:14 /30Days |
PROCTO-MED HC 2.5% CREAM |
3 |
Preferred Brand |
$45.00 | N/A | None |
procto-pak 1% cream |
2* |
Generic |
$13.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCTOSOL-HC 2.5% CREAM |
3 |
Preferred Brand |
$45.00 | N/A | None |
PROCTOZONE-HC 2.5% CREAM |
3 |
Preferred Brand |
$45.00 | N/A | None |
PROCYSBI DR 25 MG CAPSULE CAP DR SPR |
5 |
Specialty Tier |
25% | N/A | None |
PROCYSBI DR 75 MG CAPSULE CAP DR SPR |
5 |
Specialty Tier |
25% | N/A | None |
PROGESTERONE 100 MG CAPSULE |
3 |
Preferred Brand |
$45.00 | N/A | None |
PROGESTERONE 200 MG CAPSULE |
3 |
Preferred Brand |
$45.00 | N/A | None |
PROGLYCEM 50 MG/ML ORAL SUSP |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PROGRAF 5MG/ML AMPULE |
4 |
Non-Preferred Drug |
$98.00 | N/A | P |
PROLASTIN C 1,000 MG VIAL |
5 |
Specialty Tier |
25% | N/A | P |
PROLEUKIN 22 MILLION UNIT VIAL |
5 |
Specialty Tier |
25% | N/A | None |
PROLIA 60MG/ML INJECTION |
4 |
Non-Preferred Drug |
$98.00 | N/A | P Q:1 /180Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMACTA 12.5 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
PROMACTA 25 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
PROMACTA 50 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
PROMACTA 75 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
PROMETHAZINE 12.5 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | None |
PROMETHAZINE 25 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | None |
PROMETHAZINE 50 MG SUPPOSITORY |
3 |
Preferred Brand |
$45.00 | N/A | None |
PROMETHAZINE 50 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | None |
PROMETHAZINE 50 MG/ML AMPUL |
3 |
Preferred Brand |
$45.00 | N/A | None |
PROMETHAZINE 6.25 MG/5 ML SYRUP [Prometh Plain] |
3 |
Preferred Brand |
$45.00 | N/A | None |
PROMETHAZINE HYDROCHLORIDE 25mg/mL 25 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
3 |
Preferred Brand |
$45.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX |
3 |
Preferred Brand |
$45.00 | N/A | None |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX |
3 |
Preferred Brand |
$45.00 | N/A | None |
PROMETHEGAN 25MG SUPP |
3 |
Preferred Brand |
$45.00 | N/A | None |
PROMETHEGAN 50MG SUPPOS |
3 |
Preferred Brand |
$45.00 | N/A | None |
PROPAFENONE HCL 150 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | None |
PROPAFENONE HCL 225MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | None |
PROPAFENONE HCL 300 MG TAB |
3 |
Preferred Brand |
$45.00 | N/A | None |
PROPAFENONE HCL ER 225 MG CAP |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PROPAFENONE HYDROCHLORIDE 325MG CAPSULES EXTENDED RELEASE |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PROPAFENONE HYDROCHLORIDE 425MG CAPSULES EXTENDED RELEASE |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
Propantheline Bromide 15mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Preferred Brand |
$45.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Proparacaine hydrochloride 5 MG/ML Ophthalmic Solution |
1* |
Preferred Generic |
$5.00 | N/A | None |
PROPRANOLOL 10 MG TABLET |
2* |
Generic |
$13.00 | N/A | None |
PROPRANOLOL 20 MG TABLET |
2* |
Generic |
$13.00 | N/A | None |
PROPRANOLOL 20MG/5ML TUBEX |
2* |
Generic |
$13.00 | N/A | None |
PROPRANOLOL 40 MG TABLET |
2* |
Generic |
$13.00 | N/A | None |
PROPRANOLOL 40MG/5ML TUBEX |
2* |
Generic |
$13.00 | N/A | None |
PROPRANOLOL 60 MG TABLET |
2* |
Generic |
$13.00 | N/A | None |
PROPRANOLOL 80 MG TABLET |
2* |
Generic |
$13.00 | N/A | None |
PROPRANOLOL ER 120 MG CAPSULE |
2* |
Generic |
$13.00 | N/A | None |
PROPRANOLOL ER 160 MG CAPSULE |
2* |
Generic |
$13.00 | N/A | None |
PROPRANOLOL ER 60 MG CAPSULE |
2* |
Generic |
$13.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPRANOLOL ER 80 MG CAPSULE |
2* |
Generic |
$13.00 | N/A | None |
PROPRANOLOL/HCTZ 40/25 TABLET |
3 |
Preferred Brand |
$45.00 | N/A | None |
PROPRANOLOL/HCTZ 80/25 TABLET |
3 |
Preferred Brand |
$45.00 | N/A | None |
PROPYLTHIOURACIL 50MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | None |
PROQUAD VIAL |
3 |
Preferred Brand |
$45.00 | N/A | None |
PROSOL 20% INJECTION |
4 |
Non-Preferred Drug |
$98.00 | N/A | P |
PROTRIPTYLINE HCL 10 MG TABLET |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PROTRIPTYLINE HCL 5 MG TABLET |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PULMICORT FLEXHALER 180MCG AEROSOL POWDER BREATH ACTIVATED |
3 |
Preferred Brand |
$45.00 | N/A | None |
PULMICORT FLEXHALER 90MCG AEROSOL POWDER BREATH ACTIVATED |
3 |
Preferred Brand |
$45.00 | N/A | None |
PULMOZYME 1MG/ML AMPUL |
5 |
Specialty Tier |
25% | N/A | P Q:150 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PURIXAN 20 MG/ML ORAL SUSP |
5 |
Specialty Tier |
25% | N/A | Q:300 /30Days |
PYRAZINAMIDE 500 MG TABLET |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |
PYRIDOSTIGMINE BR 60 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | None |
PYRIDOSTIGMINE BR ER 180 MG TAB |
4 |
Non-Preferred Drug |
$98.00 | N/A | None |