2018 Medicare Part D Plan Formulary Information |
Apollo Constellation Health (HMO) (H8266-001-0)
Benefit Details
|
The Apollo Constellation Health (HMO) (H8266-001-0) Formulary Drugs Starting with the Letter A in Trujillo Alto County, PR: CMS MA Region 30 which includes: PR 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 |
1 |
Generic |
$5.00 | N/A | None |
ABACAVIR 300 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir] |
4 |
Specialty Tier |
33% | N/A | None |
ABACAVIR-LAMIVUDINE 600-300 MG |
4 |
Specialty Tier |
33% | N/A | None |
ABELCET INJECTION SUSPENSION 5MG/ML |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
ABILIFY 10MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
ABILIFY 15MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
ABILIFY 20MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
ABILIFY 2MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
ABILIFY 30MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABILIFY 5 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
ABILIFY MAINTENA ER 300 MG SYR |
4 |
Specialty Tier |
33% | N/A | P |
ABILIFY MAINTENA ER 300 MG VL |
4 |
Specialty Tier |
33% | N/A | P |
ABILIFY MAINTENA ER 400 MG SUSER VIAL |
4 |
Specialty Tier |
33% | N/A | P |
ABILIFY MAINTENA ER 400 MG SYR |
4 |
Specialty Tier |
33% | N/A | P |
ABSORICA 10 MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ABSORICA 20 MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ABSORICA 25 MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ABSORICA 30 MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ABSORICA 35 MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ABSORICA 40 MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Acamprosate Calcium DR 333 MG tablets [Campral] |
1 |
Generic |
$5.00 | N/A | None |
ACARBOSE 100 MG TABLET |
1 |
Generic |
$5.00 | N/A | Q:90 /30Days |
ACARBOSE 25 MG TABLET |
1 |
Generic |
$5.00 | N/A | Q:90 /30Days |
ACARBOSE 50 MG TABLET |
1 |
Generic |
$5.00 | N/A | Q:90 /30Days |
ACCOLATE 10 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:60 /30Days |
ACCOLATE 20 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:60 /30Days |
ACCUPRIL 10MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ACCUPRIL 20MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ACCUPRIL 40MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ACCUPRIL 5MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ACCURETIC 10-12.5MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACCURETIC 20-12.5MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ACCURETIC 20-25MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ACEBUTOLOL 200 MG CAPSULE |
1 |
Generic |
$5.00 | N/A | None |
ACEBUTOLOL 400 MG CAPSULE |
1 |
Generic |
$5.00 | N/A | None |
ACETAMINOP-CODEINE 120-12 MG/5 |
1 |
Generic |
$5.00 | N/A | None |
ACETAMINOPHEN-COD #2 TABLET |
1 |
Generic |
$5.00 | N/A | Q:360 /30Days |
ACETAMINOPHEN-COD #3 TABLET |
1 |
Generic |
$5.00 | N/A | Q:360 /30Days |
ACETAMINOPHEN-COD #4 TABLET |
1 |
Generic |
$5.00 | N/A | Q:180 /30Days |
ACETAZOLAMIDE 125MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
1 |
Generic |
$5.00 | N/A | None |
ACETIC ACID 2% EAR SOLUTION |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETYLCYSTEINE 10% VIAL |
1 |
Generic |
$5.00 | N/A | P |
Acetylcysteine 200 MG/ML Inhalant Solution |
1 |
Generic |
$5.00 | N/A | P |
ACITRETIN 10 MG CAPSULE [Soriatane] |
1 |
Generic |
$5.00 | N/A | None |
ACITRETIN 17.5 MG CAPSULE [Soriatane] |
1 |
Generic |
$5.00 | N/A | None |
ACITRETIN 25 MG CAPSULE [Soriatane] |
1 |
Generic |
$5.00 | N/A | None |
ACTEMRA 162 MG/0.9 ML SYRINGE |
4 |
Specialty Tier |
33% | N/A | P |
ACTEMRA 400 MG/20 ML VIAL |
4 |
Specialty Tier |
33% | N/A | P |
ACTEMRA 80 MG/4 ML VIAL |
4 |
Specialty Tier |
33% | N/A | P |
ACTEMRA INJECTION 200MG/10ML |
4 |
Specialty Tier |
33% | N/A | P |
ACTHIB VACCINE WITH DILUENT |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ACTIGALL 300MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTIMMUNE 100 MCG/0.5 ML VIAL |
4 |
Specialty Tier |
33% | N/A | P |
ACTIQ 1200MCG LOZENGE |
3 |
Non-Preferred Brand |
$75.00 | N/A | P Q:120 /30Days |
ACTIQ 1600MCG LOZENGE |
3 |
Non-Preferred Brand |
$75.00 | N/A | P Q:120 /30Days |
ACTIQ 200MCG LOZENGE |
3 |
Non-Preferred Brand |
$75.00 | N/A | P Q:120 /30Days |
ACTIQ 400MCG LOZENGE |
3 |
Non-Preferred Brand |
$75.00 | N/A | P Q:120 /30Days |
ACTIQ 600MCG LOZENGE |
3 |
Non-Preferred Brand |
$75.00 | N/A | P Q:120 /30Days |
ACTIQ 800MCG LOZENGE |
3 |
Non-Preferred Brand |
$75.00 | N/A | P Q:120 /30Days |
ACTOPLUS MET 15MG/500MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ACTOPLUS MET 15MG/850MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ACTOPLUS MET XR TABLETS ER 15;1000 MG;MG |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:60 /30Days |
ACTOPLUS MET XR TABLETS ER 30;1000 MG;MG |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTOS 15 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
ACTOS 30 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
ACTOS 45 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
ACULAR 0.5% EYE DROPS |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ACULAR LS 0.4% OPHTH SOL |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ACYCLOVIR 200 MG CAPSULE |
1 |
Generic |
$5.00 | N/A | None |
ACYCLOVIR 200 MG/5 ML SUSP |
1 |
Generic |
$5.00 | N/A | None |
ACYCLOVIR 400 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
ACYCLOVIR 800 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
Acyclovir sodium 500 mg vial |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
ADACEL VIAL 2UNT/5UNT |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADAGEN 250U/ML VIAL |
4 |
Specialty Tier |
33% | N/A | P |
ADALAT CC 30 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ADALAT CC 60 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ADALAT CC 90 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA] |
4 |
Specialty Tier |
33% | N/A | P |
ADDERALL 20 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:90 /30Days |
ADDERALL 5 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:90 /30Days |
ADDERALL 7.5 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:90 /30Days |
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera] |
1 |
Generic |
$5.00 | N/A | P |
ADEMPAS 0.5 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
ADEMPAS 1 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADEMPAS 1.5 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
ADEMPAS 2 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
ADEMPAS 2.5 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
ADVAIR DISKUS MIS 100/50 |
2 |
Preferred Brand |
$47.00 | N/A | None |
ADVAIR DISKUS MIS 250/50 |
2 |
Preferred Brand |
$47.00 | N/A | None |
ADVAIR DISKUS MIS 500/50 |
2 |
Preferred Brand |
$47.00 | N/A | None |
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER |
2 |
Preferred Brand |
$47.00 | N/A | None |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL |
2 |
Preferred Brand |
$47.00 | N/A | None |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
2 |
Preferred Brand |
$47.00 | N/A | None |
AFEDITAB CR 30MG TABLET SA |
1 |
Generic |
$5.00 | N/A | None |
AFEDITAB CR 60MG TABLET SA |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK |
4 |
Specialty Tier |
33% | N/A | P |
AFINITOR DISPERZ 2 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
AFINITOR DISPERZ 3 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
AFINITOR DISPERZ 5 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
AFINITOR TABLETS 10 MG |
4 |
Specialty Tier |
33% | N/A | P |
AFINITOR TABLETS 2.5 MG |
4 |
Specialty Tier |
33% | N/A | P |
AFINITOR TABLETS 5 MG |
4 |
Specialty Tier |
33% | N/A | P |
AGGRENOX 25-200MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
AGRYLIN 0.5MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ALBENZA 200 MG TABLET |
2 |
Preferred Brand |
$47.00 | N/A | None |
ALBUTEROL SUL 2.5 MG/3 ML SOLN |
1 |
Generic |
$5.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL SULFATE 2 MG TAB |
1 |
Generic |
$5.00 | N/A | None |
ALBUTEROL SULFATE 4 MG TAB |
1 |
Generic |
$5.00 | N/A | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
1 |
Generic |
$5.00 | N/A | P |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
1 |
Generic |
$5.00 | N/A | None |
ALCLOMETASONE DIPR 0.05% OINT |
1 |
Generic |
$5.00 | N/A | None |
ALCLOMETASONE DIPRO 0.05% CRM |
1 |
Generic |
$5.00 | N/A | None |
ALDACTAZIDE 25/25 TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ALDACTAZIDE 50/50 TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ALDACTONE 100MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ALDACTONE 25MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ALDACTONE 50MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALDARA 5% CREAM |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ALDURAZYME 2.9MG/5ML VIAL |
4 |
Specialty Tier |
33% | N/A | P |
ALECENSA 150 MG CAPSULE |
4 |
Specialty Tier |
33% | N/A | P |
ALENDRONATE SODIUM 10 MG TAB |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
ALENDRONATE SODIUM 35 MG TAB |
1 |
Generic |
$5.00 | N/A | Q:4 /28Days |
ALENDRONATE SODIUM 40 MG TABLET |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
ALENDRONATE SODIUM 5 MG TABLET |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
ALENDRONATE SODIUM 70 MG TAB |
1 |
Generic |
$5.00 | N/A | Q:4 /28Days |
ALIMTA 100 MG VIAL |
4 |
Specialty Tier |
33% | N/A | P |
ALIMTA 500 MG VIAL |
4 |
Specialty Tier |
33% | N/A | P |
ALINIA 100 MG/5 ML SUSPENSION |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALINIA 500 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ALIQOPA 60 MG VIAL |
4 |
Specialty Tier |
33% | N/A | P |
Aliskiren 150 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT] |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
Aliskiren 150 MG / Hydrochlorothiazide 25 MG Oral Tablet [Tekturna HCT] |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
Aliskiren 300 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT] |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
ALLOPURINOL 100 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
ALLOPURINOL 300 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
ALOSETRON HCL 0.5 MG TABLET [Lotronex] |
1 |
Generic |
$5.00 | N/A | Q:60 /30Days |
ALOSETRON HCL 1 MG TABLET [Lotronex] |
1 |
Generic |
$5.00 | N/A | Q:60 /30Days |
ALPHAGAN P 0.1% DROPS |
2 |
Preferred Brand |
$47.00 | N/A | None |
ALPHAGAN P 0.15% EYE DROPS |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALPRAZOLAM 0.25 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
ALPRAZOLAM 0.5 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
ALPRAZOLAM 1 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
ALPRAZOLAM 2 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
ALTACE 1.25MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ALTACE 10MG CAPSULE (100 CT) |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ALTACE 2.5 MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ALTACE 5MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ALUNBRIG 180 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
ALUNBRIG 30 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
ALUNBRIG 90 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALUNBRIG 90 MG-180 MG TABLET PACK |
4 |
Specialty Tier |
33% | N/A | P |
AMANTADINE 100 MG CAPSULE |
1 |
Generic |
$5.00 | N/A | None |
AMARYL 1MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:60 /30Days |
AMARYL 2MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:60 /30Days |
AMARYL 4MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:60 /30Days |
AMBIEN 10 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | P Q:90 /365Days |
AMBIEN TABLETS 5MG 100 BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | N/A | P Q:90 /365Days |
AMBISOME 50MG VIAL |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
AMERGE 1MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:9 /30Days |
AMERGE 2.5MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:9 /30Days |
AMILORIDE HCL 5 MG TABLET |
1 |
Generic |
$5.00 | 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 |
Generic |
$5.00 | N/A | None |
Amino Acids 15% Solution |
1 |
Generic |
$5.00 | N/A | P |
Amino acids 4.25% in dextrose 10% Injectable Solution [Clinimix 4.25/10] |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
Amino acids 4.25% in dextrose 20% Injectable Solution [Clinimix 4.25/20] |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
Amino acids 4.25% in dextrose 5% Injectable Solution [Clinimix 4.25/5] |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
Aminophylline 25 MG/ML 10 ML Injection |
1 |
Generic |
$5.00 | N/A | None |
AMINOSYN HBC INJECTION SULFITE FREE 7% |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
AMINOSYN II 10% SOL 6X2000 ML |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
AMINOSYN II 15% IV SOLUTION |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
AMINOSYN II 8.5% ELECTROLYT |
1 |
Generic |
$5.00 | N/A | P |
AMINOSYN II 8.5% ELECTROLYT |
1 |
Generic |
$5.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN PF INJECTION |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5% |
1 |
Generic |
$5.00 | N/A | P |
AMINOSYN-PF 7% IV SOLUTION |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
AMIODARONE HCL 100 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
AMIODARONE HCL 200 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
AMIODARONE HCL 400 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
AMITIZA 8MCG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:60 /30Days |
AMITIZA CAPSULES 24MCG 60 CAP BOT |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:60 /30Days |
AMITRIP/PERPHEN 10-4 TABLET |
1 |
Generic |
$5.00 | N/A | None |
AMITRIP/PERPHEN 50-4 TABLET |
1 |
Generic |
$5.00 | N/A | None |
AMITRIPTYLINE HCL 10 MG TAB |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIPTYLINE HCL 100 MG TAB |
1 |
Generic |
$5.00 | N/A | None |
AMITRIPTYLINE HCL 150 MG TAB |
1 |
Generic |
$5.00 | N/A | None |
AMITRIPTYLINE HCL 25 MG TAB |
1 |
Generic |
$5.00 | N/A | None |
AMITRIPTYLINE HCL 50 MG TAB |
1 |
Generic |
$5.00 | N/A | None |
AMITRIPTYLINE HCL 75 MG TAB |
1 |
Generic |
$5.00 | N/A | None |
AMLODIPINE BESYLATE 10 MG TAB |
1 |
Generic |
$5.00 | N/A | None |
AMLODIPINE BESYLATE 2.5 MG TAB |
1 |
Generic |
$5.00 | N/A | None |
AMLODIPINE BESYLATE 5 MG TAB |
1 |
Generic |
$5.00 | N/A | None |
AMLODIPINE-BENAZEPRIL 10-20 MG Capsule [Lotrel] |
1 |
Generic |
$5.00 | N/A | None |
AMLODIPINE-BENAZEPRIL 10-40 MG Capsule [Lotrel] |
1 |
Generic |
$5.00 | N/A | None |
AMLODIPINE-BENAZEPRIL 2.5-10 Capsule [Lotrel] |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE-BENAZEPRIL 5-10 MG Capsule [Lotrel] |
1 |
Generic |
$5.00 | N/A | None |
AMLODIPINE-BENAZEPRIL 5-20 MG Capsule [Lotrel] |
1 |
Generic |
$5.00 | N/A | None |
AMLODIPINE-BENAZEPRIL 5-40 MG Capsule [Lotrel] |
1 |
Generic |
$5.00 | N/A | None |
AMMONIUM LACTATE 12% CREAM |
1 |
Generic |
$5.00 | N/A | None |
AMMONIUM LACTATE 12% LOTION |
1 |
Generic |
$5.00 | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE [Augmentin] |
1 |
Generic |
$5.00 | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin] |
1 |
Generic |
$5.00 | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE [Augmentin] |
1 |
Generic |
$5.00 | N/A | None |
AMOX-CLAV 200-28.5 MG/5 ML SUS |
1 |
Generic |
$5.00 | N/A | None |
AMOX-CLAV 250-62.5 MG/5 ML SUS |
1 |
Generic |
$5.00 | N/A | None |
AMOX-CLAV 400-57 MG/5 ML SUSP |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOX-CLAV 500-125 MG TABLET [Augmentin] |
1 |
Generic |
$5.00 | N/A | None |
AMOX-CLAV 600-42.9 MG/5 ML SUS |
1 |
Generic |
$5.00 | N/A | None |
AMOX-CLAV 875-125 MG TABLET [Augmentin] |
1 |
Generic |
$5.00 | N/A | None |
AMOX-CLAV ER 1,000-62.5 MG TABLET [Augmentin] |
1 |
Generic |
$5.00 | N/A | None |
AMOXAPINE 100MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
AMOXAPINE 150MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
AMOXAPINE 25MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
AMOXAPINE 50MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
AMOXICILLIN 125 MG/5 ML SUSP |
1 |
Generic |
$5.00 | N/A | None |
AMOXICILLIN 125MG TABLET CHEW |
1 |
Generic |
$5.00 | N/A | None |
AMOXICILLIN 200 MG/5 ML SUSP |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN 250 MG CAPSULE |
1 |
Generic |
$5.00 | N/A | None |
AMOXICILLIN 250 MG TAB CHEW |
1 |
Generic |
$5.00 | N/A | None |
AMOXICILLIN 250 MG/5 ML SUSP |
1 |
Generic |
$5.00 | N/A | None |
AMOXICILLIN 400 MG/5 ML SUSP |
1 |
Generic |
$5.00 | N/A | None |
AMOXICILLIN 500 MG CAPSULE |
1 |
Generic |
$5.00 | N/A | None |
AMOXICILLIN 500 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
AMOXICILLIN 875 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
1 |
Generic |
$5.00 | N/A | Q:60 /30Days |
AMPHETAMINE SALT COMBO 15MG TABLET |
1 |
Generic |
$5.00 | N/A | Q:60 /30Days |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
1 |
Generic |
$5.00 | N/A | Q:90 /30Days |
AMPHETAMINE SALTS 5 MG TAB |
1 |
Generic |
$5.00 | N/A | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
amphotericin b 50mg/10mL 10 mL in 1 VIAL |
1 |
Generic |
$5.00 | N/A | P |
Ampicillin 1000 MG / Sulbactam 500 MG Injection |
1 |
Generic |
$5.00 | N/A | P |
Ampicillin 1000 MG Injection |
1 |
Generic |
$5.00 | N/A | P |
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS |
1 |
Generic |
$5.00 | N/A | P |
Ampicillin 2000 MG / Sulbactam 1000 MG Injection |
1 |
Generic |
$5.00 | N/A | P |
AMPICILLIN CAPSULES 500MG 100 BOT |
1 |
Generic |
$5.00 | N/A | None |
AMPICILLIN-SULBACTAM 15 GM VL |
1 |
Generic |
$5.00 | N/A | P |
AMPYRA ER 10 MG TABLET |
4 |
Specialty Tier |
33% | N/A | None |
ANADROL-50 TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ANAFRANIL 25 MG 30 CAPSULE BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ANAFRANIL 50 MG 30 CAPSULE BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANAFRANIL 75 MG 30 CAPSULE BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE |
1 |
Generic |
$5.00 | N/A | None |
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE |
1 |
Generic |
$5.00 | N/A | None |
ANASTROZOLE 1 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
ANCOBON 250MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ANCOBON 500MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ANDRODERM 2 MG/24HR PATCH |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ANDRODERM 4 MG/24HR PATCH |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ANDROID 10 MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ANORO ELLIPTA 62.5-25 MCG INH |
2 |
Preferred Brand |
$47.00 | N/A | None |
ANTABUSE 250MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANTABUSE 500MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Antineoplastic Agent Etoposide 20 mg / mL Intravenous Injection Multiple Dose Vial 5 mL |
1 |
Generic |
$5.00 | N/A | P |
ANUSOL-HC 2.5% CREAM |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
APOKYN 30 MG/3 ML CARTRIDGE |
4 |
Specialty Tier |
33% | N/A | None |
APREPITANT 125 MG CAPSULE [Emend] |
1 |
Generic |
$5.00 | N/A | P |
APREPITANT 125-80-80 MG PACK [Emend] |
1 |
Generic |
$5.00 | N/A | P |
APREPITANT 40 MG CAPSULE [Emend] |
1 |
Generic |
$5.00 | N/A | P |
APREPITANT 80 MG CAPSULE [Emend] |
1 |
Generic |
$5.00 | N/A | P |
APRI 0.15-0.03 TABLET |
1 |
Generic |
$5.00 | N/A | None |
APRISO CP24 |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
APTIOM 200 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APTIOM 400 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
APTIOM 600 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:60 /30Days |
APTIOM 800 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
APTIVUS 250MG CAPSULE |
4 |
Specialty Tier |
33% | N/A | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
4 |
Specialty Tier |
33% | N/A | None |
ARALAST NP 1,000 MG VIAL |
4 |
Specialty Tier |
33% | N/A | P |
ARANELLE 7-9-5 TABLET |
1 |
Generic |
$5.00 | N/A | None |
ARANESP 10 MCG/0.4 ML SYRINGE |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.5 mL in 1 SYRINGE |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
ARANESP 200MCG/0.4ML SYRINGE |
4 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP 200MCG/ML VIAL |
4 |
Specialty Tier |
33% | N/A | P |
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.42 mL in 1 SYRING |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
ARANESP 300MCG/ML VIAL |
4 |
Specialty Tier |
33% | N/A | P |
ARANESP 500MCG/1ML SYRINGE |
4 |
Specialty Tier |
33% | N/A | P |
ARANESP 60MCG/ML VIAL |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.3 mL in 1 SYRINGE |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR |
4 |
Specialty Tier |
33% | N/A | P |
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR |
4 |
Specialty Tier |
33% | N/A | P |
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARAVA 10MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ARAVA 20MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ARCALYST INJECTION 220MG/VIAL |
4 |
Specialty Tier |
33% | N/A | P |
ARICEPT 10MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
ARICEPT 23 MG TABLETS |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
ARICEPT 5MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
ARIMIDEX 1MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ARIPIPRAZOLE 1 MG/ML SOLUTION [Abilify] |
1 |
Generic |
$5.00 | N/A | None |
ARIPIPRAZOLE 10 MG TABLET [Abilify] |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
ARIPIPRAZOLE 15 MG TABLET [Abilify] |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
ARIPIPRAZOLE 2 MG TABLET [Abilify] |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARIPIPRAZOLE 20 MG TABLET [Abilify] |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
ARIPIPRAZOLE 30 MG TABLET [Abilify] |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
ARIPIPRAZOLE 5 MG TABLET [Abilify] |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
ARIPIPRAZOLE ODT 10 MG TABLET [Abilify] |
1 |
Generic |
$5.00 | N/A | Q:90 /30Days |
ARIPIPRAZOLE ODT 15 MG TABLET [Abilify] |
1 |
Generic |
$5.00 | N/A | Q:60 /30Days |
ARISTADA ER 1064 MG/3.9 ML SYR |
4 |
Specialty Tier |
33% | N/A | None |
ARISTADA ER 441 MG/1.6 ML SYRN |
4 |
Specialty Tier |
33% | N/A | None |
ARISTADA ER 662 MG/2.4 ML SYRN |
4 |
Specialty Tier |
33% | N/A | None |
ARISTADA ER 882 MG/3.2 ML SYRN |
4 |
Specialty Tier |
33% | N/A | None |
ARIXTRA 7.5 MG/0.6 ML SYRINGE |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
AROMASIN 25MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ASACOL HD DR 800 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Aspirin-Diphenhydramine ER 25-200 MG |
1 |
Generic |
$5.00 | N/A | None |
ASTAGRAF XL 0.5 MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
ASTAGRAF XL 1 MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
ASTAGRAF XL 5 MG CAPSULE |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
ATACAND 16MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:60 /30Days |
ATACAND 32 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
ATACAND 4MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:60 /30Days |
ATACAND 8MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:60 /30Days |
ATACAND HCT 16/12.5MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
ATACAND HCT 32/12.5MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATACAND HCT TABLETS 32;25MG;MG 90 TABLET BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
ATAZANAVIR SULFATE 150 MG CAP [Reyataz] |
1 |
Generic |
$5.00 | N/A | None |
ATAZANAVIR SULFATE 200 MG CAP [Reyataz] |
1 |
Generic |
$5.00 | N/A | None |
ATAZANAVIR SULFATE 300 MG CAP [Reyataz] |
1 |
Generic |
$5.00 | N/A | None |
ATENOLOL 100 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
ATENOLOL 25 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
ATENOLOL 50 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
ATENOLOL-CHLORTHALIDONE 100-25 |
1 |
Generic |
$5.00 | N/A | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
1 |
Generic |
$5.00 | N/A | None |
ATIVAN 0.5 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ATIVAN 1 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATIVAN 2 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
ATOMOXETINE HCL 10 MG CAPSULE [Strattera] |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
ATOMOXETINE HCL 100 MG CAPSULE [Strattera] |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
ATOMOXETINE HCL 18 MG CAPSULE [Strattera] |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
ATOMOXETINE HCL 25 MG CAPSULE [Strattera] |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
ATOMOXETINE HCL 40 MG CAPSULE [Strattera] |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
ATOMOXETINE HCL 60 MG CAPSULE [Strattera] |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
ATOMOXETINE HCL 80 MG CAPSULE [Strattera] |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
ATORVASTATIN 10 MG TABLET [Lipitor] |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
ATORVASTATIN 20 MG TABLET [Lipitor] |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
ATORVASTATIN 40 MG TABLET [Lipitor] |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATORVASTATIN 80 MG TABLET [Lipitor] |
1 |
Generic |
$5.00 | N/A | Q:30 /30Days |
ATOVAQUONE 750 MG/5 ML SUSP [Mepron] |
4 |
Specialty Tier |
33% | N/A | None |
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone] |
1 |
Generic |
$5.00 | N/A | None |
ATOVAQUONE-PROGUANIL 62.5-25 [Malarone] |
1 |
Generic |
$5.00 | N/A | None |
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Specialty Tier |
33% | N/A | None |
ATROVENT HFA AER 17MCG |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
AUBAGIO 14 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
AUBAGIO 7 MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
AUGMENTIN 125-31.25 MG/5 ML |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
AVALIDE 150-12.5 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
AVALIDE 300-12.5 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVAPRO 150 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
AVAPRO 300 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
AVAPRO 75 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
AVASTIN 100MG/4ML VIAL |
4 |
Specialty Tier |
33% | N/A | P |
AVASTIN 400 MG/16 ML VIAL |
4 |
Specialty Tier |
33% | N/A | P |
AVELOX 400 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
AVODART 0.5 MG SOFTGEL |
3 |
Non-Preferred Brand |
$75.00 | N/A | Q:30 /30Days |
AVONEX ADMIN PACK 30 MCG VL |
4 |
Specialty Tier |
33% | N/A | P |
AVONEX PEN 30 MCG/0.5 ML KIT |
4 |
Specialty Tier |
33% | N/A | P |
AVONEX PREFILLED SYR 30 MCG KT |
4 |
Specialty Tier |
33% | N/A | P |
Aygestin 5mg/1 50 TABLET BOTTLE |
3 |
Non-Preferred Brand |
$75.00 | 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] |
1 |
Generic |
$5.00 | N/A | P |
AZASITE 1% EYE DROPS |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
AZATHIOPRINE 50 MG TABLET |
1 |
Generic |
$5.00 | N/A | P |
AZELASTINE 137 MCG NASAL SPRAY |
1 |
Generic |
$5.00 | N/A | None |
AZILECT 0.5MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
AZILECT 1MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
AZITHROMYCIN 100 MG/5 ML SUSP |
1 |
Generic |
$5.00 | N/A | None |
AZITHROMYCIN 200 MG/5 ML SUSP |
1 |
Generic |
$5.00 | N/A | None |
AZITHROMYCIN 250 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
AZITHROMYCIN 250 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
AZITHROMYCIN 500 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE |
1 |
Generic |
$5.00 | N/A | None |
AZITHROMYCIN 600 MG TABLET |
1 |
Generic |
$5.00 | N/A | None |
AZITHROMYCIN I.V. 500 MG VIAL |
1 |
Generic |
$5.00 | N/A | None |
AZOPT 1% EYE DROPS |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
Aztreonam 1000 MG Injection [Azactam] |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
Aztreonam 2000 MG Injection [Azactam] |
3 |
Non-Preferred Brand |
$75.00 | N/A | P |
AZTREONAM FOR INJECTION |
1 |
Generic |
$5.00 | N/A | None |
AZULFIDINE 500 MG TABLET |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |
AZULFIDINE ENTAB 500 MG |
3 |
Non-Preferred Brand |
$75.00 | N/A | None |