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First Health Part D Premier Plus (PDP) (S5768-185-0)
Tier 1 (256)
Tier 2 (514)
Tier 3 (1063)
Tier 4 (2826)
Tier 5 (717)
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2018 Medicare Part D Plan Formulary Information
First Health Part D Premier Plus (PDP) (S5768-185-0)
Benefit Details           
The First Health Part D Premier Plus (PDP) (S5768-185-0)
Formulary Drugs Starting with the Letter C

in CMS PDP Region 01 which includes: ME NH
Plan Monthly Premium: $96.80 Deductible: $0 Qualifies for LIS: No
Drugs Starting with Letter C

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
CABERGOLINE 0.5 MG TABLET   4 Non-Preferred Drug 42%42%None
CABOMETYX 20 MG TABLET   5 Specialty Tier 33%N/AP
CABOMETYX 40 MG TABLET   5 Specialty Tier 33%N/AP
CABOMETYX 60 MG TABLET   5 Specialty Tier 33%N/AP
Caduet 10; 10mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Drug 42%42%S
Caduet 10; 20mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Drug 42%42%S
CADUET 10MG/40MG TABLET   4 Non-Preferred Drug 42%42%S
CADUET 10MG/80MG TABLET   4 Non-Preferred Drug 42%42%S
CADUET 5MG/10MG TABLET   4 Non-Preferred Drug 42%42%S
CADUET 5MG/20MG TABLET   4 Non-Preferred Drug 42%42%S
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CADUET 5MG/40MG TABLET   4 Non-Preferred Drug 42%42%S
CADUET 5MG/80MG TABLET   4 Non-Preferred Drug 42%42%S
CAFERGOT TABLET   4 Non-Preferred Drug 42%42%None
CALAN 120MG TABLET   4 Non-Preferred Drug 42%42%None
CALAN 80MG TABLET   4 Non-Preferred Drug 42%42%None
CALAN SR 120MG CAPLET SA   4 Non-Preferred Drug 42%42%None
CALAN SR 240 MG CAPLET   4 Non-Preferred Drug 42%42%None
CALCIPOTRIENE 0.005% CREAM   4 Non-Preferred Drug 42%42%Q:120
/30Days
CALCIPOTRIENE 0.005% SOLUTION   4 Non-Preferred Drug 42%42%None
Calcipotriene 50ug/g 60 g per CARTON   4 Non-Preferred Drug 42%42%None
Calcipotriene-Betamethasone Dipropionate Ointment [Taclonex]   4 Non-Preferred Drug 42%42%Q:400
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY   3 Preferred Brand $35.00$105.00None
CALCITRIOL 0.25 MCG CAPSULE [Rocaltrol]   2 Generic $2.00$6.00None
CALCITRIOL 0.5 MCG CAPSULE [Rocaltrol]   2 Generic $2.00$6.00None
Calcitriol 1 MCG per 1 ML Injection   4 Non-Preferred Drug 42%42%None
CALCITRIOL 1MCG/ML SOLUTION ORAL   4 Non-Preferred Drug 42%42%None
CALCITRIOL 3 MCG/G OINTMENT   4 Non-Preferred Drug 42%42%None
CALCIUM ACETATE 667 MG TABLET   4 Non-Preferred Drug 42%42%None
CALCIUM ACETATE CAPSULE 667 MG   4 Non-Preferred Drug 42%42%None
Calcium Chloride 0.002 MEQ/ML / Potassium Chloride 0.004 MEQ/ML / Sodium Chloride 0.147 MEQ/ML Injec   4 Non-Preferred Drug 42%42%None
CALQUENCE 100 MG CAPSULE   5 Specialty Tier 33%N/AP
CAMBIA 50 MG POWDER PACKET   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CAMILA 0.35 MG TABLET   3 Preferred Brand $35.00$105.00None
CAMRESE LO TABLET   3 Preferred Brand $35.00$105.00None
CANASA 1,000 MG SUPPOSITORY   4 Non-Preferred Drug 42%42%None
CANCIDAS IV 50MG VIAL   5 Specialty Tier 33%N/ANone
CANCIDAS IV 70MG VIAL   5 Specialty Tier 33%N/ANone
CANDESARTAN CILEXETIL 16 MG TABLET [Atacand]   3 Preferred Brand $35.00$105.00Q:30
/30Days
CANDESARTAN CILEXETIL 32 MG TABLET [Atacand]   3 Preferred Brand $35.00$105.00Q:30
/30Days
CANDESARTAN CILEXETIL 4 MG TABLET [Atacand]   3 Preferred Brand $35.00$105.00Q:30
/30Days
CANDESARTAN CILEXETIL 8 MG TABLET [Atacand]   3 Preferred Brand $35.00$105.00Q:30
/30Days
candesartan-hctz 16-12.5 mg tablet   3 Preferred Brand $35.00$105.00Q:60
/30Days
candesartan-hctz 32-12.5 mg tablet   3 Preferred Brand $35.00$105.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CANDESARTAN-HCTZ 32-25 MG TAB   3 Preferred Brand $35.00$105.00Q:30
/30Days
CAPASTAT SULFATE 1g/1 1 INJECTION, POWDER, FOR SOLUTION per CARTON   4 Non-Preferred Drug 42%42%None
CAPEX SHA 0.01%   4 Non-Preferred Drug 42%42%None
CAPRELSA 100 MG TABLET   5 Specialty Tier 33%N/AP
CAPRELSA 300 MG TABLET   5 Specialty Tier 33%N/AP
CAPTOPRIL 100MG TABLET   3 Preferred Brand $35.00$105.00None
CAPTOPRIL 12.5MG TABLET   3 Preferred Brand $35.00$105.00None
CAPTOPRIL 25 MG TABLET   3 Preferred Brand $35.00$105.00None
CAPTOPRIL 50MG TABLET   3 Preferred Brand $35.00$105.00None
Captopril and Hydrochlorothiazide 25; 15mg 100 TABLET BOTTLE   1 Preferred Generic $1.00$3.00None
Captopril and Hydrochlorothiazide 25; 25mg 100 TABLET BOTTLE   1 Preferred Generic $1.00$3.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Captopril and Hydrochlorothiazide 50; 15mg 100 TABLET BOTTLE   1 Preferred Generic $1.00$3.00None
Captopril and Hydrochlorothiazide 50; 25mg 100 TABLET BOTTLE   1 Preferred Generic $1.00$3.00None
CARAC CREAM   5 Specialty Tier 33%N/ANone
CARAFATE SUCRALFATE 1G TABLET ORAL   4 Non-Preferred Drug 42%42%None
CARAFATE SUS 1GM/10ML   4 Non-Preferred Drug 42%42%None
CARBAGLU 200 MG DISPER TABLET   5 Specialty Tier 33%N/AP
CARBAMAZEPINE 100 MG TAB CHEW   2 Generic $2.00$6.00None
CARBAMAZEPINE 100 MG/5 ML SUSP   2 Generic $2.00$6.00None
CARBAMAZEPINE 200 MG TABLET   2 Generic $2.00$6.00None
CARBAMAZEPINE ER 100 MG CAP CPMP 12HR [Carbatrol]   4 Non-Preferred Drug 42%42%None
CARBAMAZEPINE ER 100 MG TABLET   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBAMAZEPINE ER 200 MG CAP CPMP 12HR [Carbatrol]   4 Non-Preferred Drug 42%42%None
CARBAMAZEPINE ER 300 MG CAP CPMP 12HR [Carbatrol]   4 Non-Preferred Drug 42%42%None
CARBAMAZEPINE XR 200 MG TABLET   4 Non-Preferred Drug 42%42%None
CARBAMAZEPINE XR 400 MG TABLET   4 Non-Preferred Drug 42%42%None
Carbatrol 100mg/1 120 CAPSULE, ER in BOTTLE   4 Non-Preferred Drug 42%42%None
CARBATROL 200MG CAPSULE SA   4 Non-Preferred Drug 42%42%None
CARBATROL 300MG CAPSULE SA   4 Non-Preferred Drug 42%42%None
Carbidopa 25mg Tab 100 [Lodosyn]   5 Specialty Tier 33%N/ANone
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT   3 Preferred Brand $35.00$105.00None
CARBIDOPA AND LEVODOPA ODT 25;100MG;MG 100 BOT   3 Preferred Brand $35.00$105.00None
CARBIDOPA AND LEVODOPA ODT 25;250MG;MG 100 BOT   3 Preferred Brand $35.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBIDOPA-LEVO ER 25-100 TAB   4 Non-Preferred Drug 42%42%None
CARBIDOPA-LEVO ER 50-200 TAB   4 Non-Preferred Drug 42%42%None
CARBIDOPA-LEVODOPA 10-100 TAB   2 Generic $2.00$6.00None
CARBIDOPA-LEVODOPA 25-100 TAB   2 Generic $2.00$6.00None
CARBIDOPA-LEVODOPA 25-250 TAB   2 Generic $2.00$6.00None
CARBIDOPA-LEVODOPA-ENTA 150 MG   4 Non-Preferred Drug 42%42%None
CARBIDOPA-LEVODOPA-ENTA 75 MG   4 Non-Preferred Drug 42%42%None
CARBIDOPA-LEVODOPA-ENTACAPONE 100 MG [Stalevo]   4 Non-Preferred Drug 42%42%None
CARBIDOPA-LEVODOPA-ENTACAPONE 125 MG [Stalevo]   4 Non-Preferred Drug 42%42%None
CARBIDOPA-LEVODOPA-ENTACAPONE 200 MG [Stalevo]   4 Non-Preferred Drug 42%42%None
CARBIDOPA-LEVODOPA-ENTACAPONE 50 MG [Stalevo]   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBINOXAMINE 4 MG/5 ML LIQUID   4 Non-Preferred Drug 42%42%P
CARBINOXAMINE MALEATE 4 MG TAB   4 Non-Preferred Drug 42%42%P
Carboplatin 10 MG/ML Injectable Solution   3 Preferred Brand $35.00$105.00None
CARDIZEM 120 MG TABLET   4 Non-Preferred Drug 42%42%None
CARDIZEM 30 MG TABLET   4 Non-Preferred Drug 42%42%None
CARDIZEM 60 MG TABLET   4 Non-Preferred Drug 42%42%None
CARDIZEM CD 120 MG CAPSULE   4 Non-Preferred Drug 42%42%None
CARDIZEM CD 240 MG CAPSULE   4 Non-Preferred Drug 42%42%None
CARDIZEM CD 360 MG CAPSULE   4 Non-Preferred Drug 42%42%None
CARDIZEM LA 120 MG TABLET   4 Non-Preferred Drug 42%42%None
CARDIZEM LA 180 MG TABLET   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARDIZEM LA 240 MG TABLET ER 24H   4 Non-Preferred Drug 42%42%None
CARDIZEM LA 300 MG TABLET   4 Non-Preferred Drug 42%42%None
CARDIZEM LA 360 MG TABLET ER 24H   4 Non-Preferred Drug 42%42%None
CARDIZEM LA 420 MG TABLET   4 Non-Preferred Drug 42%42%None
CARDURA 1MG TABLET   4 Non-Preferred Drug 42%42%None
CARDURA 2MG TABLET   4 Non-Preferred Drug 42%42%None
CARDURA 4MG TABLET   4 Non-Preferred Drug 42%42%None
CARDURA 8MG TABLET   4 Non-Preferred Drug 42%42%None
CARDURA XL 4MG TABLET   4 Non-Preferred Drug 42%42%Q:60
/30Days
CARDURA XL 8MG TABLET   4 Non-Preferred Drug 42%42%Q:60
/30Days
CARIMUNE NF 6GM VIAL   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARNITOR 100MG/ML ORAL TUBEX   4 Non-Preferred Drug 42%42%None
CARNITOR 1GM/5ML VIAL   4 Non-Preferred Drug 42%42%None
CARNITOR 330MG TABLET   4 Non-Preferred Drug 42%42%None
CARTEOLOL HCL 1% EYE DROPS   2 Generic $2.00$6.00None
CARTIA XT 120MG CAPSULE SA   2 Generic $2.00$6.00None
CARTIA XT 180MG CAPSULE SA   2 Generic $2.00$6.00None
CARTIA XT 240MG CAPSULE SA   2 Generic $2.00$6.00None
CARTIA XT 300 MG CAPSULE   2 Generic $2.00$6.00None
CARVEDILOL 12.5 MG TABLET   1 Preferred Generic $1.00$3.00None
CARVEDILOL 25 MG TABLET   1 Preferred Generic $1.00$3.00None
CARVEDILOL 3.125 MG TABLET   1 Preferred Generic $1.00$3.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARVEDILOL 6.25 MG TABLET   1 Preferred Generic $1.00$3.00None
CARVEDILOL ER 10 MG CAPSULE   4 Non-Preferred Drug 42%42%Q:30
/30Days
CARVEDILOL ER 20 MG CAPSULE   4 Non-Preferred Drug 42%42%Q:30
/30Days
CARVEDILOL ER 40 MG CAPSULE   4 Non-Preferred Drug 42%42%Q:30
/30Days
CARVEDILOL ER 80 MG CAPSULE   4 Non-Preferred Drug 42%42%Q:30
/30Days
CASODEX 50mg 30 TABLET BOTTLE, PLASTIC   4 Non-Preferred Drug 42%42%None
CASPOFUNGIN ACETATE 50 MG VIAL   5 Specialty Tier 33%N/ANone
CASPOFUNGIN ACETATE 70 MG VIAL   5 Specialty Tier 33%N/ANone
CATAPRES 0.1 MG TABLET   4 Non-Preferred Drug 42%42%None
CATAPRES 0.2 MG TABLET   4 Non-Preferred Drug 42%42%None
CATAPRES 0.3 MG TABLET   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CATAPRES-TTS DIS 0.3/24HR 7.5MG/UNT   4 Non-Preferred Drug 42%42%Q:8
/28Days
CATAPRES-TTS-1 PATCH 2.52.5MG/UNT 1 X 4 CRTN   4 Non-Preferred Drug 42%42%Q:8
/28Days
CATAPRES-TTS-2 PATCH 52.5MG/UNT 1 X 4 CRTN   4 Non-Preferred Drug 42%42%Q:8
/28Days
CAYSTON KIT 75 MG/VIAL   5 Specialty Tier 33%N/AP
CAZIANT 28 DAY TABLET   3 Preferred Brand $35.00$105.00None
CEFACLOR 125 MG/5 ML SUSP Oral Suspension [Ceclor]   2 Generic $2.00$6.00None
CEFACLOR 250 MG CAPSULES   3 Preferred Brand $35.00$105.00None
CEFACLOR 250 MG/5 ML SUSPEN Oral Suspension [Ceclor]   2 Generic $2.00$6.00None
CEFACLOR 375 MG/5 ML SUSPEN Oral Suspension [Ceclor]   2 Generic $2.00$6.00None
CEFACLOR 500 MG CAPSULES   3 Preferred Brand $35.00$105.00None
CEFACLOR ER 500MG TABLET SR 12HR   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFADROXIL 1 GM TABLET   2 Generic $2.00$6.00None
CEFADROXIL 250 MG/5 ML SUSP   2 Generic $2.00$6.00None
CEFADROXIL 500 MG CAPSULE   2 Generic $2.00$6.00None
CEFADROXIL 500 MG/5 ML SUSP   2 Generic $2.00$6.00None
CEFAZOLIN 1 GM VIAL 25/Box   4 Non-Preferred Drug 42%42%None
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE   4 Non-Preferred Drug 42%42%None
CEFAZOLIN 500 MG VIAL   4 Non-Preferred Drug 42%42%None
CEFDINIR 125 MG/5 ML SUSP   3 Preferred Brand $35.00$105.00None
CEFDINIR 250 MG/5 ML SUSP   3 Preferred Brand $35.00$105.00None
CEFDINIR 300 MG CAPSULE   2 Generic $2.00$6.00None
CEFEPIME HCL 1 GM VIAL   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFEPIME HCL 2 GRAM VIAL   4 Non-Preferred Drug 42%42%None
CEFIXIME 100 MG/5 ML SUSP [Suprax]   4 Non-Preferred Drug 42%42%None
CEFIXIME 200 MG/5 ML SUSP [Suprax]   4 Non-Preferred Drug 42%42%None
Cefotaxime 500 MG Injection   4 Non-Preferred Drug 42%42%None
Cefotaxime sodium 1 gm vial   4 Non-Preferred Drug 42%42%None
Cefotaxime sodium 2 gm vial   4 Non-Preferred Drug 42%42%None
CEFOTETAN 1GM VIAL 1EA x 10   2 Generic $2.00$6.00None
CEFOTETAN 2GM VIAL 1EA x 10   2 Generic $2.00$6.00None
CEFOXITIN 1 GM VIAL   4 Non-Preferred Drug 42%42%None
CEFOXITIN 10 GM VIAL   4 Non-Preferred Drug 42%42%None
CEFOXITIN 2 GM VIAL   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFPODOXIME 100 MG TABLET   4 Non-Preferred Drug 42%42%None
CEFPODOXIME 100 MG/5 ML SUSP   4 Non-Preferred Drug 42%42%None
CEFPODOXIME 200 MG TABLET   4 Non-Preferred Drug 42%42%None
CEFPODOXIME 50 MG/5 ML SUSP   4 Non-Preferred Drug 42%42%None
CEFPROZIL 125 MG/5 ML SUSP   3 Preferred Brand $35.00$105.00None
CEFPROZIL 250 MG TABLET   3 Preferred Brand $35.00$105.00None
CEFPROZIL 250 MG/5 ML SUSP   3 Preferred Brand $35.00$105.00None
CEFPROZIL 500 MG TABLET   3 Preferred Brand $35.00$105.00None
CEFTAZIDIME 1 GM VIAL   4 Non-Preferred Drug 42%42%None
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN   4 Non-Preferred Drug 42%42%None
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFTRIAXONE 1 GM VIAL   4 Non-Preferred Drug 42%42%None
CEFTRIAXONE 10 GM VIAL   4 Non-Preferred Drug 42%42%None
CEFTRIAXONE 2 GM VIAL   4 Non-Preferred Drug 42%42%None
CEFTRIAXONE 250 MG VIAL   4 Non-Preferred Drug 42%42%None
CEFTRIAXONE 500 MG VIAL   4 Non-Preferred Drug 42%42%None
CEFUROXIME 1.5 GM/VIAL FOR INJECTION   4 Non-Preferred Drug 42%42%None
CEFUROXIME 750 MG FOR INJECTION   4 Non-Preferred Drug 42%42%None
Cefuroxime 95 MG/ML Injectable Solution   4 Non-Preferred Drug 42%42%None
CEFUROXIME AXETIL 250 MG TAB   3 Preferred Brand $35.00$105.00None
CEFUROXIME AXETIL 500 MG TAB   3 Preferred Brand $35.00$105.00None
CELEBREX 100 MG CAPSULE   4 Non-Preferred Drug 42%42%S Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CELEBREX 200 MG CAPSULE   4 Non-Preferred Drug 42%42%S Q:60
/30Days
CELEBREX 400 MG CAPSULE   4 Non-Preferred Drug 42%42%S Q:30
/30Days
CELEBREX 50 MG CAPSULE   4 Non-Preferred Drug 42%42%S Q:60
/30Days
CELECOXIB 100 MG CAPSULE [Celebrex]   4 Non-Preferred Drug 42%42%Q:60
/30Days
CELECOXIB 200 MG CAPSULE [Celebrex]   4 Non-Preferred Drug 42%42%Q:60
/30Days
CELECOXIB 400 MG CAPSULE [Celebrex]   4 Non-Preferred Drug 42%42%Q:30
/30Days
CELECOXIB 50 MG CAPSULE [Celebrex]   4 Non-Preferred Drug 42%42%Q:60
/30Days
CELEXA 10 MG TABLET   4 Non-Preferred Drug 42%42%S Q:120
/30Days
CELEXA 20 MG TABLET   4 Non-Preferred Drug 42%42%S Q:60
/30Days
CELEXA 40 MG TABLET   4 Non-Preferred Drug 42%42%S Q:30
/30Days
CELONTIN 300 MG KAPSEAL   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEPHALEXIN 125 MG/5 ML SUSP   2 Generic $2.00$6.00None
CEPHALEXIN 250 MG CAPSULE   2 Generic $2.00$6.00None
CEPHALEXIN 250 MG TABLET   2 Generic $2.00$6.00None
CEPHALEXIN 250 MG/5 ML SUSP   2 Generic $2.00$6.00None
CEPHALEXIN 500 MG CAPSULE   2 Generic $2.00$6.00None
CEPHALEXIN 500 MG TABLET   2 Generic $2.00$6.00None
CEPHALEXIN 750 MG CAPSULE   2 Generic $2.00$6.00None
CERDELGA 84 MG CAPSULE   5 Specialty Tier 33%N/AP
CEREZYME 400 UNITS VIAL   5 Specialty Tier 33%N/AP
CETIRIZINE HCL 1 MG/ML SOLN   4 Non-Preferred Drug 42%42%Q:300
/30Days
CETRAXAL 0.2% EAR SOLUTION DROPERETTE   3 Preferred Brand $35.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEVIMELINE HCL 30 MG CAPSULE [Evoxac]   4 Non-Preferred Drug 42%42%None
CHANTIX 0.5 MG TABLET   4 Non-Preferred Drug 42%42%P
CHANTIX 1 MG CONT MONTH BOX   4 Non-Preferred Drug 42%42%P
CHANTIX 1 MG TABLET   4 Non-Preferred Drug 42%42%P
CHANTIX STARTING MONTH BOX   4 Non-Preferred Drug 42%42%P
CHEMET 100 MG CAPSULE   4 Non-Preferred Drug 42%42%None
CHLORAMPHEN NA SUCC 1GM VL   2 Generic $2.00$6.00None
CHLORDIAZEPO-AMITRIPTYL 5-12.5   4 Non-Preferred Drug 42%42%P
CHLORDIAZEPOXIDE 10 MG CAPSULE   4 Non-Preferred Drug 42%42%Q:120
/30Days
CHLORDIAZEPOXIDE 25 MG CAPSULE   4 Non-Preferred Drug 42%42%Q:120
/30Days
CHLORDIAZEPOXIDE 5 MG CAPSULE   4 Non-Preferred Drug 42%42%Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHLORHEXIDINE GLUCONATE 0.12% RINSE   1 Preferred Generic $1.00$3.00None
CHLOROQUINE PH 250 MG TABLET   2 Generic $2.00$6.00None
CHLOROQUINE PH 500 MG TABLET   2 Generic $2.00$6.00None
CHLOROTHIAZIDE 250 MG TABLET   3 Preferred Brand $35.00$105.00None
Chlorothiazide 500mg 100 TABLET BOTTLE   3 Preferred Brand $35.00$105.00None
CHLORPROMAZINE 10 MG TABLET   4 Non-Preferred Drug 42%42%None
CHLORPROMAZINE 100 MG TABLET   4 Non-Preferred Drug 42%42%None
CHLORPROMAZINE 200 MG TABLET   4 Non-Preferred Drug 42%42%None
CHLORPROMAZINE 25 MG TABLET   4 Non-Preferred Drug 42%42%None
CHLORPROMAZINE 25 MG/ML AMP   4 Non-Preferred Drug 42%42%None
CHLORPROMAZINE 50 MG TABLET   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHLORTHALIDONE 25 MG TABLET (100 CT)   2 Generic $2.00$6.00None
CHLORTHALIDONE 50 MG TABLET   2 Generic $2.00$6.00None
CHLORZOXAZONE 500 MG TABLET   3 Preferred Brand $35.00$105.00P Q:180
/30Days
CHOLESTYRAMINE LIGHT POWDER   4 Non-Preferred Drug 42%42%None
CHOLESTYRAMINE PACKET   4 Non-Preferred Drug 42%42%None
CICLOPIROX 0.77% CREAM   3 Preferred Brand $35.00$105.00None
CICLOPIROX 0.77% GEL   3 Preferred Brand $35.00$105.00None
CICLOPIROX 0.77% TOPICAL SUSP   3 Preferred Brand $35.00$105.00None
CICLOPIROX 1% SHAMPOO   3 Preferred Brand $35.00$105.00None
CICLOPIROX 8% SOLUTION   3 Preferred Brand $35.00$105.00None
Cilastatin 250 MG / Imipenem 250 MG Injection   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Cilastatin 500 MG / Imipenem 500 MG Injection   4 Non-Preferred Drug 42%42%None
CILOSTAZOL 100 MG TABLET   1 Preferred Generic $1.00$3.00None
CILOSTAZOL 50 MG TABLET   1 Preferred Generic $1.00$3.00None
CILOXAN 0.3% OINTMENT   3 Preferred Brand $35.00$105.00None
CILOXAN SOLUTION 0.3% 5ML BOT   4 Non-Preferred Drug 42%42%None
Cimetidine 200mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Drug 42%42%None
Cimetidine 300 MG Oral Tablet   4 Non-Preferred Drug 42%42%None
Cimetidine 400mg/1 100 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Drug 42%42%None
Cimetidine 800mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Drug 42%42%None
Cimetidine Hydrochloride Oral Solution 300mg/5mL 237 mL in 1 BOTTLE   4 Non-Preferred Drug 42%42%None
Cinryze 500[iU]/5mL 1 VIAL per CARTON / 5 mL in 1 VIAL   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CIPRO 10% SUSPENSION 1 KIT in 1 KIT   4 Non-Preferred Drug 42%42%None
Cipro 250mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Drug 42%42%None
Cipro 2mg/mL 200 mL in 1 BOTTLE, PLASTIC   4 Non-Preferred Drug 42%42%None
CIPRO 5% SUSPENSION 1 KIT in 1 KIT   4 Non-Preferred Drug 42%42%None
Cipro 500mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Drug 42%42%None
CIPRO HC OTIC SUSPENSION   4 Non-Preferred Drug 42%42%None
CIPRODEX OTIC SUSPENSION   3 Preferred Brand $35.00$105.00None
CIPROFLOXACIN 0.2% OTIC SOLN DROPERETTE [Cetraxal]   3 Preferred Brand $35.00$105.00None
CIPROFLOXACIN 0.3% EYE DROP [Ciloxan]   2 Generic $2.00$6.00None
CIPROFLOXACIN 250 MG TABLET (100 CT) [Cipro]   2 Generic $2.00$6.00None
CIPROFLOXACIN 250 MG/5 ML SUSP MC REC [Cipro]   3 Preferred Brand $35.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CIPROFLOXACIN 500 MG/5 ML SUSP MC REC [Cipro]   3 Preferred Brand $35.00$105.00None
CIPROFLOXACIN ER 1,000 MG TAB TBMP 24HR [Cipro XR]   2 Generic $2.00$6.00None
CIPROFLOXACIN HCL 100 MG Tablet [Cipro]   2 Generic $2.00$6.00None
CIPROFLOXACIN HCL 500 MG Tablet [Cipro]   2 Generic $2.00$6.00None
CIPROFLOXACIN HCL 750 MG Tablet [Cipro]   2 Generic $2.00$6.00None
CIPROFLOXACIN-D5W 200 MG/100 ML PIGGYBACK [Cipro]   4 Non-Preferred Drug 42%42%None
CISPLATIN 50MG/50ML MDV   3 Preferred Brand $35.00$105.00None
CITALOPRAM HBR 10 MG TABLET   1 Preferred Generic $1.00$3.00Q:120
/30Days
CITALOPRAM HBR 10 MG/5 ML SOLN   3 Preferred Brand $35.00$105.00Q:600
/30Days
CITALOPRAM HBR 20 MG TABLET   1 Preferred Generic $1.00$3.00Q:60
/30Days
CITALOPRAM HBR 40 MG TABLET   1 Preferred Generic $1.00$3.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Cladribine 1 MG/ML in 10 ML Injection   4 Non-Preferred Drug 42%42%P
CLARAVIS 10 MG CAPSULE   4 Non-Preferred Drug 42%42%None
CLARAVIS 20 MG CAPSULE   4 Non-Preferred Drug 42%42%None
Claravis 30mg 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK   4 Non-Preferred Drug 42%42%None
CLARAVIS 40 MG CAPSULE   4 Non-Preferred Drug 42%42%None
Clarinex 0.5mg/mL 473 mL in 1 BOTTLE   4 Non-Preferred Drug 42%42%Q:300
/30Days
CLARINEX 5 MG TABLET   4 Non-Preferred Drug 42%42%Q:30
/30Days
CLARITHROMYCIN 125 MG/5ML FOR ORAL SUSPENSION   3 Preferred Brand $35.00$105.00None
CLARITHROMYCIN 250 MG TABLET   3 Preferred Brand $35.00$105.00None
CLARITHROMYCIN 250 MG/5MLFOR ORAL SUSPENSION   3 Preferred Brand $35.00$105.00None
CLARITHROMYCIN 500 MG TABLET   3 Preferred Brand $35.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLARITHROMYCIN ER 500 MG TAB   4 Non-Preferred Drug 42%42%None
Clemastine fum 2.68 mg tab   3 Preferred Brand $35.00$105.00P
CLEOCIN 100 MG VAGINAL OVULE   4 Non-Preferred Drug 42%42%None
CLEOCIN 2% VAGINAL CREAM   4 Non-Preferred Drug 42%42%None
CLEOCIN HCL 150 MG CAPSULE   4 Non-Preferred Drug 42%42%None
CLEOCIN HCL 300 MG CAPSULE   4 Non-Preferred Drug 42%42%None
CLEOCIN HCL 75 MG CAPSULE   4 Non-Preferred Drug 42%42%None
CLEOCIN PHOS 150 MG/ML VIAL   4 Non-Preferred Drug 42%42%None
CLEOCIN T 1% GEL   4 Non-Preferred Drug 42%42%None
CLEOCIN T 1% LOTION   4 Non-Preferred Drug 42%42%None
CLEOCIN T 1% PLEDGETS   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLEOCIN T 1% SOLUTION   4 Non-Preferred Drug 42%42%None
CLIMARA 0.025MG/DAY PATCH   4 Non-Preferred Drug 42%42%P Q:4
/28Days
CLIMARA 0.0375MG/DAY PATCH   4 Non-Preferred Drug 42%42%P Q:4
/28Days
CLIMARA 0.05MG/24H PATCH   4 Non-Preferred Drug 42%42%P Q:4
/28Days
CLIMARA 0.06/MG DAY PATCH   4 Non-Preferred Drug 42%42%P Q:4
/28Days
CLIMARA 0.075MG/DAY PATCH   4 Non-Preferred Drug 42%42%P Q:4
/28Days
CLIMARA 0.1MG/24H PATCH   4 Non-Preferred Drug 42%42%P Q:4
/28Days
CLIND PH-BENZOYL PEROX 1.2-5% [Benzaclin]   4 Non-Preferred Drug 42%42%None
CLINDACIN PAC KIT   3 Preferred Brand $35.00$105.00None
CLINDAGEL 1% GEL   4 Non-Preferred Drug 42%42%None
Clindamycin 10 MG/ML Topical Foam [Evoclin]   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Clindamycin 150 MG/ML 2ml   4 Non-Preferred Drug 42%42%None
CLINDAMYCIN 150mg/ml vl 25x6ml   4 Non-Preferred Drug 42%42%None
CLINDAMYCIN 75 MG/5 ML SOLN   4 Non-Preferred Drug 42%42%None
CLINDAMYCIN HCL 150 MG CAPSULE   2 Generic $2.00$6.00None
CLINDAMYCIN HCL 300 MG CAPSULE   2 Generic $2.00$6.00None
CLINDAMYCIN HCL 75 MG 200 CAPSULE BOTTLE   2 Generic $2.00$6.00None
CLINDAMYCIN PH 1% SOLUTION   3 Preferred Brand $35.00$105.00None
CLINDAMYCIN PH 600 MG/4 ML VL   4 Non-Preferred Drug 42%42%None
CLINDAMYCIN PHOSP 1% LOTION   4 Non-Preferred Drug 42%42%None
CLINDAMYCIN PHOSPHATE 1% FOAM   4 Non-Preferred Drug 42%42%None
Clindamycin Phosphate and Benzoyl Peroxide 1 KIT   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE   3 Preferred Brand $35.00$105.00None
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX   3 Preferred Brand $35.00$105.00None
CLINDAMYCIN PHOSPHATE VAGINAL CREAM   4 Non-Preferred Drug 42%42%None
Clindamycin-d5w 300 mg/50 ml   4 Non-Preferred Drug 42%42%None
Clindamycin-d5w 600 mg/50 ml   4 Non-Preferred Drug 42%42%None
Clindamycin-d5w 900 mg/50 ml   4 Non-Preferred Drug 42%42%None
CLINDESSE 2% VAGINAL CREAM   4 Non-Preferred Drug 42%42%None
CLINIMIX 2.75%/5% INJECTION 1000ML BAG   4 Non-Preferred Drug 42%42%P
CLINIMIX 4.25%-25% SOLUTION   4 Non-Preferred Drug 42%42%P
CLINIMIX 5/20 SOLUTION   4 Non-Preferred Drug 42%42%P
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG   4 Non-Preferred Drug 42%42%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINIMIX 5%-15% SOLUTION   4 Non-Preferred Drug 42%42%P
CLINISOL 15% SOLUTION   4 Non-Preferred Drug 42%42%P
CLOBETASOL 0.05% OINTMENT   4 Non-Preferred Drug 42%42%None
CLOBETASOL 0.05% SOLUTION   4 Non-Preferred Drug 42%42%None
CLOBETASOL 0.05% TOPICAL LOTN   4 Non-Preferred Drug 42%42%None
CLOBETASOL EMOLLIENT 0.05% CRM   4 Non-Preferred Drug 42%42%None
CLOBETASOL PROP 0.05% SPRAY   4 Non-Preferred Drug 42%42%None
Clobetasol Propionate 0.5 MG/ML Medicated Shampoo   4 Non-Preferred Drug 42%42%None
Clobetasol Propionate 0.5mg/g 1 CAN per CARTON / 100 g in 1 CAN   4 Non-Preferred Drug 42%42%None
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE   4 Non-Preferred Drug 42%42%None
CLOBEX 0.05% SPRAY   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOBEX 0.05% TOPICAL LOTION   4 Non-Preferred Drug 42%42%None
Clobex 0.05mL/100mL 118 mL in 1 BOTTLE   4 Non-Preferred Drug 42%42%None
Clodan 0.05% shampoo   4 Non-Preferred Drug 42%42%None
CLODERM 0.1% CREAM   4 Non-Preferred Drug 42%42%None
CLOFARABINE 20 MG/20 ML VIAL [Clolar]   5 Specialty Tier 33%N/ANone
CLOLAR 20 MG/20 ML VIAL   5 Specialty Tier 33%N/ANone
CLOMIPRAMINE 25 MG CAPSULE   4 Non-Preferred Drug 42%42%P
CLOMIPRAMINE 50 MG CAPSULE   4 Non-Preferred Drug 42%42%P
CLOMIPRAMINE 75 MG CAPSULE   4 Non-Preferred Drug 42%42%P
CLONAZEPAM 0.125 MG DIS TAB RAPDIS [Klonopin]   3 Preferred Brand $35.00$105.00Q:90
/30Days
CLONAZEPAM 0.25 MG ODT TAB RAPDIS [Klonopin]   3 Preferred Brand $35.00$105.00Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLONAZEPAM 0.5 MG DIS TABLET RAPDIS [Klonopin]   3 Preferred Brand $35.00$105.00Q:90
/30Days
CLONAZEPAM 0.5 MG TABLET [Klonopin]   2 Generic $2.00$6.00Q:90
/30Days
CLONAZEPAM 1 MG DIS TABLET RAPDIS [Klonopin]   3 Preferred Brand $35.00$105.00Q:120
/30Days
CLONAZEPAM 1 MG TABLET [Klonopin]   2 Generic $2.00$6.00Q:120
/30Days
CLONAZEPAM 2 MG ODT TAB RAPDIS [Klonopin]   3 Preferred Brand $35.00$105.00Q:300
/30Days
CLONAZEPAM 2 MG TABLET [Klonopin]   2 Generic $2.00$6.00Q:300
/30Days
Clonidine 0.1mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   3 Preferred Brand $35.00$105.00Q:8
/28Days
Clonidine 0.2mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   3 Preferred Brand $35.00$105.00Q:8
/28Days
Clonidine 0.3mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   3 Preferred Brand $35.00$105.00Q:8
/28Days
CLONIDINE HCL 0.1 MG TABLET   2 Generic $2.00$6.00None
CLONIDINE HCL 0.2 MG TABLET   2 Generic $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLONIDINE HCL 0.3 MG TABLET   2 Generic $2.00$6.00None
CLONIDINE HCL ER 0.1 MG TABLET   4 Non-Preferred Drug 42%42%None
CLOPIDOGREL 75 MG TABLET [Plavix]   1 Preferred Generic $1.00$3.00Q:30
/30Days
CLORAZEPATE 15 MG TABLET   3 Preferred Brand $35.00$105.00Q:180
/30Days
CLORAZEPATE 3.75 MG TABLET   3 Preferred Brand $35.00$105.00Q:90
/30Days
CLORAZEPATE 7.5 MG TABLET   3 Preferred Brand $35.00$105.00Q:90
/30Days
CLOTRIMAZOLE 1% CREAM   3 Preferred Brand $35.00$105.00None
CLOTRIMAZOLE 1% SOLUTION   3 Preferred Brand $35.00$105.00None
CLOTRIMAZOLE 10 MG TROCHE   3 Preferred Brand $35.00$105.00None
CLOTRIMAZOLE-BETAMETHASONE LOT   4 Non-Preferred Drug 42%42%None
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOZAPINE 100 MG TABLET [Clozaril]   3 Preferred Brand $35.00$105.00None
CLOZAPINE 200 MG TABLET   3 Preferred Brand $35.00$105.00None
CLOZAPINE 25 MG TABLET [Clozaril]   3 Preferred Brand $35.00$105.00None
CLOZAPINE 50 MG TABLET   3 Preferred Brand $35.00$105.00None
CLOZAPINE ODT 100 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 42%42%None
CLOZAPINE ODT 12.5 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 42%42%None
CLOZAPINE ODT 150 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 42%42%None
CLOZAPINE ODT 200 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 42%42%None
CLOZAPINE ODT 25 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 42%42%None
CLOZARIL 100 MG TABLET   4 Non-Preferred Drug 42%42%S
CLOZARIL 25 MG TABLET   4 Non-Preferred Drug 42%42%S
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COARTEM 20MG-120MG   4 Non-Preferred Drug 42%42%None
CODEINE SULFATE 15 mg tablet   4 Non-Preferred Drug 42%42%Q:180
/30Days
CODEINE SULFATE 30 mg tablet   4 Non-Preferred Drug 42%42%Q:180
/30Days
CODEINE SULFATE 60 mg tablet   4 Non-Preferred Drug 42%42%Q:180
/30Days
COGENTIN 2 MG/2 ML AMPULE   4 Non-Preferred Drug 42%42%P
COLAZAL 750MG CAPSULE   4 Non-Preferred Drug 42%42%None
COLCHICINE 0.6 MG CAPSULE [Mitigare]   3 Preferred Brand $35.00$105.00None
COLCHICINE 0.6 MG TABLET [Colcrys]   3 Preferred Brand $35.00$105.00Q:120
/30Days
COLCRYS 0.6 MG TABLET   3 Preferred Brand $35.00$105.00Q:120
/30Days
COLESTID 1GM TABLET   4 Non-Preferred Drug 42%42%None
COLESTID GRANULES PACKET   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COLESTIPOL HCL 1G TABLET   4 Non-Preferred Drug 42%42%None
COLESTIPOL HCL GRANULES PACKET   4 Non-Preferred Drug 42%42%None
COLISTIMETHATE 150 MG VIAL   4 Non-Preferred Drug 42%42%P
COLOCORT 100MG ENEMA   2 Generic $2.00$6.00None
COMBIGAN 0.2%-0.5% DROPS   3 Preferred Brand $35.00$105.00None
COMBIPATCH 0.05-0.14 MG PTCH   4 Non-Preferred Drug 42%42%P Q:8
/28Days
COMBIPATCH 0.05-0.25 MG PTCH   4 Non-Preferred Drug 42%42%P Q:8
/28Days
COMBIVENT RESPIMAT INHAL SPRAY   4 Non-Preferred Drug 42%42%Q:8
/30Days
COMETRIQ 100 MG DAILY-DOSE PK   5 Specialty Tier 33%N/AP
COMETRIQ 140 MG DAILY-DOSE PK   5 Specialty Tier 33%N/AP
COMETRIQ 60 MG DAILY-DOSE PACK   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1   5 Specialty Tier 33%N/ANone
COMPRO 25MG SUPPOSITORY   2 Generic $2.00$6.00None
COMTAN 200MG TABLET   4 Non-Preferred Drug 42%42%None
CONCERTA 54mg/1 100 TABLET, ER in BOTTLE   4 Non-Preferred Drug 42%42%P Q:30
/30Days
CONCERTA ER TABLETS 18MG 100 TABLETS BOT   4 Non-Preferred Drug 42%42%P Q:30
/30Days
CONCERTA ER TABLETS 27MG 100 TABLETS BOT   4 Non-Preferred Drug 42%42%P Q:30
/30Days
CONCERTA ER TABLETS 36MG 100 TABLETS BOT   4 Non-Preferred Drug 42%42%P Q:30
/30Days
CONDYLOX 0.5% GEL   4 Non-Preferred Drug 42%42%None
CONSTULOSE 10 GM/15 ML SOLN   2 Generic $2.00$6.00None
CONZIP 100 MG CAPSULE   4 Non-Preferred Drug 42%42%Q:30
/30Days
CONZIP 200 MG CAPSULE   4 Non-Preferred Drug 42%42%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CONZIP 300 MG CAPSULE   4 Non-Preferred Drug 42%42%Q:30
/30Days
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN   5 Specialty Tier 33%N/AP Q:30
/30Days
COPAXONE 40 MG/ML SYRINGE   5 Specialty Tier 33%N/AP Q:12
/28Days
CORDRAN 4 MCG/SQ CM TAPE LARGE   4 Non-Preferred Drug 42%42%None
COREG 12.5MG TABLET   4 Non-Preferred Drug 42%42%None
COREG 25MG TABLET   4 Non-Preferred Drug 42%42%None
COREG 3.125MG TABLET   4 Non-Preferred Drug 42%42%None
COREG 6.25MG TABLET   4 Non-Preferred Drug 42%42%None
COREG CR 10MG CAPSULE MULTIPHASIC RELEASE 24 HR   4 Non-Preferred Drug 42%42%Q:30
/30Days
COREG CR 20MG CAPSULE MULTIPHASIC RELEASE 24 HR   4 Non-Preferred Drug 42%42%Q:30
/30Days
COREG CR 40MG CAPSULE MULTIPHASIC RELEASE 24 HR   4 Non-Preferred Drug 42%42%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COREG CR 80MG CAPSULE MULTIPHASIC RELEASE 24 HR   4 Non-Preferred Drug 42%42%Q:30
/30Days
CORGARD 20 MG TABLET   4 Non-Preferred Drug 42%42%None
CORGARD 40 MG TABLET   4 Non-Preferred Drug 42%42%None
CORGARD 80 MG TABLET   4 Non-Preferred Drug 42%42%None
CORLANOR 5 MG TABLET   4 Non-Preferred Drug 42%42%S
CORLANOR 7.5 MG TABLET   4 Non-Preferred Drug 42%42%S
CORTEF 10MG TABLET   4 Non-Preferred Drug 42%42%None
CORTEF 20MG TABLET   4 Non-Preferred Drug 42%42%None
CORTEF 5MG TABLET   4 Non-Preferred Drug 42%42%None
Cortisone 25 MG Tablet   4 Non-Preferred Drug 42%42%None
CORTISPORIN CRE 0.5%   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CORTISPORIN OINTMENT   4 Non-Preferred Drug 42%42%None
COSMEGEN 0.5 MG VIAL   5 Specialty Tier 33%N/ANone
COSOPT EYE DROPS   4 Non-Preferred Drug 42%42%None
COSOPT PF EYE DROPS   4 Non-Preferred Drug 42%42%None
COTELLIC 20 MG TABLET   5 Specialty Tier 33%N/AP
COUMADIN 1 MG TABLET   4 Non-Preferred Drug 42%42%None
COUMADIN 10MG TABLET   4 Non-Preferred Drug 42%42%None
COUMADIN 2.5 MG TABLET   4 Non-Preferred Drug 42%42%None
COUMADIN 2MG TABLET   4 Non-Preferred Drug 42%42%None
COUMADIN 3mg/1 1 BOTTLE per CARTON / 100 TABLET BOTTLE   4 Non-Preferred Drug 42%42%None
COUMADIN 4mg/1 1 BOTTLE in 1 CARTON / 100 TABLET BOTTLE   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COUMADIN 5MG TABLET   4 Non-Preferred Drug 42%42%None
COUMADIN 6MG TABLET   4 Non-Preferred Drug 42%42%None
COUMADIN 7.5MG TABLET   4 Non-Preferred Drug 42%42%None
COZAAR 100 MG TABLET   4 Non-Preferred Drug 42%42%S Q:30
/30Days
COZAAR 25 MG TABLET   4 Non-Preferred Drug 42%42%S Q:60
/30Days
COZAAR 50 MG TABLET   4 Non-Preferred Drug 42%42%S Q:60
/30Days
Creon 256.11mg/1 1 BOTTLE per CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE   3 Preferred Brand $35.00$105.00None
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT   3 Preferred Brand $35.00$105.00None
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT   3 Preferred Brand $35.00$105.00None
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT   3 Preferred Brand $35.00$105.00None
CREON DR 36,000 UNITS CAPSULE   3 Preferred Brand $35.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CRESTOR 10MG TABLET   4 Non-Preferred Drug 42%42%S Q:30
/30Days
CRESTOR 20MG TABLET   4 Non-Preferred Drug 42%42%S Q:30
/30Days
CRESTOR 40mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Drug 42%42%S Q:30
/30Days
CRESTOR 5MG TABLET   4 Non-Preferred Drug 42%42%S Q:30
/30Days
CRINONE 4% GEL   4 Non-Preferred Drug 42%42%P
CRINONE 8% GEL   4 Non-Preferred Drug 42%42%P
CRIXIVAN 200MG CAPSULE   4 Non-Preferred Drug 42%42%None
CRIXIVAN 400mg, 180 CAPSULE BOTTLE   4 Non-Preferred Drug 42%42%None
CROMOLYN 20 MG/2 ML NEB SOLN   2 Generic $2.00$6.00P
CROMOLYN SODIUM 100 MG/5 ML   4 Non-Preferred Drug 42%42%None
CROMOLYN SODIUM 4% 40MG 10ML BOT   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CUBICIN 500MG VIAL   5 Specialty Tier 33%N/ANone
CUTIVATE 0.05% LOTION   4 Non-Preferred Drug 42%42%None
CUVPOSA 1 MG/5 ML SOLUTION   4 Non-Preferred Drug 42%42%Q:1350
/30Days
Cyclafem 1/35 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK   3 Preferred Brand $35.00$105.00None
CYCLAFEM 7-7-7-28 TABLET   3 Preferred Brand $35.00$105.00None
CYCLOBENZAPRINE 10 MG TABLET   3 Preferred Brand $35.00$105.00P Q:90
/30Days
CYCLOBENZAPRINE 5 MG TABLET   3 Preferred Brand $35.00$105.00P Q:90
/30Days
CYCLOBENZAPRINE 7.5 MG TABLET   3 Preferred Brand $35.00$105.00P Q:90
/30Days
CYCLOPHOSPHAMIDE 25 MG CAPSULE   4 Non-Preferred Drug 42%42%P
CYCLOPHOSPHAMIDE 50 MG CAPSULE   4 Non-Preferred Drug 42%42%P
CYCLOSET 0.8MG TABLETS   4 Non-Preferred Drug 42%42%P Q:180
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYCLOSPORINE 100MG CAPSULE   4 Non-Preferred Drug 42%42%P
CYCLOSPORINE 25MG CAPSULE   4 Non-Preferred Drug 42%42%P
Cyclosporine 50 mg/ml vial   3 Preferred Brand $35.00$105.00P
CYCLOSPORINE MODIFIED 100 MG   4 Non-Preferred Drug 42%42%P
CYCLOSPORINE MODIFIED 25 MG   4 Non-Preferred Drug 42%42%P
CYCLOSPORINE MODIFIED 50 MG   4 Non-Preferred Drug 42%42%P
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT   4 Non-Preferred Drug 42%42%P
CYMBALTA 20MG CAPSULE   4 Non-Preferred Drug 42%42%S Q:60
/30Days
CYMBALTA 60 MG CAPSULE   4 Non-Preferred Drug 42%42%S Q:60
/30Days
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT)   4 Non-Preferred Drug 42%42%S Q:90
/30Days
CYPROHEPTADINE 4 MG TABLET   4 Non-Preferred Drug 42%42%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL   4 Non-Preferred Drug 42%42%P
CYRAMZA 100 MG/10 ML VIAL   5 Specialty Tier 33%N/AP
CYRAMZA 500 MG/50 ML VIAL   5 Specialty Tier 33%N/AP
CYSTADANE 1 GRAM/1.7 ML POWDER   5 Specialty Tier 33%N/ANone
CYSTAGON 150MG CAPSULE   4 Non-Preferred Drug 42%42%P
CYSTAGON 50MG CAPSULE   4 Non-Preferred Drug 42%42%P
CYSTARAN 0.44% EYE DROPS   5 Specialty Tier 33%N/AP
CYTARABINE 20MG/ML VIAL   4 Non-Preferred Drug 42%42%P
CYTARABINE SOLUTION INJECTION 100MG 20ML VIALSD   4 Non-Preferred Drug 42%42%P
CYTOMEL 25MCG TABLET   4 Non-Preferred Drug 42%42%None
CYTOMEL 50MCG TABLET   4 Non-Preferred Drug 42%42%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYTOMEL 5MCG TABLET   4 Non-Preferred Drug 42%42%None
CYTOTEC 100 MCG TABLET   4 Non-Preferred Drug 42%42%None
CYTOTEC TABLET 200MCG (60 CT)   4 Non-Preferred Drug 42%42%None

Chart Legend:

Below are a few notes to help you understand the above 2018 Medicare Part D First Health Part D Premier Plus (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $405 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.

  • Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
    • Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.

    • No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.

  • Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
  • Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
    • Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs. *Some Part D plans exclude one or more drug tiers from the deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
    • Tier Description - This is the Medicare Part D plan’s description of this particular drug tier.
  • Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
    • Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $3750) at a "Preferred" network pharmacy. In most cases, the "Preferred" network network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
    • Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
  • Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
    • None - This drug does not fall under any drug utilization management controls.
    • P - Prior Authorization -This drug is subject to prior authorization.
    • S - Step Therapy -This drug is subject to step therapy.
    • Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.




(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2018 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.







Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.