2018 Medicare Part D Plan Formulary Information |
Aetna Medicare Rx Select (PDP) (S5810-292-0)
Benefit Details
 |
The Aetna Medicare Rx Select (PDP) (S5810-292-0) Formulary Drugs Starting with the Letter P in CMS PDP Region 21 which includes: LA Plan Monthly Premium: $17.70 Deductible: $405 Qualifies for LIS: No |
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  |
2* |
Generic |
$3.00 | N/A | None |
PACERONE 200 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
PACERONE 400MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
PACLITAXEL 100 MG/16.7 ML VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PALIPERIDONE ER 1.5 MG TABLET [INVEGA] ![Compare how all Medicare Part D PDP plans in LA cover PALIPERIDONE ER 1.5 MG TABLET [INVEGA].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
PALIPERIDONE ER 3 MG TABLET [INVEGA] ![Compare how all Medicare Part D PDP plans in LA cover PALIPERIDONE ER 3 MG TABLET [INVEGA].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
PALIPERIDONE ER 6 MG TABLET [INVEGA] ![Compare how all Medicare Part D PDP plans in LA cover PALIPERIDONE ER 6 MG TABLET [INVEGA].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
PALIPERIDONE ER 9 MG TABLET [INVEGA] ![Compare how all Medicare Part D PDP plans in LA cover PALIPERIDONE ER 9 MG TABLET [INVEGA].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
PAMELOR 10mg/1 30 CAPSULE BOTTLE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PAMELOR 25mg/1 30 CAPSULE BOTTLE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAMELOR 50mg/1 30 CAPSULE BOTTLE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PAMELOR 75mg/1 30 CAPSULE BOTTLE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PAMIDRONATE 30 MG/10 ML VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PAMIDRONATE 60MG/10ML VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PAMIDRONATE 90 MG/10 ML VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PANRETIN 0.1% GEL 60GM TUBE  |
5 |
Specialty Tier |
25% | N/A | None |
PANTOPRAZOLE SOD DR 20 MG TAB  |
2* |
Generic |
$3.00 | N/A | Q:30 /30Days |
PANTOPRAZOLE SOD DR 40 MG TAB  |
2* |
Generic |
$3.00 | N/A | Q:60 /30Days |
PANTOPRAZOLE SODIUM 40 MG VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PARICALCITOL 1 MCG CAPSULE [Zemplar] ![Compare how all Medicare Part D PDP plans in LA cover PARICALCITOL 1 MCG CAPSULE [Zemplar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | None |
PARICALCITOL 10 MCG/2 ML VIAL [Zemplar] ![Compare how all Medicare Part D PDP plans in LA cover PARICALCITOL 10 MCG/2 ML VIAL [Zemplar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | 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] ![Compare how all Medicare Part D PDP plans in LA cover PARICALCITOL 2 MCG CAPSULE [Zemplar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | None |
PARICALCITOL 2 MCG/ML VIAL [Zemplar] ![Compare how all Medicare Part D PDP plans in LA cover PARICALCITOL 2 MCG/ML VIAL [Zemplar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | None |
PARICALCITOL 4 MCG CAPSULE [Zemplar] ![Compare how all Medicare Part D PDP plans in LA cover PARICALCITOL 4 MCG CAPSULE [Zemplar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | None |
PAROMOMYCIN 250 MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PAROXETINE ER 12.5 MG TABLET 24H [Paxil CR] ![Compare how all Medicare Part D PDP plans in LA cover PAROXETINE ER 12.5 MG TABLET 24H [Paxil CR].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | Q:90 /30Days |
PAROXETINE ER 25 MG TABLET 24H [Paxil CR] ![Compare how all Medicare Part D PDP plans in LA cover PAROXETINE ER 25 MG TABLET 24H [Paxil CR].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | Q:90 /30Days |
PAROXETINE ER 37.5 MG TABLET 24H [Paxil CR] ![Compare how all Medicare Part D PDP plans in LA cover PAROXETINE ER 37.5 MG TABLET 24H [Paxil CR].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | Q:60 /30Days |
PAROXETINE HCL 10 MG TABLET  |
2* |
Generic |
$3.00 | N/A | Q:30 /30Days |
PAROXETINE HCL 20 MG TABLET  |
2* |
Generic |
$3.00 | N/A | Q:30 /30Days |
PAROXETINE HCL 30 MG TABLET  |
2* |
Generic |
$3.00 | N/A | Q:60 /30Days |
PAROXETINE HCL 40 MG TABLET  |
2* |
Generic |
$3.00 | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PASER GRANULES 4GM PACKET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PATADAY 0.2% DROPS  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PATANASE 665ug/1 240 SPRAY, METERED in 1 BOTTLE  |
4 |
Non-Preferred Drug |
37% | N/A | Q:31 /30Days |
PATANOL 0.1% EYE DROPS  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PAXIL 25mg/1  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:90 /30Days |
PAXIL CR TABLETS CONTROLLED RELEASE 12.5 MG  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:90 /30Days |
PAXIL CR TABLETS EXTENDED RELEASE 37.5 MG  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:60 /30Days |
PAXIL ORAL SUSPENSION 10 MG/5ML  |
4 |
Non-Preferred Drug |
37% | N/A | Q:900 /30Days |
PAXIL TABLETS 10 MG  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
PAXIL TABLETS 20 MG  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
PAXIL TABLETS 30 MG  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAXIL TABLETS 40 MG  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:60 /30Days |
PAZEO 0.7% EYE DROPS  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PEDVAXHIB VACCINE VIAL  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PEG 3350 ELECTROLYTE SOLN SOLN RECON [GaviLyte-C] ![Compare how all Medicare Part D PDP plans in LA cover PEG 3350 ELECTROLYTE SOLN SOLN RECON [GaviLyte-C].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$3.00 | N/A | None |
PEG 3350-ELECTROLYTE SOLUTION SOLN RECON  |
2* |
Generic |
$3.00 | N/A | None |
PEG-3350 AND ELECTROLYTES SOLN SOLN RECON  |
2* |
Generic |
$3.00 | N/A | None |
PEGANONE 250 MG TABLET  |
4 |
Non-Preferred Drug |
37% | 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 |
PEGASYS INJECTION  |
5 |
Specialty Tier |
25% | N/A | P |
PEGASYS PROCLICK 135 MCG/0.5  |
5 |
Specialty Tier |
25% | N/A | P |
PEGASYS PROCLICK 180 MCG/0.5  |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENICILLIN G PROCAINE 1200000UNT 2ML CTG  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Penicillin G Sodium 5000000[iU]/1 10 VIAL per CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL ![Compare how all Medicare Part D PDP plans in LA cover Penicillin G Sodium 5000000[iU]/1 10 VIAL per CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | None |
PENICILLIN GK 20 MILLION UNIT  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID  |
1* |
Preferred Generic |
$0.00 | N/A | None |
PENICILLIN V POTASSIUM 500MG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
PENICILLIN VK 125 MG/5 ML SOLN  |
1* |
Preferred Generic |
$0.00 | N/A | None |
PENICILLIN VK 250 MG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
PENNSAID 2% PUMP  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:224 /28Days |
PENTAM 300 INJ 300MG  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PENTASA 250MG CAPSULE SA  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PENTASA 500MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENTAZOCINE-NALOXONE TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:360 /30Days |
PENTOXIFYLLINE 400MG TABLET SA  |
2* |
Generic |
$3.00 | N/A | None |
PEPCID SOLUTION 40MG 24 X 400MG BOT  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PERCOCET 10/325MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:180 /30Days |
PERCOCET 2.5/325MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:180 /30Days |
PERCOCET 5-325 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:180 /30Days |
PERCOCET 7.5/325MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:180 /30Days |
PERFOROMIST 20MCG/2ML VIAL NEBULIZER  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:120 /30Days |
PERINDOPRIL ERBUMINE 2 MG TAB  |
2* |
Generic |
$3.00 | N/A | None |
PERINDOPRIL ERBUMINE 4 MG TAB  |
2* |
Generic |
$3.00 | N/A | None |
PERINDOPRIL ERBUMINE 8 MG TAB  |
2* |
Generic |
$3.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PERIOGARD 0.12% ORAL RINSE  |
1* |
Preferred Generic |
$0.00 | 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  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PERPHEN-AMITRIP 2 MG-10 MG TAB  |
4 |
Non-Preferred Drug |
37% | N/A | P |
PERPHEN-AMITRIP 2 MG-25 MG TAB  |
4 |
Non-Preferred Drug |
37% | N/A | P |
PERPHEN-AMITRIP 4 MG-25 MG TAB  |
4 |
Non-Preferred Drug |
37% | N/A | P |
Perphenazine 16mg/1 100 FILM COATED TABLETS in BOTTLE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PERPHENAZINE 4 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PERPHENAZINE 8 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PERPHENAZINE TABLETS USP 2MG 100 BOT  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PHENADOZ 12.5 MG SUPPOSITORY  |
4 |
Non-Preferred Drug |
37% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Phenelzine Sulfate 15mg/1 60 TABLET BOTTLE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PHENERGAN 25 MG/ML AMPUL  |
4 |
Non-Preferred Drug |
37% | N/A | P |
PHENERGAN 50 MG/ML VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | P |
Phenobarbital 100mg/1  |
3 |
Preferred Brand |
$46.00 | N/A | P Q:120 /30Days |
Phenobarbital 15mg/1  |
3 |
Preferred Brand |
$46.00 | N/A | P Q:120 /30Days |
PHENOBARBITAL 16.2 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | P Q:120 /30Days |
PHENOBARBITAL 20 MG/5 ML ELIX  |
3 |
Preferred Brand |
$46.00 | N/A | P Q:1500 /30Days |
Phenobarbital 30mg/1  |
3 |
Preferred Brand |
$46.00 | N/A | P Q:120 /30Days |
PHENOBARBITAL 32.4 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | P Q:120 /30Days |
Phenobarbital 60mg/1  |
3 |
Preferred Brand |
$46.00 | N/A | P Q:120 /30Days |
PHENOBARBITAL 64.8 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | P Q:120 /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 |
$46.00 | N/A | P Q:120 /30Days |
PHENYTEK 200 MG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PHENYTEK 300 MG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Phenytoin 50 MG Chewable Tablet  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PHENYTOIN SOD EXT 100 MG CAP  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PHENYTOIN SOD EXT 200 MG CAP  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PHENYTOIN SOD EXT 300 MG CAP  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PHENYTOIN SODIUM 100MG /2ML INJECTION  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Phoslyra 667mg/5mL 1 BOTTLE per CARTON / 473 mL in 1 BOTTLE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PHOSPHOLINE IODIDE 0.125% 6.25MG  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PHRENILIN FORTE 50-300-40 MG  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:180 /30Days |
PICATO 0.015% GEL  |
5 |
Specialty Tier |
25% | N/A | Q:3 /30Days |
PICATO 0.05% GEL  |
5 |
Specialty Tier |
25% | N/A | Q:2 /30Days |
PILOCARPINE 1% EYE DROPS [Pilocar] ![Compare how all Medicare Part D PDP plans in LA cover PILOCARPINE 1% EYE DROPS [Pilocar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | None |
PILOCARPINE 2% EYE DROPS [Pilocar] ![Compare how all Medicare Part D PDP plans in LA cover PILOCARPINE 2% EYE DROPS [Pilocar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | None |
PILOCARPINE 4% EYE DROPS [Pilocar] ![Compare how all Medicare Part D PDP plans in LA cover PILOCARPINE 4% EYE DROPS [Pilocar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | None |
PILOCARPINE HCL 5 MG TABLET [Salagen] ![Compare how all Medicare Part D PDP plans in LA cover PILOCARPINE HCL 5 MG TABLET [Salagen].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | None |
PILOCARPINE HCL 7.5 MG TABLET [Salagen] ![Compare how all Medicare Part D PDP plans in LA cover PILOCARPINE HCL 7.5 MG TABLET [Salagen].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | None |
PIMOZIDE 1 MG TABLET [Orap] ![Compare how all Medicare Part D PDP plans in LA cover PIMOZIDE 1 MG TABLET [Orap].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | None |
PIMOZIDE 2 MG TABLET [Orap] ![Compare how all Medicare Part D PDP plans in LA cover PIMOZIDE 2 MG TABLET [Orap].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | None |
PIMTREA 28 DAY TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PINDOLOL 10 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PINDOLOL 5 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
pioglitaz-glimepir 30-2 mg tab  |
1* |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
PIOGLITAZONE HCL 15 MG TABLET [Actos] ![Compare how all Medicare Part D PDP plans in LA cover PIOGLITAZONE HCL 15 MG TABLET [Actos].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
PIOGLITAZONE HCL 30 MG TABLET [Actos] ![Compare how all Medicare Part D PDP plans in LA cover PIOGLITAZONE HCL 30 MG TABLET [Actos].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
PIOGLITAZONE HCL 45 MG TABLET [Actos] ![Compare how all Medicare Part D PDP plans in LA cover PIOGLITAZONE HCL 45 MG TABLET [Actos].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
PIOGLITAZONE-GLIMEPIRIDE 30-4 Tablet [Duetact] ![Compare how all Medicare Part D PDP plans in LA cover PIOGLITAZONE-GLIMEPIRIDE 30-4 Tablet [Duetact].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
PIOGLITAZONE-METFORMIN 15-500  |
3 |
Preferred Brand |
$46.00 | N/A | Q:90 /30Days |
PIOGLITAZONE-METFORMIN 15-850  |
3 |
Preferred Brand |
$46.00 | N/A | Q:90 /30Days |
PIPERACIL-TAZOBACT 2.25 GM VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PIPERACIL-TAZOBACT 3.375 GM VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PIPERACIL-TAZOBACT 4.5 GM VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PIPERACIL-TAZOBACT 40.5 GM VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Pirmella 1-35-28 tablet  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PIROXICAM 10 MG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PIROXICAM 20 MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PLAQUENIL 200 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PLASMA-LYTE 148 IV SOLUTION  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PLASMA-LYTE A PH 7.4 SOLUTION 37;368; MG/100ML;  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PLAVIX 75 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
PODOFILOX 0.5% TOPICAL TUBEX  |
4 |
Non-Preferred Drug |
37% | N/A | None |
POLYETHYLENE GLYCOL 3350 POWD  |
2* |
Generic |
$3.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POLYMYXIN B-TMP EYE DROPS  |
1* |
Preferred Generic |
$0.00 | N/A | None |
POMALYST 1 MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P |
POMALYST 2 MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P |
POMALYST 3 MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P |
POMALYST 4 MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P |
PORTIA 0.15-0.03 TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
POT CHL/SWFI P-B 40 MEQ 24X100 ML  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Potassium Chloride 200 meq/1000mL 24 POUCH in 1 CASE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Potassium Chloride 8 MEQ Extended Release Oral Tablet  |
2* |
Generic |
$3.00 | N/A | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Potassium Chloride in Dextrose 5; 150g/100mL; mg/100mL 1000 mL in 1 BAG  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Potassium Chloride in Dextrose and Sodium Chloride 5; 0.15; 0.33g/100mL; g/100mL; g/100mL 12 CONTAI  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Potassium Chloride in Dextrose and Sodium Chloride 5; 300; 900g/100mL; mg/100mL; mg/100mL 1000 mL i  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Potassium Chloride in Lactated Ringers and Dextrose 20; 5; 179; 600; 310mg/100mL; g/100mL; mg/100mL  |
3 |
Preferred Brand |
$46.00 | N/A | None |
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION  |
4 |
Non-Preferred Drug |
37% | N/A | None |
POTASSIUM CHLORIDE INJECTION 10MEQ/100ML  |
3 |
Preferred Brand |
$46.00 | N/A | None |
POTASSIUM CITRATE ER 10 MEQ TB  |
4 |
Non-Preferred Drug |
37% | N/A | None |
POTASSIUM CITRATE ER 15 MEQ TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
POTASSIUM CITRATE ER 5 MEQ TAB  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Potassium cl 10% (20 meq/15 ml)  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Potassium cl 20% (40 meq/15 ml)  |
4 |
Non-Preferred Drug |
37% | N/A | None |
POTASSIUM CL 40 MEQ/20 ML CONC  |
2* |
Generic |
$3.00 | 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 CAPSULE  |
2* |
Generic |
$3.00 | N/A | None |
POTASSIUM CL ER 10 MEQ TABLET  |
2* |
Generic |
$3.00 | N/A | None |
POTASSIUM CL ER 10 MEQ TABLET  |
2* |
Generic |
$3.00 | N/A | None |
POTASSIUM CL ER 20 MEQ TABLET  |
2* |
Generic |
$3.00 | N/A | None |
Potassium cl er 20 meq tablet  |
2* |
Generic |
$3.00 | N/A | None |
POTASSIUM CL ER 8 MEQ CAPSULE  |
2* |
Generic |
$3.00 | N/A | None |
PRADAXA 110 MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PRADAXA 150 MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PRADAXA 75 MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PRALUENT 150 MG/ML PEN  |
5 |
Specialty Tier |
25% | N/A | P |
PRALUENT 75 MG/ML PEN  |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAMIPEXOLE 0.125 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
PRAMIPEXOLE 0.25 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
PRAMIPEXOLE 0.5 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
PRAMIPEXOLE 0.75 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
PRAMIPEXOLE 1 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
PRAMIPEXOLE 1.5 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
PRAMIPEXOLE ER 0.375 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
PRAMIPEXOLE ER 0.75 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
PRAMIPEXOLE ER 1.5 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
PRAMIPEXOLE ER 2.25 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
PRAMIPEXOLE ER 3 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAMIPEXOLE ER 3.75 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
PRAMIPEXOLE ER 4.5 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
PRANDIN 1 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:120 /30Days |
PRANDIN 2 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:240 /30Days |
PRASUGREL 10 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PRASUGREL 5 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PRAVACHOL 20MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
PRAVACHOL 40MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
PRAVACHOL 80MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
PRAVASTATIN SODIUM 10 MG TAB  |
1* |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
PRAVASTATIN SODIUM 20 MG TAB  |
1* |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAVASTATIN SODIUM 40 MG TAB  |
1* |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
PRAVASTATIN SODIUM 80 MG TAB  |
1* |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
PRAZOSIN 1 MG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PRAZOSIN 2 MG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PRAZOSIN 5MG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PRECOSE 50 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:90 /30Days |
PRECOSE TABLETS 100MG 100 BOT  |
4 |
Non-Preferred Drug |
37% | N/A | Q:90 /30Days |
PRECOSE TABLETS 25MG 100 BOT  |
4 |
Non-Preferred Drug |
37% | N/A | Q:90 /30Days |
PRED FORTE 1% EYE DROPS  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PRED MILD 0.12% EYE DROPS  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Prednicarbate 0.1% cream  |
4 |
Non-Preferred Drug |
37% | 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 |
37% | N/A | None |
Prednisolone 10 mg/5 ml soln  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PREDNISOLONE 15 MG/5 ML SOLN  |
2* |
Generic |
$3.00 | N/A | None |
PREDNISOLONE 20 MG/5 ML SOLN  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PREDNISOLONE AC 1% EYE DROP  |
2* |
Generic |
$3.00 | N/A | None |
Prednisolone odt 10 mg tablet  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Prednisolone odt 15 mg tablet  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Prednisolone odt 30 mg tablet  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PREDNISOLONE SOD 1% EYE DROP  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PREDNISOLONE SOD PH 25 MG/5 ML  |
2* |
Generic |
$3.00 | N/A | None |
PREDNISOLONE SODIUM PHOSPHATE 5MG /5ML ORAL SOLUTION  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISONE 1 MG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
Prednisone 10 MG Oral Tablet  |
1* |
Preferred Generic |
$0.00 | N/A | None |
PREDNISONE 10 MG TAB DOSE PACK  |
1* |
Preferred Generic |
$0.00 | N/A | None |
PREDNISONE 10 MG TAB DOSE PACK  |
1* |
Preferred Generic |
$0.00 | N/A | None |
PREDNISONE 2.5 MG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
Prednisone 20 MG Oral Tablet  |
1* |
Preferred Generic |
$0.00 | N/A | None |
PREDNISONE 5 MG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
PREDNISONE 5 MG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
PREDNISONE 5 MG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
PREDNISONE 5 MG/5 ML SOLUTION  |
1* |
Preferred Generic |
$0.00 | N/A | None |
PREDNISONE 50MG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISONE 5MG/ML SOLUTION  |
3 |
Preferred Brand |
$46.00 | N/A | P |
Premarin 0.625mg/g  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PREMASOL 10% IV SOLUTION  |
4 |
Non-Preferred Drug |
37% | N/A | P |
PREMASOL 6% IV SOLUTION  |
4 |
Non-Preferred Drug |
37% | N/A | P |
PREMPHASE 0.625-5 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | P |
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA  |
4 |
Non-Preferred Drug |
37% | N/A | P |
PREMPRO 0.45-1.5 MG TABLET 28 EA  |
4 |
Non-Preferred Drug |
37% | N/A | P |
PREMPRO 0.625-5 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | P |
Prempro 0.625; 2.5mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, SUGAR COATED per BLISTER PACK  |
4 |
Non-Preferred Drug |
37% | N/A | P |
PREPOPIK POWDER PACKET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PREVACID CAPSULES DELAYED RELEASE 15 MG  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREVACID CAPSULES DELAYED RELEASE 30 MG  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
PREVACID SOLUTAB EXTENDED RELEASE ORALLY DISINTEGRATING 30MG 100 BOXUD  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
PREVACID SOLUTAB TABLETS DELAYED RELEASE ORALLY DISINTEGRATING 15MG 100 BOXUD  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
PREVALITE PACKET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Previfem 6 BLISTER PACK per BLISTER PACK / 1 KIT per BLISTER PACK  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PREVPAC (TRIPLE THERAPY) KIT 30;500;500MG;MG;MG; 14 PKGCOM  |
4 |
Non-Preferred Drug |
37% | N/A | Q:224 /365Days |
PREZCOBIX 800 MG-150 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | None |
PREZISTA 100 MG/ML SUSPENSION  |
5 |
Specialty Tier |
25% | N/A | None |
PREZISTA 150MG TABLETS  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PREZISTA 800 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | None |
PREZISTA TABLET 600MG  |
5 |
Specialty Tier |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREZISTA TABLET 75MG  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PRIFTIN 150 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PRILOSEC DR 10 MG SUSPENSION  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:120 /30Days |
PRILOSEC DR 2.5 MG SUSPENSION  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:90 /30Days |
Primaquine Phosphate 26.3 MG Oral Tablet  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PRIMIDONE 250 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
PRIMIDONE 50 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
PRINIVIL 10MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PRINIVIL 20MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PRINIVIL 5MG TABLETS  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PRISTIQ 100MG TABLET SR 24HR  |
3 |
Preferred Brand |
$46.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRISTIQ ER 25 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | Q:30 /30Days |
PRISTIQ ER 50 MG TABLET ER 24H  |
3 |
Preferred Brand |
$46.00 | N/A | Q:30 /30Days |
PRIVIGEN 10% VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
PROBENECID 500 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PROBENECID/COLCHICINE 0.5MG/500MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
ProcalAmine 0.21; 0.29; 0.026; 0.014; 3; 0.42; 0.085; 0.21; 0.27; 0.22; 0.054; 0.16; 0.17; 0.041; 0  |
4 |
Non-Preferred Drug |
37% | N/A | P |
PROCARDIA 10MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | P |
PROCARDIA XL 30 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PROCARDIA XL 60 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PROCARDIA XL 90MG TABLET SA  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PROCENTRA 5 MG/5 ML SOLUTION  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:1800 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCHLORPERAZINE 10 MG TAB  |
2* |
Generic |
$3.00 | N/A | None |
Prochlorperazine 10 mg/2 ml vl  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PROCHLORPERAZINE 5 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX  |
2* |
Generic |
$3.00 | N/A | None |
PROCRIT 10000U/ML VIAL  |
3 |
Preferred Brand |
$46.00 | N/A | P |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL  |
3 |
Preferred Brand |
$46.00 | N/A | P |
PROCRIT 3,000 UNITS/ML VIAL  |
3 |
Preferred Brand |
$46.00 | N/A | P |
PROCRIT 4,000 UNITS/ML VIAL  |
3 |
Preferred Brand |
$46.00 | N/A | P |
PROCRIT 40000U/ML VIAL PR  |
5 |
Specialty Tier |
25% | N/A | P |
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY  |
5 |
Specialty Tier |
25% | N/A | P |
PROCTO-MED HC 2.5% CREAM  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
procto-pak 1% cream  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PROCTOSOL-HC 2.5% CREAM  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PROCTOZONE-HC 2.5% CREAM  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PROFENO 600 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PROGESTERONE 100 MG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PROGESTERONE 200 MG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PROGLYCEM 50 MG/ML ORAL SUSP  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PROGRAF 0.5MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | P |
PROGRAF 1MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | P |
PROGRAF 5 MG 1 BOTTLE per CARTON / 100 CAPSULE, GELATIN COATED in 1 BOTTLE  |
5 |
Specialty Tier |
25% | N/A | P |
PROGRAF 5MG/ML AMPULE  |
4 |
Non-Preferred Drug |
37% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROLASTIN C 1,000 MG VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
PROLENSA 0.07% EYE DROPS  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PROLEUKIN 22 MILLION UNIT VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
PROLIA 60MG/ML INJECTION  |
4 |
Non-Preferred Drug |
37% | N/A | Q:1 /166Days |
PROMACTA 12.5 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P Q:360 /30Days |
PROMACTA 25 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P Q:180 /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  |
2* |
Generic |
$3.00 | N/A | P |
PROMETHAZINE 25 MG TABLET  |
2* |
Generic |
$3.00 | N/A | P |
PROMETHAZINE 50 MG SUPPOSITORY  |
4 |
Non-Preferred Drug |
37% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMETHAZINE 50 MG TABLET  |
2* |
Generic |
$3.00 | N/A | P |
PROMETHAZINE 50 MG/ML AMPUL  |
4 |
Non-Preferred Drug |
37% | N/A | P |
PROMETHAZINE 6.25 MG/5 ML SYRUP [Prometh Plain] ![Compare how all Medicare Part D PDP plans in LA cover PROMETHAZINE 6.25 MG/5 ML SYRUP [Prometh Plain].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | P |
PROMETHAZINE HYDROCHLORIDE 25mg/mL 25 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE  |
4 |
Non-Preferred Drug |
37% | N/A | P |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX  |
4 |
Non-Preferred Drug |
37% | N/A | P |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX  |
4 |
Non-Preferred Drug |
37% | N/A | P |
PROMETHAZINE VC SYRUP  |
4 |
Non-Preferred Drug |
37% | N/A | P |
PROMETHEGAN 25MG SUPP  |
4 |
Non-Preferred Drug |
37% | N/A | P |
PROMETHEGAN 50MG SUPPOS  |
4 |
Non-Preferred Drug |
37% | N/A | P |
PROMETRIUM 100 MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PROMETRIUM 200 MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPAFENONE HCL 150 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PROPAFENONE HCL 225MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PROPAFENONE HCL 300 MG TAB  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PROPAFENONE HCL ER 225 MG CAP  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PROPAFENONE HYDROCHLORIDE 325MG CAPSULES EXTENDED RELEASE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PROPAFENONE HYDROCHLORIDE 425MG CAPSULES EXTENDED RELEASE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Proparacaine hydrochloride 5 MG/ML Ophthalmic Solution  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PROPRANOLOL 1 MG/ML VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PROPRANOLOL 10 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
PROPRANOLOL 20 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
PROPRANOLOL 20MG/5ML TUBEX  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPRANOLOL 40 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
PROPRANOLOL 40MG/5ML TUBEX  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PROPRANOLOL 60 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
PROPRANOLOL 80 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
PROPRANOLOL ER 120 MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PROPRANOLOL ER 160 MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PROPRANOLOL ER 60 MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PROPRANOLOL ER 80 MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PROPRANOLOL/HCTZ 40/25 TABLET  |
2* |
Generic |
$3.00 | N/A | None |
PROPRANOLOL/HCTZ 80/25 TABLET  |
2* |
Generic |
$3.00 | N/A | None |
PROPYLTHIOURACIL 50MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROQUAD VIAL  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PROSCAR TABLETS 5MG 30 BOT  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
PROSOL 20% INJECTION  |
4 |
Non-Preferred Drug |
37% | N/A | P |
PROTONIX 20MG TABLET EC  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
PROTONIX 40MG SUSP FOR RECON DELAYED REL. IN A PACKET  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
PROTONIX 40MG TABLET EC  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:60 /30Days |
Protonix I.V. 40mg/10mL 10 CARTON in 1 PACKAGE / 1 VIAL per CARTON / 40 mL in 1 VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | S |
PROTOPIC 0.03% OINTMENT  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:60 /30Days |
PROTOPIC 0.1% OINTMENT  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:60 /30Days |
PROTRIPTYLINE HCL 10 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PROTRIPTYLINE HCL 5 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROVERA 10 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PROVERA 2.5MG TABLET (100 CT)  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PROVERA 5MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PROVIGIL 100 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
PROVIGIL 200 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
PROZAC 10MG PULVULE  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
PROZAC 20 MG PULVULE  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:120 /30Days |
PROZAC 40MG PULVULE  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:60 /30Days |
Prudoxin 5% cream  |
4 |
Non-Preferred Drug |
37% | N/A | Q:45 /30Days |
PSORCON 0.05% CREAM  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PULMICORT .25MG/2ML RESPULE  |
4 |
Non-Preferred Drug |
37% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PULMICORT 1MG/2ML AMPUL FOR NEBULIZATION  |
4 |
Non-Preferred Drug |
37% | N/A | P |
PULMICORT FLEXHALER 180MCG AEROSOL POWDER BREATH ACTIVATED  |
3 |
Preferred Brand |
$46.00 | N/A | Q:2 /30Days |
PULMICORT FLEXHALER 90MCG AEROSOL POWDER BREATH ACTIVATED  |
3 |
Preferred Brand |
$46.00 | N/A | Q:2 /30Days |
PULMICORT RESPULES 0.5mg/2mL 6 POUCH per CARTON / 5 AMPULE in 1 POUCH / 2 mL in 1 AMPULE  |
4 |
Non-Preferred Drug |
37% | N/A | P |
PULMOZYME 1MG/ML AMPUL  |
5 |
Specialty Tier |
25% | N/A | P |
PURIXAN 20 MG/ML ORAL SUSP  |
5 |
Specialty Tier |
25% | N/A | None |
PYRAZINAMIDE 500 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
PYRIDOSTIGMINE BR 60 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
PYRIDOSTIGMINE BR ER 180 MG TAB  |
3 |
Preferred Brand |
$46.00 | N/A | None |