2018 Medicare Part D Plan Formulary Information |
Gateway Health Medicare Assured Prime (HMO) (H9190-018-0)
Benefit Details
|
The Gateway Health Medicare Assured Prime (HMO) (H9190-018-0) Formulary Drugs Starting with the Letter A in Grant County, KY: CMS MA Region 13 which includes: KY Plan Monthly Premium: $107.00 Deductible: $250 |
Drugs Starting with Letter A
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
ABACAVIR 20 MG/ML SOLUTION |
2* |
Generic |
$20.00 | N/A | None |
ABACAVIR 300 MG TABLET |
2* |
Generic |
$20.00 | N/A | None |
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir] |
1* |
Preferred Generic |
$0.00 | N/A | None |
ABACAVIR-LAMIVUDINE 600-300 MG |
2* |
Generic |
$20.00 | N/A | None |
ABILIFY MAINTENA ER 300 MG SYR |
5 |
Specialty Tier |
28% | N/A | P Q:1 /28Days |
ABILIFY MAINTENA ER 300 MG VL |
5 |
Specialty Tier |
28% | N/A | P Q:1 /28Days |
ABILIFY MAINTENA ER 400 MG SUSER VIAL |
5 |
Specialty Tier |
28% | N/A | P Q:1 /28Days |
ABILIFY MAINTENA ER 400 MG SYR |
5 |
Specialty Tier |
28% | N/A | P Q:1 /28Days |
ABRAXANE 100MG VIAL |
5 |
Specialty Tier |
28% | N/A | P |
Acamprosate Calcium DR 333 MG tablets [Campral] |
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 |
ACARBOSE 100 MG TABLET |
1* |
Preferred Generic |
$0.00 | N/A | Q:90 /30Days |
ACARBOSE 25 MG TABLET |
1* |
Preferred Generic |
$0.00 | N/A | None |
ACARBOSE 50 MG TABLET |
1* |
Preferred Generic |
$0.00 | N/A | Q:90 /30Days |
ACEBUTOLOL 200 MG CAPSULE |
2* |
Generic |
$20.00 | N/A | None |
ACEBUTOLOL 400 MG CAPSULE |
2* |
Generic |
$20.00 | N/A | None |
ACETAMINOP-CODEINE 120-12 MG/5 |
2* |
Generic |
$20.00 | N/A | Q:2700 /30Days |
Acetaminophen 325 MG / Hydrocodone Bitartrate 5 MG Oral Tablet [Lorcet] |
2* |
Generic |
$20.00 | N/A | Q:180 /30Days |
ACETAMINOPHEN-COD #2 TABLET |
2* |
Generic |
$20.00 | N/A | Q:180 /30Days |
ACETAMINOPHEN-COD #3 TABLET |
2* |
Generic |
$20.00 | N/A | Q:180 /30Days |
ACETAMINOPHEN-COD #4 TABLET |
2* |
Generic |
$20.00 | N/A | Q:180 /30Days |
ACETAZOLAMIDE 125MG TABLET |
2* |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
2* |
Generic |
$20.00 | N/A | None |
ACETAZOLAMIDE ER 500 MG CAP |
2* |
Generic |
$20.00 | N/A | None |
ACETIC ACID 2% EAR SOLUTION |
2* |
Generic |
$20.00 | N/A | None |
ACETYLCYSTEINE 10% VIAL |
2* |
Generic |
$20.00 | N/A | P |
Acetylcysteine 200 MG/ML Inhalant Solution |
2* |
Generic |
$20.00 | N/A | P |
ACITRETIN 10 MG CAPSULE [Soriatane] |
5 |
Specialty Tier |
28% | N/A | P |
ACITRETIN 17.5 MG CAPSULE [Soriatane] |
5 |
Specialty Tier |
28% | N/A | P |
ACITRETIN 25 MG CAPSULE [Soriatane] |
5 |
Specialty Tier |
28% | N/A | P |
ACTHIB VACCINE WITH DILUENT |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
ACTIMMUNE 100 MCG/0.5 ML VIAL |
5 |
Specialty Tier |
28% | N/A | P |
ACYCLOVIR 200 MG CAPSULE |
2* |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACYCLOVIR 200 MG/5 ML SUSP |
2* |
Generic |
$20.00 | N/A | None |
ACYCLOVIR 400 MG TABLET |
2* |
Generic |
$20.00 | N/A | None |
Acyclovir 5% Ointment |
2* |
Generic |
$20.00 | N/A | None |
ACYCLOVIR 800 MG TABLET |
2* |
Generic |
$20.00 | N/A | None |
Acyclovir sodium 500 mg vial |
2* |
Generic |
$20.00 | N/A | P |
ADACEL TDAP SYRINGE |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
ADACEL VIAL 2UNT/5UNT |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
ADAGEN 250U/ML VIAL |
3 |
Preferred Brand |
$45.00 | N/A | P |
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA] |
5 |
Specialty Tier |
28% | N/A | P Q:12 /28Days |
ADAPALENE 0.1% CREAM |
2* |
Generic |
$20.00 | N/A | None |
ADAPALENE 0.1% GEL |
2* |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Adapalene 0.3% gel |
1* |
Preferred Generic |
$0.00 | N/A | None |
ADCIRCA TABLETS 20MG 60 BOTTLE |
5 |
Specialty Tier |
28% | N/A | P Q:60 /30Days |
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera] |
2* |
Generic |
$20.00 | N/A | Q:30 /30Days |
ADEMPAS 0.5 MG TABLET |
5 |
Specialty Tier |
28% | N/A | P |
ADEMPAS 1 MG TABLET |
5 |
Specialty Tier |
28% | N/A | P |
ADEMPAS 1.5 MG TABLET |
5 |
Specialty Tier |
28% | N/A | P |
ADEMPAS 2 MG TABLET |
5 |
Specialty Tier |
28% | N/A | P |
ADEMPAS 2.5 MG TABLET |
5 |
Specialty Tier |
28% | N/A | P |
Adriamycin 20 mg/10 ml vial |
2* |
Generic |
$20.00 | N/A | P |
ADRUCIL 50mg/mL 10 VIAL in 1 TRAY / 10 mL in 1 VIAL |
2* |
Generic |
$20.00 | N/A | P |
ADVAIR DISKUS MIS 100/50 |
3 |
Preferred Brand |
$45.00 | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADVAIR DISKUS MIS 250/50 |
3 |
Preferred Brand |
$45.00 | N/A | Q:60 /30Days |
ADVAIR DISKUS MIS 500/50 |
3 |
Preferred Brand |
$45.00 | N/A | Q:60 /30Days |
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$45.00 | N/A | Q:60 /30Days |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL |
3 |
Preferred Brand |
$45.00 | N/A | Q:60 /30Days |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
3 |
Preferred Brand |
$45.00 | N/A | Q:60 /30Days |
AFEDITAB CR 30MG TABLET SA |
1* |
Preferred Generic |
$0.00 | N/A | None |
AFEDITAB CR 60MG TABLET SA |
1* |
Preferred Generic |
$0.00 | N/A | None |
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK |
5 |
Specialty Tier |
28% | N/A | P Q:60 /30Days |
AFINITOR DISPERZ 2 MG TABLET |
5 |
Specialty Tier |
28% | N/A | P Q:60 /30Days |
AFINITOR DISPERZ 3 MG TABLET |
5 |
Specialty Tier |
28% | N/A | P Q:60 /30Days |
AFINITOR DISPERZ 5 MG TABLET |
5 |
Specialty Tier |
28% | N/A | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AFINITOR TABLETS 10 MG |
5 |
Specialty Tier |
28% | N/A | P Q:60 /30Days |
AFINITOR TABLETS 2.5 MG |
5 |
Specialty Tier |
28% | N/A | P Q:60 /30Days |
AFINITOR TABLETS 5 MG |
5 |
Specialty Tier |
28% | N/A | P Q:60 /30Days |
Ala-cort 2.5% cream |
1* |
Preferred Generic |
$0.00 | N/A | None |
ALBENZA 200 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | None |
ALBUTEROL SUL 2.5 MG/3 ML SOLN |
1* |
Preferred Generic |
$0.00 | N/A | P Q:375 /30Days |
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH per CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL |
1* |
Preferred Generic |
$0.00 | N/A | P Q:375 /30Days |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
1* |
Preferred Generic |
$0.00 | N/A | P Q:375 /30Days |
ALBUTEROL SULFATE 2 MG TAB |
1* |
Preferred Generic |
$0.00 | N/A | None |
ALBUTEROL SULFATE 4 MG TAB |
1* |
Preferred Generic |
$0.00 | N/A | None |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
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 |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
1* |
Preferred Generic |
$0.00 | N/A | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
1* |
Preferred Generic |
$0.00 | N/A | P Q:80 /30Days |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
1* |
Preferred Generic |
$0.00 | N/A | None |
ALDURAZYME 2.9MG/5ML VIAL |
5 |
Specialty Tier |
28% | N/A | P |
ALECENSA 150 MG CAPSULE |
5 |
Specialty Tier |
28% | N/A | P |
ALENDRONATE SODIUM 10 MG TAB |
1* |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
ALENDRONATE SODIUM 35 MG TAB |
1* |
Preferred Generic |
$0.00 | N/A | Q:4 /28Days |
ALENDRONATE SODIUM 40 MG TABLET |
1* |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
ALENDRONATE SODIUM 5 MG TABLET |
1* |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
ALENDRONATE SODIUM 70 MG TAB |
1* |
Preferred Generic |
$0.00 | N/A | None |
ALENDRONATE SODIUM 70 MG/75 ML |
2* |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALFUZOSIN HCL ER 10 MG TABLET |
2* |
Generic |
$20.00 | N/A | None |
ALIMTA 100 MG VIAL |
5 |
Specialty Tier |
28% | N/A | P |
ALIMTA 500 MG VIAL |
5 |
Specialty Tier |
28% | N/A | P |
ALINIA 100 MG/5 ML SUSPENSION |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
ALINIA 500 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
ALIQOPA 60 MG VIAL |
5 |
Specialty Tier |
28% | N/A | P Q:3 /28Days |
ALLOPURINOL 100 MG TABLET |
1* |
Preferred Generic |
$0.00 | N/A | None |
ALLOPURINOL 300 MG TABLET |
1* |
Preferred Generic |
$0.00 | N/A | None |
ALOSETRON HCL 0.5 MG TABLET [Lotronex] |
2* |
Generic |
$20.00 | N/A | P |
ALOSETRON HCL 1 MG TABLET [Lotronex] |
2* |
Generic |
$20.00 | N/A | P |
ALPHAGAN P 0.1% DROPS |
3 |
Preferred Brand |
$45.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALPRAZOLAM 0.25 MG TABLET |
2* |
Generic |
$20.00 | N/A | Q:120 /30Days |
ALPRAZOLAM 0.5 MG TABLET |
2* |
Generic |
$20.00 | N/A | Q:120 /30Days |
ALPRAZOLAM 1 MG TABLET |
2* |
Generic |
$20.00 | N/A | Q:120 /30Days |
Alprazolam 1mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
2* |
Generic |
$20.00 | N/A | Q:120 /30Days |
Alprazolam 1mg/mL 1 BOTTLE in 1 CONTAINER / 30 mL in 1 BOTTLE |
2* |
Generic |
$20.00 | N/A | Q:300 /30Days |
ALPRAZOLAM 2 MG TABLET |
2* |
Generic |
$20.00 | N/A | Q:150 /30Days |
Alprazolam 2mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING per BLISTER PACK |
2* |
Generic |
$20.00 | N/A | Q:150 /30Days |
ALPRAZOLAM ER 0.5 MG TABLET |
2* |
Generic |
$20.00 | N/A | Q:90 /30Days |
ALPRAZOLAM ER 1 MG TABLET |
2* |
Generic |
$20.00 | N/A | Q:90 /30Days |
ALPRAZOLAM ER 2 MG TABLET |
2* |
Generic |
$20.00 | N/A | Q:90 /30Days |
ALPRAZOLAM ER 3 MG TABLET |
2* |
Generic |
$20.00 | N/A | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALPRAZOLAM ODT 0.25 MG TABLET |
2* |
Generic |
$20.00 | N/A | Q:120 /30Days |
ALPRAZOLAM ODT 0.5 MG TABLET |
2* |
Generic |
$20.00 | N/A | Q:120 /30Days |
ALTAVERA-28 TABLET |
2* |
Generic |
$20.00 | N/A | None |
ALUNBRIG 180 MG TABLET |
5 |
Specialty Tier |
28% | N/A | P |
ALUNBRIG 30 MG TABLET |
5 |
Specialty Tier |
28% | N/A | P |
ALUNBRIG 90 MG TABLET |
5 |
Specialty Tier |
28% | N/A | P |
ALUNBRIG 90 MG-180 MG TABLET PACK |
5 |
Specialty Tier |
28% | N/A | P |
ALYACEN 1-35-28 TABLET |
2* |
Generic |
$20.00 | N/A | None |
AMANTADINE 100 MG CAPSULE |
2* |
Generic |
$20.00 | N/A | None |
AMANTADINE 100 MG TABLET |
2* |
Generic |
$20.00 | N/A | None |
AMANTADINE 50 MG/5 ML SOLUTION |
2* |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMBISOME 50MG VIAL |
5 |
Specialty Tier |
28% | N/A | P |
AMIKACIN SULF 500 MG/2 ML VIAL |
2* |
Generic |
$20.00 | N/A | None |
AMILORIDE HCL 5 MG TABLET |
2* |
Generic |
$20.00 | N/A | None |
AMILORIDE HCL-HCTZ 5-50 MG TABLET |
2* |
Generic |
$20.00 | N/A | None |
Aminophylline 25 MG/ML 10 ML Injection |
2* |
Generic |
$20.00 | N/A | None |
AMINOSYN HBC INJECTION SULFITE FREE 7% |
3 |
Preferred Brand |
$45.00 | N/A | P |
AMINOSYN II 10% SOL 6X2000 ML |
3 |
Preferred Brand |
$45.00 | N/A | P |
AMINOSYN II 15% IV SOLUTION |
3 |
Preferred Brand |
$45.00 | N/A | P |
AMINOSYN II 8.5% ELECTROLYT |
3 |
Preferred Brand |
$45.00 | N/A | P |
AMINOSYN II 8.5% ELECTROLYT |
3 |
Preferred Brand |
$45.00 | N/A | P |
AMINOSYN PF INJECTION |
3 |
Preferred Brand |
$45.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5% |
3 |
Preferred Brand |
$45.00 | N/A | P |
AMINOSYN-PF 7% IV SOLUTION |
3 |
Preferred Brand |
$45.00 | N/A | P |
AMIODARONE HCL 100 MG TABLET |
2* |
Generic |
$20.00 | N/A | None |
AMIODARONE HCL 200 MG TABLET |
2* |
Generic |
$20.00 | N/A | None |
AMIODARONE HCL 400 MG TABLET |
2* |
Generic |
$20.00 | N/A | None |
AMIODARONE HCL 50 MG/ML in 3 ML Injection |
2* |
Generic |
$20.00 | N/A | None |
AMITIZA 8MCG CAPSULE |
3 |
Preferred Brand |
$45.00 | N/A | Q:60 /30Days |
AMITIZA CAPSULES 24MCG 60 CAP BOT |
3 |
Preferred Brand |
$45.00 | N/A | Q:60 /30Days |
AMITRIPTYLINE HCL 10 MG TAB |
1* |
Preferred Generic |
$0.00 | N/A | P |
AMITRIPTYLINE HCL 100 MG TAB |
1* |
Preferred Generic |
$0.00 | N/A | P |
AMITRIPTYLINE HCL 150 MG TAB |
1* |
Preferred Generic |
$0.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIPTYLINE HCL 25 MG TAB |
1* |
Preferred Generic |
$0.00 | N/A | P |
AMITRIPTYLINE HCL 50 MG TAB |
1* |
Preferred Generic |
$0.00 | N/A | P |
AMITRIPTYLINE HCL 75 MG TAB |
1* |
Preferred Generic |
$0.00 | N/A | P |
AMLODIPINE BESYLATE 10 MG TAB |
1* |
Preferred Generic |
$0.00 | N/A | None |
AMLODIPINE BESYLATE 2.5 MG TAB |
1* |
Preferred Generic |
$0.00 | N/A | None |
AMLODIPINE BESYLATE 5 MG TAB |
1* |
Preferred Generic |
$0.00 | N/A | None |
AMLODIPINE-BENAZEPRIL 10-20 MG Capsule [Lotrel] |
2* |
Generic |
$20.00 | N/A | None |
AMLODIPINE-BENAZEPRIL 10-40 MG Capsule [Lotrel] |
2* |
Generic |
$20.00 | N/A | None |
AMLODIPINE-BENAZEPRIL 2.5-10 Capsule [Lotrel] |
2* |
Generic |
$20.00 | N/A | None |
AMLODIPINE-BENAZEPRIL 5-10 MG Capsule [Lotrel] |
2* |
Generic |
$20.00 | N/A | None |
AMLODIPINE-BENAZEPRIL 5-20 MG Capsule [Lotrel] |
2* |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE-BENAZEPRIL 5-40 MG Capsule [Lotrel] |
2* |
Generic |
$20.00 | N/A | None |
AMLODIPINE-OLMESARTAN 10-20 MG [Azor] |
2* |
Generic |
$20.00 | N/A | None |
AMLODIPINE-OLMESARTAN 10-40 MG [Azor] |
2* |
Generic |
$20.00 | N/A | None |
AMLODIPINE-OLMESARTAN 5-20 MG [Azor] |
2* |
Generic |
$20.00 | N/A | None |
AMLODIPINE-OLMESARTAN 5-40 MG [Azor] |
2* |
Generic |
$20.00 | N/A | None |
AMMONIUM LACTATE 12% CREAM |
2* |
Generic |
$20.00 | N/A | None |
AMMONIUM LACTATE 12% LOTION |
2* |
Generic |
$20.00 | N/A | None |
AMNESTEEM 10 MG CAPSULE |
2* |
Generic |
$20.00 | N/A | None |
AMNESTEEM 20 MG CAPSULE |
2* |
Generic |
$20.00 | N/A | None |
AMNESTEEM 40 MG CAPSULE |
2* |
Generic |
$20.00 | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE [Augmentin] |
2* |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin] |
2* |
Generic |
$20.00 | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE [Augmentin] |
2* |
Generic |
$20.00 | N/A | None |
AMOX-CLAV 200-28.5 MG/5 ML SUS |
2* |
Generic |
$20.00 | N/A | None |
AMOX-CLAV 250-62.5 MG/5 ML SUS |
2* |
Generic |
$20.00 | N/A | None |
AMOX-CLAV 400-57 MG/5 ML SUSP |
2* |
Generic |
$20.00 | N/A | None |
AMOX-CLAV 500-125 MG TABLET [Augmentin] |
2* |
Generic |
$20.00 | N/A | None |
AMOX-CLAV 600-42.9 MG/5 ML SUS |
2* |
Generic |
$20.00 | N/A | None |
AMOX-CLAV 875-125 MG TABLET [Augmentin] |
2* |
Generic |
$20.00 | N/A | None |
AMOX-CLAV ER 1,000-62.5 MG TABLET [Augmentin] |
2* |
Generic |
$20.00 | N/A | None |
AMOXAPINE 100MG TABLET |
2* |
Generic |
$20.00 | N/A | P |
AMOXAPINE 150MG TABLET |
2* |
Generic |
$20.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXAPINE 25MG TABLET |
2* |
Generic |
$20.00 | N/A | P |
AMOXAPINE 50MG TABLET |
2* |
Generic |
$20.00 | N/A | P |
AMOXICILLIN 125 MG/5 ML SUSP |
1* |
Preferred Generic |
$0.00 | N/A | None |
AMOXICILLIN 125MG TABLET CHEW |
1* |
Preferred Generic |
$0.00 | N/A | None |
AMOXICILLIN 200 MG/5 ML SUSP |
1* |
Preferred Generic |
$0.00 | N/A | None |
AMOXICILLIN 250 MG CAPSULE |
1* |
Preferred Generic |
$0.00 | N/A | None |
AMOXICILLIN 250 MG TAB CHEW |
1* |
Preferred Generic |
$0.00 | N/A | None |
AMOXICILLIN 250 MG/5 ML SUSP |
1* |
Preferred Generic |
$0.00 | N/A | None |
AMOXICILLIN 400 MG/5 ML SUSP |
1* |
Preferred Generic |
$0.00 | N/A | None |
AMOXICILLIN 500 MG CAPSULE |
1* |
Preferred Generic |
$0.00 | N/A | None |
AMOXICILLIN 500 MG 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 |
AMOXICILLIN 875 MG TABLET |
1* |
Preferred Generic |
$0.00 | N/A | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
2* |
Generic |
$20.00 | N/A | Q:60 /30Days |
AMPHETAMINE SALT COMBO 15MG TABLET |
2* |
Generic |
$20.00 | N/A | Q:60 /30Days |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
2* |
Generic |
$20.00 | N/A | Q:60 /30Days |
AMPHETAMINE SALTS 5 MG TAB |
2* |
Generic |
$20.00 | N/A | Q:60 /30Days |
amphotericin b 50mg/10mL 10 mL in 1 VIAL |
2* |
Generic |
$20.00 | N/A | P |
AMPICILLIN 10 GM VIAL |
2* |
Generic |
$20.00 | N/A | None |
Ampicillin 1000 MG / Sulbactam 500 MG Injection |
2* |
Generic |
$20.00 | N/A | None |
Ampicillin 1000 MG Injection |
2* |
Generic |
$20.00 | N/A | None |
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS |
2* |
Generic |
$20.00 | N/A | None |
Ampicillin 2000 MG / Sulbactam 1000 MG Injection |
2* |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN CAPSULES 500MG 100 BOT |
1* |
Preferred Generic |
$0.00 | N/A | None |
AMPICILLIN-SULBACTAM 15 GM VL |
2* |
Generic |
$20.00 | N/A | None |
AMPYRA ER 10 MG TABLET |
5 |
Specialty Tier |
28% | N/A | P Q:60 /30Days |
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE |
2* |
Generic |
$20.00 | N/A | None |
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE |
2* |
Generic |
$20.00 | N/A | None |
ANASTROZOLE 1 MG TABLET |
2* |
Generic |
$20.00 | N/A | Q:30 /30Days |
ANORO ELLIPTA 62.5-25 MCG INH |
3 |
Preferred Brand |
$45.00 | N/A | Q:60 /30Days |
Antineoplastic Agent Etoposide 20 mg / mL Intravenous Injection Multiple Dose Vial 5 mL |
2* |
Generic |
$20.00 | N/A | P |
APOKYN 30 MG/3 ML CARTRIDGE |
5 |
Specialty Tier |
28% | N/A | None |
Apraclonidine 5 MG/ML Ophthalmic Solution |
2* |
Generic |
$20.00 | N/A | None |
APREPITANT 125 MG CAPSULE [Emend] |
2* |
Generic |
$20.00 | N/A | P Q:2 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APREPITANT 125-80-80 MG PACK [Emend] |
2* |
Generic |
$20.00 | N/A | P Q:6 /30Days |
APREPITANT 40 MG CAPSULE [Emend] |
2* |
Generic |
$20.00 | N/A | P Q:4 /30Days |
APREPITANT 80 MG CAPSULE [Emend] |
2* |
Generic |
$20.00 | N/A | P Q:4 /30Days |
APRI 0.15-0.03 TABLET |
2* |
Generic |
$20.00 | N/A | None |
APRISO CP24 |
3 |
Preferred Brand |
$45.00 | N/A | Q:120 /30Days |
APTIOM 200 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | Q:30 /30Days |
APTIOM 400 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | Q:30 /30Days |
APTIOM 600 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | Q:60 /30Days |
APTIOM 800 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | Q:30 /30Days |
APTIVUS 250MG CAPSULE |
3 |
Preferred Brand |
$45.00 | N/A | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
3 |
Preferred Brand |
$45.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARCALYST INJECTION 220MG/VIAL |
5 |
Specialty Tier |
28% | N/A | P |
ARIPIPRAZOLE 1 MG/ML SOLUTION [Abilify] |
2* |
Generic |
$20.00 | N/A | Q:750 /30Days |
ARIPIPRAZOLE 10 MG TABLET [Abilify] |
2* |
Generic |
$20.00 | N/A | Q:90 /30Days |
ARIPIPRAZOLE 15 MG TABLET [Abilify] |
2* |
Generic |
$20.00 | N/A | Q:60 /30Days |
ARIPIPRAZOLE 2 MG TABLET [Abilify] |
2* |
Generic |
$20.00 | N/A | Q:60 /30Days |
ARIPIPRAZOLE 20 MG TABLET [Abilify] |
2* |
Generic |
$20.00 | N/A | Q:30 /30Days |
ARIPIPRAZOLE 30 MG TABLET [Abilify] |
2* |
Generic |
$20.00 | N/A | Q:30 /30Days |
ARIPIPRAZOLE 5 MG TABLET [Abilify] |
2* |
Generic |
$20.00 | N/A | Q:60 /30Days |
ARIPIPRAZOLE ODT 10 MG TABLET [Abilify] |
2* |
Generic |
$20.00 | N/A | Q:90 /30Days |
ARIPIPRAZOLE ODT 15 MG TABLET [Abilify] |
2* |
Generic |
$20.00 | N/A | Q:60 /30Days |
ARISTADA ER 1064 MG/3.9 ML SYR |
5 |
Specialty Tier |
28% | N/A | Q:4 /56Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARISTADA ER 441 MG/1.6 ML SYRN |
5 |
Specialty Tier |
28% | N/A | Q:2 /28Days |
ARISTADA ER 662 MG/2.4 ML SYRN |
5 |
Specialty Tier |
28% | N/A | Q:2 /28Days |
ARISTADA ER 882 MG/3.2 ML SYRN |
5 |
Specialty Tier |
28% | N/A | Q:3 /28Days |
ARNUITY ELLIPTA 100 MCG INH |
3 |
Preferred Brand |
$45.00 | N/A | Q:30 /30Days |
ARNUITY ELLIPTA 200 MCG INH |
3 |
Preferred Brand |
$45.00 | N/A | Q:30 /30Days |
ARNUITY ELLIPTA 50 MCG INH BLST W/DEV |
3 |
Preferred Brand |
$45.00 | N/A | Q:30 /30Days |
ARRANON 250 MG VIAL |
5 |
Specialty Tier |
28% | N/A | P |
ASMANEX HFA 100 MCG INHALER |
3 |
Preferred Brand |
$45.00 | N/A | Q:13 /30Days |
ASMANEX HFA 200 MCG INHALER |
3 |
Preferred Brand |
$45.00 | N/A | Q:13 /30Days |
ASMANEX TWISTHALER 110 MCG #30 |
3 |
Preferred Brand |
$45.00 | N/A | Q:30 /30Days |
ASMANEX TWISTHALER 220 MCG #30 |
3 |
Preferred Brand |
$45.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ASMANEX TWISTHALER 220MCG #120 |
3 |
Preferred Brand |
$45.00 | N/A | Q:120 /30Days |
ASMANEX TWISTHALER 220MCG #60 |
3 |
Preferred Brand |
$45.00 | N/A | Q:60 /30Days |
Aspirin-Diphenhydramine ER 25-200 MG |
1* |
Preferred Generic |
$0.00 | N/A | Q:60 /30Days |
ATAZANAVIR SULFATE 150 MG CAP [Reyataz] |
2* |
Generic |
$20.00 | N/A | None |
ATAZANAVIR SULFATE 200 MG CAP [Reyataz] |
2* |
Generic |
$20.00 | N/A | None |
ATAZANAVIR SULFATE 300 MG CAP [Reyataz] |
2* |
Generic |
$20.00 | N/A | None |
ATENOLOL 100 MG TABLET |
1* |
Preferred Generic |
$0.00 | N/A | None |
ATENOLOL 25 MG TABLET |
1* |
Preferred Generic |
$0.00 | N/A | None |
ATENOLOL 50 MG TABLET |
1* |
Preferred Generic |
$0.00 | N/A | None |
ATENOLOL-CHLORTHALIDONE 100-25 |
1* |
Preferred Generic |
$0.00 | N/A | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
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 |
ATGAM 50MG/ML AMPUL |
5 |
Specialty Tier |
28% | N/A | P |
ATOMOXETINE HCL 10 MG CAPSULE [Strattera] |
2* |
Generic |
$20.00 | N/A | None |
ATOMOXETINE HCL 100 MG CAPSULE [Strattera] |
2* |
Generic |
$20.00 | N/A | None |
ATOMOXETINE HCL 18 MG CAPSULE [Strattera] |
2* |
Generic |
$20.00 | N/A | None |
ATOMOXETINE HCL 25 MG CAPSULE [Strattera] |
2* |
Generic |
$20.00 | N/A | None |
ATOMOXETINE HCL 40 MG CAPSULE [Strattera] |
2* |
Generic |
$20.00 | N/A | None |
ATOMOXETINE HCL 60 MG CAPSULE [Strattera] |
2* |
Generic |
$20.00 | N/A | None |
ATOMOXETINE HCL 80 MG CAPSULE [Strattera] |
2* |
Generic |
$20.00 | N/A | None |
ATORVASTATIN 10 MG TABLET [Lipitor] |
2* |
Generic |
$20.00 | N/A | None |
ATORVASTATIN 20 MG TABLET [Lipitor] |
2* |
Generic |
$20.00 | N/A | None |
ATORVASTATIN 40 MG TABLET [Lipitor] |
2* |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATORVASTATIN 80 MG TABLET [Lipitor] |
2* |
Generic |
$20.00 | N/A | None |
ATOVAQUONE 750 MG/5 ML SUSP [Mepron] |
5 |
Specialty Tier |
28% | N/A | None |
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone] |
2* |
Generic |
$20.00 | N/A | None |
ATOVAQUONE-PROGUANIL 62.5-25 [Malarone] |
1* |
Preferred Generic |
$0.00 | N/A | None |
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Preferred Brand |
$45.00 | N/A | None |
ATROVENT HFA AER 17MCG |
3 |
Preferred Brand |
$45.00 | N/A | Q:52 /30Days |
AUBRA-28 TABLET |
2* |
Generic |
$20.00 | N/A | None |
AVANDIA 2 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:30 /30Days |
AVANDIA 4 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:60 /30Days |
AVASTIN 100MG/4ML VIAL |
5 |
Specialty Tier |
28% | N/A | P |
AVASTIN 400 MG/16 ML VIAL |
5 |
Specialty Tier |
28% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVELOX IV 400 MG/250 ML |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
AVIANE 0.1-0.02 TABLET |
2* |
Generic |
$20.00 | N/A | None |
AVITA 0.025% CREAM |
2* |
Generic |
$20.00 | N/A | None |
Avita 0.25mg/g 45 g in 1 TUBE |
2* |
Generic |
$20.00 | N/A | None |
AVONEX ADMIN PACK 30 MCG VL |
5 |
Specialty Tier |
28% | N/A | P Q:4 /30Days |
AVONEX PEN 30 MCG/0.5 ML KIT |
5 |
Specialty Tier |
28% | N/A | P Q:4 /30Days |
AVONEX PREFILLED SYR 30 MCG KT |
5 |
Specialty Tier |
28% | N/A | P Q:4 /30Days |
Azacitidine 100 mg vial [Vidaza] |
5 |
Specialty Tier |
28% | N/A | P |
AZATHIOPRINE 50 MG TABLET |
2* |
Generic |
$20.00 | N/A | P |
AZATHIOPRINE SODIUM 100 MG VIAL |
2* |
Generic |
$20.00 | N/A | P |
AZELASTINE 0.15% NASAL SPRAY |
2* |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZELASTINE 137 MCG NASAL SPRAY |
2* |
Generic |
$20.00 | N/A | None |
AZITHROMYCIN 100 MG/5 ML SUSP |
2* |
Generic |
$20.00 | N/A | None |
AZITHROMYCIN 200 MG/5 ML SUSP |
2* |
Generic |
$20.00 | N/A | None |
AZITHROMYCIN 250 MG TABLET |
2* |
Generic |
$20.00 | N/A | None |
AZITHROMYCIN 250 MG TABLET |
2* |
Generic |
$20.00 | N/A | None |
AZITHROMYCIN 500 MG TABLET |
2* |
Generic |
$20.00 | N/A | None |
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE |
2* |
Generic |
$20.00 | N/A | None |
AZITHROMYCIN 600 MG TABLET |
2* |
Generic |
$20.00 | N/A | None |
AZITHROMYCIN I.V. 500 MG VIAL |
2* |
Generic |
$20.00 | N/A | None |
AZOPT 1% EYE DROPS |
3 |
Preferred Brand |
$45.00 | N/A | None |
Aztreonam 1000 MG Injection [Azactam] |
3 |
Preferred Brand |
$45.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Aztreonam 2000 MG Injection [Azactam] |
3 |
Preferred Brand |
$45.00 | N/A | None |
AZTREONAM FOR INJECTION |
1* |
Preferred Generic |
$0.00 | N/A | None |