2019 Medicare Part D Plan Formulary Information |
Blue Advantage Complete (PPO) (H0104-012-0)
Benefit Details
|
The Blue Advantage Complete (PPO) (H0104-012-0) Formulary Drugs Starting with the Letter P in Henry County, AL: CMS MA Region 10 which includes: AL Plan Monthly Premium: $0.00 Deductible: $100 |
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 200 MG TABLET |
2* |
Generic |
$13.00 | $26.00 | None |
PACERONE 400MG TABLET |
2* |
Generic |
$13.00 | $26.00 | None |
PALIPERIDONE ER 1.5 MG TABLET [INVEGA] |
4 |
Non-Preferred Drug |
45% | 45% | P Q:30 /30Days |
PALIPERIDONE ER 3 MG TABLET [INVEGA] |
4 |
Non-Preferred Drug |
45% | 45% | P Q:30 /30Days |
PALIPERIDONE ER 6 MG TABLET [INVEGA] |
4 |
Non-Preferred Drug |
45% | 45% | P Q:60 /30Days |
PALIPERIDONE ER 9 MG TABLET [INVEGA] |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
PALYNZIQ 10 MG/0.5 ML SYRINGE |
5 |
Specialty Tier |
25% | 25% | P |
PALYNZIQ 2.5 MG/0.5 ML SYRINGE |
5 |
Specialty Tier |
25% | 25% | P |
PALYNZIQ 20 MG/ML SYRINGE |
5 |
Specialty Tier |
25% | 25% | P |
PANRETIN 0.1% GEL 60GM TUBE |
5 |
Specialty Tier |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PANTOPRAZOLE SOD DR 20 MG TAB |
1* |
Preferred Generic |
$3.00 | $6.00 | Q:30 /30Days |
PANTOPRAZOLE SOD DR 40 MG TAB |
1* |
Preferred Generic |
$3.00 | $6.00 | Q:60 /30Days |
PARICALCITOL 1 MCG CAPSULE [Zemplar] |
2* |
Generic |
$13.00 | $26.00 | None |
PARICALCITOL 2 MCG CAPSULE [Zemplar] |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PARICALCITOL 4 MCG CAPSULE [Zemplar] |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PAROMOMYCIN 250 MG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | None |
PAROXETINE HCL 10 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | P Q:45 /30Days |
PAROXETINE HCL 20 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | P Q:30 /30Days |
PAROXETINE HCL 30 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | P Q:60 /30Days |
PAROXETINE HCL 40 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | P Q:45 /30Days |
PASER GRANULES 4GM PACKET |
4 |
Non-Preferred Drug |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAXIL ORAL SUSPENSION 10 MG/5ML |
4 |
Non-Preferred Drug |
45% | 45% | P Q:900 /30Days |
PAZEO 0.7% EYE DROPS |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PEDVAXHIB VACCINE VIAL |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PEG 3350 ELECTROLYTE SOLN SOLN RECON [GaviLyte-C] |
2* |
Generic |
$13.00 | $26.00 | None |
PEG 3350-ELECTROLYTE SOLUTION SOLN RECON |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PEG-3350 AND ELECTROLYTES SOLN SOLN RECON |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PEGANONE 250 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | 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% | 25% | P |
PEGASYS INJECTION |
5 |
Specialty Tier |
25% | 25% | P |
PEGASYS PROCLICK 180 MCG/0.5 |
5 |
Specialty Tier |
25% | 25% | P |
PENICILLIN G POTASSIUM 2MMUNITS/50ML ISO-OSM |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENICILLIN G POTASSIUM 3MMUNITS/50ML ISO-OSM |
4 |
Non-Preferred Drug |
45% | 45% | None |
Penicillin G Sodium 5000000[iU]/1 10 VIAL per CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL |
4 |
Non-Preferred Drug |
45% | 45% | None |
PENICILLIN GK 20 MILLION UNIT |
2* |
Generic |
$13.00 | $26.00 | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
2* |
Generic |
$13.00 | $26.00 | None |
PENICILLIN V POTASSIUM 500MG TABLET |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
PENICILLIN VK 125 MG/5 ML SOLN |
2* |
Generic |
$13.00 | $26.00 | None |
PENICILLIN VK 250 MG TABLET |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
PENTAM 300 INJ 300MG |
4 |
Non-Preferred Drug |
45% | 45% | None |
PENTASA 250MG CAPSULE SA |
4 |
Non-Preferred Drug |
45% | 45% | None |
PENTASA 500MG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | None |
PENTOXIFYLLINE 400MG TABLET SA |
2* |
Generic |
$13.00 | $26.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PERINDOPRIL ERBUMINE 2 MG TAB |
6* |
Select Care Drugs |
$2.00 | $4.00 | None |
PERINDOPRIL ERBUMINE 4 MG TAB |
6* |
Select Care Drugs |
$2.00 | $4.00 | None |
PERINDOPRIL ERBUMINE 8 MG TAB |
6* |
Select Care Drugs |
$2.00 | $4.00 | None |
Permethrin 50mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
4 |
Non-Preferred Drug |
45% | 45% | None |
Perphenazine 16mg/1 100 FILM COATED TABLETS in BOTTLE |
2* |
Generic |
$13.00 | $26.00 | P |
PERPHENAZINE 4 MG TABLET |
2* |
Generic |
$13.00 | $26.00 | P |
PERPHENAZINE 8 MG TABLET |
2* |
Generic |
$13.00 | $26.00 | P |
PERPHENAZINE TABLETS USP 2MG 100 BOT |
2* |
Generic |
$13.00 | $26.00 | P |
PERSERIS ER 120 MG SYRINGE KIT SUSER SYKT |
5 |
Specialty Tier |
25% | 25% | P Q:1 /30Days |
PERSERIS ER 90 MG SYRINGE KIT SUSER SYKT |
5 |
Specialty Tier |
25% | 25% | P Q:1 /30Days |
PHENADOZ 12.5 MG SUPPOSITORY |
4 |
Non-Preferred Drug |
45% | 45% | 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 |
2* |
Generic |
$13.00 | $26.00 | None |
Phenobarbital 100mg/1 |
4 |
Non-Preferred Drug |
45% | 45% | None |
Phenobarbital 15mg/1 |
4 |
Non-Preferred Drug |
45% | 45% | None |
PHENOBARBITAL 16.2 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
PHENOBARBITAL 20 MG/5 ML ELIX |
4 |
Non-Preferred Drug |
45% | 45% | None |
Phenobarbital 30mg/1 |
4 |
Non-Preferred Drug |
45% | 45% | None |
PHENOBARBITAL 32.4 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
Phenobarbital 60mg/1 |
4 |
Non-Preferred Drug |
45% | 45% | None |
PHENOBARBITAL 64.8 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
PHENOBARBITAL 97.2 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
PHENOXYBENZAMINE HCL 10 MG Capsule [Dibenzyline] |
5 |
Specialty Tier |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Phenytoin 50 MG Chewable Tablet |
2* |
Generic |
$13.00 | $26.00 | None |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT |
2* |
Generic |
$13.00 | $26.00 | None |
PHENYTOIN SOD EXT 100 MG CAP |
2* |
Generic |
$13.00 | $26.00 | None |
PHENYTOIN SOD EXT 200 MG CAP |
2* |
Generic |
$13.00 | $26.00 | None |
PHENYTOIN SOD EXT 300 MG CAP |
2* |
Generic |
$13.00 | $26.00 | None |
Phoslyra 667mg/5mL 1 BOTTLE per CARTON / 473 mL in 1 BOTTLE |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PHOSPHOLINE IODIDE 0.125% 6.25MG |
4 |
Non-Preferred Drug |
45% | 45% | None |
PHRENILIN FORTE 50-300-40 MG |
4 |
Non-Preferred Drug |
45% | 45% | Q:180 /30Days |
PICATO 0.015% GEL |
3 |
Preferred Brand |
$40.00 | $80.00 | Q:3 /30Days |
PICATO 0.05% GEL |
3 |
Preferred Brand |
$40.00 | $80.00 | Q:2 /30Days |
PIFELTRO 100 MG TABLET |
5 |
Specialty Tier |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PILOCARPINE 1% EYE DROPS [Pilocar] |
2* |
Generic |
$13.00 | $26.00 | None |
PILOCARPINE 2% EYE DROPS [Pilocar] |
2* |
Generic |
$13.00 | $26.00 | None |
PILOCARPINE 4% EYE DROPS [Pilocar] |
2* |
Generic |
$13.00 | $26.00 | None |
PILOCARPINE HCL 5 MG TABLET [Salagen] |
2* |
Generic |
$13.00 | $26.00 | None |
PILOCARPINE HCL 7.5 MG TABLET [Salagen] |
2* |
Generic |
$13.00 | $26.00 | None |
PIMECROLIMUS 1% CREAM (g) [Elidel] |
4 |
Non-Preferred Drug |
45% | 45% | P |
PIMOZIDE 1 MG TABLET [Orap] |
2* |
Generic |
$13.00 | $26.00 | None |
PIMOZIDE 2 MG TABLET [Orap] |
2* |
Generic |
$13.00 | $26.00 | None |
PIMTREA 28 DAY TABLET |
2* |
Generic |
$13.00 | $26.00 | None |
PINDOLOL 10 MG TABLET |
2* |
Generic |
$13.00 | $26.00 | None |
PINDOLOL 5 MG TABLET |
2* |
Generic |
$13.00 | $26.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PIOGLITAZONE HCL 15 MG TABLET [Actos] |
6* |
Select Care Drugs |
$2.00 | $4.00 | Q:90 /30Days |
PIOGLITAZONE HCL 30 MG TABLET [Actos] |
6* |
Select Care Drugs |
$2.00 | $4.00 | Q:30 /30Days |
PIOGLITAZONE HCL 45 MG TABLET [Actos] |
6* |
Select Care Drugs |
$2.00 | $4.00 | Q:30 /30Days |
PIOGLITAZONE-GLIMEPIRIDE 30-2 TABLET [Duetact] |
6* |
Select Care Drugs |
$2.00 | $4.00 | Q:30 /30Days |
PIOGLITAZONE-GLIMEPIRIDE 30-4 Tablet [Duetact] |
6* |
Select Care Drugs |
$2.00 | $4.00 | Q:30 /30Days |
PIOGLITAZONE-METFORMIN 15-500 |
6* |
Select Care Drugs |
$2.00 | $4.00 | Q:90 /30Days |
PIOGLITAZONE-METFORMIN 15-850 |
6* |
Select Care Drugs |
$2.00 | $4.00 | Q:90 /30Days |
PIPERACIL-TAZOBACT 2.25 GM VIAL |
2* |
Generic |
$13.00 | $26.00 | None |
PIPERACIL-TAZOBACT 3.375 GM VIAL |
4 |
Non-Preferred Drug |
45% | 45% | None |
PIPERACIL-TAZOBACT 4.5 GM VIAL |
4 |
Non-Preferred Drug |
45% | 45% | None |
Pirmella 1-35-28 tablet |
2* |
Generic |
$13.00 | $26.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PIROXICAM 10 MG CAPSULE |
2* |
Generic |
$13.00 | $26.00 | Q:60 /30Days |
PIROXICAM 20 MG CAPSULE |
2* |
Generic |
$13.00 | $26.00 | Q:30 /30Days |
PLEGRIDY 125 MCG/0.5 ML PEN |
5 |
Specialty Tier |
25% | 25% | P Q:1 /28Days |
PLEGRIDY 125 MCG/0.5 ML SYRING |
5 |
Specialty Tier |
25% | 25% | P Q:1 /28Days |
PLEGRIDY PEN INJ STARTER PACK |
5 |
Specialty Tier |
25% | 25% | P Q:1 /28Days |
PLEGRIDY SYRINGE STARTER PACK |
5 |
Specialty Tier |
25% | 25% | P Q:1 /28Days |
PODOFILOX 0.5% TOPICAL TUBEX |
2* |
Generic |
$13.00 | $26.00 | None |
POLYMYXIN B-TMP EYE DROPS |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
POMALYST 1 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P Q:21 /28Days |
POMALYST 2 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P Q:21 /28Days |
POMALYST 3 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P Q:21 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POMALYST 4 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P Q:21 /28Days |
PORTIA 0.15-0.03 TABLET |
2* |
Generic |
$13.00 | $26.00 | None |
Potassium Chloride 2 MEQ/ML Injectable Solution |
2* |
Generic |
$13.00 | $26.00 | None |
Potassium Chloride 8 MEQ Extended Release Oral Tablet |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION |
2* |
Generic |
$13.00 | $26.00 | None |
Potassium Chloride in Dextrose 5; 150g/100mL; mg/100mL 1000 mL in 1 BAG |
2* |
Generic |
$13.00 | $26.00 | None |
Potassium Chloride in Lactated Ringers and Dextrose 20; 5; 179; 600; 310mg/100mL; g/100mL; mg/100mL |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
POTASSIUM CITRATE ER 10 MEQ TB |
2* |
Generic |
$13.00 | $26.00 | None |
POTASSIUM CITRATE ER 15 MEQ TABLET |
2* |
Generic |
$13.00 | $26.00 | None |
POTASSIUM CITRATE ER 5 MEQ TAB |
2* |
Generic |
$13.00 | $26.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CL 10% (20 MEQ/15ML) Liquid [Kay Ciel] |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
POTASSIUM CL 2 MEQ/ML VIAL [PROAMP] |
2* |
Generic |
$13.00 | $26.00 | None |
POTASSIUM CL ER 10 MEQ CAPSULE |
2* |
Generic |
$13.00 | $26.00 | None |
POTASSIUM CL ER 10 MEQ TABLET |
2* |
Generic |
$13.00 | $26.00 | None |
POTASSIUM CL ER 10 MEQ TABLET |
2* |
Generic |
$13.00 | $26.00 | None |
POTASSIUM CL ER 20 MEQ TABLET |
2* |
Generic |
$13.00 | $26.00 | None |
Potassium cl er 20 meq tablet |
4 |
Non-Preferred Drug |
45% | 45% | None |
POTASSIUM CL ER 8 MEQ CAPSULE |
2* |
Generic |
$13.00 | $26.00 | None |
PRADAXA 110 MG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | Q:71 /90Days |
PRADAXA 150 MG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | Q:60 /30Days |
PRADAXA 75 MG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAMIPEXOLE 0.125 MG TABLET |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
PRAMIPEXOLE 0.25 MG TABLET |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
PRAMIPEXOLE 0.5 MG TABLET |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
PRAMIPEXOLE 0.75 MG TABLET |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
PRAMIPEXOLE 1 MG TABLET |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
PRAMIPEXOLE 1.5 MG TABLET |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
PRASUGREL 10 MG TABLET |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PRASUGREL 5 MG TABLET |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PRAVASTATIN SODIUM 10 MG TAB |
6* |
Select Care Drugs |
$2.00 | $4.00 | Q:45 /30Days |
PRAVASTATIN SODIUM 20 MG TAB |
6* |
Select Care Drugs |
$2.00 | $4.00 | Q:45 /30Days |
PRAVASTATIN SODIUM 40 MG TAB |
6* |
Select Care Drugs |
$2.00 | $4.00 | Q:45 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAVASTATIN SODIUM 80 MG TAB |
6* |
Select Care Drugs |
$2.00 | $4.00 | Q:30 /30Days |
PRAZIQUANTEL 600 MG TABLET [Biltricide] |
4 |
Non-Preferred Drug |
45% | 45% | None |
PRAZOSIN 1 MG CAPSULE |
2* |
Generic |
$13.00 | $26.00 | None |
PRAZOSIN 2 MG CAPSULE |
2* |
Generic |
$13.00 | $26.00 | None |
PRAZOSIN 5MG CAPSULE |
2* |
Generic |
$13.00 | $26.00 | None |
Prednicarbate 0.1% cream |
2* |
Generic |
$13.00 | $26.00 | None |
PREDNICARBATE 0.1% OINTMENT |
2* |
Generic |
$13.00 | $26.00 | None |
PREDNISOLONE 15 MG/5 ML SOLN |
2* |
Generic |
$13.00 | $26.00 | None |
PREDNISOLONE AC 1% EYE DROP |
2* |
Generic |
$13.00 | $26.00 | None |
PREDNISOLONE SODIUM PHOSPHATE 5MG /5ML ORAL SOLUTION |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PREDNISONE 1 MG TABLET |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISONE 10 MG TAB DOSE PACK |
2* |
Generic |
$13.00 | $26.00 | None |
PREDNISONE 10 MG TAB DOSE PACK |
2* |
Generic |
$13.00 | $26.00 | None |
PREDNISONE 10 MG TABLET [Sterapred DS] |
2* |
Generic |
$13.00 | $26.00 | None |
PREDNISONE 2.5 MG TABLET |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
Prednisone 20 MG Oral Tablet |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
PREDNISONE 5 MG TABLET |
2* |
Generic |
$13.00 | $26.00 | None |
PREDNISONE 5 MG TABLET |
2* |
Generic |
$13.00 | $26.00 | None |
PREDNISONE 5 MG TABLET |
2* |
Generic |
$13.00 | $26.00 | None |
PREDNISONE 5 MG/5 ML SOLUTION |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PREDNISONE 50MG TABLET |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PREMARIN 0.3 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREMARIN 0.45MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
PREMARIN 0.625 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
Premarin 0.625mg/g |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PREMARIN 0.9MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
PREMARIN 1.25 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
PREMASOL 6% IV SOLUTION |
2* |
Generic |
$13.00 | $26.00 | P |
PREMPHASE 0.625-5 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA |
4 |
Non-Preferred Drug |
45% | 45% | None |
PREMPRO 0.45-1.5 MG TABLET 28 EA |
4 |
Non-Preferred Drug |
45% | 45% | None |
PREMPRO 0.625-5 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
Prempro 0.625; 2.5mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, SUGAR COATED per BLISTER PACK |
4 |
Non-Preferred Drug |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREVALITE PACKET |
2* |
Generic |
$13.00 | $26.00 | None |
PREVIFEM TABLET [VyLibra] |
2* |
Generic |
$13.00 | $26.00 | None |
PREVYMIS 240 MG |
5 |
Specialty Tier |
25% | 25% | None |
PREVYMIS 480 MG |
5 |
Specialty Tier |
25% | 25% | None |
PREZCOBIX 800 MG-150 MG TABLET |
5 |
Specialty Tier |
25% | 25% | Q:30 /30Days |
PREZISTA 100 MG/ML SUSPENSION |
5 |
Specialty Tier |
25% | 25% | Q:400 /30Days |
PREZISTA 150MG TABLETS |
4 |
Non-Preferred Drug |
45% | 45% | Q:180 /30Days |
PREZISTA 800 MG TABLET |
5 |
Specialty Tier |
25% | 25% | Q:30 /30Days |
PREZISTA TABLET 600MG |
5 |
Specialty Tier |
25% | 25% | Q:60 /30Days |
PREZISTA TABLET 75MG |
4 |
Non-Preferred Drug |
45% | 45% | Q:300 /30Days |
PRIFTIN 150 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Primaquine Phosphate 26.3 MG Oral Tablet |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PRIMIDONE 250 MG TABLET [Mysoline] |
2* |
Generic |
$13.00 | $26.00 | None |
PRIMIDONE 50 MG TABLET [Mysoline] |
2* |
Generic |
$13.00 | $26.00 | None |
PROAIR HFA 90 MCG INHALER |
3 |
Preferred Brand |
$40.00 | $80.00 | Q:36 /30Days |
PROAIR RESPICLICK INHAL POWDER |
3 |
Preferred Brand |
$40.00 | $80.00 | Q:2 /30Days |
PROBENECID 500 MG TABLET |
2* |
Generic |
$13.00 | $26.00 | None |
PROBENECID/COLCHICINE 0.5MG/500MG TABLET |
2* |
Generic |
$13.00 | $26.00 | None |
PROCHLORPERAZINE 10 MG TAB |
2* |
Generic |
$13.00 | $26.00 | None |
PROCHLORPERAZINE 5 MG TABLET |
2* |
Generic |
$13.00 | $26.00 | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX |
4 |
Non-Preferred Drug |
45% | 45% | None |
PROCRIT 10000U/ML VIAL |
4 |
Non-Preferred Drug |
45% | 45% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL |
4 |
Non-Preferred Drug |
45% | 45% | P |
PROCRIT 3,000 UNITS/ML VIAL |
4 |
Non-Preferred Drug |
45% | 45% | P |
PROCRIT 4,000 UNITS/ML VIAL |
4 |
Non-Preferred Drug |
45% | 45% | P |
PROCRIT 40000U/ML VIAL PR |
5 |
Specialty Tier |
25% | 25% | P |
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY |
5 |
Specialty Tier |
25% | 25% | P |
PROCTO-MED HC 2.5% CREAM |
2* |
Generic |
$13.00 | $26.00 | None |
procto-pak 1% cream |
1* |
Preferred Generic |
$3.00 | $6.00 | None |
PROCTOSOL-HC 2.5% CREAM |
2* |
Generic |
$13.00 | $26.00 | None |
PROCTOZONE-HC 2.5% CREAM |
2* |
Generic |
$13.00 | $26.00 | None |
PROGESTERONE 100 MG CAPSULE |
2* |
Generic |
$13.00 | $26.00 | None |
PROGESTERONE 200 MG CAPSULE [Prometrium] |
2* |
Generic |
$13.00 | $26.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROGLYCEM 50 MG/ML ORAL SUSP |
4 |
Non-Preferred Drug |
45% | 45% | None |
PROGRAF 0.2 MG GRANULE PACKET |
4 |
Non-Preferred Drug |
45% | 45% | P |
PROGRAF 1 MG GRANULE PACKET |
4 |
Non-Preferred Drug |
45% | 45% | P |
PROLASTIN C 1,000 MG VIAL |
5 |
Specialty Tier |
25% | 25% | P |
PROLENSA 0.07% EYE DROPS |
4 |
Non-Preferred Drug |
45% | 45% | None |
PROLIA 60MG/ML INJECTION |
4 |
Non-Preferred Drug |
45% | 45% | P |
PROMACTA 12.5 MG SUSPEN PACKET POWDER PACK |
5 |
Specialty Tier |
25% | 25% | P |
PROMACTA 12.5 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
PROMACTA 25 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
PROMACTA 50 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
PROMACTA 75 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMETHAZINE 12.5 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | P |
PROMETHAZINE 25 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | P |
PROMETHAZINE 50 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | P |
PROMETHAZINE 6.25 MG/5 ML SYRUP [Prometh Plain] |
4 |
Non-Preferred Drug |
45% | 45% | P |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX |
4 |
Non-Preferred Drug |
45% | 45% | P |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX |
4 |
Non-Preferred Drug |
45% | 45% | P |
PROMETHEGAN 25MG SUPP |
4 |
Non-Preferred Drug |
45% | 45% | P |
PROPAFENONE HCL 150 MG TABLET |
2* |
Generic |
$13.00 | $26.00 | None |
PROPAFENONE HCL 225MG TABLET |
2* |
Generic |
$13.00 | $26.00 | None |
PROPAFENONE HCL 300 MG TAB |
2* |
Generic |
$13.00 | $26.00 | None |
PROPAFENONE HCL ER 225 MG CAP |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPAFENONE HYDROCHLORIDE 325MG CAPSULES EXTENDED RELEASE |
4 |
Non-Preferred Drug |
45% | 45% | None |
PROPAFENONE HYDROCHLORIDE 425MG CAPSULES EXTENDED RELEASE |
4 |
Non-Preferred Drug |
45% | 45% | None |
PROPRANOLOL 10 MG TABLET |
2* |
Generic |
$13.00 | $26.00 | None |
PROPRANOLOL 20 MG TABLET |
2* |
Generic |
$13.00 | $26.00 | None |
PROPRANOLOL 40 MG TABLET |
2* |
Generic |
$13.00 | $26.00 | None |
PROPRANOLOL 60 MG TABLET |
2* |
Generic |
$13.00 | $26.00 | None |
PROPRANOLOL 80 MG TABLET |
2* |
Generic |
$13.00 | $26.00 | None |
PROPRANOLOL ER 120 MG CAPSULE |
2* |
Generic |
$13.00 | $26.00 | None |
PROPRANOLOL ER 160 MG CAPSULE |
2* |
Generic |
$13.00 | $26.00 | None |
PROPRANOLOL ER 60 MG CAPSULE |
2* |
Generic |
$13.00 | $26.00 | None |
PROPRANOLOL ER 80 MG CAPSULE |
2* |
Generic |
$13.00 | $26.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPYLTHIOURACIL 50MG TABLET |
2* |
Generic |
$13.00 | $26.00 | None |
PROQUAD VIAL |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PROTRIPTYLINE HCL 10 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | P |
PROTRIPTYLINE HCL 5 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | P |
PULMOZYME 1MG/ML AMPUL |
5 |
Specialty Tier |
25% | 25% | P |
PURIXAN 20 MG/ML ORAL SUSP |
5 |
Specialty Tier |
25% | 25% | None |
PYLERA CAPSULE |
5 |
Specialty Tier |
25% | 25% | None |
PYRAZINAMIDE 500 MG TABLET |
3 |
Preferred Brand |
$40.00 | $80.00 | None |
PYRIDOSTIGMINE 60 MG/5 ML SOLN SYRUP [Mestinon] |
5 |
Specialty Tier |
25% | 25% | None |
PYRIDOSTIGMINE BR 60 MG TABLET |
2* |
Generic |
$13.00 | $26.00 | None |
PYRIDOSTIGMINE BR ER 180 MG TAB |
4 |
Non-Preferred Drug |
45% | 45% | None |