2019 Medicare Part D Plan Formulary Information |
Kaiser Permanente Medicare Plus Std w/Part D (B) (Cost) (H2150-029-0)
Benefit Details
|
The Kaiser Permanente Medicare Plus Std w/Part D (B) (Cost) (H2150-029-0) Formulary Drugs Starting with the Letter P in MANASSAS PARK CITY County, VA: CMS MA Region 7 which includes: VA Plan Monthly Premium: $57.60 Deductible: $235 |
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* |
Tier 2 |
$15.00 | $30.00 | None |
PACERONE 200 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PACERONE 400MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PALIPERIDONE ER 1.5 MG TABLET [INVEGA] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PALIPERIDONE ER 3 MG TABLET [INVEGA] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PALIPERIDONE ER 6 MG TABLET [INVEGA] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PALIPERIDONE ER 9 MG TABLET [INVEGA] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PALYNZIQ 10 MG/0.5 ML SYRINGE |
5* |
Tier 5 |
25% | 25% | None |
PALYNZIQ 2.5 MG/0.5 ML SYRINGE |
5* |
Tier 5 |
25% | 25% | None |
PALYNZIQ 20 MG/ML SYRINGE |
5* |
Tier 5 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAMELOR 10mg/1 30 CAPSULE BOTTLE |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PAMELOR 25mg/1 30 CAPSULE BOTTLE |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PAMELOR 50mg/1 30 CAPSULE BOTTLE |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PAMELOR 75mg/1 30 CAPSULE BOTTLE |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PANCREAZE DR 10,500 UNIT CAPSULE DR |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PANCREAZE DR 16,800 UNIT CAPSULE DR |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PANCREAZE DR 2,600 UNIT CAPSULE DR |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PANCREAZE DR 21,000 UNIT CAPSULE DR |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PANCREAZE DR 4,200 UNIT CAPSULE DR |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PANDEL 0.1% CREAM |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PANRETIN 0.1% GEL 60GM TUBE |
5* |
Tier 5 |
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 |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PANTOPRAZOLE SOD DR 40 MG TAB |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PANZYGA 10% (1 G/10 ML) VIAL |
5* |
Tier 5 |
25% | 25% | None |
PANZYGA 10% (10 G/100 ML) VIAL |
5* |
Tier 5 |
25% | 25% | None |
PANZYGA 10% (2.5 G/25 ML) VIAL |
5* |
Tier 5 |
25% | 25% | None |
PANZYGA 10% (20 G/200 ML) VIAL |
5* |
Tier 5 |
25% | 25% | None |
PANZYGA 10% (30 G/300 ML) VIAL |
5* |
Tier 5 |
25% | 25% | None |
PANZYGA 10% (5 G/50 ML) VIAL |
5* |
Tier 5 |
25% | 25% | None |
PARICALCITOL 1 MCG CAPSULE [Zemplar] |
2* |
Tier 2 |
$15.00 | $30.00 | P |
PARICALCITOL 2 MCG CAPSULE [Zemplar] |
2* |
Tier 2 |
$15.00 | $30.00 | P |
PARICALCITOL 4 MCG CAPSULE [Zemplar] |
2* |
Tier 2 |
$15.00 | $30.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PARLODEL 2.5 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PARLODEL 5 MG CAPSULE |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PARNATE 10 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PAROMOMYCIN 250 MG CAPSULE |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PAROXETINE ER 12.5 MG TABLET 24H [Paxil CR] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PAROXETINE ER 25 MG TABLET 24H [Paxil CR] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PAROXETINE ER 37.5 MG TABLET 24H [Paxil CR] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PAROXETINE HCL 10 MG TABLET |
1* |
Tier 1 |
$7.00 | $0.00 | None |
PAROXETINE HCL 20 MG TABLET |
1* |
Tier 1 |
$7.00 | $0.00 | None |
PAROXETINE HCL 30 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PAROXETINE HCL 40 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAROXETINE MESYLATE 7.5 MG CAP |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PASER GRANULES 4GM PACKET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PATADAY 0.2% DROPS |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PATANASE 665ug/1 240 SPRAY, METERED in 1 BOTTLE |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PATANOL 0.1% EYE DROPS |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PAXIL 25mg/1 |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PAXIL CR TABLETS CONTROLLED RELEASE 12.5 MG |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PAXIL CR TABLETS EXTENDED RELEASE 37.5 MG |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PAXIL ORAL SUSPENSION 10 MG/5ML |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PAXIL TABLETS 10 MG |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PAXIL TABLETS 20 MG |
4 |
Tier 4 |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAXIL TABLETS 30 MG |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PAXIL TABLETS 40 MG |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PAZEO 0.7% EYE DROPS |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PEDVAXHIB VACCINE VIAL |
6* |
Tier 6 |
$0.00 | N/A | None |
PEG 3350 ELECTROLYTE SOLN SOLN RECON [GaviLyte-C] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PEG 3350-ELECTROLYTE SOLUTION SOLN RECON |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PEG-3350 AND ELECTROLYTES SOLN SOLN RECON |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PEGANONE 250 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
Pegasys 180ug/0.5mL 1 PACKET in 1 BOX / 4 SYRINGE, GLASS in 1 PACKET / 0.5 mL in 1 SYRINGE, GLASS |
5* |
Tier 5 |
25% | 25% | None |
PEGASYS INJECTION |
5* |
Tier 5 |
25% | 25% | None |
PEGASYS PROCLICK 180 MCG/0.5 |
5* |
Tier 5 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENICILLAMINE 250 MG CAPSULE [Cuprimine] |
5* |
Tier 5 |
25% | 25% | None |
PENICILLIN G POTASSIUM 2MMUNITS/50ML ISO-OSM |
3* |
Tier 3 |
$42.00 | $84.00 | None |
PENICILLIN G POTASSIUM 3MMUNITS/50ML ISO-OSM |
3* |
Tier 3 |
$42.00 | $84.00 | None |
PENICILLIN G PROCAINE 1200000UNT 2ML CTG |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Penicillin G Sodium 5000000[iU]/1 10 VIAL per CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PENICILLIN GK 20 MILLION UNIT |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PENICILLIN V POTASSIUM 500MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PENICILLIN VK 125 MG/5 ML SOLN |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PENICILLIN VK 250 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PENNSAID 2% PUMP |
4 |
Tier 4 |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENTAM 300 INJ 300MG |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PENTASA 250MG CAPSULE SA |
3* |
Tier 3 |
$42.00 | $84.00 | None |
PENTASA 500MG CAPSULE |
3* |
Tier 3 |
$42.00 | $84.00 | None |
PENTAZOCINE-NALOXONE TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PENTOXIFYLLINE 400MG TABLET SA |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PEPCID 20 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PEPCID 40 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PERCOCET 10/325MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PERCOCET 2.5/325MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PERCOCET 5-325 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PERCOCET 7.5/325MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PERFOROMIST 20MCG/2ML VIAL NEBULIZER |
4 |
Tier 4 |
$95.00 | $190.00 | P |
PERINDOPRIL ERBUMINE 2 MG TAB |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PERINDOPRIL ERBUMINE 4 MG TAB |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PERINDOPRIL ERBUMINE 8 MG TAB |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Permethrin 50mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PERPHEN-AMITRIP 2 MG-10 MG TAB |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PERPHEN-AMITRIP 2 MG-25 MG TAB |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PERPHEN-AMITRIP 4 MG-25 MG TAB |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Perphenazine 16mg/1 100 FILM COATED TABLETS in BOTTLE |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PERPHENAZINE 4 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PERPHENAZINE 8 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PERPHENAZINE TABLETS USP 2MG 100 BOT |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PERSERIS ER 120 MG SYRINGE KIT SUSER SYKT |
5* |
Tier 5 |
25% | 25% | None |
PERSERIS ER 90 MG SYRINGE KIT SUSER SYKT |
5* |
Tier 5 |
25% | 25% | None |
PERTZYE DR 16,000 UNITS CAPS |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PERTZYE DR 4,000 UNIT CAPSULE |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PERTZYE DR 8,000 UNITS CAPSULE |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PEXEVA 10 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PEXEVA 20 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PEXEVA 30 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PEXEVA 40 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PHENADOZ 12.5 MG SUPPOSITORY |
2* |
Tier 2 |
$15.00 | $30.00 | None |
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* |
Tier 2 |
$15.00 | $30.00 | None |
Phenobarbital 100mg/1 |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Phenobarbital 15mg/1 |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PHENOBARBITAL 16.2 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PHENOBARBITAL 20 MG/5 ML ELIX |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Phenobarbital 30mg/1 |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PHENOBARBITAL 32.4 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Phenobarbital 60mg/1 |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PHENOBARBITAL 64.8 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PHENOBARBITAL 97.2 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PHENOXYBENZAMINE HCL 10 MG Capsule [Dibenzyline] |
5* |
Tier 5 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PHENYTEK 200 MG CAPSULE |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PHENYTEK 300 MG CAPSULE |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Phenytoin 50 MG Chewable Tablet |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PHENYTOIN SOD EXT 100 MG CAP |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PHENYTOIN SOD EXT 200 MG CAP |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PHENYTOIN SOD EXT 300 MG CAP |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Phoslyra 667mg/5mL 1 BOTTLE per CARTON / 473 mL in 1 BOTTLE |
3* |
Tier 3 |
$42.00 | $84.00 | None |
PHOSPHOLINE IODIDE 0.125% 6.25MG |
3* |
Tier 3 |
$42.00 | $84.00 | None |
PHRENILIN FORTE 50-300-40 MG |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PICATO 0.015% GEL |
4 |
Tier 4 |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PICATO 0.05% GEL |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PIFELTRO 100 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PILOCARPINE 1% EYE DROPS [Pilocar] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PILOCARPINE 2% EYE DROPS [Pilocar] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PILOCARPINE 4% EYE DROPS [Pilocar] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PILOCARPINE HCL 5 MG TABLET [Salagen] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PILOCARPINE HCL 7.5 MG TABLET [Salagen] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PIMECROLIMUS 1% CREAM (g) [Elidel] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PIMOZIDE 1 MG TABLET [Orap] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PIMOZIDE 2 MG TABLET [Orap] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PIMTREA 28 DAY TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PINDOLOL 10 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PINDOLOL 5 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PIOGLITAZONE HCL 15 MG TABLET [Actos] |
1* |
Tier 1 |
$7.00 | $0.00 | None |
PIOGLITAZONE HCL 30 MG TABLET [Actos] |
1* |
Tier 1 |
$7.00 | $0.00 | None |
PIOGLITAZONE HCL 45 MG TABLET [Actos] |
1* |
Tier 1 |
$7.00 | $0.00 | None |
PIOGLITAZONE-GLIMEPIRIDE 30-2 TABLET [Duetact] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PIOGLITAZONE-GLIMEPIRIDE 30-4 Tablet [Duetact] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PIOGLITAZONE-METFORMIN 15-500 |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PIOGLITAZONE-METFORMIN 15-850 |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PIPERACIL-TAZOBACT 2.25 GM VIAL |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PIPERACIL-TAZOBACT 3.375 GM VIAL |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PIPERACIL-TAZOBACT 4.5 GM VIAL |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PIPERACIL-TAZOBACT 40.5 GRAM VIAL [Zosyn] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Pirmella 1-35-28 tablet |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PIROXICAM 10 MG CAPSULE |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PIROXICAM 20 MG CAPSULE |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PLAQUENIL 200 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PLASMA-LYTE 148 IV SOLUTION |
3* |
Tier 3 |
$42.00 | $84.00 | None |
PLASMA-LYTE A PH 7.4 SOLUTION 37;368; MG/100ML; |
3* |
Tier 3 |
$42.00 | $84.00 | None |
PLAVIX 75 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PLEGRIDY 125 MCG/0.5 ML PEN |
5* |
Tier 5 |
25% | 25% | None |
PLEGRIDY 125 MCG/0.5 ML SYRING |
5* |
Tier 5 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PLEGRIDY PEN INJ STARTER PACK |
5* |
Tier 5 |
25% | 25% | None |
PLEGRIDY SYRINGE STARTER PACK |
5* |
Tier 5 |
25% | 25% | None |
PLENVU POWDER PACKETS SQ |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PLIAGLIS 7%-7% CREAM (g) |
4 |
Tier 4 |
$95.00 | $190.00 | P |
PODOFILOX 0.5% TOPICAL TUBEX |
2* |
Tier 2 |
$15.00 | $30.00 | None |
POLYMYXIN B SULFATE VIAL |
2* |
Tier 2 |
$15.00 | $30.00 | None |
POLYMYXIN B-TMP EYE DROPS |
2* |
Tier 2 |
$15.00 | $30.00 | None |
POLYTRIM EYE DROP |
4 |
Tier 4 |
$95.00 | $190.00 | None |
POMALYST 1 MG CAPSULE |
5* |
Tier 5 |
25% | 25% | None |
POMALYST 2 MG CAPSULE |
5* |
Tier 5 |
25% | 25% | None |
POMALYST 3 MG CAPSULE |
5* |
Tier 5 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POMALYST 4 MG CAPSULE |
5* |
Tier 5 |
25% | 25% | None |
PORTIA 0.15-0.03 TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
POT CHL/SWFI P-B 40 MEQ 24X100 ML |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Potassium Chloride 2 MEQ/ML Injectable Solution |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Potassium Chloride 200 meq/1000mL 24 POUCH in 1 CASE |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Potassium Chloride 8 MEQ Extended Release Oral Tablet |
2* |
Tier 2 |
$15.00 | $30.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Potassium Chloride in Dextrose 5; 150g/100mL; mg/100mL 1000 mL in 1 BAG |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Potassium Chloride in Dextrose and Sodium Chloride 5; 300; 900g/100mL; mg/100mL; mg/100mL 1000 mL i |
3* |
Tier 3 |
$42.00 | $84.00 | None |
Potassium Chloride in Lactated Ringers and Dextrose 20; 5; 179; 600; 310mg/100mL; g/100mL; mg/100mL |
3* |
Tier 3 |
$42.00 | $84.00 | None |
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE INJECTION 10MEQ/100ML |
2* |
Tier 2 |
$15.00 | $30.00 | None |
POTASSIUM CITRATE ER 10 MEQ TB |
2* |
Tier 2 |
$15.00 | $30.00 | None |
POTASSIUM CITRATE ER 15 MEQ TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
POTASSIUM CITRATE ER 5 MEQ TAB |
2* |
Tier 2 |
$15.00 | $30.00 | None |
POTASSIUM CL 10% (20 MEQ/15ML) Liquid [Kay Ciel] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
POTASSIUM CL 2 MEQ/ML VIAL [PROAMP] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
POTASSIUM CL 20 MEQ PACKET [Klor-Con] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
POTASSIUM CL 20% (40 MEQ/15ML) Liquid [Kaon-CL] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
POTASSIUM CL ER 10 MEQ CAPSULE |
2* |
Tier 2 |
$15.00 | $30.00 | None |
POTASSIUM CL ER 10 MEQ TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
POTASSIUM CL ER 10 MEQ TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CL ER 20 MEQ TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Potassium cl er 20 meq tablet |
2* |
Tier 2 |
$15.00 | $30.00 | None |
POTASSIUM CL ER 8 MEQ CAPSULE |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PRADAXA 110 MG CAPSULE |
3* |
Tier 3 |
$42.00 | $84.00 | None |
PRADAXA 150 MG CAPSULE |
3* |
Tier 3 |
$42.00 | $84.00 | None |
PRADAXA 75 MG CAPSULE |
3* |
Tier 3 |
$42.00 | $84.00 | None |
PRALUENT 150 MG/ML PEN |
5* |
Tier 5 |
25% | 25% | P |
PRALUENT 75 MG/ML PEN |
5* |
Tier 5 |
25% | 25% | P |
PRAMIPEXOLE 0.125 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PRAMIPEXOLE 0.25 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PRAMIPEXOLE 0.5 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAMIPEXOLE 0.75 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PRAMIPEXOLE 1 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PRAMIPEXOLE 1.5 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PRAMIPEXOLE ER 0.375 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PRAMIPEXOLE ER 0.75 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PRAMIPEXOLE ER 1.5 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PRAMIPEXOLE ER 2.25 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PRAMIPEXOLE ER 3 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PRAMIPEXOLE ER 3.75 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PRAMIPEXOLE ER 4.5 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PRANDIN 1 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRANDIN 2 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PRASUGREL 10 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PRASUGREL 5 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PRAVACHOL 20MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PRAVACHOL 40MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PRAVACHOL 80MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PRAVASTATIN SODIUM 10 MG TAB |
1* |
Tier 1 |
$7.00 | $0.00 | None |
PRAVASTATIN SODIUM 20 MG TAB |
1* |
Tier 1 |
$7.00 | $0.00 | None |
PRAVASTATIN SODIUM 40 MG TAB |
1* |
Tier 1 |
$7.00 | $0.00 | None |
PRAVASTATIN SODIUM 80 MG TAB |
1* |
Tier 1 |
$7.00 | $0.00 | None |
PRAZIQUANTEL 600 MG TABLET [Biltricide] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAZOSIN 1 MG CAPSULE |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PRAZOSIN 2 MG CAPSULE |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PRAZOSIN 5MG CAPSULE |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PRECOSE 50 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PRECOSE TABLETS 100MG 100 BOT |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PRECOSE TABLETS 25MG 100 BOT |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PRED FORTE 1% EYE DROPS |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PRED G OPHTHALMIC SUSPENSION 1;0.3%;% 5 ML BOTDR |
3* |
Tier 3 |
$42.00 | $84.00 | None |
PRED MILD 0.12% EYE DROPS |
3* |
Tier 3 |
$42.00 | $84.00 | None |
PRED-G S.O.P. EYE OINTMENT |
3* |
Tier 3 |
$42.00 | $84.00 | None |
Prednicarbate 0.1% cream |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNICARBATE 0.1% OINTMENT |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Prednisolone 10 mg/5 ml soln |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PREDNISOLONE 15 MG/5 ML SOLN |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PREDNISOLONE 20 MG/5 ML SOLN |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PREDNISOLONE AC 1% EYE DROP |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Prednisolone odt 10 mg tablet |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Prednisolone odt 15 mg tablet |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Prednisolone odt 30 mg tablet |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PREDNISOLONE SOD 1% EYE DROP |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PREDNISOLONE SOD PH 25 MG/5 ML |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PREDNISOLONE SODIUM PHOSPHATE 5MG /5ML ORAL SOLUTION |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISONE 1 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | P |
PREDNISONE 10 MG TAB DOSE PACK |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PREDNISONE 10 MG TAB DOSE PACK |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PREDNISONE 10 MG TABLET [Sterapred DS] |
2* |
Tier 2 |
$15.00 | $30.00 | P |
PREDNISONE 2.5 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | P |
Prednisone 20 MG Oral Tablet |
2* |
Tier 2 |
$15.00 | $30.00 | P |
PREDNISONE 5 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PREDNISONE 5 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PREDNISONE 5 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | P |
PREDNISONE 5 MG/5 ML SOLUTION |
2* |
Tier 2 |
$15.00 | $30.00 | P |
PREDNISONE 50MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISONE 5MG/ML SOLUTION |
2* |
Tier 2 |
$15.00 | $30.00 | P |
Prefest 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PREMARIN 0.3 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PREMARIN 0.45MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PREMARIN 0.625 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
Premarin 0.625mg/g |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PREMARIN 0.9MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PREMARIN 1.25 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PREMASOL 10% IV SOLUTION |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PREMASOL 6% IV SOLUTION |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PREMPHASE 0.625-5 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PREMPRO 0.45-1.5 MG TABLET 28 EA |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PREMPRO 0.625-5 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
Prempro 0.625; 2.5mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, SUGAR COATED per BLISTER PACK |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PREPOPIK POWDER PACKET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PREVACID CAPSULES DELAYED RELEASE 15 MG |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PREVACID CAPSULES DELAYED RELEASE 30 MG |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PREVACID SOLUTAB EXTENDED RELEASE ORALLY DISINTEGRATING 30MG 100 BOXUD |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PREVACID SOLUTAB TABLETS DELAYED RELEASE ORALLY DISINTEGRATING 15MG 100 BOXUD |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PREVALITE PACKET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PREVIFEM TABLET [VyLibra] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREVYMIS 240 MG |
5* |
Tier 5 |
25% | 25% | None |
PREVYMIS 480 MG |
5* |
Tier 5 |
25% | 25% | None |
PREZCOBIX 800 MG-150 MG TABLET |
3* |
Tier 3 |
$42.00 | $84.00 | None |
PREZISTA 100 MG/ML SUSPENSION |
3* |
Tier 3 |
$42.00 | $84.00 | None |
PREZISTA 150MG TABLETS |
3* |
Tier 3 |
$42.00 | $84.00 | None |
PREZISTA 800 MG TABLET |
3* |
Tier 3 |
$42.00 | $84.00 | None |
PREZISTA TABLET 600MG |
3* |
Tier 3 |
$42.00 | $84.00 | None |
PREZISTA TABLET 75MG |
3* |
Tier 3 |
$42.00 | $84.00 | None |
PRIFTIN 150 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PRILOSEC DR 10 MG SUSPENSION |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PRILOSEC DR 2.5 MG SUSPENSION |
4 |
Tier 4 |
$95.00 | $190.00 | 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 |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PRIMAXIN IV 500; 500mg/100mL; mg/100mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 100 mL in 1 VIAL, SINGLE-DOS |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PRIMIDONE 250 MG TABLET [Mysoline] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PRIMIDONE 50 MG TABLET [Mysoline] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PRIMLEV 10-300 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PRIMLEV 5-300 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PRIMLEV 7.5-300 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PRINIVIL 10MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PRINIVIL 20MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PRINIVIL 5MG TABLETS |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PRISTIQ 100MG TABLET SR 24HR |
4 |
Tier 4 |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRISTIQ ER 25 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PRISTIQ ER 50 MG TABLET ER 24H |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PRIVIGEN 10% VIAL |
3* |
Tier 3 |
$42.00 | $84.00 | None |
PROAIR HFA 90 MCG INHALER |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PROAIR RESPICLICK INHAL POWDER |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PROBENECID 500 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROBENECID/COLCHICINE 0.5MG/500MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | 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 |
3* |
Tier 3 |
$42.00 | $84.00 | None |
PROCARDIA 10MG CAPSULE |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PROCARDIA XL 30 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PROCARDIA XL 60 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCARDIA XL 90MG TABLET SA |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PROCENTRA 5 MG/5 ML SOLUTION |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROCHLORPERAZINE 10 MG TAB |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROCHLORPERAZINE 5 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROCRIT 10000U/ML VIAL |
3* |
Tier 3 |
$42.00 | $84.00 | P |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL |
3* |
Tier 3 |
$42.00 | $84.00 | P |
PROCRIT 3,000 UNITS/ML VIAL |
3* |
Tier 3 |
$42.00 | $84.00 | P |
PROCRIT 4,000 UNITS/ML VIAL |
3* |
Tier 3 |
$42.00 | $84.00 | P |
PROCRIT 40000U/ML VIAL PR |
3* |
Tier 3 |
$42.00 | $84.00 | P |
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY |
3* |
Tier 3 |
$42.00 | $84.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCTO-MED HC 2.5% CREAM |
2* |
Tier 2 |
$15.00 | $30.00 | None |
procto-pak 1% cream |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROCTOSOL-HC 2.5% CREAM |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROCTOZONE-HC 2.5% CREAM |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROGESTERONE 100 MG CAPSULE |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROGESTERONE 200 MG CAPSULE [Prometrium] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROGLYCEM 50 MG/ML ORAL SUSP |
3* |
Tier 3 |
$42.00 | $84.00 | None |
PROGRAF 0.2 MG GRANULE PACKET |
5* |
Tier 5 |
25% | 25% | P |
PROGRAF 0.5MG CAPSULE |
4 |
Tier 4 |
$95.00 | $190.00 | P |
PROGRAF 1 MG GRANULE PACKET |
5* |
Tier 5 |
25% | 25% | P |
PROGRAF 1MG CAPSULE |
4 |
Tier 4 |
$95.00 | $190.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROGRAF 5 MG 1 BOTTLE per CARTON / 100 CAPSULE, GELATIN COATED in 1 BOTTLE |
4 |
Tier 4 |
$95.00 | $190.00 | P |
PROLASTIN C 1,000 MG VIAL |
5* |
Tier 5 |
25% | 25% | None |
PROLENSA 0.07% EYE DROPS |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PROLIA 60MG/ML INJECTION |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PROMACTA 12.5 MG SUSPEN PACKET POWDER PACK |
5* |
Tier 5 |
25% | 25% | None |
PROMACTA 12.5 MG TABLET |
5* |
Tier 5 |
25% | 25% | None |
PROMACTA 25 MG TABLET |
5* |
Tier 5 |
25% | 25% | None |
PROMACTA 50 MG TABLET |
5* |
Tier 5 |
25% | 25% | None |
PROMACTA 75 MG TABLET |
5* |
Tier 5 |
25% | 25% | None |
PROMETHAZINE 12.5 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROMETHAZINE 25 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMETHAZINE 50 MG SUPPOSITORY |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROMETHAZINE 50 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROMETHAZINE 6.25 MG/5 ML SYRUP [Prometh Plain] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROMETHAZINE-PHENYLEPHRINE SYRUP [Prometh VC Plain] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROMETHEGAN 25MG SUPP |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROMETHEGAN 50MG SUPPOS |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROMETRIUM 100 MG CAPSULE |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PROMETRIUM 200 MG CAPSULE |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PROPAFENONE HCL 150 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPAFENONE HCL 225MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROPAFENONE HCL 300 MG TAB |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROPAFENONE HCL ER 225 MG CAP |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROPAFENONE HYDROCHLORIDE 325MG CAPSULES EXTENDED RELEASE |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROPAFENONE HYDROCHLORIDE 425MG CAPSULES EXTENDED RELEASE |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Propantheline Bromide 15mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
2* |
Tier 2 |
$15.00 | $30.00 | None |
Proparacaine hydrochloride 5 MG/ML Ophthalmic Solution |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROPRANOLOL 10 MG TABLET |
1* |
Tier 1 |
$7.00 | $0.00 | None |
PROPRANOLOL 20 MG TABLET |
1* |
Tier 1 |
$7.00 | $0.00 | None |
PROPRANOLOL 20MG/5ML TUBEX |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROPRANOLOL 40 MG TABLET |
1* |
Tier 1 |
$7.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPRANOLOL 40MG/5ML TUBEX |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROPRANOLOL 60 MG TABLET |
1* |
Tier 1 |
$7.00 | $0.00 | None |
PROPRANOLOL 80 MG TABLET |
1* |
Tier 1 |
$7.00 | $0.00 | None |
PROPRANOLOL ER 120 MG CAPSULE |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROPRANOLOL ER 160 MG CAPSULE |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROPRANOLOL ER 60 MG CAPSULE |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROPRANOLOL ER 80 MG CAPSULE |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROPRANOLOL/HCTZ 40/25 TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROPRANOLOL/HCTZ 80/25 TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROPYLTHIOURACIL 50MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROQUAD VIAL |
6* |
Tier 6 |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROSCAR TABLETS 5MG 30 BOT |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PROSOL 20% INJECTION |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PROTONIX 20MG TABLET EC |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PROTONIX 40MG SUSP FOR RECON DELAYED REL. IN A PACKET |
3* |
Tier 3 |
$42.00 | $84.00 | None |
PROTONIX 40MG TABLET EC |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PROTOPIC 0.03% OINTMENT |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PROTOPIC 0.1% OINTMENT |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PROTRIPTYLINE HCL 10 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROTRIPTYLINE HCL 5 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PROVENTIL HFA INHALER 90MCG AE |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PROVERA 10 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROVERA 2.5MG TABLET (100 CT) |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PROVERA 5 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PROVIGIL 100 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | P |
PROVIGIL 200 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | P |
PROZAC 10MG PULVULE |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PROZAC 20 MG PULVULE Capsule |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PROZAC 40MG PULVULE |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PRUDOXIN 5% CREAM (g) [Zonalon] |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PSORCON 0.05% CREAM |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PULMICORT .25MG/2ML RESPULE |
4 |
Tier 4 |
$95.00 | $190.00 | P |
PULMICORT 1MG/2ML AMPUL FOR NEBULIZATION |
4 |
Tier 4 |
$95.00 | $190.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PULMICORT FLEXHALER 180MCG AEROSOL POWDER BREATH ACTIVATED |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PULMICORT FLEXHALER 90MCG AEROSOL POWDER BREATH ACTIVATED |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PULMICORT RESPULES 0.5mg/2mL 6 POUCH per CARTON / 5 AMPULE in 1 POUCH / 2 mL in 1 AMPULE |
4 |
Tier 4 |
$95.00 | $190.00 | P |
PULMOZYME 1MG/ML AMPUL |
5* |
Tier 5 |
25% | 25% | P |
PURIXAN 20 MG/ML ORAL SUSP |
5* |
Tier 5 |
25% | 25% | None |
PYLERA CAPSULE |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PYRAZINAMIDE 500 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PYRIDOSTIGMINE 60 MG/5 ML SOLN SYRUP [Mestinon] |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PYRIDOSTIGMINE BR 60 MG TABLET |
2* |
Tier 2 |
$15.00 | $30.00 | None |
PYRIDOSTIGMINE BR ER 180 MG TAB |
2* |
Tier 2 |
$15.00 | $30.00 | None |