2019 Medicare Part D Plan Formulary Information |
Cigna-HealthSpring Rx Secure (PDP) (S5617-053-0)
Benefit Details
|
The Cigna-HealthSpring Rx Secure (PDP) (S5617-053-0) Formulary Drugs Starting with the Letter A in CMS PDP Region 11 which includes: FL Plan Monthly Premium: $72.60 Deductible: $415 Qualifies for LIS: No |
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 |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:960 /30Days |
ABACAVIR 300 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | Q:60 /30Days |
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir] |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
ABACAVIR-LAMIVUDINE 600-300 MG |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
ABELCET INJECTION SUSPENSION 5MG/ML |
5 |
Specialty Tier |
25% | N/A | P |
ABILIFY MAINTENA ER 300 MG SYR |
5 |
Specialty Tier |
25% | N/A | Q:1 /28Days |
ABILIFY MAINTENA ER 300 MG VL |
5 |
Specialty Tier |
25% | N/A | Q:1 /28Days |
ABILIFY MAINTENA ER 400 MG SUSER VIAL |
5 |
Specialty Tier |
25% | N/A | Q:1 /28Days |
ABILIFY MAINTENA ER 400 MG SYR |
5 |
Specialty Tier |
25% | N/A | Q:1 /28Days |
ABIRATERONE ACETATE 250 MG TABLET [ZYTIGA] |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Acamprosate Calcium DR 333 MG tablets [Campral] |
4 |
Non-Preferred Drug |
35% | 35% | None |
ACARBOSE 100 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | Q:90 /30Days |
ACARBOSE 25 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | Q:90 /30Days |
ACARBOSE 50 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | Q:90 /30Days |
ACEBUTOLOL 200 MG CAPSULE |
2 |
Generic |
$3.00 | $9.00 | None |
ACEBUTOLOL 400 MG CAPSULE |
2 |
Generic |
$3.00 | $9.00 | None |
ACETAMINOP-CODEINE 120-12 MG/5 |
2 |
Generic |
$3.00 | $9.00 | Q:2700 /30Days |
Acetaminophen 325 MG / Hydrocodone Bitartrate 5 MG Oral Tablet [Lorcet] |
4 |
Non-Preferred Drug |
35% | 35% | Q:360 /30Days |
ACETAMINOPHEN-COD #2 TABLET |
2 |
Generic |
$3.00 | $9.00 | Q:360 /30Days |
ACETAMINOPHEN-COD #3 TABLET |
2 |
Generic |
$3.00 | $9.00 | Q:360 /30Days |
ACETAMINOPHEN-COD #4 TABLET |
2 |
Generic |
$3.00 | $9.00 | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAZOLAMIDE 125MG TABLET |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
ACETAZOLAMIDE ER 500 MG CAP |
4 |
Non-Preferred Drug |
35% | 35% | None |
ACETIC ACID 2% EAR SOLUTION |
2 |
Generic |
$3.00 | $9.00 | None |
ACETYLCYSTEINE 10% VIAL |
4 |
Non-Preferred Drug |
35% | 35% | P |
Acetylcysteine 200 MG/ML Inhalant Solution |
4 |
Non-Preferred Drug |
35% | 35% | P |
ACITRETIN 10 MG CAPSULE [Soriatane] |
4 |
Non-Preferred Drug |
35% | 35% | P |
ACITRETIN 17.5 MG CAPSULE [Soriatane] |
4 |
Non-Preferred Drug |
35% | 35% | P |
ACITRETIN 25 MG CAPSULE [Soriatane] |
4 |
Non-Preferred Drug |
35% | 35% | P |
ACTEMRA 162 MG/0.9 ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
ACTEMRA ACTPEN 162 MG/0.9 ML PEN INJCTR |
5 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTHIB VACCINE WITH DILUENT |
4 |
Non-Preferred Drug |
35% | 35% | None |
ACTIMMUNE 100 MCG/0.5 ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
ACYCLOVIR 200 MG CAPSULE |
2 |
Generic |
$3.00 | $9.00 | None |
ACYCLOVIR 200 MG/5 ML SUSP |
4 |
Non-Preferred Drug |
35% | 35% | None |
ACYCLOVIR 400 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | None |
Acyclovir 5% Ointment |
4 |
Non-Preferred Drug |
35% | 35% | Q:30 /30Days |
ACYCLOVIR 800 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | None |
Acyclovir sodium 500 mg vial |
4 |
Non-Preferred Drug |
35% | 35% | P |
ADACEL TDAP SYRINGE |
4 |
Non-Preferred Drug |
35% | 35% | Q:1 /365Days |
ADACEL VIAL 2UNT/5UNT |
4 |
Non-Preferred Drug |
35% | 35% | Q:1 /365Days |
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA] |
5 |
Specialty Tier |
25% | N/A | P Q:2 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADEMPAS 0.5 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
ADEMPAS 1 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
ADEMPAS 1.5 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
ADEMPAS 2 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
ADEMPAS 2.5 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
ADVAIR DISKUS MIS 100/50 |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:60 /30Days |
ADVAIR DISKUS MIS 250/50 |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:60 /30Days |
ADVAIR DISKUS MIS 500/50 |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:60 /30Days |
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:12 /30Days |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:12 /30Days |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:12 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
AFINITOR DISPERZ 2 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:56 /28Days |
AFINITOR DISPERZ 3 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:56 /28Days |
AFINITOR DISPERZ 5 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:112 /28Days |
AFINITOR TABLETS 10 MG |
5 |
Specialty Tier |
25% | N/A | P Q:56 /28Days |
AFINITOR TABLETS 2.5 MG |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
AFINITOR TABLETS 5 MG |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
ALBENDAZOLE 200 MG TABLET [Albenza] |
5 |
Specialty Tier |
25% | N/A | None |
ALBENZA 200 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
ALBUTEROL SUL 2.5 MG/3 ML SOLN |
2 |
Generic |
$3.00 | $9.00 | P Q:360 /30Days |
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH per CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL |
2 |
Generic |
$3.00 | $9.00 | P Q:360 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
2 |
Generic |
$3.00 | $9.00 | P Q:360 /30Days |
ALBUTEROL SULFATE 2 MG TAB |
4 |
Non-Preferred Drug |
35% | 35% | None |
ALBUTEROL SULFATE 4 MG TAB |
4 |
Non-Preferred Drug |
35% | 35% | None |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
4 |
Non-Preferred Drug |
35% | 35% | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
4 |
Non-Preferred Drug |
35% | 35% | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
2 |
Generic |
$3.00 | $9.00 | P Q:180 /30Days |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
2 |
Generic |
$3.00 | $9.00 | None |
ALCLOMETASONE DIPR 0.05% OINT |
2 |
Generic |
$3.00 | $9.00 | None |
ALCLOMETASONE DIPRO 0.05% CRM |
2 |
Generic |
$3.00 | $9.00 | None |
ALECENSA 150 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:240 /30Days |
ALENDRONATE SODIUM 10 MG TAB |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALENDRONATE SODIUM 35 MG TABLET [Fosamax] |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:4 /28Days |
ALENDRONATE SODIUM 40 MG TABLET |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
ALENDRONATE SODIUM 5 MG TABLET |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
ALENDRONATE SODIUM 70 MG TABLET [Fosamax] |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:4 /28Days |
ALFUZOSIN HCL ER 10 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | Q:30 /30Days |
ALINIA 100 MG/5 ML SUSPENSION |
5 |
Specialty Tier |
25% | N/A | Q:150 /30Days |
ALINIA 500 MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:20 /30Days |
ALLOPURINOL 100 MG TABLET |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
ALLOPURINOL 300 MG TABLET |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
ALOSETRON HCL 0.5 MG TABLET [Lotronex] |
4 |
Non-Preferred Drug |
35% | 35% | P Q:60 /30Days |
ALOSETRON HCL 1 MG TABLET [Lotronex] |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALPHAGAN P 0.1% DROPS |
4 |
Non-Preferred Drug |
35% | 35% | None |
ALPRAZOLAM 0.25 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | Q:90 /30Days |
ALPRAZOLAM 0.5 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | Q:90 /30Days |
ALPRAZOLAM 1 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | Q:90 /30Days |
ALPRAZOLAM 2 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | Q:150 /30Days |
ALTAVERA-28 TABLET [Portia] |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
ALUNBRIG 180 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
ALUNBRIG 30 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:180 /30Days |
ALUNBRIG 90 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
ALUNBRIG 90 MG-180 MG TABLET PACK |
5 |
Specialty Tier |
25% | N/A | P Q:60 /365Days |
ALYACEN 1-35-28 TABLET |
2 |
Generic |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMANTADINE 100 MG CAPSULE |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
AMANTADINE 100 MG TABLET |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
AMANTADINE 50 MG/5 ML SOLUTION |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
AMBISOME 50MG VIAL |
5 |
Specialty Tier |
25% | N/A | P |
AMBRISENTAN 10 MG TABLET [LETAIRIS] |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
AMBRISENTAN 5 MG TABLET [LETAIRIS] |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
AMETHIA 0.15-0.03-0.01 MG TABLET |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:91 /91Days |
AMETHIA LO TABLET |
2 |
Generic |
$3.00 | $9.00 | Q:91 /91Days |
AMIKACIN SULF 500 MG/2 ML VIAL |
4 |
Non-Preferred Drug |
35% | 35% | None |
AMILORIDE HCL 5 MG TABLET [Midamor] |
2 |
Generic |
$3.00 | $9.00 | None |
AMILORIDE HCL-HCTZ 5-50 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Amino Acids 15% Solution |
4 |
Non-Preferred Drug |
35% | 35% | P |
Amino acids 4.25% in dextrose 10% Injectable Solution [Clinimix 4.25/10] |
4 |
Non-Preferred Drug |
35% | 35% | P |
Amino acids 4.25% in dextrose 5% Injectable Solution [Clinimix 4.25/5] |
4 |
Non-Preferred Drug |
35% | 35% | P |
Amino acids 4.25% with electrolytes in dextrose 10% Injectable Solution [Clinimix E 4.25/10] |
4 |
Non-Preferred Drug |
35% | 35% | P |
AMINOSYN II 10% SOL 6X2000 ML |
4 |
Non-Preferred Drug |
35% | 35% | P |
AMINOSYN II 15% IV SOLUTION |
4 |
Non-Preferred Drug |
35% | 35% | P |
AMINOSYN PF INJECTION |
4 |
Non-Preferred Drug |
35% | 35% | P |
AMINOSYN-PF 7% IV SOLUTION |
4 |
Non-Preferred Drug |
35% | 35% | P |
AMIODARONE HCL 100 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | None |
AMIODARONE HCL 200 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | None |
AMIODARONE HCL 400 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITIZA 8MCG CAPSULE |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:60 /30Days |
AMITIZA CAPSULES 24MCG 60 CAP BOT |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:60 /30Days |
AMITRIP/PERPHEN 10-4 TABLET |
4 |
Non-Preferred Drug |
35% | 35% | P |
AMITRIP/PERPHEN 50-4 TABLET |
4 |
Non-Preferred Drug |
35% | 35% | P |
AMITRIPTYLINE HCL 10 MG TAB |
2 |
Generic |
$3.00 | $9.00 | P |
AMITRIPTYLINE HCL 100 MG TAB |
2 |
Generic |
$3.00 | $9.00 | P |
AMITRIPTYLINE HCL 150 MG TAB |
2 |
Generic |
$3.00 | $9.00 | P |
AMITRIPTYLINE HCL 25 MG TAB |
2 |
Generic |
$3.00 | $9.00 | P |
AMITRIPTYLINE HCL 50 MG TAB |
2 |
Generic |
$3.00 | $9.00 | P |
AMITRIPTYLINE HCL 75 MG TAB |
2 |
Generic |
$3.00 | $9.00 | P |
AMLOD-VALSA-HCTZ 10-160-12.5MG [Exforge HCT] |
2 |
Generic |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLOD-VALSA-HCTZ 10-160-25 MG [Exforge HCT] |
2 |
Generic |
$3.00 | $9.00 | None |
AMLOD-VALSA-HCTZ 10-320-25 MG [Exforge HCT] |
2 |
Generic |
$3.00 | $9.00 | None |
AMLOD-VALSA-HCTZ 5-160-12.5 MG [Exforge HCT] |
2 |
Generic |
$3.00 | $9.00 | None |
AMLOD-VALSA-HCTZ 5-160-25 MG [Exforge HCT] |
2 |
Generic |
$3.00 | $9.00 | None |
AMLODIPINE BESYLATE 10 MG TABLET [Norvasc] |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
AMLODIPINE BESYLATE 2.5 MG TAB |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:120 /30Days |
AMLODIPINE BESYLATE 5 MG TABLET [Norvasc] |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:60 /30Days |
AMLODIPINE-BENAZEPRIL 10-20 MG Capsule [Lotrel] |
2 |
Generic |
$3.00 | $9.00 | Q:30 /30Days |
AMLODIPINE-BENAZEPRIL 10-40 MG Capsule [Lotrel] |
2 |
Generic |
$3.00 | $9.00 | Q:30 /30Days |
AMLODIPINE-BENAZEPRIL 2.5-10 Capsule [Lotrel] |
2 |
Generic |
$3.00 | $9.00 | Q:60 /30Days |
AMLODIPINE-BENAZEPRIL 5-10 MG Capsule [Lotrel] |
2 |
Generic |
$3.00 | $9.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE-BENAZEPRIL 5-20 MG Capsule [Lotrel] |
2 |
Generic |
$3.00 | $9.00 | Q:60 /30Days |
AMLODIPINE-BENAZEPRIL 5-40 MG Capsule [Lotrel] |
2 |
Generic |
$3.00 | $9.00 | Q:60 /30Days |
AMLODIPINE-VALSARTAN 10-160 MG |
2 |
Generic |
$3.00 | $9.00 | None |
AMLODIPINE-VALSARTAN 10-320 MG |
2 |
Generic |
$3.00 | $9.00 | None |
AMLODIPINE-VALSARTAN 5-160 MG |
2 |
Generic |
$3.00 | $9.00 | None |
AMLODIPINE-VALSARTAN 5-320 MG |
2 |
Generic |
$3.00 | $9.00 | None |
AMMONIUM LACTATE 12% CREAM |
2 |
Generic |
$3.00 | $9.00 | None |
AMMONIUM LACTATE 12% LOTION |
2 |
Generic |
$3.00 | $9.00 | None |
AMNESTEEM 10 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | None |
AMNESTEEM 20 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | None |
AMNESTEEM 40 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE [Augmentin] |
2 |
Generic |
$3.00 | $9.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin] |
2 |
Generic |
$3.00 | $9.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE [Augmentin] |
2 |
Generic |
$3.00 | $9.00 | None |
AMOX-CLAV 200-28.5 MG/5 ML SUS |
2 |
Generic |
$3.00 | $9.00 | None |
AMOX-CLAV 250-62.5 MG/5 ML SUS |
2 |
Generic |
$3.00 | $9.00 | None |
AMOX-CLAV 400-57 MG/5 ML SUSP |
2 |
Generic |
$3.00 | $9.00 | None |
AMOX-CLAV 500-125 MG TABLET [Augmentin] |
2 |
Generic |
$3.00 | $9.00 | None |
AMOX-CLAV 600-42.9 MG/5 ML SUS |
2 |
Generic |
$3.00 | $9.00 | None |
AMOX-CLAV 875-125 MG TABLET [Augmentin] |
2 |
Generic |
$3.00 | $9.00 | None |
AMOX-CLAV ER 1,000-62.5 MG TABLET [Augmentin] |
4 |
Non-Preferred Drug |
35% | 35% | None |
AMOXAPINE 100MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXAPINE 150MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
AMOXAPINE 25MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
AMOXAPINE 50MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
AMOXICILLIN 125 MG/5 ML SUSP |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
AMOXICILLIN 125MG TABLET CHEW |
2 |
Generic |
$3.00 | $9.00 | None |
AMOXICILLIN 200 MG/5 ML SUSP |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
AMOXICILLIN 250 MG CAPSULE |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
AMOXICILLIN 250 MG TAB CHEW |
2 |
Generic |
$3.00 | $9.00 | None |
AMOXICILLIN 250 MG/5 ML SUSP |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
AMOXICILLIN 400 MG/5 ML SUSP |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
AMOXICILLIN 500 MG CAPSULE |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN 500 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | None |
AMOXICILLIN 875 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:60 /30Days |
AMPHETAMINE SALT COMBO 15MG TABLET |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:60 /30Days |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:60 /30Days |
AMPHETAMINE SALTS 5 MG TAB |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:60 /30Days |
amphotericin b 50mg/10mL 10 mL in 1 VIAL |
4 |
Non-Preferred Drug |
35% | 35% | P |
AMPICILLIN 10 GM VIAL |
4 |
Non-Preferred Drug |
35% | 35% | None |
Ampicillin 1000 MG / Sulbactam 500 MG Injection |
4 |
Non-Preferred Drug |
35% | 35% | None |
Ampicillin 1000 MG Injection |
4 |
Non-Preferred Drug |
35% | 35% | None |
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS |
4 |
Non-Preferred Drug |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ampicillin 2000 MG / Sulbactam 1000 MG Injection |
4 |
Non-Preferred Drug |
35% | 35% | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
2 |
Generic |
$3.00 | $9.00 | None |
AMPICILLIN-SULBACTAM 15 GM VL |
4 |
Non-Preferred Drug |
35% | 35% | None |
AMPYRA ER 10 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
ANADROL-50 TABLET |
5 |
Specialty Tier |
25% | N/A | P |
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
ANASTROZOLE 1 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | Q:30 /30Days |
ANORO ELLIPTA 62.5-25 MCG INH |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:60 /30Days |
APOKYN 30 MG/3 ML CARTRIDGE |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
Apraclonidine 5 MG/ML Ophthalmic Solution |
4 |
Non-Preferred Drug |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APREPITANT 125 MG CAPSULE [Emend] |
4 |
Non-Preferred Drug |
35% | 35% | P Q:2 /28Days |
APREPITANT 125-80-80 MG PACK [Emend] |
4 |
Non-Preferred Drug |
35% | 35% | P Q:6 /28Days |
APREPITANT 40 MG CAPSULE [Emend] |
4 |
Non-Preferred Drug |
35% | 35% | P Q:1 /30Days |
APREPITANT 80 MG CAPSULE [Emend] |
4 |
Non-Preferred Drug |
35% | 35% | P Q:4 /28Days |
APRI 0.15-0.03 TABLET |
2 |
Generic |
$3.00 | $9.00 | None |
APRISO CP24 |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:120 /30Days |
APTIOM 200 MG TABLET |
5 |
Specialty Tier |
25% | N/A | S Q:30 /30Days |
APTIOM 400 MG TABLET |
5 |
Specialty Tier |
25% | N/A | S Q:30 /30Days |
APTIOM 600 MG TABLET |
5 |
Specialty Tier |
25% | N/A | S Q:60 /30Days |
APTIOM 800 MG TABLET |
5 |
Specialty Tier |
25% | N/A | S Q:30 /30Days |
APTIVUS 250MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
5 |
Specialty Tier |
25% | N/A | Q:285 /28Days |
ARALAST NP 1,000 MG VIAL |
5 |
Specialty Tier |
25% | N/A | P |
ARANELLE 7-9-5 TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
ARANESP 10 MCG/0.4 ML SYRINGE |
4 |
Non-Preferred Drug |
35% | 35% | P Q:2 /28Days |
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.5 mL in 1 SYRINGE |
5 |
Specialty Tier |
25% | N/A | P Q:2 /28Days |
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
5 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
ARANESP 200MCG/0.4ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P Q:2 /28Days |
ARANESP 200MCG/ML VIAL |
5 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.42 mL in 1 SYRING |
4 |
Non-Preferred Drug |
35% | 35% | P Q:2 /28Days |
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
4 |
Non-Preferred Drug |
35% | 35% | P Q:4 /28Days |
ARANESP 300MCG/ML VIAL |
5 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP 500MCG/1ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P Q:1 /21Days |
ARANESP 60MCG/ML VIAL |
5 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.3 mL in 1 SYRINGE |
4 |
Non-Preferred Drug |
35% | 35% | P Q:1 /28Days |
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR |
5 |
Specialty Tier |
25% | N/A | P Q:1 /28Days |
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR |
5 |
Specialty Tier |
25% | N/A | P Q:2 /28Days |
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR |
4 |
Non-Preferred Drug |
35% | 35% | P Q:2 /28Days |
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD |
4 |
Non-Preferred Drug |
35% | 35% | P Q:4 /28Days |
ARCALYST INJECTION 220MG/VIAL |
5 |
Specialty Tier |
25% | N/A | P |
ARIPIPRAZOLE 1 MG/ML SOLUTION [Abilify] |
4 |
Non-Preferred Drug |
35% | 35% | Q:900 /30Days |
ARIPIPRAZOLE 10 MG TABLET [Abilify] |
4 |
Non-Preferred Drug |
35% | 35% | Q:30 /30Days |
ARIPIPRAZOLE 15 MG TABLET [Abilify] |
4 |
Non-Preferred Drug |
35% | 35% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARIPIPRAZOLE 2 MG TABLET [Abilify] |
4 |
Non-Preferred Drug |
35% | 35% | Q:30 /30Days |
ARIPIPRAZOLE 20 MG TABLET [Abilify] |
4 |
Non-Preferred Drug |
35% | 35% | Q:30 /30Days |
ARIPIPRAZOLE 30 MG TABLET [Abilify] |
4 |
Non-Preferred Drug |
35% | 35% | Q:30 /30Days |
ARIPIPRAZOLE 5 MG TABLET [Abilify] |
4 |
Non-Preferred Drug |
35% | 35% | Q:30 /30Days |
ARIPIPRAZOLE ODT 10 MG TABLET RAPDIS [Abilify Discmelt] |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
ARIPIPRAZOLE ODT 15 MG TABLET RAPDIS [Abilify Discmelt] |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
ARISTADA ER 1064 MG/3.9 ML SYR |
5 |
Specialty Tier |
25% | N/A | Q:4 /56Days |
ARISTADA ER 441 MG/1.6 ML SYRN |
5 |
Specialty Tier |
25% | N/A | Q:2 /28Days |
ARISTADA ER 662 MG/2.4 ML SYRN |
5 |
Specialty Tier |
25% | N/A | Q:2 /28Days |
ARISTADA ER 882 MG/3.2 ML SYRN |
5 |
Specialty Tier |
25% | N/A | Q:3 /28Days |
ARISTADA INITIO ER 675 MG/2.4 SUSER SYR |
5 |
Specialty Tier |
25% | N/A | Q:5 /365Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Armodafinil 150 MG TABLET [NUVIGIL] |
4 |
Non-Preferred Drug |
35% | 35% | P Q:30 /30Days |
Armodafinil 200 MG Oral Tablet [NUVIGIL] |
4 |
Non-Preferred Drug |
35% | 35% | P Q:30 /30Days |
Armodafinil 250 MG TABLET [NUVIGIL] |
4 |
Non-Preferred Drug |
35% | 35% | P Q:30 /30Days |
Armodafinil 50 MG TABLET [NUVIGIL] |
4 |
Non-Preferred Drug |
35% | 35% | P Q:30 /30Days |
ARNUITY ELLIPTA 100 MCG INH |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:30 /30Days |
ARNUITY ELLIPTA 200 MCG INH |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:30 /30Days |
ARNUITY ELLIPTA 50 MCG INH BLST W/DEV |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:30 /30Days |
ASCOMP WITH CODEINE CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | P Q:180 /30Days |
ASHLYNA 0.15-0.03-0.01 MG TAB |
4 |
Non-Preferred Drug |
35% | 35% | Q:91 /91Days |
Aspirin-Diphenhydramine ER 25-200 MG |
4 |
Non-Preferred Drug |
35% | 35% | Q:60 /30Days |
ASTAGRAF XL 0.5 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ASTAGRAF XL 1 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | P |
ASTAGRAF XL 5 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | P |
ATAZANAVIR SULFATE 150 MG CAP [Reyataz] |
4 |
Non-Preferred Drug |
35% | 35% | Q:30 /30Days |
ATAZANAVIR SULFATE 200 MG CAP [Reyataz] |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
ATAZANAVIR SULFATE 300 MG CAP [Reyataz] |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
ATENOLOL 100 MG TABLET |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
ATENOLOL 25 MG TABLET |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
ATENOLOL 50 MG TABLET |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
ATENOLOL-CHLORTHALIDONE 100-25 |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
ATOMOXETINE HCL 10 MG CAPSULE [Strattera] |
4 |
Non-Preferred Drug |
35% | 35% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATOMOXETINE HCL 100 MG CAPSULE [Strattera] |
4 |
Non-Preferred Drug |
35% | 35% | Q:30 /30Days |
ATOMOXETINE HCL 18 MG CAPSULE [Strattera] |
4 |
Non-Preferred Drug |
35% | 35% | Q:60 /30Days |
ATOMOXETINE HCL 25 MG CAPSULE [Strattera] |
4 |
Non-Preferred Drug |
35% | 35% | Q:60 /30Days |
ATOMOXETINE HCL 40 MG CAPSULE [Strattera] |
4 |
Non-Preferred Drug |
35% | 35% | Q:60 /30Days |
ATOMOXETINE HCL 60 MG CAPSULE [Strattera] |
4 |
Non-Preferred Drug |
35% | 35% | Q:30 /30Days |
ATOMOXETINE HCL 80 MG CAPSULE [Strattera] |
4 |
Non-Preferred Drug |
35% | 35% | Q:30 /30Days |
ATORVASTATIN 10 MG TABLET [Lipitor] |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
ATORVASTATIN 20 MG TABLET [Lipitor] |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
ATORVASTATIN 40 MG TABLET [Lipitor] |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
ATORVASTATIN 80 MG TABLET [Lipitor] |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
ATOVAQUONE 750 MG/5 ML SUSP [Mepron] |
4 |
Non-Preferred Drug |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone] |
4 |
Non-Preferred Drug |
35% | 35% | None |
ATOVAQUONE-PROGUANIL 62.5-25 [Malarone] |
4 |
Non-Preferred Drug |
35% | 35% | None |
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
ATROPINE 1% EYE DROPS |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
ATROVENT HFA AER 17MCG |
4 |
Non-Preferred Drug |
35% | 35% | Q:26 /30Days |
AUBRA-28 TABLET |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
AURYXIA 210 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | P Q:360 /30Days |
AVIANE 0.1-0.02 TABLET |
2 |
Generic |
$3.00 | $9.00 | None |
AVITA 0.025% CREAM |
4 |
Non-Preferred Drug |
35% | 35% | P Q:45 /30Days |
Avita 0.25mg/g 45 g in 1 TUBE |
4 |
Non-Preferred Drug |
35% | 35% | P |
AVONEX ADMIN PACK 30 MCG VL |
5 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVONEX PEN 30 MCG/0.5 ML KIT |
5 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
AVONEX PREFILLED SYR 30 MCG KT |
5 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
AZASAN 100MG TABLET |
3 |
Preferred Brand |
$30.00 | $90.00 | P |
AZASAN 75MG TABLET |
3 |
Preferred Brand |
$30.00 | $90.00 | P |
AZASITE 1% EYE DROPS |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
AZATHIOPRINE 50 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | P |
AZELASTINE 0.15% NASAL SPRAY |
4 |
Non-Preferred Drug |
35% | 35% | Q:30 /25Days |
AZELASTINE 137 MCG NASAL SPRAY |
4 |
Non-Preferred Drug |
35% | 35% | Q:30 /25Days |
AZELASTINE HCL 0.05% DROPS |
4 |
Non-Preferred Drug |
35% | 35% | None |
AZITHROMYCIN 1 GM PWD PACKET |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
AZITHROMYCIN 100 MG/5 ML SUSP |
4 |
Non-Preferred Drug |
35% | 35% | Q:150 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZITHROMYCIN 200 MG/5 ML SUSP |
4 |
Non-Preferred Drug |
35% | 35% | Q:90 /30Days |
AZITHROMYCIN 250 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | Q:12 /28Days |
AZITHROMYCIN 250 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | Q:12 /28Days |
AZITHROMYCIN 500 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | Q:12 /28Days |
AZITHROMYCIN 500 MG TABLET [Zithromax Tri-Pak] |
2 |
Generic |
$3.00 | $9.00 | Q:12 /28Days |
AZITHROMYCIN 600 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | Q:60 /30Days |
AZITHROMYCIN I.V. 500 MG VIAL |
4 |
Non-Preferred Drug |
35% | 35% | None |
AZOPT 1% EYE DROPS |
3 |
Preferred Brand |
$30.00 | $90.00 | None |
Aztreonam 1000 MG Injection [Azactam] |
4 |
Non-Preferred Drug |
35% | 35% | None |
Aztreonam 2000 MG Injection [Azactam] |
4 |
Non-Preferred Drug |
35% | 35% | None |
AZTREONAM FOR INJECTION |
4 |
Non-Preferred Drug |
35% | 35% | None |