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Solis Health Plans (HMO) (H0982-001-0)
Tier 1 (689)
Tier 2 (1760)
Tier 3 (502)
Tier 4 (1632)
Tier 5 (592)
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2019 Medicare Part D Plan Formulary Information
Solis Health Plans (HMO) (H0982-001-0)
Benefit Details           
The Solis Health Plans (HMO) (H0982-001-0)
Formulary Drugs Starting with the Letter C

in Miami-Dade County, FL: CMS MA Region 9 which includes: FL
Plan Monthly Premium: $0.00 Deductible: $0
Drugs Starting with Letter C

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
CABERGOLINE 0.5 MG TABLET   2 Generic $0.00$0.00None
CABOMETYX 20 MG TABLET   5 Specialty Tier 33%33%P
CABOMETYX 40 MG TABLET   5 Specialty Tier 33%33%P
CABOMETYX 60 MG TABLET   5 Specialty Tier 33%33%P
Caduet 10; 10mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Brand $30.00$75.00None
Caduet 10; 20mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Brand $30.00$75.00None
CADUET 10MG/40MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CADUET 10MG/80MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CADUET 5MG/10MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CADUET 5MG/20MG TABLET   4 Non-Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CADUET 5MG/40MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CADUET 5MG/80MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CALAN 120MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CALAN SR 120MG CAPLET SA   4 Non-Preferred Brand $30.00$75.00None
CALAN SR 240 MG CAPLET   4 Non-Preferred Brand $30.00$75.00None
CALCIPOTRIENE 0.005% CREAM   2 Generic $0.00$0.00None
CALCIPOTRIENE 0.005% SOLUTION   2 Generic $0.00$0.00None
Calcipotriene 50ug/g 60 g per CARTON   2 Generic $0.00$0.00None
Calcipotriene-Betamethasone Dipropionate Ointment [Taclonex]   2 Generic $0.00$0.00None
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY   2 Generic $0.00$0.00None
CALCITRIOL 0.25 MCG CAPSULE [Rocaltrol]   2 Generic $0.00$0.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CALCITRIOL 0.5 MCG CAPSULE [Rocaltrol]   2 Generic $0.00$0.00P
CALCITRIOL 1MCG/ML SOLUTION ORAL   2 Generic $0.00$0.00P
CALCITRIOL 3 MCG/G OINTMENT   4 Non-Preferred Brand $30.00$75.00None
CALCIUM ACETATE 667 MG TABLET [PhosLo]   2 Generic $0.00$0.00None
CALCIUM ACETATE CAPSULE 667 MG   2 Generic $0.00$0.00None
CALQUENCE 100 MG CAPSULE   5 Specialty Tier 33%33%P Q:60
/30Days
CAMILA 0.35 MG TABLET   2 Generic $0.00$0.00None
CAMRESE LO TABLET   2 Generic $0.00$0.00None
CANASA 1,000 MG SUPPOSITORY   3 Preferred Brand $10.00$20.00None
CANCIDAS IV 50MG VIAL   5 Specialty Tier 33%33%None
CANCIDAS IV 70MG VIAL   5 Specialty Tier 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CAPEX SHA 0.01%   4 Non-Preferred Brand $30.00$75.00None
CAPRELSA 100 MG TABLET   5 Specialty Tier 33%33%P Q:60
/30Days
CAPRELSA 300 MG TABLET   5 Specialty Tier 33%33%P Q:30
/30Days
CAPTOPRIL 100MG TABLET   2 Generic $0.00$0.00None
CAPTOPRIL 12.5MG TABLET   2 Generic $0.00$0.00None
CAPTOPRIL 25 MG TABLET   2 Generic $0.00$0.00None
CAPTOPRIL 50MG TABLET   2 Generic $0.00$0.00None
Captopril and Hydrochlorothiazide 25; 15mg 100 TABLET BOTTLE   2 Generic $0.00$0.00None
Captopril and Hydrochlorothiazide 25; 25mg 100 TABLET BOTTLE   2 Generic $0.00$0.00None
Captopril and Hydrochlorothiazide 50; 15mg 100 TABLET BOTTLE   2 Generic $0.00$0.00None
Captopril and Hydrochlorothiazide 50; 25mg 100 TABLET BOTTLE   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARAC CREAM   4 Non-Preferred Brand $30.00$75.00None
CARAFATE SUCRALFATE 1G TABLET ORAL   4 Non-Preferred Brand $30.00$75.00None
CARAFATE SUS 1GM/10ML   3 Preferred Brand $10.00$20.00None
CARBAGLU 200 MG DISPER TABLET   4 Non-Preferred Brand $30.00$75.00P
CARBAMAZEPINE 100 MG TAB CHEW   2 Generic $0.00$0.00None
CARBAMAZEPINE 100 MG/5 ML SUSP   2 Generic $0.00$0.00None
CARBAMAZEPINE 200 MG TABLET   2 Generic $0.00$0.00None
CARBAMAZEPINE ER 100 MG CAP CPMP 12HR [Carbatrol]   2 Generic $0.00$0.00None
CARBAMAZEPINE ER 100 MG TABLET   2 Generic $0.00$0.00None
CARBAMAZEPINE ER 200 MG CAP CPMP 12HR [Carbatrol]   2 Generic $0.00$0.00None
CARBAMAZEPINE ER 300 MG CAP CPMP 12HR [Carbatrol]   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBAMAZEPINE XR 200 MG TABLET   2 Generic $0.00$0.00None
CARBAMAZEPINE XR 400 MG TABLET   2 Generic $0.00$0.00None
Carbatrol 100mg/1 120 CAPSULE, ER in BOTTLE   4 Non-Preferred Brand $30.00$75.00None
CARBATROL 200MG CAPSULE SA   4 Non-Preferred Brand $30.00$75.00None
CARBATROL 300MG CAPSULE SA   4 Non-Preferred Brand $30.00$75.00None
Carbidopa 25mg Tab 100 [Lodosyn]   2 Generic $0.00$0.00None
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT   2 Generic $0.00$0.00None
CARBIDOPA AND LEVODOPA ODT 25;100MG;MG 100 BOT   2 Generic $0.00$0.00None
CARBIDOPA AND LEVODOPA ODT 25;250MG;MG 100 BOT   2 Generic $0.00$0.00None
CARBIDOPA-LEVO ER 25-100 TAB   1 Preferred Generic $0.00$0.00None
CARBIDOPA-LEVO ER 50-200 TAB   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBIDOPA-LEVODOPA 10-100 TAB   1 Preferred Generic $0.00$0.00None
CARBIDOPA-LEVODOPA 25-100 TAB   1 Preferred Generic $0.00$0.00None
CARBIDOPA-LEVODOPA 25-250 TAB   1 Preferred Generic $0.00$0.00None
CARBIDOPA-LEVODOPA-ENTA 150 MG   2 Generic $0.00$0.00None
CARBIDOPA-LEVODOPA-ENTA 75 MG   2 Generic $0.00$0.00None
CARBIDOPA-LEVODOPA-ENTACAPONE 100 MG [Stalevo]   2 Generic $0.00$0.00None
CARBIDOPA-LEVODOPA-ENTACAPONE 125 MG [Stalevo]   2 Generic $0.00$0.00None
CARBIDOPA-LEVODOPA-ENTACAPONE 200 MG [Stalevo]   2 Generic $0.00$0.00None
CARBIDOPA-LEVODOPA-ENTACAPONE 50 MG [Stalevo]   2 Generic $0.00$0.00None
CARDIZEM 120 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CARDIZEM 30 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARDIZEM 60 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CARDIZEM CD 120 MG CAPSULE   4 Non-Preferred Brand $30.00$75.00None
CARDIZEM CD 180 MG CAPSULE   4 Non-Preferred Brand $30.00$75.00None
CARDIZEM CD 240 MG CAPSULE   4 Non-Preferred Brand $30.00$75.00None
CARDIZEM CD 300 MG CAPSULE ER 24H   4 Non-Preferred Brand $30.00$75.00None
CARDIZEM CD 360 MG CAPSULE   4 Non-Preferred Brand $30.00$75.00None
CARDIZEM LA 120 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CARDIZEM LA 180 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CARDIZEM LA 240 MG TABLET ER 24H   4 Non-Preferred Brand $30.00$75.00None
CARDIZEM LA 300 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CARDIZEM LA 360 MG TABLET ER 24H   4 Non-Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARDIZEM LA 420 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CARDURA 1MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CARDURA 2MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CARDURA 4MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CARDURA 8MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CARDURA XL 4MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CARDURA XL 8MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CARISOPRODOL 350 MG TABLET   2 Generic $0.00$0.00None
CARNITOR 100MG/ML ORAL TUBEX   4 Non-Preferred Brand $30.00$75.00P
CARNITOR 330MG TABLET   4 Non-Preferred Brand $30.00$75.00P
CARTEOLOL HCL 1% EYE DROPS   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARTIA XT 120MG CAPSULE SA   2 Generic $0.00$0.00None
CARTIA XT 180MG CAPSULE SA   2 Generic $0.00$0.00None
CARTIA XT 240MG CAPSULE SA   2 Generic $0.00$0.00None
CARTIA XT 300 MG CAPSULE   2 Generic $0.00$0.00None
CARVEDILOL 12.5 MG TABLET   1 Preferred Generic $0.00$0.00None
CARVEDILOL 25 MG TABLET   1 Preferred Generic $0.00$0.00None
CARVEDILOL 3.125 MG TABLET   1 Preferred Generic $0.00$0.00None
CARVEDILOL 6.25 MG TABLET   1 Preferred Generic $0.00$0.00None
CARVEDILOL ER 10 MG CAPSULE   2 Generic $0.00$0.00None
CARVEDILOL ER 20 MG CAPSULE   2 Generic $0.00$0.00None
CARVEDILOL ER 40 MG CAPSULE   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARVEDILOL ER 80 MG CAPSULE   2 Generic $0.00$0.00None
CASODEX 50 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CASPOFUNGIN ACETATE 50 MG VIAL   5 Specialty Tier 33%33%None
CASPOFUNGIN ACETATE 70 MG VIAL   5 Specialty Tier 33%33%None
CATAPRES 0.1 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CATAPRES 0.2 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CATAPRES 0.3 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CATAPRES-TTS DIS 0.3/24HR 7.5MG/UNT   4 Non-Preferred Brand $30.00$75.00None
CATAPRES-TTS-1 PATCH 2.52.5MG/UNT 1 X 4 CRTN   4 Non-Preferred Brand $30.00$75.00None
CATAPRES-TTS-2 PATCH 52.5MG/UNT 1 X 4 CRTN   4 Non-Preferred Brand $30.00$75.00None
CAYSTON KIT 75 MG/VIAL   5 Specialty Tier 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CAZIANT 28 DAY TABLET   2 Generic $0.00$0.00None
CEFACLOR 125 MG/5 ML SUSP Oral Suspension [Ceclor]   2 Generic $0.00$0.00None
CEFACLOR 250 MG CAPSULES   2 Generic $0.00$0.00None
CEFACLOR 250 MG/5 ML SUSPEN Oral Suspension [Ceclor]   2 Generic $0.00$0.00None
CEFACLOR 375 MG/5 ML SUSPEN Oral Suspension [Ceclor]   2 Generic $0.00$0.00None
CEFACLOR 500 MG CAPSULES   2 Generic $0.00$0.00None
CEFACLOR ER 500MG TABLET SR 12HR   4 Non-Preferred Brand $30.00$75.00None
CEFADROXIL 1 GM TABLET   2 Generic $0.00$0.00None
CEFADROXIL 250 MG/5 ML SUSP   2 Generic $0.00$0.00None
CEFADROXIL 500 MG CAPSULE   1 Preferred Generic $0.00$0.00None
CEFADROXIL 500 MG/5 ML SUSP   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFAZOLIN 1 GM VIAL 25/Box   2 Generic $0.00$0.00None
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE   2 Generic $0.00$0.00None
CEFAZOLIN 500 MG VIAL   2 Generic $0.00$0.00None
CEFDINIR 125 MG/5 ML SUSP   1 Preferred Generic $0.00$0.00None
CEFDINIR 250 MG/5 ML SUSP   1 Preferred Generic $0.00$0.00None
CEFDINIR 300 MG CAPSULE   1 Preferred Generic $0.00$0.00None
CEFEPIME HCL 1 GM VIAL [Maxipime]   2 Generic $0.00$0.00None
CEFEPIME HCL 2 GRAM VIAL [Maxipime]   2 Generic $0.00$0.00None
CEFIXIME 100 MG/5 ML SUSP [Suprax]   2 Generic $0.00$0.00None
CEFIXIME 200 MG/5 ML SUSP [Suprax]   2 Generic $0.00$0.00None
Cefotaxime 500 MG Injection   3 Preferred Brand $10.00$20.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Cefotaxime sodium 1 gm vial   3 Preferred Brand $10.00$20.00None
CEFOXITIN 1 GM VIAL   2 Generic $0.00$0.00None
CEFOXITIN 10 GM VIAL   2 Generic $0.00$0.00None
CEFOXITIN 2 GM VIAL   2 Generic $0.00$0.00None
CEFPODOXIME 100 MG TABLET   2 Generic $0.00$0.00None
CEFPODOXIME 100 MG/5 ML SUSP   2 Generic $0.00$0.00None
CEFPODOXIME 200 MG TABLET   2 Generic $0.00$0.00None
CEFPODOXIME 50 MG/5 ML SUSP   2 Generic $0.00$0.00None
CEFPROZIL 125 MG/5 ML SUSP   1 Preferred Generic $0.00$0.00None
CEFPROZIL 250 MG TABLET   1 Preferred Generic $0.00$0.00None
CEFPROZIL 250 MG/5 ML SUSP   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFPROZIL 500 MG TABLET   1 Preferred Generic $0.00$0.00None
CEFTAZIDIME 1 GM VIAL   2 Generic $0.00$0.00None
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN   2 Generic $0.00$0.00None
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN   2 Generic $0.00$0.00None
CEFTRIAXONE 1 GM VIAL   2 Generic $0.00$0.00None
CEFTRIAXONE 10 GM VIAL   2 Generic $0.00$0.00None
CEFTRIAXONE 2 GM VIAL   2 Generic $0.00$0.00None
CEFTRIAXONE 250 MG VIAL   2 Generic $0.00$0.00None
CEFTRIAXONE 500 MG VIAL   2 Generic $0.00$0.00None
CEFUROXIME 1.5 GM/VIAL FOR INJECTION   2 Generic $0.00$0.00None
CEFUROXIME 750 MG FOR INJECTION   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Cefuroxime 95 MG/ML Injectable Solution   2 Generic $0.00$0.00None
CEFUROXIME AXETIL 250 MG TAB   2 Generic $0.00$0.00None
CEFUROXIME AXETIL 500 MG TAB   2 Generic $0.00$0.00None
CELEBREX 100 MG CAPSULE   4 Non-Preferred Brand $30.00$75.00Q:60
/30Days
CELEBREX 200 MG CAPSULE   4 Non-Preferred Brand $30.00$75.00Q:60
/30Days
CELEBREX 400 MG CAPSULE   4 Non-Preferred Brand $30.00$75.00Q:60
/30Days
CELEBREX 50 MG CAPSULE   4 Non-Preferred Brand $30.00$75.00Q:60
/30Days
CELECOXIB 100 MG CAPSULE [Celebrex]   1 Preferred Generic $0.00$0.00Q:60
/30Days
CELECOXIB 200 MG CAPSULE [Celebrex]   1 Preferred Generic $0.00$0.00Q:60
/30Days
CELECOXIB 400 MG CAPSULE [Celebrex]   1 Preferred Generic $0.00$0.00Q:60
/30Days
CELECOXIB 50 MG CAPSULE [Celebrex]   1 Preferred Generic $0.00$0.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CELEXA 10 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CELEXA 20 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CELEXA 40 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CELLCEPT 200 MG/ML ORAL SUSP   4 Non-Preferred Brand $30.00$75.00P
CELLCEPT 250 MG CAPSULE   4 Non-Preferred Brand $30.00$75.00P
CELLCEPT 500 MG TABLET   4 Non-Preferred Brand $30.00$75.00P
CELONTIN 300 MG KAPSEAL   3 Preferred Brand $10.00$20.00None
CEPHALEXIN 125 MG/5 ML SUSP   1 Preferred Generic $0.00$0.00None
CEPHALEXIN 250 MG CAPSULE   1 Preferred Generic $0.00$0.00None
CEPHALEXIN 250 MG/5 ML SUSP   1 Preferred Generic $0.00$0.00None
CEPHALEXIN 500 MG CAPSULE   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CERDELGA 84 MG CAPSULE   5 Specialty Tier 33%33%P Q:60
/30Days
CESAMET 1 MG CAPSULES   4 Non-Preferred Brand $30.00$75.00P
CETIRIZINE HCL 1 MG/ML SOLN   2 Generic $0.00$0.00None
CETRAXAL 0.2% EAR SOLUTION DROPERETTE   3 Preferred Brand $10.00$20.00None
CEVIMELINE HCL 30 MG CAPSULE [Evoxac]   2 Generic $0.00$0.00None
CHANTIX 0.5 MG TABLET   3 Preferred Brand $10.00$20.00None
CHANTIX 1 MG CONT MONTH BOX   3 Preferred Brand $10.00$20.00None
CHANTIX 1 MG TABLET   3 Preferred Brand $10.00$20.00None
CHANTIX STARTING MONTH BOX   3 Preferred Brand $10.00$20.00None
CHEMET 100 MG CAPSULE   3 Preferred Brand $10.00$20.00None
CHENODAL 250 MG TABLET   5 Specialty Tier 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHLORDIAZEPO-AMITRIPTYL 5-12.5   2 Generic $0.00$0.00None
CHLORDIAZEPOXIDE 10 MG CAPSULE   1 Preferred Generic $0.00$0.00None
CHLORDIAZEPOXIDE 25 MG CAPSULE   1 Preferred Generic $0.00$0.00None
CHLORDIAZEPOXIDE 5 MG CAPSULE   1 Preferred Generic $0.00$0.00None
CHLORHEXIDINE GLUCONATE 0.12% RINSE   1 Preferred Generic $0.00$0.00None
CHLOROQUINE PH 250 MG TABLET   2 Generic $0.00$0.00None
CHLOROQUINE PH 500 MG TABLET   2 Generic $0.00$0.00None
CHLOROTHIAZIDE 250 MG TABLET   2 Generic $0.00$0.00None
Chlorothiazide 500mg 100 TABLET BOTTLE   2 Generic $0.00$0.00None
CHLORPROMAZINE 10 MG TABLET   2 Generic $0.00$0.00None
CHLORPROMAZINE 100 MG TABLET   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHLORPROMAZINE 200 MG TABLET   2 Generic $0.00$0.00None
CHLORPROMAZINE 25 MG TABLET   2 Generic $0.00$0.00None
CHLORPROMAZINE 50 MG TABLET   2 Generic $0.00$0.00None
CHLORTHALIDONE 25 MG TABLET (100 CT)   2 Generic $0.00$0.00None
CHLORTHALIDONE 50 MG TABLET   2 Generic $0.00$0.00None
CHLORZOXAZONE 500 MG TABLET   1 Preferred Generic $0.00$0.00None
CHOLBAM 250 MG CAPSULE   5 Specialty Tier 33%33%P
CHOLBAM 50 MG CAPSULE   5 Specialty Tier 33%33%P
CHOLESTYRAMINE LIGHT POWDER   2 Generic $0.00$0.00None
CHOLESTYRAMINE PACKET   2 Generic $0.00$0.00None
CICLOPIROX 0.77% CREAM   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CICLOPIROX 0.77% GEL   2 Generic $0.00$0.00None
CICLOPIROX 0.77% TOPICAL SUSP   2 Generic $0.00$0.00None
CICLOPIROX 1% SHAMPOO   2 Generic $0.00$0.00None
CICLOPIROX 8% SOLUTION   2 Generic $0.00$0.00None
Cilastatin 250 MG / Imipenem 250 MG Injection   2 Generic $0.00$0.00None
Cilastatin 500 MG / Imipenem 500 MG Injection   2 Generic $0.00$0.00None
CILOSTAZOL 100 MG TABLET   1 Preferred Generic $0.00$0.00None
CILOSTAZOL 50 MG TABLET   1 Preferred Generic $0.00$0.00None
CILOXAN 0.3% OINTMENT   4 Non-Preferred Brand $30.00$75.00None
CILOXAN SOLUTION 0.3% 5ML BOT   4 Non-Preferred Brand $30.00$75.00None
CIMDUO 300-300 MG TABLET   5 Specialty Tier 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Cimetidine 200mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC   2 Generic $0.00$0.00None
Cimetidine 300 MG Oral Tablet   2 Generic $0.00$0.00None
Cimetidine 400mg/1 100 FILM COATED TABLETS in BOTTLE   2 Generic $0.00$0.00None
Cimetidine 800mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC   2 Generic $0.00$0.00None
Cimetidine Hydrochloride Oral Solution 300mg/5mL 237 mL in 1 BOTTLE   2 Generic $0.00$0.00None
Cimzia 2 KIT per CARTON / 1 KIT in 1 KIT   5 Specialty Tier 33%33%P
CIMZIA 200 MG/ML SYRINGE KIT   5 Specialty Tier 33%33%P
CINACALCET HCL 30 MG TABLET [Sensipar]   2 Generic $0.00$0.00P
CINACALCET HCL 60 MG TABLET [Sensipar]   2 Generic $0.00$0.00P
CINACALCET HCL 90 MG TABLET [Sensipar]   2 Generic $0.00$0.00P
Cinryze 500[iU]/5mL 1 VIAL per CARTON / 5 mL in 1 VIAL   5 Specialty Tier 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CIPRO 10% SUSPENSION 1 KIT in 1 KIT   4 Non-Preferred Brand $30.00$75.00None
Cipro 250mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Brand $30.00$75.00None
CIPRO 5% SUSPENSION 1 KIT in 1 KIT   4 Non-Preferred Brand $30.00$75.00None
Cipro 500mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Brand $30.00$75.00None
CIPRO HC OTIC SUSPENSION   4 Non-Preferred Brand $30.00$75.00None
CIPRODEX OTIC SUSPENSION   3 Preferred Brand $10.00$20.00None
CIPROFLOXACIN 0.2% OTIC SOLN DROPERETTE [Cetraxal]   3 Preferred Brand $10.00$20.00None
CIPROFLOXACIN 0.3% EYE DROP [Ciloxan]   2 Generic $0.00$0.00None
CIPROFLOXACIN 250 MG TABLET (100 CT) [Cipro]   1 Preferred Generic $0.00$0.00None
CIPROFLOXACIN 500 MG/5 ML SUSP MC REC [Cipro]   2 Generic $0.00$0.00None
CIPROFLOXACIN HCL 500 MG Tablet [Cipro]   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CIPROFLOXACIN HCL 750 MG Tablet [Cipro]   1 Preferred Generic $0.00$0.00None
CIPROFLOXACIN-D5W 200 MG/100 ML PIGGYBACK [Cipro]   2 Generic $0.00$0.00None
CITALOPRAM HBR 10 MG TABLET   1 Preferred Generic $0.00$0.00None
CITALOPRAM HBR 10 MG/5 ML SOLN   2 Generic $0.00$0.00None
CITALOPRAM HBR 20 MG TABLET   1 Preferred Generic $0.00$0.00None
CITALOPRAM HBR 40 MG TABLET   1 Preferred Generic $0.00$0.00None
CLARAVIS 10 MG CAPSULE   2 Generic $0.00$0.00None
CLARAVIS 20 MG CAPSULE   2 Generic $0.00$0.00None
Claravis 30mg 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK   2 Generic $0.00$0.00None
CLARAVIS 40 MG CAPSULE   2 Generic $0.00$0.00None
Clarinex 0.5mg/mL 473 mL in 1 BOTTLE   4 Non-Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLARINEX 5 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CLARINEX-D 12 HOUR TABLET   4 Non-Preferred Brand $30.00$75.00None
CLARITHROMYCIN 125 MG/5ML FOR ORAL SUSPENSION   2 Generic $0.00$0.00None
CLARITHROMYCIN 250 MG TABLET   1 Preferred Generic $0.00$0.00None
CLARITHROMYCIN 250 MG/5MLFOR ORAL SUSPENSION   2 Generic $0.00$0.00None
CLARITHROMYCIN 500 MG TABLET   1 Preferred Generic $0.00$0.00None
CLARITHROMYCIN ER 500 MG TAB   2 Generic $0.00$0.00None
CLENPIQ 10-3.5/160   3 Preferred Brand $10.00$20.00None
CLEOCIN 100 MG VAGINAL OVULE   4 Non-Preferred Brand $30.00$75.00None
CLEOCIN 2% VAGINAL CREAM   4 Non-Preferred Brand $30.00$75.00None
CLEOCIN 300 MG/D5W/GALAXY   4 Non-Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLEOCIN 600 MG-D5W-GALAXY PIGGYBACK   4 Non-Preferred Brand $30.00$75.00None
CLEOCIN 900 MG-D5W-GALAXY PIGGYBACK   4 Non-Preferred Brand $30.00$75.00None
CLEOCIN HCL 150 MG CAPSULE   4 Non-Preferred Brand $30.00$75.00None
CLEOCIN HCL 300 MG CAPSULE   4 Non-Preferred Brand $30.00$75.00None
CLEOCIN HCL 75 MG CAPSULE   4 Non-Preferred Brand $30.00$75.00None
Cleocin Pediatric 75mg/5mL 75 mL in 1 BOTTLE   4 Non-Preferred Brand $30.00$75.00None
CLEOCIN PHOS 150 MG/ML VIAL   4 Non-Preferred Brand $30.00$75.00None
CLEOCIN T 1% GEL   4 Non-Preferred Brand $30.00$75.00None
CLEOCIN T 1% LOTION   4 Non-Preferred Brand $30.00$75.00None
CLEOCIN T 1% PLEDGETS   4 Non-Preferred Brand $30.00$75.00None
CLIMARA 0.025MG/DAY PATCH   4 Non-Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLIMARA 0.0375MG/DAY PATCH   4 Non-Preferred Brand $30.00$75.00None
CLIMARA 0.05MG/24H PATCH   4 Non-Preferred Brand $30.00$75.00None
CLIMARA 0.06/MG DAY PATCH   4 Non-Preferred Brand $30.00$75.00None
CLIMARA 0.075MG/DAY PATCH   4 Non-Preferred Brand $30.00$75.00None
CLIMARA 0.1MG/24H PATCH   4 Non-Preferred Brand $30.00$75.00None
CLIMARA PRO DIS WEEKLY 4.40MG/1.39MG   4 Non-Preferred Brand $30.00$75.00None
CLIND PH-BENZOYL PERO 1.2-2.5% GEL W/PUMP [Acanya]   4 Non-Preferred Brand $30.00$75.00None
CLIND PH-BENZOYL PEROX 1.2-5% [Benzaclin]   2 Generic $0.00$0.00None
CLINDACIN PAC KIT   2 Generic $0.00$0.00None
Clindamycin 10 MG/ML Topical Foam [Evoclin]   4 Non-Preferred Brand $30.00$75.00None
Clindamycin 150 MG/ML 2ml   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINDAMYCIN 150mg/ml vl 25x6ml   2 Generic $0.00$0.00None
CLINDAMYCIN 75 MG/5 ML SOLN   2 Generic $0.00$0.00None
CLINDAMYCIN HCL 150 MG CAPSULE   1 Preferred Generic $0.00$0.00None
CLINDAMYCIN HCL 300 MG CAPSULE   1 Preferred Generic $0.00$0.00None
CLINDAMYCIN HCL 75 MG 200 CAPSULE BOTTLE   1 Preferred Generic $0.00$0.00None
CLINDAMYCIN PH 1% SOLUTION   2 Generic $0.00$0.00None
CLINDAMYCIN PH 600 MG/4 ML VL   2 Generic $0.00$0.00None
CLINDAMYCIN PHOSP 1% LOTION   2 Generic $0.00$0.00None
CLINDAMYCIN PHOSPHATE 1% FOAM   2 Generic $0.00$0.00None
Clindamycin Phosphate and Benzoyl Peroxide 1 KIT   2 Generic $0.00$0.00None
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX   2 Generic $0.00$0.00None
CLINDAMYCIN PHOSPHATE VAGINAL CREAM   2 Generic $0.00$0.00None
Clindamycin-d5w 300 mg/50 ml   2 Generic $0.00$0.00None
Clindamycin-d5w 600 mg/50 ml   2 Generic $0.00$0.00None
Clindamycin-d5w 900 mg/50 ml   2 Generic $0.00$0.00None
CLINDAMYCIN-TRETINOIN 1.2%-0.025% [Veltin, Ziana]   2 Generic $0.00$0.00None
CLINDESSE 2% VAGINAL CREAM   4 Non-Preferred Brand $30.00$75.00None
CLINIMIX 4.25%-25% SOLUTION IV SOLN   3 Preferred Brand $10.00$20.00P
CLINIMIX 5/20 SOLUTION   3 Preferred Brand $10.00$20.00P
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG   3 Preferred Brand $10.00$20.00P
CLINIMIX 5%-15% SOLUTION   3 Preferred Brand $10.00$20.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINIMIX E 2.75/5 SOLUTION   3 Preferred Brand $10.00$20.00P
CLINIMIX E 4.25/5 SOLUTION   3 Preferred Brand $10.00$20.00P
CLINIMIX E 5/20 SOLUTION   3 Preferred Brand $10.00$20.00P
CLINIMIX E 5%/15% INJECTION 2000ML BAG   3 Preferred Brand $10.00$20.00P
CLINISOL 15% SOLUTION   2 Generic $0.00$0.00P
CLOBAZAM 10 MG TABLET [ONFI]   2 Generic $0.00$0.00None
CLOBAZAM 2.5 MG/ML Oral Suspension [ONFI]   2 Generic $0.00$0.00None
CLOBAZAM 20 MG TABLET [ONFI]   2 Generic $0.00$0.00None
CLOBETASOL 0.05% CREAM (g) [Temovate]   2 Generic $0.00$0.00None
CLOBETASOL 0.05% OINTMENT   2 Generic $0.00$0.00None
CLOBETASOL 0.05% SOLUTION   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOBETASOL 0.05% TOPICAL LOTN   2 Generic $0.00$0.00P
CLOBETASOL EMOLLIENT 0.05% CREAM (g) [Temovate E]   2 Generic $0.00$0.00None
CLOBETASOL EMOLLNT 0.05% FOAM [Olux-E]   2 Generic $0.00$0.00P
CLOBETASOL PROP 0.05% SPRAY   2 Generic $0.00$0.00P
Clobetasol Propionate 0.5 MG/ML Medicated Shampoo   2 Generic $0.00$0.00P
Clobetasol Propionate 0.5mg/g 1 CAN per CARTON / 100 g in 1 CAN   2 Generic $0.00$0.00P
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE   2 Generic $0.00$0.00None
CLOBEX 0.05% SPRAY   4 Non-Preferred Brand $30.00$75.00P
CLOBEX 0.05% TOPICAL LOTION   4 Non-Preferred Brand $30.00$75.00P
Clobex 0.05mL/100mL 118 mL in 1 BOTTLE   4 Non-Preferred Brand $30.00$75.00P
CLOCORTOLONE 0.1% CREAM PUMP (g) [Cloderm]   4 Non-Preferred Brand $30.00$75.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Clodan 0.05% shampoo   2 Generic $0.00$0.00P
CLOMIPRAMINE 25 MG CAPSULE   2 Generic $0.00$0.00P
CLOMIPRAMINE 50 MG CAPSULE   2 Generic $0.00$0.00P
CLOMIPRAMINE 75 MG CAPSULE   2 Generic $0.00$0.00P
CLONAZEPAM 0.125 MG DIS TAB RAPDIS [Klonopin]   2 Generic $0.00$0.00None
CLONAZEPAM 0.25 MG ODT TAB RAPDIS [Klonopin]   2 Generic $0.00$0.00None
CLONAZEPAM 0.5 MG DIS TABLET RAPDIS [Klonopin]   2 Generic $0.00$0.00None
CLONAZEPAM 0.5 MG TABLET [Klonopin]   1 Preferred Generic $0.00$0.00None
CLONAZEPAM 1 MG DIS TABLET RAPDIS [Klonopin]   2 Generic $0.00$0.00None
CLONAZEPAM 1 MG TABLET [Klonopin]   1 Preferred Generic $0.00$0.00None
CLONAZEPAM 2 MG ODT TAB RAPDIS [Klonopin]   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLONAZEPAM 2 MG TABLET [Klonopin]   1 Preferred Generic $0.00$0.00None
Clonidine 0.1mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   2 Generic $0.00$0.00None
Clonidine 0.2mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   2 Generic $0.00$0.00None
Clonidine 0.3mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   2 Generic $0.00$0.00None
CLONIDINE HCL 0.1 MG TABLET   1 Preferred Generic $0.00$0.00None
CLONIDINE HCL 0.2 MG TABLET   1 Preferred Generic $0.00$0.00None
CLONIDINE HCL 0.3 MG TABLET   1 Preferred Generic $0.00$0.00None
CLOPIDOGREL 75 MG TABLET [Plavix]   1 Preferred Generic $0.00$0.00None
CLORAZEPATE 15 MG TABLET   2 Generic $0.00$0.00None
CLORAZEPATE 3.75 MG TABLET   2 Generic $0.00$0.00None
CLORAZEPATE 7.5 MG TABLET   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOTRIMAZOLE 1% CREAM   2 Generic $0.00$0.00None
CLOTRIMAZOLE 1% SOLUTION   2 Generic $0.00$0.00None
CLOTRIMAZOLE 10 MG TROCHE   2 Generic $0.00$0.00None
CLOTRIMAZOLE-BETAMETHASONE LOT   2 Generic $0.00$0.00None
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE   2 Generic $0.00$0.00None
CLOZAPINE 100 MG TABLET [Clozaril]   2 Generic $0.00$0.00None
CLOZAPINE 200 MG TABLET   2 Generic $0.00$0.00None
CLOZAPINE 25 MG TABLET [Clozaril]   2 Generic $0.00$0.00None
CLOZAPINE 50 MG TABLET   2 Generic $0.00$0.00None
CLOZAPINE ODT 100 MG TABLET RAPDIS [Fazaclo]   2 Generic $0.00$0.00None
CLOZAPINE ODT 12.5 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOZAPINE ODT 150 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Brand $30.00$75.00None
CLOZAPINE ODT 200 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Brand $30.00$75.00None
CLOZAPINE ODT 25 MG TABLET RAPDIS [Fazaclo]   2 Generic $0.00$0.00None
CLOZARIL 100 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CLOZARIL 25 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
COARTEM 20MG-120MG   3 Preferred Brand $10.00$20.00None
CODEINE SULFATE 30 mg tablet   2 Generic $0.00$0.00Q:240
/30Days
CODEINE SULFATE 60 MG TABLET   2 Generic $0.00$0.00Q:180
/30Days
COLAZAL 750MG CAPSULE   4 Non-Preferred Brand $30.00$75.00None
COLCHICINE 0.6 MG TABLET [Colcrys]   4 Non-Preferred Brand $30.00$75.00P
COLESEVELAM 625 MG TABLET [WelChol]   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COLESEVELAM HCL 3.75 G PACKET POWD PACK [WelChol]   2 Generic $0.00$0.00Q:60
/30Days
COLESTID 1GM TABLET   4 Non-Preferred Brand $30.00$75.00None
COLESTID GRANULES PACKET   4 Non-Preferred Brand $30.00$75.00None
COLESTIPOL HCL 1G TABLET   2 Generic $0.00$0.00None
COLESTIPOL HCL GRANULES PACKET   2 Generic $0.00$0.00None
COLISTIMETHATE 150 MG VIAL [Coly-Mycin M]   2 Generic $0.00$0.00None
COLOCORT 100MG ENEMA   2 Generic $0.00$0.00None
COLY-MYCIN S OTIC SUSP DROP   3 Preferred Brand $10.00$20.00None
COMBIGAN 0.2%-0.5% DROPS   3 Preferred Brand $10.00$20.00None
COMBIPATCH 0.05-0.14 MG PTCH   4 Non-Preferred Brand $30.00$75.00None
COMBIPATCH 0.05-0.25 MG PTCH   4 Non-Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COMBIVENT RESPIMAT INHAL SPRAY   3 Preferred Brand $10.00$20.00None
COMBIVIR TABLET   5 Specialty Tier 33%33%None
COMETRIQ 100 MG DAILY-DOSE PK   5 Specialty Tier 33%33%P
COMETRIQ 140 MG DAILY-DOSE PK   5 Specialty Tier 33%33%P
COMETRIQ 60 MG DAILY-DOSE PACK   5 Specialty Tier 33%33%P
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1   5 Specialty Tier 33%33%None
COMPRO 25MG SUPPOSITORY   2 Generic $0.00$0.00None
COMTAN 200MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CONCERTA 54mg/1 100 TABLET, ER in BOTTLE   4 Non-Preferred Brand $30.00$75.00None
CONCERTA ER TABLETS 18MG 100 TABLETS BOT   4 Non-Preferred Brand $30.00$75.00None
CONCERTA ER TABLETS 27MG 100 TABLETS BOT   4 Non-Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CONCERTA ER TABLETS 36MG 100 TABLETS BOT   4 Non-Preferred Brand $30.00$75.00None
CONDYLOX 0.5% GEL   4 Non-Preferred Brand $30.00$75.00None
CONSTULOSE 10 GM/15 ML SOLN   1 Preferred Generic $0.00$0.00None
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN   5 Specialty Tier 33%33%None
COPAXONE 40 MG/ML SYRINGE   5 Specialty Tier 33%33%None
COPIKTRA 15 MG CAPSULE   5 Specialty Tier 33%33%P Q:60
/30Days
COPIKTRA 25 MG CAPSULE   5 Specialty Tier 33%33%P Q:60
/30Days
CORDRAN 4 MCG/SQ CM TAPE LARGE   4 Non-Preferred Brand $30.00$75.00None
COREG 12.5MG TABLET   4 Non-Preferred Brand $30.00$75.00None
COREG 25MG TABLET   4 Non-Preferred Brand $30.00$75.00None
COREG 3.125MG TABLET   4 Non-Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COREG 6.25MG TABLET   4 Non-Preferred Brand $30.00$75.00None
COREG CR 10MG CAPSULE MULTIPHASIC RELEASE 24 HR   4 Non-Preferred Brand $30.00$75.00None
COREG CR 20MG CAPSULE MULTIPHASIC RELEASE 24 HR   4 Non-Preferred Brand $30.00$75.00None
COREG CR 40MG CAPSULE MULTIPHASIC RELEASE 24 HR   4 Non-Preferred Brand $30.00$75.00None
COREG CR 80MG CAPSULE MULTIPHASIC RELEASE 24 HR   4 Non-Preferred Brand $30.00$75.00None
CORGARD 20 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CORGARD 40 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CORGARD 80 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CORLANOR 5 MG TABLET   4 Non-Preferred Brand $30.00$75.00P
CORLANOR 7.5 MG TABLET   4 Non-Preferred Brand $30.00$75.00P
CORTEF 10MG TABLET   4 Non-Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CORTEF 20MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CORTEF 5MG TABLET   4 Non-Preferred Brand $30.00$75.00None
Cortisone 25 MG Tablet   4 Non-Preferred Brand $30.00$75.00None
CORTISPORIN CRE 0.5%   4 Non-Preferred Brand $30.00$75.00None
CORTISPORIN OINTMENT   4 Non-Preferred Brand $30.00$75.00None
CORZIDE 40-5MG TABLET   4 Non-Preferred Brand $30.00$75.00None
CORZIDE 80-5MG TABLET   4 Non-Preferred Brand $30.00$75.00None
COSENTYX 300 MG DOSE-2 PENS   5 Specialty Tier 33%33%P
COSOPT EYE DROPS   4 Non-Preferred Brand $30.00$75.00None
COSOPT PF EYE DROPS   3 Preferred Brand $10.00$20.00None
COTELLIC 20 MG TABLET   5 Specialty Tier 33%33%P Q:63
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COUMADIN 1 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
COUMADIN 10MG TABLET   4 Non-Preferred Brand $30.00$75.00None
COUMADIN 2.5 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
COUMADIN 2MG TABLET   4 Non-Preferred Brand $30.00$75.00None
COUMADIN 3mg/1 1 BOTTLE per CARTON / 100 TABLET BOTTLE   4 Non-Preferred Brand $30.00$75.00None
COUMADIN 4mg/1 1 BOTTLE in 1 CARTON / 100 TABLET BOTTLE   4 Non-Preferred Brand $30.00$75.00None
COUMADIN 5MG TABLET   4 Non-Preferred Brand $30.00$75.00None
COUMADIN 6MG TABLET   4 Non-Preferred Brand $30.00$75.00None
COUMADIN 7.5MG TABLET   4 Non-Preferred Brand $30.00$75.00None
COZAAR 100 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
COZAAR 25 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COZAAR 50 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
Creon 256.11mg/1 1 BOTTLE per CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE   3 Preferred Brand $10.00$20.00None
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT   3 Preferred Brand $10.00$20.00None
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT   3 Preferred Brand $10.00$20.00None
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT   3 Preferred Brand $10.00$20.00None
CREON DR 36,000 UNITS CAPSULE   3 Preferred Brand $10.00$20.00None
CRESTOR 10MG TABLET   4 Non-Preferred Brand $30.00$75.00S
CRESTOR 20MG TABLET   4 Non-Preferred Brand $30.00$75.00S
CRESTOR 40mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Brand $30.00$75.00S
CRESTOR 5MG TABLET   4 Non-Preferred Brand $30.00$75.00S
CRINONE 4% GEL GEL/PF APP   3 Preferred Brand $10.00$20.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CRINONE 8% GEL/PF APP   3 Preferred Brand $10.00$20.00P
CRIXIVAN 200MG CAPSULE   3 Preferred Brand $10.00$20.00None
CRIXIVAN 400mg, 180 CAPSULE BOTTLE   3 Preferred Brand $10.00$20.00None
CROMOLYN 20 MG/2 ML NEB SOLN   2 Generic $0.00$0.00P
CROMOLYN SODIUM 100 MG/5 ML   2 Generic $0.00$0.00None
CROMOLYN SODIUM 4% 40MG 10ML BOT   2 Generic $0.00$0.00None
CUBICIN 500MG VIAL   5 Specialty Tier 33%33%None
CUTIVATE 0.05% LOTION   4 Non-Preferred Brand $30.00$75.00P
CUVPOSA 1 MG/5 ML SOLUTION   4 Non-Preferred Brand $30.00$75.00None
Cyclafem 1/35 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK   2 Generic $0.00$0.00None
CYCLAFEM 7-7-7-28 TABLET   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYCLOBENZAPRINE 10 MG TABLET   1 Preferred Generic $0.00$0.00None
CYCLOBENZAPRINE 5 MG TABLET   1 Preferred Generic $0.00$0.00None
CYCLOBENZAPRINE 7.5 MG TABLET   2 Generic $0.00$0.00None
CYCLOPHOSPHAMIDE 25 MG CAPSULE   3 Preferred Brand $10.00$20.00P
CYCLOPHOSPHAMIDE 50 MG CAPSULE   3 Preferred Brand $10.00$20.00P
CYCLOSET 0.8MG TABLETS   4 Non-Preferred Brand $30.00$75.00None
CYCLOSPORINE 100MG CAPSULE   2 Generic $0.00$0.00P
CYCLOSPORINE 25MG CAPSULE   2 Generic $0.00$0.00P
CYCLOSPORINE MODIFIED 100 MG   2 Generic $0.00$0.00P
CYCLOSPORINE MODIFIED 25 MG   2 Generic $0.00$0.00P
CYCLOSPORINE MODIFIED 50 MG   2 Generic $0.00$0.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT   2 Generic $0.00$0.00P
CYMBALTA 20MG CAPSULE   4 Non-Preferred Brand $30.00$75.00None
CYMBALTA 60 MG CAPSULE   4 Non-Preferred Brand $30.00$75.00None
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT)   4 Non-Preferred Brand $30.00$75.00None
CYRED EQ 28 DAY TABLET [Solia]   2 Generic $0.00$0.00None
CYSTAGON 150MG CAPSULE   3 Preferred Brand $10.00$20.00None
CYSTAGON 50MG CAPSULE   3 Preferred Brand $10.00$20.00None
CYSTARAN 0.44% EYE DROPS   5 Specialty Tier 33%33%P Q:60
/30Days
CYTOMEL 25MCG TABLET   4 Non-Preferred Brand $30.00$75.00None
CYTOMEL 50MCG TABLET   4 Non-Preferred Brand $30.00$75.00None
CYTOMEL 5MCG TABLET   4 Non-Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYTOTEC 100 MCG TABLET   4 Non-Preferred Brand $30.00$75.00None
CYTOTEC TABLET 200MCG (60 CT)   4 Non-Preferred Brand $30.00$75.00None

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D Solis Health Plans (HMO) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $415 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.

  • Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
    • Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.

    • No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.

  • Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
  • Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
    • Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs. *Some Part D plans exclude one or more drug tiers from the deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
    • Tier Description - This is the Medicare Part D plan’s description of this particular drug tier.
  • Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
    • Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $3820) at a "Preferred" network pharmacy. In most cases, the "Preferred" network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
    • Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
  • Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
    • None - This drug does not fall under any drug utilization management controls.
    • P - Prior Authorization -This drug is subject to prior authorization.
    • S - Step Therapy -This drug is subject to step therapy.
    • Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.




(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2019 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.








Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.