2019 Medicare Part D Plan Formulary Information |
Cigna-HealthSpring Rx Secure-Essential (PDP) (S5617-290-0)
Benefit Details
|
The Cigna-HealthSpring Rx Secure-Essential (PDP) (S5617-290-0) Formulary Drugs Starting with the Letter P in CMS PDP Region 11 which includes: FL Plan Monthly Premium: $21.90 Deductible: $415 Qualifies for LIS: No |
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 |
4 |
Non-Preferred Drug |
49% | 49% | None |
PACERONE 200 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
PACERONE 400MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
PALIPERIDONE ER 1.5 MG TABLET [INVEGA] |
4 |
Non-Preferred Drug |
49% | 49% | S Q:30 /30Days |
PALIPERIDONE ER 3 MG TABLET [INVEGA] |
4 |
Non-Preferred Drug |
49% | 49% | S Q:30 /30Days |
PALIPERIDONE ER 6 MG TABLET [INVEGA] |
4 |
Non-Preferred Drug |
49% | 49% | S Q:60 /30Days |
PALIPERIDONE ER 9 MG TABLET [INVEGA] |
4 |
Non-Preferred Drug |
49% | 49% | S Q:30 /30Days |
PANRETIN 0.1% GEL 60GM TUBE |
5 |
Specialty Tier |
25% | N/A | None |
PANTOPRAZOLE SOD DR 20 MG TAB |
2* |
Generic |
$3.00 | $6.00 | Q:60 /30Days |
PANTOPRAZOLE SOD DR 40 MG TAB |
2* |
Generic |
$3.00 | $6.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PARICALCITOL 1 MCG CAPSULE [Zemplar] |
4 |
Non-Preferred Drug |
49% | 49% | Q:90 /30Days |
PARICALCITOL 2 MCG CAPSULE [Zemplar] |
4 |
Non-Preferred Drug |
49% | 49% | Q:90 /30Days |
PARICALCITOL 4 MCG CAPSULE [Zemplar] |
4 |
Non-Preferred Drug |
49% | 49% | Q:60 /30Days |
PAROMOMYCIN 250 MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | None |
PAROXETINE HCL 10 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:30 /30Days |
PAROXETINE HCL 20 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:90 /30Days |
PAROXETINE HCL 30 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | Q:60 /30Days |
PAROXETINE HCL 40 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | Q:60 /30Days |
PASER GRANULES 4GM PACKET |
4 |
Non-Preferred Drug |
49% | 49% | None |
PAXIL ORAL SUSPENSION 10 MG/5ML |
4 |
Non-Preferred Drug |
49% | 49% | S Q:900 /30Days |
PEDVAXHIB VACCINE VIAL |
4 |
Non-Preferred Drug |
49% | 49% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEG 3350 ELECTROLYTE SOLN SOLN RECON [GaviLyte-C] |
2* |
Generic |
$3.00 | $6.00 | None |
PEG 3350-ELECTROLYTE SOLUTION SOLN RECON |
2* |
Generic |
$3.00 | $6.00 | None |
PEG-3350 AND ELECTROLYTES SOLN SOLN RECON |
2* |
Generic |
$3.00 | $6.00 | None |
PEGANONE 250 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
Pegasys 180ug/0.5mL 1 PACKET in 1 BOX / 4 SYRINGE, GLASS in 1 PACKET / 0.5 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
25% | N/A | P Q:2 /28Days |
PEGASYS INJECTION |
5 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
PEGASYS PROCLICK 180 MCG/0.5 |
5 |
Specialty Tier |
25% | N/A | P Q:2 /28Days |
PENICILLAMINE 250 MG CAPSULE [Cuprimine] |
5 |
Specialty Tier |
25% | N/A | None |
PENICILLIN GK 20 MILLION UNIT |
4 |
Non-Preferred Drug |
49% | 49% | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
PENICILLIN V POTASSIUM 500MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENICILLIN VK 125 MG/5 ML SOLN |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
PENICILLIN VK 250 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
PENTAM 300 INJ 300MG |
3 |
Preferred Brand |
20% | 20% | None |
PENTOXIFYLLINE 400MG TABLET SA |
2* |
Generic |
$3.00 | $6.00 | None |
PERFOROMIST 20MCG/2ML VIAL NEBULIZER |
4 |
Non-Preferred Drug |
49% | 49% | P Q:120 /30Days |
PERINDOPRIL ERBUMINE 2 MG TAB |
2* |
Generic |
$3.00 | $6.00 | Q:60 /30Days |
PERINDOPRIL ERBUMINE 4 MG TAB |
2* |
Generic |
$3.00 | $6.00 | Q:60 /30Days |
PERINDOPRIL ERBUMINE 8 MG TAB |
2* |
Generic |
$3.00 | $6.00 | Q:60 /30Days |
Permethrin 50mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
3 |
Preferred Brand |
20% | 20% | None |
PERPHEN-AMITRIP 2 MG-10 MG TAB |
4 |
Non-Preferred Drug |
49% | 49% | P |
PERPHEN-AMITRIP 2 MG-25 MG TAB |
4 |
Non-Preferred Drug |
49% | 49% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PERPHEN-AMITRIP 4 MG-25 MG TAB |
4 |
Non-Preferred Drug |
49% | 49% | P |
Perphenazine 16mg/1 100 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Drug |
49% | 49% | None |
PERPHENAZINE 4 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
PERPHENAZINE 8 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
PERPHENAZINE TABLETS USP 2MG 100 BOT |
4 |
Non-Preferred Drug |
49% | 49% | None |
PERSERIS ER 120 MG SYRINGE KIT SUSER SYKT |
5 |
Specialty Tier |
25% | N/A | Q:1 /30Days |
PERSERIS ER 90 MG SYRINGE KIT SUSER SYKT |
5 |
Specialty Tier |
25% | N/A | Q:1 /30Days |
PHENADOZ 12.5 MG SUPPOSITORY |
4 |
Non-Preferred Drug |
49% | 49% | None |
Phenelzine Sulfate 15mg/1 60 TABLET BOTTLE |
3 |
Preferred Brand |
20% | 20% | None |
Phenobarbital 100mg/1 |
4 |
Non-Preferred Drug |
49% | 49% | Q:120 /30Days |
Phenobarbital 15mg/1 |
4 |
Non-Preferred Drug |
49% | 49% | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PHENOBARBITAL 16.2 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | Q:120 /30Days |
PHENOBARBITAL 20 MG/5 ML ELIX |
4 |
Non-Preferred Drug |
49% | 49% | Q:1500 /30Days |
Phenobarbital 30mg/1 |
4 |
Non-Preferred Drug |
49% | 49% | Q:120 /30Days |
PHENOBARBITAL 32.4 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | Q:120 /30Days |
Phenobarbital 60mg/1 |
4 |
Non-Preferred Drug |
49% | 49% | Q:120 /30Days |
PHENOBARBITAL 64.8 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | Q:120 /30Days |
PHENOBARBITAL 97.2 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | Q:120 /30Days |
Phenytoin 50 MG Chewable Tablet |
3 |
Preferred Brand |
20% | 20% | None |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT |
2* |
Generic |
$3.00 | $6.00 | None |
PHENYTOIN SOD EXT 100 MG CAP |
2* |
Generic |
$3.00 | $6.00 | None |
PHENYTOIN SOD EXT 200 MG CAP |
2* |
Generic |
$3.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PHENYTOIN SOD EXT 300 MG CAP |
2* |
Generic |
$3.00 | $6.00 | None |
PHOSPHOLINE IODIDE 0.125% 6.25MG |
4 |
Non-Preferred Drug |
49% | 49% | None |
PICATO 0.015% GEL |
4 |
Non-Preferred Drug |
49% | 49% | Q:3 /56Days |
PICATO 0.05% GEL |
4 |
Non-Preferred Drug |
49% | 49% | Q:2 /56Days |
PIFELTRO 100 MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
PILOCARPINE 1% EYE DROPS [Pilocar] |
4 |
Non-Preferred Drug |
49% | 49% | None |
PILOCARPINE 2% EYE DROPS [Pilocar] |
4 |
Non-Preferred Drug |
49% | 49% | None |
PILOCARPINE 4% EYE DROPS [Pilocar] |
4 |
Non-Preferred Drug |
49% | 49% | None |
PILOCARPINE HCL 5 MG TABLET [Salagen] |
4 |
Non-Preferred Drug |
49% | 49% | None |
PILOCARPINE HCL 7.5 MG TABLET [Salagen] |
4 |
Non-Preferred Drug |
49% | 49% | None |
PIMOZIDE 1 MG TABLET [Orap] |
4 |
Non-Preferred Drug |
49% | 49% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PIMOZIDE 2 MG TABLET [Orap] |
4 |
Non-Preferred Drug |
49% | 49% | None |
PIMTREA 28 DAY TABLET |
3 |
Preferred Brand |
20% | 20% | None |
PINDOLOL 10 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
PINDOLOL 5 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
PIOGLITAZONE HCL 15 MG TABLET [Actos] |
2* |
Generic |
$3.00 | $6.00 | Q:30 /30Days |
PIOGLITAZONE HCL 30 MG TABLET [Actos] |
2* |
Generic |
$3.00 | $6.00 | Q:30 /30Days |
PIOGLITAZONE HCL 45 MG TABLET [Actos] |
2* |
Generic |
$3.00 | $6.00 | Q:30 /30Days |
PIOGLITAZONE-METFORMIN 15-500 |
2* |
Generic |
$3.00 | $6.00 | Q:90 /30Days |
PIOGLITAZONE-METFORMIN 15-850 |
2* |
Generic |
$3.00 | $6.00 | Q:90 /30Days |
PIPERACIL-TAZOBACT 2.25 GM VIAL |
4 |
Non-Preferred Drug |
49% | 49% | None |
PIPERACIL-TAZOBACT 3.375 GM VIAL |
4 |
Non-Preferred Drug |
49% | 49% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PIPERACIL-TAZOBACT 4.5 GM VIAL |
4 |
Non-Preferred Drug |
49% | 49% | None |
PIPERACIL-TAZOBACT 40.5 GRAM VIAL [Zosyn] |
4 |
Non-Preferred Drug |
49% | 49% | None |
Pirmella 1-35-28 tablet |
2* |
Generic |
$3.00 | $6.00 | None |
PODOFILOX 0.5% TOPICAL TUBEX |
4 |
Non-Preferred Drug |
49% | 49% | None |
POLYMYXIN B SULFATE VIAL |
4 |
Non-Preferred Drug |
49% | 49% | None |
POLYMYXIN B-TMP EYE DROPS |
2* |
Generic |
$3.00 | $6.00 | None |
POMALYST 1 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:21 /28Days |
POMALYST 2 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:21 /28Days |
POMALYST 3 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:21 /28Days |
POMALYST 4 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:21 /28Days |
PORTIA 0.15-0.03 TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POT CHL/SWFI P-B 40 MEQ 24X100 ML |
4 |
Non-Preferred Drug |
49% | 49% | P |
Potassium Chloride 2 MEQ/ML Injectable Solution |
4 |
Non-Preferred Drug |
49% | 49% | P |
Potassium Chloride 200 meq/1000mL 24 POUCH in 1 CASE |
4 |
Non-Preferred Drug |
49% | 49% | P |
Potassium Chloride 8 MEQ Extended Release Oral Tablet |
2* |
Generic |
$3.00 | $6.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION |
4 |
Non-Preferred Drug |
49% | 49% | P |
Potassium Chloride in Dextrose 5; 150g/100mL; mg/100mL 1000 mL in 1 BAG |
4 |
Non-Preferred Drug |
49% | 49% | P |
Potassium Chloride in Dextrose and Sodium Chloride 5; 300; 900g/100mL; mg/100mL; mg/100mL 1000 mL i |
4 |
Non-Preferred Drug |
49% | 49% | P |
Potassium Chloride in Lactated Ringers and Dextrose 20; 5; 179; 600; 310mg/100mL; g/100mL; mg/100mL |
4 |
Non-Preferred Drug |
49% | 49% | P |
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION |
4 |
Non-Preferred Drug |
49% | 49% | P |
POTASSIUM CHLORIDE INJECTION 10MEQ/100ML |
4 |
Non-Preferred Drug |
49% | 49% | P |
POTASSIUM CITRATE ER 10 MEQ TB |
4 |
Non-Preferred Drug |
49% | 49% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CITRATE ER 15 MEQ TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
POTASSIUM CITRATE ER 5 MEQ TAB |
4 |
Non-Preferred Drug |
49% | 49% | None |
POTASSIUM CL 10% (20 MEQ/15ML) Liquid [Kay Ciel] |
4 |
Non-Preferred Drug |
49% | 49% | None |
POTASSIUM CL 2 MEQ/ML VIAL [PROAMP] |
4 |
Non-Preferred Drug |
49% | 49% | P |
POTASSIUM CL 20 MEQ PACKET [Klor-Con] |
2* |
Generic |
$3.00 | $6.00 | None |
POTASSIUM CL 20% (40 MEQ/15ML) Liquid [Kaon-CL] |
4 |
Non-Preferred Drug |
49% | 49% | None |
POTASSIUM CL ER 10 MEQ CAPSULE |
2* |
Generic |
$3.00 | $6.00 | None |
POTASSIUM CL ER 10 MEQ TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
POTASSIUM CL ER 10 MEQ TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
POTASSIUM CL ER 20 MEQ TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
Potassium cl er 20 meq tablet |
2* |
Generic |
$3.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CL ER 8 MEQ CAPSULE |
2* |
Generic |
$3.00 | $6.00 | None |
PRADAXA 110 MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | Q:60 /30Days |
PRADAXA 150 MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | Q:60 /30Days |
PRADAXA 75 MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | Q:60 /30Days |
PRAMIPEXOLE 0.125 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | Q:90 /30Days |
PRAMIPEXOLE 0.25 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | Q:90 /30Days |
PRAMIPEXOLE 0.5 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | Q:90 /30Days |
PRAMIPEXOLE 0.75 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | Q:90 /30Days |
PRAMIPEXOLE 1 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | Q:90 /30Days |
PRAMIPEXOLE 1.5 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | Q:90 /30Days |
PRASUGREL 10 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRASUGREL 5 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | Q:30 /30Days |
PRAVASTATIN SODIUM 10 MG TAB |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:30 /30Days |
PRAVASTATIN SODIUM 20 MG TAB |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:30 /30Days |
PRAVASTATIN SODIUM 40 MG TAB |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:30 /30Days |
PRAVASTATIN SODIUM 80 MG TAB |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:30 /30Days |
PRAZIQUANTEL 600 MG TABLET [Biltricide] |
4 |
Non-Preferred Drug |
49% | 49% | None |
PRAZOSIN 1 MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | None |
PRAZOSIN 2 MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | None |
PRAZOSIN 5MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | None |
PREDNICARBATE 0.1% OINTMENT |
2* |
Generic |
$3.00 | $6.00 | None |
PREDNISOLONE 15 MG/5 ML SOLN |
4 |
Non-Preferred Drug |
49% | 49% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISOLONE AC 1% EYE DROP |
3 |
Preferred Brand |
20% | 20% | None |
PREDNISOLONE SOD 1% EYE DROP |
2* |
Generic |
$3.00 | $6.00 | None |
PREDNISOLONE SOD PH 25 MG/5 ML |
3 |
Preferred Brand |
20% | 20% | None |
PREDNISOLONE SODIUM PHOSPHATE 5MG /5ML ORAL SOLUTION |
4 |
Non-Preferred Drug |
49% | 49% | None |
PREDNISONE 1 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
PREDNISONE 10 MG TAB DOSE PACK |
2* |
Generic |
$3.00 | $6.00 | None |
PREDNISONE 10 MG TAB DOSE PACK |
2* |
Generic |
$3.00 | $6.00 | None |
PREDNISONE 10 MG TABLET [Sterapred DS] |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
PREDNISONE 2.5 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
Prednisone 20 MG Oral Tablet |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
PREDNISONE 5 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISONE 5 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
PREDNISONE 5 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
PREDNISONE 5 MG/5 ML SOLUTION |
2* |
Generic |
$3.00 | $6.00 | None |
PREDNISONE 50MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
PREDNISONE 5MG/ML SOLUTION |
4 |
Non-Preferred Drug |
49% | 49% | None |
Premarin 0.625mg/g |
3 |
Preferred Brand |
20% | 20% | None |
PREMASOL 10% IV SOLUTION |
4 |
Non-Preferred Drug |
49% | 49% | P |
PREMASOL 6% IV SOLUTION |
4 |
Non-Preferred Drug |
49% | 49% | P |
PREVALITE PACKET |
4 |
Non-Preferred Drug |
49% | 49% | None |
PREVIFEM TABLET [VyLibra] |
2* |
Generic |
$3.00 | $6.00 | None |
PREZCOBIX 800 MG-150 MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREZISTA 100 MG/ML SUSPENSION |
5 |
Specialty Tier |
25% | N/A | Q:400 /30Days |
PREZISTA 150MG TABLETS |
4 |
Non-Preferred Drug |
49% | 49% | Q:180 /30Days |
PREZISTA 800 MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
PREZISTA TABLET 600MG |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
PREZISTA TABLET 75MG |
4 |
Non-Preferred Drug |
49% | 49% | Q:210 /30Days |
PRIFTIN 150 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
Primaquine Phosphate 26.3 MG Oral Tablet |
4 |
Non-Preferred Drug |
49% | 49% | None |
PRIMIDONE 250 MG TABLET [Mysoline] |
2* |
Generic |
$3.00 | $6.00 | None |
PRIMIDONE 50 MG TABLET [Mysoline] |
2* |
Generic |
$3.00 | $6.00 | None |
PROAIR HFA 90 MCG INHALER |
3 |
Preferred Brand |
20% | 20% | Q:17 /30Days |
PROAIR RESPICLICK INHAL POWDER |
3 |
Preferred Brand |
20% | 20% | Q:2 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROBENECID 500 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
PROBENECID/COLCHICINE 0.5MG/500MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | 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 |
4 |
Non-Preferred Drug |
49% | 49% | P |
PROCHLORPERAZINE 10 MG TAB |
2* |
Generic |
$3.00 | $6.00 | None |
PROCHLORPERAZINE 5 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX |
4 |
Non-Preferred Drug |
49% | 49% | None |
PROCRIT 10000U/ML VIAL |
4 |
Non-Preferred Drug |
49% | 49% | P Q:12 /28Days |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL |
4 |
Non-Preferred Drug |
49% | 49% | P Q:12 /28Days |
PROCRIT 3,000 UNITS/ML VIAL |
4 |
Non-Preferred Drug |
49% | 49% | P Q:12 /28Days |
PROCRIT 4,000 UNITS/ML VIAL |
4 |
Non-Preferred Drug |
49% | 49% | P Q:12 /28Days |
PROCRIT 40000U/ML VIAL PR |
5 |
Specialty Tier |
25% | N/A | P Q:6 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY |
5 |
Specialty Tier |
25% | N/A | P Q:12 /28Days |
PROCTO-MED HC 2.5% CREAM |
4 |
Non-Preferred Drug |
49% | 49% | None |
procto-pak 1% cream |
2* |
Generic |
$3.00 | $6.00 | None |
PROCTOSOL-HC 2.5% CREAM |
4 |
Non-Preferred Drug |
49% | 49% | None |
PROCTOZONE-HC 2.5% CREAM |
4 |
Non-Preferred Drug |
49% | 49% | None |
PROGESTERONE 100 MG CAPSULE |
2* |
Generic |
$3.00 | $6.00 | None |
PROGESTERONE 200 MG CAPSULE [Prometrium] |
2* |
Generic |
$3.00 | $6.00 | None |
PROGLYCEM 50 MG/ML ORAL SUSP |
4 |
Non-Preferred Drug |
49% | 49% | None |
PROGRAF 0.2 MG GRANULE PACKET |
4 |
Non-Preferred Drug |
49% | 49% | P |
PROGRAF 1 MG GRANULE PACKET |
4 |
Non-Preferred Drug |
49% | 49% | P |
PROLASTIN C 1,000 MG VIAL |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROLENSA 0.07% EYE DROPS |
3 |
Preferred Brand |
20% | 20% | None |
PROLIA 60MG/ML INJECTION |
4 |
Non-Preferred Drug |
49% | 49% | Q:1 /180Days |
PROMACTA 12.5 MG SUSPEN PACKET POWDER PACK |
5 |
Specialty Tier |
25% | N/A | P Q:360 /30Days |
PROMACTA 12.5 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
PROMACTA 25 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
PROMACTA 50 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
PROMACTA 75 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
PROMETHAZINE 12.5 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | P |
PROMETHAZINE 25 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | P |
PROMETHAZINE 50 MG SUPPOSITORY |
4 |
Non-Preferred Drug |
49% | 49% | None |
PROMETHAZINE 50 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMETHAZINE 6.25 MG/5 ML SYRUP [Prometh Plain] |
4 |
Non-Preferred Drug |
49% | 49% | P |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX |
4 |
Non-Preferred Drug |
49% | 49% | None |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX |
4 |
Non-Preferred Drug |
49% | 49% | None |
PROMETHEGAN 25MG SUPP |
4 |
Non-Preferred Drug |
49% | 49% | None |
PROMETHEGAN 50MG SUPPOS |
4 |
Non-Preferred Drug |
49% | 49% | None |
PROPAFENONE HCL 150 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
PROPAFENONE HCL 225MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
PROPAFENONE HCL 300 MG TAB |
4 |
Non-Preferred Drug |
49% | 49% | None |
PROPAFENONE HCL ER 225 MG CAP |
4 |
Non-Preferred Drug |
49% | 49% | None |
PROPAFENONE HYDROCHLORIDE 325MG CAPSULES EXTENDED RELEASE |
4 |
Non-Preferred Drug |
49% | 49% | None |
PROPAFENONE HYDROCHLORIDE 425MG CAPSULES EXTENDED RELEASE |
4 |
Non-Preferred Drug |
49% | 49% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Propantheline Bromide 15mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
4 |
Non-Preferred Drug |
49% | 49% | None |
Proparacaine hydrochloride 5 MG/ML Ophthalmic Solution |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
PROPRANOLOL 10 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
PROPRANOLOL 20 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
PROPRANOLOL 20MG/5ML TUBEX |
4 |
Non-Preferred Drug |
49% | 49% | None |
PROPRANOLOL 40 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
PROPRANOLOL 40MG/5ML TUBEX |
4 |
Non-Preferred Drug |
49% | 49% | None |
PROPRANOLOL 60 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
PROPRANOLOL 80 MG TABLET |
2* |
Generic |
$3.00 | $6.00 | None |
PROPRANOLOL ER 120 MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | None |
PROPRANOLOL ER 160 MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPRANOLOL ER 60 MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | None |
PROPRANOLOL ER 80 MG CAPSULE |
4 |
Non-Preferred Drug |
49% | 49% | None |
PROPRANOLOL/HCTZ 40/25 TABLET |
3 |
Preferred Brand |
20% | 20% | None |
PROPRANOLOL/HCTZ 80/25 TABLET |
3 |
Preferred Brand |
20% | 20% | None |
PROPYLTHIOURACIL 50MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
PROQUAD VIAL |
4 |
Non-Preferred Drug |
49% | 49% | Q:2 /365Days |
PROSOL 20% INJECTION |
4 |
Non-Preferred Drug |
49% | 49% | P |
PROTRIPTYLINE HCL 10 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
PROTRIPTYLINE HCL 5 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
PULMOZYME 1MG/ML AMPUL |
5 |
Specialty Tier |
25% | N/A | P Q:150 /30Days |
PURIXAN 20 MG/ML ORAL SUSP |
5 |
Specialty Tier |
25% | N/A | P Q:300 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PYRAZINAMIDE 500 MG TABLET |
4 |
Non-Preferred Drug |
49% | 49% | None |
PYRIDOSTIGMINE BR 60 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
PYRIDOSTIGMINE BR ER 180 MG TAB |
3 |
Preferred Brand |
20% | 20% | None |