2019 Medicare Part D Plan Formulary Information |
Humana Walmart Rx Plan (PDP) (S5884-158-0)
Benefit Details
|
The Humana Walmart Rx Plan (PDP) (S5884-158-0) Formulary Drugs Starting with the Letter C in CMS PDP Region 12 which includes: AL TN Plan Monthly Premium: $28.80 Deductible: $415 Qualifies for LIS: No |
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 |
4 |
Non-Preferred Drug |
35% | 35% | Q:16 /28Days |
CABLIVI 11 MG KIT |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
CABOMETYX 20 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
CABOMETYX 40 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
CABOMETYX 60 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
CALCIPOTRIENE 0.005% CREAM |
4 |
Non-Preferred Drug |
35% | 35% | Q:120 /30Days |
CALCIPOTRIENE 0.005% SOLUTION |
4 |
Non-Preferred Drug |
35% | 35% | Q:60 /30Days |
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY |
3 |
Preferred Brand |
20% | 17% | Q:4 /28Days |
CALCITRIOL 0.25 MCG CAPSULE [Rocaltrol] |
2* |
Generic |
$4.00 | $8.00 | None |
CALCITRIOL 0.5 MCG CAPSULE [Rocaltrol] |
2* |
Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CALCITRIOL 1MCG/ML SOLUTION ORAL |
4 |
Non-Preferred Drug |
35% | 35% | None |
CALCIUM ACETATE 667 MG TABLET [PhosLo] |
3 |
Preferred Brand |
20% | 17% | None |
CALCIUM ACETATE CAPSULE 667 MG |
3 |
Preferred Brand |
20% | 17% | None |
CALQUENCE 100 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
CAMILA 0.35 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
CAMRESE LO TABLET |
4 |
Non-Preferred Drug |
35% | 35% | Q:91 /90Days |
CANDESARTAN CILEXETIL 16 MG TABLET [Atacand] |
3 |
Preferred Brand |
20% | 17% | Q:60 /30Days |
CANDESARTAN CILEXETIL 32 MG TABLET [Atacand] |
3 |
Preferred Brand |
20% | 17% | Q:30 /30Days |
CANDESARTAN CILEXETIL 4 MG TABLET [Atacand] |
3 |
Preferred Brand |
20% | 17% | Q:60 /30Days |
CANDESARTAN CILEXETIL 8 MG TABLET [Atacand] |
3 |
Preferred Brand |
20% | 17% | Q:60 /30Days |
candesartan-hctz 16-12.5 mg tablet |
3 |
Preferred Brand |
20% | 17% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
candesartan-hctz 32-12.5 mg tablet |
3 |
Preferred Brand |
20% | 17% | Q:30 /30Days |
CANDESARTAN-HCTZ 32-25 MG TAB |
3 |
Preferred Brand |
20% | 17% | Q:30 /30Days |
CAPRELSA 100 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
CAPRELSA 300 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
CAPTOPRIL 100MG TABLET |
3 |
Preferred Brand |
20% | 17% | None |
CAPTOPRIL 12.5MG TABLET |
3 |
Preferred Brand |
20% | 17% | None |
CAPTOPRIL 25 MG TABLET |
3 |
Preferred Brand |
20% | 17% | None |
CAPTOPRIL 50MG TABLET |
3 |
Preferred Brand |
20% | 17% | None |
Captopril and Hydrochlorothiazide 25; 15mg 100 TABLET BOTTLE |
3 |
Preferred Brand |
20% | 17% | None |
Captopril and Hydrochlorothiazide 25; 25mg 100 TABLET BOTTLE |
3 |
Preferred Brand |
20% | 17% | None |
Captopril and Hydrochlorothiazide 50; 15mg 100 TABLET BOTTLE |
3 |
Preferred Brand |
20% | 17% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Captopril and Hydrochlorothiazide 50; 25mg 100 TABLET BOTTLE |
3 |
Preferred Brand |
20% | 17% | None |
CARBAGLU 200 MG DISPER TABLET |
5 |
Specialty Tier |
25% | N/A | P |
CARBAMAZEPINE 100 MG TAB CHEW |
3 |
Preferred Brand |
20% | 17% | None |
CARBAMAZEPINE 100 MG/5 ML SUSP |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARBAMAZEPINE 200 MG TABLET |
3 |
Preferred Brand |
20% | 17% | None |
CARBAMAZEPINE ER 100 MG CAP CPMP 12HR [Carbatrol] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARBAMAZEPINE ER 100 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARBAMAZEPINE ER 200 MG CAP CPMP 12HR [Carbatrol] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARBAMAZEPINE ER 300 MG CAP CPMP 12HR [Carbatrol] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARBAMAZEPINE XR 200 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | Q:120 /30Days |
CARBAMAZEPINE XR 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 |
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARBIDOPA AND LEVODOPA ODT 25;100MG;MG 100 BOT |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARBIDOPA AND LEVODOPA ODT 25;250MG;MG 100 BOT |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARBIDOPA-LEVO ER 25-100 TAB |
3 |
Preferred Brand |
20% | 17% | None |
CARBIDOPA-LEVO ER 50-200 TAB |
3 |
Preferred Brand |
20% | 17% | None |
CARBIDOPA-LEVODOPA 10-100 TAB |
2* |
Generic |
$4.00 | $8.00 | None |
CARBIDOPA-LEVODOPA 25-100 TAB |
2* |
Generic |
$4.00 | $8.00 | None |
CARBIDOPA-LEVODOPA 25-250 TAB |
2* |
Generic |
$4.00 | $8.00 | None |
CARBIDOPA-LEVODOPA-ENTA 150 MG |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARBIDOPA-LEVODOPA-ENTA 75 MG |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARBIDOPA-LEVODOPA-ENTACAPONE 100 MG [Stalevo] |
4 |
Non-Preferred Drug |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARBIDOPA-LEVODOPA-ENTACAPONE 125 MG [Stalevo] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARBIDOPA-LEVODOPA-ENTACAPONE 200 MG [Stalevo] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARBIDOPA-LEVODOPA-ENTACAPONE 50 MG [Stalevo] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARISOPRODOL 350 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
CARTEOLOL HCL 1% EYE DROPS |
2* |
Generic |
$4.00 | $8.00 | None |
CARTIA XT 120MG CAPSULE SA |
3 |
Preferred Brand |
20% | 17% | Q:60 /30Days |
CARTIA XT 180MG CAPSULE SA |
3 |
Preferred Brand |
20% | 17% | Q:60 /30Days |
CARTIA XT 240MG CAPSULE SA |
3 |
Preferred Brand |
20% | 17% | Q:60 /30Days |
CARTIA XT 300 MG CAPSULE |
3 |
Preferred Brand |
20% | 17% | Q:30 /30Days |
CARVEDILOL 12.5 MG TABLET |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
CARVEDILOL 25 MG TABLET |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARVEDILOL 3.125 MG TABLET |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
CARVEDILOL 6.25 MG TABLET |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
CASPOFUNGIN ACETATE 50 MG VIAL |
5 |
Specialty Tier |
25% | N/A | None |
CASPOFUNGIN ACETATE 70 MG VIAL |
5 |
Specialty Tier |
25% | N/A | None |
CAYSTON KIT 75 MG/VIAL |
5 |
Specialty Tier |
25% | N/A | P Q:84 /28Days |
CAZIANT 28 DAY TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFACLOR 250 MG CAPSULES |
3 |
Preferred Brand |
20% | 17% | None |
CEFACLOR 500 MG CAPSULES |
3 |
Preferred Brand |
20% | 17% | None |
CEFADROXIL 250 MG/5 ML SUSP |
3 |
Preferred Brand |
20% | 17% | None |
CEFADROXIL 500 MG CAPSULE |
2* |
Generic |
$4.00 | $8.00 | None |
CEFADROXIL 500 MG/5 ML SUSP |
3 |
Preferred Brand |
20% | 17% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFAZOLIN 1 GM VIAL 25/Box |
4 |
Non-Preferred Drug |
35% | 35% | None |
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFAZOLIN 500 MG VIAL |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFDINIR 125 MG/5 ML SUSP |
3 |
Preferred Brand |
20% | 17% | None |
CEFDINIR 250 MG/5 ML SUSP |
3 |
Preferred Brand |
20% | 17% | None |
CEFDINIR 300 MG CAPSULE |
2* |
Generic |
$4.00 | $8.00 | None |
CEFEPIME HCL 1 GM VIAL [Maxipime] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFEPIME HCL 2 GRAM VIAL [Maxipime] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFOTETAN 1GM VIAL 1EA x 10 |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFOTETAN 2GM VIAL 1EA x 10 |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFOXITIN 1 GM VIAL |
4 |
Non-Preferred Drug |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFOXITIN 10 GM VIAL |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFOXITIN 2 GM VIAL |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFPODOXIME 100 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFPODOXIME 200 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFPROZIL 125 MG/5 ML SUSP |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFPROZIL 250 MG TABLET |
3 |
Preferred Brand |
20% | 17% | None |
CEFPROZIL 250 MG/5 ML SUSP |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFPROZIL 500 MG TABLET |
3 |
Preferred Brand |
20% | 17% | None |
CEFTAZIDIME 1 GM VIAL |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN |
4 |
Non-Preferred Drug |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFTRIAXONE 1 GM VIAL |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFTRIAXONE 10 GM VIAL |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFTRIAXONE 2 GM VIAL |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFTRIAXONE 250 MG VIAL |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFTRIAXONE 500 MG VIAL |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFUROXIME 1.5 GM/VIAL FOR INJECTION |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFUROXIME 750 MG FOR INJECTION |
4 |
Non-Preferred Drug |
35% | 35% | None |
Cefuroxime 95 MG/ML Injectable Solution |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFUROXIME AXETIL 250 MG TAB |
3 |
Preferred Brand |
20% | 17% | None |
CEFUROXIME AXETIL 500 MG TAB |
3 |
Preferred Brand |
20% | 17% | None |
CELECOXIB 100 MG CAPSULE [Celebrex] |
2* |
Generic |
$4.00 | $8.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CELECOXIB 200 MG CAPSULE [Celebrex] |
2* |
Generic |
$4.00 | $8.00 | Q:60 /30Days |
CELECOXIB 400 MG CAPSULE [Celebrex] |
2* |
Generic |
$4.00 | $8.00 | Q:60 /30Days |
CELECOXIB 50 MG CAPSULE [Celebrex] |
2* |
Generic |
$4.00 | $8.00 | Q:60 /30Days |
CELLCEPT 200 MG/ML ORAL SUSP |
5 |
Specialty Tier |
25% | N/A | P |
CELLCEPT 250 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | P |
CELLCEPT 500 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
CELONTIN 300 MG KAPSEAL |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEPHALEXIN 125 MG/5 ML SUSP |
2* |
Generic |
$4.00 | $8.00 | None |
CEPHALEXIN 250 MG CAPSULE |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
CEPHALEXIN 250 MG/5 ML SUSP |
2* |
Generic |
$4.00 | $8.00 | None |
CEPHALEXIN 500 MG CAPSULE |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CERDELGA 84 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
CETIRIZINE HCL 1 MG/ML SOLN |
2* |
Generic |
$4.00 | $8.00 | Q:300 /30Days |
CHANTIX 0.5 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | Q:56 /28Days |
CHANTIX 1 MG CONT MONTH BOX |
4 |
Non-Preferred Drug |
35% | 35% | Q:56 /28Days |
CHANTIX 1 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | Q:56 /28Days |
CHANTIX STARTING MONTH BOX |
4 |
Non-Preferred Drug |
35% | 35% | Q:56 /28Days |
CHEMET 100 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | None |
CHENODAL 250 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
CHLORDIAZEPOXIDE 10 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | Q:120 /30Days |
CHLORDIAZEPOXIDE 25 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | Q:120 /30Days |
CHLORDIAZEPOXIDE 5 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLORHEXIDINE GLUCONATE 0.12% RINSE |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
CHLOROQUINE PH 250 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
CHLOROQUINE PH 500 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
CHLOROTHIAZIDE 250 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
Chlorothiazide 500mg 100 TABLET BOTTLE |
2* |
Generic |
$4.00 | $8.00 | None |
CHLORPROMAZINE 10 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | P |
CHLORPROMAZINE 100 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
CHLORPROMAZINE 200 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
CHLORPROMAZINE 25 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | P |
CHLORPROMAZINE 50 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
CHLORTHALIDONE 25 MG TABLET (100 CT) |
2* |
Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLORTHALIDONE 50 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
CHOLBAM 250 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
CHOLBAM 50 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
CHOLESTYRAMINE LIGHT POWDER |
3 |
Preferred Brand |
20% | 17% | None |
CHOLESTYRAMINE PACKET |
3 |
Preferred Brand |
20% | 17% | None |
CICLOPIROX 0.77% CREAM |
2* |
Generic |
$4.00 | $8.00 | None |
CICLOPIROX 0.77% GEL |
4 |
Non-Preferred Drug |
35% | 35% | None |
CICLOPIROX 0.77% TOPICAL SUSP |
3 |
Preferred Brand |
20% | 17% | None |
CICLOPIROX 8% SOLUTION |
4 |
Non-Preferred Drug |
35% | 35% | None |
Cilastatin 250 MG / Imipenem 250 MG Injection |
4 |
Non-Preferred Drug |
35% | 35% | None |
Cilastatin 500 MG / Imipenem 500 MG Injection |
4 |
Non-Preferred Drug |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CILOSTAZOL 100 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
CILOSTAZOL 50 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
CIMDUO 300-300 MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
Cimetidine 200mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
2* |
Generic |
$4.00 | $8.00 | None |
Cimetidine 300 MG Oral Tablet |
2* |
Generic |
$4.00 | $8.00 | None |
Cimetidine 400mg/1 100 FILM COATED TABLETS in BOTTLE |
2* |
Generic |
$4.00 | $8.00 | None |
Cimetidine 800mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
Cimetidine Hydrochloride Oral Solution 300mg/5mL 237 mL in 1 BOTTLE |
2* |
Generic |
$4.00 | $8.00 | None |
CINACALCET HCL 30 MG TABLET [Sensipar] |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
CINACALCET HCL 60 MG TABLET [Sensipar] |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
CINACALCET HCL 90 MG TABLET [Sensipar] |
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 |
CIPROFLOXACIN 0.2% OTIC SOLN DROPERETTE [Cetraxal] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CIPROFLOXACIN 0.3% EYE DROP [Ciloxan] |
2* |
Generic |
$4.00 | $8.00 | None |
CIPROFLOXACIN 250 MG TABLET (100 CT) [Cipro] |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
CIPROFLOXACIN HCL 100 MG Tablet [Cipro] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CIPROFLOXACIN HCL 500 MG Tablet [Cipro] |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
CIPROFLOXACIN HCL 750 MG Tablet [Cipro] |
2* |
Generic |
$4.00 | $8.00 | None |
CIPROFLOXACIN-D5W 200 MG/100 ML PIGGYBACK [Cipro] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CITALOPRAM HBR 10 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | Q:30 /30Days |
CITALOPRAM HBR 10 MG/5 ML SOLN |
3 |
Preferred Brand |
20% | 17% | None |
CITALOPRAM HBR 20 MG TABLET |
1* |
Preferred Generic |
$1.00 | $0.00 | Q:60 /30Days |
CITALOPRAM HBR 40 MG TABLET |
1* |
Preferred Generic |
$1.00 | $0.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLARITHROMYCIN 125 MG/5ML FOR ORAL SUSPENSION |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLARITHROMYCIN 250 MG TABLET |
3 |
Preferred Brand |
20% | 17% | None |
CLARITHROMYCIN 250 MG/5MLFOR ORAL SUSPENSION |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLARITHROMYCIN 500 MG TABLET |
3 |
Preferred Brand |
20% | 17% | None |
CLARITHROMYCIN ER 500 MG TAB |
3 |
Preferred Brand |
20% | 17% | None |
Clemastine fum 2.68 mg tab |
4 |
Non-Preferred Drug |
35% | 35% | None |
Clindamycin 150 MG/ML 2ml |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLINDAMYCIN 150mg/ml vl 25x6ml |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLINDAMYCIN 75 MG/5 ML SOLN |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLINDAMYCIN HCL 150 MG CAPSULE |
2* |
Generic |
$4.00 | $8.00 | None |
CLINDAMYCIN HCL 300 MG CAPSULE |
2* |
Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINDAMYCIN HCL 75 MG 200 CAPSULE BOTTLE |
2* |
Generic |
$4.00 | $8.00 | None |
CLINDAMYCIN PH 1% SOLUTION |
3 |
Preferred Brand |
20% | 17% | None |
CLINDAMYCIN PH 600 MG/4 ML VL |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLINDAMYCIN PHOSP 1% LOTION |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX |
3 |
Preferred Brand |
20% | 17% | None |
CLINDAMYCIN PHOSPHATE VAGINAL CREAM |
4 |
Non-Preferred Drug |
35% | 35% | None |
Clindamycin-d5w 300 mg/50 ml |
4 |
Non-Preferred Drug |
35% | 35% | None |
Clindamycin-d5w 600 mg/50 ml |
4 |
Non-Preferred Drug |
35% | 35% | None |
Clindamycin-d5w 900 mg/50 ml |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLINIMIX 4.25%-25% SOLUTION IV SOLN |
4 |
Non-Preferred Drug |
35% | 35% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINIMIX 5/20 SOLUTION |
4 |
Non-Preferred Drug |
35% | 35% | P |
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG |
4 |
Non-Preferred Drug |
35% | 35% | P |
CLINIMIX 5%-15% SOLUTION |
4 |
Non-Preferred Drug |
35% | 35% | P |
CLINIMIX E 2.75/5 SOLUTION |
4 |
Non-Preferred Drug |
35% | 35% | P |
CLINIMIX E 4.25/5 SOLUTION |
4 |
Non-Preferred Drug |
35% | 35% | P |
CLINIMIX E 5/20 SOLUTION |
4 |
Non-Preferred Drug |
35% | 35% | P |
CLINIMIX E 5%/15% INJECTION 2000ML BAG |
4 |
Non-Preferred Drug |
35% | 35% | P |
CLOBAZAM 10 MG TABLET [ONFI] |
4 |
Non-Preferred Drug |
35% | 35% | P Q:60 /30Days |
CLOBAZAM 2.5 MG/ML Oral Suspension [ONFI] |
4 |
Non-Preferred Drug |
35% | 35% | P Q:480 /30Days |
CLOBAZAM 20 MG TABLET [ONFI] |
4 |
Non-Preferred Drug |
35% | 35% | P Q:60 /30Days |
CLOBETASOL 0.05% CREAM (g) [Temovate] |
4 |
Non-Preferred Drug |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOBETASOL 0.05% OINTMENT |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLOBETASOL 0.05% SOLUTION |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLOBETASOL EMOLLIENT 0.05% CREAM (g) [Temovate E] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLOMIPRAMINE 25 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLOMIPRAMINE 50 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLOMIPRAMINE 75 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLONAZEPAM 0.125 MG DIS TAB RAPDIS [Klonopin] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLONAZEPAM 0.25 MG ODT TAB RAPDIS [Klonopin] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLONAZEPAM 0.5 MG DIS TABLET RAPDIS [Klonopin] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLONAZEPAM 0.5 MG TABLET [Klonopin] |
3 |
Preferred Brand |
20% | 17% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLONAZEPAM 1 MG DIS TABLET RAPDIS [Klonopin] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLONAZEPAM 1 MG TABLET [Klonopin] |
3 |
Preferred Brand |
20% | 17% | None |
CLONAZEPAM 2 MG ODT TAB RAPDIS [Klonopin] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLONAZEPAM 2 MG TABLET [Klonopin] |
3 |
Preferred Brand |
20% | 17% | None |
Clonidine 0.1mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
4 |
Non-Preferred Drug |
35% | 35% | Q:4 /28Days |
Clonidine 0.2mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
4 |
Non-Preferred Drug |
35% | 35% | Q:4 /28Days |
Clonidine 0.3mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH |
4 |
Non-Preferred Drug |
35% | 35% | Q:4 /28Days |
CLONIDINE HCL 0.1 MG TABLET |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
CLONIDINE HCL 0.2 MG TABLET |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
CLONIDINE HCL 0.3 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
CLOPIDOGREL 75 MG TABLET [Plavix] |
2* |
Generic |
$4.00 | $8.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLORAZEPATE 15 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLORAZEPATE 3.75 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLORAZEPATE 7.5 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLOTRIMAZOLE 1% CREAM |
2* |
Generic |
$4.00 | $8.00 | None |
CLOTRIMAZOLE 1% SOLUTION |
3 |
Preferred Brand |
20% | 17% | None |
CLOTRIMAZOLE 10 MG TROCHE |
2* |
Generic |
$4.00 | $8.00 | None |
CLOTRIMAZOLE-BETAMETHASONE LOT |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE |
3 |
Preferred Brand |
20% | 17% | None |
CLOZAPINE 100 MG TABLET [Clozaril] |
3 |
Preferred Brand |
20% | 17% | None |
CLOZAPINE 200 MG TABLET |
3 |
Preferred Brand |
20% | 17% | None |
CLOZAPINE 25 MG TABLET [Clozaril] |
3 |
Preferred Brand |
20% | 17% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOZAPINE 50 MG TABLET |
3 |
Preferred Brand |
20% | 17% | None |
CLOZAPINE ODT 100 MG TABLET RAPDIS [Fazaclo] |
4 |
Non-Preferred Drug |
35% | 35% | P |
CLOZAPINE ODT 12.5 MG TABLET RAPDIS [Fazaclo] |
4 |
Non-Preferred Drug |
35% | 35% | P |
CLOZAPINE ODT 150 MG TABLET RAPDIS [Fazaclo] |
4 |
Non-Preferred Drug |
35% | 35% | P |
CLOZAPINE ODT 200 MG TABLET RAPDIS [Fazaclo] |
4 |
Non-Preferred Drug |
35% | 35% | P |
CLOZAPINE ODT 25 MG TABLET RAPDIS [Fazaclo] |
4 |
Non-Preferred Drug |
35% | 35% | P |
COARTEM 20MG-120MG |
4 |
Non-Preferred Drug |
35% | 35% | Q:24 /30Days |
COLCRYS 0.6 MG TABLET |
3 |
Preferred Brand |
20% | 17% | Q:120 /30Days |
COLESTIPOL HCL 1G TABLET |
3 |
Preferred Brand |
20% | 17% | None |
COLESTIPOL HCL GRANULES PACKET |
4 |
Non-Preferred Drug |
35% | 35% | None |
COLISTIMETHATE 150 MG VIAL [Coly-Mycin M] |
4 |
Non-Preferred Drug |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COLOCORT 100MG ENEMA |
4 |
Non-Preferred Drug |
35% | 35% | None |
COMBIGAN 0.2%-0.5% DROPS |
3 |
Preferred Brand |
20% | 17% | Q:5 /25Days |
COMBIVENT RESPIMAT INHAL SPRAY |
4 |
Non-Preferred Drug |
35% | 35% | Q:4 /20Days |
COMETRIQ 100 MG DAILY-DOSE PK |
5 |
Specialty Tier |
25% | N/A | P Q:56 /28Days |
COMETRIQ 140 MG DAILY-DOSE PK |
5 |
Specialty Tier |
25% | N/A | P Q:112 /28Days |
COMETRIQ 60 MG DAILY-DOSE PACK |
5 |
Specialty Tier |
25% | N/A | P Q:84 /28Days |
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1 |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
COMPRO 25MG SUPPOSITORY |
4 |
Non-Preferred Drug |
35% | 35% | None |
CONSTULOSE 10 GM/15 ML SOLN |
2* |
Generic |
$4.00 | $8.00 | None |
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
COPAXONE 40 MG/ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P Q:12 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COPIKTRA 15 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:56 /28Days |
COPIKTRA 25 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:56 /28Days |
CORLANOR 5 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | P Q:60 /30Days |
CORLANOR 7.5 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | P Q:60 /30Days |
Cortisone 25 MG Tablet |
4 |
Non-Preferred Drug |
35% | 35% | None |
COSENTYX 300 MG DOSE-2 PENS |
5 |
Specialty Tier |
25% | N/A | P Q:32 /365Days |
COTELLIC 20 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:63 /28Days |
COUMADIN 1 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
COUMADIN 10MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
COUMADIN 2.5 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
COUMADIN 2MG 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 |
COUMADIN 3mg/1 1 BOTTLE per CARTON / 100 TABLET BOTTLE |
4 |
Non-Preferred Drug |
35% | 35% | None |
COUMADIN 4mg/1 1 BOTTLE in 1 CARTON / 100 TABLET BOTTLE |
4 |
Non-Preferred Drug |
35% | 35% | None |
COUMADIN 5MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
COUMADIN 6MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
COUMADIN 7.5MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
Creon 256.11mg/1 1 BOTTLE per CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
3 |
Preferred Brand |
20% | 17% | None |
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT |
3 |
Preferred Brand |
20% | 17% | None |
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT |
3 |
Preferred Brand |
20% | 17% | None |
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT |
3 |
Preferred Brand |
20% | 17% | None |
CREON DR 36,000 UNITS CAPSULE |
3 |
Preferred Brand |
20% | 17% | None |
CRESEMBA 186 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CRIXIVAN 200MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | Q:450 /30Days |
CRIXIVAN 400mg, 180 CAPSULE BOTTLE |
4 |
Non-Preferred Drug |
35% | 35% | Q:270 /30Days |
CROMOLYN 20 MG/2 ML NEB SOLN |
4 |
Non-Preferred Drug |
35% | 35% | P |
CROMOLYN SODIUM 100 MG/5 ML |
4 |
Non-Preferred Drug |
35% | 35% | None |
CROMOLYN SODIUM 4% 40MG 10ML BOT |
2* |
Generic |
$4.00 | $8.00 | None |
CUPRIMINE 250 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | None |
Cyclafem 1/35 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
4 |
Non-Preferred Drug |
35% | 35% | None |
CYCLAFEM 7-7-7-28 TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
CYCLOBENZAPRINE 10 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
CYCLOBENZAPRINE 5 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
CYCLOPHOSPHAMIDE 25 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 |
CYCLOPHOSPHAMIDE 50 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | P |
CYCLOSPORINE 100MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | P |
CYCLOSPORINE 25MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | P |
CYCLOSPORINE MODIFIED 100 MG |
4 |
Non-Preferred Drug |
35% | 35% | P |
CYCLOSPORINE MODIFIED 25 MG |
4 |
Non-Preferred Drug |
35% | 35% | P |
CYCLOSPORINE MODIFIED 50 MG |
4 |
Non-Preferred Drug |
35% | 35% | P |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT |
4 |
Non-Preferred Drug |
35% | 35% | P |
CYPROHEPTADINE 4 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL |
4 |
Non-Preferred Drug |
35% | 35% | None |
CYRED EQ 28 DAY TABLET [Solia] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CYSTADANE 1 GRAM/1.7 ML POWDER |
5 |
Specialty Tier |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYSTAGON 150MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | None |
CYSTAGON 50MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | None |
CYSTARAN 0.44% EYE DROPS |
5 |
Specialty Tier |
25% | N/A | P Q:60 /28Days |