2020 Medicare Part D Plan Formulary Information |
Kansas Health Advantage (HMO I-SNP) (H2392-001-0)
Benefit Details
|
The Kansas Health Advantage (HMO I-SNP) (H2392-001-0) Formulary Drugs Starting with the Letter A in Sumner County, KS: CMS MA Region 18 which includes: KS Plan Monthly Premium: $31.50 Deductible: $435 |
Drugs Starting with Letter A
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
ABACAVIR 20 MG/ML SOLUTION |
1 |
Tier 1 |
25% | N/A | None |
ABACAVIR 300 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir] |
1 |
Tier 1 |
25% | N/A | None |
ABACAVIR-LAMIVUDINE 600-300 MG TABLET [Epzicom] |
1 |
Tier 1 |
25% | N/A | None |
ABELCET INJECTION SUSPENSION 5MG/ML |
1 |
Tier 1 |
25% | N/A | P |
ABILIFY MAINTENA ER 300 MG SYRINGE |
1 |
Tier 1 |
25% | N/A | S |
ABILIFY MAINTENA ER 300 MG VIAL |
1 |
Tier 1 |
25% | N/A | S |
ABILIFY MAINTENA ER 400 MG SUSER VIAL |
1 |
Tier 1 |
25% | N/A | S |
ABILIFY MAINTENA ER 400 MG SYRINGE |
1 |
Tier 1 |
25% | N/A | S |
ABILIFY MYCITE 10 MG KIT TABLET SENSPT |
1 |
Tier 1 |
25% | N/A | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABILIFY MYCITE 15 MG KIT TABLET SENSPT |
1 |
Tier 1 |
25% | N/A | S Q:30 /30Days |
ABILIFY MYCITE 2 MG KIT TABLET SENSPT |
1 |
Tier 1 |
25% | N/A | S Q:60 /30Days |
ABILIFY MYCITE 20 MG KIT TABLET SENSPT |
1 |
Tier 1 |
25% | N/A | S Q:30 /30Days |
ABILIFY MYCITE 30 MG KIT TABLET SENSPT |
1 |
Tier 1 |
25% | N/A | S Q:30 /30Days |
ABILIFY MYCITE 5 MG KIT TABLET SENSPT |
1 |
Tier 1 |
25% | N/A | S Q:60 /30Days |
ABIRATERONE ACETATE 250 MG TABLET [ZYTIGA] |
1 |
Tier 1 |
25% | N/A | P Q:120 /30Days |
Acamprosate Calcium DR 333 MG tablets [Campral] |
1 |
Tier 1 |
25% | N/A | None |
ACARBOSE 100 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
ACARBOSE 25 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
ACARBOSE 50 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
ACEBUTOLOL 200 MG CAPSULE [Sectral] |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACEBUTOLOL 400 MG CAPSULE [Sectral] |
1 |
Tier 1 |
25% | N/A | None |
ACETAMINOP-CODEINE 120-12 MG/5 |
1 |
Tier 1 |
25% | N/A | None |
ACETAMINOPHEN-COD #2 TABLET |
1 |
Tier 1 |
25% | N/A | None |
ACETAMINOPHEN-COD #3 TABLET [Tylenol with Codeine No.3] |
1 |
Tier 1 |
25% | N/A | None |
ACETAMINOPHEN-COD #4 TABLET |
1 |
Tier 1 |
25% | N/A | None |
ACETAZOLAMIDE 125MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
ACETAZOLAMIDE 250 MG TABLET [Diamox] |
1 |
Tier 1 |
25% | N/A | None |
ACETAZOLAMIDE ER 500 MG CAPSULE |
1 |
Tier 1 |
25% | N/A | None |
ACETIC ACID 2% EAR SOLUTION |
1 |
Tier 1 |
25% | N/A | None |
ACETYLCYSTEINE 10% VIAL |
1 |
Tier 1 |
25% | N/A | P |
ACETYLCYSTEINE 20% VIAL [Mucosil Acetylcysteine] |
1 |
Tier 1 |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACITRETIN 10 MG CAPSULE [Soriatane] |
1 |
Tier 1 |
25% | N/A | P |
ACITRETIN 17.5 MG CAPSULE [Soriatane] |
1 |
Tier 1 |
25% | N/A | P |
ACITRETIN 25 MG CAPSULE [Soriatane] |
1 |
Tier 1 |
25% | N/A | P |
ACTHIB VACCINE WITH DILUENT |
1 |
Tier 1 |
25% | N/A | None |
ACTIMMUNE 100 MCG/0.5 ML VIAL |
1 |
Tier 1 |
25% | N/A | P |
ACYCLOVIR 200 MG CAPSULE |
1 |
Tier 1 |
25% | N/A | None |
ACYCLOVIR 200 MG/5 ML SUSP |
1 |
Tier 1 |
25% | N/A | None |
ACYCLOVIR 400 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
ACYCLOVIR 5% OINTMENT [Zovirax] |
1 |
Tier 1 |
25% | N/A | None |
ACYCLOVIR 800 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
Acyclovir sodium 500 mg vial |
1 |
Tier 1 |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADACEL TDAP SYRINGE |
1 |
Tier 1 |
25% | N/A | None |
ADACEL VIAL 2UNT/5UNT |
1 |
Tier 1 |
25% | N/A | None |
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA] |
1 |
Tier 1 |
25% | N/A | P |
ADAPALENE 0.1% CREAM |
1 |
Tier 1 |
25% | N/A | P |
ADAPALENE 0.1% GEL |
1 |
Tier 1 |
25% | N/A | P |
ADAPALENE 0.3% GEL [Differin Pump] |
1 |
Tier 1 |
25% | N/A | P |
ADEFOVIR DIPIVOXIL 10 MG TABLET [Hepsera] |
1 |
Tier 1 |
25% | N/A | P Q:30 /30Days |
ADEMPAS 0.5 MG TABLET |
1 |
Tier 1 |
25% | N/A | P Q:90 /30Days |
ADEMPAS 1 MG TABLET |
1 |
Tier 1 |
25% | N/A | P Q:90 /30Days |
ADEMPAS 1.5 MG TABLET |
1 |
Tier 1 |
25% | N/A | P Q:90 /30Days |
ADEMPAS 2 MG TABLET |
1 |
Tier 1 |
25% | N/A | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADEMPAS 2.5 MG TABLET |
1 |
Tier 1 |
25% | N/A | P Q:90 /30Days |
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER |
1 |
Tier 1 |
25% | N/A | None |
ADVAIR HFA INHALER 115;21MCG;MCG 120 ACTN INHL |
1 |
Tier 1 |
25% | N/A | None |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
1 |
Tier 1 |
25% | N/A | None |
AFINITOR 10 MG TABLET |
1 |
Tier 1 |
25% | N/A | P Q:30 /30Days |
AFINITOR DISPERZ 2 MG TABLET |
1 |
Tier 1 |
25% | N/A | P Q:30 /30Days |
AFINITOR DISPERZ 3 MG TABLET |
1 |
Tier 1 |
25% | N/A | P Q:30 /30Days |
AFINITOR DISPERZ 5 MG TABLET |
1 |
Tier 1 |
25% | N/A | P Q:60 /30Days |
ALBENDAZOLE 200 MG TABLET [Albenza] |
1 |
Tier 1 |
25% | N/A | None |
ALBUTEROL 2.5 MG/0.5 ML SOL VIAL-NEB |
1 |
Tier 1 |
25% | N/A | P |
ALBUTEROL SUL 0.63 MG/3 ML SOL VIAL-NEB |
1 |
Tier 1 |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL SUL 1.25 MG/3 ML SOL VIAL-NEB |
1 |
Tier 1 |
25% | N/A | P |
ALBUTEROL SUL 2.5 MG/3 ML SOLN |
1 |
Tier 1 |
25% | N/A | P |
ALBUTEROL SULFATE 2 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
ALBUTEROL SULFATE 4 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
1 |
Tier 1 |
25% | N/A | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
1 |
Tier 1 |
25% | N/A | None |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOTTLE |
1 |
Tier 1 |
25% | N/A | None |
ALCLOMETASONE DIPR 0.05% OINTMENT |
1 |
Tier 1 |
25% | N/A | None |
ALCLOMETASONE DIPRO 0.05% CREAM |
1 |
Tier 1 |
25% | N/A | None |
ALECENSA 150 MG CAPSULE |
1 |
Tier 1 |
25% | N/A | P |
ALENDRONATE SODIUM 10 MG TABLET [Fosamax] |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALENDRONATE SODIUM 35 MG TABLET [Fosamax] |
1 |
Tier 1 |
25% | N/A | None |
ALENDRONATE SODIUM 70 MG TABLET [Fosamax] |
1 |
Tier 1 |
25% | N/A | None |
ALENDRONATE SODIUM 70 MG/75 ML |
1 |
Tier 1 |
25% | N/A | None |
ALFUZOSIN HCL ER 10 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
ALINIA 100 MG/5 ML SUSPENSION |
1 |
Tier 1 |
25% | N/A | P Q:180 /30Days |
ALINIA 500 MG TABLET |
1 |
Tier 1 |
25% | N/A | P Q:14 /30Days |
Aliskiren 150 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT] |
1 |
Tier 1 |
25% | N/A | None |
Aliskiren 150 MG / Hydrochlorothiazide 25 MG Oral Tablet [Tekturna HCT] |
1 |
Tier 1 |
25% | N/A | None |
ALISKIREN 150 MG TABLET [Tekturna] |
1 |
Tier 1 |
25% | N/A | None |
Aliskiren 300 MG / Hydrochlorothiazide 12.5 MG Oral Tablet [Tekturna HCT] |
1 |
Tier 1 |
25% | N/A | None |
ALISKIREN 300 MG TABLET [Tekturna] |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALLOPURINOL 100 MG TABLET [Zyloprim] |
1 |
Tier 1 |
25% | N/A | None |
ALLOPURINOL 300 MG TABLET [Zyloprim] |
1 |
Tier 1 |
25% | N/A | None |
ALMOTRIPTAN MALATE 12.5 MG TABLET [Axert] |
1 |
Tier 1 |
25% | N/A | Q:12 /30Days |
ALMOTRIPTAN MALATE 6.25 MG TABLET [Axert] |
1 |
Tier 1 |
25% | N/A | Q:12 /30Days |
ALOSETRON HCL 0.5 MG TABLET [Lotronex] |
1 |
Tier 1 |
25% | N/A | P |
ALOSETRON HCL 1 MG TABLET [Lotronex] |
1 |
Tier 1 |
25% | N/A | P |
ALPHAGAN P 0.1% EYE DROPS |
1 |
Tier 1 |
25% | N/A | None |
ALPRAZOLAM 0.25 MG TABLET [Xanax] |
1 |
Tier 1 |
25% | N/A | None |
ALPRAZOLAM 0.5 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
ALPRAZOLAM 1 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
Alprazolam 1mg/mL 1 BOTTLE in 1 CONTAINER / 30 mL in 1 BOTTLE |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALPRAZOLAM 2 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
ALPRAZOLAM ODT 0.25 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
ALPRAZOLAM ODT 0.5 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
ALPRAZOLAM ODT 1 MG TABLET RAPDIS [Niravam] |
1 |
Tier 1 |
25% | N/A | None |
ALPRAZOLAM ODT 2 MG TABLET RAPDIS [Niravam] |
1 |
Tier 1 |
25% | N/A | None |
ALTAVERA-28 TABLET [Portia] |
1 |
Tier 1 |
25% | N/A | None |
ALUNBRIG 180 MG TABLET |
1 |
Tier 1 |
25% | N/A | P Q:30 /30Days |
ALUNBRIG 30 MG TABLET |
1 |
Tier 1 |
25% | N/A | P Q:180 /30Days |
ALUNBRIG 90 MG TABLET |
1 |
Tier 1 |
25% | N/A | P Q:60 /30Days |
ALUNBRIG 90 MG-180 MG TABLET PACK |
1 |
Tier 1 |
25% | N/A | P Q:30 /30Days |
ALYACEN 1-35-28 TABLET |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Amabelz 0.5 MG/0.1 MG 28 TABLET/BLISTER PACK 3 PER CARTON |
1 |
Tier 1 |
25% | N/A | None |
Amabelz 1 MG/0.5 MG 28 TABLET/BLISTER PACK 3 PER CARTON |
1 |
Tier 1 |
25% | N/A | None |
AMANTADINE 100 MG CAPSULE |
1 |
Tier 1 |
25% | N/A | None |
AMANTADINE 100 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
AMANTADINE 50 MG/5 ML SOLUTION |
1 |
Tier 1 |
25% | N/A | None |
AMBISOME 50MG VIAL |
1 |
Tier 1 |
25% | N/A | P |
AMBRISENTAN 10 MG TABLET [LETAIRIS] |
1 |
Tier 1 |
25% | N/A | P Q:30 /30Days |
AMBRISENTAN 5 MG TABLET [LETAIRIS] |
1 |
Tier 1 |
25% | N/A | P Q:30 /30Days |
AMCINONIDE 0.1% CREAM |
1 |
Tier 1 |
25% | N/A | None |
AMCINONIDE 0.1% LOTION |
1 |
Tier 1 |
25% | N/A | None |
AMCINONIDE 0.1% OINTMENT 60GM TUBE |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMETHIA 0.15-0.03-0.01 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
AMETHIA LO TABLET |
1 |
Tier 1 |
25% | N/A | None |
AMIKACIN SULF 500 MG/2 ML VIAL |
1 |
Tier 1 |
25% | N/A | P |
AMILORIDE HCL 5 MG TABLET [Midamor] |
1 |
Tier 1 |
25% | N/A | None |
AMILORIDE HCL-HCTZ 5-50 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
Amino Acids 15% Solution |
1 |
Tier 1 |
25% | N/A | P |
Amino acids 4.25% in dextrose 10% Injectable Solution [Clinimix 4.25/10] |
1 |
Tier 1 |
25% | N/A | P |
Amino acids 4.25% in dextrose 5% Injectable Solution [Clinimix 4.25/5] |
1 |
Tier 1 |
25% | N/A | P |
AMINOSYN II 10% SOL 6X2000 ML |
1 |
Tier 1 |
25% | N/A | P |
AMINOSYN-PF 7% IV SOLUTION |
1 |
Tier 1 |
25% | N/A | P |
AMIODARONE HCL 100 MG TABLET [Pacerone] |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMIODARONE HCL 200 MG TABLET [Pacerone] |
1 |
Tier 1 |
25% | N/A | None |
AMIODARONE HCL 400 MG TABLET [Pacerone] |
1 |
Tier 1 |
25% | N/A | None |
AMITIZA 24 MCG 60 CAPSULE BOTTLE |
1 |
Tier 1 |
25% | N/A | None |
AMITIZA 8MCG CAPSULE |
1 |
Tier 1 |
25% | N/A | None |
AMITRIP/CDP 25-10 TABLET |
1 |
Tier 1 |
25% | N/A | None |
AMITRIP/PERPHEN 10-4 TABLET |
1 |
Tier 1 |
25% | N/A | None |
AMITRIP/PERPHEN 50-4 TABLET |
1 |
Tier 1 |
25% | N/A | None |
AMITRIPTYLINE HCL 10 MG TABLET [Elavil] |
1 |
Tier 1 |
25% | N/A | None |
AMITRIPTYLINE HCL 100 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
AMITRIPTYLINE HCL 150 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
AMITRIPTYLINE HCL 25 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIPTYLINE HCL 50 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
AMITRIPTYLINE HCL 75 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
AMLOD-VALSA-HCTZ 10-160-12.5 MG [Exforge HCT] |
1 |
Tier 1 |
25% | N/A | None |
AMLOD-VALSA-HCTZ 10-160-25 MG [Exforge HCT] |
1 |
Tier 1 |
25% | N/A | None |
AMLOD-VALSA-HCTZ 10-320-25 MG [Exforge HCT] |
1 |
Tier 1 |
25% | N/A | None |
AMLOD-VALSA-HCTZ 5-160-12.5 MG [Exforge HCT] |
1 |
Tier 1 |
25% | N/A | None |
AMLOD-VALSA-HCTZ 5-160-25 MG [Exforge HCT] |
1 |
Tier 1 |
25% | N/A | None |
AMLODIPINE BESYLATE 10 MG TABLET [Norvasc] |
1 |
Tier 1 |
25% | N/A | None |
AMLODIPINE BESYLATE 2.5 MG TABLET [Norvasc] |
1 |
Tier 1 |
25% | N/A | None |
AMLODIPINE BESYLATE 5 MG TABLET [Norvasc] |
1 |
Tier 1 |
25% | N/A | None |
AMLODIPINE-ATORVAST 10-20 MG [Caduet] |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE-ATORVAST 10-40 MG [Caduet] |
1 |
Tier 1 |
25% | N/A | None |
Amlodipine-Atorvastatin 10-10 mg [Caduet] |
1 |
Tier 1 |
25% | N/A | None |
Amlodipine-Atorvastatin 10-80 mg [Caduet] |
1 |
Tier 1 |
25% | N/A | None |
Amlodipine-Atorvastatin 2.5-10 mg [Caduet] |
1 |
Tier 1 |
25% | N/A | None |
Amlodipine-Atorvastatin 2.5-20 mg [Caduet] |
1 |
Tier 1 |
25% | N/A | None |
Amlodipine-Atorvastatin 2.5-40 mg [Caduet] |
1 |
Tier 1 |
25% | N/A | None |
Amlodipine-Atorvastatin 5-10 mg [Caduet] |
1 |
Tier 1 |
25% | N/A | None |
Amlodipine-Atorvastatin 5-20 mg [Caduet] |
1 |
Tier 1 |
25% | N/A | None |
Amlodipine-Atorvastatin 5-40 mg [Caduet] |
1 |
Tier 1 |
25% | N/A | None |
Amlodipine-Atorvastatin 5-80 mg [Caduet] |
1 |
Tier 1 |
25% | N/A | None |
AMLODIPINE-BENAZEPRIL 10-20 MG CAPSULE [Lotrel] |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE-BENAZEPRIL 10-40 MG CAPSULE [Lotrel] |
1 |
Tier 1 |
25% | N/A | None |
AMLODIPINE-BENAZEPRIL 2.5-10 CAPSULE [Lotrel] |
1 |
Tier 1 |
25% | N/A | None |
AMLODIPINE-BENAZEPRIL 5-10 MG CAPSULE [Lotrel] |
1 |
Tier 1 |
25% | N/A | None |
AMLODIPINE-BENAZEPRIL 5-20 MG CAPSULE [Lotrel] |
1 |
Tier 1 |
25% | N/A | None |
AMLODIPINE-BENAZEPRIL 5-40 MG CAPSULE [Lotrel] |
1 |
Tier 1 |
25% | N/A | None |
AMLODIPINE-OLMESARTAN 10-20 MG TABLET [AZOR] |
1 |
Tier 1 |
25% | N/A | None |
AMLODIPINE-OLMESARTAN 10-40 MG TABLET [AZOR] |
1 |
Tier 1 |
25% | N/A | None |
AMLODIPINE-OLMESARTAN 5-20 MG TABLET [AZOR] |
1 |
Tier 1 |
25% | N/A | None |
AMLODIPINE-OLMESARTAN 5-40 MG TABLET [AZOR] |
1 |
Tier 1 |
25% | N/A | None |
AMLODIPINE-VALSARTAN 10-160 MG TABLET [Exforge] |
1 |
Tier 1 |
25% | N/A | None |
AMLODIPINE-VALSARTAN 10-320 MG TABLET [Exforge] |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE-VALSARTAN 5-160 MG TABLET [Exforge] |
1 |
Tier 1 |
25% | N/A | None |
AMLODIPINE-VALSARTAN 5-320 MG TABLET [Exforge] |
1 |
Tier 1 |
25% | N/A | None |
AMMONIUM LACTATE 12% CREAM (g) [Lac-Hydrin] |
1 |
Tier 1 |
25% | N/A | None |
AMMONIUM LACTATE 12% LOTION |
1 |
Tier 1 |
25% | N/A | None |
AMNESTEEM 10 MG CAPSULE [ZENATANE] |
1 |
Tier 1 |
25% | N/A | None |
AMNESTEEM 20 MG CAPSULE [ZENATANE] |
1 |
Tier 1 |
25% | N/A | None |
AMNESTEEM 40 MG CAPSULE [ZENATANE] |
1 |
Tier 1 |
25% | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE [Augmentin] |
1 |
Tier 1 |
25% | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin] |
1 |
Tier 1 |
25% | N/A | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE [Augmentin] |
1 |
Tier 1 |
25% | N/A | None |
AMOX-CLAV 200-28.5 MG/5 ML SUS |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOX-CLAV 250-62.5 MG/5 ML SUS |
1 |
Tier 1 |
25% | N/A | None |
AMOX-CLAV 400-57 MG/5 ML SUSP |
1 |
Tier 1 |
25% | N/A | None |
AMOX-CLAV 500-125 MG TABLET [Augmentin] |
1 |
Tier 1 |
25% | N/A | None |
AMOX-CLAV 600-42.9 MG/5 ML SUS |
1 |
Tier 1 |
25% | N/A | None |
AMOX-CLAV 875-125 MG TABLET [Augmentin] |
1 |
Tier 1 |
25% | N/A | None |
AMOXAPINE 100MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
AMOXAPINE 150MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
AMOXAPINE 25MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
AMOXAPINE 50MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
AMOXICILLIN 125 MG/5 ML SUSP |
1 |
Tier 1 |
25% | N/A | None |
AMOXICILLIN 125MG TABLET CHEW |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN 200 MG/5 ML SUSP |
1 |
Tier 1 |
25% | N/A | None |
AMOXICILLIN 250 MG CAPSULE |
1 |
Tier 1 |
25% | N/A | None |
AMOXICILLIN 250 MG TABLET CHEW |
1 |
Tier 1 |
25% | N/A | None |
AMOXICILLIN 250 MG/5 ML SUSP |
1 |
Tier 1 |
25% | N/A | None |
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [Amoxil] |
1 |
Tier 1 |
25% | N/A | None |
AMOXICILLIN 500 MG CAPSULE |
1 |
Tier 1 |
25% | N/A | None |
AMOXICILLIN 500 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
AMOXICILLIN 875 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
AMPHETAMINE SALT COMBO 15MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPHETAMINE SALTS 5 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
amphotericin b 50mg/10mL 10 mL in 1 VIAL |
1 |
Tier 1 |
25% | N/A | P |
Ampicillin 1000 MG / Sulbactam 500 MG Injection |
1 |
Tier 1 |
25% | N/A | None |
Ampicillin 1000 MG Injection |
1 |
Tier 1 |
25% | N/A | None |
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS |
1 |
Tier 1 |
25% | N/A | None |
AMPICILLIN CAPSULES 500MG 100 BOTTLE |
1 |
Tier 1 |
25% | N/A | None |
AMPICILLIN-SULBACTAM 15 GM VIAL [Unasyn] |
1 |
Tier 1 |
25% | N/A | P |
AMPICILLIN-SULBACTAM 3 GM VIAL [Unasyn] |
1 |
Tier 1 |
25% | N/A | None |
ANADROL-50 TABLET |
1 |
Tier 1 |
25% | N/A | None |
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE |
1 |
Tier 1 |
25% | N/A | None |
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANASTROZOLE 1 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
ANORO ELLIPTA 62.5-25 MCG INH |
1 |
Tier 1 |
25% | N/A | None |
APOKYN 30 MG/3 ML CARTRIDGE |
1 |
Tier 1 |
25% | N/A | P Q:60 /30Days |
Apraclonidine 5 MG/ML Ophthalmic Solution |
1 |
Tier 1 |
25% | N/A | None |
APREPITANT 125 MG CAPSULE [Emend] |
1 |
Tier 1 |
25% | N/A | P Q:8 /30Days |
APREPITANT 125-80-80 MG PACK [Emend] |
1 |
Tier 1 |
25% | N/A | P Q:12 /30Days |
APREPITANT 40 MG CAPSULE [Emend] |
1 |
Tier 1 |
25% | N/A | P Q:8 /30Days |
APREPITANT 80 MG CAPSULE [Emend] |
1 |
Tier 1 |
25% | N/A | P Q:8 /30Days |
APRI 0.15-0.03 TABLET |
1 |
Tier 1 |
25% | N/A | None |
APTIOM 200 MG TABLET |
1 |
Tier 1 |
25% | N/A | P Q:30 /30Days |
APTIOM 400 MG TABLET |
1 |
Tier 1 |
25% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APTIOM 600 MG TABLET |
1 |
Tier 1 |
25% | N/A | P Q:60 /30Days |
APTIOM 800 MG TABLET |
1 |
Tier 1 |
25% | N/A | P Q:45 /30Days |
APTIVUS 250MG CAPSULE |
1 |
Tier 1 |
25% | N/A | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
1 |
Tier 1 |
25% | N/A | None |
ARANELLE 7-9-5 TABLET |
1 |
Tier 1 |
25% | N/A | None |
ARCALYST INJECTION 220MG/VIAL |
1 |
Tier 1 |
25% | N/A | P |
ARIKAYCE 590 MG/8.4 ML VIAL-NEB |
1 |
Tier 1 |
25% | N/A | P |
ARIPIPRAZOLE 1 MG/ML SOLUTION [Abilify] |
1 |
Tier 1 |
25% | N/A | Q:750 /30Days |
ARIPIPRAZOLE 10 MG TABLET [Abilify] |
1 |
Tier 1 |
25% | N/A | Q:30 /30Days |
ARIPIPRAZOLE 15 MG TABLET [Abilify] |
1 |
Tier 1 |
25% | N/A | Q:30 /30Days |
ARIPIPRAZOLE 2 MG TABLET [Abilify] |
1 |
Tier 1 |
25% | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARIPIPRAZOLE 20 MG TABLET [Abilify] |
1 |
Tier 1 |
25% | N/A | Q:30 /30Days |
ARIPIPRAZOLE 30 MG TABLET [Abilify] |
1 |
Tier 1 |
25% | N/A | Q:30 /30Days |
ARIPIPRAZOLE 5 MG TABLET [Abilify] |
1 |
Tier 1 |
25% | N/A | Q:60 /30Days |
ARIPIPRAZOLE ODT 10 MG TABLET RAPDIS [Abilify Discmelt] |
1 |
Tier 1 |
25% | N/A | Q:60 /30Days |
ARIPIPRAZOLE ODT 15 MG TABLET RAPDIS [Abilify Discmelt] |
1 |
Tier 1 |
25% | N/A | Q:60 /30Days |
ARMODAFINIL 150 MG TABLET [Nuvigil] |
1 |
Tier 1 |
25% | N/A | Q:30 /30Days |
ARMODAFINIL 200 MG TABLET [Nuvigil] |
1 |
Tier 1 |
25% | N/A | Q:30 /30Days |
ARMODAFINIL 250 MG TABLET [Nuvigil] |
1 |
Tier 1 |
25% | N/A | Q:30 /30Days |
ARMODAFINIL 50 MG TABLET [Nuvigil] |
1 |
Tier 1 |
25% | N/A | Q:30 /30Days |
ARNUITY ELLIPTA 100 MCG INH |
1 |
Tier 1 |
25% | N/A | None |
ARNUITY ELLIPTA 200 MCG INH |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARNUITY ELLIPTA 50 MCG INH BLST W/DEV |
1 |
Tier 1 |
25% | N/A | None |
ASCOMP WITH CODEINE CAPSULE |
1 |
Tier 1 |
25% | N/A | Q:180 /30Days |
ASMANEX HFA 100 MCG INHALER |
1 |
Tier 1 |
25% | N/A | None |
ASMANEX HFA 200 MCG INHALER |
1 |
Tier 1 |
25% | N/A | None |
ASMANEX HFA 50 MCG INHALER HFA AER AD |
1 |
Tier 1 |
25% | N/A | None |
ASMANEX TWISTHALER 110 MCG #30 |
1 |
Tier 1 |
25% | N/A | None |
ASMANEX TWISTHALER 220 MCG #30 |
1 |
Tier 1 |
25% | N/A | None |
ASMANEX TWISTHALER 220MCG #120 |
1 |
Tier 1 |
25% | N/A | None |
ASMANEX TWISTHALER 220MCG #60 |
1 |
Tier 1 |
25% | N/A | None |
Aspirin-Diphenhydramine ER 25-200 MG |
1 |
Tier 1 |
25% | N/A | None |
ATAZANAVIR SULFATE 150 MG CAPSULE [Reyataz] |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATAZANAVIR SULFATE 200 MG CAPSULE [Reyataz] |
1 |
Tier 1 |
25% | N/A | None |
ATAZANAVIR SULFATE 300 MG CAPSULE [Reyataz] |
1 |
Tier 1 |
25% | N/A | None |
ATENOLOL 100 MG TABLET [Tenormin] |
1 |
Tier 1 |
25% | N/A | None |
ATENOLOL 25 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
ATENOLOL 50 MG TABLET [Tenormin] |
1 |
Tier 1 |
25% | N/A | None |
ATENOLOL-CHLORTHALIDONE 100-25 |
1 |
Tier 1 |
25% | N/A | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
1 |
Tier 1 |
25% | N/A | None |
ATOMOXETINE HCL 10 MG CAPSULE [Strattera] |
1 |
Tier 1 |
25% | N/A | Q:60 /30Days |
ATOMOXETINE HCL 100 MG CAPSULE [Strattera] |
1 |
Tier 1 |
25% | N/A | Q:30 /30Days |
ATOMOXETINE HCL 18 MG CAPSULE [Strattera] |
1 |
Tier 1 |
25% | N/A | Q:60 /30Days |
ATOMOXETINE HCL 25 MG CAPSULE [Strattera] |
1 |
Tier 1 |
25% | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATOMOXETINE HCL 40 MG CAPSULE [Strattera] |
1 |
Tier 1 |
25% | N/A | Q:60 /30Days |
ATOMOXETINE HCL 60 MG CAPSULE [Strattera] |
1 |
Tier 1 |
25% | N/A | Q:30 /30Days |
ATOMOXETINE HCL 80 MG CAPSULE [Strattera] |
1 |
Tier 1 |
25% | N/A | Q:30 /30Days |
ATORVASTATIN 10 MG TABLET [Lipitor] |
1 |
Tier 1 |
25% | N/A | None |
ATORVASTATIN 20 MG TABLET [Lipitor] |
1 |
Tier 1 |
25% | N/A | None |
ATORVASTATIN 40 MG TABLET [Lipitor] |
1 |
Tier 1 |
25% | N/A | None |
ATORVASTATIN 80 MG TABLET [Lipitor] |
1 |
Tier 1 |
25% | N/A | None |
ATOVAQUONE 750 MG/5 ML SUSP [Mepron] |
1 |
Tier 1 |
25% | N/A | None |
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone] |
1 |
Tier 1 |
25% | N/A | None |
ATOVAQUONE-PROGUANIL 62.5-25 [Malarone] |
1 |
Tier 1 |
25% | N/A | None |
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATROPINE 1% EYE DROPS |
1 |
Tier 1 |
25% | N/A | None |
ATROVENT HFA AER 17MCG |
1 |
Tier 1 |
25% | N/A | None |
AUBRA-28 TABLET [Vienva] |
1 |
Tier 1 |
25% | N/A | None |
AURYXIA 210 MG TABLET |
1 |
Tier 1 |
25% | N/A | P |
AUSTEDO 12 MG TABLET |
1 |
Tier 1 |
25% | N/A | P Q:120 /30Days |
AUSTEDO 6 MG TABLET |
1 |
Tier 1 |
25% | N/A | P Q:120 /30Days |
AUSTEDO 9 MG TABLET |
1 |
Tier 1 |
25% | N/A | P Q:120 /30Days |
AVANDIA 2 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
AVANDIA 4 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
AVIANE 0.1-0.02 TABLET |
1 |
Tier 1 |
25% | N/A | None |
AVITA 0.025% CREAM (g) [Tretin-X] |
1 |
Tier 1 |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Avita 0.25mg/g 45 g in 1 TUBE |
1 |
Tier 1 |
25% | N/A | P |
AVONEX PEN 30 MCG/0.5 ML KIT |
1 |
Tier 1 |
25% | N/A | P |
AVONEX PREFILLED SYR 30 MCG KT |
1 |
Tier 1 |
25% | N/A | P |
AYVAKIT 100 MG TABLET |
1 |
Tier 1 |
25% | N/A | P |
AYVAKIT 200 MG TABLET |
1 |
Tier 1 |
25% | N/A | P |
AYVAKIT 300 MG TABLET |
1 |
Tier 1 |
25% | N/A | P |
AZASAN 100 MG TABLET |
1 |
Tier 1 |
25% | N/A | P |
AZASAN 75 MG TABLET |
1 |
Tier 1 |
25% | N/A | P |
AZATHIOPRINE 50 MG TABLET |
1 |
Tier 1 |
25% | N/A | P |
AZELASTINE 0.15% NASAL SPRAY |
1 |
Tier 1 |
25% | N/A | None |
AZELASTINE 137 MCG NASAL SPRAY |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZELASTINE HCL 0.05% EYE DROPS [Optivar] |
1 |
Tier 1 |
25% | N/A | None |
AZITHROMYCIN 1 GM POWDER PACKET |
1 |
Tier 1 |
25% | N/A | None |
AZITHROMYCIN 100 MG/5 ML SUSP |
1 |
Tier 1 |
25% | N/A | None |
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [Zithromax] |
1 |
Tier 1 |
25% | N/A | None |
AZITHROMYCIN 250 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
AZITHROMYCIN 250 MG TABLET [Zithromax Z-Pak] |
1 |
Tier 1 |
25% | N/A | None |
AZITHROMYCIN 500 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
AZITHROMYCIN 500 MG TABLET [Zithromax Tri-Pak] |
1 |
Tier 1 |
25% | N/A | None |
AZITHROMYCIN 600 MG TABLET [Zithromax Z-Pak] |
1 |
Tier 1 |
25% | N/A | None |
AZITHROMYCIN I.V. 500 MG VIAL |
1 |
Tier 1 |
25% | N/A | P |
AZOPT 1% EYE DROPS |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Aztreonam 2000 MG Injection [Azactam] |
1 |
Tier 1 |
25% | N/A | P |
AZTREONAM FOR INJECTION |
1 |
Tier 1 |
25% | N/A | None |