2020 Medicare Part D Plan Formulary Information |
Presbyterian Senior Care Plan 2 with Rx (HMO) (H3204-001-0)
Benefit Details
|
The Presbyterian Senior Care Plan 2 with Rx (HMO) (H3204-001-0) Formulary Drugs Starting with the Letter A in Torrance County, NM: CMS MA Region 20 which includes: NM Plan Monthly Premium: $19.00 Deductible: $0 |
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 |
4 |
Tier 4 |
$95.00 | $285.00 | None |
ABACAVIR 300 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir] |
5 |
Tier 5 |
33% | N/A | None |
ABACAVIR-LAMIVUDINE 600-300 MG TABLET [Epzicom] |
4 |
Tier 4 |
$95.00 | $285.00 | None |
ABILIFY MYCITE 10 MG KIT TABLET SENSPT |
5 |
Tier 5 |
33% | N/A | P Q:1 /1Days |
ABILIFY MYCITE 15 MG KIT TABLET SENSPT |
5 |
Tier 5 |
33% | N/A | P Q:1 /1Days |
ABILIFY MYCITE 2 MG KIT TABLET SENSPT |
5 |
Tier 5 |
33% | N/A | P Q:1 /1Days |
ABILIFY MYCITE 20 MG KIT TABLET SENSPT |
5 |
Tier 5 |
33% | N/A | P Q:1 /1Days |
ABILIFY MYCITE 30 MG KIT TABLET SENSPT |
5 |
Tier 5 |
33% | N/A | P Q:1 /1Days |
ABILIFY MYCITE 5 MG KIT TABLET SENSPT |
5 |
Tier 5 |
33% | N/A | P Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABIRATERONE ACETATE 250 MG TABLET [ZYTIGA] |
5 |
Tier 5 |
33% | N/A | P Q:4 /1Days |
Acamprosate Calcium DR 333 MG tablets [Campral] |
4 |
Tier 4 |
$95.00 | $285.00 | None |
ACARBOSE 100 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
ACARBOSE 25 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
ACARBOSE 50 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
ACEBUTOLOL 200 MG CAPSULE [Sectral] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
ACEBUTOLOL 400 MG CAPSULE [Sectral] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
ACETAMINOP-CODEINE 120-12 MG/5 |
2 |
Tier 2 |
$10.00 | $20.00 | None |
ACETAMINOPHEN-COD #2 TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | Q:6 /1Days |
ACETAMINOPHEN-COD #3 TABLET [Tylenol with Codeine No.3] |
2 |
Tier 2 |
$10.00 | $20.00 | Q:6 /1Days |
ACETAMINOPHEN-COD #4 TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | Q:6 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAZOLAMIDE 125MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
ACETAZOLAMIDE 250 MG TABLET [Diamox] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
ACETYLCYSTEINE 10% VIAL |
2 |
Tier 2 |
$10.00 | $20.00 | P |
ACETYLCYSTEINE 20% VIAL [Mucosil Acetylcysteine] |
2 |
Tier 2 |
$10.00 | $20.00 | P |
ACITRETIN 10 MG CAPSULE [Soriatane] |
4 |
Tier 4 |
$95.00 | $285.00 | None |
ACITRETIN 17.5 MG CAPSULE [Soriatane] |
5 |
Tier 5 |
33% | N/A | None |
ACITRETIN 25 MG CAPSULE [Soriatane] |
4 |
Tier 4 |
$95.00 | $285.00 | None |
ACTEMRA 162 MG/0.9 ML SYRINGE |
5 |
Tier 5 |
33% | N/A | P Q:4 /28Days |
ACTEMRA ACTPEN 162 MG/0.9 ML PEN INJCTR |
5 |
Tier 5 |
33% | N/A | P Q:4 /28Days |
ACTHIB VACCINE WITH DILUENT |
3 |
Tier 3 |
$45.00 | $112.50 | None |
ACTIMMUNE 100 MCG/0.5 ML VIAL |
5 |
Tier 5 |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACYCLOVIR 200 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
ACYCLOVIR 200 MG/5 ML SUSP |
2 |
Tier 2 |
$10.00 | $20.00 | None |
ACYCLOVIR 400 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
ACYCLOVIR 5% CREAM (g) [Zovirax] |
5 |
Tier 5 |
33% | N/A | Q:5 /30Days |
ACYCLOVIR 5% OINTMENT [Zovirax] |
4 |
Tier 4 |
$95.00 | $285.00 | Q:30 /30Days |
ACYCLOVIR 800 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Acyclovir sodium 500 mg vial |
2 |
Tier 2 |
$10.00 | $20.00 | P |
ADACEL TDAP SYRINGE |
3 |
Tier 3 |
$45.00 | $112.50 | None |
ADACEL VIAL 2UNT/5UNT |
3 |
Tier 3 |
$45.00 | $112.50 | None |
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA] |
5 |
Tier 5 |
33% | N/A | P |
ADEFOVIR DIPIVOXIL 10 MG TABLET [Hepsera] |
5 |
Tier 5 |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADEMPAS 0.5 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:3 /1Days |
ADEMPAS 1 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:3 /1Days |
ADEMPAS 1.5 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:3 /1Days |
ADEMPAS 2 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:3 /1Days |
ADEMPAS 2.5 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:3 /1Days |
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER |
4 |
Tier 4 |
$95.00 | $285.00 | S |
ADVAIR HFA INHALER 115;21MCG;MCG 120 ACTN INHL |
4 |
Tier 4 |
$95.00 | $285.00 | S |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
4 |
Tier 4 |
$95.00 | $285.00 | S |
AFINITOR 10 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
AFINITOR 2.5 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
AFINITOR DISPERZ 2 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AFINITOR DISPERZ 3 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
AFINITOR DISPERZ 5 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
AIMOVIG 140 MG/ML AUTOINJECTOR |
4 |
Tier 4 |
$95.00 | $285.00 | P Q:1 /30Days |
AIMOVIG 70 MG/ML AUTOINJECTOR |
4 |
Tier 4 |
$95.00 | $285.00 | P Q:1 /30Days |
ALBENDAZOLE 200 MG TABLET [Albenza] |
5 |
Tier 5 |
33% | N/A | None |
ALBUTEROL 2.5 MG/0.5 ML SOL VIAL-NEB |
2 |
Tier 2 |
$10.00 | $20.00 | P |
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA] |
4 |
Tier 4 |
$95.00 | $285.00 | None |
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA] |
4 |
Tier 4 |
$95.00 | $285.00 | None |
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA] |
4 |
Tier 4 |
$95.00 | $285.00 | None |
ALBUTEROL SUL 0.63 MG/3 ML SOL VIAL-NEB |
2 |
Tier 2 |
$10.00 | $20.00 | P |
ALBUTEROL SUL 1.25 MG/3 ML SOL VIAL-NEB |
2 |
Tier 2 |
$10.00 | $20.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL SUL 2.5 MG/3 ML SOLN |
2 |
Tier 2 |
$10.00 | $20.00 | P |
ALBUTEROL SULFATE 2 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
ALBUTEROL SULFATE 4 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
2 |
Tier 2 |
$10.00 | $20.00 | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
2 |
Tier 2 |
$10.00 | $20.00 | None |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOTTLE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
ALCLOMETASONE DIPR 0.05% OINTMENT |
2 |
Tier 2 |
$10.00 | $20.00 | None |
ALCLOMETASONE DIPRO 0.05% CREAM |
2 |
Tier 2 |
$10.00 | $20.00 | None |
ALDACTAZIDE 50/50 TABLET |
4 |
Tier 4 |
$95.00 | $285.00 | None |
ALECENSA 150 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P Q:8 /1Days |
ALENDRONATE SODIUM 10 MG TABLET [Fosamax] |
2 |
Tier 2 |
$10.00 | $20.00 | 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 |
$0.00 | $0.00 | None |
ALENDRONATE SODIUM 70 MG TABLET [Fosamax] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALFUZOSIN HCL ER 10 MG TABLET |
4 |
Tier 4 |
$95.00 | $285.00 | None |
ALINIA 500 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
ALISKIREN 150 MG TABLET [Tekturna] |
4 |
Tier 4 |
$95.00 | $285.00 | S Q:1 /1Days |
ALISKIREN 300 MG TABLET [Tekturna] |
4 |
Tier 4 |
$95.00 | $285.00 | S Q:1 /1Days |
ALLOPURINOL 100 MG TABLET [Zyloprim] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALLOPURINOL 300 MG TABLET [Zyloprim] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ALMOTRIPTAN MALATE 12.5 MG TABLET [Axert] |
4 |
Tier 4 |
$95.00 | $285.00 | S Q:18 /30Days |
ALMOTRIPTAN MALATE 6.25 MG TABLET [Axert] |
4 |
Tier 4 |
$95.00 | $285.00 | S Q:18 /30Days |
ALOCRIL 2% EYE DROPS |
3 |
Tier 3 |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALOGLIPTIN 12.5 MG TABLET [Nesina] |
3 |
Tier 3 |
$45.00 | $112.50 | S Q:1 /1Days |
ALOGLIPTIN 25 MG TABLET [Nesina] |
3 |
Tier 3 |
$45.00 | $112.50 | S Q:1 /1Days |
ALOGLIPTIN 6.25 MG TABLET [Nesina] |
3 |
Tier 3 |
$45.00 | $112.50 | S Q:1 /1Days |
ALOGLIPTIN-METFORMIN 12.5-1000 [Kazano] |
3 |
Tier 3 |
$45.00 | $112.50 | S Q:2 /1Days |
ALOGLIPTIN-METFORMIN 12.5-500 [Kazano] |
3 |
Tier 3 |
$45.00 | $112.50 | S Q:2 /1Days |
ALOGLIPTIN-PIOGLIT 12.5-15 MG [Oseni] |
3 |
Tier 3 |
$45.00 | $112.50 | S Q:1 /1Days |
ALOGLIPTIN-PIOGLIT 12.5-30 MG [Oseni] |
3 |
Tier 3 |
$45.00 | $112.50 | S Q:1 /1Days |
ALOGLIPTIN-PIOGLIT 12.5-45 MG [Oseni] |
3 |
Tier 3 |
$45.00 | $112.50 | S Q:1 /1Days |
ALOGLIPTIN-PIOGLIT 25-15 MG TABLET [Oseni] |
3 |
Tier 3 |
$45.00 | $112.50 | S Q:1 /1Days |
ALOGLIPTIN-PIOGLIT 25-30 MG TABLET [Oseni] |
3 |
Tier 3 |
$45.00 | $112.50 | S Q:1 /1Days |
ALOGLIPTIN-PIOGLIT 25-45 MG TABLET [Oseni] |
3 |
Tier 3 |
$45.00 | $112.50 | S Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALOMIDE 0.1% EYE DROPS |
3 |
Tier 3 |
$45.00 | $112.50 | None |
ALORA 0.025 MG PATCH TDSW [Vivelle-Dot] |
4 |
Tier 4 |
$95.00 | $285.00 | P |
ALORA 0.05 MG PATCH TDSW [Vivelle-Dot] |
4 |
Tier 4 |
$95.00 | $285.00 | P |
ALORA 0.075 MG PATCH TDSW [Vivelle-Dot] |
4 |
Tier 4 |
$95.00 | $285.00 | P |
ALORA 0.1 MG PATCH TDSW [Vivelle-Dot] |
4 |
Tier 4 |
$95.00 | $285.00 | P |
ALOSETRON HCL 0.5 MG TABLET [Lotronex] |
5 |
Tier 5 |
33% | N/A | Q:2 /1Days |
ALOSETRON HCL 1 MG TABLET [Lotronex] |
5 |
Tier 5 |
33% | N/A | Q:2 /1Days |
ALPHAGAN P 0.1% EYE DROPS |
3 |
Tier 3 |
$45.00 | $112.50 | None |
ALPRAZOLAM 0.25 MG TABLET [Xanax] |
2 |
Tier 2 |
$10.00 | $20.00 | Q:3 /1Days |
ALPRAZOLAM 0.5 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | Q:3 /1Days |
ALPRAZOLAM 1 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | Q:3 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALPRAZOLAM 2 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | Q:5 /1Days |
ALREX 0.2% EYE DROPS |
3 |
Tier 3 |
$45.00 | $112.50 | None |
ALTAVERA-28 TABLET [Portia] |
3 |
Tier 3 |
$45.00 | $112.50 | None |
ALUNBRIG 180 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:1 /1Days |
ALUNBRIG 30 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:2 /1Days |
ALUNBRIG 90 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:1 /1Days |
ALUNBRIG 90 MG-180 MG TABLET PACK |
5 |
Tier 5 |
33% | N/A | P Q:1 /1Days |
ALYACEN 1-35-28 TABLET |
3 |
Tier 3 |
$45.00 | $112.50 | None |
ALYQ 20 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:2 /1Days |
Amabelz 0.5 MG/0.1 MG 28 TABLET/BLISTER PACK 3 PER CARTON |
4 |
Tier 4 |
$95.00 | $285.00 | P |
Amabelz 1 MG/0.5 MG 28 TABLET/BLISTER PACK 3 PER CARTON |
4 |
Tier 4 |
$95.00 | $285.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMANTADINE 100 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMANTADINE 100 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMBISOME 50MG VIAL |
5 |
Tier 5 |
33% | N/A | P |
AMBRISENTAN 10 MG TABLET [LETAIRIS] |
5 |
Tier 5 |
33% | N/A | Q:1 /1Days |
AMBRISENTAN 5 MG TABLET [LETAIRIS] |
5 |
Tier 5 |
33% | N/A | Q:1 /1Days |
AMCINONIDE 0.1% OINTMENT 60GM TUBE |
4 |
Tier 4 |
$95.00 | $285.00 | None |
AMETHIA LO TABLET |
3 |
Tier 3 |
$45.00 | $112.50 | None |
AMIKACIN SULF 500 MG/2 ML VIAL |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMILORIDE HCL 5 MG TABLET [Midamor] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMILORIDE HCL-HCTZ 5-50 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Amino Acids 15% Solution |
3 |
Tier 3 |
$45.00 | $112.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN II 15% IV SOLUTION |
3 |
Tier 3 |
$45.00 | $112.50 | P |
AMINOSYN-PF 7% IV SOLUTION |
3 |
Tier 3 |
$45.00 | $112.50 | P |
AMIODARONE HCL 100 MG TABLET [Pacerone] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMIODARONE HCL 200 MG TABLET [Pacerone] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMIODARONE HCL 400 MG TABLET [Pacerone] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMITIZA 24 MCG 60 CAPSULE BOTTLE |
3 |
Tier 3 |
$45.00 | $112.50 | Q:2 /1Days |
AMITIZA 8MCG CAPSULE |
3 |
Tier 3 |
$45.00 | $112.50 | Q:2 /1Days |
AMITRIPTYLINE HCL 10 MG TABLET [Elavil] |
4 |
Tier 4 |
$95.00 | $285.00 | P |
AMITRIPTYLINE HCL 100 MG TABLET |
4 |
Tier 4 |
$95.00 | $285.00 | P |
AMITRIPTYLINE HCL 150 MG TABLET |
4 |
Tier 4 |
$95.00 | $285.00 | P |
AMITRIPTYLINE HCL 25 MG TABLET |
4 |
Tier 4 |
$95.00 | $285.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIPTYLINE HCL 50 MG TABLET |
4 |
Tier 4 |
$95.00 | $285.00 | P |
AMITRIPTYLINE HCL 75 MG TABLET |
4 |
Tier 4 |
$95.00 | $285.00 | P |
AMLODIPINE BESYLATE 10 MG TABLET [Norvasc] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMLODIPINE BESYLATE 2.5 MG TABLET [Norvasc] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMLODIPINE BESYLATE 5 MG TABLET [Norvasc] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMLODIPINE-BENAZEPRIL 10-20 MG CAPSULE [Lotrel] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMLODIPINE-BENAZEPRIL 10-40 MG CAPSULE [Lotrel] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMLODIPINE-BENAZEPRIL 2.5-10 CAPSULE [Lotrel] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMLODIPINE-BENAZEPRIL 5-10 MG CAPSULE [Lotrel] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMLODIPINE-BENAZEPRIL 5-20 MG CAPSULE [Lotrel] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMLODIPINE-BENAZEPRIL 5-40 MG CAPSULE [Lotrel] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMMONIUM LACTATE 12% LOTION |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE [Augmentin] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE [Augmentin] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMOX-CLAV 200-28.5 MG/5 ML SUS |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMOX-CLAV 250-62.5 MG/5 ML SUS |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMOX-CLAV 400-57 MG/5 ML SUSP |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMOX-CLAV 500-125 MG TABLET [Augmentin] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMOX-CLAV 600-42.9 MG/5 ML SUS |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMOX-CLAV 875-125 MG TABLET [Augmentin] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMOXAPINE 100MG TABLET |
3 |
Tier 3 |
$45.00 | $112.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXAPINE 150MG TABLET |
3 |
Tier 3 |
$45.00 | $112.50 | P |
AMOXAPINE 25MG TABLET |
3 |
Tier 3 |
$45.00 | $112.50 | P |
AMOXAPINE 50MG TABLET |
3 |
Tier 3 |
$45.00 | $112.50 | P |
AMOXICILLIN 125 MG/5 ML SUSP |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMOXICILLIN 125MG TABLET CHEW |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMOXICILLIN 200 MG/5 ML SUSP |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMOXICILLIN 250 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMOXICILLIN 250 MG TABLET CHEW |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMOXICILLIN 250 MG/5 ML SUSP |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [Amoxil] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMOXICILLIN 500 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN 500 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMOXICILLIN 875 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | Q:3 /1Days |
AMPHETAMINE SALT COMBO 15MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | Q:3 /1Days |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | Q:3 /1Days |
AMPHETAMINE SALTS 5 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | Q:3 /1Days |
amphotericin b 50mg/10mL 10 mL in 1 VIAL |
3 |
Tier 3 |
$45.00 | $112.50 | P |
AMPICILLIN 10 GM VIAL |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Ampicillin 1000 MG / Sulbactam 500 MG Injection |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Ampicillin 1000 MG Injection |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMPICILLIN CAPSULES 500MG 100 BOTTLE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN-SULBACTAM 15 GM VIAL [Unasyn] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AMPICILLIN-SULBACTAM 3 GM VIAL [Unasyn] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
ANADROL-50 TABLET |
5 |
Tier 5 |
33% | N/A | None |
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
ANASTROZOLE 1 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
ANDRODERM 2 MG/24HR PATCH |
4 |
Tier 4 |
$95.00 | $285.00 | P Q:1 /1Days |
ANDRODERM 4 MG/24HR PATCH |
4 |
Tier 4 |
$95.00 | $285.00 | P Q:1 /1Days |
APOKYN 30 MG/3 ML CARTRIDGE |
5 |
Tier 5 |
33% | N/A | P |
Apraclonidine 5 MG/ML Ophthalmic Solution |
2 |
Tier 2 |
$10.00 | $20.00 | None |
APREPITANT 125 MG CAPSULE [Emend] |
3 |
Tier 3 |
$45.00 | $112.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APREPITANT 125-80-80 MG PACK [Emend] |
3 |
Tier 3 |
$45.00 | $112.50 | P Q:12 /30Days |
APREPITANT 40 MG CAPSULE [Emend] |
3 |
Tier 3 |
$45.00 | $112.50 | P |
APRI 0.15-0.03 TABLET |
3 |
Tier 3 |
$45.00 | $112.50 | None |
APTIOM 200 MG TABLET |
5 |
Tier 5 |
33% | N/A | S |
APTIOM 400 MG TABLET |
5 |
Tier 5 |
33% | N/A | S |
APTIOM 600 MG TABLET |
5 |
Tier 5 |
33% | N/A | S |
APTIOM 800 MG TABLET |
5 |
Tier 5 |
33% | N/A | S |
APTIVUS 250MG CAPSULE |
5 |
Tier 5 |
33% | N/A | None |
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT |
5 |
Tier 5 |
33% | N/A | None |
ARANELLE 7-9-5 TABLET |
3 |
Tier 3 |
$45.00 | $112.50 | None |
ARCALYST INJECTION 220MG/VIAL |
5 |
Tier 5 |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARIPIPRAZOLE 1 MG/ML SOLUTION [Abilify] |
4 |
Tier 4 |
$95.00 | $285.00 | None |
ARIPIPRAZOLE 10 MG TABLET [Abilify] |
4 |
Tier 4 |
$95.00 | $285.00 | Q:1 /1Days |
ARIPIPRAZOLE 15 MG TABLET [Abilify] |
4 |
Tier 4 |
$95.00 | $285.00 | Q:1 /1Days |
ARIPIPRAZOLE 2 MG TABLET [Abilify] |
4 |
Tier 4 |
$95.00 | $285.00 | Q:1 /1Days |
ARIPIPRAZOLE 20 MG TABLET [Abilify] |
4 |
Tier 4 |
$95.00 | $285.00 | Q:1 /1Days |
ARIPIPRAZOLE 30 MG TABLET [Abilify] |
4 |
Tier 4 |
$95.00 | $285.00 | Q:1 /1Days |
ARIPIPRAZOLE 5 MG TABLET [Abilify] |
4 |
Tier 4 |
$95.00 | $285.00 | Q:1 /1Days |
ARIPIPRAZOLE ODT 10 MG TABLET RAPDIS [Abilify Discmelt] |
5 |
Tier 5 |
33% | N/A | P Q:2 /1Days |
ARIPIPRAZOLE ODT 15 MG TABLET RAPDIS [Abilify Discmelt] |
5 |
Tier 5 |
33% | N/A | P Q:2 /1Days |
ARISTADA ER 1064 MG/3.9 ML SYRINGE |
5 |
Tier 5 |
33% | N/A | None |
ARISTADA ER 441 MG/1.6 ML SYRINGE |
5 |
Tier 5 |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARISTADA ER 662 MG/2.4 ML SYRINGE |
5 |
Tier 5 |
33% | N/A | None |
ARISTADA ER 882 MG/3.2 ML SYRINGE |
5 |
Tier 5 |
33% | N/A | None |
ARISTADA INITIO ER 675 MG/2.4 SUSER SYRINGE |
5 |
Tier 5 |
33% | N/A | None |
ARMODAFINIL 150 MG TABLET [Nuvigil] |
3 |
Tier 3 |
$45.00 | $112.50 | P Q:1 /1Days |
ARMODAFINIL 200 MG TABLET [Nuvigil] |
3 |
Tier 3 |
$45.00 | $112.50 | P Q:1 /1Days |
ARMODAFINIL 250 MG TABLET [Nuvigil] |
3 |
Tier 3 |
$45.00 | $112.50 | P Q:1 /1Days |
ARMODAFINIL 50 MG TABLET [Nuvigil] |
3 |
Tier 3 |
$45.00 | $112.50 | P Q:1 /1Days |
ASMANEX HFA 100 MCG INHALER |
3 |
Tier 3 |
$45.00 | $112.50 | None |
ASMANEX HFA 200 MCG INHALER |
3 |
Tier 3 |
$45.00 | $112.50 | None |
ASMANEX TWISTHALER 110 MCG #30 |
3 |
Tier 3 |
$45.00 | $112.50 | None |
ASMANEX TWISTHALER 220 MCG #30 |
3 |
Tier 3 |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ASMANEX TWISTHALER 220MCG #120 |
3 |
Tier 3 |
$45.00 | $112.50 | None |
ASMANEX TWISTHALER 220MCG #60 |
3 |
Tier 3 |
$45.00 | $112.50 | None |
Aspirin-Diphenhydramine ER 25-200 MG |
4 |
Tier 4 |
$95.00 | $285.00 | None |
ATAZANAVIR SULFATE 150 MG CAPSULE [Reyataz] |
5 |
Tier 5 |
33% | N/A | None |
ATAZANAVIR SULFATE 200 MG CAPSULE [Reyataz] |
5 |
Tier 5 |
33% | N/A | None |
ATAZANAVIR SULFATE 300 MG CAPSULE [Reyataz] |
5 |
Tier 5 |
33% | N/A | None |
ATENOLOL 100 MG TABLET [Tenormin] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ATENOLOL 25 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ATENOLOL 50 MG TABLET [Tenormin] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ATENOLOL-CHLORTHALIDONE 100-25 |
2 |
Tier 2 |
$10.00 | $20.00 | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATOMOXETINE HCL 10 MG CAPSULE [Strattera] |
4 |
Tier 4 |
$95.00 | $285.00 | Q:1 /1Days |
ATOMOXETINE HCL 100 MG CAPSULE [Strattera] |
4 |
Tier 4 |
$95.00 | $285.00 | Q:1 /1Days |
ATOMOXETINE HCL 18 MG CAPSULE [Strattera] |
4 |
Tier 4 |
$95.00 | $285.00 | Q:1 /1Days |
ATOMOXETINE HCL 25 MG CAPSULE [Strattera] |
4 |
Tier 4 |
$95.00 | $285.00 | Q:1 /1Days |
ATOMOXETINE HCL 40 MG CAPSULE [Strattera] |
4 |
Tier 4 |
$95.00 | $285.00 | Q:1 /1Days |
ATOMOXETINE HCL 60 MG CAPSULE [Strattera] |
4 |
Tier 4 |
$95.00 | $285.00 | Q:1 /1Days |
ATOMOXETINE HCL 80 MG CAPSULE [Strattera] |
4 |
Tier 4 |
$95.00 | $285.00 | Q:1 /1Days |
ATORVASTATIN 10 MG TABLET [Lipitor] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
ATORVASTATIN 20 MG TABLET [Lipitor] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
ATORVASTATIN 40 MG TABLET [Lipitor] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
ATORVASTATIN 80 MG TABLET [Lipitor] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATOVAQUONE 750 MG/5 ML SUSP [Mepron] |
5 |
Tier 5 |
33% | N/A | None |
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone] |
4 |
Tier 4 |
$95.00 | $285.00 | None |
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
5 |
Tier 5 |
33% | N/A | None |
ATROPINE 1% EYE DROPS |
3 |
Tier 3 |
$45.00 | $112.50 | None |
ATROVENT HFA AER 17MCG |
3 |
Tier 3 |
$45.00 | $112.50 | None |
AUBAGIO 14 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:1 /1Days |
AUBAGIO 7 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:1 /1Days |
AUBRA-28 TABLET [Vienva] |
3 |
Tier 3 |
$45.00 | $112.50 | None |
AUSTEDO 12 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:4 /1Days |
AUSTEDO 6 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:1 /1Days |
AUSTEDO 9 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVANDIA 2 MG TABLET |
4 |
Tier 4 |
$95.00 | $285.00 | None |
AVANDIA 4 MG TABLET |
4 |
Tier 4 |
$95.00 | $285.00 | None |
AVIANE 0.1-0.02 TABLET |
3 |
Tier 3 |
$45.00 | $112.50 | None |
AVITA 0.025% CREAM (g) [Tretin-X] |
4 |
Tier 4 |
$95.00 | $285.00 | None |
AVONEX PEN 30 MCG/0.5 ML KIT |
5 |
Tier 5 |
33% | N/A | None |
AVONEX PREFILLED SYR 30 MCG KT |
5 |
Tier 5 |
33% | N/A | None |
AVYCAZ 2.5 GRAM VIAL |
5 |
Tier 5 |
33% | N/A | None |
AYVAKIT 100 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:1 /1Days |
AYVAKIT 200 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:1 /1Days |
AYVAKIT 300 MG TABLET |
5 |
Tier 5 |
33% | N/A | P Q:1 /1Days |
AZATHIOPRINE 50 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZELAIC ACID 15% GEL [Finacea] |
4 |
Tier 4 |
$95.00 | $285.00 | None |
AZELASTINE 137 MCG NASAL SPRAY |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AZELASTINE HCL 0.05% EYE DROPS [Optivar] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AZELEX 20% CREAM (G) |
3 |
Tier 3 |
$45.00 | $112.50 | None |
AZITHROMYCIN 250 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AZITHROMYCIN 250 MG TABLET [Zithromax Z-Pak] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AZITHROMYCIN 500 MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AZITHROMYCIN 500 MG TABLET [Zithromax Tri-Pak] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AZITHROMYCIN 600 MG TABLET [Zithromax Z-Pak] |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AZITHROMYCIN I.V. 500 MG VIAL |
2 |
Tier 2 |
$10.00 | $20.00 | None |
AZOPT 1% EYE DROPS |
3 |
Tier 3 |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZTREONAM FOR INJECTION |
4 |
Tier 4 |
$95.00 | $285.00 | None |