2020 Medicare Part D Plan Formulary Information |
Platino Ultra (HMO D-SNP) (H5774-025-0)
Benefit Details
|
The Platino Ultra (HMO D-SNP) (H5774-025-0) Formulary Drugs Starting with the Letter P in Utuado County, PR: CMS MA Region 30 which includes: PR Plan Monthly Premium: $0.00 Deductible: $435 |
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 |
PALIPERIDONE ER 1.5 MG TABLET [INVEGA] |
2 |
Tier 2 |
$15.00 | $30.00 | S |
PALIPERIDONE ER 3 MG TABLET [INVEGA] |
2 |
Tier 2 |
$15.00 | $30.00 | S |
PALIPERIDONE ER 6 MG TABLET [INVEGA] |
2 |
Tier 2 |
$15.00 | $30.00 | S |
PALIPERIDONE ER 9 MG TABLET [INVEGA] |
5 |
Tier 5 |
25% | 25% | S |
PANRETIN 0.1% GEL 60GM TUBE |
5 |
Tier 5 |
25% | 25% | None |
PANTOPRAZOLE SOD DR 20 MG TAB |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PANTOPRAZOLE SOD DR 40 MG TAB |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PARICALCITOL 1 MCG CAPSULE [Zemplar] |
2 |
Tier 2 |
$15.00 | $30.00 | P |
PARICALCITOL 2 MCG CAPSULE [Zemplar] |
2 |
Tier 2 |
$15.00 | $30.00 | P |
PARICALCITOL 4 MCG CAPSULE [Zemplar] |
2 |
Tier 2 |
$15.00 | $30.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAROMOMYCIN 250 MG CAPSULE |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PAROXETINE ER 12.5 MG TABLET 24H [Paxil CR] |
2 |
Tier 2 |
$15.00 | $30.00 | P |
PAROXETINE ER 25 MG TABLET 24H [Paxil CR] |
2 |
Tier 2 |
$15.00 | $30.00 | P |
PAROXETINE ER 37.5 MG TABLET ER 24H [Paxil CR] |
2 |
Tier 2 |
$15.00 | $30.00 | P |
PAROXETINE HCL 10 MG TABLET |
1 |
Tier 1 |
$14.00 | $28.00 | P |
PAROXETINE HCL 20 MG TABLET |
1 |
Tier 1 |
$14.00 | $28.00 | P |
PAROXETINE HCL 30 MG TABLET |
1 |
Tier 1 |
$14.00 | $28.00 | P |
PAROXETINE HCL 40 MG TABLET |
1 |
Tier 1 |
$14.00 | $28.00 | P |
PASER GRANULES 4GM PACKET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PAXIL ORAL SUSPENSION 10 MG/5ML |
4 |
Tier 4 |
$95.00 | $190.00 | P |
PEDVAXHIB VACCINE VIAL |
3 |
Tier 3 |
$42.00 | $84.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEG 3350-ELECTROLYTE SOLUTION RECON [TriLyte] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PEG-3350 AND ELECTROLYTES SOLN SOLN RECON |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PEGANONE 250 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
Pegasys 180ug/0.5mL 1 PACKET in 1 BOX / 4 SYRINGE, GLASS in 1 PACKET / 0.5 mL in 1 SYRINGE, GLASS |
5 |
Tier 5 |
25% | 25% | P |
PEGASYS INJECTION |
5 |
Tier 5 |
25% | 25% | P |
PEGASYS PROCLICK 180 MCG/0.5 |
5 |
Tier 5 |
25% | 25% | P |
PEMAZYRE 13.5 MG TABLET |
5 |
Tier 5 |
25% | 25% | P |
PEMAZYRE 4.5 MG TABLET |
5 |
Tier 5 |
25% | 25% | P |
PEMAZYRE 9 MG TABLET |
5 |
Tier 5 |
25% | 25% | P |
PENICILLIN G POTASSIUM 2MMUNITS/50ML ISO-OSM |
2 |
Tier 2 |
$15.00 | $30.00 | P |
PENICILLIN G POTASSIUM 3MMUNITS/50ML ISO-OSM |
2 |
Tier 2 |
$15.00 | $30.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENICILLIN G PROCAINE 1200000UNT 2ML CTG |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Penicillin G Sodium 5000000[iU]/1 10 VIAL per CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL |
5 |
Tier 5 |
25% | 25% | P |
PENICILLIN GK 20 MILLION UNIT |
2 |
Tier 2 |
$15.00 | $30.00 | P |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PENICILLIN VK 125 MG/5 ML SOLN |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PENICILLIN VK 250 MG TABLET |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PENICILLIN VK 500 MG TABLET [Veetids] |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PENTAM 300 INJ 300MG |
4 |
Tier 4 |
$95.00 | $190.00 | P |
PENTOXIFYLLINE 400MG TABLET SA |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PERINDOPRIL ERBUMINE 2 MG TAB |
6 |
Tier 6 |
$1.00 | $2.00 | None |
PERINDOPRIL ERBUMINE 4 MG TAB |
6 |
Tier 6 |
$1.00 | $2.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PERINDOPRIL ERBUMINE 8 MG TAB |
6 |
Tier 6 |
$1.00 | $2.00 | None |
Permethrin 50mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PERPHENAZINE 16 MG TABLET [Trilafon] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PERPHENAZINE 2 MG TABLET [Trilafon] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PERPHENAZINE 4 MG TABLET [Trilafon] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PERPHENAZINE 8 MG TABLET [Trilafon] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Phenelzine Sulfate 15mg/1 60 TABLET BOTTLE |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Phenobarbital 100mg/1 |
2 |
Tier 2 |
$15.00 | $30.00 | P |
PHENOBARBITAL 15 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | P |
PHENOBARBITAL 16.2 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | P |
PHENOBARBITAL 20 MG/5 ML ELIX |
2 |
Tier 2 |
$15.00 | $30.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PHENOBARBITAL 30 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | P |
PHENOBARBITAL 32.4 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | P |
Phenobarbital 60mg/1 |
2 |
Tier 2 |
$15.00 | $30.00 | P |
PHENOBARBITAL 64.8 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | P |
PHENOBARBITAL 97.2 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | P |
PHENYTOIN 125 MG/5 ML ORAL SUSPENSION [Dilantin] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PHENYTOIN 50 MG CHEWABLE TABLET [Dilantin] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PHENYTOIN SOD EXT 100 MG CAP |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PHENYTOIN SOD EXT 200 MG CAP |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PHENYTOIN SOD EXT 300 MG CAPSULE [Phenytek] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Phoslyra 667mg/5mL 1 BOTTLE per CARTON / 473 mL in 1 BOTTLE |
4 |
Tier 4 |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PIFELTRO 100 MG TABLET |
5 |
Tier 5 |
25% | 25% | None |
PILOCARPINE 1% EYE DROPS [Pilocar] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PILOCARPINE 2% EYE DROPS [Pilocar] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PILOCARPINE 4% EYE DROPS [Pilocar] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PILOCARPINE HCL 5 MG TABLET [Salagen] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PILOCARPINE HCL 7.5 MG TABLET [Salagen] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PIMOZIDE 1 MG TABLET [Orap] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PIMOZIDE 2 MG TABLET [Orap] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PINDOLOL 10 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PINDOLOL 5 MG TABLET [Visken] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PIOGLITAZONE HCL 15 MG TABLET [Actos] |
6 |
Tier 6 |
$1.00 | $2.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PIOGLITAZONE HCL 30 MG TABLET [Actos] |
6 |
Tier 6 |
$1.00 | $2.00 | None |
PIOGLITAZONE HCL 45 MG TABLET [Actos] |
6 |
Tier 6 |
$1.00 | $2.00 | None |
PIOGLITAZONE-GLIMEPIRIDE 30-2 TABLET [Duetact] |
6 |
Tier 6 |
$1.00 | $2.00 | None |
PIOGLITAZONE-GLIMEPIRIDE 30-4 Tablet [Duetact] |
6 |
Tier 6 |
$1.00 | $2.00 | None |
PIOGLITAZONE-METFORMIN 15-500 TABLET [Actoplus Met] |
6 |
Tier 6 |
$1.00 | $2.00 | None |
PIOGLITAZONE-METFORMIN 15-850 |
6 |
Tier 6 |
$1.00 | $2.00 | None |
PIPERACIL-TAZOBACT 3.375 GM VIAL [Zosyn] |
2 |
Tier 2 |
$15.00 | $30.00 | P |
PIPERACIL-TAZOBACT 4.5 GM VIAL |
2 |
Tier 2 |
$15.00 | $30.00 | P |
PIQRAY 200 MG DAILY DOSE TABLET |
5 |
Tier 5 |
25% | 25% | P |
PIQRAY 250 MG DAILY DOSE TABLET |
5 |
Tier 5 |
25% | 25% | P |
PIQRAY 300 MG DAILY DOSE TABLET |
5 |
Tier 5 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PLASMA-LYTE 148 IV SOLUTION |
2 |
Tier 2 |
$15.00 | $30.00 | P |
PLASMA-LYTE A PH 7.4 SOLUTION 37;368; MG/100ML; |
2 |
Tier 2 |
$15.00 | $30.00 | P |
PLEGRIDY 125 MCG/0.5 ML PEN |
5 |
Tier 5 |
25% | 25% | P |
PLEGRIDY 125 MCG/0.5 ML SYRING |
5 |
Tier 5 |
25% | 25% | P |
PLEGRIDY PEN INJ STARTER PACK |
5 |
Tier 5 |
25% | 25% | P |
PLEGRIDY SYRINGE STARTER PACK |
5 |
Tier 5 |
25% | 25% | P |
PODOFILOX 0.5% TOPICAL TUBEX |
2 |
Tier 2 |
$15.00 | $30.00 | None |
POLYMYXIN B SULFATE VIAL |
2 |
Tier 2 |
$15.00 | $30.00 | P |
POLYMYXIN B-TMP EYE DROPS |
1 |
Tier 1 |
$14.00 | $28.00 | None |
POMALYST 1 MG CAPSULE |
5 |
Tier 5 |
25% | 25% | P |
POMALYST 2 MG CAPSULE |
5 |
Tier 5 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POMALYST 3 MG CAPSULE |
5 |
Tier 5 |
25% | 25% | P |
POMALYST 4 MG CAPSULE |
5 |
Tier 5 |
25% | 25% | P |
Potassium Chloride 8 MEQ Extended Release Oral Tablet |
1 |
Tier 1 |
$14.00 | $28.00 | None |
Potassium Chloride in Dextrose 5; 150g/100mL; mg/100mL 1000 mL in 1 BAG |
2 |
Tier 2 |
$15.00 | $30.00 | P |
POTASSIUM CITRATE ER 10 MEQ TB |
2 |
Tier 2 |
$15.00 | $30.00 | None |
POTASSIUM CITRATE ER 15 MEQ TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
POTASSIUM CITRATE ER 5 MEQ TAB |
2 |
Tier 2 |
$15.00 | $30.00 | None |
POTASSIUM CL 10 MEQ/100 ML SOL PIGGYBACK |
1 |
Tier 1 |
$14.00 | $28.00 | P |
POTASSIUM CL 10% (20 MEQ/15ML) Liquid [Kay Ciel] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
POTASSIUM CL 20 MEQ-0.45% NACL IV SOLN |
2 |
Tier 2 |
$15.00 | $30.00 | P |
POTASSIUM CL 20 MEQ/100 ML SOL PIGGYBACK |
2 |
Tier 2 |
$15.00 | $30.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CL 20% (40 MEQ/15ML) Liquid [Kaon-CL] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
POTASSIUM CL 40 MEQ/100 ML SOL PIGGYBACK |
2 |
Tier 2 |
$15.00 | $30.00 | P |
POTASSIUM CL 40 MEQ/20 ML CONC VIAL [PROAMP] |
2 |
Tier 2 |
$15.00 | $30.00 | P |
POTASSIUM CL ER 10 MEQ TABLET [Klotrix] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Potassium cl er 20 meq tablet |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PRADAXA 110 MG CAPSULE |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PRADAXA 150 MG CAPSULE |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PRADAXA 75 MG CAPSULE |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PRALUENT 150 MG/ML PEN INJCTR |
3 |
Tier 3 |
$42.00 | $84.00 | P |
PRALUENT 75 MG/ML PEN INJCTR |
3 |
Tier 3 |
$42.00 | $84.00 | P |
PRAMIPEXOLE 0.125 MG TABLET |
1 |
Tier 1 |
$14.00 | $28.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAMIPEXOLE 0.25 MG TABLET |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PRAMIPEXOLE 0.5 MG TABLET |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PRAMIPEXOLE 0.75 MG TABLET |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PRAMIPEXOLE 1 MG TABLET |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PRAMIPEXOLE 1.5 MG TABLET [Mirapex] |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PRAVASTATIN SODIUM 10 MG TABLET [Pravachol] |
6 |
Tier 6 |
$1.00 | $2.00 | None |
PRAVASTATIN SODIUM 20 MG TAB |
6 |
Tier 6 |
$1.00 | $2.00 | None |
PRAVASTATIN SODIUM 40 MG TABLET [Pravachol] |
6 |
Tier 6 |
$1.00 | $2.00 | None |
PRAVASTATIN SODIUM 80 MG TABLET [Pravachol] |
6 |
Tier 6 |
$1.00 | $2.00 | None |
PRAZIQUANTEL 600 MG TABLET [Biltricide] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PRAZOSIN 1 MG CAPSULE |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAZOSIN 2 MG CAPSULE |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PRAZOSIN 5MG CAPSULE |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PREDNISOLONE 15 MG/5 ML SOLN |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PREDNISOLONE AC 1% EYE DROP |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PREDNISONE 1 MG TABLET |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PREDNISONE 10 MG TABLET [Sterapred DS] |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PREDNISONE 10 MG TABLET DOSE PACK |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PREDNISONE 10 MG TABLET DOSE PACK |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PREDNISONE 2.5 MG TABLET |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PREDNISONE 20 MG TABLET [Predone] |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PREDNISONE 5 MG TABLET |
1 |
Tier 1 |
$14.00 | $28.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISONE 5 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PREDNISONE 5 MG TABLET [Sterapred] |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PREDNISONE 5 MG/5 ML SOLUTION |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PREDNISONE 50MG TABLET |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PREGABALIN 100 MG CAPSULE [Lyrica] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PREGABALIN 150 MG CAPSULE [Lyrica] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PREGABALIN 20 MG/ML SOLUTION [Lyrica] |
2 |
Tier 2 |
$15.00 | $30.00 | Q:900 /30Days |
PREGABALIN 200 MG CAPSULE [Lyrica] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PREGABALIN 225 MG CAPSULE [Lyrica] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PREGABALIN 25 MG CAPSULE [Lyrica] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PREGABALIN 300 MG CAPSULE [Lyrica] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREGABALIN 50 MG CAPSULE [Lyrica] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PREGABALIN 75 MG CAPSULE [Lyrica] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PREMARIN 0.3 MG TABLET |
3 |
Tier 3 |
$42.00 | $84.00 | P |
PREMARIN 0.45MG TABLET |
3 |
Tier 3 |
$42.00 | $84.00 | P |
PREMARIN 0.625 MG TABLET |
3 |
Tier 3 |
$42.00 | $84.00 | P |
Premarin 0.625mg/g |
3 |
Tier 3 |
$42.00 | $84.00 | None |
PREMARIN 0.9MG TABLET |
3 |
Tier 3 |
$42.00 | $84.00 | P |
PREMARIN 1.25 MG TABLET |
3 |
Tier 3 |
$42.00 | $84.00 | P |
PREMASOL 10% IV SOLUTION |
4 |
Tier 4 |
$95.00 | $190.00 | P |
PRETOMANID 200 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | P |
PREZCOBIX 800 MG-150 MG TABLET |
5 |
Tier 5 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREZISTA 100 MG/ML SUSPENSION |
5 |
Tier 5 |
25% | 25% | None |
PREZISTA 150MG TABLETS |
5 |
Tier 5 |
25% | 25% | None |
PREZISTA 800 MG TABLET |
5 |
Tier 5 |
25% | 25% | None |
PREZISTA TABLET 600MG |
5 |
Tier 5 |
25% | 25% | None |
PREZISTA TABLET 75MG |
4 |
Tier 4 |
$95.00 | $190.00 | None |
PRIFTIN 150 MG TABLET |
4 |
Tier 4 |
$95.00 | $190.00 | None |
Primaquine Phosphate 26.3 MG Oral Tablet |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PRIMIDONE 250 MG TABLET [Mysoline] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PRIMIDONE 50 MG TABLET [Mysoline] |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PRIVIGEN 10% VIAL |
5 |
Tier 5 |
25% | 25% | P |
PROBENECID 500 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROBENECID-COLCHICINE TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | 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 |
Tier 4 |
$95.00 | $190.00 | P |
PROCHLORPERAZINE 10 MG TAB |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PROCHLORPERAZINE 5 MG TABLET |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PROCRIT 10000U/ML VIAL |
3 |
Tier 3 |
$42.00 | $84.00 | P |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL |
3 |
Tier 3 |
$42.00 | $84.00 | P |
PROCRIT 3,000 UNITS/ML VIAL |
3 |
Tier 3 |
$42.00 | $84.00 | P |
PROCRIT 4,000 UNITS/ML VIAL |
3 |
Tier 3 |
$42.00 | $84.00 | P |
PROCRIT 40000U/ML VIAL PR |
5 |
Tier 5 |
25% | 25% | P |
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY |
5 |
Tier 5 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROGRAF 0.2 MG GRANULE PACKET |
4 |
Tier 4 |
$95.00 | $190.00 | P |
PROGRAF 1 MG GRANULE PACKET |
4 |
Tier 4 |
$95.00 | $190.00 | P |
PROLASTIN C 1,000 MG VIAL |
5 |
Tier 5 |
25% | 25% | P |
PROLIA 60MG/ML INJECTION |
4 |
Tier 4 |
$95.00 | $190.00 | P Q:1 /180Days |
PROMACTA 12.5 MG TABLET |
5 |
Tier 5 |
25% | 25% | P |
PROMACTA 25 MG TABLET |
5 |
Tier 5 |
25% | 25% | P |
PROMACTA 50 MG TABLET |
5 |
Tier 5 |
25% | 25% | P |
PROMACTA 75 MG TABLET |
5 |
Tier 5 |
25% | 25% | P |
PROMETHAZINE 12.5 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | P |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX |
2 |
Tier 2 |
$15.00 | $30.00 | P |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX |
2 |
Tier 2 |
$15.00 | $30.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPAFENONE HCL 150 MG TABLET [Rythmol] |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PROPAFENONE HCL 225MG TABLET |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PROPAFENONE HCL 300 MG TAB |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PROPAFENONE HCL ER 225 MG CAP |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PROPAFENONE HYDROCHLORIDE 325MG CAPSULES EXTENDED RELEASE |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PROPAFENONE HYDROCHLORIDE 425MG CAPSULES EXTENDED RELEASE |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Proparacaine hydrochloride 5 MG/ML Ophthalmic Solution |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PROPRANOLOL 10 MG TABLET |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PROPRANOLOL 20 MG TABLET |
1 |
Tier 1 |
$14.00 | $28.00 | None |
PROPRANOLOL 20MG/5ML TUBEX |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PROPRANOLOL 40 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPRANOLOL 40MG/5ML TUBEX |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PROPRANOLOL 60 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PROPRANOLOL 80 MG TABLET [Inderal] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PROPRANOLOL ER 120 MG CAPSULE |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PROPRANOLOL ER 160 MG CAPSULE |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PROPRANOLOL ER 60 MG CAPSULE |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PROPRANOLOL ER 80 MG CAPSULE |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PROPRANOLOL/HCTZ 40/25 TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PROPRANOLOL/HCTZ 80/25 TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PROPYLTHIOURACIL 50MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PROQUAD VIAL |
3 |
Tier 3 |
$42.00 | $84.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROTRIPTYLINE HCL 10 MG TABLET [Vivactil] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PROTRIPTYLINE HCL 5 MG TABLET [Vivactil] |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PULMOZYME 1MG/ML AMPUL |
5 |
Tier 5 |
25% | 25% | P |
PURIXAN 20 MG/ML ORAL SUSP |
5 |
Tier 5 |
25% | 25% | None |
PYRAZINAMIDE 500 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PYRIDOSTIGMINE BR 60 MG TABLET |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PYRIDOSTIGMINE BR ER 180 MG TAB |
2 |
Tier 2 |
$15.00 | $30.00 | None |
PYRIMETHAMINE 25 MG TABLET [Daraprim] |
5 |
Tier 5 |
25% | 25% | None |