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2020 Medicare Part D and Medicare Advantage Plan Formulary Browser

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SOLIS SPF 001 (HMO) (H0982-001-0)
Tier 1 (716)
Tier 2 (1780)
Tier 3 (465)
Tier 4 (1475)
Tier 5 (618)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
  *required
 
Cick on the first letter of your drug name to browse the formulary:

A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2020 Medicare Part D Plan Formulary Information
SOLIS SPF 001 (HMO) (H0982-001-0)
Benefits & Contact Info           
The SOLIS SPF 001 (HMO) (H0982-001-0)
Formulary Drugs Starting with the Letter C

in Miami-Dade County, FL: CMS MA Region 9 which includes: FL
Plan Monthly Premium: $0.00 Deductible: $0
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   2 Tier 2 $0.00$0.00None
CABOMETYX 20 MG TABLET   5 Tier 5 33%N/AP
CABOMETYX 40 MG TABLET   5 Tier 5 33%N/AP
CABOMETYX 60 MG TABLET   5 Tier 5 33%N/AP
Caduet 10; 10mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE   4 Tier 4 $35.00N/ANone
Caduet 10; 20mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE   4 Tier 4 $35.00N/ANone
CADUET 10MG/40MG TABLET   4 Tier 4 $35.00N/ANone
CADUET 10MG/80MG TABLET   4 Tier 4 $35.00N/ANone
CADUET 5MG/10MG TABLET   4 Tier 4 $35.00N/ANone
CADUET 5MG/20MG TABLET   4 Tier 4 $35.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CADUET 5MG/40MG TABLET   4 Tier 4 $35.00N/ANone
CADUET 5MG/80MG TABLET   4 Tier 4 $35.00N/ANone
CALAN SR 120MG CAPLET SA   4 Tier 4 $35.00N/ANone
CALAN SR 240 MG CAPLET   4 Tier 4 $35.00N/ANone
CALCIPOTRIENE 0.005% CREAM (g) [Dovonex]   2 Tier 2 $0.00$0.00Q:240
/30Days
CALCIPOTRIENE 0.005% OINTMENT [Dovonex]   2 Tier 2 $0.00$0.00Q:200
/30Days
CALCIPOTRIENE 0.005% SOLUTION [Dovonex Scalp]   2 Tier 2 $0.00$0.00None
CALCIPOTRIENE-BETAMETH DP OINTMENT [Taclonex]   2 Tier 2 $0.00$0.00Q:420
/30Days
CALCIPOTRIENE-BETAMETH DP SUSPENSION [Taclonex Scalp]   4 Tier 4 $35.00N/AQ:420
/30Days
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY   2 Tier 2 $0.00$0.00None
CALCITRIOL 0.25 MCG CAPSULE [Rocaltrol]   2 Tier 2 $0.00$0.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CALCITRIOL 0.5 MCG CAPSULE [Rocaltrol]   2 Tier 2 $0.00$0.00P
CALCITRIOL 1 MCG/ML SOLUTION ORAL   2 Tier 2 $0.00$0.00P
CALCITRIOL 3 MCG/G OINTMENT   4 Tier 4 $35.00N/ANone
CALCIUM ACETATE 667 MG GELCAPSULE [PhosLo]   2 Tier 2 $0.00$0.00None
CALCIUM ACETATE 667 MG TABLET [PhosLo]   2 Tier 2 $0.00$0.00None
CALQUENCE 100 MG CAPSULE   5 Tier 5 33%N/AP Q:60
/30Days
CAMILA 0.35 MG TABLET [Sharobel 28-Day]   2 Tier 2 $0.00$0.00None
CAMRESE LO TABLET   2 Tier 2 $0.00$0.00None
CANCIDAS IV 50MG VIAL   5 Tier 5 33%N/ANone
CANCIDAS IV 70MG VIAL   5 Tier 5 33%N/ANone
CAPEX SHA 0.01%   4 Tier 4 $35.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CAPLYTA 42 MG CAPSULE   4 Tier 4 $35.00N/AP Q:30
/30Days
CAPRELSA 100 MG TABLET   5 Tier 5 33%N/AP Q:60
/30Days
CAPRELSA 300 MG TABLET   5 Tier 5 33%N/AP Q:30
/30Days
CAPTOPRIL 100MG TABLET   2 Tier 2 $0.00$0.00None
CAPTOPRIL 12.5MG TABLET   2 Tier 2 $0.00$0.00None
CAPTOPRIL 25 MG TABLET   2 Tier 2 $0.00$0.00None
CAPTOPRIL 50MG TABLET   2 Tier 2 $0.00$0.00None
Captopril and Hydrochlorothiazide 25; 15mg 100 TABLET BOTTLE   2 Tier 2 $0.00$0.00None
Captopril and Hydrochlorothiazide 25; 25mg 100 TABLET BOTTLE   2 Tier 2 $0.00$0.00None
Captopril and Hydrochlorothiazide 50; 15mg 100 TABLET BOTTLE   2 Tier 2 $0.00$0.00None
Captopril and Hydrochlorothiazide 50; 25mg 100 TABLET BOTTLE   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARAC CREAM   4 Tier 4 $35.00N/ANone
CARAFATE SUCRALFATE 1G TABLET ORAL   4 Tier 4 $35.00N/ANone
CARAFATE SUS 1GM/10ML   3 Tier 3 $0.00N/ANone
CARBAGLU 200 MG DISPER TABLET   4 Tier 4 $35.00N/AP
CARBAMAZEPINE 100 MG TABLET CHEW   2 Tier 2 $0.00$0.00None
CARBAMAZEPINE 100 MG/5 ML SUSP   2 Tier 2 $0.00$0.00None
CARBAMAZEPINE 200 MG TABLET [Tegretol]   2 Tier 2 $0.00$0.00None
CARBAMAZEPINE ER 100 MG CAPSULE CPMP 12HR [Carbatrol]   2 Tier 2 $0.00$0.00None
CARBAMAZEPINE ER 100 MG TABLET   2 Tier 2 $0.00$0.00None
CARBAMAZEPINE ER 200 MG CAPSULE CPMP 12HR [Carbatrol]   2 Tier 2 $0.00$0.00None
CARBAMAZEPINE ER 300 MG CAPSULE CPMP 12HR [Carbatrol]   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBAMAZEPINE XR 200 MG TABLET   2 Tier 2 $0.00$0.00None
CARBAMAZEPINE XR 400 MG TABLET   2 Tier 2 $0.00$0.00None
Carbatrol 100mg/1 120 CAPSULE, ER in BOTTLE   4 Tier 4 $35.00N/ANone
CARBATROL 200MG CAPSULE SA   4 Tier 4 $35.00N/ANone
CARBATROL 300MG CAPSULE SA   4 Tier 4 $35.00N/ANone
CARBIDOPA 25 MG TABLET [Lodosyn]   2 Tier 2 $0.00$0.00None
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT   2 Tier 2 $0.00$0.00None
CARBIDOPA AND LEVODOPA ODT 25;100MG;MG 100 BOT   2 Tier 2 $0.00$0.00None
CARBIDOPA AND LEVODOPA ODT 25;250MG;MG 100 BOT   2 Tier 2 $0.00$0.00None
CARBIDOPA-LEVO ER 25-100 TABLET [SINEMET CR]   1 Tier 1 $0.00$0.00None
CARBIDOPA-LEVO ER 50-200 TABLET [SINEMET CR]   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBIDOPA-LEVODOPA 10-100 TABLET [SINEMET]   1 Tier 1 $0.00$0.00None
CARBIDOPA-LEVODOPA 100 MG-ENTA TABLET [Stalevo]   2 Tier 2 $0.00$0.00None
CARBIDOPA-LEVODOPA 125 MG-ENTA TABLET [Stalevo]   2 Tier 2 $0.00$0.00None
CARBIDOPA-LEVODOPA 150 MG-ENTA TABLET [Stalevo]   2 Tier 2 $0.00$0.00None
CARBIDOPA-LEVODOPA 200 MG-ENTA TABLET [Stalevo]   2 Tier 2 $0.00$0.00None
CARBIDOPA-LEVODOPA 25-100 TABLET   1 Tier 1 $0.00$0.00None
CARBIDOPA-LEVODOPA 25-250 TABLET   1 Tier 1 $0.00$0.00None
CARBIDOPA-LEVODOPA 75 MG-ENTA TABLET [Stalevo]   2 Tier 2 $0.00$0.00None
CARBIDOPA-LEVODOPA-ENTACAPONE 50 MG [Stalevo]   2 Tier 2 $0.00$0.00None
CARDIZEM 120 MG TABLET   4 Tier 4 $35.00N/ANone
CARDIZEM 30 MG TABLET   4 Tier 4 $35.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARDIZEM 60 MG TABLET   4 Tier 4 $35.00N/ANone
CARDIZEM CD 120 MG CAPSULE   4 Tier 4 $35.00N/ANone
CARDIZEM CD 180 MG CAPSULE   4 Tier 4 $35.00N/ANone
CARDIZEM CD 240 MG CAPSULE   4 Tier 4 $35.00N/ANone
CARDIZEM CD 300 MG CAPSULE ER 24H   4 Tier 4 $35.00N/ANone
CARDIZEM CD 360 MG CAPSULE   4 Tier 4 $35.00N/ANone
CARDIZEM LA 120 MG TABLET   4 Tier 4 $35.00N/ANone
CARDIZEM LA 180 MG TABLET   4 Tier 4 $35.00N/ANone
CARDIZEM LA 240 MG TABLET ER 24H   4 Tier 4 $35.00N/ANone
CARDIZEM LA 300 MG TABLET   4 Tier 4 $35.00N/ANone
CARDIZEM LA 360 MG TABLET ER 24H   4 Tier 4 $35.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARDIZEM LA 420 MG TABLET   4 Tier 4 $35.00N/ANone
CARDURA 1MG TABLET   4 Tier 4 $35.00N/ANone
CARDURA 2MG TABLET   4 Tier 4 $35.00N/ANone
CARDURA 4MG TABLET   4 Tier 4 $35.00N/ANone
CARDURA 8MG TABLET   4 Tier 4 $35.00N/ANone
CARDURA XL 4MG TABLET   4 Tier 4 $35.00N/ANone
CARDURA XL 8MG TABLET   4 Tier 4 $35.00N/ANone
CARISOPRODOL 350 MG TABLET   2 Tier 2 $0.00$0.00None
CARNITOR 100MG/ML ORAL TUBEX   4 Tier 4 $35.00N/AP
CARNITOR 330MG TABLET   4 Tier 4 $35.00N/AP
CARTEOLOL HCL 1% EYE DROPS   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARTIA XT 120MG CAPSULE SA   2 Tier 2 $0.00$0.00None
CARTIA XT 180MG CAPSULE SA   2 Tier 2 $0.00$0.00None
CARTIA XT 240MG CAPSULE SA   2 Tier 2 $0.00$0.00None
CARTIA XT 300 MG CAPSULE   2 Tier 2 $0.00$0.00None
CARVEDILOL 12.5 MG TABLET   1 Tier 1 $0.00$0.00None
CARVEDILOL 25 MG TABLET [Coreg]   1 Tier 1 $0.00$0.00None
CARVEDILOL 3.125 MG TABLET [Coreg]   1 Tier 1 $0.00$0.00None
CARVEDILOL 6.25 MG TABLET [Coreg]   1 Tier 1 $0.00$0.00None
CARVEDILOL ER 10 MG CAPSULE   2 Tier 2 $0.00$0.00None
CARVEDILOL ER 20 MG CAPSULE   2 Tier 2 $0.00$0.00None
CARVEDILOL ER 40 MG CAPSULE CPMP 24HR [Coreg CR]   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARVEDILOL ER 80 MG CAPSULE   2 Tier 2 $0.00$0.00None
CASODEX 50 MG TABLET   4 Tier 4 $35.00N/ANone
CASPOFUNGIN ACETATE 50 MG VIAL   5 Tier 5 33%N/ANone
CASPOFUNGIN ACETATE 70 MG VIAL   5 Tier 5 33%N/ANone
CATAPRES 0.1 MG TABLET   4 Tier 4 $35.00N/ANone
CATAPRES 0.2 MG TABLET   4 Tier 4 $35.00N/ANone
CATAPRES 0.3 MG TABLET   4 Tier 4 $35.00N/ANone
CATAPRES-TTS DIS 0.3/24HR 7.5MG/UNT   4 Tier 4 $35.00N/ANone
CATAPRES-TTS-1 PATCH 2.52.5MG/UNT 1 X 4 CRTN   4 Tier 4 $35.00N/ANone
CATAPRES-TTS-2 PATCH 52.5MG/UNT 1 X 4 CRTN   4 Tier 4 $35.00N/ANone
CAYSTON KIT 75 MG/VIAL   5 Tier 5 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CAZIANT 28 DAY TABLET   2 Tier 2 $0.00$0.00None
CEFACLOR 125 MG/5 ML ORAL SUSPENSION [Ceclor]   2 Tier 2 $0.00$0.00None
CEFACLOR 250 MG CAPSULES   2 Tier 2 $0.00$0.00None
CEFACLOR 250 MG/5 ML ORAL SUSPENSION [Ceclor]   2 Tier 2 $0.00$0.00None
CEFACLOR 375 MG/5 ML ORAL SUSPENSION [Ceclor]   2 Tier 2 $0.00$0.00None
CEFACLOR 500 MG CAPSULES   2 Tier 2 $0.00$0.00None
CEFACLOR ER 500MG TABLET SR 12HR   4 Tier 4 $35.00N/ANone
CEFADROXIL 1 GM TABLET   2 Tier 2 $0.00$0.00None
CEFADROXIL 250 MG/5 ML ORAL SUSPENSION [Duricef]   2 Tier 2 $0.00$0.00None
CEFADROXIL 500 MG CAPSULE   1 Tier 1 $0.00$0.00None
CEFADROXIL 500 MG/5 ML SUSPENSION   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFAZOLIN 1 GM VIAL 25/Box   2 Tier 2 $0.00$0.00None
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE   2 Tier 2 $0.00$0.00None
CEFAZOLIN 500 MG VIAL   2 Tier 2 $0.00$0.00None
CEFDINIR 125 MG/5 ML SUSPENSION   1 Tier 1 $0.00$0.00None
CEFDINIR 250 MG/5 ML ORAL SUSPENSION [Omnicef]   1 Tier 1 $0.00$0.00None
CEFDINIR 300 MG CAPSULE   1 Tier 1 $0.00$0.00None
CEFEPIME HCL 1 GM VIAL [Maxipime]   2 Tier 2 $0.00$0.00None
CEFEPIME HCL 2 GRAM VIAL [Maxipime]   2 Tier 2 $0.00$0.00None
CEFIXIME 100 MG/5 ML SUSPENSION [Suprax]   2 Tier 2 $0.00$0.00None
CEFIXIME 200 MG/5 ML SUSPENSION [Suprax]   2 Tier 2 $0.00$0.00None
CEFIXIME 400 MG CAPSULE [Suprax]   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFOTETAN 1GM VIAL 1EA x 10   2 Tier 2 $0.00$0.00None
CEFOTETAN 2GM VIAL 1EA x 10   2 Tier 2 $0.00$0.00None
CEFOXITIN 1 GM VIAL [Mefoxin]   2 Tier 2 $0.00$0.00None
CEFOXITIN 10 GM VIAL   2 Tier 2 $0.00$0.00None
CEFOXITIN 2 GM VIAL [Mefoxin]   2 Tier 2 $0.00$0.00None
CEFPODOXIME 100 MG TABLET [Vantin]   2 Tier 2 $0.00$0.00None
CEFPODOXIME 100 MG/5 ML ORAL SUSPENSION [Vantin]   2 Tier 2 $0.00$0.00None
CEFPODOXIME 200 MG TABLET   2 Tier 2 $0.00$0.00None
CEFPODOXIME 50 MG/5 ML SUSPENSION   2 Tier 2 $0.00$0.00None
CEFPROZIL 125 MG/5 ML SUSPENSION   1 Tier 1 $0.00$0.00None
CEFPROZIL 250 MG TABLET   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFPROZIL 250 MG/5 ML SUSPENSION   1 Tier 1 $0.00$0.00None
CEFPROZIL 500 MG TABLET   1 Tier 1 $0.00$0.00None
CEFTAZIDIME 1 GM VIAL [Tazidime]   2 Tier 2 $0.00$0.00None
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN   2 Tier 2 $0.00$0.00None
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN   2 Tier 2 $0.00$0.00None
CEFTRIAXONE 1 GM VIAL   2 Tier 2 $0.00$0.00None
CEFTRIAXONE 10 GM VIAL [Rocephin]   2 Tier 2 $0.00$0.00None
CEFTRIAXONE 2 GM VIAL [Rocephin]   2 Tier 2 $0.00$0.00None
CEFTRIAXONE 250 MG VIAL   2 Tier 2 $0.00$0.00None
CEFTRIAXONE 500 MG VIAL   2 Tier 2 $0.00$0.00None
CEFUROXIME 1.5 GM/VIAL FOR INJECTION   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFUROXIME 750 MG FOR INJECTION   2 Tier 2 $0.00$0.00None
CEFUROXIME AXETIL 250 MG TABLET   2 Tier 2 $0.00$0.00None
CEFUROXIME AXETIL 500 MG TABLET [Ceftin]   2 Tier 2 $0.00$0.00None
CEFUROXIME SOD 7.5 GM VIAL [Zinacef]   2 Tier 2 $0.00$0.00None
CELEBREX 100 MG CAPSULE   4 Tier 4 $35.00N/AQ:60
/30Days
CELEBREX 200 MG CAPSULE   4 Tier 4 $35.00N/AQ:60
/30Days
CELEBREX 400 MG CAPSULE   4 Tier 4 $35.00N/AQ:60
/30Days
CELEBREX 50 MG CAPSULE   4 Tier 4 $35.00N/AQ:60
/30Days
CELECOXIB 100 MG CAPSULE [Celebrex]   1 Tier 1 $0.00$0.00Q:60
/30Days
CELECOXIB 200 MG CAPSULE [Celebrex]   1 Tier 1 $0.00$0.00Q:60
/30Days
CELECOXIB 400 MG CAPSULE [Celebrex]   1 Tier 1 $0.00$0.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CELECOXIB 50 MG CAPSULE [Celebrex]   1 Tier 1 $0.00$0.00Q:60
/30Days
CELEXA 10 MG TABLET   4 Tier 4 $35.00N/ANone
CELEXA 20 MG TABLET   4 Tier 4 $35.00N/ANone
CELEXA 40 MG TABLET   4 Tier 4 $35.00N/ANone
CELLCEPT 200 MG/ML ORAL SUSPENSION   4 Tier 4 $35.00N/AP
CELLCEPT 250 MG CAPSULE   4 Tier 4 $35.00N/AP
CELLCEPT 500 MG TABLET   4 Tier 4 $35.00N/AP
CELONTIN 300 MG KAPSEAL   3 Tier 3 $0.00N/ANone
CEPHALEXIN 125 MG/5 ML SUSPENSION   1 Tier 1 $0.00$0.00None
CEPHALEXIN 250 MG CAPSULE   1 Tier 1 $0.00$0.00None
CEPHALEXIN 250 MG/5 ML SUSPENSION   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEPHALEXIN 500 MG CAPSULE   1 Tier 1 $0.00$0.00None
CERDELGA 84 MG CAPSULE   5 Tier 5 33%N/AP Q:60
/30Days
CETIRIZINE HCL 1 MG/ML SYRUP SOLUTION [Zyrtec Pre-Filled Spoons]   2 Tier 2 $0.00$0.00None
CETRAXAL 0.2% EAR SOLUTION DROPERETTE   3 Tier 3 $0.00N/ANone
CEVIMELINE HCL 30 MG CAPSULE [Evoxac]   2 Tier 2 $0.00$0.00None
CHANTIX 0.5 MG TABLET   3 Tier 3 $0.00N/ANone
CHANTIX 1 MG CONT MONTH BOX   3 Tier 3 $0.00N/ANone
CHANTIX 1 MG TABLET   3 Tier 3 $0.00N/ANone
CHANTIX STARTING MONTH BOX   3 Tier 3 $0.00N/ANone
CHEMET 100 MG CAPSULE   3 Tier 3 $0.00N/ANone
CHENODAL 250 MG TABLET   5 Tier 5 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHLORDIAZEPO-AMITRIPTYL 5-12.5   2 Tier 2 $0.00$0.00None
CHLORDIAZEPOXIDE 10 MG CAPSULE   1 Tier 1 $0.00$0.00None
CHLORDIAZEPOXIDE 25 MG CAPSULE   1 Tier 1 $0.00$0.00None
CHLORDIAZEPOXIDE 5 MG CAPSULE   1 Tier 1 $0.00$0.00None
CHLORHEXIDINE GLUCONATE 0.12% RINSE   1 Tier 1 $0.00$0.00None
CHLOROQUINE PH 250 MG TABLET   2 Tier 2 $0.00$0.00None
CHLOROQUINE PH 500 MG TABLET   2 Tier 2 $0.00$0.00None
CHLORPROMAZINE 10 MG TABLET   2 Tier 2 $0.00$0.00None
CHLORPROMAZINE 100 MG TABLET   2 Tier 2 $0.00$0.00None
CHLORPROMAZINE 200 MG TABLET   2 Tier 2 $0.00$0.00None
CHLORPROMAZINE 25 MG TABLET   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHLORPROMAZINE 50 MG TABLET   2 Tier 2 $0.00$0.00None
CHLORTHALIDONE 25 MG TABLET   2 Tier 2 $0.00$0.00None
CHLORTHALIDONE 50 MG TABLET   2 Tier 2 $0.00$0.00None
CHLORZOXAZONE 500 MG TABLET   1 Tier 1 $0.00$0.00None
CHOLBAM 250 MG CAPSULE   5 Tier 5 33%N/AP
CHOLBAM 50 MG CAPSULE   5 Tier 5 33%N/AP
CHOLESTYRAMINE LIGHT POWDER   2 Tier 2 $0.00$0.00None
CHOLESTYRAMINE PACKET   2 Tier 2 $0.00$0.00None
CICLOPIROX 0.77% CREAM (g) [Loprox]   2 Tier 2 $0.00$0.00None
CICLOPIROX 0.77% GEL   2 Tier 2 $0.00$0.00None
CICLOPIROX 0.77% TOPICAL SUSPENSION   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CICLOPIROX 1% SHAMPOO   2 Tier 2 $0.00$0.00None
CICLOPIROX 8% SOLUTION [Penlac]   2 Tier 2 $0.00$0.00None
Cilastatin 250 MG / Imipenem 250 MG Injection   2 Tier 2 $0.00$0.00None
Cilastatin 500 MG / Imipenem 500 MG Injection   2 Tier 2 $0.00$0.00None
CILOSTAZOL 100 MG TABLET   1 Tier 1 $0.00$0.00None
CILOSTAZOL 50 MG TABLET   1 Tier 1 $0.00$0.00None
CILOXAN 0.3% OINTMENT   4 Tier 4 $35.00N/ANone
CILOXAN SOLUTION 0.3% 5ML BOT   4 Tier 4 $35.00N/ANone
CIMDUO 300-300 MG TABLET   5 Tier 5 33%N/ANone
Cimetidine 200mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC   2 Tier 2 $0.00$0.00None
Cimetidine 300 MG Oral Tablet   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CIMETIDINE 400 MG TABLET [Tagamet]   2 Tier 2 $0.00$0.00None
Cimetidine 800mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC   2 Tier 2 $0.00$0.00None
Cimetidine Hydrochloride Oral Solution 300mg/5mL 237 mL in 1 BOTTLE   2 Tier 2 $0.00$0.00None
Cimzia 2 KIT per CARTON / 1 KIT in 1 KIT   5 Tier 5 33%N/AP
CIMZIA 200 MG/ML SYRINGE KIT   5 Tier 5 33%N/AP
CINACALCET HCL 30 MG TABLET [Sensipar]   2 Tier 2 $0.00$0.00P
CINACALCET HCL 60 MG TABLET [Sensipar]   2 Tier 2 $0.00$0.00P
CINACALCET HCL 90 MG TABLET [Sensipar]   2 Tier 2 $0.00$0.00P
Cinryze 500[iU]/5mL 1 VIAL per CARTON / 5 mL in 1 VIAL   5 Tier 5 33%N/AP
CIPRO 10% SUSPENSION 1 KIT in 1 KIT   4 Tier 4 $35.00N/ANone
Cipro 250mg 100 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Tier 4 $35.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CIPRO 5% SUSPENSION 1 KIT in 1 KIT   4 Tier 4 $35.00N/ANone
Cipro 500mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Tier 4 $35.00N/ANone
CIPRO HC OTIC SUSPENSION   4 Tier 4 $35.00N/ANone
CIPRODEX OTIC SUSPENSION   3 Tier 3 $0.00N/ANone
CIPROFLOXACIN 0.2% OTIC SOLN DROPERETTE [Cetraxal]   3 Tier 3 $0.00N/ANone
CIPROFLOXACIN 0.3% EYE DROPS [Ciloxan]   2 Tier 2 $0.00$0.00None
CIPROFLOXACIN HCL 250 MG TABLET [Cipro]   1 Tier 1 $0.00$0.00None
CIPROFLOXACIN HCL 500 MG TABLET [Cipro]   1 Tier 1 $0.00$0.00None
CIPROFLOXACIN HCL 750 MG TABLET [Cipro]   1 Tier 1 $0.00$0.00None
CIPROFLOXACIN-D5W 200 MG/100 ML PIGGYBACK [Cipro]   2 Tier 2 $0.00$0.00None
CITALOPRAM HBR 10 MG TABLET [Celexa]   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CITALOPRAM HBR 10 MG/5 ML SOLUTION [Celexa]   2 Tier 2 $0.00$0.00None
CITALOPRAM HBR 20 MG TABLET [Celexa]   1 Tier 1 $0.00$0.00None
CITALOPRAM HBR 40 MG TABLET   1 Tier 1 $0.00$0.00None
CLARAVIS 10 MG CAPSULE   2 Tier 2 $0.00$0.00None
CLARAVIS 20 MG CAPSULE   2 Tier 2 $0.00$0.00None
Claravis 30mg 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK   2 Tier 2 $0.00$0.00None
CLARAVIS 40 MG CAPSULE   2 Tier 2 $0.00$0.00None
CLARINEX 5 MG TABLET   4 Tier 4 $35.00N/ANone
CLARINEX-D 12 HOUR TABLET   4 Tier 4 $35.00N/ANone
CLARITHROMYCIN 125 MG/5ML FOR ORAL SUSPENSION   2 Tier 2 $0.00$0.00None
CLARITHROMYCIN 250 MG TABLET   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLARITHROMYCIN 250 MG/5MLFOR ORAL SUSPENSION   2 Tier 2 $0.00$0.00None
CLARITHROMYCIN 500 MG TABLET [Biaxin]   1 Tier 1 $0.00$0.00None
CLARITHROMYCIN ER 500 MG TABLET 24H [Biaxin XL]   2 Tier 2 $0.00$0.00None
CLENPIQ SOLUTION   3 Tier 3 $0.00N/ANone
CLEOCIN 100 MG VAGINAL OVULE   4 Tier 4 $35.00N/ANone
CLEOCIN 2% VAGINAL CREAM   4 Tier 4 $35.00N/ANone
CLEOCIN HCL 150 MG CAPSULE   4 Tier 4 $35.00N/ANone
CLEOCIN HCL 300 MG CAPSULE   4 Tier 4 $35.00N/ANone
CLEOCIN HCL 75 MG CAPSULE   4 Tier 4 $35.00N/ANone
Cleocin Pediatric 75mg/5mL 75 mL in 1 BOTTLE   4 Tier 4 $35.00N/ANone
CLEOCIN PHOS 150 MG/ML VIAL   4 Tier 4 $35.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLEOCIN T 1% GEL   4 Tier 4 $35.00N/ANone
CLEOCIN T 1% LOTION   4 Tier 4 $35.00N/ANone
CLIMARA 0.025MG/DAY PATCH   4 Tier 4 $35.00N/ANone
CLIMARA 0.0375MG/DAY PATCH   4 Tier 4 $35.00N/ANone
CLIMARA 0.05MG/24H PATCH   4 Tier 4 $35.00N/ANone
CLIMARA 0.06/MG DAY PATCH   4 Tier 4 $35.00N/ANone
CLIMARA 0.075MG/DAY PATCH   4 Tier 4 $35.00N/ANone
CLIMARA 0.1MG/24H PATCH   4 Tier 4 $35.00N/ANone
CLIMARA PRO DIS WEEKLY 4.40MG/1.39MG   4 Tier 4 $35.00N/ANone
CLIND PH-BENZOYL PERO 1.2-2.5% GEL W/PUMP [Acanya]   2 Tier 2 $0.00$0.00None
CLIND PH-BENZOYL PEROX 1.2-5% [Benzaclin]   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINDACIN PAC KIT   2 Tier 2 $0.00$0.00None
CLINDAMYCIN 150mg/ml vl 25x6ml   2 Tier 2 $0.00$0.00None
CLINDAMYCIN 2% VAGINAL CREAM w/APPL [Clindesse]   2 Tier 2 $0.00$0.00None
CLINDAMYCIN HCL 150 MG CAPSULE [Cleocin]   1 Tier 1 $0.00$0.00None
CLINDAMYCIN HCL 300 MG CAPSULE   1 Tier 1 $0.00$0.00None
CLINDAMYCIN HCL 75 MG 200 CAPSULE BOTTLE   1 Tier 1 $0.00$0.00None
CLINDAMYCIN PEDIATR 75 MG/5 ML SOLN RECON [Cleocin Pediatric]   2 Tier 2 $0.00$0.00None
CLINDAMYCIN PH 1% SOLUTION   2 Tier 2 $0.00$0.00Q:300
/30Days
CLINDAMYCIN PH 300 MG/2 ML VIAL [Cleocin]   2 Tier 2 $0.00$0.00None
CLINDAMYCIN PH 600 MG/4 ML VIAL [Cleocin]   2 Tier 2 $0.00$0.00None
CLINDAMYCIN PHOSP 1% LOTION [ClindaMax]   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINDAMYCIN PHOSPHATE 1% FOAM   2 Tier 2 $0.00$0.00None
Clindamycin Phosphate and Benzoyl Peroxide 1 KIT   2 Tier 2 $0.00$0.00None
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE   2 Tier 2 $0.00$0.00None
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX   2 Tier 2 $0.00$0.00None
Clindamycin-d5w 300 mg/50 ml   2 Tier 2 $0.00$0.00None
Clindamycin-d5w 600 mg/50 ml   2 Tier 2 $0.00$0.00None
Clindamycin-d5w 900 mg/50 ml   2 Tier 2 $0.00$0.00None
CLINDAMYCIN-TRETINOIN 1.2%-0.025% [Veltin, Ziana]   2 Tier 2 $0.00$0.00None
CLINDESSE 2% VAGINAL CREAM   4 Tier 4 $35.00N/ANone
CLINIMIX 5/20 SOLUTION   3 Tier 3 $0.00N/AP
CLINIMIX 5%-15% IV SOLUTION   3 Tier 3 $0.00N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINIMIX E 2.75/5 SOLUTION   3 Tier 3 $0.00N/AP
CLINIMIX E 4.25/5 SOLUTION   3 Tier 3 $0.00N/AP
CLINIMIX E 4.25%-10% IV SOLUTION   3 Tier 3 $0.00N/AP
CLINIMIX E 5/20 SOLUTION   3 Tier 3 $0.00N/AP
CLINIMIX E 5%-15% IV SOLUTION   3 Tier 3 $0.00N/AP
CLINISOL 15% SOLUTION   2 Tier 2 $0.00$0.00P
CLOBAZAM 10 MG TABLET [ONFI]   2 Tier 2 $0.00$0.00None
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION [ONFI]   2 Tier 2 $0.00$0.00None
CLOBAZAM 20 MG TABLET [ONFI]   2 Tier 2 $0.00$0.00None
CLOBETASOL 0.05% CREAM (g) [Temovate]   1 Tier 1 $0.00$0.00None
CLOBETASOL 0.05% OINTMENT [Temovate E]   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOBETASOL 0.05% SOLUTION [Temovate]   1 Tier 1 $0.00$0.00Q:450
/30Days
CLOBETASOL 0.05% TOPICAL LOTION [Clobex]   2 Tier 2 $0.00$0.00None
CLOBETASOL EMOLLIENT 0.05% CREAM (g) [Temovate E]   2 Tier 2 $0.00$0.00None
CLOBETASOL EMOLLNT 0.05% FOAM [Olux-E]   2 Tier 2 $0.00$0.00P
CLOBETASOL PROP 0.05% FOAM [Olux]   2 Tier 2 $0.00$0.00None
CLOBETASOL PROP 0.05% SPRAY   2 Tier 2 $0.00$0.00None
Clobetasol Propionate 0.5 MG/ML Medicated Shampoo   2 Tier 2 $0.00$0.00None
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE   2 Tier 2 $0.00$0.00None
CLOBEX 0.05% SPRAY   4 Tier 4 $35.00N/AP
CLOBEX 0.05% TOPICAL LOTION   4 Tier 4 $35.00N/AP
Clobex 0.05mL/100mL 118 mL in 1 BOTTLE   4 Tier 4 $35.00N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOCORTOLONE PIVALATE 0.1% CREAM (g) [Cloderm]   4 Tier 4 $35.00N/AP
Clodan 0.05% shampoo   2 Tier 2 $0.00$0.00None
CLODERM 0.1% CREAM (g)   4 Tier 4 $35.00N/AP
CLOMIPRAMINE 25 MG CAPSULE   2 Tier 2 $0.00$0.00P
CLOMIPRAMINE 50 MG CAPSULE   2 Tier 2 $0.00$0.00P
CLOMIPRAMINE 75 MG CAPSULE   2 Tier 2 $0.00$0.00P
CLONAZEPAM 0.125 MG DIS TABLET RAPDIS [Klonopin]   2 Tier 2 $0.00$0.00None
CLONAZEPAM 0.25 MG ODT TABLET RAPDIS [Klonopin]   2 Tier 2 $0.00$0.00None
CLONAZEPAM 0.5 MG DIS TABLET RAPDIS [Klonopin]   2 Tier 2 $0.00$0.00None
CLONAZEPAM 0.5 MG TABLET [Klonopin]   1 Tier 1 $0.00$0.00None
CLONAZEPAM 1 MG DIS TABLET RAPDIS [Klonopin]   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLONAZEPAM 1 MG TABLET [Klonopin]   1 Tier 1 $0.00$0.00None
CLONAZEPAM 2 MG ODT TABLET RAPDIS [Klonopin]   2 Tier 2 $0.00$0.00None
CLONAZEPAM 2 MG TABLET [Klonopin]   1 Tier 1 $0.00$0.00None
Clonidine 0.1mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   2 Tier 2 $0.00$0.00None
Clonidine 0.2mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   2 Tier 2 $0.00$0.00None
Clonidine 0.3mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   2 Tier 2 $0.00$0.00None
CLONIDINE HCL 0.1 MG TABLET   1 Tier 1 $0.00$0.00None
CLONIDINE HCL 0.2 MG TABLET   1 Tier 1 $0.00$0.00None
CLONIDINE HCL 0.3 MG TABLET   1 Tier 1 $0.00$0.00None
CLOPIDOGREL 75 MG TABLET [Plavix]   1 Tier 1 $0.00$0.00None
CLORAZEPATE 15 MG TABLET   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLORAZEPATE 3.75 MG TABLET   2 Tier 2 $0.00$0.00None
CLORAZEPATE 7.5 MG TABLET   2 Tier 2 $0.00$0.00None
CLOTRIMAZOLE 1% CREAM (g) [Mycelex]   2 Tier 2 $0.00$0.00None
CLOTRIMAZOLE 1% SOLUTION   2 Tier 2 $0.00$0.00None
CLOTRIMAZOLE 10 MG TROCHE   2 Tier 2 $0.00$0.00None
CLOTRIMAZOLE-BETAMETHASONE LOT   2 Tier 2 $0.00$0.00None
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE   2 Tier 2 $0.00$0.00None
CLOVIQUE 250 MG CAPSULE [Syprine]   2 Tier 2 $0.00$0.00P
CLOZAPINE 100 MG TABLET [Clozaril]   2 Tier 2 $0.00$0.00None
CLOZAPINE 200 MG TABLET   2 Tier 2 $0.00$0.00None
CLOZAPINE 25 MG TABLET [Clozaril]   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOZAPINE 50 MG TABLET   2 Tier 2 $0.00$0.00None
CLOZAPINE ODT 100 MG TABLET RAPDIS [Fazaclo]   2 Tier 2 $0.00$0.00None
CLOZAPINE ODT 12.5 MG TABLET RAPDIS [Fazaclo]   2 Tier 2 $0.00$0.00None
CLOZAPINE ODT 150 MG TABLET RAPDIS [Fazaclo]   4 Tier 4 $35.00N/ANone
CLOZAPINE ODT 200 MG TABLET RAPDIS [Fazaclo]   4 Tier 4 $35.00N/ANone
CLOZAPINE ODT 25 MG TABLET RAPDIS [Fazaclo]   2 Tier 2 $0.00$0.00None
CLOZARIL 100 MG TABLET   4 Tier 4 $35.00N/ANone
CLOZARIL 200 MG TABLET   4 Tier 4 $35.00N/ANone
CLOZARIL 25 MG TABLET   4 Tier 4 $35.00N/ANone
CLOZARIL 50 MG TABLET   4 Tier 4 $35.00N/ANone
COARTEM 20MG-120MG   3 Tier 3 $0.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CODEINE SULFATE 15 MG TABLET   2 Tier 2 $0.00$0.00Q:240
/30Days
CODEINE SULFATE 30 MG TABLET   2 Tier 2 $0.00$0.00Q:240
/30Days
CODEINE SULFATE 60 MG TABLET   2 Tier 2 $0.00$0.00Q:180
/30Days
COLAZAL 750MG CAPSULE   4 Tier 4 $35.00N/ANone
COLCHICINE 0.6 MG TABLET [Colcrys]   4 Tier 4 $35.00N/AP
COLESEVELAM 625 MG TABLET [WelChol]   2 Tier 2 $0.00$0.00None
COLESEVELAM HCL 3.75 G PACKET POWDER PACK [WelChol]   2 Tier 2 $0.00$0.00None
COLESTID 1GM TABLET   4 Tier 4 $35.00N/ANone
COLESTID GRANULES PACKET   4 Tier 4 $35.00N/ANone
COLESTIPOL HCL GRANULES PACKET [Colestid]   2 Tier 2 $0.00$0.00None
COLESTIPOL MICRONIZED 1 GM TABLET [Colestid]   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COLISTIMETHATE 150 MG VIAL [Coly-Mycin M]   2 Tier 2 $0.00$0.00None
COMBIGAN 0.2%-0.5% DROPS   3 Tier 3 $0.00N/ANone
COMBIPATCH 0.05-0.14 MG PATCH   4 Tier 4 $35.00N/ANone
COMBIPATCH 0.05-0.25 MG PATCH   4 Tier 4 $35.00N/ANone
COMBIVENT RESPIMAT INHAL SPRAY   3 Tier 3 $0.00N/ANone
COMBIVIR TABLET   5 Tier 5 33%N/ANone
COMETRIQ 100 MG DAILY-DOSE PACK   5 Tier 5 33%N/AP
COMETRIQ 140 MG DAILY-DOSE PACK   5 Tier 5 33%N/AP
COMETRIQ 60 MG DAILY-DOSE PACK   5 Tier 5 33%N/AP
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1   5 Tier 5 33%N/ANone
COMPRO 25MG SUPPOSITORY   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COMTAN 200MG TABLET   4 Tier 4 $35.00N/ANone
CONCERTA 54mg/1 100 TABLET, ER in BOTTLE   4 Tier 4 $35.00N/ANone
CONCERTA ER TABLETS 18MG 100 TABLET BOTTLE   4 Tier 4 $35.00N/ANone
CONCERTA ER TABLETS 27MG 100 TABLET BOTTLE   4 Tier 4 $35.00N/ANone
CONCERTA ER TABLETS 36MG 100 TABLET BOTTLE   4 Tier 4 $35.00N/ANone
CONDYLOX 0.5% GEL   4 Tier 4 $35.00N/ANone
CONSTULOSE 10 GM/15 ML SOLN   1 Tier 1 $0.00$0.00None
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN   5 Tier 5 33%N/ANone
COPAXONE 40 MG/ML SYRINGE   5 Tier 5 33%N/ANone
COPIKTRA 15 MG CAPSULE   5 Tier 5 33%N/AP Q:60
/30Days
COPIKTRA 25 MG CAPSULE   5 Tier 5 33%N/AP Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CORDRAN 4 MCG/SQ CM LARGE MED. TAPE   4 Tier 4 $35.00N/ANone
COREG 12.5MG TABLET   4 Tier 4 $35.00N/ANone
COREG 25MG TABLET   4 Tier 4 $35.00N/ANone
COREG 3.125MG TABLET   4 Tier 4 $35.00N/ANone
COREG 6.25MG TABLET   4 Tier 4 $35.00N/ANone
COREG CR 10 MG CAPSULE CPMP 24HR   4 Tier 4 $35.00N/ANone
COREG CR 20MG CAPSULE MULTIPHASIC RELEASE 24 HR   4 Tier 4 $35.00N/ANone
COREG CR 40MG CAPSULE MULTIPHASIC RELEASE 24 HR   4 Tier 4 $35.00N/ANone
COREG CR 80MG CAPSULE MULTIPHASIC RELEASE 24 HR   4 Tier 4 $35.00N/ANone
CORGARD 20 MG TABLET   4 Tier 4 $35.00N/ANone
CORGARD 40 MG TABLET   4 Tier 4 $35.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CORGARD 80 MG TABLET   4 Tier 4 $35.00N/ANone
CORLANOR 5 MG TABLET   4 Tier 4 $35.00N/AP
CORLANOR 5 MG/5 ML ORAL SOLUTION   4 Tier 4 $35.00N/AP
CORLANOR 7.5 MG TABLET   4 Tier 4 $35.00N/AP
CORTEF 10MG TABLET   4 Tier 4 $35.00N/ANone
CORTEF 20MG TABLET   4 Tier 4 $35.00N/ANone
CORTEF 5MG TABLET   4 Tier 4 $35.00N/ANone
Cortisone 25 MG TABLET   4 Tier 4 $35.00N/ANone
CORTISPORIN CRE 0.5%   4 Tier 4 $35.00N/ANone
CORTISPORIN OINTMENT   4 Tier 4 $35.00N/ANone
COSENTYX 300 MG DOSE-2 PENS   5 Tier 5 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COSENTYX 300 MG DOSE-2 SYRINGE   5 Tier 5 33%N/AP
COSOPT EYE DROPS   4 Tier 4 $35.00N/ANone
COTELLIC 20 MG TABLET   5 Tier 5 33%N/AP Q:63
/28Days
COZAAR 100 MG TABLET   4 Tier 4 $35.00N/ANone
COZAAR 25 MG TABLET   4 Tier 4 $35.00N/ANone
COZAAR 50 MG TABLET   4 Tier 4 $35.00N/ANone
Creon 256.11mg/1 1 BOTTLE per CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE   3 Tier 3 $0.00N/ANone
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOTTLE   3 Tier 3 $0.00N/ANone
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOTTLE   3 Tier 3 $0.00N/ANone
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOTTLE   3 Tier 3 $0.00N/ANone
CREON DR 36,000 UNITS CAPSULE   3 Tier 3 $0.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CRESTOR 10MG TABLET   4 Tier 4 $35.00N/AS
CRESTOR 20MG TABLET   4 Tier 4 $35.00N/AS
CRESTOR 40mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Tier 4 $35.00N/AS
CRESTOR 5MG TABLET   4 Tier 4 $35.00N/AS
CRINONE 4% GEL/PF APP   3 Tier 3 $0.00N/AP
CRINONE 8% GEL/PF APP   3 Tier 3 $0.00N/AP
CRIXIVAN 200MG CAPSULE   3 Tier 3 $0.00N/ANone
CRIXIVAN 400mg, 180 CAPSULE BOTTLE   3 Tier 3 $0.00N/ANone
CROMOLYN 100 MG/5 ML ORAL CONC [Gastrocrom]   2 Tier 2 $0.00$0.00None
CROMOLYN 20 MG/2 ML NEB SOLN AMPUL-NEB [Intal]   2 Tier 2 $0.00$0.00P
CROMOLYN SODIUM 4% 40MG 10ML BOTTLE   2 Tier 2 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CUBICIN 500MG VIAL   5 Tier 5 33%N/ANone
CUTIVATE 0.05% LOTION   4 Tier 4 $35.00N/AP
CUVPOSA 1 MG/5 ML SOLUTION   4 Tier 4 $35.00N/ANone
CYCLAFEM 1-35-28 TABLET [Pirmella]   2 Tier 2 $0.00$0.00None
CYCLAFEM 7-7-7-28 TABLET   2 Tier 2 $0.00$0.00None
CYCLOBENZAPRINE 10 MG TABLET [Flexeril]   1 Tier 1 $0.00$0.00None
CYCLOBENZAPRINE 5 MG TABLET   1 Tier 1 $0.00$0.00None
CYCLOBENZAPRINE 7.5 MG TABLET   2 Tier 2 $0.00$0.00None
CYCLOPHOSPHAMIDE 25 MG CAPSULE   3 Tier 3 $0.00N/AP
CYCLOPHOSPHAMIDE 50 MG CAPSULE   3 Tier 3 $0.00N/AP
CYCLOSET 0.8MG TABLETS   4 Tier 4 $35.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYCLOSPORINE 100MG CAPSULE   2 Tier 2 $0.00$0.00P
CYCLOSPORINE 25MG CAPSULE   2 Tier 2 $0.00$0.00P
CYCLOSPORINE MODIFIED 100 MG   2 Tier 2 $0.00$0.00P
CYCLOSPORINE MODIFIED 25 MG   2 Tier 2 $0.00$0.00P
CYCLOSPORINE MODIFIED 50 MG   2 Tier 2 $0.00$0.00P
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOTTLE   2 Tier 2 $0.00$0.00P
CYMBALTA 20MG CAPSULE   4 Tier 4 $35.00N/ANone
CYMBALTA 60 MG CAPSULE   4 Tier 4 $35.00N/ANone
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT)   4 Tier 4 $35.00N/ANone
CYRED 28 DAY TABLET [Solia]   2 Tier 2 $0.00$0.00None
CYSTAGON 150MG CAPSULE   3 Tier 3 $0.00N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYSTAGON 50MG CAPSULE   3 Tier 3 $0.00N/ANone
CYSTARAN 0.44% EYE DROPS   5 Tier 5 33%N/AP Q:60
/30Days
CYTOMEL 25MCG TABLET   4 Tier 4 $35.00N/ANone
CYTOMEL 50MCG TABLET   4 Tier 4 $35.00N/ANone
CYTOMEL 5MCG TABLET   4 Tier 4 $35.00N/ANone
CYTOTEC 100 MCG TABLET   4 Tier 4 $35.00N/ANone
CYTOTEC TABLET 200MCG (60 CT)   4 Tier 4 $35.00N/ANone

Chart Legend:

Below are a few notes to help you understand the above 2020 Medicare Part D SOLIS SPF 001 (HMO) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug or Medicare Advantage plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $435 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.

  • Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
    • Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
    • No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.

  • Plan ID: This is the Medicare Part D prescription drug plan's unique ID.

  • Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
    • Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs.
    • Tier Number* - Some Part D drug plans exclude one or more drug tiers from the plan’s deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
    • Tier Description - This is the Medicare Part D plan’s description of this particular drug tier.

  • Cost Sharing - Copay / Coinsurance - This is what you will pay for formulary drugs in the Initial Coverage Phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
    • Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $4020) at a "Preferred" network pharmacy. In most cases, the "Preferred" network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
    • Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).

  • Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
    • None - This drug does not fall under any drug utilization management controls.
    • P - Prior Authorization -This drug is subject to prior authorization.
    • S - Step Therapy -This drug is subject to step therapy.
    • Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.


(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2020 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Medicare plan provider.








Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.