2021 Medicare Part D Plan Formulary Information |
Harvard Pilgrim Stride Basic Rx (HMO) (H1660-015-0)
Benefit Details
This plan covers select insulin pay $35 copay.
See individual insulin cost-sharing below. |
The Harvard Pilgrim Stride Basic Rx (HMO) (H1660-015-0) Formulary Drugs Starting with the Letter P in York County, ME: CMS MA Region 1 which includes: ME Plan Monthly Premium: $0.00 Deductible: $445 |
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 |
PACERONE 200 MG TABLET |
2* |
Generic |
$15.00 | $30.00 | None |
PALIPERIDONE ER 1.5 MG TABLET ER 24 [Invega] |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:30 /30Days |
PALIPERIDONE ER 3 MG TABLET ER 24 [Invega] |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:30 /30Days |
PALIPERIDONE ER 6 MG TABLET ER 24 [Invega] |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:60 /30Days |
PALIPERIDONE ER 9 MG TABLET ER 24 [Invega] |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
PANTOPRAZOLE SOD DR 20 MG TAB |
2* |
Generic |
$15.00 | $30.00 | None |
PANTOPRAZOLE SOD DR 40 MG TABLET DR [Protonix] |
2* |
Generic |
$15.00 | $30.00 | None |
PANZYGA 10% (1 G/10 ML) VIAL |
5 |
Specialty Tier |
25% | N/A | P |
PANZYGA 10% (10 G/100 ML) VIAL |
5 |
Specialty Tier |
25% | N/A | P |
PANZYGA 10% (2.5 G/25 ML) VIAL |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PANZYGA 10% (20 G/200 ML) VIAL |
5 |
Specialty Tier |
25% | N/A | P |
PANZYGA 10% (30 G/300 ML) VIAL |
5 |
Specialty Tier |
25% | N/A | P |
PANZYGA 10% (5 G/50 ML) VIAL |
5 |
Specialty Tier |
25% | N/A | P |
PARICALCITOL 1 MCG CAPSULE [Zemplar] |
2* |
Generic |
$15.00 | $30.00 | None |
PARICALCITOL 2 MCG CAPSULE [Zemplar] |
2* |
Generic |
$15.00 | $30.00 | None |
PARICALCITOL 4 MCG CAPSULE [Zemplar] |
2* |
Generic |
$15.00 | $30.00 | None |
PAROMOMYCIN 250 MG CAPSULE |
2* |
Generic |
$15.00 | $30.00 | None |
PAROXETINE ER 12.5 MG TABLET ER 24H [Paxil CR] |
2* |
Generic |
$15.00 | $30.00 | Q:60 /30Days |
PAROXETINE ER 25 MG TABLET ER 24H [Paxil CR] |
2* |
Generic |
$15.00 | $30.00 | Q:90 /30Days |
PAROXETINE ER 37.5 MG TABLET ER 24H [Paxil CR] |
2* |
Generic |
$15.00 | $30.00 | Q:60 /30Days |
PAROXETINE HCL 10 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:45 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAROXETINE HCL 20 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:45 /30Days |
PAROXETINE HCL 30 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days |
PAROXETINE HCL 40 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:45 /30Days |
PAROXETINE MESYLATE 7.5 MG CAP |
2* |
Generic |
$15.00 | $30.00 | None |
PASER GRANULES 4GM PACKET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
PAXIL ORAL SUSPENSION 10 MG/5ML |
3 |
Preferred Brand |
$47.00 | $94.00 | S |
PEDVAXHIB VACCINE VIAL |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
PEG 3350-ELECTROLYTE SOLUTION RECON [TriLyte] |
2* |
Generic |
$15.00 | $30.00 | None |
PEG-3350 AND ELECTROLYTES SOLUTION SOLUTION RECON |
2* |
Generic |
$15.00 | $30.00 | None |
PEG3350 100-7.5-2.691-1.01-5.9 POWDER PACK [MoviPrep] |
2* |
Generic |
$15.00 | $30.00 | None |
Pegasys 180ug/0.5mL 1 PACKET in 1 BOX / 4 SYRINGE, GLASS in 1 PACKET / 0.5 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEGASYS INJECTION |
5 |
Specialty Tier |
25% | N/A | None |
PEMAZYRE 13.5 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
PEMAZYRE 4.5 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
PEMAZYRE 9 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
PENICILLAMINE 250 MG TABLET [Depen] |
5 |
Specialty Tier |
25% | N/A | None |
PENICILLIN G POTASSIUM 2MMUNITS/50ML ISO-OSM |
2* |
Generic |
$15.00 | $30.00 | None |
PENICILLIN G POTASSIUM 3MMUNITS/50ML ISO-OSM |
2* |
Generic |
$15.00 | $30.00 | None |
PENICILLIN G PROCAINE 1200000UNT 2ML CTG |
2* |
Generic |
$15.00 | $30.00 | None |
Penicillin G Sodium 5000000[iU]/1 10 VIAL per CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL |
5 |
Specialty Tier |
25% | N/A | None |
PENICILLIN GK 20 MILLION UNIT |
2* |
Generic |
$15.00 | $30.00 | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
2* |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENICILLIN VK 125 MG/5 ML SOLUTION |
2* |
Generic |
$15.00 | $30.00 | None |
PENICILLIN VK 250 MG TABLET |
2* |
Generic |
$15.00 | $30.00 | None |
PENICILLIN VK 500 MG TABLET [Veetids] |
2* |
Generic |
$15.00 | $30.00 | None |
PENTAMIDINE 300 MG INHAL POWDER VIAL-NEB [NebuPent] |
2* |
Generic |
$15.00 | $30.00 | P |
PENTAMIDINE 300 MG VIAL [Pentam] |
2* |
Generic |
$15.00 | $30.00 | None |
PENTASA 250MG CAPSULE SA |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
PENTASA 500MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
PENTOXIFYLLINE 400MG TABLET SA |
2* |
Generic |
$15.00 | $30.00 | None |
PERFOROMIST 20MCG/2ML VIAL NEBULIZER |
3 |
Preferred Brand |
$47.00 | $94.00 | P |
PERINDOPRIL ERBUMINE 2 MG TAB |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
PERINDOPRIL ERBUMINE 4 MG TAB |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PERINDOPRIL ERBUMINE 8 MG TAB |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
PERIOGARD 0.12% ORAL RINSE MOUTHWASH [Perisol] |
2* |
Generic |
$15.00 | $30.00 | None |
PERMETHRIN 5% CREAM (G) [Elimite] |
2* |
Generic |
$15.00 | $30.00 | None |
PERPHEN-AMITRIP 2 MG-10 MG TAB |
2* |
Generic |
$15.00 | $30.00 | None |
PERPHEN-AMITRIP 2 MG-25 MG TAB |
2* |
Generic |
$15.00 | $30.00 | None |
PERPHEN-AMITRIP 4 MG-25 MG TAB |
2* |
Generic |
$15.00 | $30.00 | None |
PERPHENAZINE 16 MG TABLET [Trilafon] |
2* |
Generic |
$15.00 | $30.00 | None |
PERPHENAZINE 2 MG TABLET [Trilafon] |
2* |
Generic |
$15.00 | $30.00 | None |
PERPHENAZINE 4 MG TABLET [Trilafon] |
2* |
Generic |
$15.00 | $30.00 | None |
PERPHENAZINE 8 MG TABLET [Trilafon] |
2* |
Generic |
$15.00 | $30.00 | None |
PERSERIS ER 120 MG SYRINGE KIT SUSER SYKT |
5 |
Specialty Tier |
25% | N/A | Q:1 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PERSERIS ER 90 MG SYRINGE KIT SUSER SYKT |
5 |
Specialty Tier |
25% | N/A | Q:1 /28Days |
PHENELZINE SULFATE 15 MG TABLET [Nardil] |
2* |
Generic |
$15.00 | $30.00 | None |
Phenobarbital 100mg/1 |
2* |
Generic |
$15.00 | $30.00 | P |
PHENOBARBITAL 15 MG TABLET |
2* |
Generic |
$15.00 | $30.00 | P |
PHENOBARBITAL 16.2 MG TABLET |
2* |
Generic |
$15.00 | $30.00 | P |
PHENOBARBITAL 20 MG/5 ML ELIX |
2* |
Generic |
$15.00 | $30.00 | P |
PHENOBARBITAL 30 MG TABLET |
2* |
Generic |
$15.00 | $30.00 | P |
PHENOBARBITAL 32.4 MG TABLET |
2* |
Generic |
$15.00 | $30.00 | P |
Phenobarbital 60mg/1 |
2* |
Generic |
$15.00 | $30.00 | P |
PHENOBARBITAL 64.8 MG TABLET |
2* |
Generic |
$15.00 | $30.00 | P |
PHENOBARBITAL 97.2 MG TABLET |
2* |
Generic |
$15.00 | $30.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PHENOXYBENZAMINE HCL 10 MG CAPSULE [Dibenzyline] |
5 |
Specialty Tier |
25% | N/A | None |
PHENYTOIN 125 MG/5 ML ORAL SUSPENSION [Dilantin] |
2* |
Generic |
$15.00 | $30.00 | None |
PHENYTOIN 50 MG CHEWABLE TABLET [Dilantin] |
2* |
Generic |
$15.00 | $30.00 | None |
PHENYTOIN SOD EXT 100 MG CAP |
2* |
Generic |
$15.00 | $30.00 | None |
PHENYTOIN SOD EXT 200 MG CAP |
2* |
Generic |
$15.00 | $30.00 | None |
PHENYTOIN SOD EXT 300 MG CAPSULE [Phenytek] |
2* |
Generic |
$15.00 | $30.00 | None |
PICATO 0.015% GEL |
5 |
Specialty Tier |
25% | N/A | None |
PICATO 0.05% GEL |
5 |
Specialty Tier |
25% | N/A | None |
PIFELTRO 100 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
PILOCARPINE 1% EYE DROPS [Pilocar] |
2* |
Generic |
$15.00 | $30.00 | None |
PILOCARPINE 2% EYE DROPS [Pilocar] |
2* |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PILOCARPINE 4% EYE DROPS [Pilocar] |
2* |
Generic |
$15.00 | $30.00 | None |
PILOCARPINE HCL 5 MG TABLET [Salagen] |
2* |
Generic |
$15.00 | $30.00 | None |
PILOCARPINE HCL 7.5 MG TABLET [Salagen] |
2* |
Generic |
$15.00 | $30.00 | None |
PIMECROLIMUS 1% CREAM (g) [Elidel] |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
PIMOZIDE 1 MG TABLET [Orap] |
2* |
Generic |
$15.00 | $30.00 | None |
PIMOZIDE 2 MG TABLET [Orap] |
2* |
Generic |
$15.00 | $30.00 | None |
PINDOLOL 10 MG TABLET |
2* |
Generic |
$15.00 | $30.00 | None |
PINDOLOL 5 MG TABLET [Visken] |
2* |
Generic |
$15.00 | $30.00 | None |
PIOGLITAZONE HCL 15 MG TABLET [Actos] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:90 /30Days |
PIOGLITAZONE HCL 30 MG TABLET [Actos] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:45 /30Days |
PIOGLITAZONE HCL 45 MG TABLET [Actos] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PIOGLITAZONE-GLIMEPIRIDE 30-2 TABLET [Duetact] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:45 /30Days |
PIOGLITAZONE-GLIMEPIRIDE 30-4 Tablet [Duetact] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:45 /30Days |
PIOGLITAZONE-METFORMIN 15-500 TABLET [Actoplus Met] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:90 /30Days |
PIOGLITAZONE-METFORMIN 15-850 TABLET [Actoplus Met] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:90 /30Days |
PIPERACIL-TAZOBACT 2.25 GM VIAL [Zosyn] |
2* |
Generic |
$15.00 | $30.00 | None |
PIPERACIL-TAZOBACT 3.375 GM VIAL [Zosyn] |
2* |
Generic |
$15.00 | $30.00 | None |
PIPERACIL-TAZOBACT 4.5 GM VIAL |
2* |
Generic |
$15.00 | $30.00 | None |
PIPERACIL-TAZOBACT 40.5 GRAM VIAL [Zosyn] |
2* |
Generic |
$15.00 | $30.00 | None |
PIQRAY 200 MG DAILY DOSE TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
PIQRAY 250 MG DAILY DOSE TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:56 /28Days |
PIQRAY 300 MG DAILY DOSE TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:56 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PIROXICAM 10 MG CAPSULE |
2* |
Generic |
$15.00 | $30.00 | None |
PIROXICAM 20 MG CAPSULE [Feldene] |
2* |
Generic |
$15.00 | $30.00 | None |
PLASMA-LYTE 148 IV SOLUTION |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
PLASMA-LYTE A PH 7.4 SOLUTION 37;368; MG/100ML; |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
PODOFILOX 0.5% TOPICAL SOLUTION [Condylox] |
2* |
Generic |
$15.00 | $30.00 | None |
POLYMYXIN B SULFATE VIAL |
2* |
Generic |
$15.00 | $30.00 | None |
POLYMYXIN B-TMP EYE DROPS |
2* |
Generic |
$15.00 | $30.00 | None |
POMALYST 1 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
POMALYST 2 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
POMALYST 3 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
POMALYST 4 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POSACONAZOLE DR 100 MG TABLET [Noxafil] |
5 |
Specialty Tier |
25% | N/A | None |
Potassium Chloride 2 MEQ/ML Injectable Solution |
2* |
Generic |
$15.00 | $30.00 | None |
Potassium Chloride 8 MEQ Extended Release Oral Tablet |
2* |
Generic |
$15.00 | $30.00 | None |
Potassium Chloride in Dextrose 5; 150g/100mL; mg/100mL 1000 mL in 1 BAG |
2* |
Generic |
$15.00 | $30.00 | None |
Potassium Chloride in Dextrose and Sodium Chloride 5; 300; 900g/100mL; mg/100mL; mg/100mL 1000 mL i |
2* |
Generic |
$15.00 | $30.00 | None |
POTASSIUM CITRATE ER 10 MEQ TB |
2* |
Generic |
$15.00 | $30.00 | None |
POTASSIUM CITRATE ER 15 MEQ TABLET |
2* |
Generic |
$15.00 | $30.00 | None |
POTASSIUM CITRATE ER 5 MEQ TAB |
2* |
Generic |
$15.00 | $30.00 | None |
POTASSIUM CL 10 MEQ/100 ML SOL PIGGYBACK |
2* |
Generic |
$15.00 | $30.00 | None |
POTASSIUM CL 10% (20 MEQ/15ML) LIQUID [Kay Ciel] |
2* |
Generic |
$15.00 | $30.00 | None |
POTASSIUM CL 20 MEQ PACKET [Klor-Con] |
2* |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CL 20 MEQ-0.45% NACL IV SOLUTION |
2* |
Generic |
$15.00 | $30.00 | None |
POTASSIUM CL 20 MEQ/100 ML SOL PIGGYBACK |
2* |
Generic |
$15.00 | $30.00 | None |
POTASSIUM CL 20% (40 MEQ/15ML) LIQUID [Kaon-CL] |
2* |
Generic |
$15.00 | $30.00 | None |
POTASSIUM CL 40 MEQ/100 ML SOL PIGGYBACK |
2* |
Generic |
$15.00 | $30.00 | None |
POTASSIUM CL 40 MEQ/20 ML CONC VIAL [PROAMP] |
2* |
Generic |
$15.00 | $30.00 | None |
POTASSIUM CL ER 10 MEQ CAPSULE ER [Micro-K Extencaps] |
2* |
Generic |
$15.00 | $30.00 | None |
POTASSIUM CL ER 10 MEQ TABLET |
2* |
Generic |
$15.00 | $30.00 | None |
POTASSIUM CL ER 10 MEQ TABLET [Klotrix] |
2* |
Generic |
$15.00 | $30.00 | None |
POTASSIUM CL ER 20 MEQ TABLET |
2* |
Generic |
$15.00 | $30.00 | None |
Potassium cl er 20 meq tablet |
2* |
Generic |
$15.00 | $30.00 | None |
POTASSIUM CL ER 8 MEQ CAPSULE ER [Micro-K Extencaps] |
2* |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRADAXA 110 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
PRADAXA 150 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
PRADAXA 75 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
PRAMIPEXOLE 0.125 MG TABLET [Mirapex] |
2* |
Generic |
$15.00 | $30.00 | None |
PRAMIPEXOLE 0.25 MG TABLET [Mirapex] |
2* |
Generic |
$15.00 | $30.00 | None |
PRAMIPEXOLE 0.5 MG TABLET |
2* |
Generic |
$15.00 | $30.00 | None |
PRAMIPEXOLE 0.75 MG TABLET |
2* |
Generic |
$15.00 | $30.00 | None |
PRAMIPEXOLE 1 MG TABLET [Mirapex] |
2* |
Generic |
$15.00 | $30.00 | None |
PRAMIPEXOLE 1.5 MG TABLET [Mirapex] |
2* |
Generic |
$15.00 | $30.00 | None |
PRAMIPEXOLE ER 0.375 MG TABLET ER 24H [Mirapex ER] |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
PRAMIPEXOLE ER 0.75 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAMIPEXOLE ER 1.5 MG TABLET ER 24H [Mirapex ER] |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
PRAMIPEXOLE ER 2.25 MG TABLET ER 24H [Mirapex ER] |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
PRAMIPEXOLE ER 3 MG TABLET ER 24H [Mirapex ER] |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
PRAMIPEXOLE ER 3.75 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
PRAMIPEXOLE ER 4.5 MG TABLET ER 24H [Mirapex ER] |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
PRASUGREL 10 MG TABLET [Effient] |
2* |
Generic |
$15.00 | $30.00 | None |
PRASUGREL 5 MG TABLET [Effient] |
2* |
Generic |
$15.00 | $30.00 | None |
PRAVASTATIN SODIUM 10 MG TABLET [Pravachol] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
PRAVASTATIN SODIUM 20 MG TAB |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
PRAVASTATIN SODIUM 40 MG TABLET [Pravachol] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
PRAVASTATIN SODIUM 80 MG TABLET [Pravachol] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAZIQUANTEL 600 MG TABLET [Biltricide] |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
PRAZOSIN 1 MG CAPSULE |
2* |
Generic |
$15.00 | $30.00 | None |
PRAZOSIN 2 MG CAPSULE [Minipress] |
2* |
Generic |
$15.00 | $30.00 | None |
PRAZOSIN 5 MG CAPSULE [Minipress] |
2* |
Generic |
$15.00 | $30.00 | None |
PRED G OPHTHALMIC SUSPENSION 1;0.3%;% 5 ML BOTDR |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
PRED MILD 0.12% EYE DROPS |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
PRED-G S.O.P. EYE OINTMENT |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
PREDNICARBATE 0.1% OINTMENT [Dermatop] |
2* |
Generic |
$15.00 | $30.00 | None |
PREDNISOLONE 10 MG/5 ML SOLUTION |
2* |
Generic |
$15.00 | $30.00 | None |
PREDNISOLONE 15 MG/5 ML SOLUTION |
2* |
Generic |
$15.00 | $30.00 | None |
PREDNISOLONE 20 MG/5 ML SOLUTION [Veripred-20] |
2* |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISOLONE AC 1% EYE DROP |
2* |
Generic |
$15.00 | $30.00 | None |
PREDNISOLONE SOD 1% EYE DROP |
2* |
Generic |
$15.00 | $30.00 | None |
PREDNISOLONE SOD PH 25 MG/5 ML |
2* |
Generic |
$15.00 | $30.00 | None |
PREDNISOLONE SODIUM PHOSPHATE 5MG /5ML ORAL SOLUTION |
2* |
Generic |
$15.00 | $30.00 | None |
PREDNISONE 1 MG TABLET |
2* |
Generic |
$15.00 | $30.00 | None |
PREDNISONE 10 MG TABLET [Sterapred DS] |
2* |
Generic |
$15.00 | $30.00 | None |
PREDNISONE 10 MG TABLET DOSE PACK |
2* |
Generic |
$15.00 | $30.00 | None |
PREDNISONE 10 MG TABLET DOSE PACK |
2* |
Generic |
$15.00 | $30.00 | None |
PREDNISONE 2.5 MG TABLET |
2* |
Generic |
$15.00 | $30.00 | None |
PREDNISONE 20 MG TABLET [Predone] |
2* |
Generic |
$15.00 | $30.00 | None |
PREDNISONE 5 MG TABLET |
2* |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISONE 5 MG TABLET |
2* |
Generic |
$15.00 | $30.00 | None |
PREDNISONE 5 MG TABLET [Sterapred] |
2* |
Generic |
$15.00 | $30.00 | None |
PREDNISONE 5 MG/5 ML SOLUTION |
2* |
Generic |
$15.00 | $30.00 | None |
PREDNISONE 50MG TABLET |
2* |
Generic |
$15.00 | $30.00 | None |
PREDNISONE 5MG/ML SOLUTION |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
PREGABALIN 100 MG CAPSULE [Lyrica] |
2* |
Generic |
$15.00 | $30.00 | Q:90 /30Days |
PREGABALIN 150 MG CAPSULE [Lyrica] |
2* |
Generic |
$15.00 | $30.00 | Q:90 /30Days |
PREGABALIN 20 MG/ML SOLUTION [Lyrica] |
2* |
Generic |
$15.00 | $30.00 | Q:900 /30Days |
PREGABALIN 200 MG CAPSULE [Lyrica] |
2* |
Generic |
$15.00 | $30.00 | Q:90 /30Days |
PREGABALIN 225 MG CAPSULE [Lyrica] |
2* |
Generic |
$15.00 | $30.00 | Q:60 /30Days |
PREGABALIN 25 MG CAPSULE [Lyrica] |
2* |
Generic |
$15.00 | $30.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREGABALIN 300 MG CAPSULE [Lyrica] |
2* |
Generic |
$15.00 | $30.00 | Q:60 /30Days |
PREGABALIN 50 MG CAPSULE [Lyrica] |
2* |
Generic |
$15.00 | $30.00 | Q:90 /30Days |
PREGABALIN 75 MG CAPSULE [Lyrica] |
2* |
Generic |
$15.00 | $30.00 | Q:90 /30Days |
PREMARIN 0.3 MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
PREMARIN 0.45MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
PREMARIN 0.625 MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Premarin 0.625mg/g |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
PREMARIN 0.9MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
PREMARIN 1.25 MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
PREMASOL 10% IV SOLUTION |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P |
PREMPHASE 0.625-5 MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
PREMPRO 0.45-1.5 MG TABLET 28 EA |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
PREMPRO 0.625-5 MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Prempro 0.625; 2.5mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, SUGAR COATED per BLISTER PACK |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
PREVALITE PACKET |
2* |
Generic |
$15.00 | $30.00 | None |
PREVIFEM TABLET [VyLibra] |
2* |
Generic |
$15.00 | $30.00 | None |
PREZCOBIX 800 MG-150 MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
PREZISTA 100 MG/ML SUSPENSION |
5 |
Specialty Tier |
25% | N/A | Q:360 /30Days |
PREZISTA 150MG TABLETS |
5 |
Specialty Tier |
25% | N/A | Q:240 /30Days |
PREZISTA 800 MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
PREZISTA TABLET 600MG |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREZISTA TABLET 75MG |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:480 /30Days |
PRIFTIN 150 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
PRIMAQUINE 26.3 MG TABLET [Primaquine] |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
PRIMIDONE 250 MG TABLET [Mysoline] |
2* |
Generic |
$15.00 | $30.00 | None |
PRIMIDONE 50 MG TABLET [Mysoline] |
2* |
Generic |
$15.00 | $30.00 | None |
PRIVIGEN 10% VIAL |
5 |
Specialty Tier |
25% | N/A | P |
PROAIR HFA 90 MCG INHALER |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
PROAIR RESPICLICK INHAL POWDER |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
PROBENECID 500 MG TABLET |
2* |
Generic |
$15.00 | $30.00 | None |
PROBENECID-COLCHICINE TABLET |
2* |
Generic |
$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 |
Non-Preferred Brand |
$100.00 | $250.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCHLORPERAZINE 10 MG TAB |
2* |
Generic |
$15.00 | $30.00 | None |
PROCHLORPERAZINE 5 MG TABLET |
2* |
Generic |
$15.00 | $30.00 | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX |
2* |
Generic |
$15.00 | $30.00 | None |
PROCRIT 10000U/ML VIAL |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P Q:12 /28Days |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P Q:12 /28Days |
PROCRIT 3,000 UNITS/ML VIAL |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P Q:12 /28Days |
PROCRIT 4,000 UNITS/ML VIAL |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P Q:12 /28Days |
PROCRIT 40000U/ML VIAL PR |
5 |
Specialty Tier |
25% | N/A | P Q:6 /28Days |
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY |
5 |
Specialty Tier |
25% | N/A | P Q:12 /28Days |
PROCTO-MED HC 2.5% CREAM CRM/PE APP [Proctozone-HC] |
2* |
Generic |
$15.00 | $30.00 | None |
procto-pak 1% cream |
2* |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCTOSOL-HC 2.5% CREAM |
2* |
Generic |
$15.00 | $30.00 | None |
PROCTOZONE-HC 2.5% CREAM |
2* |
Generic |
$15.00 | $30.00 | None |
PROGESTERONE 100 MG CAPSULE |
2* |
Generic |
$15.00 | $30.00 | None |
PROGESTERONE 200 MG CAPSULE [Prometrium] |
2* |
Generic |
$15.00 | $30.00 | None |
PROLASTIN C 1,000 MG VIAL |
5 |
Specialty Tier |
25% | N/A | None |
PROLENSA 0.07% EYE DROPS |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
PROLIA 60MG/ML INJECTION |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P |
PROMACTA 12.5 MG SUSPEN PACKET POWDER PACK |
5 |
Specialty Tier |
25% | N/A | P |
PROMACTA 12.5 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
PROMACTA 25 MG SUSPENSION POWDER PACK |
5 |
Specialty Tier |
25% | N/A | P |
PROMACTA 25 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMACTA 50 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
PROMACTA 75 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
PROMETHAZINE 12.5 MG TABLET |
2* |
Generic |
$15.00 | $30.00 | P |
PROMETHAZINE 25 MG TABLET |
2* |
Generic |
$15.00 | $30.00 | P |
PROMETHAZINE 50 MG TABLET |
2* |
Generic |
$15.00 | $30.00 | P |
PROMETHAZINE 6.25 MG/5 ML SYRUP [Prometh Plain] |
2* |
Generic |
$15.00 | $30.00 | P |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX |
2* |
Generic |
$15.00 | $30.00 | P |
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX |
2* |
Generic |
$15.00 | $30.00 | P |
PROMETHEGAN 25MG SUPP |
2* |
Generic |
$15.00 | $30.00 | P |
PROMETHEGAN 50MG SUPPOS |
2* |
Generic |
$15.00 | $30.00 | P |
PROPAFENONE HCL 150 MG TABLET [Rythmol] |
2* |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPAFENONE HCL 225MG TABLET |
2* |
Generic |
$15.00 | $30.00 | None |
PROPAFENONE HCL 300 MG TABLET [Rythmol] |
2* |
Generic |
$15.00 | $30.00 | None |
PROPAFENONE HCL ER 225 MG CAP |
2* |
Generic |
$15.00 | $30.00 | None |
PROPAFENONE HYDROCHLORIDE 325MG CAPSULES EXTENDED RELEASE |
2* |
Generic |
$15.00 | $30.00 | None |
PROPAFENONE HYDROCHLORIDE 425MG CAPSULES EXTENDED RELEASE |
2* |
Generic |
$15.00 | $30.00 | None |
PROPARACAINE 0.5% EYE DROPS [Parcaine] |
2* |
Generic |
$15.00 | $30.00 | None |
PROPRANOLOL 10 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
PROPRANOLOL 20 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
PROPRANOLOL 20MG/5ML TUBEX |
2* |
Generic |
$15.00 | $30.00 | None |
PROPRANOLOL 40 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
PROPRANOLOL 40MG/5ML TUBEX |
2* |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPRANOLOL 60 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
PROPRANOLOL 80 MG TABLET [Inderal] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
PROPRANOLOL ER 120 MG CAPSULE |
2* |
Generic |
$15.00 | $30.00 | None |
PROPRANOLOL ER 160 MG CAPSULE |
2* |
Generic |
$15.00 | $30.00 | None |
PROPRANOLOL ER 60 MG CAPSULE |
2* |
Generic |
$15.00 | $30.00 | None |
PROPRANOLOL ER 80 MG CAPSULE |
2* |
Generic |
$15.00 | $30.00 | None |
PROPYLTHIOURACIL 50 MG TABLET |
2* |
Generic |
$15.00 | $30.00 | None |
PROQUAD VIAL |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
PROSOL 20% INJECTION |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P |
PROTRIPTYLINE HCL 10 MG TABLET [Vivactil] |
2* |
Generic |
$15.00 | $30.00 | None |
PROTRIPTYLINE HCL 5 MG TABLET [Vivactil] |
2* |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PULMICORT FLEXHALER 180MCG AEROSOL POWDER BREATH ACTIVATED |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
PULMICORT FLEXHALER 90MCG AEROSOL POWDER BREATH ACTIVATED |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
PULMOZYME 1MG/ML AMPUL |
5 |
Specialty Tier |
25% | N/A | P |
PURIXAN 20 MG/ML ORAL SUSPENSION |
5 |
Specialty Tier |
25% | N/A | None |
PYRAZINAMIDE 500 MG TABLET |
2* |
Generic |
$15.00 | $30.00 | None |
PYRIDOSTIGMINE 60 MG/5 ML SOLUTION SYRUP [Mestinon] |
5 |
Specialty Tier |
25% | N/A | None |
PYRIDOSTIGMINE BR 30 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
PYRIDOSTIGMINE BR 60 MG TABLET |
2* |
Generic |
$15.00 | $30.00 | None |
PYRIDOSTIGMINE BR ER 180 MG TAB |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
PYRIMETHAMINE 25 MG TABLET [Daraprim] |
5 |
Specialty Tier |
25% | N/A | P |