2022 Medicare Part D Plan Formulary Information |
Clear Spring Health Premier Rx (PDP) (S6946-037-0)
Benefit Details
|
The Clear Spring Health Premier Rx (PDP) (S6946-037-0) Formulary Drugs Starting with the Letter P in CMS PDP Region 11 which includes: FL
|
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 100MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
PACERONE 200 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
PACERONE 400 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
PALIPERIDONE ER 1.5 MG TABLET ER 24 [Invega] |
4 |
Non-Preferred Drug |
45% | 45% | Q:30 /30Days |
PALIPERIDONE ER 3 MG TABLET ER 24 [Invega] |
4 |
Non-Preferred Drug |
45% | 45% | Q:30 /30Days |
PALIPERIDONE ER 6 MG TABLET ER 24 [Invega] |
4 |
Non-Preferred Drug |
45% | 45% | Q:60 /30Days |
PALIPERIDONE ER 9 MG TABLET ER 24 [Invega] |
4 |
Non-Preferred Drug |
45% | 45% | Q:30 /30Days |
PANRETIN 0.1% GEL |
5 |
Specialty Tier |
25% | 25% | P |
PANTOPRAZOLE SOD DR 20 MG TAB |
1* |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
PANTOPRAZOLE SOD DR 40 MG TABLET DR [Protonix] |
1* |
Preferred Generic |
$1.00 | $3.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PARICALCITOL 1 MCG CAPSULE [Zemplar] |
4 |
Non-Preferred Drug |
45% | 45% | P |
PARICALCITOL 2 MCG CAPSULE [Zemplar] |
4 |
Non-Preferred Drug |
45% | 45% | P |
PARICALCITOL 4 MCG CAPSULE [Zemplar] |
4 |
Non-Preferred Drug |
45% | 45% | P |
PAROMOMYCIN 250 MG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | None |
PAROXETINE HCL 10 MG TABLET |
2* |
Generic |
$5.00 | $15.00 | Q:30 /30Days |
PAROXETINE HCL 10 MG/5 ML ORAL SUSPENSION [Paxil] |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:900 /30Days |
PAROXETINE HCL 20 MG TABLET |
2* |
Generic |
$5.00 | $15.00 | Q:30 /30Days |
PAROXETINE HCL 30 MG TABLET |
2* |
Generic |
$5.00 | $15.00 | Q:60 /30Days |
PAROXETINE HCL 40 MG TABLET |
2* |
Generic |
$5.00 | $15.00 | Q:30 /30Days |
PASER GRANULES 4GM PACKET |
4 |
Non-Preferred Drug |
45% | 45% | None |
PEDVAXHIB VACCINE VIAL |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEG 3350-ELECTROLYTE SOLUTION RECON [TriLyte] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PEG-3350 AND ELECTROLYTES SOLUTION SOLUTION RECON |
3 |
Preferred Brand |
$42.00 | $126.00 | 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% | 25% | P Q:2 /28Days |
PEGASYS INJECTION |
5 |
Specialty Tier |
25% | 25% | P Q:4 /28Days |
PEMAZYRE 13.5 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:14 /21Days |
PEMAZYRE 4.5 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:14 /21Days |
PEMAZYRE 9 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:14 /21Days |
PENICILLAMINE 250 MG TABLET [Depen] |
4 |
Non-Preferred Drug |
45% | 45% | P |
PENICILLIN G POTASSIUM 2MMUNITS/50ML ISO-OSM |
4 |
Non-Preferred Drug |
45% | 45% | P |
PENICILLIN G POTASSIUM 3MMUNITS/50ML ISO-OSM |
4 |
Non-Preferred Drug |
45% | 45% | P |
PENICILLIN G PROCAINE 1200000UNT 2ML CTG |
4 |
Non-Preferred Drug |
45% | 45% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Penicillin G Sodium 5000000[iU]/1 10 VIAL per CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL |
4 |
Non-Preferred Drug |
45% | 45% | P |
PENICILLIN GK 20 MILLION UNIT |
4 |
Non-Preferred Drug |
45% | 45% | P |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID |
2* |
Generic |
$5.00 | $15.00 | None |
PENICILLIN VK 125 MG/5 ML SOLUTION |
2* |
Generic |
$5.00 | $15.00 | None |
PENICILLIN VK 250 MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PENICILLIN VK 500 MG TABLET [Veetids] |
2* |
Generic |
$5.00 | $15.00 | None |
PENTACEL VIAL KIT |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PENTAMIDINE 300 MG INHAL POWDER VIAL-NEB [NebuPent] |
4 |
Non-Preferred Drug |
45% | 45% | P Q:1 /28Days |
PENTAMIDINE 300 MG VIAL [Pentam] |
4 |
Non-Preferred Drug |
45% | 45% | None |
PENTASA 250MG CAPSULE SA |
4 |
Non-Preferred Drug |
45% | 45% | None |
PENTASA 500MG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENTOXIFYLLINE 400MG TABLET SA |
4 |
Non-Preferred Drug |
45% | 45% | None |
PERINDOPRIL ERBUMINE 2 MG TAB |
2* |
Generic |
$5.00 | $15.00 | None |
PERINDOPRIL ERBUMINE 4 MG TAB |
2* |
Generic |
$5.00 | $15.00 | None |
PERINDOPRIL ERBUMINE 8 MG TAB |
2* |
Generic |
$5.00 | $15.00 | None |
PERMETHRIN 5% CREAM (G) [Elimite] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PERPHEN-AMITRIP 2 MG-10 MG TAB |
4 |
Non-Preferred Drug |
45% | 45% | None |
PERPHEN-AMITRIP 2 MG-25 MG TAB |
4 |
Non-Preferred Drug |
45% | 45% | None |
PERPHEN-AMITRIP 4 MG-25 MG TAB |
4 |
Non-Preferred Drug |
45% | 45% | None |
PERPHENAZINE 16 MG TABLET [Trilafon] |
4 |
Non-Preferred Drug |
45% | 45% | None |
PERPHENAZINE 2 MG TABLET [Trilafon] |
4 |
Non-Preferred Drug |
45% | 45% | None |
PERPHENAZINE 4 MG TABLET [Trilafon] |
4 |
Non-Preferred Drug |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PERPHENAZINE 8 MG TABLET [Trilafon] |
4 |
Non-Preferred Drug |
45% | 45% | None |
PERSERIS ER 120 MG SYRINGE KIT SUSER SYKT |
4 |
Non-Preferred Drug |
45% | 45% | Q:1 /30Days |
PERSERIS ER 90 MG SYRINGE KIT SUSER SYKT |
4 |
Non-Preferred Drug |
45% | 45% | Q:1 /30Days |
PHENELZINE SULFATE 15 MG TABLET [Nardil] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Phenobarbital 100mg/1 |
3 |
Preferred Brand |
$42.00 | $126.00 | P |
PHENOBARBITAL 15 MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | P |
PHENOBARBITAL 16.2 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | P |
PHENOBARBITAL 20 MG/5 ML ELIX ELIXIR |
4 |
Non-Preferred Drug |
45% | 45% | P |
PHENOBARBITAL 30 MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | P |
PHENOBARBITAL 32.4 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | P |
Phenobarbital 60mg/1 |
3 |
Preferred Brand |
$42.00 | $126.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PHENOBARBITAL 64.8 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | P |
PHENOBARBITAL 97.2 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | P |
PHENYTOIN 125 MG/5 ML ORAL SUSPENSION [Dilantin] |
4 |
Non-Preferred Drug |
45% | 45% | None |
PHENYTOIN 50 MG CHEWABLE TABLET [Dilantin] |
4 |
Non-Preferred Drug |
45% | 45% | None |
PHENYTOIN SOD EXT 100 MG CAP |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PHENYTOIN SOD EXT 200 MG CAP |
4 |
Non-Preferred Drug |
45% | 45% | None |
PHENYTOIN SOD EXT 300 MG CAPSULE [Phenytek] |
4 |
Non-Preferred Drug |
45% | 45% | None |
PIFELTRO 100 MG TABLET |
5 |
Specialty Tier |
25% | 25% | Q:30 /30Days |
PILOCARPINE 1% EYE DROPS [Pilocar] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PILOCARPINE 2% EYE DROPS [Pilocar] |
4 |
Non-Preferred Drug |
45% | 45% | None |
PILOCARPINE 4% EYE DROPS [Pilocar] |
4 |
Non-Preferred Drug |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PILOCARPINE HCL 5 MG TABLET [Salagen] |
4 |
Non-Preferred Drug |
45% | 45% | None |
PILOCARPINE HCL 7.5 MG TABLET [Salagen] |
4 |
Non-Preferred Drug |
45% | 45% | None |
PIMECROLIMUS 1% CREAM (g) [Elidel] |
4 |
Non-Preferred Drug |
45% | 45% | P S Q:100 /30Days |
PIMOZIDE 1 MG TABLET [Orap] |
4 |
Non-Preferred Drug |
45% | 45% | None |
PIMOZIDE 2 MG TABLET [Orap] |
4 |
Non-Preferred Drug |
45% | 45% | None |
PIMTREA 28 DAY TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
PINDOLOL 10 MG TABLET [Visken] |
4 |
Non-Preferred Drug |
45% | 45% | None |
PINDOLOL 5 MG TABLET [Visken] |
4 |
Non-Preferred Drug |
45% | 45% | None |
PIOGLITAZONE HCL 15 MG TABLET [Actos] |
1* |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
PIOGLITAZONE HCL 30 MG TABLET [Actos] |
1* |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
PIOGLITAZONE HCL 45 MG TABLET [Actos] |
1* |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PIPERACIL-TAZOBACT 2.25 GM VIAL [Zosyn] |
4 |
Non-Preferred Drug |
45% | 45% | None |
PIPERACIL-TAZOBACT 3.375 GM VIAL [Zosyn] |
4 |
Non-Preferred Drug |
45% | 45% | None |
PIPERACIL-TAZOBACT 4.5 GM VIAL [Zosyn] |
4 |
Non-Preferred Drug |
45% | 45% | None |
PIPERACIL-TAZOBACT 40.5 GRAM VIAL [Zosyn] |
4 |
Non-Preferred Drug |
45% | 45% | None |
PIQRAY 200 MG DAILY DOSE TABLET |
5 |
Specialty Tier |
25% | 25% | P |
PIQRAY 250 MG DAILY DOSE TABLET |
5 |
Specialty Tier |
25% | 25% | P |
PIQRAY 300 MG DAILY DOSE TABLET |
5 |
Specialty Tier |
25% | 25% | P |
PIRFENIDONE 267 MG TABLET [ESBRIET] |
5 |
Specialty Tier |
25% | 25% | P Q:270 /30Days |
PIRFENIDONE 801 MG TABLET [ESBRIET] |
5 |
Specialty Tier |
25% | 25% | P Q:90 /30Days |
PIRMELLA 1-35 28 TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
PIROXICAM 10 MG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PIROXICAM 20 MG CAPSULE [Feldene] |
4 |
Non-Preferred Drug |
45% | 45% | None |
PLASMA-LYTE 148 IV SOLUTION |
4 |
Non-Preferred Drug |
45% | 45% | None |
PLASMA-LYTE A PH 7.4 SOLUTION 37;368; MG/100ML; |
4 |
Non-Preferred Drug |
45% | 45% | None |
PODOFILOX 0.5% TOPICAL SOLUTION [Condylox] |
4 |
Non-Preferred Drug |
45% | 45% | None |
POLYMYXIN B-TMP EYE DROPS |
2* |
Generic |
$5.00 | $15.00 | None |
POMALYST 1 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P Q:21 /28Days |
POMALYST 2 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P Q:21 /28Days |
POMALYST 3 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P Q:21 /28Days |
POMALYST 4 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P Q:21 /28Days |
PORTIA 0.15-0.03 TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
POSACONAZOLE DR 100 MG TABLET [Noxafil] |
4 |
Non-Preferred Drug |
45% | 45% | P Q:96 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Potassium Chloride in Dextrose 5; 150g/100mL; mg/100mL 1000 mL in 1 BAG |
4 |
Non-Preferred Drug |
45% | 45% | None |
Potassium Chloride in Dextrose and Sodium Chloride 5; 300; 900g/100mL; mg/100mL; mg/100mL 1000 mL i |
4 |
Non-Preferred Drug |
45% | 45% | None |
POTASSIUM CITRATE ER 10 MEQ TB |
4 |
Non-Preferred Drug |
45% | 45% | None |
POTASSIUM CITRATE ER 15 MEQ TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
POTASSIUM CITRATE ER 5 MEQ TAB |
4 |
Non-Preferred Drug |
45% | 45% | None |
POTASSIUM CL 10% (20 MEQ/15ML) LIQUID [Kay Ciel] |
4 |
Non-Preferred Drug |
45% | 45% | None |
POTASSIUM CL 20 MEQ-0.45% NACL IV SOLUTION |
4 |
Non-Preferred Drug |
45% | 45% | None |
POTASSIUM CL 20 MEQ/100 ML SOL PIGGYBACK |
4 |
Non-Preferred Drug |
45% | 45% | None |
POTASSIUM CL 20% (40 MEQ/15ML) LIQUID [Kaon-CL] |
4 |
Non-Preferred Drug |
45% | 45% | None |
POTASSIUM CL 40 MEQ/20 ML CONC VIAL [PROAMP] |
4 |
Non-Preferred Drug |
45% | 45% | None |
POTASSIUM CL ER 10 MEQ CAPSULE ER [Micro-K Extencaps] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CL ER 10 MEQ TABLET [Klotrix] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
POTASSIUM CL ER 10 MEQ TABLET ER PRT [Klotrix] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Potassium cl er 20 meq tablet |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
POTASSIUM CL ER 20 MEQ TABLET ER PRT [Klor-Con M20] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
POTASSIUM CL ER 8 MEQ CAPSULE ER [Micro-K Extencaps] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
POTASSIUM CL ER 8 MEQ TABLET [Slow-K] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PRADAXA 75 MG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | P |
PRAMIPEXOLE 0.125 MG TABLET [Mirapex] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PRAMIPEXOLE 0.25 MG TABLET [Mirapex] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PRAMIPEXOLE 0.5 MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PRAMIPEXOLE 0.75 MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRAMIPEXOLE 1 MG TABLET [Mirapex] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PRAMIPEXOLE 1.5 MG TABLET [Mirapex] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PRAMIPEXOLE ER 3.75 MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PRAVASTATIN SODIUM 10 MG TABLET [Pravachol] |
1* |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
PRAVASTATIN SODIUM 20 MG TAB |
1* |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
PRAVASTATIN SODIUM 40 MG TABLET [Pravachol] |
1* |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
PRAVASTATIN SODIUM 80 MG TABLET [Pravachol] |
1* |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
PRAZOSIN 1 MG CAPSULE [Minipress] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PRAZOSIN 2 MG CAPSULE [Minipress] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PRAZOSIN 5 MG CAPSULE [Minipress] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PREDNICARBATE 0.1% OINTMENT [Dermatop] |
4 |
Non-Preferred Drug |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISOLONE 15 MG/5 ML SOLUTION |
4 |
Non-Preferred Drug |
45% | 45% | None |
PREDNISOLONE 5 MG/5 ML SOLUTION [Pediapred] |
4 |
Non-Preferred Drug |
45% | 45% | None |
PREDNISOLONE AC 1% EYE DROP |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PREDNISOLONE SOD 1% EYE DROP |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PREDNISOLONE SOD PH 25 MG/5 ML SOLUTION |
4 |
Non-Preferred Drug |
45% | 45% | None |
PREDNISONE 1 MG TABLET |
1* |
Preferred Generic |
$1.00 | $3.00 | None |
PREDNISONE 10 MG TABLET [Sterapred DS] |
1* |
Preferred Generic |
$1.00 | $3.00 | None |
PREDNISONE 10 MG TABLET DOSE PACK |
2* |
Generic |
$5.00 | $15.00 | None |
PREDNISONE 10 MG TABLET DOSE PACK |
2* |
Generic |
$5.00 | $15.00 | None |
PREDNISONE 2.5 MG TABLET |
1* |
Preferred Generic |
$1.00 | $3.00 | None |
PREDNISONE 20 MG TABLET [Predone] |
1* |
Preferred Generic |
$1.00 | $3.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISONE 5 MG TABLET |
2* |
Generic |
$5.00 | $15.00 | None |
PREDNISONE 5 MG TABLET |
2* |
Generic |
$5.00 | $15.00 | None |
PREDNISONE 5 MG TABLET [Sterapred] |
1* |
Preferred Generic |
$1.00 | $3.00 | None |
PREDNISONE 5 MG/5 ML SOLUTION |
4 |
Non-Preferred Drug |
45% | 45% | None |
PREDNISONE 50MG TABLET |
1* |
Preferred Generic |
$1.00 | $3.00 | None |
PREDNISONE 5MG/ML SOLUTION |
4 |
Non-Preferred Drug |
45% | 45% | None |
PREGABALIN 100 MG CAPSULE [Lyrica] |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:90 /30Days |
PREGABALIN 150 MG CAPSULE [Lyrica] |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:90 /30Days |
PREGABALIN 20 MG/ML SOLUTION [Lyrica] |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:900 /30Days |
PREGABALIN 200 MG CAPSULE [Lyrica] |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:90 /30Days |
PREGABALIN 225 MG CAPSULE [Lyrica] |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREGABALIN 25 MG CAPSULE [Lyrica] |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:90 /30Days |
PREGABALIN 300 MG CAPSULE [Lyrica] |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:60 /30Days |
PREGABALIN 50 MG CAPSULE [Lyrica] |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:90 /30Days |
PREGABALIN 75 MG CAPSULE [Lyrica] |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:90 /30Days |
PREHEVBRIO 10 MCG/ML VIAL |
3 |
Preferred Brand |
$42.00 | $126.00 | P |
Premarin 0.625mg/g |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PREMASOL 10% IV SOLUTION |
4 |
Non-Preferred Drug |
45% | 45% | P |
PREVALITE PACKET |
4 |
Non-Preferred Drug |
45% | 45% | None |
PREVYMIS 240 MG |
5 |
Specialty Tier |
25% | 25% | Q:30 /30Days |
PREVYMIS 480 MG |
5 |
Specialty Tier |
25% | 25% | Q:30 /30Days |
PREZCOBIX 800 MG-150 MG TABLET |
5 |
Specialty Tier |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREZISTA 100 MG/ML SUSPENSION |
5 |
Specialty Tier |
25% | 25% | Q:360 /30Days |
PREZISTA 150MG TABLETS |
4 |
Non-Preferred Drug |
45% | 45% | Q:240 /30Days |
PREZISTA 800 MG TABLET |
5 |
Specialty Tier |
25% | 25% | Q:30 /30Days |
PREZISTA TABLET 600MG |
5 |
Specialty Tier |
25% | 25% | Q:60 /30Days |
PREZISTA TABLET 75MG |
4 |
Non-Preferred Drug |
45% | 45% | Q:420 /30Days |
PRIFTIN 150 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
PRIMAQUINE 26.3 MG TABLET [Primaquine] |
4 |
Non-Preferred Drug |
45% | 45% | None |
PRIMIDONE 250 MG TABLET [Mysoline] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PRIMIDONE 50 MG TABLET [Mysoline] |
2* |
Generic |
$5.00 | $15.00 | None |
PRIVIGEN 10% VIAL |
5 |
Specialty Tier |
25% | 25% | P |
PROBENECID 500 MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROBENECID-COLCHICINE TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | 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 Drug |
45% | 45% | P |
PROCHLORPERAZINE 10 MG TAB |
2* |
Generic |
$5.00 | $15.00 | None |
PROCHLORPERAZINE 5 MG TABLET |
2* |
Generic |
$5.00 | $15.00 | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX |
4 |
Non-Preferred Drug |
45% | 45% | None |
PROCRIT 10000U/ML VIAL |
4 |
Non-Preferred Drug |
45% | 45% | P Q:12 /28Days |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL |
4 |
Non-Preferred Drug |
45% | 45% | P Q:23 /30Days |
PROCRIT 3,000 UNITS/ML VIAL |
4 |
Non-Preferred Drug |
45% | 45% | P Q:16 /30Days |
PROCRIT 4,000 UNITS/ML VIAL |
4 |
Non-Preferred Drug |
45% | 45% | P Q:12 /28Days |
PROCRIT 40000U/ML VIAL PR |
5 |
Specialty Tier |
25% | 25% | P Q:12 /30Days |
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY |
5 |
Specialty Tier |
25% | 25% | P Q:12 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCTO-MED HC 2.5% CREAM CRM/PE APP [Proctozone-HC] |
4 |
Non-Preferred Drug |
45% | 45% | None |
procto-pak 1% cream |
4 |
Non-Preferred Drug |
45% | 45% | None |
PROCTOSOL-HC 2.5% CREAM |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PROCTOZONE-HC 2.5% CREAM |
4 |
Non-Preferred Drug |
45% | 45% | None |
PROGESTERONE 100 MG CAPSULE [Prometrium] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PROGESTERONE 200 MG CAPSULE [Prometrium] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PROGRAF 0.2 MG GRANULE PACKET |
4 |
Non-Preferred Drug |
45% | 45% | P |
PROGRAF 1 MG GRANULE PACKET |
4 |
Non-Preferred Drug |
45% | 45% | P |
PROLASTIN C 1,000 MG VIAL |
5 |
Specialty Tier |
25% | 25% | P |
PROLENSA 0.07% EYE DROPS |
4 |
Non-Preferred Drug |
45% | 45% | None |
PROLIA 60MG/ML INJECTION |
4 |
Non-Preferred Drug |
45% | 45% | P Q:1 /180Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROMACTA 12.5 MG SUSPEN PACKET POWDER PACK |
5 |
Specialty Tier |
25% | 25% | P Q:180 /30Days |
PROMACTA 12.5 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
PROMACTA 25 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
PROMACTA 50 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
PROMACTA 75 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
PROMETHAZINE 12.5 MG TABLET |
2* |
Generic |
$5.00 | $15.00 | P |
PROMETHAZINE 25 MG TABLET |
2* |
Generic |
$5.00 | $15.00 | P |
PROMETHAZINE 50 MG TABLET |
2* |
Generic |
$5.00 | $15.00 | P |
PROPAFENONE HCL 150 MG TABLET [Rythmol] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PROPAFENONE HCL 225MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PROPAFENONE HCL 300 MG TABLET [Rythmol] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPAFENONE HCL ER 225 MG CAP |
4 |
Non-Preferred Drug |
45% | 45% | None |
PROPAFENONE HYDROCHLORIDE 325MG CAPSULES EXTENDED RELEASE |
4 |
Non-Preferred Drug |
45% | 45% | None |
PROPAFENONE HYDROCHLORIDE 425MG CAPSULES EXTENDED RELEASE |
4 |
Non-Preferred Drug |
45% | 45% | None |
PROPRANOLOL 10 MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PROPRANOLOL 20 MG TABLET [Inderal] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PROPRANOLOL 20MG/5ML TUBEX |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PROPRANOLOL 40 MG TABLET [Inderal] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PROPRANOLOL 40MG/5ML TUBEX |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PROPRANOLOL 60 MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PROPRANOLOL 80 MG TABLET [Inderal] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PROPRANOLOL ER 120 MG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPRANOLOL ER 160 MG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | None |
PROPRANOLOL ER 60 MG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | None |
PROPRANOLOL ER 80 MG CAPSULE |
4 |
Non-Preferred Drug |
45% | 45% | None |
PROPYLTHIOURACIL 50 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
PROQUAD VIAL |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PROSOL 20% INJECTION |
4 |
Non-Preferred Drug |
45% | 45% | P |
PROTRIPTYLINE HCL 10 MG TABLET [Vivactil] |
4 |
Non-Preferred Drug |
45% | 45% | None |
PROTRIPTYLINE HCL 5 MG TABLET [Vivactil] |
4 |
Non-Preferred Drug |
45% | 45% | None |
PULMOZYME 1MG/ML AMPUL |
5 |
Specialty Tier |
25% | 25% | P |
PURIXAN 20 MG/ML ORAL SUSPENSION |
5 |
Specialty Tier |
25% | 25% | None |
PYRAZINAMIDE 500 MG TABLET |
4 |
Non-Preferred Drug |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PYRIDOSTIGMINE 60 MG/5 ML SOLUTION SYRUP [Mestinon] |
4 |
Non-Preferred Drug |
45% | 45% | None |
PYRIDOSTIGMINE BR 60 MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
PYRIDOSTIGMINE BR ER 180 MG TAB |
4 |
Non-Preferred Drug |
45% | 45% | None |