2023 Medicare Part D Plan Formulary Information |
RiverSpring Star (HMO I-SNP) (H6776-001-0)
Benefit Details
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less. Call drug plan for more details. |
The RiverSpring Star (HMO I-SNP) (H6776-001-0) Formulary Drugs Starting with the Letter A in Nassau County, NY: CMS MA Region 3 which includes: NY
|
Drugs Starting with Letter A
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
ABACAVIR 20 MG/ML SOLUTION [Ziagen] |
1 |
Tier 1 |
25% | 25% | None |
ABACAVIR 300 MG TABLET [Ziagen] |
1 |
Tier 1 |
25% | 25% | None |
ABACAVIR-LAMIVUDINE 600-300 MG TABLET [Epzicom] |
1 |
Tier 1 |
25% | 25% | None |
ABELCET INJECTION SUSPENSION 5MG/ML |
1 |
Tier 1 |
25% | 25% | P |
ABILIFY 10MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ABILIFY 15MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ABILIFY 20MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ABILIFY 2MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ABILIFY 30MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ABILIFY 5 MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABILIFY ASIMTUFII 720 MG/2.4ML SUSER SYRINGE |
1 |
Tier 1 |
25% | 25% | Q:2 /56Days |
ABILIFY ASIMTUFII 960 MG/3.2ML SUSER SYRINGE |
1 |
Tier 1 |
25% | 25% | Q:3 /56Days |
ABILIFY MAINTENA ER 300 MG SYRINGE |
1 |
Tier 1 |
25% | 25% | Q:1 /28Days |
ABILIFY MAINTENA ER 300 MG VIAL |
1 |
Tier 1 |
25% | 25% | Q:1 /28Days |
ABILIFY MAINTENA ER 400 MG SUSER VIAL |
1 |
Tier 1 |
25% | 25% | Q:1 /28Days |
ABILIFY MAINTENA ER 400 MG SYRINGE |
1 |
Tier 1 |
25% | 25% | Q:1 /28Days |
ABILIFY MYCITE 10 MG START KIT TABSENSTPD |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ABILIFY MYCITE 15 MG MAINT KIT TABSENSSTR |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ABILIFY MYCITE 2 MG MAINT KIT TABSENSSTR |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ABILIFY MYCITE 20 MG MAINT KIT TABSENSSTR |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ABILIFY MYCITE 30 MG MAINT KIT TABSENSSTR |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABILIFY MYCITE 5 MG MAINT KIT TABSENSSTR |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ABIRATERONE 500 MG TABLET [ZYTIGA] |
1 |
Tier 1 |
25% | 25% | P Q:60 /30Days |
ABIRATERONE ACETATE 250 MG TABLET [ZYTIGA] |
1 |
Tier 1 |
25% | 25% | P Q:120 /30Days |
ABSORICA 10 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
ABSORICA 20 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
ABSORICA 25 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
ABSORICA 30 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
ABSORICA 35 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
ABSORICA 40 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
ABSORICA LD 16 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
ABSORICA LD 24 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABSORICA LD 32 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
ABSORICA LD 8 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
Acamprosate Calcium DR 333 MG tablets [Campral] |
1 |
Tier 1 |
25% | 25% | None |
ACANYA 25; 10mg/g; mg/g 1 BOTTLE, PUMP per CARTON / 50 g in 1 BOTTLE, PUMP |
1 |
Tier 1 |
25% | 25% | None |
ACARBOSE 100 MG TABLET [Precose] |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
ACARBOSE 25 MG TABLET [Precose] |
1 |
Tier 1 |
25% | 25% | Q:360 /30Days |
ACARBOSE 50 MG TABLET [Precose] |
1 |
Tier 1 |
25% | 25% | Q:180 /30Days |
ACCOLATE 10 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ACCOLATE 20 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ACCUTANE 10 MG CAPSULE [ZENATANE] |
1 |
Tier 1 |
25% | 25% | None |
ACCUTANE 20 MG CAPSULE [ZENATANE] |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACCUTANE 30 MG CAPSULE [ZENATANE] |
1 |
Tier 1 |
25% | 25% | None |
ACCUTANE 40 MG CAPSULE [ZENATANE] |
1 |
Tier 1 |
25% | 25% | None |
ACEBUTOLOL 200 MG CAPSULE [Sectral] |
1 |
Tier 1 |
25% | 25% | None |
ACEBUTOLOL 400 MG CAPSULE [Sectral] |
1 |
Tier 1 |
25% | 25% | None |
ACETAMINOP-CODEINE 120-12 MG/5 SOLUTION |
1 |
Tier 1 |
25% | 25% | Q:4500 /30Days |
ACETAMINOPHEN-COD #2 TABLET |
1 |
Tier 1 |
25% | 25% | Q:360 /30Days |
ACETAMINOPHEN-COD #3 TABLET [Tylenol with Codeine No.3] |
1 |
Tier 1 |
25% | 25% | Q:360 /30Days |
ACETAMINOPHEN-COD #4 TABLET |
1 |
Tier 1 |
25% | 25% | Q:180 /30Days |
ACETAMN-CAF-DIHYDRCODEIN 320.5 CAPSULE [Trezix] |
1 |
Tier 1 |
25% | 25% | Q:300 /30Days |
ACETAZOLAMIDE 125 MG TABLET [Diamox] |
1 |
Tier 1 |
25% | 25% | None |
ACETAZOLAMIDE 250 MG TABLET [Diamox] |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAZOLAMIDE ER 500 MG CAPSULE ER [Diamox Sequels] |
1 |
Tier 1 |
25% | 25% | None |
ACETIC ACID 2% EAR SOLUTION [VoSoL] |
1 |
Tier 1 |
25% | 25% | None |
ACETYLCYSTEINE 10% VIAL [Mucosil Acetylcysteine] |
1 |
Tier 1 |
25% | 25% | P |
ACETYLCYSTEINE 20% VIAL [Mucosil Acetylcysteine] |
1 |
Tier 1 |
25% | 25% | P |
ACIPHEX DR 20 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ACITRETIN 10 MG CAPSULE [Soriatane] |
1 |
Tier 1 |
25% | 25% | None |
ACITRETIN 17.5 MG CAPSULE [Soriatane] |
1 |
Tier 1 |
25% | 25% | None |
ACITRETIN 25 MG CAPSULE [Soriatane] |
1 |
Tier 1 |
25% | 25% | None |
ACTEMRA 162 MG/0.9 ML SYRINGE |
1 |
Tier 1 |
25% | 25% | P Q:4 /28Days |
ACTEMRA ACTPEN 162 MG/0.9 ML PEN INJCTR |
1 |
Tier 1 |
25% | 25% | P Q:4 /28Days |
ACTHIB VACCINE WITH DILUENT |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACTIMMUNE 100 MCG/0.5 ML VIAL |
1 |
Tier 1 |
25% | 25% | P |
ACTIVELLA 1 MG-0.5 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
ACTONEL 150 MG TABLET |
1 |
Tier 1 |
25% | 25% | S Q:1 /30Days |
ACTONEL 35 MG TABLET |
1 |
Tier 1 |
25% | 25% | S Q:4 /28Days |
ACTOPLUS MET 15MG/850MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
ACTOS 15 MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ACTOS 30 MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ACTOS 45 MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ACULAR 0.5% EYE DROPS |
1 |
Tier 1 |
25% | 25% | S |
ACULAR LS 0.4% OPHTH SOLUTION |
1 |
Tier 1 |
25% | 25% | S |
ACUVAIL 0.45% OPHTH SOLUTION DROPERETTE |
1 |
Tier 1 |
25% | 25% | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACYCLOVIR 200 MG CAPSULE [Zovirax] |
1 |
Tier 1 |
25% | 25% | None |
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION [Zovirax Suspension] |
1 |
Tier 1 |
25% | 25% | None |
ACYCLOVIR 400 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ACYCLOVIR 5% CREAM (g) [Zovirax] |
1 |
Tier 1 |
25% | 25% | P Q:5 /30Days |
ACYCLOVIR 5% OINTMENT [Zovirax] |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
ACYCLOVIR 800 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ACYCLOVIR SODIUM 500 MG VIAL |
1 |
Tier 1 |
25% | 25% | P |
ACZONE 5% GEL |
1 |
Tier 1 |
25% | 25% | None |
ACZONE 7.5% GEL W/PUMP |
1 |
Tier 1 |
25% | 25% | None |
ADACEL TDAP SYRINGE |
1 |
Tier 1 |
25% | 25% | None |
ADACEL VIAL 2UNT/5UNT |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADALIMUMAB-FKJP(CF) 20 MG SYRINGE KIT [Hulio] |
1 |
Tier 1 |
25% | 25% | P Q:2 /28Days |
ADALIMUMAB-FKJP(CF) 40 MG SYRINGE KIT [Idacio] |
1 |
Tier 1 |
25% | 25% | P Q:6 /28Days |
ADALIMUMAB-FKJP(CF) PEN 40 MG PEN INJECTOR KIT [Idacio] |
1 |
Tier 1 |
25% | 25% | P Q:6 /28Days |
ADAPALENE 0.1% CREAM (G) [Differin] |
1 |
Tier 1 |
25% | 25% | P |
ADAPALENE 0.1% MED. SWAB [Plixda] |
1 |
Tier 1 |
25% | 25% | P |
ADAPALENE 0.3% GEL [Differin Pump] |
1 |
Tier 1 |
25% | 25% | P |
ADAPALENE-BNZYL PEROX 0.1-2.5% GEL W/PUMP [Epiduo] |
1 |
Tier 1 |
25% | 25% | P |
ADAPALENE-BNZYL PEROX 0.3-2.5% GEL W/PUMP [Epiduo] |
1 |
Tier 1 |
25% | 25% | P |
ADBRY 150 MG/ML SYRINGE |
1 |
Tier 1 |
25% | 25% | P Q:6 /28Days |
ADCIRCA TABLETS 20MG 60 BOTTLE |
1 |
Tier 1 |
25% | 25% | P Q:60 /30Days |
ADDERALL 20 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADDERALL 5 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ADDERALL 7.5 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ADDERALL XR 10MG CAPSULE SA |
1 |
Tier 1 |
25% | 25% | S |
ADDERALL XR 15MG CAPSULE SA |
1 |
Tier 1 |
25% | 25% | S |
ADDERALL XR 20MG CAPSULE SA |
1 |
Tier 1 |
25% | 25% | S |
ADDERALL XR 25MG CAPSULE SA |
1 |
Tier 1 |
25% | 25% | S |
ADDERALL XR 30MG CAPSULE SA |
1 |
Tier 1 |
25% | 25% | S |
ADDERALL XR 5MG CAPSULE SA |
1 |
Tier 1 |
25% | 25% | S |
ADEFOVIR DIPIVOXIL 10 MG TABLET [Hepsera] |
1 |
Tier 1 |
25% | 25% | None |
ADEMPAS 0.5 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
ADEMPAS 1 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADEMPAS 1.5 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
ADEMPAS 2 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
ADEMPAS 2.5 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
ADLARITY 10MG/DAY WEEKLY PATCH |
1 |
Tier 1 |
25% | 25% | None |
ADLARITY 5 MG/DAY WEEKLY PATCH |
1 |
Tier 1 |
25% | 25% | None |
ADMELOG 100 UNIT/ML VIAL [Humalog] |
1 |
Tier 1 |
$35 max* | 25% | S |
ADMELOG SOLOSTAR 100 UNIT/ML INSULIN PEN [Humalog KwikPen] |
1 |
Tier 1 |
$35 max* | 25% | S |
ADVAIR DISKUS MIS 100/50 |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
ADVAIR DISKUS MIS 250/50 |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
ADVAIR DISKUS MIS 500/50 |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER |
1 |
Tier 1 |
25% | 25% | Q:12 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADVAIR HFA INHALER 115;21MCG;MCG 120 ACTN INHL |
1 |
Tier 1 |
25% | 25% | Q:12 /30Days |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
1 |
Tier 1 |
25% | 25% | Q:12 /30Days |
ADZENYS XR-ODT 12.5 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
ADZENYS XR-ODT 15.7 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
ADZENYS XR-ODT 18.8 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
ADZENYS XR-ODT 3.1 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
ADZENYS XR-ODT 6.3 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
ADZENYS XR-ODT 9.4 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
AEMCOLO DR 194 MG TABLET DR |
1 |
Tier 1 |
25% | 25% | Q:12 /30Days |
AFINITOR 10 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
AFINITOR 2.5 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AFINITOR 5 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
AFINITOR 7.5 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
AFINITOR DISPERZ 2 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:330 /30Days |
AFINITOR DISPERZ 3 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:240 /30Days |
AFINITOR DISPERZ 5 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:180 /30Days |
AFREZZA 12 UNIT CARTRIDGE INHALER |
1 |
Tier 1 |
$35 max* | 25% | None |
AFREZZA 4 UNIT CARTRIDGE INHALER |
1 |
Tier 1 |
$35 max* | 25% | None |
AFREZZA 4 UNIT/8 UNIT/12 UNIT |
1 |
Tier 1 |
$35 max* | 25% | None |
AFREZZA 8 UNIT CARTRIDGE INHALER |
1 |
Tier 1 |
$35 max* | 25% | None |
AFREZZA 90-4 UNIT / 90-8 UNIT |
1 |
Tier 1 |
$35 max* | 25% | None |
AFREZZA 90-8 UNIT / 90-12 UNIT CARTRIDGE INHALER |
1 |
Tier 1 |
$35 max* | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AGRYLIN 0.5MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
AIMOVIG 140 MG/ML AUTOINJECTOR |
1 |
Tier 1 |
25% | 25% | P Q:1 /30Days |
AIMOVIG 70 MG/ML AUTOINJECTOR |
1 |
Tier 1 |
25% | 25% | P Q:1 /30Days |
AIRDUO DIGIHALER 113-14 MCG AER PW BAS |
1 |
Tier 1 |
25% | 25% | S Q:1 /30Days |
AIRDUO DIGIHALER 232-14 MCG AER PW BAS |
1 |
Tier 1 |
25% | 25% | S Q:1 /30Days |
AIRDUO DIGIHALER 55-14 MCG AER PW BAS |
1 |
Tier 1 |
25% | 25% | S Q:1 /30Days |
AIRDUO RESPICLICK 113-14 MCG |
1 |
Tier 1 |
25% | 25% | S Q:1 /30Days |
AIRDUO RESPICLICK 232-14 MCG |
1 |
Tier 1 |
25% | 25% | S Q:1 /30Days |
AIRDUO RESPICLICK 55-14 MCG |
1 |
Tier 1 |
25% | 25% | S Q:1 /30Days |
AJOVY 225 MG/1.5 ML AUTOINJECT |
1 |
Tier 1 |
25% | 25% | P Q:2 /30Days |
AJOVY 225 MG/1.5 ML SYRINGE |
1 |
Tier 1 |
25% | 25% | P Q:2 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AKLIEF 0.005% CREAM (G) |
1 |
Tier 1 |
25% | 25% | P |
ALA-CORT 2.5% CREAM (G) [Proctozone-HC] |
1 |
Tier 1 |
25% | 25% | None |
ALA-SCALP 2% LOTION [Scalacort] |
1 |
Tier 1 |
25% | 25% | None |
ALBENDAZOLE 200 MG TABLET [Albenza] |
1 |
Tier 1 |
25% | 25% | None |
ALBUTEROL 2.5 MG/0.5 ML SOL VIAL-NEB |
1 |
Tier 1 |
25% | 25% | P |
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA] |
1 |
Tier 1 |
25% | 25% | S Q:36 /30Days |
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA] |
1 |
Tier 1 |
25% | 25% | Q:17 /30Days |
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA] |
1 |
Tier 1 |
25% | 25% | Q:13 /30Days |
ALBUTEROL SUL 0.63 MG/3 ML SOLUTION VIAL-NEB [Accuneb] |
1 |
Tier 1 |
25% | 25% | P |
ALBUTEROL SUL 1.25 MG/3 ML SOLUTION VIAL-NEB [Accuneb] |
1 |
Tier 1 |
25% | 25% | P |
ALBUTEROL SULF 2 MG/5 ML SYRUP |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL SULFATE 2 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ALBUTEROL SULFATE 2.5 MG/3 ML SOLUTION VIAL-NEB |
1 |
Tier 1 |
25% | 25% | P |
ALBUTEROL SULFATE 4 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ALCLOMETASONE DIPR 0.05% OINTMENT [Aclovate] |
1 |
Tier 1 |
25% | 25% | None |
ALCLOMETASONE DIPRO 0.05% CREAM (G) [Aclovate] |
1 |
Tier 1 |
25% | 25% | None |
ALDACTAZIDE 25/25 TABLET |
1 |
Tier 1 |
25% | 25% | None |
ALDACTONE 100MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ALDACTONE 25MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ALDACTONE 50MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ALECENSA 150 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P Q:240 /30Days |
ALENDRONATE SOD 70 MG/75 ML SOLUTION [Fosamax] |
1 |
Tier 1 |
25% | 25% | Q:300 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALENDRONATE SODIUM 10 MG TABLET [Fosamax] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ALENDRONATE SODIUM 35 MG TABLET [Fosamax] |
1 |
Tier 1 |
25% | 25% | Q:4 /28Days |
ALENDRONATE SODIUM 70 MG TABLET [Fosamax] |
1 |
Tier 1 |
25% | 25% | Q:4 /28Days |
ALFUZOSIN HCL ER 10 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ALISKIREN 150 MG TABLET [Tekturna] |
1 |
Tier 1 |
25% | 25% | None |
ALISKIREN 300 MG TABLET [Tekturna] |
1 |
Tier 1 |
25% | 25% | None |
ALKINDI SPRINKLE 0.5 MG CAPSULE SPRINK |
1 |
Tier 1 |
25% | 25% | None |
ALKINDI SPRINKLE 1 MG CAPSULE SPRINK |
1 |
Tier 1 |
25% | 25% | None |
ALKINDI SPRINKLE 2 MG CAPSULE SPRINK |
1 |
Tier 1 |
25% | 25% | None |
ALKINDI SPRINKLE 5 MG CAPSULE SPRINK |
1 |
Tier 1 |
25% | 25% | None |
ALLOPURINOL 100 MG TABLET [Zyloprim] |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALLOPURINOL 200 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ALLOPURINOL 300 MG TABLET [Zyloprim] |
1 |
Tier 1 |
25% | 25% | None |
ALMOTRIPTAN MALATE 12.5 MG TABLET [Axert] |
1 |
Tier 1 |
25% | 25% | Q:24 /28Days |
ALMOTRIPTAN MALATE 6.25 MG TABLET [Axert] |
1 |
Tier 1 |
25% | 25% | Q:18 /28Days |
ALOGLIPTIN 12.5 MG TABLET [Nesina] |
1 |
Tier 1 |
25% | 25% | S Q:30 /30Days |
ALOGLIPTIN 25 MG TABLET [Nesina] |
1 |
Tier 1 |
25% | 25% | S Q:30 /30Days |
ALOGLIPTIN 6.25 MG TABLET [Nesina] |
1 |
Tier 1 |
25% | 25% | S Q:30 /30Days |
ALOGLIPTIN-METFORMIN 12.5-1000 [Kazano] |
1 |
Tier 1 |
25% | 25% | S Q:60 /30Days |
ALOGLIPTIN-METFORMIN 12.5-500 [Kazano] |
1 |
Tier 1 |
25% | 25% | S Q:60 /30Days |
ALOGLIPTIN-PIOGLIT 12.5-30 MG [Oseni] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ALOGLIPTIN-PIOGLIT 25-15 MG TABLET [Oseni] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALOGLIPTIN-PIOGLIT 25-30 MG TABLET [Oseni] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ALOGLIPTIN-PIOGLIT 25-45 MG TABLET [Oseni] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ALOMIDE 0.1% EYE DROPS |
1 |
Tier 1 |
25% | 25% | None |
ALOSETRON HCL 0.5 MG TABLET [Lotronex] |
1 |
Tier 1 |
25% | 25% | P |
ALOSETRON HCL 1 MG TABLET [Lotronex] |
1 |
Tier 1 |
25% | 25% | P |
ALPHAGAN P 0.1% EYE DROPS |
1 |
Tier 1 |
25% | 25% | None |
ALPHAGAN P 0.15% EYE DROPS |
1 |
Tier 1 |
25% | 25% | None |
ALREX 0.2% EYE DROPS |
1 |
Tier 1 |
25% | 25% | None |
ALTABAX 1% OINTMENT |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ALTACE 1.25MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
ALTACE 10MG CAPSULE (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALTACE 2.5 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
ALTACE 5MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
ALTAVERA-28 TABLET [Portia] |
1 |
Tier 1 |
25% | 25% | None |
ALTOPREV 20 MG TABLET |
1 |
Tier 1 |
25% | 25% | S Q:30 /30Days |
ALTOPREV 40 MG TABLET ER 24H |
1 |
Tier 1 |
25% | 25% | S Q:30 /30Days |
ALTOPREV 60 MG TABLET |
1 |
Tier 1 |
25% | 25% | S Q:30 /30Days |
ALTRENO 0.05% LOTION |
1 |
Tier 1 |
25% | 25% | P |
ALUNBRIG 180 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
ALUNBRIG 30 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:60 /30Days |
ALUNBRIG 90 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
ALUNBRIG 90 MG-180 MG TABLET PACK |
1 |
Tier 1 |
25% | 25% | P Q:30 /180Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALVESCO 160 MCG INHALER HFA AER AD |
1 |
Tier 1 |
25% | 25% | Q:12 /30Days |
ALVESCO 80 MCG INHALER HFA AER AD |
1 |
Tier 1 |
25% | 25% | Q:6 /30Days |
ALYACEN 1-35-28 TABLET |
1 |
Tier 1 |
25% | 25% | None |
ALYQ 20 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:60 /30Days |
AMABELZ 0.5 MG-0.1 MG TABLET [Mimvey Lo] |
1 |
Tier 1 |
25% | 25% | P |
AMABELZ 1 MG-0.5 MG TABLET [Mimvey] |
1 |
Tier 1 |
25% | 25% | P |
AMANTADINE 100 MG CAPSULE [Symmetrel] |
1 |
Tier 1 |
25% | 25% | None |
AMANTADINE 100 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
AMANTADINE 50 MG/5 ML SOLUTION |
1 |
Tier 1 |
25% | 25% | None |
AMBIEN 10 MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
AMBIEN CR 12.5MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMBIEN CR 6.25MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
AMBIEN TABLETS 5MG 100 BOTTLE |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
AMBISOME 50MG VIAL |
1 |
Tier 1 |
25% | 25% | P |
AMBRISENTAN 10 MG TABLET [LETAIRIS] |
1 |
Tier 1 |
25% | 25% | P |
AMBRISENTAN 5 MG TABLET [LETAIRIS] |
1 |
Tier 1 |
25% | 25% | P |
AMCINONIDE 0.1% LOTION |
1 |
Tier 1 |
25% | 25% | None |
AMETHIA 0.15-0.03-0.01 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
AMIKACIN SULF 500 MG/2 ML VIAL |
1 |
Tier 1 |
25% | 25% | P |
AMILORIDE HCL 5 MG TABLET [Midamor] |
1 |
Tier 1 |
25% | 25% | None |
AMILORIDE HCL-HCTZ 5-50 MG TABLET [Moduretic] |
1 |
Tier 1 |
25% | 25% | None |
Amino acids 4.25% in dextrose 10% Injectable Solution [Clinimix 4.25/10] |
1 |
Tier 1 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMIODARONE HCL 100 MG TABLET [Pacerone] |
1 |
Tier 1 |
25% | 25% | None |
AMIODARONE HCL 200 MG TABLET [Pacerone] |
1 |
Tier 1 |
25% | 25% | None |
AMIODARONE HCL 400 MG TABLET [Pacerone] |
1 |
Tier 1 |
25% | 25% | None |
AMITIZA 24 MCG 60 CAPSULE BOTTLE |
1 |
Tier 1 |
25% | 25% | S Q:60 /30Days |
AMITIZA 8MCG CAPSULE |
1 |
Tier 1 |
25% | 25% | S Q:60 /30Days |
AMITRIPTYLINE HCL 10 MG TABLET [Elavil] |
1 |
Tier 1 |
25% | 25% | None |
AMITRIPTYLINE HCL 100 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
AMITRIPTYLINE HCL 150 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
AMITRIPTYLINE HCL 25 MG TABLET [Elavil] |
1 |
Tier 1 |
25% | 25% | None |
AMITRIPTYLINE HCL 50 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
AMITRIPTYLINE HCL 75 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMJEVITA 20 MG/0.4 ML SYRINGE |
1 |
Tier 1 |
25% | 25% | P Q:2 /28Days |
AMJEVITA 40 MG/0.8 ML AUTO INJCT |
1 |
Tier 1 |
25% | 25% | P Q:6 /28Days |
AMJEVITA 40 MG/0.8 ML SYRINGE |
1 |
Tier 1 |
25% | 25% | P Q:6 /28Days |
AMJEVITA(CF) 10MG/0.2ML SYRINGE |
1 |
Tier 1 |
25% | 25% | P |
AMLOD-VALSA-HCTZ 10-160-12.5MG TABLET [Exforge HCT] |
1 |
Tier 1 |
25% | 25% | None |
AMLOD-VALSA-HCTZ 10-160-25 MG TABLET [Exforge HCT] |
1 |
Tier 1 |
25% | 25% | None |
AMLOD-VALSA-HCTZ 10-320-25 MG TABLET [Exforge HCT] |
1 |
Tier 1 |
25% | 25% | None |
AMLOD-VALSA-HCTZ 5-160-12.5 MG TABLET [Exforge HCT] |
1 |
Tier 1 |
25% | 25% | None |
AMLOD-VALSA-HCTZ 5-160-25 MG TABLET [Exforge HCT] |
1 |
Tier 1 |
25% | 25% | None |
AMLODIPINE BESYLATE 10 MG TABLET [Norvasc] |
1 |
Tier 1 |
25% | 25% | None |
AMLODIPINE BESYLATE 2.5 MG TABLET [Norvasc] |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE BESYLATE 5 MG TABLET [Norvasc] |
1 |
Tier 1 |
25% | 25% | None |
AMLODIPINE-ATORVAST 10-10 MG [Caduet] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
AMLODIPINE-ATORVAST 10-20 MG [Caduet] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
AMLODIPINE-ATORVAST 10-40 MG [Caduet] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
Amlodipine-Atorvastatin 10-80 mg [Caduet] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
Amlodipine-Atorvastatin 2.5-10 mg [Caduet] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
Amlodipine-Atorvastatin 2.5-20 mg [Caduet] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
Amlodipine-Atorvastatin 2.5-40 mg [Caduet] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
Amlodipine-Atorvastatin 5-10 mg [Caduet] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
Amlodipine-Atorvastatin 5-20 mg [Caduet] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
Amlodipine-Atorvastatin 5-40 mg [Caduet] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Amlodipine-Atorvastatin 5-80 mg [Caduet] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
AMLODIPINE-BENAZEPRIL 10-20 MG CAPSULE [Lotrel] |
1 |
Tier 1 |
25% | 25% | None |
AMLODIPINE-BENAZEPRIL 10-40 MG CAPSULE [Lotrel] |
1 |
Tier 1 |
25% | 25% | None |
AMLODIPINE-BENAZEPRIL 2.5-10 CAPSULE [Lotrel] |
1 |
Tier 1 |
25% | 25% | None |
AMLODIPINE-BENAZEPRIL 5-10 MG CAPSULE [Lotrel] |
1 |
Tier 1 |
25% | 25% | None |
AMLODIPINE-BENAZEPRIL 5-20 MG CAPSULE [Lotrel] |
1 |
Tier 1 |
25% | 25% | None |
AMLODIPINE-BENAZEPRIL 5-40 MG CAPSULE [Lotrel] |
1 |
Tier 1 |
25% | 25% | None |
AMLODIPINE-OLMESARTAN 10-20 MG TABLET [AZOR] |
1 |
Tier 1 |
25% | 25% | None |
AMLODIPINE-OLMESARTAN 10-40 MG TABLET [AZOR] |
1 |
Tier 1 |
25% | 25% | None |
AMLODIPINE-OLMESARTAN 5-20 MG TABLET [AZOR] |
1 |
Tier 1 |
25% | 25% | None |
AMLODIPINE-OLMESARTAN 5-40 MG TABLET [AZOR] |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE-VALSARTAN 10-160 MG TABLET [Exforge] |
1 |
Tier 1 |
25% | 25% | None |
AMLODIPINE-VALSARTAN 10-320 MG TABLET [Exforge] |
1 |
Tier 1 |
25% | 25% | None |
AMLODIPINE-VALSARTAN 5-160 MG TABLET [Exforge] |
1 |
Tier 1 |
25% | 25% | None |
AMLODIPINE-VALSARTAN 5-320 MG TABLET [Exforge] |
1 |
Tier 1 |
25% | 25% | None |
AMMONIUM LACTATE 12% CREAM (g) [Lac-Hydrin] |
1 |
Tier 1 |
25% | 25% | None |
AMMONIUM LACTATE 12% LOTION |
1 |
Tier 1 |
25% | 25% | None |
AMNESTEEM 10 MG CAPSULE [ZENATANE] |
1 |
Tier 1 |
25% | 25% | None |
AMNESTEEM 20 MG CAPSULE [ZENATANE] |
1 |
Tier 1 |
25% | 25% | None |
AMNESTEEM 40 MG CAPSULE [ZENATANE] |
1 |
Tier 1 |
25% | 25% | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE [Augmentin] |
1 |
Tier 1 |
25% | 25% | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin] |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE [Augmentin] |
1 |
Tier 1 |
25% | 25% | None |
AMOX-CLAV 200-28.5 MG/5 ML SUS |
1 |
Tier 1 |
25% | 25% | None |
AMOX-CLAV 250-62.5 MG/5 ML ORAL SUSPENSION [Augmentin] |
1 |
Tier 1 |
25% | 25% | None |
AMOX-CLAV 400-57 MG/5 ML ORAL SUSPENSION [Augmentin] |
1 |
Tier 1 |
25% | 25% | None |
AMOX-CLAV 500-125 MG TABLET [Augmentin] |
1 |
Tier 1 |
25% | 25% | None |
AMOX-CLAV 600-42.9 MG/5 ML SUS |
1 |
Tier 1 |
25% | 25% | None |
AMOX-CLAV 875-125 MG TABLET [Augmentin] |
1 |
Tier 1 |
25% | 25% | None |
AMOX-CLAV ER 1,000-62.5 MG TABLET [Augmentin] |
1 |
Tier 1 |
25% | 25% | None |
AMOXAPINE 100MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
AMOXAPINE 150MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
AMOXAPINE 25MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXAPINE 50MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN 125 MG/5 ML SUSP |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN 125MG CHEWABLE TABLET |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION [Amoxil] |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN 250 MG CHEWABLE TABLET |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN 250 MG CAPSULE [Trimox] |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION [Trimox] |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [Amoxil] |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN 500 MG CAPSULE [Trimox] |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN 500 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
AMOXICILLIN 875 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
AMPHETAMINE SALT COMBO 15MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
AMPHETAMINE SALTS 5 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
AMPHETAMINE SULFATE 10 MG TABLET [Evekeo] |
1 |
Tier 1 |
25% | 25% | P |
AMPHETAMINE SULFATE 5 MG TABLET [Evekeo] |
1 |
Tier 1 |
25% | 25% | P |
AMPHOTERICIN B 50 MG VIAL [Fungizone] |
1 |
Tier 1 |
25% | 25% | P |
AMPICILLIN 1 GM VIAL |
1 |
Tier 1 |
25% | 25% | P |
AMPICILLIN 10 GM BOTTLE VIAL |
1 |
Tier 1 |
25% | 25% | P |
AMPICILLIN 1000 MG / Sulbactam 500 MG Injection |
1 |
Tier 1 |
25% | 25% | P |
AMPICILLIN 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS |
1 |
Tier 1 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN CAPSULES 500MG 100 BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
AMPICILLIN-SULBACTAM 15 GM VIAL [Unasyn] |
1 |
Tier 1 |
25% | 25% | P |
AMPICILLIN-SULBACTAM 3 GM VIAL [Unasyn] |
1 |
Tier 1 |
25% | 25% | P |
AMPYRA ER 10 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:60 /30Days |
AMZEEQ 4% FOAM |
1 |
Tier 1 |
25% | 25% | None |
ANAFRANIL 25 MG 30 CAPSULE BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
ANAFRANIL 50 MG 30 CAPSULE BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
ANAFRANIL 75 MG 30 CAPSULE BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
ANAGRELIDE HCL 0.5 MG CAPSULE [Agrylin] |
1 |
Tier 1 |
25% | 25% | None |
ANAGRELIDE HCL 1 MG CAPSULE [Agrylin] |
1 |
Tier 1 |
25% | 25% | None |
ANASTROZOLE 1 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANCOBON 250MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
ANCOBON 500MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
Androgel 16.2mg/g 1 BOTTLE, PUMP per CARTON / 88 g in 1 BOTTLE, PUMP |
1 |
Tier 1 |
25% | 25% | P Q:150 /30Days |
Angeliq 0.25/0.5 28 Day Pack |
1 |
Tier 1 |
25% | 25% | P |
ANGELIQ 1-0.5MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
ANNOVERA VAGINAL RING |
1 |
Tier 1 |
25% | 25% | None |
ANORO ELLIPTA 62.5-25 MCG INH |
1 |
Tier 1 |
25% | 25% | S Q:60 /30Days |
ANTARA 90 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
ANTIVERT 25 MG CHEWABLE TABLET |
1 |
Tier 1 |
25% | 25% | None |
ANTIVERT 50 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ANUSOL-HC 2.5% CREAM |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ANZEMET 50 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
APEXICON E 0.05% CREAM (G) [Apexicon E] |
1 |
Tier 1 |
25% | 25% | Q:120 /30Days |
APIDRA 100 UNITS/ML VIAL |
1 |
Tier 1 |
$35 max* | 25% | S |
APIDRA SOLOSTAR 100 UNITS/ML |
1 |
Tier 1 |
$35 max* | 25% | S |
APLENZIN ER 174 MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
APLENZIN ER 348 MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
APLENZIN ER 522 MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
APOKYN 30 MG/3 ML CARTRIDGE |
1 |
Tier 1 |
25% | 25% | P Q:90 /30Days |
APOMORPHINE 30 MG/3 ML CARTRIDGE [Apokyn] |
1 |
Tier 1 |
25% | 25% | P Q:90 /30Days |
APRACLONIDINE HCL 0.5% DROPS [Iopidine] |
1 |
Tier 1 |
25% | 25% | None |
APREPITANT 125 MG CAPSULE [Emend] |
1 |
Tier 1 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APREPITANT 125-80-80 MG PACK CAPSULE DS PK [Emend] |
1 |
Tier 1 |
25% | 25% | P |
APREPITANT 40 MG CAPSULE [Emend] |
1 |
Tier 1 |
25% | 25% | P |
APREPITANT 80 MG CAPSULE [Emend] |
1 |
Tier 1 |
25% | 25% | P |
APRI 0.15-0.03 TABLET |
1 |
Tier 1 |
25% | 25% | None |
APRISO CP24 |
1 |
Tier 1 |
25% | 25% | None |
APTENSIO XR 10 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | S |
APTENSIO XR 15 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | S |
APTENSIO XR 20 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | S |
APTENSIO XR 30 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | S |
APTENSIO XR 40 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | S |
APTENSIO XR 50 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APTENSIO XR 60 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | S |
APTIOM 200 MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:180 /30Days |
APTIOM 400 MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
APTIOM 600 MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
APTIOM 800 MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
APTIVUS 250MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
ARALAST NP 1,000 MG VIAL |
1 |
Tier 1 |
25% | 25% | P |
ARANELLE 7-9-5 TABLET |
1 |
Tier 1 |
25% | 25% | None |
ARANESP 10 MCG/0.4 ML SYRINGE |
1 |
Tier 1 |
25% | 25% | P |
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.5 mL in 1 SYRINGE |
1 |
Tier 1 |
25% | 25% | P |
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
1 |
Tier 1 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP 200MCG/0.4ML SYRINGE |
1 |
Tier 1 |
25% | 25% | P |
ARANESP 200MCG/ML VIAL |
1 |
Tier 1 |
25% | 25% | P |
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.42 mL in 1 SYRING |
1 |
Tier 1 |
25% | 25% | P |
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
1 |
Tier 1 |
25% | 25% | P |
ARANESP 500MCG/1ML SYRINGE |
1 |
Tier 1 |
25% | 25% | P |
ARANESP 60MCG/ML VIAL |
1 |
Tier 1 |
25% | 25% | P |
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.3 mL in 1 SYRINGE |
1 |
Tier 1 |
25% | 25% | P |
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR |
1 |
Tier 1 |
25% | 25% | P |
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR |
1 |
Tier 1 |
25% | 25% | P |
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR |
1 |
Tier 1 |
25% | 25% | P |
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD |
1 |
Tier 1 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARAVA 10MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ARAVA 20MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ARAZLO 0.045% LOTION |
1 |
Tier 1 |
25% | 25% | P |
ARCALYST 220 MG VIAL |
1 |
Tier 1 |
25% | 25% | P |
ARFORMOTEROL 15 MCG/2 ML SOLUTION VIAL-NEB [Brovana] |
1 |
Tier 1 |
25% | 25% | P |
ARICEPT 10MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ARICEPT 23 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ARICEPT 5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ARIKAYCE 590 MG/8.4 ML VIAL-NEB |
1 |
Tier 1 |
25% | 25% | P |
ARIMIDEX 1 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ARIPIPRAZOLE 1 MG/ML SOLUTION [Abilify] |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARIPIPRAZOLE 10 MG TABLET [Abilify] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ARIPIPRAZOLE 15 MG TABLET [Abilify] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ARIPIPRAZOLE 2 MG TABLET [Abilify] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ARIPIPRAZOLE 20 MG TABLET [Abilify] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ARIPIPRAZOLE 30 MG TABLET [Abilify] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ARIPIPRAZOLE 5 MG TABLET [Abilify] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ARIPIPRAZOLE ODT 10 MG TABLET RAPDIS [Abilify Discmelt] |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
ARIPIPRAZOLE ODT 15 MG TABLET RAPDIS [Abilify Discmelt] |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
ARISTADA ER 1064 MG/3.9 ML SYRINGE |
1 |
Tier 1 |
25% | 25% | Q:4 /56Days |
ARISTADA ER 441 MG/1.6 ML SYRINGE |
1 |
Tier 1 |
25% | 25% | Q:2 /28Days |
ARISTADA ER 662 MG/2.4 ML SYRINGE |
1 |
Tier 1 |
25% | 25% | Q:2 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARISTADA ER 882 MG/3.2 ML SYRINGE |
1 |
Tier 1 |
25% | 25% | Q:3 /28Days |
ARISTADA INITIO ER 675 MG/2.4 SUSER SYRINGE |
1 |
Tier 1 |
25% | 25% | Q:5 /365Days |
ARIXTRA 7.5 MG/0.6 ML SYRINGE |
1 |
Tier 1 |
25% | 25% | None |
ARMODAFINIL 150 MG TABLET [Nuvigil] |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
ARMODAFINIL 200 MG TABLET [Nuvigil] |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
ARMODAFINIL 250 MG TABLET [Nuvigil] |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
ARMODAFINIL 50 MG TABLET [Nuvigil] |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
ARMONAIR DIGIHALER 113 MCG AER PW BAS |
1 |
Tier 1 |
25% | 25% | S Q:1 /30Days |
ARMONAIR DIGIHALER 232 MCG AER PW BAS |
1 |
Tier 1 |
25% | 25% | S Q:1 /30Days |
ARMONAIR DIGIHALER 55 MCG AER PW BAS |
1 |
Tier 1 |
25% | 25% | S Q:1 /30Days |
ARNUITY ELLIPTA 100 MCG INH |
1 |
Tier 1 |
25% | 25% | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARNUITY ELLIPTA 200 MCG INH |
1 |
Tier 1 |
25% | 25% | S Q:30 /30Days |
ARNUITY ELLIPTA 50 MCG INH BLST W/DEV |
1 |
Tier 1 |
25% | 25% | S Q:30 /30Days |
AROMASIN 25MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ARTHROTEC 50 50MG TABLET -200MCG (60 CT) |
1 |
Tier 1 |
25% | 25% | S |
ARTHROTEC 75 TABLET EC |
1 |
Tier 1 |
25% | 25% | S |
ASENAPINE 10 MG SUBLIGUAL TABLET [Saphris] |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
ASENAPINE 2.5 MG TABLET SUBLIGUAL [Saphris] |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
ASENAPINE 5 MG SUBLIGUAL TABLET [Saphris] |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
ASHLYNA 0.15-0.03-0.01 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ASMANEX HFA 100 MCG INHALER HFA AER AD |
1 |
Tier 1 |
25% | 25% | Q:13 /30Days |
ASMANEX HFA 200 MCG INHALER HFA AER AD |
1 |
Tier 1 |
25% | 25% | Q:13 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ASMANEX HFA 50 MCG INHALER HFA AER AD |
1 |
Tier 1 |
25% | 25% | Q:13 /30Days |
ASMANEX TWISTHALER 110 MCG #30 AER POW BA |
1 |
Tier 1 |
25% | 25% | Q:1 /30Days |
ASMANEX TWISTHALER 220 MCG #120 AER POW BA |
1 |
Tier 1 |
25% | 25% | Q:2 /30Days |
ASMANEX TWISTHALER 220 MCG #30 AER POW BA |
1 |
Tier 1 |
25% | 25% | Q:1 /30Days |
ASMANEX TWISTHALER 220 MCG #60 AER POW BA |
1 |
Tier 1 |
25% | 25% | Q:1 /30Days |
ASPIRIN-DIPYRIDAM ER 25-200 MG CPMP 12HR [Aggrenox] |
1 |
Tier 1 |
25% | 25% | None |
ASPRUZYO SPRINKLE ER 1000MG PACK ER GR |
1 |
Tier 1 |
25% | 25% | None |
ASPRUZYO SPRINKLE ER 500MG PACK ER GR |
1 |
Tier 1 |
25% | 25% | None |
ASTAGRAF XL 0.5 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P |
ASTAGRAF XL 1 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P |
ASTAGRAF XL 5 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATACAND 16 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
ATACAND 32 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
ATACAND 4 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
ATACAND 8 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
ATACAND HCT 16-12.5 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
ATACAND HCT 32-12.5 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
ATACAND HCT 32-25 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
ATAZANAVIR SULFATE 150 MG CAPSULE [Reyataz] |
1 |
Tier 1 |
25% | 25% | None |
ATAZANAVIR SULFATE 200 MG CAPSULE [Reyataz] |
1 |
Tier 1 |
25% | 25% | None |
ATAZANAVIR SULFATE 300 MG CAPSULE [Reyataz] |
1 |
Tier 1 |
25% | 25% | None |
Atelvia 35mg/1 36 DOSE PACK CASE / 4 TABLET, DELAYED RELEASE in 1 DOSE PACK |
1 |
Tier 1 |
25% | 25% | S Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATENOLOL 100 MG TABLET [Tenormin] |
1 |
Tier 1 |
25% | 25% | None |
ATENOLOL 25 MG TABLET [Tenormin] |
1 |
Tier 1 |
25% | 25% | None |
ATENOLOL 50 MG TABLET [Tenormin] |
1 |
Tier 1 |
25% | 25% | None |
ATENOLOL-CHLORTHALIDONE 100-25 TABLET [Tenoretic] |
1 |
Tier 1 |
25% | 25% | None |
ATENOLOL-CHLORTHALIDONE 50-25 TABLET [Tenoretic] |
1 |
Tier 1 |
25% | 25% | None |
ATIVAN 0.5 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:90 /30Days |
ATIVAN 1 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:90 /30Days |
ATIVAN 2 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:150 /30Days |
ATOMOXETINE HCL 10 MG CAPSULE [Strattera] |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
ATOMOXETINE HCL 100 MG CAPSULE [Strattera] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ATOMOXETINE HCL 18 MG CAPSULE [Strattera] |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATOMOXETINE HCL 25 MG CAPSULE [Strattera] |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
ATOMOXETINE HCL 40 MG CAPSULE [Strattera] |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
ATOMOXETINE HCL 60 MG CAPSULE [Strattera] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ATOMOXETINE HCL 80 MG CAPSULE [Strattera] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ATORVASTATIN 10 MG TABLET [Lipitor] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ATORVASTATIN 20 MG TABLET [Lipitor] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ATORVASTATIN 40 MG TABLET [Lipitor] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ATORVASTATIN 80 MG TABLET [Lipitor] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION [Mepron] |
1 |
Tier 1 |
25% | 25% | None |
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone] |
1 |
Tier 1 |
25% | 25% | None |
ATOVAQUONE-PROGUANIL 62.5-25 [Malarone] |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATRALIN 0.05% GEL |
1 |
Tier 1 |
25% | 25% | P |
ATROPINE 1% EYE DROPS [Isopto Atropine] |
1 |
Tier 1 |
25% | 25% | None |
ATROVENT HFA AER 17MCG |
1 |
Tier 1 |
25% | 25% | Q:26 /30Days |
AUBAGIO 14 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
AUBAGIO 7 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
AUBRA EQ-28 TABLET [Vienva] |
1 |
Tier 1 |
25% | 25% | None |
AUGMENTIN 125-31.25 MG/5 ML ORAL SUSPENSION |
1 |
Tier 1 |
25% | 25% | None |
AUGMENTIN ES-600 ORAL SUSPENSION |
1 |
Tier 1 |
25% | 25% | None |
AURYXIA 210 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
AUSTEDO 12 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:120 /30Days |
AUSTEDO 6 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AUSTEDO 9 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:120 /30Days |
AUSTEDO XR 12 MG TABLET ER 24H |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
AUSTEDO XR 24 MG TABLET ER 24H |
1 |
Tier 1 |
25% | 25% | P Q:60 /30Days |
AUSTEDO XR 6 MG TABLET ER 24H |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
AUVELITY ER 45-105 MG TABLET IR ER |
1 |
Tier 1 |
25% | 25% | S Q:60 /30Days |
AUVI-Q 0.1 MG AUTO-INJECTOR |
1 |
Tier 1 |
25% | 25% | Q:2 /30Days |
AUVI-Q 0.15 MG AUTO-INJECTOR |
1 |
Tier 1 |
25% | 25% | Q:2 /30Days |
AUVI-Q 0.3 MG AUTO-INJECTOR |
1 |
Tier 1 |
25% | 25% | Q:2 /30Days |
AVALIDE 150-12.5 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
AVALIDE 300-12.5 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
AVAPRO 150 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVAPRO 300 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
AVAPRO 75 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
AVEED 750 MG/3 ML VIAL |
1 |
Tier 1 |
25% | 25% | P |
AVIANE 0.1-0.02 TABLET |
1 |
Tier 1 |
25% | 25% | None |
AVITA 0.025% CREAM (G) [Tretin-X] |
1 |
Tier 1 |
25% | 25% | P |
AVONEX PEN 30 MCG/0.5 ML KIT |
1 |
Tier 1 |
25% | 25% | P Q:1 /28Days |
AVONEX PREFILLED SYR 30 MCG KT |
1 |
Tier 1 |
25% | 25% | P Q:1 /28Days |
AVYCAZ 2.5 GRAM VIAL |
1 |
Tier 1 |
25% | 25% | P |
Aygestin 5mg/1 50 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
AYVAKIT 100 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
AYVAKIT 200 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AYVAKIT 25 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
AYVAKIT 300 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
AYVAKIT 50 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
AZASAN 100 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
AZASAN 75 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
AZASITE 1% EYE DROPS |
1 |
Tier 1 |
25% | 25% | None |
AZATHIOPRINE 100 MG TABLET [Azasan] |
1 |
Tier 1 |
25% | 25% | P |
AZATHIOPRINE 50 MG TABLET [Imuran] |
1 |
Tier 1 |
25% | 25% | P |
AZATHIOPRINE 75 MG TABLET [Azasan] |
1 |
Tier 1 |
25% | 25% | P |
AZELAIC ACID 15% GEL [Finacea] |
1 |
Tier 1 |
25% | 25% | None |
AZELASTIN-FLUTIC 137-50MCG SPRAY/PUMP [Dymista] |
1 |
Tier 1 |
25% | 25% | Q:23 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZELASTINE 137 MCG NASAL SPRAY |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
AZELASTINE HCL 0.05% EYE DROPS [Optivar] |
1 |
Tier 1 |
25% | 25% | None |
AZELEX 20% CREAM (G) |
1 |
Tier 1 |
25% | 25% | None |
AZILECT 0.5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
AZILECT 1MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
AZITHROMYCIN 1 GM POWDER PACKET |
1 |
Tier 1 |
25% | 25% | None |
AZITHROMYCIN 100 MG/5 ML ORAL SUSPENSION [Zithromax Powder] |
1 |
Tier 1 |
25% | 25% | None |
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [Zithromax] |
1 |
Tier 1 |
25% | 25% | None |
AZITHROMYCIN 250 MG TABLET [Zithromax Z-Pak] |
1 |
Tier 1 |
25% | 25% | None |
AZITHROMYCIN 250 MG TABLET [Zithromax Z-Pak] |
1 |
Tier 1 |
25% | 25% | None |
AZITHROMYCIN 500 MG TABLET [Zithromax Tri-Pak] |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZITHROMYCIN 500 MG TABLET [Zithromax Tri-Pak] |
1 |
Tier 1 |
25% | 25% | None |
AZITHROMYCIN 600 MG TABLET [Zithromax Z-Pak] |
1 |
Tier 1 |
25% | 25% | None |
AZITHROMYCIN I.V. 500 MG VIAL [Zithromax Powder] |
1 |
Tier 1 |
25% | 25% | P |
AZOPT 1% EYE DROPS/EYE DROPPER |
1 |
Tier 1 |
25% | 25% | None |
AZOR 10-20 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
AZOR 10-40 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
AZOR 5-20 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
AZOR 5-40 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
AZSTARYS 26.1 MG-5.2 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | S |
AZSTARYS 39.2 MG-7.8 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | S |
AZSTARYS 52.3 MG-10.4 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Aztreonam 1000 MG Injection [Azactam] |
1 |
Tier 1 |
25% | 25% | P |
AZTREONAM 2 GM VIAL [Azactam] |
1 |
Tier 1 |
25% | 25% | P |
Aztreonam 2000 MG Injection [Azactam] |
1 |
Tier 1 |
25% | 25% | P |
AZTREONAM FOR INJECTION |
1 |
Tier 1 |
25% | 25% | P |
AZULFIDINE 500 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
AZULFIDINE ENTAB 500 MG TABLET DR |
1 |
Tier 1 |
25% | 25% | None |