2023 Medicare Part D Plan Formulary Information |
Cigna Saver Rx (PDP) (S5617-356-0)
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 Cigna Saver Rx (PDP) (S5617-356-0) Formulary Drugs Starting with the Letter A in CMS PDP Region 6 which includes: PA WV
|
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] |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:960 /30Days |
ABACAVIR 300 MG TABLET [Ziagen] |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
ABACAVIR-LAMIVUDINE 600-300 MG TABLET [Epzicom] |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days |
ABELCET INJECTION SUSPENSION 5MG/ML |
4 |
Non-Preferred Drug |
50% | 50% | P |
ABILIFY MAINTENA ER 300 MG SYRINGE |
4 |
Non-Preferred Drug |
50% | 50% | Q:1 /28Days |
ABILIFY MAINTENA ER 300 MG VIAL |
4 |
Non-Preferred Drug |
50% | 50% | Q:1 /28Days |
ABILIFY MAINTENA ER 400 MG SUSER VIAL |
4 |
Non-Preferred Drug |
50% | 50% | Q:1 /28Days |
ABILIFY MAINTENA ER 400 MG SYRINGE |
4 |
Non-Preferred Drug |
50% | 50% | Q:1 /28Days |
ABIRATERONE 500 MG TABLET [ZYTIGA] |
4 |
Non-Preferred Drug |
50% | 50% | P Q:60 /30Days |
ABIRATERONE ACETATE 250 MG TABLET [ZYTIGA] |
4 |
Non-Preferred Drug |
50% | 50% | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Acamprosate Calcium DR 333 MG tablets [Campral] |
4 |
Non-Preferred Drug |
50% | 50% | None |
ACARBOSE 100 MG TABLET [Precose] |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:90 /30Days |
ACARBOSE 25 MG TABLET [Precose] |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:360 /30Days |
ACARBOSE 50 MG TABLET [Precose] |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:180 /30Days |
ACEBUTOLOL 200 MG CAPSULE [Sectral] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ACEBUTOLOL 400 MG CAPSULE [Sectral] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ACETAMINOP-CODEINE 120-12 MG/5 SOLUTION |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:4500 /30Days |
ACETAMINOPHEN-COD #2 TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:360 /30Days |
ACETAMINOPHEN-COD #3 TABLET [Tylenol with Codeine No.3] |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:360 /30Days |
ACETAMINOPHEN-COD #4 TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:180 /30Days |
ACETAZOLAMIDE 125 MG TABLET [Diamox] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAZOLAMIDE 250 MG TABLET [Diamox] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ACETAZOLAMIDE ER 500 MG CAPSULE ER [Diamox Sequels] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ACETIC ACID 2% EAR SOLUTION [VoSoL] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ACETYLCYSTEINE 10% VIAL [Mucosil Acetylcysteine] |
3 |
Preferred Brand |
$40.00 | $120.00 | P |
ACETYLCYSTEINE 20% VIAL [Mucosil Acetylcysteine] |
3 |
Preferred Brand |
$40.00 | $120.00 | P |
ACITRETIN 10 MG CAPSULE [Soriatane] |
4 |
Non-Preferred Drug |
50% | 50% | P |
ACITRETIN 17.5 MG CAPSULE [Soriatane] |
4 |
Non-Preferred Drug |
50% | 50% | P |
ACITRETIN 25 MG CAPSULE [Soriatane] |
4 |
Non-Preferred Drug |
50% | 50% | P |
ACTHIB VACCINE WITH DILUENT |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ACTIMMUNE 100 MCG/0.5 ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
ACYCLOVIR 200 MG CAPSULE [Zovirax] |
2* |
Generic |
$10.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION [Zovirax Suspension] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ACYCLOVIR 400 MG TABLET |
2* |
Generic |
$10.00 | $6.00 | None |
ACYCLOVIR 800 MG TABLET |
2* |
Generic |
$10.00 | $6.00 | None |
ACYCLOVIR SODIUM 500 MG VIAL |
4 |
Non-Preferred Drug |
50% | 50% | P |
ADACEL TDAP SYRINGE |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ADACEL VIAL 2UNT/5UNT |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ADAPALENE 0.3% GEL [Differin Pump] |
4 |
Non-Preferred Drug |
50% | 50% | Q:45 /30Days |
ADEMPAS 0.5 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
ADEMPAS 1 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
ADEMPAS 1.5 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
ADEMPAS 2 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADEMPAS 2.5 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
ADLARITY 10MG/DAY WEEKLY PATCH |
4 |
Non-Preferred Drug |
50% | 50% | S Q:4 /28Days |
ADLARITY 5 MG/DAY WEEKLY PATCH |
4 |
Non-Preferred Drug |
50% | 50% | S Q:4 /28Days |
ADVAIR DISKUS MIS 100/50 |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days |
ADVAIR DISKUS MIS 250/50 |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days |
ADVAIR DISKUS MIS 500/50 |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days |
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:12 /30Days |
ADVAIR HFA INHALER 115;21MCG;MCG 120 ACTN INHL |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:12 /30Days |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:12 /30Days |
AIMOVIG 140 MG/ML AUTOINJECTOR |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:1 /30Days |
AIMOVIG 70 MG/ML AUTOINJECTOR |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:1 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AJOVY 225 MG/1.5 ML AUTOINJECT |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:2 /30Days |
AJOVY 225 MG/1.5 ML SYRINGE |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:2 /30Days |
ALBENDAZOLE 200 MG TABLET [Albenza] |
5 |
Specialty Tier |
25% | N/A | None |
ALBUTEROL 2.5 MG/0.5 ML SOL VIAL-NEB |
3 |
Preferred Brand |
$40.00 | $120.00 | P |
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA] |
4 |
Non-Preferred Drug |
50% | 50% | Q:17 /30Days |
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA] |
4 |
Non-Preferred Drug |
50% | 50% | Q:36 /30Days |
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA] |
4 |
Non-Preferred Drug |
50% | 50% | Q:13 /30Days |
ALBUTEROL SUL 0.63 MG/3 ML SOLUTION VIAL-NEB [Accuneb] |
3 |
Preferred Brand |
$40.00 | $120.00 | P |
ALBUTEROL SUL 1.25 MG/3 ML SOLUTION VIAL-NEB [Accuneb] |
3 |
Preferred Brand |
$40.00 | $120.00 | P |
ALBUTEROL SULF 2 MG/5 ML SYRUP |
2* |
Generic |
$10.00 | $6.00 | None |
ALBUTEROL SULFATE 2 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL SULFATE 2.5 MG/3 ML SOLUTION VIAL-NEB |
2* |
Generic |
$10.00 | $6.00 | P |
ALBUTEROL SULFATE 4 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
ALCLOMETASONE DIPR 0.05% OINTMENT [Aclovate] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ALCLOMETASONE DIPRO 0.05% CREAM (G) [Aclovate] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ALECENSA 150 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:240 /30Days |
ALENDRONATE SOD 70 MG/75 ML SOLUTION [Fosamax] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ALENDRONATE SODIUM 10 MG TABLET [Fosamax] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
ALENDRONATE SODIUM 35 MG TABLET [Fosamax] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:4 /28Days |
ALENDRONATE SODIUM 70 MG TABLET [Fosamax] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:4 /28Days |
ALFUZOSIN HCL ER 10 MG TABLET |
2* |
Generic |
$10.00 | $6.00 | None |
ALLOPURINOL 100 MG TABLET [Zyloprim] |
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 |
ALLOPURINOL 300 MG TABLET [Zyloprim] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ALOSETRON HCL 0.5 MG TABLET [Lotronex] |
4 |
Non-Preferred Drug |
50% | 50% | P |
ALOSETRON HCL 1 MG TABLET [Lotronex] |
4 |
Non-Preferred Drug |
50% | 50% | P |
ALPHAGAN P 0.1% EYE DROPS |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ALPRAZOLAM 0.25 MG TABLET [Xanax] |
2* |
Generic |
$10.00 | $6.00 | Q:120 /30Days |
ALPRAZOLAM 0.5 MG TABLET [Xanax] |
2* |
Generic |
$10.00 | $6.00 | Q:120 /30Days |
ALPRAZOLAM 1 MG TABLET [Xanax] |
2* |
Generic |
$10.00 | $6.00 | Q:120 /30Days |
ALPRAZOLAM 2 MG TABLET [Xanax] |
2* |
Generic |
$10.00 | $6.00 | Q:150 /30Days |
ALTAVERA-28 TABLET [Portia] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ALUNBRIG 180 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
ALUNBRIG 30 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALUNBRIG 90 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
ALUNBRIG 90 MG-180 MG TABLET PACK |
5 |
Specialty Tier |
25% | N/A | P Q:60 /365Days |
ALYACEN 1-35-28 TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ALYQ 20 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | P Q:60 /30Days |
AMANTADINE 100 MG CAPSULE [Symmetrel] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
AMANTADINE 100 MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
AMANTADINE 50 MG/5 ML SOLUTION |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
AMBRISENTAN 10 MG TABLET [LETAIRIS] |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
AMBRISENTAN 5 MG TABLET [LETAIRIS] |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
AMETHIA 0.15-0.03-0.01 MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
AMIKACIN SULF 500 MG/2 ML VIAL |
4 |
Non-Preferred Drug |
50% | 50% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMILORIDE HCL 5 MG TABLET [Midamor] |
2* |
Generic |
$10.00 | $6.00 | None |
AMILORIDE HCL-HCTZ 5-50 MG TABLET [Moduretic] |
2* |
Generic |
$10.00 | $6.00 | None |
Amino acids 4.25% in dextrose 10% Injectable Solution [Clinimix 4.25/10] |
4 |
Non-Preferred Drug |
50% | 50% | P |
AMIODARONE HCL 100 MG TABLET [Pacerone] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
AMIODARONE HCL 200 MG TABLET [Pacerone] |
2* |
Generic |
$10.00 | $6.00 | None |
AMIODARONE HCL 400 MG TABLET [Pacerone] |
4 |
Non-Preferred Drug |
50% | 50% | None |
AMITRIP/PERPHEN 10-4 TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
AMITRIP/PERPHEN 50-4 TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
AMITRIPTYLINE HCL 10 MG TABLET [Elavil] |
2* |
Generic |
$10.00 | $6.00 | None |
AMITRIPTYLINE HCL 100 MG TABLET |
2* |
Generic |
$10.00 | $6.00 | None |
AMITRIPTYLINE HCL 150 MG TABLET |
2* |
Generic |
$10.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIPTYLINE HCL 25 MG TABLET [Elavil] |
2* |
Generic |
$10.00 | $6.00 | None |
AMITRIPTYLINE HCL 50 MG TABLET |
2* |
Generic |
$10.00 | $6.00 | None |
AMITRIPTYLINE HCL 75 MG TABLET |
2* |
Generic |
$10.00 | $6.00 | None |
AMLOD-VALSA-HCTZ 10-160-12.5MG TABLET [Exforge HCT] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
AMLOD-VALSA-HCTZ 10-160-25 MG TABLET [Exforge HCT] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
AMLOD-VALSA-HCTZ 10-320-25 MG TABLET [Exforge HCT] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
AMLOD-VALSA-HCTZ 5-160-12.5 MG TABLET [Exforge HCT] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
AMLOD-VALSA-HCTZ 5-160-25 MG TABLET [Exforge HCT] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
AMLODIPINE BESYLATE 10 MG TABLET [Norvasc] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMLODIPINE BESYLATE 2.5 MG TABLET [Norvasc] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMLODIPINE BESYLATE 5 MG TABLET [Norvasc] |
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 |
AMLODIPINE-BENAZEPRIL 10-20 MG CAPSULE [Lotrel] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMLODIPINE-BENAZEPRIL 10-40 MG CAPSULE [Lotrel] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMLODIPINE-BENAZEPRIL 2.5-10 CAPSULE [Lotrel] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMLODIPINE-BENAZEPRIL 5-10 MG CAPSULE [Lotrel] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMLODIPINE-BENAZEPRIL 5-20 MG CAPSULE [Lotrel] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMLODIPINE-BENAZEPRIL 5-40 MG CAPSULE [Lotrel] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMLODIPINE-VALSARTAN 10-160 MG TABLET [Exforge] |
2* |
Generic |
$10.00 | $6.00 | None |
AMLODIPINE-VALSARTAN 10-320 MG TABLET [Exforge] |
2* |
Generic |
$10.00 | $6.00 | None |
AMLODIPINE-VALSARTAN 5-160 MG TABLET [Exforge] |
2* |
Generic |
$10.00 | $6.00 | None |
AMLODIPINE-VALSARTAN 5-320 MG TABLET [Exforge] |
2* |
Generic |
$10.00 | $6.00 | None |
AMMONIUM LACTATE 12% CREAM (g) [Lac-Hydrin] |
2* |
Generic |
$10.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMMONIUM LACTATE 12% LOTION |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE [Augmentin] |
2* |
Generic |
$10.00 | $6.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin] |
2* |
Generic |
$10.00 | $6.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE [Augmentin] |
4 |
Non-Preferred Drug |
50% | 50% | None |
AMOX-CLAV 200-28.5 MG/5 ML SUS |
2* |
Generic |
$10.00 | $6.00 | None |
AMOX-CLAV 250-62.5 MG/5 ML ORAL SUSPENSION [Augmentin] |
4 |
Non-Preferred Drug |
50% | 50% | None |
AMOX-CLAV 400-57 MG/5 ML ORAL SUSPENSION [Augmentin] |
2* |
Generic |
$10.00 | $6.00 | None |
AMOX-CLAV 500-125 MG TABLET [Augmentin] |
2* |
Generic |
$10.00 | $6.00 | None |
AMOX-CLAV 600-42.9 MG/5 ML SUS |
2* |
Generic |
$10.00 | $6.00 | None |
AMOX-CLAV 875-125 MG TABLET [Augmentin] |
2* |
Generic |
$10.00 | $6.00 | None |
AMOX-CLAV ER 1,000-62.5 MG TABLET [Augmentin] |
4 |
Non-Preferred Drug |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXAPINE 100MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
AMOXAPINE 150MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
AMOXAPINE 25MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
AMOXAPINE 50MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
AMOXICILLIN 125 MG/5 ML SUSP |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMOXICILLIN 125MG CHEWABLE TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION [Amoxil] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMOXICILLIN 250 MG CHEWABLE TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMOXICILLIN 250 MG CAPSULE [Trimox] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION [Trimox] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [Amoxil] |
2* |
Generic |
$10.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN 500 MG CAPSULE [Trimox] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMOXICILLIN 500 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMOXICILLIN 875 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days |
AMPHETAMINE SALT COMBO 15MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:120 /30Days |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days |
AMPHETAMINE SALTS 5 MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:360 /30Days |
AMPHOTERICIN B 50 MG VIAL [Fungizone] |
4 |
Non-Preferred Drug |
50% | 50% | P |
AMPICILLIN 1 GM VIAL |
4 |
Non-Preferred Drug |
50% | 50% | P |
AMPICILLIN 10 GM BOTTLE VIAL |
4 |
Non-Preferred Drug |
50% | 50% | P |
AMPICILLIN 1000 MG / Sulbactam 500 MG Injection |
4 |
Non-Preferred Drug |
50% | 50% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS |
4 |
Non-Preferred Drug |
50% | 50% | P |
AMPICILLIN CAPSULES 500MG 100 BOTTLE |
2* |
Generic |
$10.00 | $6.00 | None |
AMPICILLIN-SULBACTAM 15 GM VIAL [Unasyn] |
4 |
Non-Preferred Drug |
50% | 50% | P |
AMPICILLIN-SULBACTAM 3 GM VIAL [Unasyn] |
4 |
Non-Preferred Drug |
50% | 50% | P |
ANAGRELIDE HCL 0.5 MG CAPSULE [Agrylin] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ANAGRELIDE HCL 1 MG CAPSULE [Agrylin] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ANASTROZOLE 1 MG TABLET |
2* |
Generic |
$10.00 | $6.00 | None |
ANORO ELLIPTA 62.5-25 MCG INH |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days |
APRACLONIDINE HCL 0.5% DROPS [Iopidine] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
APREPITANT 125 MG CAPSULE [Emend] |
4 |
Non-Preferred Drug |
50% | 50% | P |
APREPITANT 125-80-80 MG PACK CAPSULE DS PK [Emend] |
4 |
Non-Preferred Drug |
50% | 50% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APREPITANT 40 MG CAPSULE [Emend] |
4 |
Non-Preferred Drug |
50% | 50% | P |
APREPITANT 80 MG CAPSULE [Emend] |
4 |
Non-Preferred Drug |
50% | 50% | P |
APRI 0.15-0.03 TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
APTIOM 200 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | Q:180 /30Days |
APTIOM 400 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | Q:90 /30Days |
APTIOM 600 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
APTIOM 800 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
APTIVUS 250MG CAPSULE |
4 |
Non-Preferred Drug |
50% | 50% | Q:120 /30Days |
ARANELLE 7-9-5 TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ARCALYST 220 MG VIAL |
5 |
Specialty Tier |
25% | N/A | P |
ARIKAYCE 590 MG/8.4 ML VIAL-NEB |
4 |
Non-Preferred Drug |
50% | 50% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARIPIPRAZOLE 1 MG/ML SOLUTION [Abilify] |
4 |
Non-Preferred Drug |
50% | 50% | None |
ARIPIPRAZOLE 10 MG TABLET [Abilify] |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days |
ARIPIPRAZOLE 15 MG TABLET [Abilify] |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days |
ARIPIPRAZOLE 2 MG TABLET [Abilify] |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days |
ARIPIPRAZOLE 20 MG TABLET [Abilify] |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days |
ARIPIPRAZOLE 30 MG TABLET [Abilify] |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days |
ARIPIPRAZOLE 5 MG TABLET [Abilify] |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days |
ARIPIPRAZOLE ODT 10 MG TABLET RAPDIS [Abilify Discmelt] |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
ARIPIPRAZOLE ODT 15 MG TABLET RAPDIS [Abilify Discmelt] |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
ARISTADA ER 1064 MG/3.9 ML SYRINGE |
4 |
Non-Preferred Drug |
50% | 50% | Q:4 /56Days |
ARISTADA ER 441 MG/1.6 ML SYRINGE |
4 |
Non-Preferred Drug |
50% | 50% | Q:2 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARISTADA ER 662 MG/2.4 ML SYRINGE |
4 |
Non-Preferred Drug |
50% | 50% | Q:2 /28Days |
ARISTADA ER 882 MG/3.2 ML SYRINGE |
4 |
Non-Preferred Drug |
50% | 50% | Q:3 /28Days |
ARISTADA INITIO ER 675 MG/2.4 SUSER SYRINGE |
4 |
Non-Preferred Drug |
50% | 50% | Q:5 /365Days |
ARMODAFINIL 150 MG TABLET [Nuvigil] |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:30 /30Days |
ARMODAFINIL 200 MG TABLET [Nuvigil] |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:30 /30Days |
ARMODAFINIL 250 MG TABLET [Nuvigil] |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:30 /30Days |
ARMODAFINIL 50 MG TABLET [Nuvigil] |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:30 /30Days |
ARNUITY ELLIPTA 100 MCG INH |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days |
ARNUITY ELLIPTA 200 MCG INH |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days |
ARNUITY ELLIPTA 50 MCG INH BLST W/DEV |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days |
ASENAPINE 10 MG SUBLIGUAL TABLET [Saphris] |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ASENAPINE 2.5 MG TABLET SUBLIGUAL [Saphris] |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
ASENAPINE 5 MG SUBLIGUAL TABLET [Saphris] |
4 |
Non-Preferred Drug |
50% | 50% | Q:90 /30Days |
ASHLYNA 0.15-0.03-0.01 MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ATAZANAVIR SULFATE 150 MG CAPSULE [Reyataz] |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
ATAZANAVIR SULFATE 200 MG CAPSULE [Reyataz] |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
ATAZANAVIR SULFATE 300 MG CAPSULE [Reyataz] |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
ATENOLOL 100 MG TABLET [Tenormin] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ATENOLOL 25 MG TABLET [Tenormin] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ATENOLOL 50 MG TABLET [Tenormin] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ATENOLOL-CHLORTHALIDONE 100-25 TABLET [Tenoretic] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ATENOLOL-CHLORTHALIDONE 50-25 TABLET [Tenoretic] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATOMOXETINE HCL 10 MG CAPSULE [Strattera] |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
ATOMOXETINE HCL 100 MG CAPSULE [Strattera] |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
ATOMOXETINE HCL 18 MG CAPSULE [Strattera] |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
ATOMOXETINE HCL 25 MG CAPSULE [Strattera] |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
ATOMOXETINE HCL 40 MG CAPSULE [Strattera] |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
ATOMOXETINE HCL 60 MG CAPSULE [Strattera] |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
ATOMOXETINE HCL 80 MG CAPSULE [Strattera] |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
ATORVASTATIN 10 MG TABLET [Lipitor] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
ATORVASTATIN 20 MG TABLET [Lipitor] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
ATORVASTATIN 40 MG TABLET [Lipitor] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
ATORVASTATIN 80 MG TABLET [Lipitor] |
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 |
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION [Mepron] |
4 |
Non-Preferred Drug |
50% | 50% | None |
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone] |
4 |
Non-Preferred Drug |
50% | 50% | None |
ATOVAQUONE-PROGUANIL 62.5-25 [Malarone] |
4 |
Non-Preferred Drug |
50% | 50% | None |
ATROPINE 1% EYE DROPS [Isopto Atropine] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ATROVENT HFA AER 17MCG |
4 |
Non-Preferred Drug |
50% | 50% | Q:26 /30Days |
AUBAGIO 14 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
AUBAGIO 7 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
AUBRA EQ-28 TABLET [Vienva] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
AUGMENTIN 125-31.25 MG/5 ML ORAL SUSPENSION |
4 |
Non-Preferred Drug |
50% | 50% | None |
AUSTEDO 12 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
AUSTEDO 6 MG TABLET |
5 |
Specialty Tier |
25% | N/A | 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 |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
AUSTEDO XR 12 MG TABLET ER 24H |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
AUSTEDO XR 24 MG TABLET ER 24H |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
AUSTEDO XR 6 MG TABLET ER 24H |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
AUVELITY ER 45-105 MG TABLET IR ER |
4 |
Non-Preferred Drug |
50% | 50% | S Q:60 /30Days |
AVIANE 0.1-0.02 TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
AVONEX PEN 30 MCG/0.5 ML KIT |
5 |
Specialty Tier |
25% | N/A | P Q:1 /28Days |
AVONEX PREFILLED SYR 30 MCG KT |
5 |
Specialty Tier |
25% | N/A | P Q:1 /28Days |
AYVAKIT 100 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
AYVAKIT 200 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
AYVAKIT 25 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AYVAKIT 300 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
AYVAKIT 50 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
AZATHIOPRINE 50 MG TABLET [Imuran] |
3 |
Preferred Brand |
$40.00 | $120.00 | P |
AZELASTINE 137 MCG NASAL SPRAY |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days |
AZELASTINE HCL 0.05% EYE DROPS [Optivar] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
AZITHROMYCIN 1 GM POWDER PACKET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
AZITHROMYCIN 100 MG/5 ML ORAL SUSPENSION [Zithromax Powder] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [Zithromax] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
AZITHROMYCIN 250 MG TABLET [Zithromax Z-Pak] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AZITHROMYCIN 250 MG TABLET [Zithromax Z-Pak] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AZITHROMYCIN 500 MG TABLET [Zithromax Tri-Pak] |
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 |
AZITHROMYCIN 500 MG TABLET [Zithromax Tri-Pak] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AZITHROMYCIN 600 MG TABLET [Zithromax Z-Pak] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
AZITHROMYCIN I.V. 500 MG VIAL [Zithromax Powder] |
4 |
Non-Preferred Drug |
50% | 50% | P |
AZTREONAM 2 GM VIAL [Azactam] |
4 |
Non-Preferred Drug |
50% | 50% | P |
AZTREONAM FOR INJECTION |
4 |
Non-Preferred Drug |
50% | 50% | P |