2023 Medicare Part D Plan Formulary Information |
Clear Spring Health Value Rx (PDP) (S6946-002-0)
Sanctioned Plan
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 Clear Spring Health Value Rx (PDP) (S6946-002-0) Formulary Drugs Starting with the Letter C in CMS PDP Region 5 which includes: DC DE MD
|
Drugs Starting with Letter C
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
CABERGOLINE 0.5 MG TABLET [Dostinex] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CABLIVI 11 MG KIT |
5 |
Specialty Tier |
25% | 25% | P Q:32 /30Days |
CABOMETYX 20 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
CABOMETYX 40 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
CABOMETYX 60 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
CALCIPOTRIENE 0.005% SOLUTION [Dovonex Scalp] |
4 |
Non-Preferred Drug |
35% | 35% | Q:120 /30Days |
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
CALCITRIOL 0.25 MCG CAPSULE [Rocaltrol] |
2 |
Generic |
$3.00 | $9.00 | None |
CALCITRIOL 0.5 MCG CAPSULE [Rocaltrol] |
2 |
Generic |
$3.00 | $9.00 | None |
CALCITRIOL 1 MCG/ML SOLUTION ORAL |
4 |
Non-Preferred Drug |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CALCIUM ACETATE 667 MG GELCAPSULE [PhosLo] |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:360 /30Days |
CALCIUM ACETATE 667 MG TABLET [PhosLo] |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:360 /30Days |
CALQUENCE 100 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P Q:60 /30Days |
CALQUENCE 100 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:60 /30Days |
CAMILA 0.35 MG TABLET [Sharobel 28-Day] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CANDESARTAN CILEXETIL 16 MG TABLET [Atacand] |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:60 /30Days |
CANDESARTAN CILEXETIL 32 MG TABLET [Atacand] |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:30 /30Days |
CANDESARTAN CILEXETIL 4 MG TABLET [Atacand] |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:60 /30Days |
CANDESARTAN CILEXETIL 8 MG TABLET [Atacand] |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:60 /30Days |
CANDESARTAN-HCTZ 16-12.5 MG TABLET [Atacand HCT] |
4 |
Non-Preferred Drug |
35% | 35% | Q:30 /30Days |
CANDESARTAN-HCTZ 32-12.5 MG TABLET [Atacand HCT] |
4 |
Non-Preferred Drug |
35% | 35% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CANDESARTAN-HCTZ 32-25 MG TABLET [Atacand HCT] |
4 |
Non-Preferred Drug |
35% | 35% | Q:30 /30Days |
CAPLYTA 10.5 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | S Q:30 /30Days |
CAPLYTA 21 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | S Q:30 /30Days |
CAPLYTA 42 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | S Q:30 /30Days |
CAPRELSA 100 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:60 /30Days |
CAPRELSA 300 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
CAPTOPRIL 100 MG TABLET [Capoten] |
2 |
Generic |
$3.00 | $9.00 | None |
CAPTOPRIL 12.5 MG TABLET [Capoten] |
2 |
Generic |
$3.00 | $9.00 | None |
CAPTOPRIL 25 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | None |
CAPTOPRIL 50 MG TABLET [Capoten] |
2 |
Generic |
$3.00 | $9.00 | None |
CARBAMAZEPINE 100 MG TABLET CHEW |
4 |
Non-Preferred Drug |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARBAMAZEPINE 100 MG/5 ML SUSP |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARBAMAZEPINE 200 MG TABLET [Tegretol] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARBAMAZEPINE ER 100 MG CAPSULE CPMP 12HR [Carbatrol] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARBAMAZEPINE ER 100 MG TABLET 12H [Tegretol -XR] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARBAMAZEPINE ER 200 MG CAPSULE CPMP 12HR [Carbatrol] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARBAMAZEPINE ER 200 MG TABLET 12H [Tegretol -XR] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARBAMAZEPINE ER 300 MG CAPSULE CPMP 12HR [Carbatrol] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARBAMAZEPINE ER 400 MG TABLET 12H [Tegretol -XR] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARBIDOPA 25 MG TABLET [Lodosyn] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARBIDOPA-LEVO 10-100 MG ODT TABLET RAPDIS [Parcopa] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARBIDOPA-LEVO 25-100 MG ODT TABLET RAPDIS [Parcopa] |
4 |
Non-Preferred Drug |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARBIDOPA-LEVO 25-250 MG ODT TABLET RAPDIS [Parcopa] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARBIDOPA-LEVO ER 25-100 TABLET [SINEMET CR] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
CARBIDOPA-LEVO ER 50-200 TABLET [SINEMET CR] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
CARBIDOPA-LEVODOPA 10-100 TABLET [SINEMET] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
CARBIDOPA-LEVODOPA 100 MG-ENTA TABLET [Stalevo] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARBIDOPA-LEVODOPA 125 MG-ENTA TABLET [Stalevo] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARBIDOPA-LEVODOPA 150 MG-ENTA TABLET [Stalevo] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARBIDOPA-LEVODOPA 200 MG-ENTA TABLET [Stalevo] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARBIDOPA-LEVODOPA 25-100 TABLET [SINEMET] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
CARBIDOPA-LEVODOPA 25-250 TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
CARBIDOPA-LEVODOPA 50 MG-ENTA TABLET [Stalevo] |
4 |
Non-Preferred Drug |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARBIDOPA-LEVODOPA 75 MG-ENTA TABLET [Stalevo] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CARGLUMIC ACID 200 MG TABLET SUSP TABLET DISPER [Carbaglu] |
5 |
Specialty Tier |
25% | 25% | P |
CARTEOLOL HCL 1% EYE DROPS |
2 |
Generic |
$3.00 | $9.00 | None |
CARTIA XT 120MG CAPSULE SA |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
CARTIA XT 180 MG CAPSULE ER 24H [Tiazac] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
CARTIA XT 240MG CAPSULE SA |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
CARTIA XT 300 MG CAPSULE |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
CARVEDILOL 12.5 MG TABLET [Coreg] |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
CARVEDILOL 25 MG TABLET [Coreg] |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
CARVEDILOL 3.125 MG TABLET [Coreg] |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
CARVEDILOL 6.25 MG TABLET [Coreg] |
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 |
CASPOFUNGIN ACETATE 50 MG VIAL [Cancidas] |
5 |
Specialty Tier |
25% | 25% | None |
CASPOFUNGIN ACETATE 70 MG VIAL [Cancidas] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CAYSTON KIT 75 MG/VIAL |
5 |
Specialty Tier |
25% | 25% | P Q:84 /28Days |
CEFACLOR 125 MG/5 ML ORAL SUSPENSION [Ceclor] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFACLOR 250 MG CAPSULE [Ceclor] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFACLOR 250 MG/5 ML ORAL SUSPENSION [Ceclor] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFACLOR 375 MG/5 ML ORAL SUSPENSION [Ceclor] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFACLOR 500 MG CAPSULE [Ceclor] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFACLOR ER 500MG TABLET SR 12HR |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFADROXIL 1 GM TABLET [Duricef] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFADROXIL 250 MG/5 ML ORAL SUSPENSION [Duricef] |
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 |
CEFADROXIL 500 MG CAPSULE |
2 |
Generic |
$3.00 | $9.00 | None |
CEFADROXIL 500 MG/5 ML SUSPENSION |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
CEFAZOLIN 1 GM VIAL [Kefzol] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFAZOLIN 10 GM VIAL [Kefzol] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFAZOLIN 500 MG VIAL [Ancef] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFDINIR 125 MG/5 ML ORAL SUSPENSION [Omnicef] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFDINIR 250 MG/5 ML ORAL SUSPENSION [Omnicef] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFDINIR 300 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFEPIME HCL 1 GM VIAL [Maxipime] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFEPIME HCL 2 GRAM VIAL [Maxipime] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFIXIME 400 MG CAPSULE [Suprax] |
4 |
Non-Preferred Drug |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFOXITIN 1 GM VIAL [Mefoxin] |
4 |
Non-Preferred Drug |
35% | 35% | P |
CEFOXITIN 10 GM VIAL |
4 |
Non-Preferred Drug |
35% | 35% | P |
CEFOXITIN 2 GM VIAL [Mefoxin] |
4 |
Non-Preferred Drug |
35% | 35% | P |
CEFPODOXIME 100 MG TABLET [Vantin] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFPODOXIME 100 MG/5 ML ORAL SUSPENSION [Vantin] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFPODOXIME 200 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFPODOXIME 50 MG/5 ML SUSPENSION |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFPROZIL 125 MG/5 ML SUSPENSION |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFPROZIL 250 MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
CEFPROZIL 250 MG/5 ML SUSPENSION |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFPROZIL 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 |
CEFTAZIDIME 1 GM VIAL [Tazidime] |
4 |
Non-Preferred Drug |
35% | 35% | P |
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN |
4 |
Non-Preferred Drug |
35% | 35% | P |
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN |
4 |
Non-Preferred Drug |
35% | 35% | P |
CEFTRIAXONE 1 GM VIAL [Rocephin] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFTRIAXONE 10 GM VIAL [Rocephin] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFTRIAXONE 2 GM VIAL [Rocephin] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFTRIAXONE 250 MG VIAL [Rocephin] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFTRIAXONE 500 MG VIAL [Rocephin] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEFUROXIME 1.5 GM/VIAL FOR INJECTION |
4 |
Non-Preferred Drug |
35% | 35% | P |
CEFUROXIME 750 MG FOR INJECTION |
4 |
Non-Preferred Drug |
35% | 35% | P |
CEFUROXIME AXETIL 250 MG TABLET [Ceftin] |
4 |
Non-Preferred Drug |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFUROXIME AXETIL 500 MG TABLET [Ceftin] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CELECOXIB 100 MG CAPSULE [Celebrex] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CELECOXIB 200 MG CAPSULE [Celebrex] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CELECOXIB 400 MG CAPSULE [Celebrex] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CELECOXIB 50 MG CAPSULE [Celebrex] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CELONTIN 300 MG KAPSEAL |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEPHALEXIN 125 MG/5 ML ORAL SUSPENSION [Keflex] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEPHALEXIN 250 MG CAPSULE |
2 |
Generic |
$3.00 | $9.00 | None |
CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION [Keflex] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CEPHALEXIN 500 MG CAPSULE |
2 |
Generic |
$3.00 | $9.00 | None |
CETIRIZINE HCL 1 MG/ML SYRUP SOLUTION [Zyrtec Pre-Filled Spoons] |
2 |
Generic |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHEMET 100 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | P |
CHLORDIAZEPOXIDE 10 MG CAPSULE |
2 |
Generic |
$3.00 | $9.00 | Q:120 /30Days |
CHLORDIAZEPOXIDE 25 MG CAPSULE |
2 |
Generic |
$3.00 | $9.00 | Q:120 /30Days |
CHLORDIAZEPOXIDE 5 MG CAPSULE |
2 |
Generic |
$3.00 | $9.00 | Q:120 /30Days |
CHLORHEXIDINE GLUCONATE 0.12% RINSE |
2 |
Generic |
$3.00 | $9.00 | None |
CHLOROQUINE PH 250 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | None |
CHLOROQUINE PH 500 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | None |
CHLORPROMAZINE 10 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
CHLORPROMAZINE 100 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
CHLORPROMAZINE 100 MG/ML ORAL CONC |
4 |
Non-Preferred Drug |
35% | 35% | None |
CHLORPROMAZINE 200 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLORPROMAZINE 25 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
CHLORPROMAZINE 30 MG/ML ORAL CONC |
4 |
Non-Preferred Drug |
35% | 35% | None |
CHLORPROMAZINE 50 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
CHLORTHALIDONE 25 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | None |
CHLORTHALIDONE 50 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | None |
CHOLESTYRAMINE LIGHT PACKET POWDER PACK [Questran Light] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CHOLESTYRAMINE PACKET |
4 |
Non-Preferred Drug |
35% | 35% | None |
CICLOPIROX 0.77% CREAM (g) [Loprox] |
4 |
Non-Preferred Drug |
35% | 35% | Q:90 /28Days |
CICLOPIROX 0.77% GEL |
4 |
Non-Preferred Drug |
35% | 35% | Q:45 /28Days |
CICLOPIROX 0.77% TOPICAL SUSPENSION |
4 |
Non-Preferred Drug |
35% | 35% | Q:60 /28Days |
CICLOPIROX 1% SHAMPOO [Loprox] |
4 |
Non-Preferred Drug |
35% | 35% | Q:120 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CICLOPIROX 8% SOLUTION [Penlac] |
4 |
Non-Preferred Drug |
35% | 35% | Q:7 /28Days |
Cilastatin 250 MG / Imipenem 250 MG Injection |
4 |
Non-Preferred Drug |
35% | 35% | P |
Cilastatin 500 MG / Imipenem 500 MG Injection |
4 |
Non-Preferred Drug |
35% | 35% | P |
CILOSTAZOL 100 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | None |
CILOSTAZOL 50 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | None |
CIMDUO 300-300 MG TABLET |
5 |
Specialty Tier |
25% | 25% | Q:30 /30Days |
CINACALCET HCL 30 MG TABLET [Sensipar] |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:60 /30Days |
CINACALCET HCL 60 MG TABLET [Sensipar] |
5 |
Specialty Tier |
25% | 25% | P Q:60 /30Days |
CINACALCET HCL 90 MG TABLET [Sensipar] |
5 |
Specialty Tier |
25% | 25% | P Q:120 /30Days |
CINRYZE 500 UNIT VIAL-DILUENT |
5 |
Specialty Tier |
25% | 25% | P |
CIPRO 10% SUSPENSION 1 KIT in 1 KIT |
4 |
Non-Preferred Drug |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIPROFLOX-DEXAMETH OTIC SUSPENSION EYE DROPPER [Ciprodex Otic] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
CIPROFLOX-FLUOCINLN 0.3-0.025% VIAL [OTOVEL] |
4 |
Non-Preferred Drug |
35% | 35% | Q:14 /28Days |
CIPROFLOXACIN 0.2% OTIC SOLUTION DROPERETTE [Cetraxal] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CIPROFLOXACIN 0.3% EYE DROPS [Ciloxan] |
2 |
Generic |
$3.00 | $9.00 | None |
CIPROFLOXACIN HCL 100 MG TABLET [Cipro] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CIPROFLOXACIN HCL 250 MG TABLET [Cipro] |
2 |
Generic |
$3.00 | $9.00 | None |
CIPROFLOXACIN HCL 500 MG TABLET [Cipro] |
2 |
Generic |
$3.00 | $9.00 | None |
CIPROFLOXACIN HCL 750 MG TABLET [Cipro] |
2 |
Generic |
$3.00 | $9.00 | None |
CIPROFLOXACIN-D5W 200 MG/100 ML PIGGYBACK [Cipro] |
4 |
Non-Preferred Drug |
35% | 35% | P |
CITALOPRAM HBR 10 MG TABLET [Celexa] |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
CITALOPRAM HBR 10 MG/5 ML SOLUTION [Celexa] |
4 |
Non-Preferred Drug |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CITALOPRAM HBR 20 MG TABLET [Celexa] |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
CITALOPRAM HBR 30 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | Q:30 /30Days |
CITALOPRAM HBR 40 MG TABLET |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
CLARAVIS 20 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | None |
Claravis 30mg 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLARAVIS 40 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLARITHROMYCIN 125 MG/5ML FOR ORAL SUSPENSION |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLARITHROMYCIN 250 MG TABLET |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLARITHROMYCIN 250 MG/5MLFOR ORAL SUSPENSION |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLARITHROMYCIN 500 MG TABLET [Biaxin] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLARITHROMYCIN ER 500 MG TABLET ER 24H [Biaxin XL] |
4 |
Non-Preferred Drug |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINDAMYCIN 2% VAGINAL CREAM w/APPL [Clindesse] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLINDAMYCIN HCL 150 MG CAPSULE [Cleocin] |
2 |
Generic |
$3.00 | $9.00 | None |
CLINDAMYCIN HCL 300 MG CAPSULE [Cleocin] |
2 |
Generic |
$3.00 | $9.00 | None |
CLINDAMYCIN HCL 75 MG CAPSULE [Cleocin] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLINDAMYCIN PEDIATR 75 MG/5 ML SOLUTION RECON [Cleocin Pediatric] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLINDAMYCIN PH 1% GEL [ClindaMax] |
4 |
Non-Preferred Drug |
35% | 35% | Q:120 /30Days |
CLINDAMYCIN PH 1% SOLUTION |
4 |
Non-Preferred Drug |
35% | 35% | Q:120 /30Days |
CLINDAMYCIN PH 300 MG/2 ML VIAL [Cleocin] |
4 |
Non-Preferred Drug |
35% | 35% | P |
CLINDAMYCIN PH 600 MG/4 ML VIAL [Cleocin] |
4 |
Non-Preferred Drug |
35% | 35% | P |
CLINDAMYCIN PH 900 MG/6 ML VIAL [Cleocin] |
4 |
Non-Preferred Drug |
35% | 35% | P |
CLINDAMYCIN PHOSP 1% LOTION [ClindaMax] |
4 |
Non-Preferred Drug |
35% | 35% | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINDAMYCIN-BENZOYL PEROX 1-5% GEL [BenzaClin] |
4 |
Non-Preferred Drug |
35% | 35% | None |
Clindamycin-d5w 300 mg/50 ml |
4 |
Non-Preferred Drug |
35% | 35% | P |
Clindamycin-d5w 600 mg/50 ml |
4 |
Non-Preferred Drug |
35% | 35% | P |
Clindamycin-d5w 900 mg/50 ml |
4 |
Non-Preferred Drug |
35% | 35% | P |
CLINIMIX 4.25%-5% IV SOLUTION |
4 |
Non-Preferred Drug |
35% | 35% | P |
CLINIMIX 5/20 SOLUTION |
4 |
Non-Preferred Drug |
35% | 35% | P |
CLINIMIX 5%-15% IV SOLUTION |
4 |
Non-Preferred Drug |
35% | 35% | P |
CLOBAZAM 10 MG TABLET [ONFI] |
4 |
Non-Preferred Drug |
35% | 35% | P Q:60 /30Days |
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION [ONFI] |
4 |
Non-Preferred Drug |
35% | 35% | P Q:480 /30Days |
CLOBAZAM 20 MG TABLET [ONFI] |
4 |
Non-Preferred Drug |
35% | 35% | P Q:60 /30Days |
CLOBETASOL 0.05% CREAM (g) [Temovate] |
4 |
Non-Preferred Drug |
35% | 35% | Q:120 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOMIPRAMINE 25 MG CAPSULE [Anafranil] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLOMIPRAMINE 50 MG CAPSULE [Anafranil] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLOMIPRAMINE 75 MG CAPSULE [Anafranil] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLONAZEPAM 0.125 MG DIS TABLET RAPDIS [Klonopin] |
4 |
Non-Preferred Drug |
35% | 35% | Q:90 /30Days |
CLONAZEPAM 0.25 MG ODT TABLET RAPDIS [Klonopin] |
4 |
Non-Preferred Drug |
35% | 35% | Q:90 /30Days |
CLONAZEPAM 0.5 MG DIS TABLET RAPDIS [Klonopin] |
4 |
Non-Preferred Drug |
35% | 35% | Q:90 /30Days |
CLONAZEPAM 0.5 MG TABLET [Klonopin] |
2 |
Generic |
$3.00 | $9.00 | Q:90 /30Days |
CLONAZEPAM 1 MG DIS TABLET RAPDIS [Klonopin] |
4 |
Non-Preferred Drug |
35% | 35% | Q:90 /30Days |
CLONAZEPAM 1 MG TABLET [Klonopin] |
2 |
Generic |
$3.00 | $9.00 | Q:90 /30Days |
CLONAZEPAM 2 MG ODT TABLET RAPDIS [Klonopin] |
4 |
Non-Preferred Drug |
35% | 35% | Q:300 /30Days |
CLONAZEPAM 2 MG TABLET [Klonopin] |
2 |
Generic |
$3.00 | $9.00 | Q:300 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLONIDINE 0.1 MG/DAY PATCH [Catapres-TTS] |
4 |
Non-Preferred Drug |
35% | 35% | Q:4 /28Days |
CLONIDINE 0.2 MG/DAY PATCH [Catapres-TTS] |
4 |
Non-Preferred Drug |
35% | 35% | Q:4 /28Days |
CLONIDINE 0.3 MG/DAY PATCH [Catapres-TTS] |
4 |
Non-Preferred Drug |
35% | 35% | Q:4 /28Days |
CLONIDINE HCL 0.1 MG TABLET [Catapres] |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
CLONIDINE HCL 0.2 MG TABLET |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
CLONIDINE HCL 0.3 MG TABLET [Catapres] |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
CLOPIDOGREL 75 MG TABLET [Plavix] |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
CLORAZEPATE 15 MG TABLET [Tranxene] |
4 |
Non-Preferred Drug |
35% | 35% | P Q:180 /30Days |
CLORAZEPATE 3.75 MG TABLET [Tranxene] |
4 |
Non-Preferred Drug |
35% | 35% | P Q:90 /30Days |
CLORAZEPATE 7.5 MG TABLET [Tranxene T-Tab] |
4 |
Non-Preferred Drug |
35% | 35% | P Q:360 /30Days |
CLOTRIMAZOLE 1% SOLUTION [Lotrimin AF] |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:30 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOTRIMAZOLE 1% TOPICAL CREAM (G) [Mycozyl AC] |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:45 /28Days |
CLOTRIMAZOLE 10 MG TROCHE [Mycelex Troche] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CLOTRIMAZOLE-BETAMETHASONE CREAM (G) [Lotrisone] |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:45 /28Days |
CLOTRIMAZOLE-BETAMETHASONE LOT |
4 |
Non-Preferred Drug |
35% | 35% | Q:60 /28Days |
CLOZAPINE 100 MG TABLET [Clozaril] |
4 |
Non-Preferred Drug |
35% | 35% | S Q:180 /30Days |
CLOZAPINE 200 MG TABLET [Clozaril] |
4 |
Non-Preferred Drug |
35% | 35% | S Q:120 /30Days |
CLOZAPINE 25 MG TABLET [Clozaril] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
CLOZAPINE 50 MG TABLET [Clozaril] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
CLOZAPINE ODT 100 MG TABLET RAPDIS [Fazaclo] |
4 |
Non-Preferred Drug |
35% | 35% | S Q:180 /30Days |
CLOZAPINE ODT 12.5 MG TABLET RAPDIS [Fazaclo] |
4 |
Non-Preferred Drug |
35% | 35% | S Q:120 /30Days |
CLOZAPINE ODT 150 MG TABLET RAPDIS [Fazaclo] |
4 |
Non-Preferred Drug |
35% | 35% | S Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOZAPINE ODT 200 MG TABLET RAPDIS [Fazaclo] |
4 |
Non-Preferred Drug |
35% | 35% | S Q:120 /30Days |
CLOZAPINE ODT 25 MG TABLET RAPDIS [Fazaclo] |
4 |
Non-Preferred Drug |
35% | 35% | S Q:90 /30Days |
COARTEM 20MG-120MG |
4 |
Non-Preferred Drug |
35% | 35% | Q:24 /30Days |
COLCHICINE 0.6 MG TABLET [Colcrys] |
4 |
Non-Preferred Drug |
35% | 35% | None |
COLESTIPOL HCL GRANULES PACKET [Colestid] |
4 |
Non-Preferred Drug |
35% | 35% | None |
COLESTIPOL MICRONIZED 1 GM TABLET [Colestid] |
4 |
Non-Preferred Drug |
35% | 35% | None |
COLISTIMETHATE 150 MG VIAL [Coly-Mycin M] |
4 |
Non-Preferred Drug |
35% | 35% | P Q:30 /10Days |
COMBIVENT RESPIMAT INHAL SPRAY |
4 |
Non-Preferred Drug |
35% | 35% | Q:8 /30Days |
COMETRIQ 100 MG DAILY-DOSE PACK |
5 |
Specialty Tier |
25% | 25% | P Q:56 /28Days |
COMETRIQ 140 MG DAILY-DOSE PACK |
5 |
Specialty Tier |
25% | 25% | P Q:112 /28Days |
COMETRIQ 60 MG DAILY-DOSE PACK |
5 |
Specialty Tier |
25% | 25% | P Q:84 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1 |
5 |
Specialty Tier |
25% | 25% | Q:30 /30Days |
COMPRO 25MG SUPPOSITORY |
4 |
Non-Preferred Drug |
35% | 35% | None |
CONSTULOSE 10 GM/15 ML SOLUTION |
2 |
Generic |
$3.00 | $9.00 | None |
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
COPAXONE 40 MG/ML SYRINGE |
5 |
Specialty Tier |
25% | 25% | P Q:12 /28Days |
COPIKTRA 15 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P Q:60 /30Days |
COPIKTRA 25 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P Q:60 /30Days |
CORLANOR 5 MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:60 /30Days |
CORLANOR 5 MG/5 ML ORAL SOLUTION |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:450 /30Days |
CORLANOR 7.5 MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:60 /30Days |
COTELLIC 20 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:63 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CRESEMBA 186 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
CROMOLYN 100 MG/5 ML ORAL CONC [Gastrocrom] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CROMOLYN 20 MG/2 ML NEB SOLN AMPUL-NEB [Intal] |
3 |
Preferred Brand |
$42.00 | $126.00 | P |
CROMOLYN SODIUM 4% 40MG 10ML BOTTLE |
2 |
Generic |
$3.00 | $9.00 | None |
CYCLOBENZAPRINE 10 MG TABLET [Flexeril] |
2 |
Generic |
$3.00 | $9.00 | P Q:90 /30Days |
CYCLOBENZAPRINE 5 MG TABLET [Flexeril] |
2 |
Generic |
$3.00 | $9.00 | P Q:90 /30Days |
CYCLOPHOSPHAMIDE 25 MG CAPSULE |
3 |
Preferred Brand |
$42.00 | $126.00 | P |
CYCLOPHOSPHAMIDE 50 MG CAPSULE |
3 |
Preferred Brand |
$42.00 | $126.00 | P |
CYCLOSPORINE 100MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | P |
CYCLOSPORINE 25MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | P |
CYCLOSPORINE MODIFIED 100 MG CAPSULE [Neoral] |
4 |
Non-Preferred Drug |
35% | 35% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYCLOSPORINE MODIFIED 25 MG CAPSULE [Neoral] |
4 |
Non-Preferred Drug |
35% | 35% | P |
CYCLOSPORINE MODIFIED 50 MG CAPSULE [Neoral] |
4 |
Non-Preferred Drug |
35% | 35% | P |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOTTLE |
4 |
Non-Preferred Drug |
35% | 35% | P |
CYLTEZO(CF) 10 MG/0.2 ML SYRINGEKIT |
5 |
Specialty Tier |
25% | 25% | P Q:2 /28Days |
CYLTEZO(CF) 20 MG/0.4 ML SYRINGEKIT |
5 |
Specialty Tier |
25% | 25% | P Q:2 /28Days |
CYLTEZO(CF) 40 MG/0.8 ML SYRINGE KIT |
5 |
Specialty Tier |
25% | 25% | P Q:4 /28Days |
CYLTEZO(CF) PEN 40 MG/0.8 ML PEN INJECTOR KIT |
5 |
Specialty Tier |
25% | 25% | P Q:4 /28Days |
CYLTEZO(CF) PEN CRH-UC-HS 40MG PEN INJECTOR KIT |
5 |
Specialty Tier |
25% | 25% | P Q:6 /180Days |
CYLTEZO(CF) PEN PSORIASIS 40MG PEN INJECTOR KIT |
5 |
Specialty Tier |
25% | 25% | P Q:4 /180Days |
CYRED EQ 28 DAY TABLET [Solia] |
4 |
Non-Preferred Drug |
35% | 35% | None |
CYSTAGON 150MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYSTAGON 50MG CAPSULE |
4 |
Non-Preferred Drug |
35% | 35% | P |
CYSTARAN 0.44% EYE DROPS |
5 |
Specialty Tier |
25% | 25% | P |