2024 Medicare Part D Plan Formulary Information |
Triple S Advantage Platino Blindao (HMO D-SNP) (H5774-028-0)
Benefits & Contact Info
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 Triple S Advantage Platino Blindao (HMO D-SNP) (H5774-028-0) Formulary Drugs Starting with the Letter A in Las Piedras County, PR: CMS MA Region 30 which includes: PR
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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] |
2 |
Generic |
$17.00 | $34.00 | None |
ABACAVIR 300 MG TABLET [Ziagen] |
2 |
Generic |
$17.00 | $34.00 | None |
ABACAVIR-LAMIVUDINE 600-300 MG TABLET [Epzicom] |
2 |
Generic |
$17.00 | $34.00 | None |
ABELCET INJECTION SUSPENSION 5MG/ML |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P |
ABILIFY ASIMTUFII 720 MG/2.4ML SUSER SYRINGE |
5 |
Tier 5 |
25% | 25% | S |
ABILIFY ASIMTUFII 960 MG/3.2ML SUSER SYRINGE |
5 |
Tier 5 |
25% | 25% | S |
ABILIFY MAINTENA ER 300 MG SYRINGE |
5 |
Tier 5 |
25% | 25% | S |
ABILIFY MAINTENA ER 300 MG VIAL |
5 |
Tier 5 |
25% | 25% | S |
ABILIFY MAINTENA ER 400 MG SUSER VIAL |
5 |
Tier 5 |
25% | 25% | S |
ABILIFY MAINTENA ER 400 MG SYRINGE |
5 |
Tier 5 |
25% | 25% | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ABIRATERONE 500 MG TABLET [ZYTIGA] |
5 |
Tier 5 |
25% | 25% | P |
ABIRATERONE ACETATE 250 MG TABLET [ZYTIGA] |
2 |
Generic |
$17.00 | $34.00 | P |
ABRYSVO 120 MCG / 0.5 ML INJECTION Prefilled Syringe |
6 |
Tier 6 |
$8.00 | $16.00 | None |
Acamprosate Calcium DR 333 MG tablets [Campral] |
2 |
Generic |
$17.00 | $34.00 | None |
ACARBOSE 100 MG TABLET [Precose] |
2 |
Generic |
$17.00 | $34.00 | None |
ACARBOSE 25 MG TABLET [Precose] |
2 |
Generic |
$17.00 | $34.00 | None |
ACARBOSE 50 MG TABLET [Precose] |
2 |
Generic |
$17.00 | $34.00 | None |
ACEBUTOLOL 200 MG CAPSULE [Sectral] |
2 |
Generic |
$17.00 | $34.00 | None |
ACEBUTOLOL 400 MG CAPSULE [Sectral] |
2 |
Generic |
$17.00 | $34.00 | None |
ACETAMINOP-CODEINE 120-12 MG/5 SOLUTION |
1 |
Preferred Generic |
$16.00 | $32.00 | Q:4500.00 /30Days |
ACETAMINOPHEN-COD #2 TABLET |
1 |
Preferred Generic |
$16.00 | $32.00 | Q:360.00 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAMINOPHEN-COD #3 TABLET [Tylenol with Codeine No.3] |
1 |
Preferred Generic |
$16.00 | $32.00 | Q:360.00 /30Days |
ACETAMINOPHEN-COD #4 TABLET |
2 |
Generic |
$17.00 | $34.00 | Q:180.00 /30Days |
ACETAZOLAMIDE 125 MG TABLET [Diamox] |
2 |
Generic |
$17.00 | $34.00 | None |
ACETAZOLAMIDE 250 MG TABLET [Diamox] |
2 |
Generic |
$17.00 | $34.00 | None |
ACETIC ACID 2% EAR SOLUTION [VoSoL] |
2 |
Generic |
$17.00 | $34.00 | None |
ACETYLCYSTEINE 10% VIAL [Mucosil Acetylcysteine] |
2 |
Generic |
$17.00 | $34.00 | P |
ACETYLCYSTEINE 20% VIAL [Mucosil Acetylcysteine] |
2 |
Generic |
$17.00 | $34.00 | P |
ACITRETIN 10 MG CAPSULE [Soriatane] |
2 |
Generic |
$17.00 | $34.00 | None |
ACITRETIN 17.5 MG CAPSULE [Soriatane] |
2 |
Generic |
$17.00 | $34.00 | None |
ACITRETIN 25 MG CAPSULE [Soriatane] |
2 |
Generic |
$17.00 | $34.00 | None |
ACTHIB VACCINE WITH DILUENT |
6 |
Tier 6 |
$8.00 | $16.00 | 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 |
5 |
Tier 5 |
25% | 25% | P |
ACYCLOVIR 200 MG CAPSULE [Zovirax] |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION [Zovirax Suspension] |
2 |
Generic |
$17.00 | $34.00 | None |
ACYCLOVIR 400 MG TABLET |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
ACYCLOVIR 5% OINTMENT [Zovirax] |
2 |
Generic |
$17.00 | $34.00 | None |
ACYCLOVIR 800 MG TABLET |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
ACYCLOVIR SODIUM 500 MG VIAL |
2 |
Generic |
$17.00 | $34.00 | P |
ADACEL TDAP SYRINGE |
6 |
Tier 6 |
$8.00 | $16.00 | None |
ADACEL VIAL 2UNT/5UNT |
6 |
Tier 6 |
$8.00 | $16.00 | None |
ADAPALENE 0.1% CREAM (G) [Differin] |
2 |
Generic |
$17.00 | $34.00 | None |
ADAPALENE 0.3% GEL [Differin Pump] |
2 |
Generic |
$17.00 | $34.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ADAPALENE-BNZYL PEROX 0.1-2.5% GEL W/PUMP [Epiduo] |
2 |
Generic |
$17.00 | $34.00 | P |
ADEFOVIR DIPIVOXIL 10 MG TABLET [Hepsera] |
2 |
Generic |
$17.00 | $34.00 | P |
ADEMPAS 0.5 MG TABLET |
5 |
Tier 5 |
25% | 25% | P |
ADEMPAS 1 MG TABLET |
5 |
Tier 5 |
25% | 25% | P |
ADEMPAS 1.5 MG TABLET |
5 |
Tier 5 |
25% | 25% | P |
ADEMPAS 2 MG TABLET |
5 |
Tier 5 |
25% | 25% | P |
ADEMPAS 2.5 MG TABLET |
5 |
Tier 5 |
25% | 25% | P |
AFINITOR DISPERZ 2 MG TABLET |
5 |
Tier 5 |
25% | 25% | P Q:300.00 /30Days |
AFINITOR DISPERZ 3 MG TABLET |
5 |
Tier 5 |
25% | 25% | P Q:180.00 /30Days |
AFINITOR DISPERZ 5 MG TABLET |
5 |
Tier 5 |
25% | 25% | P Q:120.00 /30Days |
AKEEGA 100-500 MG TABLET |
5 |
Tier 5 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AKEEGA 50-500 MG TABLET |
5 |
Tier 5 |
25% | 25% | P |
ALBENDAZOLE 200 MG TABLET [Albenza] |
2 |
Generic |
$17.00 | $34.00 | None |
ALBUTEROL 2.5 MG/0.5 ML SOL VIAL-NEB |
2 |
Generic |
$17.00 | $34.00 | P Q:60.00 /30Days |
ALBUTEROL HFA 90 MCG INHALER HFA AER AD [Ventolin HFA] |
2 |
Generic |
$17.00 | $34.00 | Q:36.00 /30Days |
ALBUTEROL SUL 0.63 MG/3 ML SOLUTION VIAL-NEB [Accuneb] |
2 |
Generic |
$17.00 | $34.00 | P Q:360.00 /30Days |
ALBUTEROL SUL 1.25 MG/3 ML SOLUTION VIAL-NEB [Accuneb] |
2 |
Generic |
$17.00 | $34.00 | P Q:360.00 /30Days |
ALBUTEROL SULF 2 MG/5 ML SYRUP |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
ALBUTEROL SULFATE 2.5 MG/3 ML SOLUTION VIAL-NEB |
2 |
Generic |
$17.00 | $34.00 | P Q:360.00 /30Days |
ALECENSA 150 MG CAPSULE |
5 |
Tier 5 |
25% | 25% | P |
ALENDRONATE SOD 70 MG/75 ML SOLUTION [Fosamax] |
2 |
Generic |
$17.00 | $34.00 | None |
ALENDRONATE SODIUM 10 MG TABLET [Fosamax] |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALENDRONATE SODIUM 35 MG TABLET [Fosamax] |
1 |
Preferred Generic |
$16.00 | $32.00 | Q:4.00 /28Days |
ALENDRONATE SODIUM 70 MG TABLET [Fosamax] |
1 |
Preferred Generic |
$16.00 | $32.00 | Q:4.00 /28Days |
ALFUZOSIN HCL ER 10 MG TABLET |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
ALISKIREN 150 MG TABLET [Tekturna] |
6 |
Tier 6 |
$8.00 | $16.00 | None |
ALISKIREN 300 MG TABLET [Tekturna] |
6 |
Tier 6 |
$8.00 | $16.00 | None |
ALLOPURINOL 100 MG TABLET [Zyloprim] |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
ALLOPURINOL 300 MG TABLET [Zyloprim] |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
ALOSETRON HCL 0.5 MG TABLET [Lotronex] |
2 |
Generic |
$17.00 | $34.00 | None |
ALOSETRON HCL 1 MG TABLET [Lotronex] |
2 |
Generic |
$17.00 | $34.00 | None |
ALPHAGAN P 0.1% EYE DROPS |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
ALPRAZOLAM 0.25 MG TABLET [Xanax] |
1 |
Preferred Generic |
$16.00 | $32.00 | Q:120.00 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALPRAZOLAM 0.5 MG TABLET [Xanax] |
1 |
Preferred Generic |
$16.00 | $32.00 | Q:120.00 /30Days |
ALPRAZOLAM 1 MG TABLET [Xanax] |
1 |
Preferred Generic |
$16.00 | $32.00 | Q:120.00 /30Days |
ALPRAZOLAM 2 MG TABLET [Xanax] |
1 |
Preferred Generic |
$16.00 | $32.00 | Q:150.00 /30Days |
ALUNBRIG 180 MG TABLET |
5 |
Tier 5 |
25% | 25% | P |
ALUNBRIG 30 MG TABLET |
5 |
Tier 5 |
25% | 25% | P |
ALUNBRIG 90 MG TABLET |
5 |
Tier 5 |
25% | 25% | P |
ALUNBRIG 90 MG-180 MG TABLET PACK |
5 |
Tier 5 |
25% | 25% | P |
AMANTADINE 100 MG CAPSULE [Symmetrel] |
2 |
Generic |
$17.00 | $34.00 | None |
AMANTADINE 50 MG/5 ML SOLUTION |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
AMIKACIN SULF 500 MG/2 ML VIAL |
2 |
Generic |
$17.00 | $34.00 | None |
AMILORIDE HCL 5 MG TABLET [Midamor] |
2 |
Generic |
$17.00 | $34.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMILORIDE HCL-HCTZ 5-50 MG TABLET [Moduretic] |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
Amino acids 4.25% in dextrose 10% Injectable Solution [Clinimix 4.25/10] |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P |
AMIODARONE HCL 100 MG TABLET [Pacerone] |
2 |
Generic |
$17.00 | $34.00 | None |
AMIODARONE HCL 200 MG TABLET [Pacerone] |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
AMIODARONE HCL 400 MG TABLET [Pacerone] |
2 |
Generic |
$17.00 | $34.00 | None |
AMITRIPTYLINE HCL 10 MG TABLET [Elavil] |
2 |
Generic |
$17.00 | $34.00 | None |
AMITRIPTYLINE HCL 100 MG TABLET [Elavil] |
2 |
Generic |
$17.00 | $34.00 | None |
AMITRIPTYLINE HCL 150 MG TABLET |
2 |
Generic |
$17.00 | $34.00 | None |
AMITRIPTYLINE HCL 25 MG TABLET [Elavil] |
2 |
Generic |
$17.00 | $34.00 | None |
AMITRIPTYLINE HCL 50 MG TABLET [Vanatrip] |
2 |
Generic |
$17.00 | $34.00 | None |
AMITRIPTYLINE HCL 75 MG TABLET |
2 |
Generic |
$17.00 | $34.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMLODIPINE BESYLATE 10 MG TABLET [Norvasc] |
1 |
Preferred Generic |
$16.00 | $32.00 | Q:30.00 /30Days |
AMLODIPINE BESYLATE 2.5 MG TABLET [Norvasc] |
1 |
Preferred Generic |
$16.00 | $32.00 | Q:30.00 /30Days |
AMLODIPINE BESYLATE 5 MG TABLET [Norvasc] |
1 |
Preferred Generic |
$16.00 | $32.00 | Q:60.00 /30Days |
AMLODIPINE-ATORVAST 10-10 MG [Caduet] |
6 |
Tier 6 |
$8.00 | $16.00 | None |
AMLODIPINE-ATORVAST 10-20 MG [Caduet] |
6 |
Tier 6 |
$8.00 | $16.00 | None |
AMLODIPINE-ATORVAST 10-40 MG [Caduet] |
6 |
Tier 6 |
$8.00 | $16.00 | None |
Amlodipine-Atorvastatin 10-80 mg [Caduet] |
6 |
Tier 6 |
$8.00 | $16.00 | None |
Amlodipine-Atorvastatin 2.5-10 mg [Caduet] |
6 |
Tier 6 |
$8.00 | $16.00 | None |
Amlodipine-Atorvastatin 2.5-20 mg [Caduet] |
6 |
Tier 6 |
$8.00 | $16.00 | None |
Amlodipine-Atorvastatin 2.5-40 mg [Caduet] |
6 |
Tier 6 |
$8.00 | $16.00 | None |
Amlodipine-Atorvastatin 5-10 mg [Caduet] |
6 |
Tier 6 |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Amlodipine-Atorvastatin 5-20 mg [Caduet] |
6 |
Tier 6 |
$8.00 | $16.00 | None |
Amlodipine-Atorvastatin 5-40 mg [Caduet] |
6 |
Tier 6 |
$8.00 | $16.00 | None |
Amlodipine-Atorvastatin 5-80 mg [Caduet] |
6 |
Tier 6 |
$8.00 | $16.00 | None |
AMLODIPINE-BENAZEPRIL 10-20 MG CAPSULE [Lotrel] |
6 |
Tier 6 |
$8.00 | $16.00 | None |
AMLODIPINE-BENAZEPRIL 10-40 MG CAPSULE [Lotrel] |
6 |
Tier 6 |
$8.00 | $16.00 | None |
AMLODIPINE-BENAZEPRIL 2.5-10 CAPSULE [Lotrel] |
6 |
Tier 6 |
$8.00 | $16.00 | None |
AMLODIPINE-BENAZEPRIL 5-10 MG CAPSULE [Lotrel] |
6 |
Tier 6 |
$8.00 | $16.00 | None |
AMLODIPINE-BENAZEPRIL 5-20 MG CAPSULE [Lotrel] |
6 |
Tier 6 |
$8.00 | $16.00 | None |
AMLODIPINE-BENAZEPRIL 5-40 MG CAPSULE [Lotrel] |
6 |
Tier 6 |
$8.00 | $16.00 | None |
AMMONIUM LACTATE 12% CREAM (g) [Lac-Hydrin] |
2 |
Generic |
$17.00 | $34.00 | None |
AMMONIUM LACTATE 12% LOTION |
2 |
Generic |
$17.00 | $34.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE [Augmentin] |
2 |
Generic |
$17.00 | $34.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin] |
2 |
Generic |
$17.00 | $34.00 | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE [Augmentin] |
2 |
Generic |
$17.00 | $34.00 | None |
AMOX-CLAV 200-28.5 MG/5 ML SUS |
2 |
Generic |
$17.00 | $34.00 | None |
AMOX-CLAV 250-62.5 MG/5 ML ORAL SUSPENSION [Augmentin] |
2 |
Generic |
$17.00 | $34.00 | None |
AMOX-CLAV 400-57 MG/5 ML ORAL SUSPENSION [Augmentin] |
2 |
Generic |
$17.00 | $34.00 | None |
AMOX-CLAV 500-125 MG TABLET [Augmentin] |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
AMOX-CLAV 600-42.9 MG/5 ML SUS |
2 |
Generic |
$17.00 | $34.00 | None |
AMOX-CLAV 875-125 MG TABLET [Augmentin] |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
AMOX-CLAV ER 1,000-62.5 MG TABLET [Augmentin] |
2 |
Generic |
$17.00 | $34.00 | None |
AMOXAPINE 100MG TABLET |
2 |
Generic |
$17.00 | $34.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXAPINE 150MG TABLET |
2 |
Generic |
$17.00 | $34.00 | None |
AMOXAPINE 25MG TABLET |
2 |
Generic |
$17.00 | $34.00 | None |
AMOXAPINE 50MG TABLET |
2 |
Generic |
$17.00 | $34.00 | None |
AMOXICILLIN 125 MG/5 ML SUSP |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
AMOXICILLIN 125MG CHEWABLE TABLET |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION [Amoxil] |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
AMOXICILLIN 250 MG CHEWABLE TABLET |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
AMOXICILLIN 250 MG CAPSULE [Trimox] |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION [Trimox] |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [Amoxil] |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
AMOXICILLIN 500 MG CAPSULE [Trimox] |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOXICILLIN 875 MG TABLET |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
2 |
Generic |
$17.00 | $34.00 | None |
AMPHETAMINE SALT COMBO 15MG TABLET |
2 |
Generic |
$17.00 | $34.00 | None |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
2 |
Generic |
$17.00 | $34.00 | None |
AMPHETAMINE SALTS 5 MG TABLET |
2 |
Generic |
$17.00 | $34.00 | None |
AMPHOTERICIN B 50 MG VIAL [Fungizone] |
2 |
Generic |
$17.00 | $34.00 | P |
AMPICILLIN 1 GM VIAL |
2 |
Generic |
$17.00 | $34.00 | P |
AMPICILLIN 10 GM VIAL |
2 |
Generic |
$17.00 | $34.00 | P |
AMPICILLIN 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS |
2 |
Generic |
$17.00 | $34.00 | P |
AMPICILLIN CAPSULES 500MG 100 BOTTLE |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
AMPICILLIN-SULBACTAM 15 GM VIAL [Unasyn] |
2 |
Generic |
$17.00 | $34.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN-SULBACTAM 3 GM VIAL [Unasyn] |
2 |
Generic |
$17.00 | $34.00 | None |
ANAGRELIDE HCL 0.5 MG CAPSULE [Agrylin] |
2 |
Generic |
$17.00 | $34.00 | None |
ANAGRELIDE HCL 1 MG CAPSULE [Agrylin] |
2 |
Generic |
$17.00 | $34.00 | None |
ANASTROZOLE 1 MG TABLET |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
ANORO ELLIPTA 62.5-25 MCG INH |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:60.00 /30Days |
APOKYN 30 MG/3 ML CARTRIDGE |
5 |
Tier 5 |
25% | 25% | None |
APREPITANT 125 MG CAPSULE [Emend] |
2 |
Generic |
$17.00 | $34.00 | P Q:2.00 /28Days |
APREPITANT 125-80-80 MG PACK CAPSULE DS PK [Emend] |
2 |
Generic |
$17.00 | $34.00 | P Q:6.00 /28Days |
APREPITANT 40 MG CAPSULE [Emend] |
2 |
Generic |
$17.00 | $34.00 | P Q:1.00 /30Days |
APREPITANT 80 MG CAPSULE [Emend] |
2 |
Generic |
$17.00 | $34.00 | P Q:4.00 /28Days |
APTIOM 200 MG TABLET |
5 |
Tier 5 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
APTIOM 400 MG TABLET |
5 |
Tier 5 |
25% | 25% | None |
APTIOM 600 MG TABLET |
5 |
Tier 5 |
25% | 25% | None |
APTIOM 800 MG TABLET |
5 |
Tier 5 |
25% | 25% | None |
APTIVUS 250MG CAPSULE |
5 |
Tier 5 |
25% | 25% | None |
ARANESP 10 MCG/0.4 ML SYRINGE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P |
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.5 mL in 1 SYRINGE |
5 |
Tier 5 |
25% | 25% | P |
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
5 |
Tier 5 |
25% | 25% | P |
ARANESP 200MCG/0.4ML SYRINGE |
5 |
Tier 5 |
25% | 25% | P |
ARANESP 200MCG/ML VIAL |
5 |
Tier 5 |
25% | 25% | P |
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.42 mL in 1 SYRING |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P |
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARANESP 500MCG/1ML SYRINGE |
5 |
Tier 5 |
25% | 25% | P |
ARANESP 60MCG/ML VIAL |
5 |
Tier 5 |
25% | 25% | P |
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.3 mL in 1 SYRINGE |
5 |
Tier 5 |
25% | 25% | P |
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR |
5 |
Tier 5 |
25% | 25% | P |
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR |
5 |
Tier 5 |
25% | 25% | P |
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P |
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P |
ARCALYST 220 MG VIAL |
5 |
Tier 5 |
25% | 25% | P |
AREXVY 120 MCG / 0.5 ML INJECTION SINGLE-DOSE VIAL 0.5 ML |
6 |
Tier 6 |
$8.00 | $16.00 | None |
ARIPIPRAZOLE 1 MG/ML SOLUTION [Abilify] |
2 |
Generic |
$17.00 | $34.00 | S |
ARIPIPRAZOLE 10 MG TABLET [Abilify] |
2 |
Generic |
$17.00 | $34.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ARIPIPRAZOLE 15 MG TABLET [Abilify] |
2 |
Generic |
$17.00 | $34.00 | None |
ARIPIPRAZOLE 2 MG TABLET [Abilify] |
2 |
Generic |
$17.00 | $34.00 | None |
ARIPIPRAZOLE 20 MG TABLET [Abilify] |
2 |
Generic |
$17.00 | $34.00 | None |
ARIPIPRAZOLE 30 MG TABLET [Abilify] |
2 |
Generic |
$17.00 | $34.00 | None |
ARIPIPRAZOLE 5 MG TABLET [Abilify] |
2 |
Generic |
$17.00 | $34.00 | None |
ARIPIPRAZOLE ODT 10 MG TABLET RAPDIS [Abilify Discmelt] |
2 |
Generic |
$17.00 | $34.00 | S |
ARIPIPRAZOLE ODT 15 MG TABLET RAPDIS [Abilify Discmelt] |
5 |
Tier 5 |
25% | 25% | S |
ASPIRIN-DIPYRIDAM ER 25-200 MG CPMP 12HR [Aggrenox] |
2 |
Generic |
$17.00 | $34.00 | None |
ATAZANAVIR SULFATE 150 MG CAPSULE [Reyataz] |
2 |
Generic |
$17.00 | $34.00 | None |
ATAZANAVIR SULFATE 200 MG CAPSULE [Reyataz] |
2 |
Generic |
$17.00 | $34.00 | None |
ATAZANAVIR SULFATE 300 MG CAPSULE [Reyataz] |
2 |
Generic |
$17.00 | $34.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATENOLOL 100 MG TABLET [Tenormin] |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
ATENOLOL 25 MG TABLET [Tenormin] |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
ATENOLOL 50 MG TABLET [Tenormin] |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
ATENOLOL-CHLORTHALIDONE 100-25 TABLET [Tenoretic] |
2 |
Generic |
$17.00 | $34.00 | None |
ATENOLOL-CHLORTHALIDONE 50-25 TABLET [Tenoretic] |
2 |
Generic |
$17.00 | $34.00 | None |
ATOMOXETINE HCL 10 MG CAPSULE [Strattera] |
2 |
Generic |
$17.00 | $34.00 | S Q:120.00 /30Days |
ATOMOXETINE HCL 100 MG CAPSULE [Strattera] |
2 |
Generic |
$17.00 | $34.00 | S Q:30.00 /30Days |
ATOMOXETINE HCL 18 MG CAPSULE [Strattera] |
2 |
Generic |
$17.00 | $34.00 | S Q:120.00 /30Days |
ATOMOXETINE HCL 25 MG CAPSULE [Strattera] |
2 |
Generic |
$17.00 | $34.00 | S Q:120.00 /30Days |
ATOMOXETINE HCL 40 MG CAPSULE [Strattera] |
2 |
Generic |
$17.00 | $34.00 | S Q:60.00 /30Days |
ATOMOXETINE HCL 60 MG CAPSULE [Strattera] |
2 |
Generic |
$17.00 | $34.00 | S Q:30.00 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATOMOXETINE HCL 80 MG CAPSULE [Strattera] |
2 |
Generic |
$17.00 | $34.00 | S Q:30.00 /30Days |
ATORVASTATIN 10 MG TABLET [Lipitor] |
6 |
Tier 6 |
$8.00 | $16.00 | None |
ATORVASTATIN 20 MG TABLET [Lipitor] |
6 |
Tier 6 |
$8.00 | $16.00 | None |
ATORVASTATIN 40 MG TABLET [Lipitor] |
6 |
Tier 6 |
$8.00 | $16.00 | None |
ATORVASTATIN 80 MG TABLET [Lipitor] |
6 |
Tier 6 |
$8.00 | $16.00 | None |
ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION [Mepron] |
2 |
Generic |
$17.00 | $34.00 | None |
Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone] |
2 |
Generic |
$17.00 | $34.00 | None |
ATOVAQUONE-PROGUANIL 62.5-25 [Malarone] |
2 |
Generic |
$17.00 | $34.00 | None |
ATROPINE 1% EYE DROPS [Isopto Atropine] |
2 |
Generic |
$17.00 | $34.00 | Q:15.00 /15Days |
ATROVENT HFA AER 17MCG |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | Q:25.80 /30Days |
AUGTYRO 40 MG CAPSULE |
5 |
Tier 5 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AUVELITY ER 45-105 MG TABLET IR ER |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | S Q:60.000 /30Days |
AVONEX PEN 30 MCG/0.5 ML KIT |
5 |
Tier 5 |
25% | 25% | P |
AVONEX PREFILLED SYR 30 MCG KT |
5 |
Tier 5 |
25% | 25% | P |
AYVAKIT 100 MG TABLET |
5 |
Tier 5 |
25% | 25% | P |
AYVAKIT 200 MG TABLET |
5 |
Tier 5 |
25% | 25% | P |
AYVAKIT 25 MG TABLET |
5 |
Tier 5 |
25% | 25% | P |
AYVAKIT 300 MG TABLET |
5 |
Tier 5 |
25% | 25% | P |
AYVAKIT 50 MG TABLET |
5 |
Tier 5 |
25% | 25% | P |
AZASAN 100 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P |
AZASAN 75 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P |
AZASITE 1% EYE DROPS |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZATHIOPRINE 50 MG TABLET [Imuran] |
2 |
Generic |
$17.00 | $34.00 | P |
AZELASTINE 137 MCG NASAL SPRAY |
2 |
Generic |
$17.00 | $34.00 | Q:30.00 /25Days |
AZELASTINE HCL 0.05% EYE DROPS [Optivar] |
2 |
Generic |
$17.00 | $34.00 | None |
AZITHROMYCIN 100 MG/5 ML ORAL SUSPENSION [Zithromax Powder] |
2 |
Generic |
$17.00 | $34.00 | None |
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [Zithromax Powder] |
2 |
Generic |
$17.00 | $34.00 | None |
AZITHROMYCIN 250 MG TABLET [Zithromax Z-Pak] |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
AZITHROMYCIN 250 MG TABLET [Zithromax Z-Pak] |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
AZITHROMYCIN 500 MG TABLET [Zithromax Tri-Pak] |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
AZITHROMYCIN 500 MG TABLET [Zithromax Tri-Pak] |
1 |
Preferred Generic |
$16.00 | $32.00 | None |
AZITHROMYCIN 600 MG TABLET [Zithromax Z-Pak] |
2 |
Generic |
$17.00 | $34.00 | None |
AZITHROMYCIN I.V. 500 MG VIAL [Zithromax Powder] |
2 |
Generic |
$17.00 | $34.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZTREONAM FOR INJECTION |
2 |
Generic |
$17.00 | $34.00 | None |