2009 Medicare Part D Plan Formulary Information |
Blue Rx Enhanced (S5766-003-0)
Benefit Details
|
The Blue Rx Enhanced (S5766-003-0) Formulary Drugs Starting with the Letter E in CMS PDP Region 5 which includes: DC DE MD
|
Drugs Starting with Letter E
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
E.E.S. 200MG/5ML GRANULES |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
E.E.S. 200MG/5ML SUSPENSION |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
E.E.S. 400 TABLET 400MG |
1 |
Generic |
$9.00 | N/A | None |
E.E.S. 400MG/5ML SUSPENSION |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EC-NAPROSYN 375MG TABLET EC |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EC-NAPROSYN 500MG TABLET EC |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ECONAZOLE NITRATE 1% CREAM 85GM TUBE |
1 |
Generic |
$9.00 | N/A | None |
ECONOPRED PLUS 1% EYE DROPS |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ED DOXY-CAPS 100MG CAPSULE |
1 |
Generic |
$9.00 | N/A | None |
ED K+10 TABLET |
1 |
Generic |
$9.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EDECRIN 25MG TABLET (100 CT) |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EDECRIN SODIUM 50MG VIAL |
4 |
Non-Self-Administered Medical Injectables |
25% | N/A | None |
EFFEXOR 100MG TABLET |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EFFEXOR 25MG TABLET (60 CT) |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EFFEXOR 37.5MG CAPSULE ER (90 CT) |
2 |
Preferred Brand |
$28.00 | N/A | None |
EFFEXOR 37.5MG TABLET |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EFFEXOR 50MG TABLET (30 CT) |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EFFEXOR 75MG TABLET (30 CT) |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EFFEXOR XR 150MG CAPSULE ER 15 CAPSULES BOT |
2 |
Preferred Brand |
$28.00 | N/A | None |
EFFEXOR XR 75MG CAPSULE ER 15 CAPSULES BOT |
2 |
Preferred Brand |
$28.00 | N/A | None |
EFUDEX 2% SOLUTION |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EFUDEX 5% CREAM |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EFUDEX 5% SOLUTION |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EFUDEX OCCLUSION PACK |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ELAPRASE 6MG/3ML VIAL |
4 |
Non-Self-Administered Medical Injectables |
25% | N/A | None |
ELDEPRYL 5MG CAPSULE |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ELESTAT 0.05% EYE DROPS |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ELESTRIN 0.87G GEL IN METERED-DOSE PUMP |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ELIDEL 1% CREAM |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ELIGARD 22.5MG SYRINGE |
2 |
Preferred Brand |
$28.00 | N/A | None |
ELIGARD 30MG SYRINGE |
2 |
Preferred Brand |
$28.00 | N/A | None |
ELIGARD 45MG SYRINGE |
2 |
Preferred Brand |
$28.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIGARD 7.5MG SYRINGE |
2 |
Preferred Brand |
$28.00 | N/A | None |
ELIMITE 5% CREAM |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ELITEK 1.5MG VIAL |
4 |
Non-Self-Administered Medical Injectables |
25% | N/A | None |
ELITEK 7.5MG VIAL |
4 |
Non-Self-Administered Medical Injectables |
25% | N/A | None |
ELIXOPHYLLIN 80MG/15ML ELIX |
1 |
Generic |
$9.00 | N/A | None |
ELLENCE 2MG/ML VIAL |
4 |
Non-Self-Administered Medical Injectables |
25% | N/A | None |
ELMIRON 100MG CAPSULE |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ELOCON 0.1% CREAM |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ELOCON 0.1% LOTION |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ELOCON 0.1% OINTMENT |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ELOXATIN 100MG/20ML VIAL |
4 |
Non-Self-Administered Medical Injectables |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELOXATIN 50MG/10ML VIAL |
4 |
Non-Self-Administered Medical Injectables |
25% | N/A | None |
ELSPAR INJ 10000UNT |
4 |
Non-Self-Administered Medical Injectables |
25% | N/A | None |
EMADINE 0.05% EYE DROPS |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EMCYT 140MG CAPSULE |
2 |
Preferred Brand |
$28.00 | N/A | None |
EMEND 125MG CAPSULE |
2 |
Preferred Brand |
$28.00 | N/A | Q:2 /1Days |
EMEND 40MG CAPSULE |
2 |
Preferred Brand |
$28.00 | N/A | Q:1 /1Days |
EMEND 80MG CAPSULE |
2 |
Preferred Brand |
$28.00 | N/A | Q:4 /1Days |
EMEND TRIFOLD PACK |
2 |
Preferred Brand |
$28.00 | N/A | Q:6 /1Days |
EMLA CREAM 25MG/25MG |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EMLA CREAM W/TEGADERM 25MG/25MG |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EMSAM 12MG/24 HOURS PATCH |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMSAM 6MG/24 HOURS PATCH |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EMSAM 9MG/24 HOURS PATCH |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EMTRIVA 10MG/ML SOLUTION |
2 |
Preferred Brand |
$28.00 | N/A | None |
EMTRIVA 200MG CAPSULE |
2 |
Preferred Brand |
$28.00 | N/A | None |
ENABLEX 15MG TABLET |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ENABLEX 7.5MG TABLET |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ENALAPRIL MALEATE 10MG TABLET (100 CT) |
1 |
Generic |
$9.00 | N/A | None |
ENALAPRIL MALEATE 2.5MG TABLET |
1 |
Generic |
$9.00 | N/A | None |
ENALAPRIL MALEATE 20MG TABLET (1000 CT) |
1 |
Generic |
$9.00 | N/A | None |
ENALAPRIL MALEATE 5MG TABLET |
1 |
Generic |
$9.00 | N/A | None |
ENALAPRIL MALEATE-HCTZ 10MG-25MG TABLET (100 CT) |
1 |
Generic |
$9.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET (100 CT) |
1 |
Generic |
$9.00 | N/A | None |
ENBREL 50MG/ML SURECLICK SYR |
2 |
Preferred Brand |
$28.00 | N/A | P |
ENBREL INJECTION 50MG/ML SYR |
2 |
Preferred Brand |
$28.00 | N/A | P |
ENBREL INJECTION KIT 25MG 1 DOSE TRAY PKGCOM |
2 |
Preferred Brand |
$28.00 | N/A | P |
ENDOCET 10/650MG TABLET |
1 |
Generic |
$9.00 | N/A | None |
ENDOCET 10MG-325MG TABLET |
1 |
Generic |
$9.00 | N/A | None |
ENDOCET 5/325 TABLET |
1 |
Generic |
$9.00 | N/A | None |
ENDOCET 7.5-325MG TABLET |
1 |
Generic |
$9.00 | N/A | None |
ENDOCET 7.5/500MG TABLET |
1 |
Generic |
$9.00 | N/A | None |
ENGERIX-B 10MCG 10 X 0.5ML VIALSD |
4 |
Non-Self-Administered Medical Injectables |
25% | N/A | None |
ENGERIX-B 10MCG/0.5ML SYRN |
4 |
Non-Self-Administered Medical Injectables |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENGERIX-B 20MCG/ML SYRINGE |
4 |
Non-Self-Administered Medical Injectables |
25% | N/A | None |
ENJUVIA 0.3MG TABLET |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ENJUVIA 0.45MG TABLET |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ENJUVIA 0.625MG TABLET |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ENJUVIA 0.9MG TABLET |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ENJUVIA 1.25MG TABLET |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ENPRESSE-28 TABLET |
1 |
Generic |
$9.00 | N/A | None |
ENTOCORT EC 3MG CAPSULE |
2 |
Preferred Brand |
$28.00 | N/A | None |
ENULOSE SYRUP 10GM/15ML 1 PINT BOTPL |
1 |
Generic |
$9.00 | N/A | None |
ENZYMAX 500MG TABLET |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EPIDUO GEL 0.1;2.5%;% 45 TRADE SIZE TUBE |
3 |
Non-Preferred Brand |
$66.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPINEPHRINE 0.1MG/ML ABBJCT |
4 |
Non-Self-Administered Medical Injectables |
25% | N/A | None |
EPIPEN 0.3MG AUTO-INJECTOR |
2 |
Preferred Brand |
$28.00 | N/A | Q:2 /1Days |
EPIPEN JR 0.15MG AUTO-INJCT |
2 |
Preferred Brand |
$28.00 | N/A | Q:2 /1Days |
EPIRUBICIN HCL INJECTION SOLUTION 2MG 1 X 25ML VIAL |
4 |
Non-Self-Administered Medical Injectables |
25% | N/A | None |
EPITOL 200MG TABLET |
1 |
Generic |
$9.00 | N/A | None |
EPIVIR 10MG/ML ORAL SOLUTION |
2 |
Preferred Brand |
$28.00 | N/A | None |
EPIVIR 150MG TABLET |
2 |
Preferred Brand |
$28.00 | N/A | None |
EPIVIR 300MG TABLET |
2 |
Preferred Brand |
$28.00 | N/A | None |
EPIVIR HBV 100MG TABLET |
2 |
Preferred Brand |
$28.00 | N/A | None |
EPIVIR HBV 25MG/5ML TUBEX |
2 |
Preferred Brand |
$28.00 | N/A | None |
EPLERENONE 25MG TABS |
1 |
Generic |
$9.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPLERENONE 50MG TABS |
1 |
Generic |
$9.00 | N/A | None |
EPOGEN 10000U/ML VIAL MDV |
3 |
Non-Preferred Brand |
$66.00 | N/A | P |
EPOGEN 2000U/ML VIAL SDV |
3 |
Non-Preferred Brand |
$66.00 | N/A | P |
EPOGEN 3000U/ML VIAL SDV |
3 |
Non-Preferred Brand |
$66.00 | N/A | P |
EPOGEN 4000U/ML VIAL SDV |
3 |
Non-Preferred Brand |
$66.00 | N/A | P |
EPOGEN INJECTION 20000U 10 X 1ML CRTN |
3 |
Non-Preferred Brand |
$66.00 | N/A | P |
EPOGEN INJECTION 40000U 10 X 4ML VIALS VIALSD |
3 |
Non-Preferred Brand |
$66.00 | N/A | P |
EPZICOM TABLET |
2 |
Preferred Brand |
$28.00 | N/A | None |
EQUAGESIC TABLET |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EQUETRO 100MG CAPSULE |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EQUETRO 200MG CAPSULE |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EQUETRO 300MG CAPSULE |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ERAXIS 100MG VIAL |
4 |
Non-Self-Administered Medical Injectables |
25% | N/A | None |
ERAXIS 50MG VIAL |
4 |
Non-Self-Administered Medical Injectables |
25% | N/A | None |
ERBITUX 100MG/50ML VIAL |
4 |
Non-Self-Administered Medical Injectables |
25% | N/A | None |
ERGOLOID MESYLATES 1MG TABLET (500 CT) |
1 |
Generic |
$9.00 | N/A | None |
ERGOMAR SUBLINGUAL TABLET 2MG |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ERGOTAMINE-CAFFEINE 1-100MG TABLET |
1 |
Generic |
$9.00 | N/A | None |
ERRIN 0.35MG TABLET |
1 |
Generic |
$9.00 | N/A | None |
ERTACZO 2% CREAM |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ERY 2% SWAB MEDICATED |
1 |
Generic |
$9.00 | N/A | None |
ERY-TAB 250MG TABLET EC |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERY-TAB 333MG TABLET EC |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ERY-TAB 500MG TABLET EC |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ERYDERM 2% TOP SOLUTION |
1 |
Generic |
$9.00 | N/A | None |
ERYGEL 2% GEL |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ERYPED 100MG/2.5ML DROPS |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ERYPED 400MG/5ML GRANULES |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ERYPED-200MG/5ML GRANULES |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ERYTHROCIN 250MG FILMTAB |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ERYTHROCIN 500MG ADDVNT VL |
4 |
Non-Self-Administered Medical Injectables |
25% | N/A | None |
ERYTHROCIN 500MG FILMTAB |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ERYTHROCIN 500MG VIAL |
4 |
Non-Self-Administered Medical Injectables |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROCIN LACTOBIONATE IV POWDER FOR INJECTION |
4 |
Non-Self-Administered Medical Injectables |
25% | N/A | None |
ERYTHROMYCIN 2% GEL |
1 |
Generic |
$9.00 | N/A | None |
ERYTHROMYCIN 2% SOLUTION |
1 |
Generic |
$9.00 | N/A | None |
ERYTHROMYCIN 200MG/5ML SUSP |
1 |
Generic |
$9.00 | N/A | None |
ERYTHROMYCIN 250MG CAP EC |
1 |
Generic |
$9.00 | N/A | None |
ERYTHROMYCIN 250MG FILMTAB |
1 |
Generic |
$9.00 | N/A | None |
ERYTHROMYCIN 400MG/5ML SUSP |
1 |
Generic |
$9.00 | N/A | None |
ERYTHROMYCIN 500MG FILMTAB |
1 |
Generic |
$9.00 | N/A | None |
ERYTHROMYCIN ETHYLSUCCINATE 400MG TABLET (500 CT) |
1 |
Generic |
$9.00 | N/A | None |
ERYTHROMYCIN OPHTHALMIC OINTMENT 5MG 1/8 OZ TUBE |
1 |
Generic |
$9.00 | N/A | None |
ERYTHROMYCIN-BENZOYL PEROXIDE 3-5% GEL |
1 |
Generic |
$9.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROMYCIN/SULFISOX SUSP |
1 |
Generic |
$9.00 | N/A | None |
ESTRACE 0.5MG TABLET |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ESTRACE 2MG TABLET |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ESTRACE TABLET 1MG (100 CT) |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ESTRACE VAG CREAM 0.1MG/GM |
2 |
Preferred Brand |
$28.00 | N/A | None |
ESTRADERM 0.05MG/24H PATCH TRANSDERMAL SEMIWEEKLY |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ESTRADERM 0.1MG/24HR PATCH TRANSDERMAL SEMIWEEKLY |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ESTRADIOL .025MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Generic |
$9.00 | N/A | None |
ESTRADIOL .0375MG/24 PATCH TRANSDERMAL WEEKLY |
1 |
Generic |
$9.00 | N/A | None |
ESTRADIOL .075MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Generic |
$9.00 | N/A | None |
ESTRADIOL 0.05MG/DAY PATCH |
1 |
Generic |
$9.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL 0.06MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Generic |
$9.00 | N/A | None |
ESTRADIOL 0.1MG/DAY PATCH |
1 |
Generic |
$9.00 | N/A | None |
ESTRADIOL 0.5MG TABLET |
1 |
Generic |
$9.00 | N/A | None |
ESTRADIOL 2MG TABLET |
1 |
Generic |
$9.00 | N/A | None |
ESTRADIOL TABLET 1MG (500 CT) |
1 |
Generic |
$9.00 | N/A | None |
ESTRADIOL VALERATE INJECTION |
4 |
Non-Self-Administered Medical Injectables |
25% | N/A | None |
ESTRADIOL VALERATE INJECTION |
4 |
Non-Self-Administered Medical Injectables |
25% | N/A | None |
ESTRADIOL VALERATE INJECTION |
4 |
Non-Self-Administered Medical Injectables |
25% | N/A | None |
ESTRADIOL-NORETH 1.0-0.5MG TABLET |
1 |
Generic |
$9.00 | N/A | None |
ESTRASORB 2.5MG 56 POU |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ESTRING 2MG VAGINAL RING |
3 |
Non-Preferred Brand |
$66.00 | N/A | Q:1 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTROGEL 0.06% GEL |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ESTROPIPATE 0.625 TABLET |
1 |
Generic |
$9.00 | N/A | None |
ESTROPIPATE 1.25 TABLET |
1 |
Generic |
$9.00 | N/A | None |
ESTROPIPATE 2.5 TABLET |
1 |
Generic |
$9.00 | N/A | None |
ESTROSTEP FE-28 TABLET |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
ETHAMBUTOL HCL 100MG TABLET |
1 |
Generic |
$9.00 | N/A | None |
ETHAMBUTOL HCL 400MG TABLET (100 CT) |
1 |
Generic |
$9.00 | N/A | None |
ETHOSUXIMIDE 250MG CAPSULE |
1 |
Generic |
$9.00 | N/A | None |
ETHOSUXIMIDE 250MG/5ML SYRP |
1 |
Generic |
$9.00 | N/A | None |
ETHYOL POWDER FOR INJECTION 500MG 3 X 10ML VILSU CRTN |
4 |
Non-Self-Administered Medical Injectables |
25% | N/A | None |
ETIDRONATE DISODIUM 200MG TABLET |
1 |
Generic |
$9.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETIDRONATE DISODIUM 400MG TABLET (60 CT) |
1 |
Generic |
$9.00 | N/A | None |
ETODOLAC 200MG CAPSULE |
1 |
Generic |
$9.00 | N/A | None |
ETODOLAC 300MG CAPSULE |
1 |
Generic |
$9.00 | N/A | None |
ETODOLAC 400MG TABLET (500 CT) |
1 |
Generic |
$9.00 | N/A | None |
ETODOLAC 400MG TABLET SR 24HR |
1 |
Generic |
$9.00 | N/A | None |
ETODOLAC 500MG TABLET (100 CT) |
1 |
Generic |
$9.00 | N/A | None |
ETODOLAC 500MG TABLET SR 24HR |
1 |
Generic |
$9.00 | N/A | None |
ETODOLAC 600MG TABLET SR 24HR |
1 |
Generic |
$9.00 | N/A | None |
ETOPOPHOS 100MG VIAL |
4 |
Non-Self-Administered Medical Injectables |
25% | N/A | None |
ETOPOSIDE INJECTION 20MG 25ML VIALMD |
4 |
Non-Self-Administered Medical Injectables |
25% | N/A | None |
EURAX 10% CREAM |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EURAX 10% LOTION |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EVAMIST 1.53/SPRAY SPRAY NON-AEROSOL |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EVISTA 60MG TABLET (30 CT) |
2 |
Preferred Brand |
$28.00 | N/A | None |
EVOCLIN 1% FOAM |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EVOXAC 30MG CAPSULE |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EXELDERM 1% CREAM |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EXELDERM 1% SOLUTION |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EXELON 1.5MG CAPSULE |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EXELON 2MG/ML ORAL SOLUTION |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EXELON 3MG CAPSULE |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EXELON 4.5MG CAPSULE |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EXELON 6MG CAPSULE |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EXFORGE 10MG-160MG TABLET |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EXFORGE 10MG-320MG TABLET |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EXFORGE 5MG-160MG TABLET |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EXFORGE 5MG-320MG TABLET |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EXJADE 125MG TABLET |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EXJADE 250MG TABLET |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EXJADE 500MG TABLET |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |
EXTINA 2% FOAM |
3 |
Non-Preferred Brand |
$66.00 | N/A | None |