2010 Medicare Part D Plan Formulary Information |
SeniorChoice Secure (HMO) (H3351-002-0)
Benefit Details
|
The SeniorChoice Secure (HMO) (H3351-002-0) Formulary Drugs Starting with the Letter E in Erie County, NY: CMS MA Region 3 which includes: NY
|
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 |
Tier 3 |
$75.00 | $187.50 | None |
EC-NAPROSYN 375MG TABLET EC |
3 |
Tier 3 |
$75.00 | $187.50 | S |
EC-NAPROSYN 500MG TABLET EC |
3 |
Tier 3 |
$75.00 | $187.50 | S |
ECONAZOLE NITRATE 1% CREAM 85GM TUBE |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ED DOXY-CAPS 100MG CAPSULE |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ED K+10 TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
EDECRIN 25MG TABLET (100 CT) |
3 |
Tier 3 |
$75.00 | $187.50 | None |
EES 400 TABLET 400MG 100 BOT |
1 |
Tier 1 |
$5.00 | $12.50 | None |
EFFEXOR 100MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | S |
EFFEXOR 25MG TABLET (60 CT) |
3 |
Tier 3 |
$75.00 | $187.50 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EFFEXOR 37.5MG CAPSULE ER (90 CT) |
3 |
Tier 3 |
$75.00 | $187.50 | S Q:30 /30Days |
EFFEXOR 37.5MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | S |
EFFEXOR 50MG TABLET (30 CT) |
3 |
Tier 3 |
$75.00 | $187.50 | S |
EFFEXOR XR 150MG CAPSULE ER 15 CAPSULES BOT |
3 |
Tier 3 |
$75.00 | $187.50 | S Q:60 /30Days |
EFFEXOR XR 75MG CAPSULE ER 15 CAPSULES BOT |
3 |
Tier 3 |
$75.00 | $187.50 | S Q:30 /30Days |
EFUDEX 5% CREAM |
3 |
Tier 3 |
$75.00 | $187.50 | None |
EFUDEX SOLUTION TOPICAL 5% 10 ML BOTDR |
3 |
Tier 3 |
$75.00 | $187.50 | None |
ELAPRASE 6MG/3ML VIAL |
4 |
Tier 4 |
33% | 33% | P |
ELDEPRYL 5MG CAPSULE |
3 |
Tier 3 |
$75.00 | $187.50 | None |
ELESTAT 0.05% EYE DROPS |
3 |
Tier 3 |
$75.00 | $187.50 | None |
ELESTRIN 0.87G GEL IN METERED-DOSE PUMP |
3 |
Tier 3 |
$75.00 | $187.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIDEL 1% CREAM |
3 |
Tier 3 |
$75.00 | $187.50 | Q:100 /30Days |
ELIGARD 22.5MG SYRINGE |
3 |
Tier 3 |
$75.00 | $187.50 | P |
ELIGARD 30MG SYRINGE |
3 |
Tier 3 |
$75.00 | $187.50 | P |
ELIGARD 45MG SYRINGE |
3 |
Tier 3 |
$75.00 | $187.50 | P |
ELIGARD 7.5MG SYRINGE |
3 |
Tier 3 |
$75.00 | $187.50 | P |
ELIMITE 5% CREAM |
3 |
Tier 3 |
$75.00 | $187.50 | None |
ELIPHOS TABLETS CALCIUM ACETATE TABLETS 667MG 200 BOT |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ELITEK 1.5MG VIAL |
4 |
Tier 4 |
33% | 33% | None |
ELIXOPHYLLIN 80MG/15ML ELIX |
3 |
Tier 3 |
$75.00 | $187.50 | None |
ELLENCE 2MG/ML VIAL |
4 |
Tier 4 |
33% | 33% | None |
ELMIRON CAPSULES 100MG |
2 |
Tier 2 |
$30.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELOCON 0.1% CREAM |
3 |
Tier 3 |
$75.00 | $187.50 | S |
ELOCON 0.1% LOTION |
3 |
Tier 3 |
$75.00 | $187.50 | S |
ELOCON 0.1% OINTMENT |
3 |
Tier 3 |
$75.00 | $187.50 | S |
ELOXATIN 100MG/20ML VIAL |
4 |
Tier 4 |
33% | 33% | None |
ELSPAR INJ 10000UNT |
2 |
Tier 2 |
$30.00 | $75.00 | None |
EMADINE 0.05% EYE DROPS |
3 |
Tier 3 |
$75.00 | $187.50 | None |
EMCYT 140MG CAPSULE |
2 |
Tier 2 |
$30.00 | $75.00 | None |
EMEND 40MG CAPSULE |
3 |
Tier 3 |
$75.00 | $187.50 | P Q:4 /30Days |
EMEND CAPSULES 125MG 6 BLPK |
3 |
Tier 3 |
$75.00 | $187.50 | P Q:2 /30Days |
EMEND CAPSULES 80MG 2 BLPK |
3 |
Tier 3 |
$75.00 | $187.50 | P Q:4 /30Days |
EMEND TRIFOLD PACK |
3 |
Tier 3 |
$75.00 | $187.50 | P Q:6 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMLA CREAM 2.5%/2.5% 30 GM TUBE |
3 |
Tier 3 |
$75.00 | $187.50 | None |
EMSAM 12MG/24 HOURS PATCH |
3 |
Tier 3 |
$75.00 | $187.50 | S Q:30 /30Days |
EMSAM 6MG/24 HOURS PATCH |
3 |
Tier 3 |
$75.00 | $187.50 | S Q:30 /30Days |
EMSAM 9MG/24 HOURS PATCH |
3 |
Tier 3 |
$75.00 | $187.50 | S Q:30 /30Days |
EMTRIVA 10MG/ML SOLUTION |
2 |
Tier 2 |
$30.00 | $75.00 | None |
EMTRIVA 200MG CAPSULE |
2 |
Tier 2 |
$30.00 | $75.00 | None |
ENABLEX 15MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | S Q:30 /30Days |
ENABLEX 7.5MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | S Q:30 /30Days |
ENALAPRIL MALEATE 10MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ENALAPRIL MALEATE 2.5MG TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ENALAPRIL MALEATE 20MG TABLET (1000 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENALAPRIL MALEATE TABLETS 5MG |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ENALAPRIL MALEATE-HCTZ 10MG-25MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ENBREL 50MG/ML SURECLICK SYR |
4 |
Tier 4 |
33% | 33% | P Q:8 /28Days |
ENBREL INJECTION 50MG/ML SYR |
4 |
Tier 4 |
33% | 33% | P Q:8 /28Days |
ENBREL INJECTION KIT 25MG 1 DOSE TRAY PKGCOM |
4 |
Tier 4 |
33% | 33% | P Q:16 /28Days |
ENDOCET 10/650MG TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ENDOCET 10MG-325MG TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ENDOCET 5/325 TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ENDOCET 7.5-325MG TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ENDOCET 7.5/500MG TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENDODAN TABLETS 325;4.8355MG;MG 100 BOT |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ENGERIX-B 10MCG 10 X 0.5ML VIALSD |
3 |
Tier 3 |
$75.00 | $187.50 | P |
ENGERIX-B 10MCG/0.5ML SYRN |
3 |
Tier 3 |
$75.00 | $187.50 | P |
ENGERIX-B 20MCG/ML SYRINGE |
3 |
Tier 3 |
$75.00 | $187.50 | P |
ENJUVIA 0.3MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | Q:30 /30Days |
ENJUVIA 0.45MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | Q:30 /30Days |
ENJUVIA 0.625MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | Q:30 /30Days |
ENJUVIA 0.9MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | Q:30 /30Days |
ENJUVIA 1.25MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | Q:30 /30Days |
ENPRESSE-28 TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | Q:30 /30Days |
ENTOCORT EC 3MG CAPSULE |
3 |
Tier 3 |
$75.00 | $187.50 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENULOSE SYRUP 10GM/15ML 1 PINT BOTPL |
1 |
Tier 1 |
$5.00 | $12.50 | None |
EPIDUO GEL 0.1;2.5%;% 45 TRADE SIZE TUBE |
3 |
Tier 3 |
$75.00 | $187.50 | Q:45 /30Days |
EPINEPHRINE 0.1MG/ML ABBJCT |
1 |
Tier 1 |
$5.00 | $12.50 | None |
EPIPEN 0.3MG AUTO-INJECTOR |
2 |
Tier 2 |
$30.00 | $75.00 | Q:2 /30Days |
EPIPEN JR 0.15MG AUTO-INJCT |
2 |
Tier 2 |
$30.00 | $75.00 | Q:2 /30Days |
EPIRUBICIN HCL INJECTION SOLUTION 2MG 1 X 25ML VIAL |
1 |
Tier 1 |
$5.00 | $12.50 | None |
EPITOL 200MG TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
EPIVIR 10MG/ML ORAL SOLUTION |
2 |
Tier 2 |
$30.00 | $75.00 | None |
EPIVIR 150MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
EPIVIR 300MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | None |
EPIVIR HBV 100MG TABLET |
2 |
Tier 2 |
$30.00 | $75.00 | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPIVIR HBV 25MG/5ML TUBEX |
2 |
Tier 2 |
$30.00 | $75.00 | P Q:600 /30Days |
EPLERENONE 25MG TABS |
1 |
Tier 1 |
$5.00 | $12.50 | Q:30 /30Days |
EPLERENONE 50MG TABS |
1 |
Tier 1 |
$5.00 | $12.50 | Q:60 /30Days |
EPOGEN 10000U/ML VIAL MDV |
4 |
Tier 4 |
33% | 33% | P |
EPOGEN 2000U/ML VIAL SDV |
2 |
Tier 2 |
$30.00 | $75.00 | P Q:10 /30Days |
EPOGEN 3000U/ML VIAL SDV |
2 |
Tier 2 |
$30.00 | $75.00 | P Q:10 /30Days |
EPOGEN 4000U/ML VIAL SDV |
2 |
Tier 2 |
$30.00 | $75.00 | P Q:10 /30Days |
EPOGEN INJECTION 20000U 10 X 1ML CRTN |
4 |
Tier 4 |
33% | 33% | P |
EPOGEN INJECTION 40000U 10 X 4ML VIALS VIALSD |
4 |
Tier 4 |
33% | 33% | P |
EPZICOM TABLET |
4 |
Tier 4 |
33% | 33% | None |
EQUAGESIC TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EQUETRO CAPSULES 200MG 120 BOT |
3 |
Tier 3 |
$75.00 | $187.50 | None |
EQUETRO CAPSULES 300MG 120 BOT |
3 |
Tier 3 |
$75.00 | $187.50 | None |
EQUETRO EXTENDED RELEASE CAPSULES 100MG 120 BOT |
3 |
Tier 3 |
$75.00 | $187.50 | None |
ERAXIS 100MG VIAL |
3 |
Tier 3 |
$75.00 | $187.50 | None |
ERBITUX 100MG/50ML VIAL |
4 |
Tier 4 |
33% | 33% | P |
ERGOLOID MESYLATES TABLETS 1MG 100 BOT |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ERGOMAR SUBLINGUAL TABLET 2MG |
3 |
Tier 3 |
$75.00 | $187.50 | Q:20 /28Days |
ERGOTAMINE-CAFFEINE 1-100MG TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | Q:40 /28Days |
ERRIN 0.35MG TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | Q:30 /30Days |
ERTACZO 2% CREAM |
3 |
Tier 3 |
$75.00 | $187.50 | S |
ERY 2% PADS 2% 60 PADS JAR |
1 |
Tier 1 |
$5.00 | $12.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERY-TAB 500MG TABLET EC |
3 |
Tier 3 |
$75.00 | $187.50 | None |
ERYTHROCIN 500MG ADDVNT VL |
3 |
Tier 3 |
$75.00 | $187.50 | None |
ERYTHROCIN 500MG FILMTAB |
3 |
Tier 3 |
$75.00 | $187.50 | None |
ERYTHROMYCIN 2% SOLUTION |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ERYTHROMYCIN 500MG FILMTAB |
3 |
Tier 3 |
$75.00 | $187.50 | None |
ERYTHROMYCIN ETHYLSUCCINATE AND SULFISOXAZOLE ACETYL POWDER FOR ORAL SUSPENSION 200;600MG/5ML;MG/ 10 |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ERYTHROMYCIN GEL TOPICAL USP 2% 60 GM TUBE |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ERYTHROMYCIN OPHTHALMIC OINTMENT 0.5% 1 G BOX OF 50 TUBE |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ERYTHROMYCIN-BENZOYL PEROXIDE 3-5% GEL |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ESTRACE 0.5MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | None |
ESTRACE 2MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRACE TABLET 1MG (100 CT) |
3 |
Tier 3 |
$75.00 | $187.50 | None |
ESTRACE VAG CREAM 0.1MG/GM |
3 |
Tier 3 |
$75.00 | $187.50 | None |
ESTRADERM 0.05MG/24H PATCH TRANSDERMAL SEMIWEEKLY |
3 |
Tier 3 |
$75.00 | $187.50 | Q:8 /28Days |
ESTRADERM 0.1MG/24HR PATCH TRANSDERMAL SEMIWEEKLY |
3 |
Tier 3 |
$75.00 | $187.50 | Q:8 /28Days |
ESTRADIOL .025MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Tier 1 |
$5.00 | $12.50 | Q:4 /28Days |
ESTRADIOL .0375MG/24 PATCH TRANSDERMAL WEEKLY |
1 |
Tier 1 |
$5.00 | $12.50 | Q:4 /28Days |
ESTRADIOL .075MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Tier 1 |
$5.00 | $12.50 | Q:4 /28Days |
ESTRADIOL 0.05MG/DAY PATCH |
1 |
Tier 1 |
$5.00 | $12.50 | Q:4 /28Days |
ESTRADIOL 0.06MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Tier 1 |
$5.00 | $12.50 | Q:4 /28Days |
ESTRADIOL 0.1MG/DAY PATCH |
1 |
Tier 1 |
$5.00 | $12.50 | Q:4 /28Days |
ESTRADIOL 0.5MG TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL 2MG TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ESTRADIOL TABLET 1MG (500 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ESTRADIOL VALERATE INJECTION |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ESTRADIOL VALERATE INJECTION |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ESTRADIOL VALERATE INJECTION |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ESTRADIOL-NORETH 1.0-0.5MG TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ESTRASORB 2.5MG 56 POU |
3 |
Tier 3 |
$75.00 | $187.50 | None |
ESTRING 2MG VAGINAL RING |
3 |
Tier 3 |
$75.00 | $187.50 | Q:1 /90Days |
ESTROGEL 0.06% GEL |
3 |
Tier 3 |
$75.00 | $187.50 | None |
ESTROPIPATE 0.625 TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ESTROPIPATE 1.25 TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTROPIPATE 2.5 TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ESTROSTEP TABLETS 1;.02MG;MG 28 BLPK |
3 |
Tier 3 |
$75.00 | $187.50 | Q:30 /30Days |
ETHAMBUTOL HCL 100MG TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ETHAMBUTOL HCL 400MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ETHOSUXIMIDE 250MG CAPSULE |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ETHOSUXIMIDE 250MG/5ML SYRP |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ETHYOL POWDER FOR INJECTION 500MG 3 X 10ML VILSU CRTN |
4 |
Tier 4 |
33% | 33% | None |
ETIDRONATE DISODIUM 400MG TABLET (60 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ETODOLAC 200MG CAPSULE |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ETODOLAC 300MG CAPSULE |
1 |
Tier 1 |
$5.00 | $12.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETODOLAC 400MG TABLET (500 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ETODOLAC 400MG TABLET SR 24HR |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ETODOLAC 500MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ETODOLAC 500MG TABLET SR 24HR |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ETODOLAC 600MG TABLET SR 24HR |
1 |
Tier 1 |
$5.00 | $12.50 | None |
ETOPOPHOS 100MG VIAL |
4 |
Tier 4 |
33% | 33% | None |
ETOPOSIDE INJECTION 20MG 25ML VIALMD |
1 |
Tier 1 |
$5.00 | $12.50 | None |
EURAX 10% CREAM 60GM |
3 |
Tier 3 |
$75.00 | $187.50 | None |
EURAX 10% LOTION 454ML |
3 |
Tier 3 |
$75.00 | $187.50 | None |
EVAMIST 1.53/SPRAY SPRAY NON-AEROSOL |
3 |
Tier 3 |
$75.00 | $187.50 | None |
EVISTA TABLETS 60MG |
2 |
Tier 2 |
$30.00 | $75.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EVOCLIN 1% FOAM |
3 |
Tier 3 |
$75.00 | $187.50 | None |
EVOXAC 30MG CAPSULE |
2 |
Tier 2 |
$30.00 | $75.00 | None |
EXELDERM 1% CREAM |
3 |
Tier 3 |
$75.00 | $187.50 | S |
EXELDERM SOLUTION 1% 30 ML BOTPL |
3 |
Tier 3 |
$75.00 | $187.50 | S |
EXELON 1.5MG CAPSULE |
3 |
Tier 3 |
$75.00 | $187.50 | Q:60 /30Days |
EXELON 2MG/ML ORAL SOLUTION |
3 |
Tier 3 |
$75.00 | $187.50 | Q:240 /30Days |
EXELON 3MG CAPSULE |
3 |
Tier 3 |
$75.00 | $187.50 | Q:60 /30Days |
EXELON 4.5MG CAPSULE |
3 |
Tier 3 |
$75.00 | $187.50 | Q:60 /30Days |
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS |
3 |
Tier 3 |
$75.00 | $187.50 | Q:30 /30Days |
EXELON 6MG CAPSULE |
3 |
Tier 3 |
$75.00 | $187.50 | Q:60 /30Days |
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS |
3 |
Tier 3 |
$75.00 | $187.50 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EXFORGE 10MG-160MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | Q:30 /30Days |
EXFORGE 10MG-320MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | Q:30 /30Days |
EXFORGE 5MG-160MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | Q:30 /30Days |
EXFORGE 5MG-320MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | Q:30 /30Days |
EXJADE 125MG TABLET |
4 |
Tier 4 |
33% | 33% | None |
EXJADE 250MG TABLET |
4 |
Tier 4 |
33% | 33% | None |
EXJADE 500MG TABLET |
4 |
Tier 4 |
33% | 33% | None |
EXTINA 2% FOAM |
3 |
Tier 3 |
$75.00 | $187.50 | S |