2011 Medicare Part D Plan Formulary Information |
FreedomBlue PPO Standard (PPO) (H5106-013-0)
Benefit Details
|
The FreedomBlue PPO Standard (PPO) (H5106-013-0) Formulary Drugs Starting with the Letter E in Boone County, WV: CMS MA Region 6 which includes: WV
|
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 |
$80.00 | $200.00 | None |
EC-NAPROSYN 375MG TABLET EC |
3 |
Tier 3 |
$80.00 | $200.00 | None |
EC-NAPROSYN 500MG TABLET EC |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ECONAZOLE NITRATE 1% CREAM 85GM TUBE |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ED K+10 TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
EDECRIN 25MG TABLET (100 CT) |
2 |
Tier 2 |
$42.00 | $105.00 | None |
EES 400 TABLET 400MG 100 BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
EFFEXOR 37.5MG CAPSULE ER (90 CT) |
3 |
Tier 3 |
$80.00 | $200.00 | None |
EFFEXOR 50MG TABLET (30 CT) |
3 |
Tier 3 |
$80.00 | $200.00 | None |
EFFEXOR XR 150MG CAPSULE ER 15 CAPSULES BOT |
3 |
Tier 3 |
$80.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EFFEXOR XR 75MG CAPSULE ER 15 CAPSULES BOT |
3 |
Tier 3 |
$80.00 | $200.00 | None |
EFUDEX 5% CREAM |
3 |
Tier 3 |
$80.00 | $200.00 | None |
EFUDEX SOLUTION TOPICAL 5% 10 ML BOTDR |
3 |
Tier 3 |
$80.00 | $200.00 | None |
EGG YOLK PHOSPHOLIPIDS 12 MG/ML / GLYCERIN 25 MG/ML / SAFFLOWER OIL 100 MG/ML / SOYBEAN OIL 100 MG/M |
2 |
Tier 2 |
$42.00 | $105.00 | P |
EGG YOLK PHOSPHOLIPIDS 12 MG/ML / GLYCERIN 25 MG/ML / SOYBEAN OIL 100 MG/ML INJECTABLE SUSPENSION [L |
2 |
Tier 2 |
$42.00 | $105.00 | P |
EGG YOLK PHOSPHOLIPIDS 12 MG/ML / GLYCERIN 25 MG/ML / SOYBEAN OIL 200 MG/ML INJECTABLE SUSPENSION [L |
2 |
Tier 2 |
$42.00 | $105.00 | P |
ELAPRASE 6MG/3ML VIAL |
4 |
Tier 4 |
33% | 33% | None |
ELDEPRYL 5MG CAPSULE |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ELESTAT 0.05% EYE DROPS |
2 |
Tier 2 |
$42.00 | $105.00 | None |
ELESTRIN GEL |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ELIDEL 1% CREAM |
3 |
Tier 3 |
$80.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIGARD 22.5MG SYRINGE |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ELIGARD 30MG SYRINGE |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ELIGARD 45MG SYRINGE |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ELIGARD 7.5MG SYRINGE |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ELIPHOS TABLETS CALCIUM ACETATE TABLETS 667MG 200 BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ELITEK 1.5MG VIAL |
4 |
Tier 4 |
33% | 33% | None |
ELIXOPHYLLIN 80MG/15ML ELIX |
2 |
Tier 2 |
$42.00 | $105.00 | None |
ELLENCE 2MG/ML VIAL |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ELMIRON CAPSULES 100MG |
2 |
Tier 2 |
$42.00 | $105.00 | None |
ELOCON 0.1% CREAM |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ELOCON 0.1% LOTION |
3 |
Tier 3 |
$80.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELOCON 0.1% OINTMENT |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ELOXATIN 100MG/20ML VIAL |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ELSPAR INJ 10000UNT |
3 |
Tier 3 |
$80.00 | $200.00 | None |
EMADINE 0.05% EYE DROPS |
3 |
Tier 3 |
$80.00 | $200.00 | None |
EMBEDA 20-0.8 MG CAPSULE |
3 |
Tier 3 |
$80.00 | $200.00 | Q:60 /25Days |
EMBEDA 30-1.2 MG CAPSULE |
3 |
Tier 3 |
$80.00 | $200.00 | Q:60 /25Days |
EMBEDA 50-2 MG CAPSULE |
3 |
Tier 3 |
$80.00 | $200.00 | Q:60 /25Days |
EMBEDA CAPSULES EXTENDED RELEASE |
3 |
Tier 3 |
$80.00 | $200.00 | Q:60 /25Days |
EMBEDA CAPSULES EXTENDED RELEASE |
3 |
Tier 3 |
$80.00 | $200.00 | Q:60 /25Days |
EMBEDA CAPSULES EXTENDED RELEASE |
3 |
Tier 3 |
$80.00 | $200.00 | Q:60 /25Days |
EMCYT 140MG CAPSULE |
2 |
Tier 2 |
$42.00 | $105.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMEND 40MG CAPSULE |
3 |
Tier 3 |
$80.00 | $200.00 | P |
EMEND CAPSULES 125MG 6 BLPK |
3 |
Tier 3 |
$80.00 | $200.00 | P |
EMEND CAPSULES 80MG 2 BLPK |
3 |
Tier 3 |
$80.00 | $200.00 | P |
EMEND TRIFOLD PACK |
3 |
Tier 3 |
$80.00 | $200.00 | P |
EMLA CREAM 2.5%/2.5% 30 GM TUBE |
3 |
Tier 3 |
$80.00 | $200.00 | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
3 |
Tier 3 |
$80.00 | $200.00 | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
3 |
Tier 3 |
$80.00 | $200.00 | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
3 |
Tier 3 |
$80.00 | $200.00 | None |
EMTRIVA 10MG/ML SOLUTION |
2 |
Tier 2 |
$42.00 | $105.00 | None |
EMTRIVA 200MG CAPSULE |
2 |
Tier 2 |
$42.00 | $105.00 | None |
ENABLEX 15MG TABLET |
2 |
Tier 2 |
$42.00 | $105.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENABLEX 7.5MG TABLET |
2 |
Tier 2 |
$42.00 | $105.00 | None |
ENALAPRIL MALEATE 10MG TABLET (100 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ENALAPRIL MALEATE 2.5MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ENALAPRIL MALEATE 20MG TABLET (1000 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ENALAPRIL MALEATE TABLETS 5MG |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ENALAPRIL MALEATE-HCTZ 10MG-25MG TABLET (100 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET (100 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ENBREL 25 MG/0.5 ML SYRINGE |
4 |
Tier 4 |
33% | 33% | P |
ENBREL 25MG KIT |
4 |
Tier 4 |
33% | 33% | P |
ENBREL INJECTION 50MG/ML SYR |
4 |
Tier 4 |
33% | 33% | P |
ENDOCET 10/650MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENDOCET 10MG-325MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ENDOCET 5/325 TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ENDOCET 7.5-325MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ENDOCET 7.5/500MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ENDODAN TABLETS 325;4.8355MG;MG 100 BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ENDOMETRIN PROGESTERONE MICRONIZED 100MG INSERT |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ENGERIX B INJECTION |
2 |
Tier 2 |
$42.00 | $105.00 | None |
ENGERIX B INJECTION 20MCG/ML |
2 |
Tier 2 |
$42.00 | $105.00 | None |
ENGERIX-B 10MCG 10 X 0.5ML VIALSD |
2 |
Tier 2 |
$42.00 | $105.00 | None |
ENJUVIA 0.3MG TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ENJUVIA 0.45MG TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENJUVIA 0.625MG TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ENJUVIA 0.9MG TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ENJUVIA 1.25MG TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ENOXAPARIN SODIUM INJECTION |
4 |
Tier 4 |
33% | 33% | None |
ENOXAPARIN SODIUM INJECTION |
4 |
Tier 4 |
33% | 33% | None |
ENOXAPARIN SODIUM INJECTION |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ENOXAPARIN SODIUM INJECTION |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ENOXAPARIN SODIUM INJECTION |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ENOXAPARIN SODIUM INJECTION |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ENOXAPARIN SODIUM INJECTION |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ENTOCORT EC 3MG CAPSULE |
3 |
Tier 3 |
$80.00 | $200.00 | None |
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 |
$7.00 | $17.50 | None |
EPIDUO GEL 0.1;2.5%;% 45 TRADE SIZE TUBE |
3 |
Tier 3 |
$80.00 | $200.00 | None |
EPINEPHRINE 0.1MG/ML ABBJCT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
EPIPEN 0.3MG AUTO-INJECTOR |
2 |
Tier 2 |
$42.00 | $105.00 | None |
EPIPEN JR 0.15MG AUTO-INJCT |
2 |
Tier 2 |
$42.00 | $105.00 | None |
EPIRUBICIN HCL INJECTION SOLUTION 2MG 1 X 25ML VIAL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
EPITOL 200MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
EPIVIR 300MG TABLET |
2 |
Tier 2 |
$42.00 | $105.00 | None |
EPIVIR HBV 100MG TABLET |
2 |
Tier 2 |
$42.00 | $105.00 | None |
EPIVIR HBV 25MG/5ML TUBEX |
2 |
Tier 2 |
$42.00 | $105.00 | None |
EPIVIR ORAL SOLUTION |
2 |
Tier 2 |
$42.00 | $105.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPIVIR TABLETS |
2 |
Tier 2 |
$42.00 | $105.00 | None |
EPLERENONE 25MG TABS |
1 |
Tier 1 |
$7.00 | $17.50 | None |
EPLERENONE 50MG TABS |
1 |
Tier 1 |
$7.00 | $17.50 | None |
EPOGEN 10000U/ML VIAL MDV |
2 |
Tier 2 |
$42.00 | $105.00 | None |
EPOGEN 2000U/ML VIAL SDV |
2 |
Tier 2 |
$42.00 | $105.00 | None |
EPOGEN 3000U/ML VIAL SDV |
2 |
Tier 2 |
$42.00 | $105.00 | None |
EPOGEN 4000U/ML VIAL SDV |
2 |
Tier 2 |
$42.00 | $105.00 | None |
EPOGEN INJECTION 20000U 10 X 1ML CRTN |
4 |
Tier 4 |
33% | 33% | None |
EPOGEN INJECTION 40000U 10 X 4ML VIALS VIALSD |
4 |
Tier 4 |
33% | 33% | None |
EPZICOM TABLETS |
2 |
Tier 2 |
$42.00 | $105.00 | None |
EQUETRO CAPSULES 200MG 120 BOT |
3 |
Tier 3 |
$80.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EQUETRO CAPSULES 300MG 120 BOT |
3 |
Tier 3 |
$80.00 | $200.00 | None |
EQUETRO EXTENDED RELEASE CAPSULES 100MG 120 BOT |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ERBITUX 100MG/50ML VIAL |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ERGOLOID MESYLATES TABLETS 1MG 100 BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ERGOMAR SUBLINGUAL TABLET 2MG |
2 |
Tier 2 |
$42.00 | $105.00 | None |
ERGOTAMINE-CAFFEINE 1-100MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ERRIN 0.35MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ERTACZO 2% CREAM |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ERY 2% PADS 2% 60 PADS JAR |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ERY DELAYED RELEASE TABLETS 250MG 100 BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ERY TAB TABLETS 333MG 100 BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERY-TAB 500MG TABLET EC |
2 |
Tier 2 |
$42.00 | $105.00 | None |
ERYPED 200MG/5ML 100 ML BOT |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ERYPED POWDER FOR ORAL SOLUTION 400MG/5ML 100 ML BOT |
2 |
Tier 2 |
$42.00 | $105.00 | None |
ERYTHROCIN 500MG ADDVNT VL |
2 |
Tier 2 |
$42.00 | $105.00 | None |
ERYTHROCIN 500MG FILMTAB |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ERYTHROCIN STEARATE TABLETS 250MG 100 BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ERYTHROMYCIN 2% SOLUTION |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ERYTHROMYCIN 250MG 100 BOT |
2 |
Tier 2 |
$42.00 | $105.00 | None |
ERYTHROMYCIN 500MG FILMTAB |
2 |
Tier 2 |
$42.00 | $105.00 | None |
ERYTHROMYCIN ETHYLSUCCINATE AND SULFISOXAZOLE ACETYL POWDER FOR ORAL SUSPENSION 200;600MG/5ML;MG/ 10 |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ERYTHROMYCIN GEL TOPICAL USP 2% 60 GM TUBE |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROMYCIN OPHTHALMIC OINTMENT 0.5% 1 G BOX OF 50 TUBE |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ERYTHROMYCIN-BENZOYL PEROXIDE 3-5% GEL |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ESTRACE 0.5MG TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ESTRACE 2MG TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ESTRACE TABLET 1MG (100 CT) |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ESTRACE VAG CREAM 0.1MG/GM |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ESTRADERM 0.05MG/24H PATCH TRANSDERMAL SEMIWEEKLY |
2 |
Tier 2 |
$42.00 | $105.00 | None |
ESTRADERM 0.1MG/24HR PATCH TRANSDERMAL SEMIWEEKLY |
2 |
Tier 2 |
$42.00 | $105.00 | None |
ESTRADIOL .025MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ESTRADIOL .0375MG/24 PATCH TRANSDERMAL WEEKLY |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ESTRADIOL .075MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL 0.05MG/DAY PATCH |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ESTRADIOL 0.06MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ESTRADIOL 0.1MG/DAY PATCH |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ESTRADIOL 0.5MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ESTRADIOL 2MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ESTRADIOL TABLET 1MG (500 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ESTRADIOL VALERATE INJECTION |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ESTRADIOL VALERATE INJECTION |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ESTRADIOL VALERATE INJECTION |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ESTRADIOL-NORETH 1.0-0.5MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ESTRING 2MG VAGINAL RING |
3 |
Tier 3 |
$80.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTROPIPATE 0.625 TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ESTROPIPATE 1.25 TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ESTROPIPATE 2.5 TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ESTROSTEP TABLETS 1;.02MG;MG 28 BLPK |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ETHAMBUTOL 400 MG ORAL TABLET [MYAMBUTOL] |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ETHAMBUTOL HCL 100MG TABLET |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ETHAMBUTOL HCL 400MG TABLET (100 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ETHINYL ESTRADIOL 0.02 MG / NORETHINDRONE 1 MG ORAL TABLET) } PACK [LOESTRIN 1/20 21 DAY] |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ETHINYL ESTRADIOL 0.03 MG / NORETHINDRONE 1.5 MG ORAL TABLET) } PACK [LOESTRIN 1.5/30 21 DAY] |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21 |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETHOSUXIMIDE 250MG CAPSULE |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ETHOSUXIMIDE 250MG/5ML SYRP |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ETHYOL POWDER FOR INJECTION 500MG 3 X 10ML VILSU CRTN |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ETIDRONATE DISODIUM 400MG TABLET (60 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ETODOLAC 200MG CAPSULE |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ETODOLAC 300MG CAPSULE |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ETODOLAC 400MG TABLET (500 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ETODOLAC 400MG TABLET SR 24HR |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ETODOLAC 500MG TABLET (100 CT) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ETODOLAC 500MG TABLET SR 24HR |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETODOLAC 600MG TABLET SR 24HR |
1 |
Tier 1 |
$7.00 | $17.50 | None |
ETOPOPHOS 100MG VIAL |
3 |
Tier 3 |
$80.00 | $200.00 | None |
ETOPOSIDE INJECTION 20MG 25ML VIALMD |
1 |
Tier 1 |
$7.00 | $17.50 | None |
EURAX 10% CREAM 60GM |
2 |
Tier 2 |
$42.00 | $105.00 | None |
EURAX 10% LOTION 454ML |
3 |
Tier 3 |
$80.00 | $200.00 | None |
EVAMIST 1.53/SPRAY SPRAY NON-AEROSOL |
3 |
Tier 3 |
$80.00 | $200.00 | None |
EVOCLIN 1% FOAM |
3 |
Tier 3 |
$80.00 | $200.00 | None |
EVOXAC 30MG CAPSULE |
2 |
Tier 2 |
$42.00 | $105.00 | None |
EXELDERM 1% CREAM |
3 |
Tier 3 |
$80.00 | $200.00 | None |
EXELDERM SOLUTION 1% 30 ML BOTPL |
3 |
Tier 3 |
$80.00 | $200.00 | None |
EXELON 1.5MG CAPSULE |
2 |
Tier 2 |
$42.00 | $105.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EXELON 2MG/ML ORAL SOLUTION |
2 |
Tier 2 |
$42.00 | $105.00 | None |
EXELON 3MG CAPSULE |
2 |
Tier 2 |
$42.00 | $105.00 | None |
EXELON 4.5MG CAPSULE |
2 |
Tier 2 |
$42.00 | $105.00 | None |
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS |
2 |
Tier 2 |
$42.00 | $105.00 | None |
EXELON 6MG CAPSULE |
2 |
Tier 2 |
$42.00 | $105.00 | None |
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS |
2 |
Tier 2 |
$42.00 | $105.00 | None |
EXFORGE 10MG-160MG TABLET |
2 |
Tier 2 |
$42.00 | $105.00 | None |
EXFORGE 10MG-320MG TABLET |
2 |
Tier 2 |
$42.00 | $105.00 | None |
EXFORGE 5MG-160MG TABLET |
2 |
Tier 2 |
$42.00 | $105.00 | None |
EXFORGE 5MG-320MG TABLET |
2 |
Tier 2 |
$42.00 | $105.00 | None |
EXJADE 125MG TABLET |
4 |
Tier 4 |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EXJADE 250MG TABLET |
4 |
Tier 4 |
33% | 33% | None |
EXJADE 500MG TABLET |
4 |
Tier 4 |
33% | 33% | None |
EXTENDED PHENYTOIN SODIUM CAPSULES 300 MG |
1 |
Tier 1 |
$7.00 | $17.50 | None |
EXTINA 2% FOAM |
3 |
Tier 3 |
$80.00 | $200.00 | None |