2012 Medicare Part D Plan Formulary Information |
United American - Preferred (PDP) (S5755-009-0)
Benefit Details
|
The United American - Preferred (PDP) (S5755-009-0) Formulary Drugs Starting with the Letter E in CMS PDP Region 6 which includes: PA 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. GRAN SUS 200/5ML |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
ECONAZOLE NITRATE 1% CREAM 85GM TUBE |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
EDECRIN 25MG TABLET (100 CT) |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
EDURANT 27.5mg/1 |
5 |
Specialty Tier Drugs |
30% | 30% | None |
EES 400 TABLET 400MG 100 BOT |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
Effient 10mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
Effient 5mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
ELESTAT 0.5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
ELIDEL 1% CREAM |
4 |
Non-Preferred Brand Drugs |
$95.00 | $190.00 | None |
ELIGARD 1 KIT in 1 CARTON |
4 |
Non-Preferred Brand Drugs |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIGARD 1 KIT in 1 CARTON |
4 |
Non-Preferred Brand Drugs |
$95.00 | $190.00 | None |
ELIGARD 1 KIT in 1 CARTON |
4 |
Non-Preferred Brand Drugs |
$95.00 | $190.00 | None |
ELIGARD 1 KIT in 1 CARTON |
4 |
Non-Preferred Brand Drugs |
$95.00 | $190.00 | None |
ELIPHOS TABLETS CALCIUM ACETATE TABLETS 667MG 200 BOT |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
Elitek 3 KIT in 1 CARTON / 1 KIT in 1 KIT |
5 |
Specialty Tier Drugs |
30% | 30% | None |
ELIXOPHYLLIN 80mg/15mL 473 mL in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
$95.00 | $190.00 | None |
Ella 30mg/1 1 BLISTER PACK in 1 CARTON / 1 TABLET in 1 BLISTER PACK |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
ELLENCE 2MG/ML VIAL |
4 |
Non-Preferred Brand Drugs |
$95.00 | $190.00 | None |
ELMIRON 100mg/1 100 CAPSULE, GELATIN COATED in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
ELOXATIN 100MG/20ML VIAL |
4 |
Non-Preferred Brand Drugs |
$95.00 | $190.00 | None |
ELSPAR INJ 10000UNT |
4 |
Non-Preferred Brand Drugs |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMBEDA 20-0.8 MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
$95.00 | $190.00 | None |
EMBEDA 30-1.2 MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
$95.00 | $190.00 | None |
EMBEDA 50-2 MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
$95.00 | $190.00 | None |
EMBEDA CAPSULES EXTENDED RELEASE |
4 |
Non-Preferred Brand Drugs |
$95.00 | $190.00 | None |
EMBEDA CAPSULES EXTENDED RELEASE |
4 |
Non-Preferred Brand Drugs |
$95.00 | $190.00 | None |
EMBEDA CAPSULES EXTENDED RELEASE |
4 |
Non-Preferred Brand Drugs |
$95.00 | $190.00 | None |
EMCYT 140MG CAPSULE |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
EMEND 40MG CAPSULE |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | P Q:3 /90Days |
EMEND CAPSULES 125MG 6 BLPK |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | P Q:6 /90Days |
EMEND CAPSULES 80MG 2 BLPK |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | P Q:24 /90Days |
EMEND TRIFOLD PACK |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | P Q:18 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Emoquette 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
4 |
Non-Preferred Brand Drugs |
$95.00 | $190.00 | Q:90 /90Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
4 |
Non-Preferred Brand Drugs |
$95.00 | $190.00 | Q:90 /90Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
4 |
Non-Preferred Brand Drugs |
$95.00 | $190.00 | Q:90 /90Days |
EMTRIVA 10MG/ML SOLUTION |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
EMTRIVA 200MG CAPSULE |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
ENABLEX 15MG TABLET |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | Q:90 /90Days |
Enablex 7.5mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | Q:90 /90Days |
ENALAPRIL MALEATE 10MG TABLET (100 CT) |
1* |
Preferred Generic Drugs |
$3.00 | $0.00 | None |
Enalapril Maleate 2.5mg/1 100 TABLET in 1 BOTTLE |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
Enalapril Maleate 20mg/1 500 TABLET in 1 BOTTLE, PLASTIC |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Enalapril Maleate 5mg/1 1000 TABLET in 1 BOTTLE, PLASTIC |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ENALAPRIL MALEATE-HCTZ 10MG-25MG TABLET (100 CT) |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | Q:180 /90Days |
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET (100 CT) |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | Q:90 /90Days |
ENBREL 25 MG/0.5 ML SYRINGE |
5 |
Specialty Tier Drugs |
30% | 30% | P Q:600 /90Days |
ENBREL 25MG KIT |
5 |
Specialty Tier Drugs |
30% | 30% | P Q:600 /90Days |
ENBREL 50mg/mL |
5 |
Specialty Tier Drugs |
30% | 30% | P Q:600 /90Days |
ENDOCET 10/650MG TABLET |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ENDOCET 10MG-325MG TABLET |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ENDOCET 5/325 TABLET |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ENDOCET 7.5-325MG TABLET |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ENDOCET 7.5/500MG TABLET |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENGERIX B INJECTION |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | P |
ENGERIX B INJECTION 20MCG/ML |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | P |
ENGERIX-B 10MCG 10 X 0.5ML VIALSD |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | P |
ENJUVIA 0.3MG TABLET |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | Q:90 /90Days |
ENJUVIA 0.45MG TABLET |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | Q:90 /90Days |
ENJUVIA 0.625MG TABLET |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | Q:90 /90Days |
ENJUVIA 0.9MG TABLET |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | Q:90 /90Days |
ENJUVIA 1.25MG TABLET |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | Q:90 /90Days |
ENOXAPARIN SODIUM INJECTION |
5 |
Specialty Tier Drugs |
30% | 30% | None |
ENOXAPARIN SODIUM INJECTION |
5 |
Specialty Tier Drugs |
30% | 30% | None |
ENOXAPARIN SODIUM INJECTION |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENOXAPARIN SODIUM INJECTION |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ENOXAPARIN SODIUM INJECTION |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ENOXAPARIN SODIUM INJECTION |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ENOXAPARIN SODIUM INJECTION |
5 |
Specialty Tier Drugs |
30% | 30% | None |
ENTOCORT EC 3MG CAPSULE |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
ENULOSE SYRUP 10GM/15ML 1 PINT BOTPL |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
Epinastine HCl 0.5mg/mL |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
Epinephrine 0.1mg/mL |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
EPIPEN 0.3MG AUTO-INJECTOR |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
EPIPEN JR 0.15MG AUTO-INJCT |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
EPIRUBICIN HCL INJECTION SOLUTION 2MG 1 X 25ML VIAL |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPITOL 200MG TABLET |
1* |
Preferred Generic Drugs |
$3.00 | $0.00 | None |
EPIVIR 300mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
EPIVIR HBV 100MG TABLET |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
EPIVIR HBV 25MG/5ML TUBEX |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
EPIVIR ORAL SOLUTION |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
EPIVIR TABLETS |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
Eplerenone 25mg/1 30 TABLET in 1 BOTTLE |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
Eplerenone 50mg/1 30 TABLET in 1 BOTTLE |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
EPOGEN 10000U/ML VIAL MDV |
4 |
Non-Preferred Brand Drugs |
$95.00 | $190.00 | P Q:72 /90Days |
EPOGEN 2000[iU]/mL 10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL |
4 |
Non-Preferred Brand Drugs |
$95.00 | $190.00 | P Q:36 /90Days |
EPOGEN 3000U/ML VIAL SDV |
4 |
Non-Preferred Brand Drugs |
$95.00 | $190.00 | P Q:36 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPOGEN 4000U/ML VIAL SDV |
4 |
Non-Preferred Brand Drugs |
$95.00 | $190.00 | P Q:36 /90Days |
EPOGEN INJECTION 20000U 10 X 1ML CRTN |
4 |
Non-Preferred Brand Drugs |
$95.00 | $190.00 | P Q:36 /90Days |
EPROSARTAN MESYLATE 600 MG TABLET |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | Q:90 /90Days |
EPZICOM TABLETS |
5 |
Specialty Tier Drugs |
30% | 30% | None |
EQUETRO CAPSULES 200MG 120 BOT |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
EQUETRO CAPSULES 300MG 120 BOT |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
EQUETRO EXTENDED RELEASE CAPSULES 100MG 120 BOT |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
ERAXIS 100mg/30mL 30 mL in 1 VIAL, SINGLE-USE |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
ERBITUX 100MG/50ML VIAL |
4 |
Non-Preferred Brand Drugs |
$95.00 | $190.00 | None |
ERGOTAMINE-CAFFEINE TABLET 100 CT Bottle |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ERIVEDGE 150 MG CAPSULE |
5 |
Specialty Tier Drugs |
30% | 30% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERRIN 0.35MG TABLET |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ERTACZO 2% CREAM |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
ERY 2% PADS 2% 60 PADS JAR |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
ERY-TAB TAB 250MG EC |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ERY-TAB TAB 333MG EC |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ERYTHROCIN 500MG ADDVNT VL |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
ERYTHROCIN TAB 250MG |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ERYTHROMYCIN 2% SOLUTION |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
Erythromycin 20mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ERYTHROMYCIN 500 MG FILMTAB |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROMYCIN ETHYLSUCCINATE AND SULFISOXAZOLE ACETYL POWDER FOR ORAL SUSPENSION 200;600MG/5ML;MG/ 10 |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ERYTHROMYCIN ETHYLSUCCINATE TABLETS 400 MG 100 BOT |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ERYTHROMYCIN OPHTHALMIC OINTMENT 0.5% 1 G BOX OF 50 TUBE |
1* |
Preferred Generic Drugs |
$3.00 | $0.00 | None |
ERYTHROMYCIN TAB 250MG BS |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
ERYTHROMYCIN-BENZOYL PEROXIDE 3-5% GEL |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ESCITALOPRAM 10 MG TABLET |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | Q:90 /90Days |
ESCITALOPRAM 20 MG TABLET |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | Q:90 /90Days |
ESCITALOPRAM 5 MG TABLET |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | Q:90 /90Days |
ESCITALOPRAM OXALATE 5 MG/5 ML |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ESTRADERM 0.05MG/24H PATCH TRANSDERMAL SEMIWEEKLY |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
ESTRADERM 0.1MG/24HR PATCH TRANSDERMAL SEMIWEEKLY |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL .025MG/24H PATCH TRANSDERMAL WEEKLY |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ESTRADIOL .0375MG/24 PATCH TRANSDERMAL WEEKLY |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ESTRADIOL .075MG/24H PATCH TRANSDERMAL WEEKLY |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ESTRADIOL 0.05MG/DAY PATCH |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ESTRADIOL 0.06MG/24H PATCH TRANSDERMAL WEEKLY |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ESTRADIOL 0.1MG/DAY PATCH |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ESTRADIOL 0.5MG TABLET |
1* |
Preferred Generic Drugs |
$3.00 | $0.00 | None |
ESTRADIOL 2MG TABLET |
1* |
Preferred Generic Drugs |
$3.00 | $0.00 | None |
ESTRADIOL TABLET 1MG (500 CT) |
1* |
Preferred Generic Drugs |
$3.00 | $0.00 | None |
ESTRADIOL VALERATE INJECTION |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ESTRADIOL VALERATE INJECTION |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL VALERATE INJECTION |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ESTRADIOL-NORETH 1.0-0.5MG TABLET |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ESTRING 2MG VAGINAL RING |
4 |
Non-Preferred Brand Drugs |
$95.00 | $190.00 | Q:1 /90Days |
ESTROPIPATE 0.625 TABLET |
1* |
Preferred Generic Drugs |
$3.00 | $0.00 | None |
ESTROPIPATE 1.25 TABLET |
1* |
Preferred Generic Drugs |
$3.00 | $0.00 | None |
ESTROPIPATE 2.5 TABLET |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ETHAMBUTOL HCL 400MG TABLET (100 CT) |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
Ethambutol Hydrochloride 100mg/1 |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21 |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
Ethosuximide 250mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETHOSUXIMIDE 250MG/5ML SYRP |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ETIDRONATE DISODIUM 400MG TABLET (60 CT) |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ETODOLAC 200MG CAPSULE |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ETODOLAC 300 MG CAPSULE |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ETODOLAC 400MG TABLET (500 CT) |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ETODOLAC 400MG TABLET SR 24HR |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ETODOLAC 500MG TABLET SR 24HR |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ETODOLAC 500mg/1 |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ETODOLAC 600MG TABLET SR 24HR |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
ETOPOPHOS 100MG VIAL |
4 |
Non-Preferred Brand Drugs |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Etoposide 20mg/mL 1 VIAL in 1 BOX, UNIT-DOSE / 50 mL in 1 VIAL |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
Eurax Lotion and Cream 100mg/g 454 g in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
Eurax Lotion and Cream 100mg/g 60 g in 1 TUBE |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
Evista 60mg/1 100 TABLET in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | Q:90 /90Days |
EVOXAC 30MG CAPSULE |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
EXALGO 12mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
EXALGO 16mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
EXALGO 8mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
EXELON 2MG/ML ORAL SOLUTION |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | Q:90 /90Days |
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | Q:90 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Exemestane 25mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |
EXFORGE 10MG-160MG TABLET |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | Q:90 /90Days |
EXFORGE 10MG-320MG TABLET |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | Q:90 /90Days |
EXFORGE 5MG-160MG TABLET |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | Q:90 /90Days |
EXFORGE 5MG-320MG TABLET |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | Q:90 /90Days |
Exforge HCT 10; 12.5; 160mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | Q:90 /90Days |
Exforge HCT 10; 25; 160mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | Q:90 /90Days |
Exforge HCT 10; 25; 320mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | Q:90 /90Days |
Exforge HCT 5; 12.5; 160mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | Q:90 /90Days |
Exforge HCT 5; 25; 160mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | Q:90 /90Days |
EXJADE 125MG TABLET |
3 |
Preferred Brand Drugs |
$45.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EXJADE 250MG TABLET |
5 |
Specialty Tier Drugs |
30% | 30% | None |
EXJADE 500MG TABLET |
5 |
Specialty Tier Drugs |
30% | 30% | None |
EXTENDED PHENYTOIN SODIUM CAPSULES 300 MG |
2* |
Non-Preferred Generic Drugs |
$9.00 | $21.00 | None |