2012 Medicare Part D Plan Formulary Information |
Anthem Medicare Preferred Core (PPO) (H1517-004-0)
Benefit Details
|
The Anthem Medicare Preferred Core (PPO) (H1517-004-0) Formulary Drugs Starting with the Letter E in BARRY County, MO: CMS MA Region 15 which includes: MO
|
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 |
Tier 3 |
$85.00 | $212.50 | None |
EC-NAPROSYN 375MG TABLET EC |
3 |
Tier 3 |
$85.00 | $212.50 | None |
EC-NAPROSYN 500MG TABLET EC |
3 |
Tier 3 |
$85.00 | $212.50 | None |
ECONAZOLE NITRATE 1% CREAM 85GM TUBE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ED K+10 TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
EDECRIN 25MG TABLET (100 CT) |
3 |
Tier 3 |
$85.00 | $212.50 | None |
EDURANT 27.5mg/1 |
5* |
Tier 5 |
33% | N/A | None |
EES 400 TABLET 400MG 100 BOT |
3 |
Tier 3 |
$85.00 | $212.50 | None |
EFFEXOR 37.5MG CAPSULE ER (90 CT) |
3 |
Tier 3 |
$85.00 | $212.50 | Q:30 /30Days |
EFFEXOR XR 150MG CAPSULE ER 15 CAPSULES BOT |
3 |
Tier 3 |
$85.00 | $212.50 | Q:60 /30Days |
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 |
$85.00 | $212.50 | Q:60 /30Days |
Effient 10mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
$43.00 | $107.50 | Q:30 /30Days |
Effient 5mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
$43.00 | $107.50 | Q:30 /30Days |
EFUDEX 5% CREAM |
3 |
Tier 3 |
$85.00 | $212.50 | None |
EGG YOLK PHOSPHOLIPIDS 12 MG/ML / GLYCERIN 25 MG/ML / SAFFLOWER OIL 100 MG/ML / SOYBEAN OIL 100 MG/M |
4* |
Tier 4 |
33% | 33% | None |
ELAPRASE 6mg/3mL 1 VIAL, GLASS in 1 BOX / 3 mL in 1 VIAL, GLASS |
5* |
Tier 5 |
33% | N/A | P |
ELDEPRYL 5 MG CAPSULE |
3 |
Tier 3 |
$85.00 | $212.50 | None |
ELESTAT 0.5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER |
3 |
Tier 3 |
$85.00 | $212.50 | None |
ELIDEL 1% CREAM |
3 |
Tier 3 |
$85.00 | $212.50 | P |
ELIGARD 1 KIT in 1 CARTON |
4* |
Tier 4 |
33% | 33% | P |
ELIGARD 1 KIT in 1 CARTON |
4* |
Tier 4 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIGARD 1 KIT in 1 CARTON |
4* |
Tier 4 |
33% | 33% | P |
ELIGARD 1 KIT in 1 CARTON |
4* |
Tier 4 |
33% | 33% | P |
Elitek 3 KIT in 1 CARTON / 1 KIT in 1 KIT |
5* |
Tier 5 |
33% | N/A | None |
ELIXOPHYLLIN 80mg/15mL 473 mL in 1 BOTTLE |
2 |
Tier 2 |
$43.00 | $107.50 | None |
ELLENCE 2MG/ML VIAL |
4* |
Tier 4 |
33% | 33% | P |
ELMIRON 100mg/1 100 CAPSULE, GELATIN COATED in 1 BOTTLE |
3 |
Tier 3 |
$85.00 | $212.50 | None |
ELOCON 0.1% CREAM |
3 |
Tier 3 |
$85.00 | $212.50 | None |
ELOCON 0.1% LOTION |
3 |
Tier 3 |
$85.00 | $212.50 | None |
ELOCON 0.1% OINTMENT |
3 |
Tier 3 |
$85.00 | $212.50 | None |
ELOXATIN 100MG/20ML VIAL |
5* |
Tier 5 |
33% | N/A | P |
ELSPAR INJ 10000UNT |
4* |
Tier 4 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMADINE 0.05% EYE DROPS |
3 |
Tier 3 |
$85.00 | $212.50 | None |
EMCYT 140MG CAPSULE |
3 |
Tier 3 |
$85.00 | $212.50 | None |
EMEND 40MG CAPSULE |
2 |
Tier 2 |
$43.00 | $107.50 | P Q:1 /1Days |
EMEND CAPSULES 125MG 6 BLPK |
2 |
Tier 2 |
$43.00 | $107.50 | P Q:4 /30Days |
EMEND CAPSULES 80MG 2 BLPK |
2 |
Tier 2 |
$43.00 | $107.50 | P Q:8 /30Days |
EMEND TRIFOLD PACK |
2 |
Tier 2 |
$43.00 | $107.50 | P Q:12 /30Days |
EMLA CREAM 2.5%/2.5% 30 GM TUBE |
3 |
Tier 3 |
$85.00 | $212.50 | None |
Emoquette 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
1* |
Tier 1 |
$0.00 | $0.00 | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
3 |
Tier 3 |
$85.00 | $212.50 | Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
3 |
Tier 3 |
$85.00 | $212.50 | Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
3 |
Tier 3 |
$85.00 | $212.50 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMTRIVA 10MG/ML SOLUTION |
3 |
Tier 3 |
$85.00 | $212.50 | None |
EMTRIVA 200MG CAPSULE |
3 |
Tier 3 |
$85.00 | $212.50 | None |
ENABLEX 15MG TABLET |
2 |
Tier 2 |
$43.00 | $107.50 | Q:30 /30Days |
Enablex 7.5mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2 |
Tier 2 |
$43.00 | $107.50 | Q:30 /30Days |
ENALAPRIL MALEATE 10MG TABLET (100 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Enalapril Maleate 2.5mg/1 100 TABLET in 1 BOTTLE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Enalapril Maleate 20mg/1 500 TABLET in 1 BOTTLE, PLASTIC |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Enalapril Maleate 5mg/1 1000 TABLET in 1 BOTTLE, PLASTIC |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE-HCTZ 10MG-25MG TABLET (100 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET (100 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ENBREL 25 MG/0.5 ML SYRINGE |
5* |
Tier 5 |
33% | N/A | P Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENBREL 25MG KIT |
5* |
Tier 5 |
33% | N/A | P Q:8 /28Days |
ENBREL 50mg/mL |
5* |
Tier 5 |
33% | N/A | P Q:8 /28Days |
ENDOCET 10/650MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | Q:180 /30Days |
ENDOCET 10MG-325MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | Q:360 /30Days |
ENDOCET 5/325 TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | Q:360 /30Days |
ENDOCET 7.5-325MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | Q:360 /30Days |
ENDOCET 7.5/500MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | Q:240 /30Days |
ENDODAN TABLETS 325;4.8355MG;MG 100 BOT |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ENGERIX B INJECTION |
2 |
Tier 2 |
$43.00 | $107.50 | None |
ENGERIX B INJECTION 20MCG/ML |
2 |
Tier 2 |
$43.00 | $107.50 | None |
ENGERIX-B 10MCG 10 X 0.5ML VIALSD |
2 |
Tier 2 |
$43.00 | $107.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENJUVIA 0.3MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | None |
ENJUVIA 0.45MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | None |
ENJUVIA 0.625MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | None |
ENJUVIA 0.9MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | None |
ENJUVIA 1.25MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | None |
ENOXAPARIN SODIUM INJECTION |
5* |
Tier 5 |
33% | N/A | None |
ENOXAPARIN SODIUM INJECTION |
5* |
Tier 5 |
33% | N/A | None |
ENOXAPARIN SODIUM INJECTION |
4* |
Tier 4 |
33% | 33% | None |
ENOXAPARIN SODIUM INJECTION |
4* |
Tier 4 |
33% | 33% | None |
ENOXAPARIN SODIUM INJECTION |
4* |
Tier 4 |
33% | 33% | None |
ENOXAPARIN SODIUM INJECTION |
4* |
Tier 4 |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENOXAPARIN SODIUM INJECTION |
4* |
Tier 4 |
33% | 33% | None |
ENTOCORT EC 3MG CAPSULE |
5* |
Tier 5 |
33% | N/A | None |
ENULOSE SYRUP 10GM/15ML 1 PINT BOTPL |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Epinastine HCl 0.5mg/mL |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Epinephrine 0.1mg/mL |
4* |
Tier 4 |
33% | 33% | None |
EPIPEN 0.3MG AUTO-INJECTOR |
4* |
Tier 4 |
33% | 33% | Q:2 /1Days |
EPIPEN JR 0.15MG AUTO-INJCT |
4* |
Tier 4 |
33% | 33% | Q:2 /1Days |
EPIRUBICIN HCL INJECTION SOLUTION 2MG 1 X 25ML VIAL |
4* |
Tier 4 |
33% | 33% | P |
EPITOL 200MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
EPIVIR 300mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
3 |
Tier 3 |
$85.00 | $212.50 | None |
EPIVIR HBV 100MG TABLET |
2 |
Tier 2 |
$43.00 | $107.50 | None |
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 |
$43.00 | $107.50 | None |
EPIVIR ORAL SOLUTION |
3 |
Tier 3 |
$85.00 | $212.50 | None |
EPIVIR TABLETS |
3 |
Tier 3 |
$85.00 | $212.50 | None |
Eplerenone 25mg/1 30 TABLET in 1 BOTTLE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Eplerenone 50mg/1 30 TABLET in 1 BOTTLE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
EPOGEN 10000U/ML VIAL MDV |
4* |
Tier 4 |
33% | 33% | P |
EPOGEN 2000[iU]/mL 10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL |
4* |
Tier 4 |
33% | 33% | P |
EPOGEN 3000U/ML VIAL SDV |
4* |
Tier 4 |
33% | 33% | P |
EPOGEN 4000U/ML VIAL SDV |
4* |
Tier 4 |
33% | 33% | P |
EPOGEN INJECTION 20000U 10 X 1ML CRTN |
5* |
Tier 5 |
33% | N/A | P |
EPROSARTAN MESYLATE 600 MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPZICOM TABLETS |
5* |
Tier 5 |
33% | N/A | None |
EQUETRO CAPSULES 200MG 120 BOT |
2 |
Tier 2 |
$43.00 | $107.50 | Q:240 /30Days |
EQUETRO CAPSULES 300MG 120 BOT |
2 |
Tier 2 |
$43.00 | $107.50 | None |
EQUETRO EXTENDED RELEASE CAPSULES 100MG 120 BOT |
2 |
Tier 2 |
$43.00 | $107.50 | Q:240 /30Days |
ERBITUX 100MG/50ML VIAL |
5* |
Tier 5 |
33% | N/A | P |
ERGOLOID MESYLATES TABLETS 1MG 100 BOT |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ERGOMAR SUBLINGUAL TABLET 2MG |
3 |
Tier 3 |
$85.00 | $212.50 | None |
ERGOTAMINE-CAFFEINE TABLET 100 CT Bottle |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ERIVEDGE 150 MG CAPSULE |
5* |
Tier 5 |
33% | N/A | P |
ERRIN 0.35MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ERTACZO 2% CREAM |
3 |
Tier 3 |
$85.00 | $212.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERY 2% PADS 2% 60 PADS JAR |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE |
3 |
Tier 3 |
$85.00 | $212.50 | None |
ERY-TAB TAB 250MG EC |
3 |
Tier 3 |
$85.00 | $212.50 | None |
ERY-TAB TAB 333MG EC |
3 |
Tier 3 |
$85.00 | $212.50 | None |
ERYPED 200MG/5ML 100 ML BOT |
3 |
Tier 3 |
$85.00 | $212.50 | None |
ERYPED POWDER FOR ORAL SOLUTION 400MG/5ML 100 ML BOT |
3 |
Tier 3 |
$85.00 | $212.50 | None |
ERYTHROCIN 500MG ADDVNT VL |
4* |
Tier 4 |
33% | 33% | None |
ERYTHROCIN TAB 250MG |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ERYTHROMYCIN 2% SOLUTION |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Erythromycin 20mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ERYTHROMYCIN 500 MG FILMTAB |
1* |
Tier 1 |
$0.00 | $0.00 | 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 |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ERYTHROMYCIN ETHYLSUCCINATE TABLETS 400 MG 100 BOT |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ERYTHROMYCIN OPHTHALMIC OINTMENT 0.5% 1 G BOX OF 50 TUBE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ERYTHROMYCIN TAB 250MG BS |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ERYTHROMYCIN-BENZOYL PEROXIDE 3-5% GEL |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ESCITALOPRAM 10 MG TABLET |
2 |
Tier 2 |
$43.00 | $107.50 | Q:45 /30Days |
ESCITALOPRAM 20 MG TABLET |
2 |
Tier 2 |
$43.00 | $107.50 | Q:30 /30Days |
ESCITALOPRAM 5 MG TABLET |
2 |
Tier 2 |
$43.00 | $107.50 | Q:45 /30Days |
ESCITALOPRAM OXALATE 5 MG/5 ML |
2 |
Tier 2 |
$43.00 | $107.50 | Q:600 /30Days |
ESTRACE 0.5MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | None |
ESTRACE 2MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | 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 |
$85.00 | $212.50 | None |
ESTRACE VAG CREAM 0.1MG/GM |
3 |
Tier 3 |
$85.00 | $212.50 | None |
ESTRADERM 0.05MG/24H PATCH TRANSDERMAL SEMIWEEKLY |
3 |
Tier 3 |
$85.00 | $212.50 | S Q:8 /28Days |
ESTRADERM 0.1MG/24HR PATCH TRANSDERMAL SEMIWEEKLY |
3 |
Tier 3 |
$85.00 | $212.50 | S Q:8 /28Days |
ESTRADIOL .025MG/24H PATCH TRANSDERMAL WEEKLY |
1* |
Tier 1 |
$0.00 | $0.00 | Q:4 /28Days |
ESTRADIOL .0375MG/24 PATCH TRANSDERMAL WEEKLY |
1* |
Tier 1 |
$0.00 | $0.00 | Q:4 /28Days |
ESTRADIOL .075MG/24H PATCH TRANSDERMAL WEEKLY |
1* |
Tier 1 |
$0.00 | $0.00 | Q:4 /28Days |
ESTRADIOL 0.05MG/DAY PATCH |
1* |
Tier 1 |
$0.00 | $0.00 | Q:4 /28Days |
ESTRADIOL 0.06MG/24H PATCH TRANSDERMAL WEEKLY |
1* |
Tier 1 |
$0.00 | $0.00 | Q:4 /28Days |
ESTRADIOL 0.1MG/DAY PATCH |
1* |
Tier 1 |
$0.00 | $0.00 | Q:4 /28Days |
ESTRADIOL 0.5MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL 2MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ESTRADIOL TABLET 1MG (500 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ESTRADIOL VALERATE INJECTION |
4* |
Tier 4 |
33% | 33% | None |
ESTRADIOL VALERATE INJECTION |
4* |
Tier 4 |
33% | 33% | None |
ESTRADIOL VALERATE INJECTION |
4* |
Tier 4 |
33% | 33% | None |
ESTRADIOL-NORETH 1.0-0.5MG TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ESTRING 2MG VAGINAL RING |
3 |
Tier 3 |
$85.00 | $212.50 | Q:1 /90Days |
ESTROPIPATE 0.625 TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ESTROPIPATE 1.25 TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ESTROPIPATE 2.5 TABLET |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ESTROSTEP TABLETS 1;.02MG;MG 28 BLPK |
3 |
Tier 3 |
$85.00 | $212.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETHAMBUTOL 400 MG ORAL TABLET [MYAMBUTOL] |
3 |
Tier 3 |
$85.00 | $212.50 | None |
ETHAMBUTOL HCL 400MG TABLET (100 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Ethambutol Hydrochloride 100mg/1 |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ETHINYL ESTRADIOL 0.02 MG / NORETHINDRONE 1 MG ORAL TABLET) } PACK [LOESTRIN 1/20 21 DAY] |
3 |
Tier 3 |
$85.00 | $212.50 | None |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ETHINYL ESTRADIOL 0.03 MG / NORETHINDRONE 1.5 MG ORAL TABLET) } PACK [LOESTRIN 1.5/30 21 DAY] |
3 |
Tier 3 |
$85.00 | $212.50 | None |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21 |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Ethosuximide 250mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ETHOSUXIMIDE 250MG/5ML SYRP |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ETHYOL POWDER FOR INJECTION 500MG 3 X 10ML VILSU CRTN |
5* |
Tier 5 |
33% | N/A | P |
ETIDRONATE DISODIUM 400MG TABLET (60 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ETODOLAC 200MG CAPSULE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ETODOLAC 300 MG CAPSULE |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ETODOLAC 400MG TABLET (500 CT) |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ETODOLAC 400MG TABLET SR 24HR |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ETODOLAC 500MG TABLET SR 24HR |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ETODOLAC 500mg/1 |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ETODOLAC 600MG TABLET SR 24HR |
1* |
Tier 1 |
$0.00 | $0.00 | None |
ETOPOPHOS 100MG VIAL |
4* |
Tier 4 |
33% | 33% | P |
Etoposide 20mg/mL 1 VIAL in 1 BOX, UNIT-DOSE / 50 mL in 1 VIAL |
4* |
Tier 4 |
33% | 33% | P |
Eurax Lotion and Cream 100mg/g 454 g in 1 BOTTLE |
3 |
Tier 3 |
$85.00 | $212.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Eurax Lotion and Cream 100mg/g 60 g in 1 TUBE |
3 |
Tier 3 |
$85.00 | $212.50 | None |
Evista 60mg/1 100 TABLET in 1 BOTTLE |
2 |
Tier 2 |
$43.00 | $107.50 | Q:30 /30Days |
EVOCLIN 1% FOAM |
3 |
Tier 3 |
$85.00 | $212.50 | None |
EVOXAC 30MG CAPSULE |
3 |
Tier 3 |
$85.00 | $212.50 | None |
Exelderm 10mg/g 30 g in 1 TUBE |
3 |
Tier 3 |
$85.00 | $212.50 | None |
Exelderm 10mg/mL 30 mL in 1 BOTTLE, PLASTIC |
3 |
Tier 3 |
$85.00 | $212.50 | None |
EXELON 1.5MG CAPSULE |
3 |
Tier 3 |
$85.00 | $212.50 | Q:60 /30Days |
EXELON 2MG/ML ORAL SOLUTION |
2 |
Tier 2 |
$43.00 | $107.50 | Q:180 /30Days |
EXELON 3MG CAPSULE |
3 |
Tier 3 |
$85.00 | $212.50 | Q:60 /30Days |
EXELON 4.5MG CAPSULE |
3 |
Tier 3 |
$85.00 | $212.50 | Q:60 /30Days |
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS |
2 |
Tier 2 |
$43.00 | $107.50 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EXELON 6MG CAPSULE |
3 |
Tier 3 |
$85.00 | $212.50 | Q:60 /30Days |
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS |
2 |
Tier 2 |
$43.00 | $107.50 | Q:30 /30Days |
Exemestane 25mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
$43.00 | $107.50 | None |
EXFORGE 10MG-160MG TABLET |
2 |
Tier 2 |
$43.00 | $107.50 | Q:30 /30Days |
EXFORGE 10MG-320MG TABLET |
2 |
Tier 2 |
$43.00 | $107.50 | Q:30 /30Days |
EXFORGE 5MG-160MG TABLET |
2 |
Tier 2 |
$43.00 | $107.50 | Q:30 /30Days |
EXFORGE 5MG-320MG TABLET |
2 |
Tier 2 |
$43.00 | $107.50 | Q:30 /30Days |
Exforge HCT 10; 12.5; 160mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
$43.00 | $107.50 | Q:30 /30Days |
Exforge HCT 10; 25; 160mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
$43.00 | $107.50 | Q:30 /30Days |
Exforge HCT 10; 25; 320mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
$43.00 | $107.50 | Q:30 /30Days |
Exforge HCT 5; 12.5; 160mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
$43.00 | $107.50 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Exforge HCT 5; 25; 160mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
$43.00 | $107.50 | Q:30 /30Days |
EXJADE 125MG TABLET |
3 |
Tier 3 |
$85.00 | $212.50 | P |
EXJADE 250MG TABLET |
5* |
Tier 5 |
33% | N/A | P |
EXJADE 500MG TABLET |
5* |
Tier 5 |
33% | N/A | P |
EXTAVIA 15 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
5* |
Tier 5 |
33% | N/A | P |
EXTENDED PHENYTOIN SODIUM CAPSULES 300 MG |
2 |
Tier 2 |
$43.00 | $107.50 | None |