2013 Medicare Part D Plan Formulary Information |
HumanaChoice R5826-009 (Regional PPO) (R5826-009-0)
Benefit Details
|
The HumanaChoice R5826-009 (Regional PPO) (R5826-009-0) Formulary Drugs Starting with the Letter E in Statewide County, IL: CMS MA Region 14 which includes: WI IL
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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. 400 FILMTAB |
3 |
Tier 3 |
25% | 25% | None |
E.E.S. GRAN SUS 200/5ML |
3 |
Tier 3 |
25% | 25% | None |
EC-NAPROSYN 375MG TABLET EC |
3 |
Tier 3 |
25% | 25% | P |
EC-NAPROSYN 500MG TABLET EC |
3 |
Tier 3 |
25% | 25% | P |
ECONAZOLE NITRATE 1% CREAM 85GM TUBE |
1 |
Tier 1 |
25% | 25% | None |
edarbi 40mg/1 |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
edarbi 80mg/1 |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
EDARBYCLOR 40-12.5 MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
EDARBYCLOR 40-25 MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
EDURANT 27.5mg/1 |
3 |
Tier 3 |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EFFIENT 10 MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
EFFIENT 5 MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
Egrifta 1 KIT in 1 CARTON |
4 |
Tier 4 |
25% | 25% | P Q:60 /30Days |
ELAPRASE 6mg/3mL 1 VIAL, GLASS in 1 BOX / 3 mL in 1 VIAL, GLASS |
4 |
Tier 4 |
25% | 25% | P |
ELELYSO 200 UNITS VIAL |
4 |
Tier 4 |
25% | 25% | P Q:60 /30Days |
ELESTAT 0.5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER |
3 |
Tier 3 |
25% | 25% | None |
ELIDEL 1% CREAM |
3 |
Tier 3 |
25% | 25% | None |
ELIGARD 1 KIT in 1 CARTON |
3 |
Tier 3 |
25% | 25% | P |
ELIGARD 1 KIT in 1 CARTON |
3 |
Tier 3 |
25% | 25% | P |
ELIGARD 1 KIT in 1 CARTON |
3 |
Tier 3 |
25% | 25% | P |
ELIGARD 1 KIT in 1 CARTON |
3 |
Tier 3 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIPHOS TABLETS CALCIUM ACETATE TABLETS 667MG 200 BOT |
2 |
Tier 2 |
25% | 25% | None |
ELIQUIS 2.5 MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
ELIQUIS 5 MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days |
Elitek 3 KIT in 1 CARTON / 1 KIT in 1 KIT |
4 |
Tier 4 |
25% | 25% | P |
ELIXOPHYLLIN 80mg/15mL 473 mL in 1 BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
ELLENCE 2MG/ML VIAL |
4 |
Tier 4 |
25% | 25% | P |
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE |
3 |
Tier 3 |
25% | 25% | None |
ELOCON 0.1% CREAM |
3 |
Tier 3 |
25% | 25% | None |
ELOCON 0.1% LOTION |
3 |
Tier 3 |
25% | 25% | None |
ELOCON 0.1% OINTMENT |
3 |
Tier 3 |
25% | 25% | None |
ELOXATIN 100MG/20ML VIAL |
4 |
Tier 4 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELSPAR INJ 10000UNT |
3 |
Tier 3 |
25% | 25% | P |
EMADINE 0.05% EYE DROPS |
3 |
Tier 3 |
25% | 25% | None |
EMCYT 140MG CAPSULE |
3 |
Tier 3 |
25% | 25% | None |
EMEND 40MG CAPSULE |
3 |
Tier 3 |
25% | 25% | P Q:2 /28Days |
EMEND CAPSULES 125MG 6 BLPK |
3 |
Tier 3 |
25% | 25% | P Q:2 /28Days |
EMEND CAPSULES 80MG 2 BLPK |
3 |
Tier 3 |
25% | 25% | P Q:4 /28Days |
EMEND TRIFOLD PACK |
3 |
Tier 3 |
25% | 25% | P Q:6 /28Days |
EMLA CREAM |
3 |
Tier 3 |
25% | 25% | P |
Emoquette 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
3 |
Tier 3 |
25% | 25% | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
4 |
Tier 4 |
25% | 25% | Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
3 |
Tier 3 |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
4 |
Tier 4 |
25% | 25% | Q:30 /30Days |
EMTRIVA 10MG/ML SOLUTION |
3 |
Tier 3 |
25% | 25% | Q:680 /28Days |
EMTRIVA 200MG CAPSULE |
3 |
Tier 3 |
25% | 25% | Q:30 /30Days |
Enablex 15mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Tier 3 |
25% | 25% | Q:30 /30Days |
Enablex 7.5mg EXTENDED RELEASE 90 TABLET BOTTLE |
3 |
Tier 3 |
25% | 25% | Q:30 /30Days |
ENALAPRIL MALEATE 10MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
ENALAPRIL MALEATE 2.5 MG TAB |
1 |
Tier 1 |
25% | 25% | None |
Enalapril Maleate 20mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Tier 1 |
25% | 25% | None |
ENALAPRIL MALEATE 5 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ENALAPRIL MALEATE-HCTZ 10MG-25MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET (100 CT) |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENBREL 25 MG/0.5 ML SYRINGE |
4 |
Tier 4 |
25% | 25% | P Q:8 /28Days |
ENBREL 25MG KIT |
4 |
Tier 4 |
25% | 25% | P Q:8 /28Days |
ENBREL 50mg/mL |
4 |
Tier 4 |
25% | 25% | P Q:8 /28Days |
ENDOCET 10/650MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:180 /30Days |
ENDOCET 10MG-325MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:360 /30Days |
ENDOCET 5/325 TABLET |
2 |
Tier 2 |
25% | 25% | Q:360 /30Days |
ENDOCET 7.5-325MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:360 /30Days |
ENDOCET 7.5/500MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:240 /30Days |
Endometrin 100mg/1 1 CARTON in 1 CARTON / 21 BLISTER PACK in 1 CARTON / 1 INSERT in 1 BLISTER PACK |
3 |
Tier 3 |
25% | 25% | None |
ENGERIX B INJECTION |
3 |
Tier 3 |
25% | 25% | P |
ENGERIX B INJECTION 20MCG/ML |
3 |
Tier 3 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENGERIX-B 10MCG 10 X 0.5ML VIALSD |
3 |
Tier 3 |
25% | 25% | P |
ENOXAPARIN 100 MG/ML SYRINGE |
3 |
Tier 3 |
25% | 25% | Q:28 /30Days |
ENOXAPARIN 120 MG/0.8 ML SYR |
3 |
Tier 3 |
25% | 25% | Q:28 /30Days |
ENOXAPARIN 150 MG/ML SYRINGE |
3 |
Tier 3 |
25% | 25% | Q:28 /30Days |
ENOXAPARIN 30 MG/0.3 ML SYR |
3 |
Tier 3 |
25% | 25% | Q:28 /30Days |
ENOXAPARIN 300 MG/3 ML VIAL |
3 |
Tier 3 |
25% | 25% | Q:28 /30Days |
ENOXAPARIN 40 MG/0.4 ML SYR |
3 |
Tier 3 |
25% | 25% | Q:28 /30Days |
ENOXAPARIN 60 MG/0.6 ML SYR |
3 |
Tier 3 |
25% | 25% | Q:28 /30Days |
ENOXAPARIN 80 MG/0.8 ML SYR |
3 |
Tier 3 |
25% | 25% | Q:28 /30Days |
entacapone 200 mg tablet |
2 |
Tier 2 |
25% | 25% | Q:300 /30Days |
ENULOSE 10 GM/15 ML SOLUTION |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPIDUO GEL 0.1;2.5%;% 45 TRADE SIZE TUBE |
3 |
Tier 3 |
25% | 25% | None |
Epinastine HCl 0.5mg/mL |
3 |
Tier 3 |
25% | 25% | None |
Epinephrine 0.1mg/mL |
1 |
Tier 1 |
25% | 25% | None |
EPIPEN 0.3MG AUTO-INJECTOR |
2 |
Tier 2 |
25% | 25% | None |
EPIPEN JR 0.15MG AUTO-INJCT |
2 |
Tier 2 |
25% | 25% | None |
EPIRUBICIN HCL INJECTION SOLUTION 2MG 1 X 25ML VIAL |
3 |
Tier 3 |
25% | 25% | P |
EPITOL 200MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
EPIVIR 300mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Tier 3 |
25% | 25% | Q:30 /30Days |
EPIVIR HBV 100MG TABLET |
3 |
Tier 3 |
25% | 25% | Q:90 /30Days |
EPIVIR HBV 25MG/5ML TUBEX |
3 |
Tier 3 |
25% | 25% | Q:1680 /28Days |
EPIVIR ORAL SOLUTION |
3 |
Tier 3 |
25% | 25% | Q:960 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPIVIR TABLETS |
3 |
Tier 3 |
25% | 25% | Q:60 /30Days |
Eplerenone 25mg/1 90 TABLET BOTTLE |
3 |
Tier 3 |
25% | 25% | None |
Eplerenone 50mg/1 90 TABLET BOTTLE |
3 |
Tier 3 |
25% | 25% | None |
EPOGEN 10000U/ML VIAL MDV |
3 |
Tier 3 |
25% | 25% | P Q:14 /30Days |
EPOGEN 2000[iU]/mL 10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL |
2 |
Tier 2 |
25% | 25% | P Q:14 /30Days |
EPOGEN 3000U/ML VIAL SDV |
2 |
Tier 2 |
25% | 25% | P Q:14 /30Days |
EPOGEN 4000U/ML VIAL SDV |
2 |
Tier 2 |
25% | 25% | P Q:14 /30Days |
EPOGEN INJECTION 20000U 10 X 1ML CRTN |
3 |
Tier 3 |
25% | 25% | P Q:14 /30Days |
EPZICOM TABLETS |
4 |
Tier 4 |
25% | 25% | Q:30 /30Days |
EQUETRO CAPSULES 200MG 120 BOT |
3 |
Tier 3 |
25% | 25% | None |
EQUETRO CAPSULES 300MG 120 BOT |
3 |
Tier 3 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EQUETRO EXTENDED RELEASE CAPSULES 100MG 120 BOT |
3 |
Tier 3 |
25% | 25% | None |
ERAXIS 100mg/30mL 30 mL in 1 VIAL, SINGLE-USE |
3 |
Tier 3 |
25% | 25% | P |
ERBITUX 100MG/50ML VIAL |
4 |
Tier 4 |
25% | 25% | P |
ERGOMAR 2 MG TABLET SL |
1 |
Tier 1 |
25% | 25% | None |
ERIVEDGE 150 MG CAPSULE |
4 |
Tier 4 |
25% | 25% | P Q:28 /28Days |
ERRIN 0.35MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
ERY 2% PADS 2% 60 PADS JAR |
1 |
Tier 1 |
25% | 25% | None |
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE |
3 |
Tier 3 |
25% | 25% | None |
ERY-TAB TAB 250MG EC |
3 |
Tier 3 |
25% | 25% | None |
ERY-TAB TAB 333MG EC |
3 |
Tier 3 |
25% | 25% | None |
ERYPED 200 MG/5 ML SUSPENSION |
3 |
Tier 3 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYPED 400 MG/5 ML SUSPENSION |
3 |
Tier 3 |
25% | 25% | None |
ERYTHROCIN 500MG ADDVNT VL |
1 |
Tier 1 |
25% | 25% | None |
ERYTHROCIN TAB 250MG |
1 |
Tier 1 |
25% | 25% | None |
Erythromycin 2% solution |
1 |
Tier 1 |
25% | 25% | None |
Erythromycin 20mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
1 |
Tier 1 |
25% | 25% | None |
ERYTHROMYCIN 500 MG FILMTAB |
1 |
Tier 1 |
25% | 25% | None |
ERYTHROMYCIN ES 400 MG TAB |
1 |
Tier 1 |
25% | 25% | None |
ERYTHROMYCIN OPHTHALMIC OINTMENT 0.5% 1 G BOX OF 50 TUBE |
1 |
Tier 1 |
25% | 25% | None |
ERYTHROMYCIN TAB 250MG BS |
1 |
Tier 1 |
25% | 25% | None |
ERYTHROMYCIN-BENZOYL PEROXIDE 3-5% GEL |
2 |
Tier 2 |
25% | 25% | None |
ESCITALOPRAM 10 MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:45 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESCITALOPRAM 20 MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ESCITALOPRAM 5 MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
ESCITALOPRAM OXALATE 5 MG/5 ML |
2 |
Tier 2 |
25% | 25% | Q:600 /30Days |
ESTRACE VAG CREAM 0.1MG/GM |
3 |
Tier 3 |
25% | 25% | None |
ESTRADIOL .025MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Tier 1 |
25% | 25% | P Q:4 /28Days |
ESTRADIOL .0375MG/24 PATCH TRANSDERMAL WEEKLY |
1 |
Tier 1 |
25% | 25% | P Q:4 /28Days |
ESTRADIOL .075MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Tier 1 |
25% | 25% | P Q:4 /28Days |
ESTRADIOL 0.05MG/DAY PATCH |
1 |
Tier 1 |
25% | 25% | P Q:4 /28Days |
ESTRADIOL 0.06MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Tier 1 |
25% | 25% | P Q:4 /28Days |
ESTRADIOL 0.1MG/DAY PATCH |
1 |
Tier 1 |
25% | 25% | P Q:4 /28Days |
ESTRADIOL 0.5MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL 2MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
ESTRADIOL TABLET 1MG (500 CT) |
1 |
Tier 1 |
25% | 25% | P |
ESTRADIOL VALERATE 20mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
3 |
Tier 3 |
25% | 25% | P |
ESTRADIOL VALERATE 40mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
3 |
Tier 3 |
25% | 25% | P |
ESTRADIOL VALERATE INJECTION |
3 |
Tier 3 |
25% | 25% | P |
ESTRING 2MG VAGINAL RING |
3 |
Tier 3 |
25% | 25% | Q:1 /90Days |
ESTROSTEP TABLETS 1;.02MG;MG 28 BLPK |
3 |
Tier 3 |
25% | 25% | None |
ETHAMBUTOL HCL 400 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Ethambutol Hydrochloride 100mg/1 |
1 |
Tier 1 |
25% | 25% | None |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 |
3 |
Tier 3 |
25% | 25% | None |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21 |
3 |
Tier 3 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ethosuximide 250mg 100 CAPSULE BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
ETHOSUXIMIDE 250MG/5ML SYRP |
1 |
Tier 1 |
25% | 25% | None |
ETIDRONATE DISODIUM 400MG TABLET (60 CT) |
2 |
Tier 2 |
25% | 25% | None |
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT |
2 |
Tier 2 |
25% | 25% | None |
ETODOLAC 200MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
Etodolac 300 mg capsule |
1 |
Tier 1 |
25% | 25% | None |
ETODOLAC 400MG TABLET SR 24HR |
2 |
Tier 2 |
25% | 25% | None |
Etodolac 400mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
ETODOLAC 500MG TABLET SR 24HR |
2 |
Tier 2 |
25% | 25% | None |
Etodolac 500mg/1 500 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
ETODOLAC 600MG TABLET SR 24HR |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETOPOPHOS 100MG VIAL |
4 |
Tier 4 |
25% | 25% | P |
Etoposide 20mg/mL 1 VIAL in 1 BOX, UNIT-DOSE / 25 mL in 1 VIAL |
2 |
Tier 2 |
25% | 25% | None |
Eurax Lotion and Cream 100mg/g 454 g in 1 BOTTLE |
3 |
Tier 3 |
25% | 25% | None |
Eurax Lotion and Cream 100mg/g 60 g in 1 TUBE |
3 |
Tier 3 |
25% | 25% | None |
Evista 60mg/1 100 TABLET BOTTLE |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
EXALGO 12mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Tier 3 |
25% | 25% | Q:180 /30Days |
EXALGO 16mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Tier 3 |
25% | 25% | Q:120 /30Days |
EXALGO 8mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Tier 3 |
25% | 25% | Q:240 /30Days |
Exelderm 10mg/g 30 g in 1 TUBE |
3 |
Tier 3 |
25% | 25% | None |
Exelderm 10mg/mL 30 mL in 1 BOTTLE, PLASTIC |
3 |
Tier 3 |
25% | 25% | None |
EXELON 13.3 MG/24HR PATCH |
3 |
Tier 3 |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EXELON 2MG/ML ORAL SOLUTION |
3 |
Tier 3 |
25% | 25% | Q:240 /30Days |
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS |
3 |
Tier 3 |
25% | 25% | Q:30 /30Days |
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS |
3 |
Tier 3 |
25% | 25% | Q:30 /30Days |
Exemestane 25mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Tier 3 |
25% | 25% | Q:60 /30Days |
EXFORGE 10MG-160MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
EXFORGE 10MG-320MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
EXFORGE 5MG-160MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
EXFORGE 5MG-320MG TABLET |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
Exforge HCT 10; 12.5; 160mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
Exforge HCT 10; 25; 160mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
Exforge HCT 10; 25; 320mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Exforge HCT 5; 12.5; 160mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
Exforge HCT 5; 25; 160mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days |
EXJADE 125MG TABLET |
3 |
Tier 3 |
25% | 25% | P |
EXJADE 250MG TABLET |
4 |
Tier 4 |
25% | 25% | P |
EXJADE 500MG TABLET |
4 |
Tier 4 |
25% | 25% | P |
EXTENDED PHENYTOIN SODIUM CAPSULES 300 MG |
1 |
Tier 1 |
25% | 25% | None |
EXTINA 2% FOAM |
3 |
Tier 3 |
25% | 25% | P |