2018 Medicare Part D Plan Formulary Information |
HumanaChoice H5216-082 (PPO) (H5216-082-0)
Benefit Details
|
The HumanaChoice H5216-082 (PPO) (H5216-082-0) Formulary Drugs Starting with the Letter E in Logan County, AR: CMS MA Region 15 which includes: AR Plan Monthly Premium: $93.00 Deductible: $195 |
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 |
ECONAZOLE NITRATE 1% CREAM 85GM TUBE |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
EDURANT 27.5mg/1 |
5 |
Specialty Tier |
29% | N/A | Q:30 /30Days |
EFAVIRENZ 200 MG CAPSULE [Sustiva] |
5 |
Specialty Tier |
29% | N/A | Q:120 /30Days |
EFAVIRENZ 50 MG CAPSULE [Sustiva] |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:480 /30Days |
EFAVIRENZ 600 MG TABLET [Sustiva] |
5 |
Specialty Tier |
29% | N/A | Q:30 /30Days |
EFFIENT 10 MG TABLET |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:30 /30Days |
EFFIENT 5 MG TABLET |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:30 /30Days |
EGRIFTA 2 MG VIAL |
5 |
Specialty Tier |
29% | N/A | P Q:60 /30Days |
ELELYSO 200 UNITS VIAL |
5 |
Specialty Tier |
29% | N/A | P Q:70 /30Days |
ELIDEL 1% CREAM |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIGARD 22.5 MG SYRINGE |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P |
ELIGARD 30 MG SYRINGE KIT |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P |
ELIGARD 45 MG SYRINGE KIT |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P |
ELIGARD 7.5 MG SYRINGE KIT |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P |
ELIQUIS 2.5 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
ELIQUIS 5 MG STARTER PACK |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:74 /30Days |
ELIQUIS 5 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:74 /30Days |
Elitek 3 KIT per CARTON / 1 KIT in 1 KIT |
5 |
Specialty Tier |
29% | N/A | P |
ELITEK 7.5 MG VIAL |
5 |
Specialty Tier |
29% | N/A | P |
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:90 /30Days |
EMBEDA ER 100-4 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMBEDA ER 20-0.8 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
EMBEDA ER 30-1.2 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
EMBEDA ER 50-2 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
EMBEDA ER 60-2.4 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
EMBEDA ER 80-3.2 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
EMCYT 140MG CAPSULE |
5 |
Specialty Tier |
29% | N/A | None |
EMEND 125 MG POWDER PACKET |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:3 /28Days |
EMEND 150 MG VIAL |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P |
EMEND 40 MG CAPSULE |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:2 /28Days |
EMEND CAPSULES 125MG 6 BLPK |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:2 /28Days |
EMEND CAPSULES 80MG 2 BLPK |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMEND TRIFOLD PACK |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:6 /28Days |
Emoquette 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
Empagliflozin 5 MG / Metformin hydrochloride 500 MG Oral Tablet [Synjardy] |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
EMPLICITI 300 MG VIAL |
5 |
Specialty Tier |
29% | N/A | P |
EMPLICITI 400 MG VIAL |
5 |
Specialty Tier |
29% | N/A | P |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
5 |
Specialty Tier |
29% | N/A | Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
5 |
Specialty Tier |
29% | N/A | Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
5 |
Specialty Tier |
29% | N/A | Q:30 /30Days |
EMTRIVA 10MG/ML SOLUTION |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:680 /28Days |
EMTRIVA 200MG CAPSULE |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days |
ENALAPRIL MALEATE 10 MG TAB |
1* |
Preferred Generic |
$8.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENALAPRIL MALEATE 2.5 MG TAB |
1* |
Preferred Generic |
$8.00 | $0.00 | None |
ENALAPRIL MALEATE 20 MG TAB |
1* |
Preferred Generic |
$8.00 | $0.00 | None |
ENALAPRIL MALEATE 5 MG TABLET |
1* |
Preferred Generic |
$8.00 | $0.00 | None |
Enalapril Maleate and Hydrochlorothiazide 10; 25mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1* |
Preferred Generic |
$8.00 | $0.00 | None |
ENALAPRIL-HCTZ 5-12.5 MG TAB |
1* |
Preferred Generic |
$8.00 | $0.00 | None |
ENBREL 25 MG/0.5 ML SYRINGE |
5 |
Specialty Tier |
29% | N/A | P Q:4 /28Days |
ENBREL 25MG KIT |
5 |
Specialty Tier |
29% | N/A | P Q:8 /28Days |
ENBREL 50 MG/ML SURECLICK SYR |
5 |
Specialty Tier |
29% | N/A | P Q:8 /28Days |
ENBREL 50mg/mL |
5 |
Specialty Tier |
29% | N/A | P Q:8 /28Days |
ENDOCET 10MG-325MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days |
ENDOCET 5/325 TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENDOCET 7.5-325MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days |
ENGERIX B INJECTION |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P |
ENGERIX-B 20 MCG/ML SYRN |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P |
ENOXAPARIN 100 MG/ML SYRINGE |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:28 /28Days |
ENOXAPARIN 120 MG/0.8 ML SYRINGE |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:22 /28Days |
ENOXAPARIN 150 MG/ML SYRINGE |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:28 /28Days |
ENOXAPARIN 30 MG/0.3 ML SYR |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:17 /28Days |
ENOXAPARIN 300 MG/3 ML VIAL |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:84 /28Days |
ENOXAPARIN 40 MG/0.4 ML SYR |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:11 /28Days |
ENOXAPARIN 60 MG/0.6 ML SYRINGE |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:17 /28Days |
ENOXAPARIN 80 MG/0.8 ML SYRINGE |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:22 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENSKYCE 28 TABLET |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
ENSTILAR 0.005%-0.064% FOAM |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:120 /30Days |
ENTACAPONE 200 MG TABLET [Comtan Entacapone] |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:300 /30Days |
ENTECAVIR 0.5 MG TABLET [Baraclude] |
5 |
Specialty Tier |
29% | N/A | Q:30 /30Days |
ENTECAVIR 1 MG TABLET [Baraclude] |
5 |
Specialty Tier |
29% | N/A | Q:30 /30Days |
ENTRESTO 24 MG-26 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | P Q:60 /30Days |
ENTRESTO 49 MG-51 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | P Q:60 /30Days |
ENTRESTO 97 MG-103 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | P Q:60 /30Days |
ENULOSE 10 GM/15 ML SOLUTION |
2* |
Generic |
$15.00 | $0.00 | None |
EPCLUSA 400 MG-100 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P Q:28 /28Days |
EPINASTINE HCL 0.05% EYE DROPS |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:5 /25Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPINEPHRINE 0.15 MG AUTO-INJCT |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:4 /30Days |
EPINEPHRINE 0.3 MG AUTO-INJECT |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:4 /30Days |
EPINEPHRINE 0.3 MG AUTO-INJECT |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:4 /30Days |
EPIPEN 0.3MG AUTO-INJECTOR |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:4 /30Days |
EPIPEN JR 0.15MG AUTO-INJCT |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:4 /30Days |
Epirubicin HCl 200 MG per 100 ML Injection |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P |
EPITOL 200MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
EPIVIR HBV 25MG/5ML TUBEX |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
Eplerenone 25mg/1 90 TABLET BOTTLE |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
Eplerenone 50mg/1 90 TABLET BOTTLE |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
EPOGEN 10000U/ML VIAL MDV |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:28 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPOGEN 2000[iU]/mL 10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:14 /30Days |
EPOGEN 3000U/ML VIAL SDV |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:14 /30Days |
EPOGEN 4000U/ML VIAL SDV |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:14 /30Days |
EPOGEN INJECTION 20000U 10 X 1ML CRTN |
5 |
Specialty Tier |
29% | N/A | P Q:14 /30Days |
EPZICOM 600MG/300MG TABLETS |
5 |
Specialty Tier |
29% | N/A | Q:30 /30Days |
EQUETRO CAPSULES 200MG 120 BOT |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
EQUETRO CAPSULES 300MG 120 BOT |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
EQUETRO EXTENDED RELEASE CAPSULES 100MG 120 BOT |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
ERAXIS 100mg/30mL 30 mL in 1 VIAL, SINGLE-USE |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
ERAXIS(WATER DIL) 50 MG VIAL |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
ERBITUX 100MG/50ML VIAL |
5 |
Specialty Tier |
29% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERIVEDGE 150 MG CAPSULE |
5 |
Specialty Tier |
29% | N/A | P Q:28 /28Days |
ERLEADA 60 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P Q:120 /30Days |
Errin 0.35 mg tablet |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
ERWINAZE 10,000 UNITS VIAL |
5 |
Specialty Tier |
29% | N/A | P Q:60 /28Days |
ERY 2% PADS 2% 60 PADS JAR |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
ERYTHROCIN 500MG ADDVNT VL |
1* |
Preferred Generic |
$8.00 | $0.00 | None |
ERYTHROMYCIN 0.5% EYE OINTMENT |
2* |
Generic |
$15.00 | $0.00 | None |
ERYTHROMYCIN 2% GEL |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
ERYTHROMYCIN 2% SOLUTION |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
ERYTHROMYCIN 500 MG FILMTAB |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
ERYTHROMYCIN TAB 250MG BS |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROMYCIN-BENZOYL GEL |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
ESBRIET 267 MG CAPSULE |
5 |
Specialty Tier |
29% | N/A | P Q:270 /30Days |
ESBRIET 267 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P Q:270 /30Days |
ESBRIET 801 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P Q:90 /30Days |
ESCITALOPRAM 10 MG TABLET [Lexapro] |
1* |
Preferred Generic |
$8.00 | $0.00 | Q:45 /30Days |
ESCITALOPRAM 20 MG TABLET [Lexapro] |
1* |
Preferred Generic |
$8.00 | $0.00 | Q:30 /30Days |
ESCITALOPRAM 5 MG TABLET [Lexapro] |
1* |
Preferred Generic |
$8.00 | $0.00 | Q:30 /30Days |
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro] |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:600 /30Days |
ESOMEPRAZOLE MAG DR 20 MG CAP [Nexium] |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days |
ESOMEPRAZOLE MAG DR 40 MG CAP [Nexium] |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days |
ESTRACE VAG CREAM 0.1MG/GM |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Estradiol / Norethindrone Acetate 0.5; 0.1mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, FILM C |
3 |
Preferred Brand |
$47.00 | $131.00 | P |
ESTRADIOL 0.5 MG TABLET |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P |
ESTRADIOL 1 MG TABLET |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P |
ESTRADIOL 10 MCG VAGINAL INSRT |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
ESTRADIOL 2MG TABLET |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P |
ESTRADIOL VALERATE 20mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
ESTRADIOL VALERATE 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
ESTRADIOL-NORETH 1.0-0.5MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | P |
ESTRING 2MG VAGINAL RING |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:1 /90Days |
ESTROPIPATE 0.625(0.75 MG) TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | P |
ESTROPIPATE 1.25(1.5 MG) TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESZOPICLONE 1 MG TABLET [Lunesta] |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
ESZOPICLONE 2 MG TABLET [Lunesta] |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
ESZOPICLONE 3 MG TABLET [Lunesta] |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
ETHACRYNATE SODIUM 50 MG VIAL [Edecrin] |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
ETHAMBUTOL HCL 400 MG TABLET |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
Ethambutol Hydrochloride 100mg/1 |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21 |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
ETHOSUXIMIDE 250 MG CAPSULE |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
ETHOSUXIMIDE 250 MG/5 ML SOLN |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
ETHYNODIOL-ETH ESTRA 1MG-35MCG [ZOVIA] |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ethynodiol-eth estra 1mg-50mcg [ZOVIA] |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
ETIDRONATE DISODIUM 400MG TABLET (60 CT) |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
ETODOLAC 200 MG CAPSULE [LODINE] |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
ETODOLAC 300 MG CAPSULE [LODINE] |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
ETODOLAC 400 MG TABLET [LODINE] |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
ETODOLAC 500 MG TABLET [LODINE] |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
ETODOLAC ER 400 MG TABLET [LODINE] |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
ETODOLAC ER 500 MG TABLET [LODINE] |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
ETODOLAC ER 600 MG TABLET [LODINE] |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None |
ETOPOPHOS 100MG VIAL |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EVOTAZ 300 MG-150 MG TABLET |
5 |
Specialty Tier |
29% | N/A | Q:30 /30Days |
EXELON 13.3 MG/24HR PATCH |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days |
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days |
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days |
EXEMESTANE 25 MG TABLET |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:60 /30Days |
EXJADE 125MG TABLET |
5 |
Specialty Tier |
29% | N/A | P |
EXJADE 250MG TABLET |
5 |
Specialty Tier |
29% | N/A | P |
EXJADE 500MG TABLET |
5 |
Specialty Tier |
29% | N/A | P |
EXONDYS 51 100 MG/2 ML VIAL |
5 |
Specialty Tier |
29% | N/A | P |
EXONDYS 51 500 MG/10 ML VIAL |
5 |
Specialty Tier |
29% | N/A | P |
Ezetimibe 10 MG Oral Tablet [Zetia] |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ezetimibe-Simvastatin 10-10 MG [Vytorin] |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:30 /30Days |
Ezetimibe-Simvastatin 10-20 MG [Vytorin] |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:30 /30Days |
Ezetimibe-Simvastatin 10-40 MG [Vytorin] |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:30 /30Days |
Ezetimibe-Simvastatin 10-80 MG [Vytorin] |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:30 /30Days |