2019 Medicare Part D Plan Formulary Information |
Kaiser Permanente Sr Advantage Basic Sac., Sonoma (HMO) (H0524-051-0)
Benefit Details
|
The Kaiser Permanente Sr Advantage Basic Sac., Sonoma (HMO) (H0524-051-0) Formulary Drugs Starting with the Letter E in Sutter County, CA: CMS MA Region 24 which includes: CA Plan Monthly Premium: $24.00 Deductible: $0 |
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. 200 MG/5 ML GRANULES |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
E.E.S. 400 FILMTAB |
2 |
Generic |
$18.00 | $36.00 | None |
ECONAZOLE NITRATE 1% CREAM 85GM TUBE |
2 |
Generic |
$18.00 | $36.00 | None |
EDARBI 40 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EDARBI 80 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EDARBYCLOR 40-12.5 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EDARBYCLOR 40-25 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EDECRIN 25 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
Edluar 10mg/1 3 BLISTER PACK per CARTON / 10 TABLET per BLISTER PACK |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
Edluar 5mg/1 3 BLISTER PACK per CARTON / 10 TABLET per BLISTER PACK |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EDURANT 27.5mg/1 |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
EFAVIRENZ 200 MG CAPSULE [Sustiva] |
2 |
Generic |
$18.00 | $36.00 | None |
EFAVIRENZ 50 MG CAPSULE [Sustiva] |
2 |
Generic |
$18.00 | $36.00 | None |
EFAVIRENZ 600 MG TABLET [Sustiva] |
2 |
Generic |
$18.00 | $36.00 | None |
EFFEXOR XR 150 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EFFEXOR XR 37.5 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EFFEXOR XR 75 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EFFIENT 10 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EFFIENT 5 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EFUDEX 5% CREAM |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EGRIFTA 2 MG VIAL |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELESTAT 0.5mg/mL 1 BOTTLE, DROPPER per CARTON / 5 mL in 1 BOTTLE, DROPPER |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ELESTRIN 0.06% GEL MD PMP |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ELETRIPTAN HBR 20 MG TABLET [Relpax] |
2 |
Generic |
$18.00 | $36.00 | None |
ELETRIPTAN HBR 40 MG TABLET [Relpax] |
2 |
Generic |
$18.00 | $36.00 | None |
ELIDEL 1% CREAM |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
ELIGARD 22.5 MG SYRINGE |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ELIGARD 30 MG SYRINGE KIT |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ELIGARD 45 MG SYRINGE KIT |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ELIGARD 7.5 MG SYRINGE KIT |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ELIMITE 5 % CREAM |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ELIQUIS 2.5 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIQUIS 5 MG STARTER PACK |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ELIQUIS 5 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
ELOCON 0.1% CREAM |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ELOCON 0.1% OINTMENT |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EMBEDA ER 100-4 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EMBEDA ER 20-0.8 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EMBEDA ER 30-1.2 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EMBEDA ER 50-2 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EMBEDA ER 60-2.4 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EMBEDA ER 80-3.2 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMCYT 140MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
EMEND 125 MG POWDER PACKET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | P |
EMEND 40 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | P |
EMEND CAPSULES 125MG 6 BLPK |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | P |
EMEND CAPSULES 80MG 2 BLPK |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | P |
EMEND TRIFOLD PACK |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | P |
EMFLAZA 18 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
EMFLAZA 22.75 MG/ML ORAL SUSP |
5 |
Specialty Tier |
33% | 33% | None |
EMFLAZA 30 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
EMFLAZA 36 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
EMFLAZA 6 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMGALITY 120 MG/ML PEN INJCTR |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EMGALITY 120 MG/ML SYRINGE |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EMOQUETTE 28 DAY TABLET [Solia] |
2 |
Generic |
$18.00 | $36.00 | None |
Empagliflozin 5 MG / Metformin hydrochloride 500 MG Oral Tablet [Synjardy] |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EMTRIVA 10MG/ML SOLUTION |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
EMTRIVA 200MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
EMVERM 100 MG TABLET CHEW |
2 |
Generic |
$18.00 | $36.00 | None |
ENABLEX 15 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENABLEX 7.5 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
Enalapril Maleate 10 MG Oral Tablet [Vasotec] |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ENALAPRIL MALEATE 10 MG TAB |
2 |
Generic |
$18.00 | $36.00 | None |
Enalapril Maleate 2.5 MG Oral Tablet [Vasotec] |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ENALAPRIL MALEATE 2.5 MG TAB |
2 |
Generic |
$18.00 | $36.00 | None |
ENALAPRIL MALEATE 20 MG TAB |
2 |
Generic |
$18.00 | $36.00 | None |
ENALAPRIL MALEATE 5 MG TABLET |
2 |
Generic |
$18.00 | $36.00 | None |
Enalapril Maleate and Hydrochlorothiazide 10; 25mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
2 |
Generic |
$18.00 | $36.00 | None |
ENALAPRIL-HCTZ 5-12.5 MG TAB |
2 |
Generic |
$18.00 | $36.00 | None |
ENBREL 25 MG/0.5 ML SYRINGE |
5 |
Specialty Tier |
33% | 33% | None |
ENBREL 25MG KIT |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENBREL 50 MG/ML SURECLICK SYR |
5 |
Specialty Tier |
33% | 33% | None |
ENBREL 50mg/mL |
5 |
Specialty Tier |
33% | 33% | None |
ENDARI 5 GRAM POWDER PACKET |
5 |
Specialty Tier |
33% | 33% | None |
ENDOCET 10MG-325MG TABLET |
2 |
Generic |
$18.00 | $36.00 | None |
ENDOCET 5/325 TABLET |
2 |
Generic |
$18.00 | $36.00 | None |
ENDOCET 7.5-325MG TABLET |
2 |
Generic |
$18.00 | $36.00 | None |
ENGERIX B INJECTION |
6 |
Vaccines |
$0.00 | N/A | P |
ENGERIX-B 20 MCG/ML SYRN |
6 |
Vaccines |
$0.00 | N/A | P |
ENOXAPARIN 100 MG/ML SYRINGE |
2 |
Generic |
$18.00 | $36.00 | None |
ENOXAPARIN 120 MG/0.8 ML SYRINGE |
2 |
Generic |
$18.00 | $36.00 | None |
ENOXAPARIN 150 MG/ML SYRINGE |
2 |
Generic |
$18.00 | $36.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENOXAPARIN 30 MG/0.3 ML SYR |
2 |
Generic |
$18.00 | $36.00 | None |
ENOXAPARIN 40 MG/0.4 ML SYR |
2 |
Generic |
$18.00 | $36.00 | None |
ENOXAPARIN 60 MG/0.6 ML SYRINGE |
2 |
Generic |
$18.00 | $36.00 | None |
ENOXAPARIN 80 MG/0.8 ML SYRINGE |
2 |
Generic |
$18.00 | $36.00 | None |
ENSKYCE 28 TABLET [Solia] |
2 |
Generic |
$18.00 | $36.00 | None |
ENSTILAR 0.005%-0.064% FOAM |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ENTACAPONE 200 MG TABLET [Comtan Entacapone] |
2 |
Generic |
$18.00 | $36.00 | None |
ENTECAVIR 0.5 MG TABLET [Baraclude] |
2 |
Generic |
$18.00 | $36.00 | None |
ENTECAVIR 1 MG TABLET [Baraclude] |
2 |
Generic |
$18.00 | $36.00 | None |
ENTOCORT EC 3 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
ENTRESTO 24 MG-26 MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENTRESTO 49 MG-51 MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
ENTRESTO 97 MG-103 MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
ENULOSE 10 GM/15 ML SOLUTION |
2 |
Generic |
$18.00 | $36.00 | None |
ENVARSUS XR 0.75 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | P |
ENVARSUS XR 1 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | P |
ENVARSUS XR 4 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | P |
EPCLUSA 400 MG-100 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
EPIDIOLEX 100 MG/ML SOLUTION |
5 |
Specialty Tier |
33% | 33% | None |
EPIDUO FORTE 0.3-2.5% GEL PUMP |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
EPIDUO GEL |
2 |
Generic |
$18.00 | $36.00 | None |
EPINASTINE HCL 0.05% EYE DROPS |
2 |
Generic |
$18.00 | $36.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPINEPHRINE 0.15 MG AUTO-INJCT |
2 |
Generic |
$18.00 | $36.00 | None |
EPINEPHRINE 0.15 MG AUTO-INJECT |
2 |
Generic |
$18.00 | $36.00 | None |
EPINEPHRINE 0.3 MG AUTO-INJECT |
2 |
Generic |
$18.00 | $36.00 | None |
EPINEPHRINE 0.3 MG AUTO-INJECT [Twinject] |
2 |
Generic |
$18.00 | $36.00 | None |
EPIPEN 0.3MG AUTO-INJECTOR |
2 |
Generic |
$18.00 | $36.00 | None |
EPIPEN JR 0.15MG AUTO-INJCT |
2 |
Generic |
$18.00 | $36.00 | None |
EPITOL 200MG TABLET |
2 |
Generic |
$18.00 | $36.00 | None |
EPIVIR 10 MG/ML ORAL SOLUTION |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EPIVIR 150 MG TABLETS |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EPIVIR 300mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EPIVIR HBV 100MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPIVIR HBV 25MG/5ML TUBEX |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Eplerenone 25mg/1 90 TABLET BOTTLE |
2 |
Generic |
$18.00 | $36.00 | None |
Eplerenone 50mg/1 90 TABLET BOTTLE |
2 |
Generic |
$18.00 | $36.00 | None |
EPOGEN 10000U/ML VIAL MDV |
3 |
Preferred Brand |
$47.00 | $94.00 | P |
EPOGEN 2000[iU]/mL 10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL |
3 |
Preferred Brand |
$47.00 | $94.00 | P |
EPOGEN 3000U/ML VIAL SDV |
3 |
Preferred Brand |
$47.00 | $94.00 | P |
EPOGEN 4000U/ML VIAL SDV |
3 |
Preferred Brand |
$47.00 | $94.00 | P |
EPOGEN INJECTION 20000U 10 X 1ML CRTN |
3 |
Preferred Brand |
$47.00 | $94.00 | P |
EPROSARTAN MESYLATE 600 MG TABLET |
2 |
Generic |
$18.00 | $36.00 | None |
EPZICOM 600MG/300MG TABLETS |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EQUETRO CAPSULES 200MG 120 BOT |
4 |
Non-Preferred Brand |
$100.00 | $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 |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EQUETRO EXTENDED RELEASE CAPSULES 100MG 120 BOT |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ERAXIS 100mg/30mL 30 mL in 1 VIAL, SINGLE-USE |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ERAXIS(WATER DIL) 50 MG VIAL |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ERGOLOID MESYLATES TABLETS 1MG 100 BOT |
2 |
Generic |
$18.00 | $36.00 | None |
Ergotamine-caffeine 1-100mg tb |
2 |
Generic |
$18.00 | $36.00 | None |
ERIVEDGE 150 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
ERLEADA 60 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
ERLOTINIB HCL 100 MG TABLET [Tarceva] |
5 |
Specialty Tier |
33% | 33% | None |
ERLOTINIB HCL 150 MG TABLET [Tarceva] |
5 |
Specialty Tier |
33% | 33% | None |
ERLOTINIB HCL 25 MG TABLET [Tarceva] |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Errin 0.35 mg tablet |
2 |
Generic |
$18.00 | $36.00 | None |
ERTACZO 2% CREAM |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ERTAPENEM 1 GRAM VIAL [Invanz] |
2 |
Generic |
$18.00 | $36.00 | None |
ERY 2% PADS 2% 60 PADS JAR |
2 |
Generic |
$18.00 | $36.00 | None |
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE |
2 |
Generic |
$18.00 | $36.00 | None |
ERY-TAB TAB 250MG EC |
2 |
Generic |
$18.00 | $36.00 | None |
ERY-TAB TAB 333MG EC |
2 |
Generic |
$18.00 | $36.00 | None |
ERYGEL 2% GEL |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ERYPED 200 MG/5 ML SUSPENSION |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ERYPED 400 MG/5 ML SUSPENSION |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ERYTHROCIN 500MG ADDVNT VL |
2 |
Generic |
$18.00 | $36.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROCIN TAB 250MG |
2 |
Generic |
$18.00 | $36.00 | None |
ERYTHROMYCIN 0.5% EYE OINTMENT |
2 |
Generic |
$18.00 | $36.00 | None |
ERYTHROMYCIN 2% GEL |
2 |
Generic |
$18.00 | $36.00 | None |
ERYTHROMYCIN 2% SOLUTION |
2 |
Generic |
$18.00 | $36.00 | None |
ERYTHROMYCIN 200 MG/5 ML GRAN Oral Suspension [EryPed] |
2 |
Generic |
$18.00 | $36.00 | None |
ERYTHROMYCIN 400 MG/5 ML SUSP Oral Suspension [EryPed] |
2 |
Generic |
$18.00 | $36.00 | None |
ERYTHROMYCIN 500 MG FILMTAB |
2 |
Generic |
$18.00 | $36.00 | None |
ERYTHROMYCIN EC 250 MG CAP |
2 |
Generic |
$18.00 | $36.00 | None |
ERYTHROMYCIN ES 400 MG TAB |
2 |
Generic |
$18.00 | $36.00 | None |
ERYTHROMYCIN TAB 250MG BS |
2 |
Generic |
$18.00 | $36.00 | None |
ERYTHROMYCIN-BENZOYL GEL |
2 |
Generic |
$18.00 | $36.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESBRIET 267 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P |
ESBRIET 267 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
ESBRIET 801 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
ESCITALOPRAM 10 MG TABLET [Lexapro] |
2 |
Generic |
$18.00 | $36.00 | None |
ESCITALOPRAM 20 MG TABLET [Lexapro] |
2 |
Generic |
$18.00 | $36.00 | None |
ESCITALOPRAM 5 MG TABLET [Lexapro] |
2 |
Generic |
$18.00 | $36.00 | None |
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro] |
2 |
Generic |
$18.00 | $36.00 | None |
ESGIC 50-325-40 MG TABLET |
2 |
Generic |
$18.00 | $36.00 | None |
ESOMEPRAZOLE DR 49.3 MG CAP [Nexium] |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ESOMEPRAZOLE MAG DR 20 MG CAP [Nexium] |
2 |
Generic |
$18.00 | $36.00 | None |
ESOMEPRAZOLE MAG DR 40 MG CAP [Nexium] |
2 |
Generic |
$18.00 | $36.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTARYLLA 0.25-0.035 MG TABLET [VyLibra] |
2 |
Generic |
$18.00 | $36.00 | None |
Estazolam 1mg/1 100 TABLET BOTTLE |
2 |
Generic |
$18.00 | $36.00 | None |
Estazolam 2mg/1 100 TABLET BOTTLE |
2 |
Generic |
$18.00 | $36.00 | None |
ESTRACE 0.5MG TABLET |
2 |
Generic |
$18.00 | $36.00 | None |
ESTRACE 2MG TABLET |
2 |
Generic |
$18.00 | $36.00 | None |
ESTRACE TABLET 1MG (100 CT) |
2 |
Generic |
$18.00 | $36.00 | None |
ESTRACE VAG CREAM 0.1MG/GM |
2 |
Generic |
$18.00 | $36.00 | None |
Estradiol / Norethindrone Acetate 0.5; 0.1mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, FILM C |
2 |
Generic |
$18.00 | $36.00 | None |
ESTRADIOL 0.01% CREAM |
2 |
Generic |
$18.00 | $36.00 | None |
Estradiol 0.025 mg patch |
2 |
Generic |
$18.00 | $36.00 | None |
Estradiol 0.0375 mg patch |
2 |
Generic |
$18.00 | $36.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Estradiol 0.05 mg patch |
2 |
Generic |
$18.00 | $36.00 | None |
Estradiol 0.075 mg patch |
2 |
Generic |
$18.00 | $36.00 | None |
Estradiol 0.1 mg patch |
2 |
Generic |
$18.00 | $36.00 | None |
ESTRADIOL 0.5 MG TABLET |
2 |
Generic |
$18.00 | $36.00 | None |
ESTRADIOL 1 MG TABLET |
2 |
Generic |
$18.00 | $36.00 | None |
ESTRADIOL 10 MCG VAGINAL INSRT |
2 |
Generic |
$18.00 | $36.00 | None |
ESTRADIOL 2MG TABLET |
2 |
Generic |
$18.00 | $36.00 | None |
ESTRADIOL TDS 0.025 MG/DAY |
2 |
Generic |
$18.00 | $36.00 | None |
ESTRADIOL TDS 0.0375 MG/DAY |
2 |
Generic |
$18.00 | $36.00 | None |
ESTRADIOL TDS 0.05 MG/DAY |
2 |
Generic |
$18.00 | $36.00 | None |
ESTRADIOL TDS 0.06 MG/DAY |
2 |
Generic |
$18.00 | $36.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL TDS 0.075 MG/DAY |
2 |
Generic |
$18.00 | $36.00 | None |
ESTRADIOL TDS 0.1 MG/DAY |
2 |
Generic |
$18.00 | $36.00 | None |
ESTRADIOL VALERATE 20mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
2 |
Generic |
$18.00 | $36.00 | None |
ESTRADIOL VALERATE 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
2 |
Generic |
$18.00 | $36.00 | None |
ESTRADIOL-NORETH 1.0-0.5MG TABLET |
2 |
Generic |
$18.00 | $36.00 | None |
ESTRING 2MG VAGINAL RING |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
ESZOPICLONE 1 MG TABLET [Lunesta] |
2 |
Generic |
$18.00 | $36.00 | None |
ESZOPICLONE 2 MG TABLET [Lunesta] |
2 |
Generic |
$18.00 | $36.00 | None |
ESZOPICLONE 3 MG TABLET [Lunesta] |
2 |
Generic |
$18.00 | $36.00 | None |
ETHACRYNIC ACID 25 MG TABLET [Edecrin] |
2 |
Generic |
$18.00 | $36.00 | None |
ETHAMBUTOL HCL 400 MG TABLET |
2 |
Generic |
$18.00 | $36.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ethambutol Hydrochloride 100mg/1 |
2 |
Generic |
$18.00 | $36.00 | None |
Ethinyl Estradiol 0.0025 MG / norethindrone acetate 0.5 MG Oral Tablet [Fyavolv] |
2 |
Generic |
$18.00 | $36.00 | None |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 |
2 |
Generic |
$18.00 | $36.00 | None |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21 |
2 |
Generic |
$18.00 | $36.00 | None |
ETHOSUXIMIDE 250 MG CAPSULE |
2 |
Generic |
$18.00 | $36.00 | None |
ETHOSUXIMIDE 250 MG/5 ML SOLN |
2 |
Generic |
$18.00 | $36.00 | None |
ETHYNODIOL-ETH ESTRA 1MG-35MCG [ZOVIA] |
2 |
Generic |
$18.00 | $36.00 | None |
ethynodiol-eth estra 1mg-50mcg [ZOVIA] |
2 |
Generic |
$18.00 | $36.00 | None |
ETIDRONATE DISODIUM 400MG TABLET (60 CT) |
2 |
Generic |
$18.00 | $36.00 | None |
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT |
2 |
Generic |
$18.00 | $36.00 | None |
ETODOLAC 200 MG CAPSULE [LODINE] |
2 |
Generic |
$18.00 | $36.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETODOLAC 300 MG CAPSULE [LODINE] |
2 |
Generic |
$18.00 | $36.00 | None |
ETODOLAC 400 MG TABLET [LODINE] |
2 |
Generic |
$18.00 | $36.00 | None |
ETODOLAC 500 MG TABLET [LODINE] |
2 |
Generic |
$18.00 | $36.00 | None |
ETODOLAC ER 400 MG TABLET [LODINE] |
2 |
Generic |
$18.00 | $36.00 | None |
ETODOLAC ER 500 MG TABLET [LODINE] |
2 |
Generic |
$18.00 | $36.00 | None |
ETODOLAC ER 600 MG TABLET [LODINE] |
2 |
Generic |
$18.00 | $36.00 | None |
EUCRISA 2% OINTMENT |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EURAX 10% LOTION |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
Eurax Lotion and Cream 100mg/g 60 g in 1 TUBE |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EVAMIST 1.53 MG/SPRAY |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EVEKEO 10 MG TABLET |
2 |
Generic |
$18.00 | $36.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EVEKEO 5 MG TABLET |
2 |
Generic |
$18.00 | $36.00 | None |
EVENITY 210 MG DOSE-2 SYRINGES |
5 |
Specialty Tier |
33% | 33% | None |
EVISTA 60 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EVOTAZ 300 MG-150 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EVOXAC 30MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EVZIO 2 MG AUTO-INJECTOR |
5 |
Specialty Tier |
33% | 33% | None |
Exelderm 10mg/g 60 g in 1 TUBE |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
Exelderm 10mg/mL 30 mL in 1 BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EXELON 13.3 MG/24HR PATCH |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EXEMESTANE 25 MG TABLET |
2 |
Generic |
$18.00 | $36.00 | None |
EXFORGE 10MG-160MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EXFORGE 10MG-320MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EXFORGE 5MG-160MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EXFORGE 5MG-320MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EXFORGE HCT 10-160-12.5 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EXFORGE HCT 10-160-25 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EXFORGE HCT 10-320-25 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EXFORGE HCT 5-160-12.5 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EXFORGE HCT 5-160-25 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EXJADE 125MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EXJADE 250MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
EXJADE 500MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
EXTAVIA 15 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2 |
Generic |
$18.00 | $36.00 | None |
EXTINA 2% FOAM |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EZETIMIBE 10 MG TABLET [Zetia] |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
Ezetimibe-Simvastatin 10-10 MG [Vytorin] |
2 |
Generic |
$18.00 | $36.00 | None |
Ezetimibe-Simvastatin 10-20 MG [Vytorin] |
2 |
Generic |
$18.00 | $36.00 | None |
Ezetimibe-Simvastatin 10-40 MG [Vytorin] |
2 |
Generic |
$18.00 | $36.00 | None |
Ezetimibe-Simvastatin 10-80 MG [Vytorin] |
2 |
Generic |
$18.00 | $36.00 | None |