2021 Medicare Part D Plan Formulary Information |
Magellan Complete Care of Virginia, LLC (HMO D-SNP) (H7559-001-0)
Benefit Details
|
The Magellan Complete Care of Virginia, LLC (HMO D-SNP) (H7559-001-0) Formulary Drugs Starting with the Letter E in Loudoun County, VA: CMS MA Region 7 which includes: VA Plan Monthly Premium: $31.40 Deductible: $445 |
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 (G) [Spectazole] |
1 |
Tier 1 |
15% | 15% | None |
EDURANT 27.5mg/1 |
1 |
Tier 1 |
15% | 15% | None |
EFAVIR-EMTRI-TENOF 600-200-300 TABLET [Atripla] |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
EFAVIR-LAMIV-TENOF 400-300-300 TABLET [SYMFI LO] |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
EFAVIR-LAMIV-TENOF 600-300-300 TABLET [SYMFI] |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
EFAVIRENZ 200 MG CAPSULE [Sustiva] |
1 |
Tier 1 |
15% | 15% | None |
EFAVIRENZ 50 MG CAPSULE [Sustiva] |
1 |
Tier 1 |
15% | 15% | None |
EFAVIRENZ 600 MG TABLET [Sustiva] |
1 |
Tier 1 |
15% | 15% | None |
EGRIFTA SV 2 MG VIAL |
1 |
Tier 1 |
15% | 15% | P Q:30 /30Days |
ELESTRIN 0.06% GEL MD PUMP |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELETRIPTAN HBR 20 MG TABLET [Relpax] |
1 |
Tier 1 |
15% | 15% | Q:12 /30Days |
ELETRIPTAN HBR 40 MG TABLET [Relpax] |
1 |
Tier 1 |
15% | 15% | Q:12 /30Days |
ELIQUIS 2.5 MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
ELIQUIS 5 MG STARTER PACK |
1 |
Tier 1 |
15% | 15% | Q:148 /365Days |
ELIQUIS 5 MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:90 /30Days |
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
EMCYT 140MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
EMEND 125 MG POWDER PACKET |
1 |
Tier 1 |
15% | 15% | P Q:6 /30Days |
EMFLAZA 18 MG TABLET |
1 |
Tier 1 |
15% | 15% | P |
EMFLAZA 22.75 MG/ML ORAL SUSPENSION |
1 |
Tier 1 |
15% | 15% | P |
EMFLAZA 30 MG TABLET |
1 |
Tier 1 |
15% | 15% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMFLAZA 36 MG TABLET |
1 |
Tier 1 |
15% | 15% | P |
EMFLAZA 6 MG TABLET |
1 |
Tier 1 |
15% | 15% | P |
EMGALITY 120 MG/ML PEN INJCTR |
1 |
Tier 1 |
15% | 15% | P Q:1 /30Days |
EMGALITY 120 MG/ML SYRINGE |
1 |
Tier 1 |
15% | 15% | P Q:1 /30Days |
EMGALITY 300 MG (100 MG X3SYR) SYRINGE |
1 |
Tier 1 |
15% | 15% | P Q:3 /30Days |
EMOQUETTE 28 DAY TABLET [Solia] |
1 |
Tier 1 |
15% | 15% | None |
Empagliflozin 5 MG / Metformin hydrochloride 500 MG Oral Tablet [Synjardy] |
1 |
Tier 1 |
15% | 15% | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
1 |
Tier 1 |
15% | 15% | S Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
1 |
Tier 1 |
15% | 15% | S Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
1 |
Tier 1 |
15% | 15% | S Q:30 /30Days |
EMTRICITABINE 200 MG CAPSULE [Emtriva] |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMTRICITABINE-TENOFV 100-150MG TABLET [Truvada] |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
EMTRICITABINE-TENOFV 133-200MG TABLET [Truvada] |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
EMTRICITABINE-TENOFV 167-250MG TABLET [Truvada] |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
EMTRICITABINE-TENOFV 200-300MG TABLET [Truvada] |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
EMTRIVA 10MG/ML SOLUTION |
1 |
Tier 1 |
15% | 15% | None |
EMTRIVA 200MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
ENALAPRIL MALEATE 10 MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
ENALAPRIL MALEATE 2.5 MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
ENALAPRIL MALEATE 20 MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
ENALAPRIL MALEATE 5 MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
ENALAPRIL-HCTZ 10-25 MG TABLET [Vaseretic] |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENALAPRIL-HCTZ 5-12.5 MG TABLET [Vaseretic] |
1 |
Tier 1 |
15% | 15% | None |
ENBREL 25 MG/0.5 ML SYRINGE |
1 |
Tier 1 |
15% | 15% | P |
ENBREL 25 MG/0.5 ML VIAL |
1 |
Tier 1 |
15% | 15% | P |
ENBREL 25MG KIT |
1 |
Tier 1 |
15% | 15% | P |
ENBREL 50 MG/ML MINI CARTRIDGE |
1 |
Tier 1 |
15% | 15% | P |
ENBREL 50 MG/ML SURECLICK PEN INJECTOR |
1 |
Tier 1 |
15% | 15% | P |
ENBREL 50 MG/ML SYRINGE |
1 |
Tier 1 |
15% | 15% | P |
ENDARI 5 GRAM POWDER PACKET |
1 |
Tier 1 |
15% | 15% | P |
ENDOCET 10MG-325MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
ENDOCET 5/325 TABLET |
1 |
Tier 1 |
15% | 15% | None |
ENDOCET 7.5-325MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENGERIX B INJECTION |
1 |
Tier 1 |
15% | 15% | P |
ENGERIX-B 20 MCG/ML SYRINGE |
1 |
Tier 1 |
15% | 15% | P |
ENOXAPARIN 100 MG/ML SYRINGE [Lovenox] |
1 |
Tier 1 |
15% | 15% | Q:35 /90Days |
ENOXAPARIN 120 MG/0.8 ML SYRINGE [Lovenox] |
1 |
Tier 1 |
15% | 15% | Q:28 /90Days |
ENOXAPARIN 150 MG/ML SYRINGE [Lovenox] |
1 |
Tier 1 |
15% | 15% | Q:35 /90Days |
ENOXAPARIN 30 MG/0.3 ML SYRINGE [Lovenox] |
1 |
Tier 1 |
15% | 15% | Q:11 /90Days |
ENOXAPARIN 40 MG/0.4 ML SYRINGE [Lovenox] |
1 |
Tier 1 |
15% | 15% | Q:14 /90Days |
ENOXAPARIN 60 MG/0.6 ML SYRINGE [Lovenox] |
1 |
Tier 1 |
15% | 15% | Q:21 /90Days |
ENOXAPARIN 80 MG/0.8 ML SYRINGE [Lovenox] |
1 |
Tier 1 |
15% | 15% | Q:28 /90Days |
ENSKYCE 28 TABLET [Solia] |
1 |
Tier 1 |
15% | 15% | None |
ENSPRYNG 120 MG/ML SYRINGE |
1 |
Tier 1 |
15% | 15% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENTACAPONE 200 MG TABLET [Comtan] |
1 |
Tier 1 |
15% | 15% | None |
ENTECAVIR 0.5 MG TABLET [Baraclude] |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
ENTECAVIR 1 MG TABLET [Baraclude] |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
ENTRESTO 24 MG-26 MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
ENTRESTO 49 MG-51 MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
ENTRESTO 97 MG-103 MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
ENULOSE 10 GM/15 ML SOLUTION |
1 |
Tier 1 |
15% | 15% | None |
EPIDIOLEX 100 MG/ML SOLUTION |
1 |
Tier 1 |
15% | 15% | P |
EPINASTINE HCL 0.05% EYE DROPS |
1 |
Tier 1 |
15% | 15% | None |
EPINEPHRINE 0.15 MG AUTO-INJECT |
1 |
Tier 1 |
15% | 15% | None |
EPINEPHRINE 0.15 MG AUTO-INJECT [Twinject] |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPINEPHRINE 0.3 MG AUTO-INJECT |
1 |
Tier 1 |
15% | 15% | None |
EPINEPHRINE 0.3 MG AUTO-INJECT [Twinject] |
1 |
Tier 1 |
15% | 15% | None |
EPIPEN 0.3MG AUTO-INJECTOR |
1 |
Tier 1 |
15% | 15% | None |
EPIPEN JR 0.15MG AUTO-INJCT |
1 |
Tier 1 |
15% | 15% | None |
EPITOL 200MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
EPIVIR HBV 25MG/5ML TUBEX |
1 |
Tier 1 |
15% | 15% | None |
EPLERENONE 25 MG TABLET [Inspra] |
1 |
Tier 1 |
15% | 15% | None |
EPLERENONE 50 MG TABLET [Inspra] |
1 |
Tier 1 |
15% | 15% | None |
EQUETRO CAPSULES 200MG 120 BOT |
1 |
Tier 1 |
15% | 15% | None |
EQUETRO CAPSULES 300MG 120 BOT |
1 |
Tier 1 |
15% | 15% | None |
EQUETRO EXTENDED RELEASE CAPSULES 100MG 120 BOT |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERGOLOID MESYLATES TABLETS 1MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
Ergotamine-caffeine 1-100mg tablet |
1 |
Tier 1 |
15% | 15% | None |
ERIVEDGE 150 MG CAPSULE |
1 |
Tier 1 |
15% | 15% | P |
ERLEADA 60 MG TABLET |
1 |
Tier 1 |
15% | 15% | P |
ERLOTINIB HCL 100 MG TABLET [Tarceva] |
1 |
Tier 1 |
15% | 15% | P |
ERLOTINIB HCL 150 MG TABLET [Tarceva] |
1 |
Tier 1 |
15% | 15% | P |
ERLOTINIB HCL 25 MG TABLET [Tarceva] |
1 |
Tier 1 |
15% | 15% | P |
ERRIN 0.35 MG TABLET [Sharobel 28-Day] |
1 |
Tier 1 |
15% | 15% | None |
ERTAPENEM 1 GRAM VIAL [Invanz] |
1 |
Tier 1 |
15% | 15% | None |
ERY 2% PADS 2% 60 PADS JAR |
1 |
Tier 1 |
15% | 15% | None |
ERYPED 400 MG/5 ML SUSPENSION |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROCIN 250 MG FILMTAB TABLET |
1 |
Tier 1 |
15% | 15% | None |
ERYTHROMYCIN 0.5% EYE OINTMENT [Romycin] |
1 |
Tier 1 |
15% | 15% | None |
ERYTHROMYCIN 2% GEL [Erygel] |
1 |
Tier 1 |
15% | 15% | None |
ERYTHROMYCIN 2% SOLUTION |
1 |
Tier 1 |
15% | 15% | None |
ERYTHROMYCIN 200 MG/5 ML ORAL SUSPENSION [EryPed] |
1 |
Tier 1 |
15% | 15% | None |
ERYTHROMYCIN 250 MG FILMTAB TABLET |
1 |
Tier 1 |
15% | 15% | None |
ERYTHROMYCIN 400 MG/5 ML ORAL SUSPENSION [EryPed] |
1 |
Tier 1 |
15% | 15% | None |
ERYTHROMYCIN 500 MG FILMTAB TABLET |
1 |
Tier 1 |
15% | 15% | None |
ERYTHROMYCIN DR 250 MG CAPSULE DR [ERYC] |
1 |
Tier 1 |
15% | 15% | None |
ERYTHROMYCIN DR 250 MG TABLET DR [Ery-Tab] |
1 |
Tier 1 |
15% | 15% | None |
ERYTHROMYCIN DR 333 MG TABLET DR [Ery-Tab] |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROMYCIN DR 500 MG TABLET DR [Ery-Tab] |
1 |
Tier 1 |
15% | 15% | None |
ERYTHROMYCIN ES 400 MG TABLET [E.E.S.] |
1 |
Tier 1 |
15% | 15% | None |
ERYTHROMYCIN-BENZOYL GEL |
1 |
Tier 1 |
15% | 15% | None |
ESBRIET 267 MG CAPSULE |
1 |
Tier 1 |
15% | 15% | P |
ESBRIET 267 MG TABLET |
1 |
Tier 1 |
15% | 15% | P |
ESBRIET 801 MG TABLET |
1 |
Tier 1 |
15% | 15% | P |
ESCITALOPRAM 10 MG TABLET [Lexapro] |
1 |
Tier 1 |
15% | 15% | None |
ESCITALOPRAM 20 MG TABLET [Lexapro] |
1 |
Tier 1 |
15% | 15% | None |
ESCITALOPRAM 5 MG TABLET [Lexapro] |
1 |
Tier 1 |
15% | 15% | None |
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro] |
1 |
Tier 1 |
15% | 15% | None |
ESOMEPRAZOLE DR 10 MG SUSPDR PACKET [Nexium] |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESOMEPRAZOLE DR 20 MG SUSPDR PACKET [Nexium] |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
ESOMEPRAZOLE DR 40 MG SUSPDR PACKET [Nexium] |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
ESOMEPRAZOLE MAG DR 20 MG CAPSULE [Nexium] |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
ESOMEPRAZOLE MAG DR 40 MG CAPSULE [Nexium] |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
ESTARYLLA 0.25-0.035 MG TABLET [VyLibra] |
1 |
Tier 1 |
15% | 15% | None |
Estazolam 1mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
ESTAZOLAM 2 MG TABLET [ProSom] |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
Estradiol / Norethindrone Acetate 0.5; 0.1mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, FILM C |
1 |
Tier 1 |
15% | 15% | None |
ESTRADIOL 0.01% CREAM |
1 |
Tier 1 |
15% | 15% | None |
Estradiol 0.025 mg patch |
1 |
Tier 1 |
15% | 15% | None |
ESTRADIOL 0.0375MG PATCH(2/WK) PATCH TDSW [Vivelle-Dot] |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Estradiol 0.05 mg patch |
1 |
Tier 1 |
15% | 15% | None |
ESTRADIOL 0.05 MG PATCH (1/WK) [Climara] |
1 |
Tier 1 |
15% | 15% | None |
ESTRADIOL 0.06 MG PATCH (1/WK) [Climara] |
1 |
Tier 1 |
15% | 15% | None |
Estradiol 0.075 mg patch |
1 |
Tier 1 |
15% | 15% | None |
Estradiol 0.1 mg patch |
1 |
Tier 1 |
15% | 15% | None |
ESTRADIOL 0.1 MG PATCH (1/WK) [Climara] |
1 |
Tier 1 |
15% | 15% | None |
ESTRADIOL 0.5 MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
ESTRADIOL 1 MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
ESTRADIOL 10 MCG VAGINAL INSRT |
1 |
Tier 1 |
15% | 15% | None |
ESTRADIOL 2MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
ESTRADIOL TDS 0.025 MG/DAY |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL TDS 0.0375 MG/DAY |
1 |
Tier 1 |
15% | 15% | None |
ESTRADIOL TDS 0.075 MG/DAY |
1 |
Tier 1 |
15% | 15% | None |
ESTRADIOL VALERATE 20mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
1 |
Tier 1 |
15% | 15% | None |
ESTRADIOL VALERATE 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
1 |
Tier 1 |
15% | 15% | None |
ESTRADIOL-NORETH 1.0-0.5MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
ESTRING 2MG VAGINAL RING |
1 |
Tier 1 |
15% | 15% | Q:1 /90Days |
ESZOPICLONE 1 MG TABLET [Lunesta] |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
ESZOPICLONE 2 MG TABLET [Lunesta] |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
ESZOPICLONE 3 MG TABLET [Lunesta] |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
ETHACRYNIC ACID 25 MG TABLET [Edecrin] |
1 |
Tier 1 |
15% | 15% | None |
ETHAMBUTOL HCL 400 MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ethambutol Hydrochloride 100mg/1 |
1 |
Tier 1 |
15% | 15% | None |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 |
1 |
Tier 1 |
15% | 15% | None |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TABLET 21 |
1 |
Tier 1 |
15% | 15% | None |
ETHOSUXIMIDE 250 MG CAPSULE [Zarontin] |
1 |
Tier 1 |
15% | 15% | None |
ETHOSUXIMIDE 250 MG/5 ML SOLUTION |
1 |
Tier 1 |
15% | 15% | None |
ETHYNODIOL-ETH ESTRA 1MG-35MCG [ZOVIA] |
1 |
Tier 1 |
15% | 15% | None |
ETHYNODIOL-ETH ESTRA 1MG-50MCG [ZOVIA] |
1 |
Tier 1 |
15% | 15% | None |
ETODOLAC 200 MG CAPSULE [Lodine] |
1 |
Tier 1 |
15% | 15% | None |
ETODOLAC 300 MG CAPSULE [Lodine] |
1 |
Tier 1 |
15% | 15% | None |
ETODOLAC 400 MG TABLET [Lodine] |
1 |
Tier 1 |
15% | 15% | None |
ETODOLAC 500 MG TABLET [Lodine] |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EUCRISA 2% OINTMENT |
1 |
Tier 1 |
15% | 15% | P |
EVENITY 210 MG DOSE-2 SYRINGES |
1 |
Tier 1 |
15% | 15% | P Q:2 /28Days |
EVEROLIMUS 0.25 MG TABLET [Zortress] |
1 |
Tier 1 |
15% | 15% | P |
EVEROLIMUS 0.5 MG TABLET [Zortress] |
1 |
Tier 1 |
15% | 15% | P |
EVEROLIMUS 0.75 MG TABLET [Zortress] |
1 |
Tier 1 |
15% | 15% | P |
EVEROLIMUS 2.5 MG TABLET [Afinitor] |
1 |
Tier 1 |
15% | 15% | P Q:30 /30Days |
EVEROLIMUS 5 MG TABLET [Afinitor] |
1 |
Tier 1 |
15% | 15% | P Q:30 /30Days |
EVEROLIMUS 7.5 MG TABLET [Afinitor] |
1 |
Tier 1 |
15% | 15% | P Q:30 /30Days |
EVOTAZ 300 MG-150 MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
EVRYSDI 60 MG/80 ML(0.75MG/ML) SOLUTION RECON |
1 |
Tier 1 |
15% | 15% | P Q:240 /30Days |
EXEMESTANE 25 MG TABLET [Aromasin] |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EXTAVIA 0.3 MG KIT |
1 |
Tier 1 |
15% | 15% | P Q:15 /30Days |
EZETIMIBE 10 MG TABLET [Zetia] |
1 |
Tier 1 |
15% | 15% | None |
EZETIMIBE-SIMVASTATIN 10-10 MG TABLET [Vytorin] |
1 |
Tier 1 |
15% | 15% | None |
EZETIMIBE-SIMVASTATIN 10-20 MG TABLET [Vytorin] |
1 |
Tier 1 |
15% | 15% | None |
EZETIMIBE-SIMVASTATIN 10-40 MG TABLET [Vytorin] |
1 |
Tier 1 |
15% | 15% | None |
EZETIMIBE-SIMVASTATIN 10-80 MG TABLET [Vytorin] |
1 |
Tier 1 |
15% | 15% | None |