2022 Medicare Part D Plan Formulary Information |
Blue Rx PDP Plus (PDP) (S5593-002-0)
Benefit Details
|
The Blue Rx PDP Plus (PDP) (S5593-002-0) Formulary Drugs Starting with the Letter E in CMS PDP Region 6 which includes: PA WV
|
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 TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
ECONAZOLE NITRATE 1% CREAM (G) [Spectazole] |
2 |
Generic |
$7.00 | $17.50 | Q:85 /28Days |
EDARBYCLOR 40-12.5 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
EDARBYCLOR 40-25 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
EDURANT 27.5mg/1 |
5 |
Specialty Tier |
25% | N/A | None |
EFAVIR-EMTRI-TENOF 600-200-300 TABLET [Atripla] |
5 |
Specialty Tier |
25% | N/A | None |
EFAVIR-LAMIV-TENOF 400-300-300 TABLET [SYMFI LO] |
5 |
Specialty Tier |
25% | N/A | Q:31 /31Days |
EFAVIR-LAMIV-TENOF 600-300-300 TABLET [SYMFI] |
5 |
Specialty Tier |
25% | N/A | Q:31 /31Days |
EFAVIRENZ 200 MG CAPSULE [Sustiva] |
3 |
Preferred Brand |
20% | 20% | None |
EFAVIRENZ 50 MG CAPSULE [Sustiva] |
3 |
Preferred Brand |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EFAVIRENZ 600 MG TABLET [Sustiva] |
3 |
Preferred Brand |
20% | 20% | None |
EGRIFTA SV 2 MG VIAL |
5 |
Specialty Tier |
25% | N/A | P |
ELETRIPTAN HBR 20 MG TABLET [Relpax] |
4 |
Non-Preferred Drug |
40% | 40% | Q:12 /28Days |
ELETRIPTAN HBR 40 MG TABLET [Relpax] |
4 |
Non-Preferred Drug |
40% | 40% | Q:6 /28Days |
ELIGARD 22.5 MG SYRINGE |
4 |
Non-Preferred Drug |
40% | 40% | None |
ELIGARD 30 MG SYRINGE KIT |
4 |
Non-Preferred Drug |
40% | 40% | None |
ELIGARD 45 MG SYRINGE KIT |
4 |
Non-Preferred Drug |
40% | 40% | None |
ELIGARD 7.5 MG SYRINGE KIT |
4 |
Non-Preferred Drug |
40% | 40% | None |
ELIQUIS 2.5 MG TABLET |
3 |
Preferred Brand |
20% | 20% | Q:60 /30Days |
ELIQUIS 5 MG STARTER PACK |
3 |
Preferred Brand |
20% | 20% | Q:74 /30Days |
ELIQUIS 5 MG TABLET |
3 |
Preferred Brand |
20% | 20% | Q:74 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE |
4 |
Non-Preferred Drug |
40% | 40% | None |
ELURYNG VAGINAL RING [NuvaRing] |
3 |
Preferred Brand |
20% | 20% | None |
EMCYT 140MG CAPSULE |
3 |
Preferred Brand |
20% | 20% | None |
EMEND 125 MG POWDER PACKET |
4 |
Non-Preferred Drug |
40% | 40% | P |
EMFLAZA 18 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
EMFLAZA 22.75 MG/ML ORAL SUSPENSION |
5 |
Specialty Tier |
25% | N/A | P |
EMFLAZA 30 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
EMFLAZA 36 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
EMFLAZA 6 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
EMGALITY 120 MG/ML PEN INJCTR |
3 |
Preferred Brand |
20% | 20% | P Q:1 /28Days |
EMGALITY 120 MG/ML SYRINGE |
3 |
Preferred Brand |
20% | 20% | P Q:1 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMGALITY 300 MG (100 MG X3SYR) SYRINGE |
3 |
Preferred Brand |
20% | 20% | P Q:3 /28Days |
EMOQUETTE 28 DAY TABLET [Solia] |
2 |
Generic |
$7.00 | $17.50 | None |
Empagliflozin 5 MG / Metformin hydrochloride 500 MG Oral Tablet [Synjardy] |
3 |
Preferred Brand |
20% | 20% | Q:62 /31Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
EMTRICITABINE 200 MG CAPSULE [Emtriva] |
3 |
Preferred Brand |
20% | 20% | None |
EMTRICITABINE-TENOFV 100-150MG TABLET [Truvada] |
5 |
Specialty Tier |
25% | N/A | None |
EMTRICITABINE-TENOFV 133-200MG TABLET [Truvada] |
5 |
Specialty Tier |
25% | N/A | None |
EMTRICITABINE-TENOFV 167-250MG TABLET [Truvada] |
5 |
Specialty Tier |
25% | N/A | None |
EMTRICITABINE-TENOFV 200-300MG TABLET [Truvada] |
5 |
Specialty Tier |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMTRIVA 10MG/ML SOLUTION |
3 |
Preferred Brand |
20% | 20% | None |
EMVERM 100 MG TABLET CHEW |
5 |
Specialty Tier |
25% | N/A | None |
ENALAPRIL 1 MG/ML ORAL SOLUTION [Epaned] |
4 |
Non-Preferred Drug |
40% | 40% | None |
ENALAPRIL MALEATE 10 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 2.5 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 20 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 5 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ENALAPRIL-HCTZ 10-25 MG TABLET [Vaseretic] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ENALAPRIL-HCTZ 5-12.5 MG TABLET [Vaseretic] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ENBREL 25 MG/0.5 ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
ENBREL 25 MG/0.5 ML VIAL |
5 |
Specialty Tier |
25% | 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 |
Specialty Tier |
25% | N/A | P Q:8 /28Days |
ENBREL 50 MG/ML MINI CARTRIDGE |
5 |
Specialty Tier |
25% | N/A | P Q:8 /28Days |
ENBREL 50 MG/ML SURECLICK PEN INJECTOR |
5 |
Specialty Tier |
25% | N/A | P Q:8 /28Days |
ENBREL 50 MG/ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P Q:8 /28Days |
ENDARI 5 GRAM POWDER PACKET |
4 |
Non-Preferred Drug |
40% | 40% | P Q:180 /30Days |
ENDOCET 10MG-325MG TABLET |
3 |
Preferred Brand |
20% | 20% | P Q:372 /31Days |
ENDOCET 5/325 TABLET |
2 |
Generic |
$7.00 | $17.50 | P Q:372 /31Days |
ENDOCET 7.5-325MG TABLET |
2 |
Generic |
$7.00 | $17.50 | P Q:372 /31Days |
ENGERIX B INJECTION |
3 |
Preferred Brand |
20% | 20% | P |
ENGERIX-B 20 MCG/ML SYRINGE |
3 |
Preferred Brand |
20% | 20% | P |
ENOXAPARIN 100 MG/ML SYRINGE [Lovenox] |
4 |
Non-Preferred Drug |
40% | 40% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENOXAPARIN 120 MG/0.8 ML SYRINGE [Lovenox] |
4 |
Non-Preferred Drug |
40% | 40% | None |
ENOXAPARIN 150 MG/ML SYRINGE [Lovenox] |
4 |
Non-Preferred Drug |
40% | 40% | None |
ENOXAPARIN 30 MG/0.3 ML SYRINGE [Lovenox] |
2 |
Generic |
$7.00 | $17.50 | None |
ENOXAPARIN 40 MG/0.4 ML SYRINGE [Lovenox] |
2 |
Generic |
$7.00 | $17.50 | None |
ENOXAPARIN 60 MG/0.6 ML SYRINGE [Lovenox] |
2 |
Generic |
$7.00 | $17.50 | None |
ENOXAPARIN 80 MG/0.8 ML SYRINGE [Lovenox] |
2 |
Generic |
$7.00 | $17.50 | None |
ENSKYCE 28 TABLET [Solia] |
2 |
Generic |
$7.00 | $17.50 | None |
ENSPRYNG 120 MG/ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P Q:1 /28Days |
ENTACAPONE 200 MG TABLET [Comtan] |
2 |
Generic |
$7.00 | $17.50 | None |
ENTECAVIR 0.5 MG TABLET [Baraclude] |
4 |
Non-Preferred Drug |
40% | 40% | None |
ENTECAVIR 1 MG TABLET [Baraclude] |
4 |
Non-Preferred Drug |
40% | 40% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENTRESTO 24 MG-26 MG TABLET |
3 |
Preferred Brand |
20% | 20% | Q:186 /31Days |
ENTRESTO 49 MG-51 MG TABLET |
3 |
Preferred Brand |
20% | 20% | Q:93 /31Days |
ENTRESTO 97 MG-103 MG TABLET |
3 |
Preferred Brand |
20% | 20% | Q:62 /31Days |
ENULOSE 10 GM/15 ML SOLUTION |
2 |
Generic |
$7.00 | $17.50 | None |
ENVARSUS XR 0.75 MG TABLET ER 24H |
4 |
Non-Preferred Drug |
40% | 40% | P |
ENVARSUS XR 1 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | P |
ENVARSUS XR 4 MG TABLET ER 24H |
4 |
Non-Preferred Drug |
40% | 40% | P |
EPCLUSA 150-37.5 MG PELLET PACK |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
EPCLUSA 200 MG-50 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
EPCLUSA 200-50 MG PELLET PACK |
5 |
Specialty Tier |
25% | N/A | P Q:56 /28Days |
EPCLUSA 400 MG-100 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPIDIOLEX 100 MG/ML SOLUTION |
5 |
Specialty Tier |
25% | N/A | P |
EPINASTINE HCL 0.05% EYE DROPS |
2 |
Generic |
$7.00 | $17.50 | None |
EPINEPHRINE 0.15 MG AUTO-INJECT |
3 |
Preferred Brand |
20% | 20% | None |
EPINEPHRINE 0.15 MG AUTO-INJECT [Twinject] |
3 |
Preferred Brand |
20% | 20% | None |
EPINEPHRINE 0.3 MG AUTO-INJECT |
3 |
Preferred Brand |
20% | 20% | None |
EPINEPHRINE 0.3 MG AUTO-INJECT [Twinject] |
3 |
Preferred Brand |
20% | 20% | None |
EPITOL 200MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
EPIVIR HBV 25MG/5ML TUBEX |
3 |
Preferred Brand |
20% | 20% | None |
EPLERENONE 25 MG TABLET [Inspra] |
2 |
Generic |
$7.00 | $17.50 | None |
EPLERENONE 50 MG TABLET [Inspra] |
2 |
Generic |
$7.00 | $17.50 | None |
EPOGEN 10000U/ML VIAL MDV |
4 |
Non-Preferred Drug |
40% | 40% | P |
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 |
40% | 40% | P |
EPOGEN 3000U/ML VIAL SDV |
4 |
Non-Preferred Drug |
40% | 40% | P |
EPOGEN 4000U/ML VIAL SDV |
4 |
Non-Preferred Drug |
40% | 40% | P |
EPOGEN INJECTION 20000U 10 X 1ML CRTN |
4 |
Non-Preferred Drug |
40% | 40% | P |
EPRONTIA 25 MG/ML SOLUTION |
4 |
Non-Preferred Drug |
40% | 40% | P Q:496 /31Days |
EQUETRO CAPSULES 200MG 120 BOT |
4 |
Non-Preferred Drug |
40% | 40% | None |
EQUETRO CAPSULES 300MG 120 BOT |
4 |
Non-Preferred Drug |
40% | 40% | None |
EQUETRO EXTENDED RELEASE CAPSULES 100MG 120 BOT |
4 |
Non-Preferred Drug |
40% | 40% | None |
ERAXIS 100mg/30mL 30 mL in 1 VIAL, SINGLE-USE |
4 |
Non-Preferred Drug |
40% | 40% | None |
ERAXIS(WATER DIL) 50 MG VIAL |
4 |
Non-Preferred Drug |
40% | 40% | None |
ERGOLOID MESYLATES TABLETS 1MG 100 BOT |
2 |
Generic |
$7.00 | $17.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ergotamine-caffeine 1-100mg tablet |
2 |
Generic |
$7.00 | $17.50 | P |
ERIVEDGE 150 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:31 /31Days |
ERLEADA 60 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:124 /31Days |
ERLOTINIB HCL 100 MG TABLET [Tarceva] |
5 |
Specialty Tier |
25% | N/A | P Q:31 /31Days |
ERLOTINIB HCL 150 MG TABLET [Tarceva] |
5 |
Specialty Tier |
25% | N/A | P Q:31 /31Days |
ERLOTINIB HCL 25 MG TABLET [Tarceva] |
5 |
Specialty Tier |
25% | N/A | P Q:31 /31Days |
ERRIN 0.35 MG TABLET [Sharobel 28-Day] |
2 |
Generic |
$7.00 | $17.50 | None |
ERTAPENEM 1 GRAM VIAL [Invanz] |
4 |
Non-Preferred Drug |
40% | 40% | None |
ERY 2% PADS 2% 60 PADS JAR |
2 |
Generic |
$7.00 | $17.50 | None |
ERY-TAB DR 250 MG TABLET DR |
2 |
Generic |
$7.00 | $17.50 | None |
ERY-TAB DR 333 MG TABLET DR |
2 |
Generic |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYGEL 2% GEL |
3 |
Preferred Brand |
20% | 20% | Q:60 /28Days |
ERYPED 200 MG/5 ML SUSPENSION |
4 |
Non-Preferred Drug |
40% | 40% | None |
ERYTHROCIN 250 MG FILMTAB TABLET |
2 |
Generic |
$7.00 | $17.50 | None |
ERYTHROCIN LACT 500 MG VIAL |
3 |
Preferred Brand |
20% | 20% | None |
ERYTHROMYCIN 0.5% EYE OINTMENT [Romycin] |
2 |
Generic |
$7.00 | $17.50 | None |
ERYTHROMYCIN 2% GEL [Erygel] |
2 |
Generic |
$7.00 | $17.50 | Q:60 /28Days |
ERYTHROMYCIN 2% SOLUTION |
2 |
Generic |
$7.00 | $17.50 | Q:60 /28Days |
ERYTHROMYCIN 200 MG/5 ML ORAL SUSPENSION [EryPed] |
4 |
Non-Preferred Drug |
40% | 40% | None |
ERYTHROMYCIN 250 MG TABLET |
2 |
Generic |
$7.00 | $17.50 | None |
ERYTHROMYCIN 500 MG TABLET |
2 |
Generic |
$7.00 | $17.50 | None |
ERYTHROMYCIN ES 400 MG TABLET [E.E.S.] |
4 |
Non-Preferred Drug |
40% | 40% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROMYCIN-BENZOYL GEL [Benzamycin] |
2 |
Generic |
$7.00 | $17.50 | None |
ESBRIET 267 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:279 /31Days |
ESBRIET 267 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:279 /31Days |
ESBRIET 801 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:93 /31Days |
ESCITALOPRAM 10 MG TABLET [Lexapro] |
2 |
Generic |
$7.00 | $17.50 | Q:45 /30Days |
ESCITALOPRAM 20 MG TABLET [Lexapro] |
2 |
Generic |
$7.00 | $17.50 | Q:30 /30Days |
ESCITALOPRAM 5 MG TABLET [Lexapro] |
2 |
Generic |
$7.00 | $17.50 | Q:30 /30Days |
ESCITALOPRAM OXALATE 5 MG/5 ML SOLUTION [Lexapro] |
4 |
Non-Preferred Drug |
40% | 40% | Q:620 /31Days |
ESOMEPRAZOLE MAG DR 20 MG CAPSULE DR [Nexium 24HR Clear Minis] |
2 |
Generic |
$7.00 | $17.50 | Q:31 /31Days |
ESOMEPRAZOLE MAG DR 40 MG CAPSULE DR [Nexium] |
2 |
Generic |
$7.00 | $17.50 | Q:31 /31Days |
ESTARYLLA 0.25-0.035 MG TABLET [VyLibra] |
2 |
Generic |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Estazolam 1mg/1 100 TABLET BOTTLE |
2 |
Generic |
$7.00 | $17.50 | None |
ESTAZOLAM 2 MG TABLET [ProSom] |
2 |
Generic |
$7.00 | $17.50 | None |
Estradiol / Norethindrone Acetate 0.5; 0.1mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, FILM C |
2 |
Generic |
$7.00 | $17.50 | None |
ESTRADIOL 0.01% CREAM |
4 |
Non-Preferred Drug |
40% | 40% | None |
Estradiol 0.025 mg patch |
2 |
Generic |
$7.00 | $17.50 | None |
ESTRADIOL 0.0375MG PATCH(1/WKClimara] |
2 |
Generic |
$7.00 | $17.50 | None |
ESTRADIOL 0.0375MG PATCH(2/WK) TDSW [Vivelle-Dot] |
2 |
Generic |
$7.00 | $17.50 | None |
Estradiol 0.05 mg patch |
2 |
Generic |
$7.00 | $17.50 | None |
ESTRADIOL 0.05 MG PATCH (1/WK) [Climara] |
2 |
Generic |
$7.00 | $17.50 | None |
ESTRADIOL 0.06 MG PATCH (1/WK) [Climara] |
2 |
Generic |
$7.00 | $17.50 | None |
Estradiol 0.075 mg patch |
2 |
Generic |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL 0.075 MG PATCH(1/WKClimara] |
2 |
Generic |
$7.00 | $17.50 | None |
Estradiol 0.1 mg patch |
2 |
Generic |
$7.00 | $17.50 | None |
ESTRADIOL 0.1 MG PATCH (1/WK) [Climara] |
2 |
Generic |
$7.00 | $17.50 | None |
ESTRADIOL 0.5 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ESTRADIOL 1 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ESTRADIOL 10 MCG VAGINAL INSRT |
4 |
Non-Preferred Drug |
40% | 40% | None |
ESTRADIOL 2MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ESTRADIOL TDS 0.025 MG/DAY |
2 |
Generic |
$7.00 | $17.50 | None |
ESTRADIOL-NORETH 1.0-0.5MG TABLET |
2 |
Generic |
$7.00 | $17.50 | None |
ESTRING 2MG VAGINAL RING |
4 |
Non-Preferred Drug |
40% | 40% | None |
ESZOPICLONE 1 MG TABLET [Lunesta] |
2 |
Generic |
$7.00 | $17.50 | P Q:31 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESZOPICLONE 2 MG TABLET [Lunesta] |
2 |
Generic |
$7.00 | $17.50 | P Q:31 /31Days |
ESZOPICLONE 3 MG TABLET [Lunesta] |
2 |
Generic |
$7.00 | $17.50 | P Q:31 /31Days |
ETHACRYNIC ACID 25 MG TABLET [Edecrin] |
4 |
Non-Preferred Drug |
40% | 40% | None |
ETHAMBUTOL HCL 400 MG TABLET |
2 |
Generic |
$7.00 | $17.50 | None |
Ethambutol Hydrochloride 100mg/1 |
2 |
Generic |
$7.00 | $17.50 | None |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 |
2 |
Generic |
$7.00 | $17.50 | None |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TABLET 21 |
2 |
Generic |
$7.00 | $17.50 | None |
ETHOSUXIMIDE 250 MG CAPSULE [Zarontin] |
3 |
Preferred Brand |
20% | 20% | None |
ETHOSUXIMIDE 250 MG/5 ML SOLUTION [Zarontin] |
2 |
Generic |
$7.00 | $17.50 | None |
ETHYNODIOL-ETH ESTRA 1MG-35MCG [ZOVIA] |
2 |
Generic |
$7.00 | $17.50 | None |
ETHYNODIOL-ETH ESTRA 1MG-50MCG [ZOVIA] |
2 |
Generic |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETODOLAC 200 MG CAPSULE [Lodine] |
3 |
Preferred Brand |
20% | 20% | None |
ETODOLAC 300 MG CAPSULE [Lodine] |
3 |
Preferred Brand |
20% | 20% | None |
ETODOLAC 400 MG TABLET [Lodine] |
2 |
Generic |
$7.00 | $17.50 | None |
ETODOLAC 500 MG TABLET [Lodine] |
2 |
Generic |
$7.00 | $17.50 | None |
ETODOLAC ER 400 MG TABLET ER 24H [Lodine XL] |
3 |
Preferred Brand |
20% | 20% | None |
ETODOLAC ER 500 MG TABLET ER 24H [Lodine XL] |
3 |
Preferred Brand |
20% | 20% | None |
ETODOLAC ER 600 MG TABLET ER 24H [Lodine XL] |
3 |
Preferred Brand |
20% | 20% | None |
ETONOGESTREL-EE VAGINAL RING [NuvaRing] |
3 |
Preferred Brand |
20% | 20% | None |
ETRAVIRINE 100 MG TABLET [INTELENCE] |
4 |
Non-Preferred Drug |
40% | 40% | None |
ETRAVIRINE 200 MG TABLET [INTELENCE] |
5 |
Specialty Tier |
25% | N/A | None |
EVAMIST 1.53 MG/SPRAY |
4 |
Non-Preferred Drug |
40% | 40% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EVENITY 210 MG DOSE-2 SYRINGES |
5 |
Specialty Tier |
25% | N/A | P Q:2 /28Days |
EVEROLIMUS 0.25 MG TABLET [Zortress] |
5 |
Specialty Tier |
25% | N/A | P |
EVEROLIMUS 0.5 MG TABLET [Zortress] |
5 |
Specialty Tier |
25% | N/A | P |
EVEROLIMUS 0.75 MG TABLET [Zortress] |
5 |
Specialty Tier |
25% | N/A | P |
EVEROLIMUS 1 MG TABLET [Zortress] |
5 |
Specialty Tier |
25% | N/A | P |
EVEROLIMUS 10 MG TABLET [Afinitor] |
5 |
Specialty Tier |
25% | N/A | P Q:31 /31Days |
EVEROLIMUS 2 MG TABLET FOR SUSP [Afinitor DISPERZ] |
5 |
Specialty Tier |
25% | N/A | P Q:62 /31Days |
EVEROLIMUS 2.5 MG TABLET [Afinitor] |
5 |
Specialty Tier |
25% | N/A | P Q:31 /31Days |
EVEROLIMUS 3 MG TABLET FOR SUSP [Afinitor DISPERZ] |
5 |
Specialty Tier |
25% | N/A | P Q:93 /31Days |
EVEROLIMUS 5 MG TABLET [Afinitor] |
5 |
Specialty Tier |
25% | N/A | P Q:62 /31Days |
EVEROLIMUS 5 MG TABLET FOR SUSP [Afinitor DISPERZ] |
5 |
Specialty Tier |
25% | N/A | P Q:62 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EVEROLIMUS 7.5 MG TABLET [Afinitor] |
5 |
Specialty Tier |
25% | N/A | P Q:31 /31Days |
EVOTAZ 300 MG-150 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
EVRYSDI 60 MG/80 ML(0.75MG/ML) SOLUTION RECON |
5 |
Specialty Tier |
25% | N/A | P Q:240 /31Days |
EXEMESTANE 25 MG TABLET [Aromasin] |
2 |
Generic |
$7.00 | $17.50 | None |
EXKIVITY 40 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:124 /31Days |
EXSERVAN 50 MG FILM |
5 |
Specialty Tier |
25% | N/A | P Q:62 /31Days |
EXTAVIA 0.3 MG KIT |
5 |
Specialty Tier |
25% | N/A | Q:15 /30Days |
EZETIMIBE 10 MG TABLET [Zetia] |
2 |
Generic |
$7.00 | $17.50 | None |
EZETIMIBE-SIMVASTATIN 10-10 MG TABLET [Vytorin] |
3 |
Preferred Brand |
20% | 20% | None |
EZETIMIBE-SIMVASTATIN 10-20 MG TABLET [Vytorin] |
3 |
Preferred Brand |
20% | 20% | None |
EZETIMIBE-SIMVASTATIN 10-40 MG TABLET [Vytorin] |
3 |
Preferred Brand |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EZETIMIBE-SIMVASTATIN 10-80 MG TABLET [Vytorin] |
3 |
Preferred Brand |
20% | 20% | None |