2023 Medicare Part D Plan Formulary Information |
RiverSpring Star (HMO I-SNP) (H6776-001-0)
Benefit Details
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less. Call drug plan for more details. |
The RiverSpring Star (HMO I-SNP) (H6776-001-0) Formulary Drugs Starting with the Letter E in Bronx County, NY: CMS MA Region 3 which includes: NY
|
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 |
1 |
Tier 1 |
25% | 25% | None |
E.E.S. 400 FILMTAB TABLET |
1 |
Tier 1 |
25% | 25% | None |
ECONAZOLE NITRATE 1% CREAM (G) [Spectazole] |
1 |
Tier 1 |
25% | 25% | Q:85 /28Days |
EDARBI 40 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
EDARBI 80 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
EDARBYCLOR 40-12.5 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
EDARBYCLOR 40-25 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
EDECRIN 25 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
EDURANT 27.5mg/1 |
1 |
Tier 1 |
25% | 25% | None |
EFAVIR-EMTRI-TENOF 600-200-300 TABLET [Atripla] |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EFAVIR-LAMIV-TENOF 400-300-300 TABLET [SYMFI LO] |
1 |
Tier 1 |
25% | 25% | None |
EFAVIR-LAMIV-TENOF 600-300-300 TABLET [SYMFI] |
1 |
Tier 1 |
25% | 25% | None |
EFAVIRENZ 200 MG CAPSULE [Sustiva] |
1 |
Tier 1 |
25% | 25% | None |
EFAVIRENZ 50 MG CAPSULE [Sustiva] |
1 |
Tier 1 |
25% | 25% | None |
EFAVIRENZ 600 MG TABLET [Sustiva] |
1 |
Tier 1 |
25% | 25% | None |
EFFEXOR XR 150 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
EFFEXOR XR 37.5 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
EFFEXOR XR 75 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
EFFIENT 10 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
EFFIENT 5 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
EFUDEX 5% CREAM |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EGRIFTA SV 2 MG VIAL |
1 |
Tier 1 |
25% | 25% | P |
ELESTRIN 0.06% GEL MD PUMP |
1 |
Tier 1 |
25% | 25% | P Q:52 /30Days |
ELETRIPTAN HBR 20 MG TABLET [Relpax] |
1 |
Tier 1 |
25% | 25% | Q:18 /28Days |
ELETRIPTAN HBR 40 MG TABLET [Relpax] |
1 |
Tier 1 |
25% | 25% | Q:18 /28Days |
ELIDEL 1% CREAM |
1 |
Tier 1 |
25% | 25% | P Q:100 /30Days |
ELIGARD 22.5 MG SYRINGE |
1 |
Tier 1 |
25% | 25% | P |
ELIGARD 30 MG SYRINGE KIT |
1 |
Tier 1 |
25% | 25% | P |
ELIGARD 45 MG SYRINGE KIT |
1 |
Tier 1 |
25% | 25% | P |
ELIGARD 7.5 MG SYRINGE KIT |
1 |
Tier 1 |
25% | 25% | P |
ELIQUIS 2.5 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ELIQUIS 5 MG STARTER PACK |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIQUIS 5 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
ELURYNG VAGINAL RING [NuvaRing] |
1 |
Tier 1 |
25% | 25% | None |
EMCYT 140MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
EMEND 125 MG POWDER PACKET |
1 |
Tier 1 |
25% | 25% | P |
EMEND CAPSULES 80MG 2 BLPK |
1 |
Tier 1 |
25% | 25% | P |
EMEND TRIFOLD PACK |
1 |
Tier 1 |
25% | 25% | P |
EMFLAZA 18 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
EMFLAZA 22.75 MG/ML ORAL SUSPENSION |
1 |
Tier 1 |
25% | 25% | P |
EMFLAZA 30 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
EMFLAZA 36 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMFLAZA 6 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
EMGALITY 120 MG/ML PEN INJCTR |
1 |
Tier 1 |
25% | 25% | P Q:2 /30Days |
EMGALITY 120 MG/ML SYRINGE |
1 |
Tier 1 |
25% | 25% | P Q:2 /30Days |
EMGALITY 300 MG (100 MG X3SYR) SYRINGE |
1 |
Tier 1 |
25% | 25% | P Q:3 /30Days |
Empagliflozin 5 MG / Metformin hydrochloride 500 MG Oral Tablet [Synjardy] |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
1 |
Tier 1 |
25% | 25% | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
1 |
Tier 1 |
25% | 25% | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
1 |
Tier 1 |
25% | 25% | None |
EMTRICITABINE 200 MG CAPSULE [Emtriva] |
1 |
Tier 1 |
25% | 25% | None |
EMTRICITABINE-TENOFV 100-150MG TABLET [Truvada] |
1 |
Tier 1 |
25% | 25% | None |
EMTRICITABINE-TENOFV 133-200MG TABLET [Truvada] |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMTRICITABINE-TENOFV 167-250MG TABLET [Truvada] |
1 |
Tier 1 |
25% | 25% | None |
EMTRICITABINE-TENOFV 200-300MG TABLET [Truvada] |
1 |
Tier 1 |
25% | 25% | None |
EMTRIVA 10MG/ML SOLUTION |
1 |
Tier 1 |
25% | 25% | None |
EMTRIVA 200MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
EMVERM 100 MG TABLET CHEW |
1 |
Tier 1 |
25% | 25% | None |
ENALAPRIL 1 MG/ML ORAL SOLUTION [Epaned] |
1 |
Tier 1 |
25% | 25% | None |
ENALAPRIL MALEATE 10 MG TABLET [Vasotec] |
1 |
Tier 1 |
25% | 25% | None |
Enalapril Maleate 2.5 MG Oral Tablet [Vasotec] |
1 |
Tier 1 |
25% | 25% | None |
ENALAPRIL MALEATE 2.5 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ENALAPRIL MALEATE 20 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ENALAPRIL MALEATE 5 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENALAPRIL-HCTZ 10-25 MG TABLET [Vaseretic] |
1 |
Tier 1 |
25% | 25% | None |
ENALAPRIL-HCTZ 5-12.5 MG TABLET [Vaseretic] |
1 |
Tier 1 |
25% | 25% | None |
ENBREL 25 MG/0.5 ML SYRINGE |
1 |
Tier 1 |
25% | 25% | P Q:8 /28Days |
ENBREL 25 MG/0.5 ML VIAL |
1 |
Tier 1 |
25% | 25% | P Q:8 /28Days |
ENBREL 50 MG/ML MINI CARTRIDGE |
1 |
Tier 1 |
25% | 25% | P Q:8 /28Days |
ENBREL 50 MG/ML SURECLICK PEN INJECTOR |
1 |
Tier 1 |
25% | 25% | P Q:8 /28Days |
ENBREL 50 MG/ML SYRINGE |
1 |
Tier 1 |
25% | 25% | P Q:8 /28Days |
ENDARI 5 GRAM POWDER PACKET |
1 |
Tier 1 |
25% | 25% | P |
ENDOCET 10MG-325MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:360 /30Days |
ENDOCET 2.5-325 MG TABLET [Percocet] |
1 |
Tier 1 |
25% | 25% | Q:360 /30Days |
ENDOCET 5/325 TABLET |
1 |
Tier 1 |
25% | 25% | 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 |
1 |
Tier 1 |
25% | 25% | Q:360 /30Days |
ENGERIX B INJECTION |
1 |
Tier 1 |
25% | 25% | P |
ENGERIX-B 20 MCG/ML SYRINGE |
1 |
Tier 1 |
25% | 25% | P |
ENGERIX-B 20 MCG/ML VIAL |
1 |
Tier 1 |
25% | 25% | P |
ENOXAPARIN 100 MG/ML SYRINGE [Lovenox] |
1 |
Tier 1 |
25% | 25% | Q:28 /28Days |
ENOXAPARIN 120 MG/0.8 ML SYRINGE [Lovenox] |
1 |
Tier 1 |
25% | 25% | Q:22 /28Days |
ENOXAPARIN 150 MG/ML SYRINGE [Lovenox] |
1 |
Tier 1 |
25% | 25% | Q:28 /28Days |
ENOXAPARIN 30 MG/0.3 ML SYRINGE [Lovenox] |
1 |
Tier 1 |
25% | 25% | Q:17 /28Days |
ENOXAPARIN 40 MG/0.4 ML SYRINGE [Lovenox] |
1 |
Tier 1 |
25% | 25% | Q:11 /28Days |
ENOXAPARIN 60 MG/0.6 ML SYRINGE [Lovenox] |
1 |
Tier 1 |
25% | 25% | Q:17 /28Days |
ENOXAPARIN 80 MG/0.8 ML SYRINGE [Lovenox] |
1 |
Tier 1 |
25% | 25% | Q:22 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENSKYCE 28 TABLET [Solia] |
1 |
Tier 1 |
25% | 25% | None |
ENSPRYNG 120 MG/ML SYRINGE |
1 |
Tier 1 |
25% | 25% | P |
ENSTILAR 0.005%-0.064% FOAM |
1 |
Tier 1 |
25% | 25% | Q:400 /30Days |
ENTACAPONE 200 MG TABLET [Comtan] |
1 |
Tier 1 |
25% | 25% | None |
ENTADFI 5-5 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
ENTECAVIR 0.5 MG TABLET [Baraclude] |
1 |
Tier 1 |
25% | 25% | None |
ENTECAVIR 1 MG TABLET [Baraclude] |
1 |
Tier 1 |
25% | 25% | None |
ENTRESTO 24 MG-26 MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
ENTRESTO 49 MG-51 MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
ENTRESTO 97 MG-103 MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:60 /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 |
ENVARSUS XR 0.75 MG TABLET ER 24H |
1 |
Tier 1 |
25% | 25% | P |
ENVARSUS XR 1 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
ENVARSUS XR 4 MG TABLET ER 24H |
1 |
Tier 1 |
25% | 25% | P |
EPCLUSA 150-37.5 MG PELLET PACK |
1 |
Tier 1 |
25% | 25% | P Q:28 /28Days |
EPCLUSA 200 MG-50 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:56 /28Days |
EPCLUSA 200-50 MG PELLET PACK |
1 |
Tier 1 |
25% | 25% | P Q:56 /28Days |
EPCLUSA 400 MG-100 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:28 /28Days |
EPIDIOLEX 100 MG/ML SOLUTION |
1 |
Tier 1 |
25% | 25% | P |
EPIDUO 0.1-2.5% GEL PUMP GEL W/PUMP |
1 |
Tier 1 |
25% | 25% | P |
EPIDUO FORTE 0.3-2.5% GEL PUMP |
1 |
Tier 1 |
25% | 25% | P |
EPINASTINE HCL 0.05% EYE DROPS |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPINEPHRINE 0.15 MG AUTO-INJCT [Twinject] |
1 |
Tier 1 |
25% | 25% | Q:2 /30Days |
EPINEPHRINE 0.15 MG AUTO-INJECT |
1 |
Tier 1 |
25% | 25% | Q:2 /30Days |
EPINEPHRINE 0.3 MG AUTO-INJECT |
1 |
Tier 1 |
25% | 25% | Q:2 /30Days |
EPINEPHRINE 0.3 MG AUTO-INJECT [Twinject] |
1 |
Tier 1 |
25% | 25% | Q:2 /30Days |
EPIPEN 0.3MG AUTO-INJECTOR |
1 |
Tier 1 |
25% | 25% | Q:2 /30Days |
EPIPEN JR 0.15MG AUTO-INJCT |
1 |
Tier 1 |
25% | 25% | Q:2 /30Days |
EPITOL 200MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
EPIVIR 10 MG/ML ORAL SOLUTION |
1 |
Tier 1 |
25% | 25% | None |
EPIVIR 150 MG TABLETS |
1 |
Tier 1 |
25% | 25% | None |
EPIVIR 300mg/1 30 FILM COATED TABLETS in BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
EPLERENONE 25 MG TABLET [Inspra] |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPLERENONE 50 MG TABLET [Inspra] |
1 |
Tier 1 |
25% | 25% | None |
EPOGEN 10000U/ML VIAL MDV |
1 |
Tier 1 |
25% | 25% | P |
EPOGEN 2000[iU]/mL 10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL |
1 |
Tier 1 |
25% | 25% | P |
EPOGEN 3000U/ML VIAL SDV |
1 |
Tier 1 |
25% | 25% | P |
EPOGEN 4000U/ML VIAL SDV |
1 |
Tier 1 |
25% | 25% | P |
EPOGEN INJECTION 20000U 10 X 1ML CRTN |
1 |
Tier 1 |
25% | 25% | P |
EPRONTIA 25 MG/ML SOLUTION |
1 |
Tier 1 |
25% | 25% | P |
EPSOLAY 5% CREAM PUMP (G) |
1 |
Tier 1 |
25% | 25% | S |
EPZICOM 600MG/300MG TABLETS |
1 |
Tier 1 |
25% | 25% | None |
EQUETRO CAPSULES 200MG 120 BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
EQUETRO CAPSULES 300MG 120 BOTTLE |
1 |
Tier 1 |
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 BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
ERAXIS 100mg/30mL 30 mL in 1 VIAL, SINGLE-USE |
1 |
Tier 1 |
25% | 25% | None |
ERAXIS(WATER DIL) 50 MG VIAL |
1 |
Tier 1 |
25% | 25% | None |
ERGOLOID MESYLATES TABLETS 1MG 100 BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
Ergotamine-caffeine 1-100mg tablet |
1 |
Tier 1 |
25% | 25% | None |
ERIVEDGE 150 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
ERLEADA 240 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
ERLEADA 60 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:120 /30Days |
ERLOTINIB HCL 100 MG TABLET [Tarceva] |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
ERLOTINIB HCL 150 MG TABLET [Tarceva] |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
ERLOTINIB HCL 25 MG TABLET [Tarceva] |
1 |
Tier 1 |
25% | 25% | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERMEZA 150 MCG/5 ML SOLUTION |
1 |
Tier 1 |
25% | 25% | None |
ERRIN 0.35 MG TABLET [Sharobel 28-Day] |
1 |
Tier 1 |
25% | 25% | None |
ERTACZO 2% CREAM |
1 |
Tier 1 |
25% | 25% | Q:60 /28Days |
ERTAPENEM 1 GRAM VIAL [Invanz] |
1 |
Tier 1 |
25% | 25% | P Q:14 /14Days |
ERY 2% PADS 2% 60 PADS JAR |
1 |
Tier 1 |
25% | 25% | None |
ERY-TAB DR 250 MG TABLET DR |
1 |
Tier 1 |
25% | 25% | None |
ERY-TAB DR 333 MG TABLET DR |
1 |
Tier 1 |
25% | 25% | None |
ERY-TAB DR 500 MG TABLET DR |
1 |
Tier 1 |
25% | 25% | None |
ERYGEL 2% GEL |
1 |
Tier 1 |
25% | 25% | None |
ERYPED 200 MG/5 ML SUSPENSION |
1 |
Tier 1 |
25% | 25% | None |
ERYPED 400 MG/5 ML SUSPENSION |
1 |
Tier 1 |
25% | 25% | 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 |
25% | 25% | None |
ERYTHROCIN LACT 500 MG VIAL |
1 |
Tier 1 |
25% | 25% | P |
ERYTHROMYCIN 0.5% EYE OINTMENT [Romycin] |
1 |
Tier 1 |
25% | 25% | Q:4 /14Days |
ERYTHROMYCIN 2% GEL [Erygel] |
1 |
Tier 1 |
25% | 25% | None |
ERYTHROMYCIN 2% SOLUTION |
1 |
Tier 1 |
25% | 25% | None |
ERYTHROMYCIN 200 MG/5 ML ORAL SUSPENSION [EryPed] |
1 |
Tier 1 |
25% | 25% | None |
ERYTHROMYCIN 250 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ERYTHROMYCIN 400 MG/5 ML ORAL SUSPENSION [EryPed] |
1 |
Tier 1 |
25% | 25% | None |
ERYTHROMYCIN 500 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ERYTHROMYCIN DR 250 MG CAPSULE DR [ERYC] |
1 |
Tier 1 |
25% | 25% | None |
ERYTHROMYCIN DR 250 MG TABLET DR [Ery-Tab] |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROMYCIN DR 333 MG TABLET DR [Ery-Tab] |
1 |
Tier 1 |
25% | 25% | None |
ERYTHROMYCIN DR 500 MG TABLET DR [Ery-Tab] |
1 |
Tier 1 |
25% | 25% | None |
ERYTHROMYCIN ES 400 MG TABLET [E.E.S.] |
1 |
Tier 1 |
25% | 25% | None |
ERYTHROMYCIN-BENZOYL GEL [Benzamycin] |
1 |
Tier 1 |
25% | 25% | None |
ESBRIET 267 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P Q:270 /30Days |
ESBRIET 267 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:270 /30Days |
ESBRIET 801 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:90 /30Days |
ESCITALOPRAM 10 MG TABLET [Lexapro] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ESCITALOPRAM 20 MG TABLET [Lexapro] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ESCITALOPRAM 5 MG TABLET [Lexapro] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ESCITALOPRAM OXALATE 5 MG/5 ML SOLUTION [Lexapro] |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESOMEPRAZOLE DR 10 MG SUSPDR PACKET [Nexium] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ESOMEPRAZOLE DR 20 MG SUSPDR PACKET [Nexium] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ESOMEPRAZOLE DR 40 MG SUSPDR PACKET [Nexium] |
1 |
Tier 1 |
25% | 25% | None |
ESOMEPRAZOLE MAG DR 20 MG CAPSULE DR [Nexium 24HR Clear Minis] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ESOMEPRAZOLE MAG DR 40 MG CAPSULE DR [Nexium] |
1 |
Tier 1 |
25% | 25% | None |
ESTARYLLA 0.25-0.035 MG TABLET [VyLibra] |
1 |
Tier 1 |
25% | 25% | None |
ESTRACE 0.5MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
ESTRACE 2MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
ESTRACE TABLET 1MG (100 CT) |
1 |
Tier 1 |
25% | 25% | P |
ESTRACE VAGINAL CREAM 0.1MG/GM |
1 |
Tier 1 |
25% | 25% | S |
Estradiol / Norethindrone Acetate 0.5; 0.1mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, FILM C |
1 |
Tier 1 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL 0.01% CREAM/APPL [Estrace] |
1 |
Tier 1 |
25% | 25% | None |
Estradiol 0.025 mg patch |
1 |
Tier 1 |
25% | 25% | P Q:8 /28Days |
ESTRADIOL 0.025 MG PATCH(1/WK) [FemPatch] |
1 |
Tier 1 |
25% | 25% | P Q:4 /28Days |
ESTRADIOL 0.0375MG PATCH(1/WKClimara] |
1 |
Tier 1 |
25% | 25% | P Q:4 /28Days |
ESTRADIOL 0.0375MG PATCH(2/WK) TDSW [Vivelle-Dot] |
1 |
Tier 1 |
25% | 25% | P Q:8 /28Days |
Estradiol 0.05 mg patch |
1 |
Tier 1 |
25% | 25% | P Q:8 /28Days |
ESTRADIOL 0.05 MG PATCH (1/WK) [Climara] |
1 |
Tier 1 |
25% | 25% | P Q:4 /28Days |
ESTRADIOL 0.06 MG PATCH (1/WK) [Climara] |
1 |
Tier 1 |
25% | 25% | P Q:4 /28Days |
Estradiol 0.075 mg patch |
1 |
Tier 1 |
25% | 25% | P Q:8 /28Days |
ESTRADIOL 0.075 MG PATCH(1/WKClimara] |
1 |
Tier 1 |
25% | 25% | P Q:4 /28Days |
Estradiol 0.1 mg patch |
1 |
Tier 1 |
25% | 25% | P Q:8 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL 0.1 MG PATCH (1/WK) [Climara] |
1 |
Tier 1 |
25% | 25% | P Q:4 /28Days |
ESTRADIOL 0.1% (0.25MG) GEL PACKET [Divigel] |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
ESTRADIOL 0.1% (0.5MG) GEL PACKET [Divigel] |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
ESTRADIOL 0.1% (0.75MG) GEL PACKET [Divigel] |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
ESTRADIOL 0.1% (1 MG) GEL PACKET [Divigel] |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
ESTRADIOL 0.1% (1.25MG) GEL PACKET [Divigel] |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
ESTRADIOL 0.5 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
ESTRADIOL 1 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
ESTRADIOL 10 MCG VAGINAL INSRT |
1 |
Tier 1 |
25% | 25% | None |
ESTRADIOL 2MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
ESTRADIOL 50 MG/5 ML VIAL [Delestrogen] |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL VALERATE 100 MG/5 ML VIAL [Gynogen LA] |
1 |
Tier 1 |
25% | 25% | None |
ESTRADIOL VALERATE 200 MG/5 ML VIAL [Delestrogen] |
1 |
Tier 1 |
25% | 25% | None |
ESTRADIOL-NORETH 1.0-0.5MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
ESTRING 7.5 MCG/DAY (2MG) VAG RING |
1 |
Tier 1 |
25% | 25% | None |
ESTROGEL 0.06% GEL MD PMP |
1 |
Tier 1 |
25% | 25% | Q:50 /30Days |
ESZOPICLONE 1 MG TABLET [Lunesta] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ESZOPICLONE 2 MG TABLET [Lunesta] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ESZOPICLONE 3 MG TABLET [Lunesta] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ETHACRYNIC ACID 25 MG TABLET [Edecrin] |
1 |
Tier 1 |
25% | 25% | None |
ETHAMBUTOL HCL 400 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Ethambutol Hydrochloride 100mg/1 |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 |
1 |
Tier 1 |
25% | 25% | None |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TABLET 21 |
1 |
Tier 1 |
25% | 25% | None |
ETHOSUXIMIDE 250 MG CAPSULE [Zarontin] |
1 |
Tier 1 |
25% | 25% | None |
ETHOSUXIMIDE 250 MG/5 ML SOLUTION [Zarontin] |
1 |
Tier 1 |
25% | 25% | None |
ETHYNODIOL-ETH ESTRA 1MG-35MCG [ZOVIA] |
1 |
Tier 1 |
25% | 25% | None |
ETHYNODIOL-ETH ESTRA 1MG-50MCG [ZOVIA] |
1 |
Tier 1 |
25% | 25% | None |
ETODOLAC 200 MG CAPSULE [Lodine] |
1 |
Tier 1 |
25% | 25% | None |
ETODOLAC 300 MG CAPSULE [Lodine] |
1 |
Tier 1 |
25% | 25% | None |
ETODOLAC 400 MG TABLET [Lodine] |
1 |
Tier 1 |
25% | 25% | None |
ETODOLAC 500 MG TABLET [Lodine] |
1 |
Tier 1 |
25% | 25% | None |
ETODOLAC ER 400 MG TABLET 24H [Lodine XL] |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETODOLAC ER 500 MG TABLET 24H [Lodine XL] |
1 |
Tier 1 |
25% | 25% | None |
ETODOLAC ER 600 MG TABLET 24H [Lodine XL] |
1 |
Tier 1 |
25% | 25% | None |
ETONOGESTREL-EE VAGINAL RING [NuvaRing] |
1 |
Tier 1 |
25% | 25% | None |
ETRAVIRINE 100 MG TABLET [INTELENCE] |
1 |
Tier 1 |
25% | 25% | None |
ETRAVIRINE 200 MG TABLET [INTELENCE] |
1 |
Tier 1 |
25% | 25% | None |
EUCRISA 2% OINTMENT |
1 |
Tier 1 |
25% | 25% | P Q:120 /30Days |
EUTHYROX 100 MCG TABLET |
1 |
Tier 1 |
25% | 25% | None |
EUTHYROX 112 MCG TABLET |
1 |
Tier 1 |
25% | 25% | None |
EUTHYROX 125 MCG TABLET |
1 |
Tier 1 |
25% | 25% | None |
EUTHYROX 137 MCG TABLET |
1 |
Tier 1 |
25% | 25% | None |
EUTHYROX 150 MCG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EUTHYROX 175 MCG TABLET |
1 |
Tier 1 |
25% | 25% | None |
EUTHYROX 200 MCG TABLET |
1 |
Tier 1 |
25% | 25% | None |
EUTHYROX 25 MCG TABLET |
1 |
Tier 1 |
25% | 25% | None |
EUTHYROX 50 MCG TABLET |
1 |
Tier 1 |
25% | 25% | None |
EUTHYROX 75 MCG TABLET |
1 |
Tier 1 |
25% | 25% | None |
EUTHYROX 88 MCG TABLET |
1 |
Tier 1 |
25% | 25% | None |
EVAMIST 1.53 MG/SPRAY |
1 |
Tier 1 |
25% | 25% | P Q:16 /30Days |
EVEKEO 10 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
EVEKEO 5 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
EVEKEO ODT 10 MG TABLET RAPDIS |
1 |
Tier 1 |
25% | 25% | P |
EVEKEO ODT 15 MG TABLET RAPDIS |
1 |
Tier 1 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EVEKEO ODT 20 MG TABLET RAPDIS |
1 |
Tier 1 |
25% | 25% | P |
EVEKEO ODT 5 MG TABLET RAPDIS |
1 |
Tier 1 |
25% | 25% | P |
EVENITY 210 MG DOSE-2 SYRINGES |
1 |
Tier 1 |
25% | 25% | P Q:2 /30Days |
EVEROLIMUS 0.25 MG TABLET [Zortress] |
1 |
Tier 1 |
25% | 25% | P |
EVEROLIMUS 0.5 MG TABLET [Zortress] |
1 |
Tier 1 |
25% | 25% | P |
EVEROLIMUS 0.75 MG TABLET [Zortress] |
1 |
Tier 1 |
25% | 25% | P |
EVEROLIMUS 1 MG TABLET [Zortress] |
1 |
Tier 1 |
25% | 25% | P |
EVEROLIMUS 10 MG TABLET [Afinitor] |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
EVEROLIMUS 2 MG TABLET FOR SUSP [Afinitor DISPERZ] |
1 |
Tier 1 |
25% | 25% | P Q:330 /30Days |
EVEROLIMUS 2.5 MG TABLET [Afinitor] |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
EVEROLIMUS 3 MG TABLET FOR SUSP [Afinitor DISPERZ] |
1 |
Tier 1 |
25% | 25% | P Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EVEROLIMUS 5 MG TABLET [Afinitor] |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
EVEROLIMUS 5 MG TABLET FOR SUSP [Afinitor DISPERZ] |
1 |
Tier 1 |
25% | 25% | P Q:180 /30Days |
EVEROLIMUS 7.5 MG TABLET [Afinitor] |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
EVISTA 60 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
EVOTAZ 300 MG-150 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
EVOXAC 30 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | None |
EVRYSDI 60 MG/80 ML(0.75MG/ML) SOLUTION RECON |
1 |
Tier 1 |
25% | 25% | P Q:240 /30Days |
EXELDERM 1% CREAM (G) |
1 |
Tier 1 |
25% | 25% | Q:60 /28Days |
EXELDERM 1% SOLUTION |
1 |
Tier 1 |
25% | 25% | Q:60 /28Days |
EXELON 13.3 MG/24HR PATCH |
1 |
Tier 1 |
25% | 25% | None |
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS |
1 |
Tier 1 |
25% | 25% | None |
EXEMESTANE 25 MG TABLET [Aromasin] |
1 |
Tier 1 |
25% | 25% | None |
EXFORGE 10MG-160MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
EXFORGE 10MG-320MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
EXFORGE 5MG-160MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
EXFORGE 5MG-320MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
EXFORGE HCT 10-160-12.5 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
EXFORGE HCT 10-160-25 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
EXFORGE HCT 10-320-25 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
EXFORGE HCT 5-160-12.5 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
EXFORGE HCT 5-160-25 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EXJADE 125MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
EXJADE 250MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
EXJADE 500MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
EXKIVITY 40 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P Q:120 /30Days |
EXSERVAN 50 MG FILM |
1 |
Tier 1 |
25% | 25% | P |
EXTAVIA 0.3 MG KIT |
1 |
Tier 1 |
25% | 25% | P Q:15 /28Days |
EYSUVIS 0.25% EYE DROPS EYE DROPPER |
1 |
Tier 1 |
25% | 25% | P Q:8 /14Days |
EZALLOR SPRINKLE 10 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | S Q:30 /30Days |
EZALLOR SPRINKLE 20 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | S Q:30 /30Days |
EZALLOR SPRINKLE 40 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | S Q:30 /30Days |
EZALLOR SPRINKLE 5 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EZETIMIBE 10 MG TABLET [Zetia] |
1 |
Tier 1 |
25% | 25% | None |
EZETIMIBE-SIMVASTATIN 10-10 MG TABLET [Vytorin] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
EZETIMIBE-SIMVASTATIN 10-20 MG TABLET [Vytorin] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
EZETIMIBE-SIMVASTATIN 10-40 MG TABLET [Vytorin] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
EZETIMIBE-SIMVASTATIN 10-80 MG TABLET [Vytorin] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |