2023 Medicare Part D Plan Formulary Information |
Blue Rx Standard (PDP) (S3375-001-0)
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 Blue Rx Standard (PDP) (S3375-001-0) Formulary Drugs Starting with the Letter E in CMS PDP 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. 400 FILMTAB TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
ECONAZOLE NITRATE 1% CREAM (G) [Spectazole] |
4 |
Non-Preferred Drug |
40% | 40% | Q:90 /30Days |
EDURANT 27.5mg/1 |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
EFAVIR-EMTRI-TENOF 600-200-300 TABLET [Atripla] |
4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days |
EFAVIR-LAMIV-TENOF 400-300-300 TABLET [SYMFI LO] |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
EFAVIR-LAMIV-TENOF 600-300-300 TABLET [SYMFI] |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
EFAVIRENZ 200 MG CAPSULE [Sustiva] |
4 |
Non-Preferred Drug |
40% | 40% | Q:120 /30Days |
EFAVIRENZ 50 MG CAPSULE [Sustiva] |
4 |
Non-Preferred Drug |
40% | 40% | Q:360 /30Days |
EFAVIRENZ 600 MG TABLET [Sustiva] |
4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days |
ELIQUIS 2.5 MG TABLET |
3 |
Preferred Brand |
$46.00 | $138.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIQUIS 5 MG STARTER PACK |
3 |
Preferred Brand |
$46.00 | $138.00 | Q:74 /180Days |
ELIQUIS 5 MG TABLET |
3 |
Preferred Brand |
$46.00 | $138.00 | Q:60 /30Days |
EMCYT 140MG CAPSULE |
4 |
Non-Preferred Drug |
40% | 40% | None |
EMGALITY 120 MG/ML PEN INJCTR |
3 |
Preferred Brand |
$46.00 | $138.00 | P Q:2 /28Days |
EMGALITY 120 MG/ML SYRINGE |
3 |
Preferred Brand |
$46.00 | $138.00 | P Q:2 /28Days |
EMGALITY 300 MG (100 MG X3SYR) SYRINGE |
3 |
Preferred Brand |
$46.00 | $138.00 | P Q:3 /28Days |
Empagliflozin 5 MG / Metformin hydrochloride 500 MG Oral Tablet [Synjardy] |
3 |
Preferred Brand |
$46.00 | $138.00 | Q:60 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days |
EMTRICITABINE 200 MG CAPSULE [Emtriva] |
4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMTRICITABINE-TENOFV 100-150MG TABLET [Truvada] |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
EMTRICITABINE-TENOFV 133-200MG TABLET [Truvada] |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
EMTRICITABINE-TENOFV 167-250MG TABLET [Truvada] |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
EMTRICITABINE-TENOFV 200-300MG TABLET [Truvada] |
4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days |
EMTRIVA 10MG/ML SOLUTION |
4 |
Non-Preferred Drug |
40% | 40% | Q:850 /30Days |
ENALAPRIL MALEATE 10 MG TABLET [Vasotec] |
2* |
Generic |
$1.00 | $3.00 | None |
ENALAPRIL MALEATE 2.5 MG TABLET |
2* |
Generic |
$1.00 | $3.00 | None |
ENALAPRIL MALEATE 20 MG TABLET |
2* |
Generic |
$1.00 | $3.00 | None |
ENALAPRIL MALEATE 5 MG TABLET |
2* |
Generic |
$1.00 | $3.00 | None |
ENALAPRIL-HCTZ 10-25 MG TABLET [Vaseretic] |
2* |
Generic |
$1.00 | $3.00 | None |
ENALAPRIL-HCTZ 5-12.5 MG TABLET [Vaseretic] |
2* |
Generic |
$1.00 | $3.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
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 |
ENDOCET 10MG-325MG TABLET |
3 |
Preferred Brand |
$46.00 | $138.00 | Q:180 /30Days |
ENDOCET 2.5-325 MG TABLET [Percocet] |
3 |
Preferred Brand |
$46.00 | $138.00 | Q:180 /30Days |
ENDOCET 5/325 TABLET |
3 |
Preferred Brand |
$46.00 | $138.00 | Q:180 /30Days |
ENDOCET 7.5-325MG TABLET |
3 |
Preferred Brand |
$46.00 | $138.00 | Q:180 /30Days |
ENGERIX B INJECTION |
3 |
Preferred Brand |
$46.00 | $138.00 | P |
ENGERIX-B 20 MCG/ML SYRINGE |
3 |
Preferred Brand |
$46.00 | $138.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENGERIX-B 20 MCG/ML VIAL |
3 |
Preferred Brand |
$46.00 | $138.00 | P |
ENOXAPARIN 100 MG/ML SYRINGE [Lovenox] |
4 |
Non-Preferred Drug |
40% | 40% | Q:56 /28Days |
ENOXAPARIN 120 MG/0.8 ML SYRINGE [Lovenox] |
4 |
Non-Preferred Drug |
40% | 40% | Q:45 /28Days |
ENOXAPARIN 150 MG/ML SYRINGE [Lovenox] |
4 |
Non-Preferred Drug |
40% | 40% | Q:56 /28Days |
ENOXAPARIN 30 MG/0.3 ML SYRINGE [Lovenox] |
4 |
Non-Preferred Drug |
40% | 40% | Q:17 /28Days |
ENOXAPARIN 40 MG/0.4 ML SYRINGE [Lovenox] |
4 |
Non-Preferred Drug |
40% | 40% | Q:22 /28Days |
ENOXAPARIN 60 MG/0.6 ML SYRINGE [Lovenox] |
4 |
Non-Preferred Drug |
40% | 40% | Q:34 /28Days |
ENOXAPARIN 80 MG/0.8 ML SYRINGE [Lovenox] |
4 |
Non-Preferred Drug |
40% | 40% | Q:45 /28Days |
ENSKYCE 28 TABLET [Solia] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
ENTACAPONE 200 MG TABLET [Comtan] |
4 |
Non-Preferred Drug |
40% | 40% | None |
ENTECAVIR 0.5 MG TABLET [Baraclude] |
4 |
Non-Preferred Drug |
40% | 40% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENTECAVIR 1 MG TABLET [Baraclude] |
4 |
Non-Preferred Drug |
40% | 40% | P |
ENTRESTO 24 MG-26 MG TABLET |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
ENTRESTO 49 MG-51 MG TABLET |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
ENTRESTO 97 MG-103 MG TABLET |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
ENULOSE 10 GM/15 ML SOLUTION |
2* |
Generic |
$1.00 | $3.00 | None |
EPCLUSA 150-37.5 MG PELLET PACK |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
EPCLUSA 200 MG-50 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
EPCLUSA 200-50 MG PELLET PACK |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
EPCLUSA 400 MG-100 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
EPIDIOLEX 100 MG/ML SOLUTION |
4 |
Non-Preferred Drug |
40% | 40% | P |
EPINASTINE HCL 0.05% EYE DROPS |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPINEPHRINE 0.15 MG AUTO-INJCT [Twinject] |
3 |
Preferred Brand |
$46.00 | $138.00 | Q:2 /28Days |
EPINEPHRINE 0.15 MG AUTO-INJECT |
3 |
Preferred Brand |
$46.00 | $138.00 | Q:2 /28Days |
EPINEPHRINE 0.3 MG AUTO-INJECT |
3 |
Preferred Brand |
$46.00 | $138.00 | Q:2 /28Days |
EPINEPHRINE 0.3 MG AUTO-INJECT [Twinject] |
3 |
Preferred Brand |
$46.00 | $138.00 | Q:2 /28Days |
EPITOL 200MG TABLET |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
EPLERENONE 25 MG TABLET [Inspra] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
EPLERENONE 50 MG TABLET [Inspra] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
EPRONTIA 25 MG/ML SOLUTION |
4 |
Non-Preferred Drug |
40% | 40% | None |
Ergotamine-caffeine 1-100mg tablet |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
ERIVEDGE 150 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
ERLEADA 240 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERLEADA 60 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
ERLOTINIB HCL 100 MG TABLET [Tarceva] |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
ERLOTINIB HCL 150 MG TABLET [Tarceva] |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
ERLOTINIB HCL 25 MG TABLET [Tarceva] |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
ERRIN 0.35 MG TABLET [Sharobel 28-Day] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
ERTAPENEM 1 GRAM VIAL [Invanz] |
4 |
Non-Preferred Drug |
40% | 40% | None |
ERY 2% PADS 2% 60 PADS JAR |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
ERY-TAB DR 250 MG TABLET DR |
4 |
Non-Preferred Drug |
40% | 40% | None |
ERYTHROCIN 250 MG FILMTAB TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
ERYTHROCIN LACT 500 MG VIAL |
4 |
Non-Preferred Drug |
40% | 40% | None |
ERYTHROMYCIN 0.5% EYE OINTMENT [Romycin] |
2* |
Generic |
$1.00 | $3.00 | Q:4 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROMYCIN 2% GEL [Erygel] |
4 |
Non-Preferred Drug |
40% | 40% | None |
ERYTHROMYCIN 2% SOLUTION |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
ERYTHROMYCIN 250 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
ERYTHROMYCIN 500 MG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
ERYTHROMYCIN DR 250 MG CAPSULE DR [ERYC] |
4 |
Non-Preferred Drug |
40% | 40% | None |
ERYTHROMYCIN DR 250 MG TABLET DR [Ery-Tab] |
4 |
Non-Preferred Drug |
40% | 40% | None |
ERYTHROMYCIN DR 333 MG TABLET DR [Ery-Tab] |
4 |
Non-Preferred Drug |
40% | 40% | None |
ERYTHROMYCIN DR 500 MG TABLET DR [Ery-Tab] |
4 |
Non-Preferred Drug |
40% | 40% | None |
ERYTHROMYCIN ES 400 MG TABLET [E.E.S.] |
4 |
Non-Preferred Drug |
40% | 40% | None |
ESBRIET 267 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:270 /30Days |
ESBRIET 267 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:270 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESBRIET 801 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
ESCITALOPRAM 10 MG TABLET [Lexapro] |
2* |
Generic |
$1.00 | $3.00 | Q:60 /30Days |
ESCITALOPRAM 20 MG TABLET [Lexapro] |
2* |
Generic |
$1.00 | $3.00 | Q:30 /30Days |
ESCITALOPRAM 5 MG TABLET [Lexapro] |
2* |
Generic |
$1.00 | $3.00 | Q:120 /30Days |
ESCITALOPRAM OXALATE 5 MG/5 ML SOLUTION [Lexapro] |
4 |
Non-Preferred Drug |
40% | 40% | Q:600 /30Days |
ESTARYLLA 0.25-0.035 MG TABLET [VyLibra] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
ESTRADIOL 0.01% CREAM/APPL [Estrace] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
Estradiol 0.025 mg patch |
3 |
Preferred Brand |
$46.00 | $138.00 | P Q:8 /28Days |
ESTRADIOL 0.025 MG PATCH(1/WK) [FemPatch] |
3 |
Preferred Brand |
$46.00 | $138.00 | P Q:4 /28Days |
ESTRADIOL 0.0375MG PATCH(1/WKClimara] |
3 |
Preferred Brand |
$46.00 | $138.00 | P Q:4 /28Days |
ESTRADIOL 0.0375MG PATCH(2/WK) TDSW [Vivelle-Dot] |
3 |
Preferred Brand |
$46.00 | $138.00 | P Q:8 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Estradiol 0.05 mg patch |
3 |
Preferred Brand |
$46.00 | $138.00 | P Q:8 /28Days |
ESTRADIOL 0.05 MG PATCH (1/WK) [Climara] |
3 |
Preferred Brand |
$46.00 | $138.00 | P Q:4 /28Days |
ESTRADIOL 0.06 MG PATCH (1/WK) [Climara] |
3 |
Preferred Brand |
$46.00 | $138.00 | P Q:4 /28Days |
Estradiol 0.075 mg patch |
3 |
Preferred Brand |
$46.00 | $138.00 | P Q:8 /28Days |
ESTRADIOL 0.075 MG PATCH(1/WKClimara] |
3 |
Preferred Brand |
$46.00 | $138.00 | P Q:4 /28Days |
Estradiol 0.1 mg patch |
3 |
Preferred Brand |
$46.00 | $138.00 | P Q:8 /28Days |
ESTRADIOL 0.1 MG PATCH (1/WK) [Climara] |
3 |
Preferred Brand |
$46.00 | $138.00 | P Q:4 /28Days |
ESTRADIOL 0.5 MG TABLET |
2* |
Generic |
$1.00 | $3.00 | None |
ESTRADIOL 1 MG TABLET |
2* |
Generic |
$1.00 | $3.00 | None |
ESTRADIOL 10 MCG VAGINAL INSRT |
4 |
Non-Preferred Drug |
40% | 40% | None |
ESTRADIOL 2MG TABLET |
2* |
Generic |
$1.00 | $3.00 | 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] |
4 |
Non-Preferred Drug |
40% | 40% | None |
ESTRADIOL VALERATE 200 MG/5 ML VIAL [Delestrogen] |
4 |
Non-Preferred Drug |
40% | 40% | None |
ETHAMBUTOL HCL 400 MG TABLET |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
Ethambutol Hydrochloride 100mg/1 |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TABLET 21 |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
ETHOSUXIMIDE 250 MG CAPSULE [Zarontin] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
ETHOSUXIMIDE 250 MG/5 ML SOLUTION [Zarontin] |
4 |
Non-Preferred Drug |
40% | 40% | None |
ETHYNODIOL-ETH ESTRA 1MG-35MCG [ZOVIA] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
ETHYNODIOL-ETH ESTRA 1MG-50MCG [ZOVIA] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
ETODOLAC 200 MG CAPSULE [Lodine] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETODOLAC 300 MG CAPSULE [Lodine] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
ETODOLAC 400 MG TABLET [Lodine] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
ETODOLAC 500 MG TABLET [Lodine] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |
ETRAVIRINE 100 MG TABLET [INTELENCE] |
5 |
Specialty Tier |
25% | N/A | Q:120 /30Days |
ETRAVIRINE 200 MG TABLET [INTELENCE] |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
EUTHYROX 100 MCG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
EUTHYROX 112 MCG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
EUTHYROX 125 MCG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
EUTHYROX 137 MCG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
EUTHYROX 150 MCG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
EUTHYROX 175 MCG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EUTHYROX 200 MCG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
EUTHYROX 25 MCG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
EUTHYROX 50 MCG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
EUTHYROX 75 MCG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
EUTHYROX 88 MCG TABLET |
4 |
Non-Preferred Drug |
40% | 40% | None |
EVEROLIMUS 0.25 MG TABLET [Zortress] |
4 |
Non-Preferred Drug |
40% | 40% | 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 |
EVEROLIMUS 2 MG TABLET FOR SUSP [Afinitor DISPERZ] |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EVEROLIMUS 2.5 MG TABLET [Afinitor] |
5 |
Specialty Tier |
25% | N/A | P |
EVEROLIMUS 3 MG TABLET FOR SUSP [Afinitor DISPERZ] |
5 |
Specialty Tier |
25% | N/A | P |
EVEROLIMUS 5 MG TABLET [Afinitor] |
5 |
Specialty Tier |
25% | N/A | P |
EVEROLIMUS 5 MG TABLET FOR SUSP [Afinitor DISPERZ] |
5 |
Specialty Tier |
25% | N/A | P |
EVEROLIMUS 7.5 MG TABLET [Afinitor] |
5 |
Specialty Tier |
25% | N/A | P |
EVOTAZ 300 MG-150 MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
EXEMESTANE 25 MG TABLET [Aromasin] |
4 |
Non-Preferred Drug |
40% | 40% | Q:60 /30Days |
EXKIVITY 40 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
EZETIMIBE 10 MG TABLET [Zetia] |
3 |
Preferred Brand |
$46.00 | $138.00 | None |