2024 Medicare Part D Plan Formulary Information |
American Health Advantage of Louisiana (HMO I-SNP) (H8492-001-0)
Benefits & Contact Info
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 American Health Advantage of Louisiana (HMO I-SNP) (H8492-001-0) Formulary Drugs Starting with the Letter E in St. Bernard Parish, LA: CMS MA Region 16 which includes: LA
|
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 |
EC-NAPROXEN DR 500 MG TABLET [EC-Naprosyn] |
1 |
Tier 1 |
25% | 25% | None |
ECONAZOLE NITRATE 1% CREAM (G) [Spectazole] |
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 |
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 |
ELIGARD 22.5 MG SYRINGE |
1 |
Tier 1 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
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 |
EMGALITY 120 MG/ML PEN INJCTR |
1 |
Tier 1 |
25% | 25% | P |
EMGALITY 120 MG/ML SYRINGE |
1 |
Tier 1 |
25% | 25% | P |
Empagliflozin 5 MG / Metformin hydrochloride 500 MG Oral Tablet [Synjardy] |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
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 |
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 |
EMVERM 100 MG TABLET CHEW |
1 |
Tier 1 |
25% | 25% | None |
ENALAPRIL MALEATE 10 MG TABLET [Vasotec] |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
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 |
ENBREL 25 MG/0.5 ML VIAL |
1 |
Tier 1 |
25% | 25% | P |
ENBREL 50 MG/ML MINI CARTRIDGE |
1 |
Tier 1 |
25% | 25% | P |
ENBREL 50 MG/ML SURECLICK PEN INJECTOR |
1 |
Tier 1 |
25% | 25% | P |
ENBREL 50 MG/ML SYRINGE |
1 |
Tier 1 |
25% | 25% | P |
ENDARI 5 GRAM POWDER PACKET |
1 |
Tier 1 |
25% | 25% | P Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
ENILLORING VAGINAL RING [NuvaRing] |
1 |
Tier 1 |
25% | 25% | None |
ENOXAPARIN 100 MG/ML SYRINGE [Lovenox] |
1 |
Tier 1 |
25% | 25% | None |
ENOXAPARIN 120 MG/0.8 ML SYRINGE [Lovenox] |
1 |
Tier 1 |
25% | 25% | None |
ENOXAPARIN 150 MG/ML SYRINGE [Lovenox] |
1 |
Tier 1 |
25% | 25% | None |
ENOXAPARIN 30 MG/0.3 ML SYRINGE [Lovenox] |
1 |
Tier 1 |
25% | 25% | None |
ENOXAPARIN 40 MG/0.4 ML SYRINGE [Lovenox] |
1 |
Tier 1 |
25% | 25% | None |
ENOXAPARIN 60 MG/0.6 ML SYRINGE [Lovenox] |
1 |
Tier 1 |
25% | 25% | None |
ENOXAPARIN 80 MG/0.8 ML SYRINGE [Lovenox] |
1 |
Tier 1 |
25% | 25% | None |
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 |
ENTACAPONE 200 MG TABLET [Comtan] |
1 |
Tier 1 |
25% | 25% | None |
ENTECAVIR 0.5 MG TABLET [Baraclude] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ENTECAVIR 1 MG TABLET [Baraclude] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
ENTRESTO 24 MG-26 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ENTRESTO 49 MG-51 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ENTRESTO 97 MG-103 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ENULOSE 10 GM/15 ML SOLUTION |
1 |
Tier 1 |
25% | 25% | None |
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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPIDIOLEX 100 MG/ML SOLUTION |
1 |
Tier 1 |
25% | 25% | P |
EPINASTINE HCL 0.05% EYE DROPS [Elestat] |
1 |
Tier 1 |
25% | 25% | None |
EPINEPHRINE 0.15 MG AUTO-INJCT [Twinject] |
1 |
Tier 1 |
25% | 25% | None |
EPINEPHRINE 0.15 MG AUTO-INJECT |
1 |
Tier 1 |
25% | 25% | None |
EPINEPHRINE 0.3 MG AUTO-INJECT |
1 |
Tier 1 |
25% | 25% | None |
EPINEPHRINE 0.3 MG AUTO-INJECT [Twinject] |
1 |
Tier 1 |
25% | 25% | None |
EPITOL 200MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
EPLERENONE 25 MG TABLET [Inspra] |
1 |
Tier 1 |
25% | 25% | None |
EPLERENONE 50 MG TABLET [Inspra] |
1 |
Tier 1 |
25% | 25% | None |
EPRONTIA 25 MG/ML SOLUTION |
1 |
Tier 1 |
25% | 25% | None |
ERAXIS 100mg/30mL 30 mL in 1 VIAL, SINGLE-USE |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERAXIS(WATER DIL) 50 MG VIAL |
1 |
Tier 1 |
25% | 25% | None |
Ergotamine-caffeine 1-100mg tablet |
1 |
Tier 1 |
25% | 25% | Q:40 /28Days |
ERIVEDGE 150 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P |
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:90 /30Days |
ERRIN 0.35 MG TABLET [Sharobel 28-Day] |
1 |
Tier 1 |
25% | 25% | None |
ERTAPENEM 1 GRAM VIAL [Invanz] |
1 |
Tier 1 |
25% | 25% | None |
ERY 2% PADS 2% 60 PADS JAR |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROCIN LACT 500 MG VIAL |
1 |
Tier 1 |
25% | 25% | None |
ERYTHROMYCIN 0.5% EYE OINTMENT [Romycin] |
1 |
Tier 1 |
25% | 25% | None |
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 |
ERYTHROMYCIN DR 333 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 500 MG TABLET DR [Ery-Tab] |
1 |
Tier 1 |
25% | 25% | None |
ERYTHROMYCIN-BENZOYL GEL [Benzamycin] |
1 |
Tier 1 |
25% | 25% | None |
ESCITALOPRAM 10 MG TABLET [Lexapro] |
1 |
Tier 1 |
25% | 25% | None |
ESCITALOPRAM 20 MG TABLET [Lexapro] |
1 |
Tier 1 |
25% | 25% | None |
ESCITALOPRAM 5 MG TABLET [Lexapro] |
1 |
Tier 1 |
25% | 25% | None |
ESCITALOPRAM OXALATE 5 MG/5 ML SOLUTION [Lexapro] |
1 |
Tier 1 |
25% | 25% | None |
ESOMEPRAZOLE DR 10 MG SUSPDR PACKET [Nexium] |
1 |
Tier 1 |
25% | 25% | None |
ESOMEPRAZOLE DR 20 MG SUSPDR PACKET [Nexium] |
1 |
Tier 1 |
25% | 25% | None |
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% | None |
ESOMEPRAZOLE MAG DR 40 MG CAPSULE DR [Nexium] |
1 |
Tier 1 |
25% | 25% | 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] |
1 |
Tier 1 |
25% | 25% | None |
ESTRADIOL 0.01% CREAM/APPL [Estrace] |
1 |
Tier 1 |
25% | 25% | None |
Estradiol 0.025 mg patch |
1 |
Tier 1 |
25% | 25% | None |
ESTRADIOL 0.025 MG PATCH(1/WK) [FemPatch] |
1 |
Tier 1 |
25% | 25% | None |
ESTRADIOL 0.0375MG PATCH(1/WKClimara] |
1 |
Tier 1 |
25% | 25% | None |
ESTRADIOL 0.0375MG PATCH(2/WK) TDSW [Vivelle-Dot] |
1 |
Tier 1 |
25% | 25% | None |
ESTRADIOL 0.05 MG PATCH (1/WK) [Climara] |
1 |
Tier 1 |
25% | 25% | None |
ESTRADIOL 0.05 MG PATCH (2/WK) PATCH TDSW [Vivelle-Dot] |
1 |
Tier 1 |
25% | 25% | None |
ESTRADIOL 0.06 MG PATCH (1/WK) [Climara] |
1 |
Tier 1 |
25% | 25% | None |
ESTRADIOL 0.06% 1.25G GEL MD PUMP [EstroGel] |
1 |
Tier 1 |
25% | 25% | None |
Estradiol 0.075 mg patch |
1 |
Tier 1 |
25% | 25% | 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] |
1 |
Tier 1 |
25% | 25% | None |
Estradiol 0.1 mg patch |
1 |
Tier 1 |
25% | 25% | None |
ESTRADIOL 0.1 MG PATCH (1/WK) [Climara] |
1 |
Tier 1 |
25% | 25% | None |
ESTRADIOL 0.5 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ESTRADIOL 1 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
ESTRADIOL 10 MCG VAGINAL INSRT |
1 |
Tier 1 |
25% | 25% | None |
ESTRADIOL 2MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
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 |
ETHAMBUTOL HCL 400 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 |
Ethambutol Hydrochloride 100mg/1 |
1 |
Tier 1 |
25% | 25% | None |
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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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% | None |
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 |
EUTHYROX 175 MCG TABLET |
1 |
Tier 1 |
25% | 25% | None |
EUTHYROX 200 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 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 |
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:30 /30Days |
EVEROLIMUS 2.5 MG TABLET [Afinitor] |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EVEROLIMUS 3 MG TABLET FOR SUSP [Afinitor DISPERZ] |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
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:60 /30Days |
EVEROLIMUS 7.5 MG TABLET [Afinitor] |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
EVOTAZ 300 MG-150 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
EVRYSDI 60 MG/80 ML(0.75MG/ML) SOLUTION RECON |
1 |
Tier 1 |
25% | 25% | P |
EXEMESTANE 25 MG TABLET [Aromasin] |
1 |
Tier 1 |
25% | 25% | None |
EZETIMIBE 10 MG TABLET [Zetia] |
1 |
Tier 1 |
25% | 25% | None |
EZETIMIBE-SIMVASTATIN 10-10 MG TABLET [Vytorin] |
1 |
Tier 1 |
25% | 25% | None |
EZETIMIBE-SIMVASTATIN 10-20 MG TABLET [Vytorin] |
1 |
Tier 1 |
25% | 25% | None |
EZETIMIBE-SIMVASTATIN 10-40 MG TABLET [Vytorin] |
1 |
Tier 1 |
25% | 25% | 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] |
1 |
Tier 1 |
25% | 25% | None |