2014 Medicare Part D Plan Formulary Information |
BlueValue Basic (HMO) (H5422-006-0)
Benefit Details
|
The BlueValue Basic (HMO) (H5422-006-0) Formulary Drugs Starting with the Letter E in MUSCOGEE County, GA: CMS MA Region 8 which includes: GA Plan Monthly Premium: $21.00 Deductible: $145 |
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 85GM TUBE |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
EDURANT 27.5mg/1 |
6* |
Specialty Tier |
33% | N/A | None |
EFFIENT 10 MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days |
EFFIENT 5 MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days |
ELAPRASE 6mg/3mL 1 VIAL, GLASS in 1 BOX / 3 mL in 1 VIAL, GLASS |
6* |
Specialty Tier |
33% | N/A | P |
ELIDEL 1% CREAM |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | P Q:60 /1Days |
ELIQUIS 2.5 MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days |
ELIQUIS 5 MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days |
Elitek 3 KIT per CARTON / 1 KIT in 1 KIT |
6* |
Specialty Tier |
33% | N/A | None |
ELIXOPHYLLIN 80mg/15mL 473 mL in 1 BOTTLE |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELLENCE 2MG/ML VIAL |
5* |
Injectable Drugs |
33% | 33% | P |
ELOXATIN 100MG/20ML VIAL |
6* |
Specialty Tier |
33% | N/A | P |
EMCYT 140MG CAPSULE |
6* |
Specialty Tier |
33% | N/A | None |
EMEND 40MG CAPSULE |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:1 /1Days |
EMEND CAPSULES 125MG 6 BLPK |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:4 /30Days |
EMEND CAPSULES 80MG 2 BLPK |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:8 /30Days |
EMEND TRIFOLD PACK |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:12 /30Days |
Emoquette 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMTRIVA 10MG/ML SOLUTION |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
EMTRIVA 200MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
ENALAPRIL MALEATE 10MG TABLET (100 CT) |
1* |
Preferred Generic |
$5.00 | $10.00 | None |
ENALAPRIL MALEATE 2.5 MG TAB |
1* |
Preferred Generic |
$5.00 | $10.00 | None |
Enalapril Maleate 20mg/1 100 TABLET BOTTLE, PLASTIC |
1* |
Preferred Generic |
$5.00 | $10.00 | None |
ENALAPRIL MALEATE 5 MG TABLET |
1* |
Preferred Generic |
$5.00 | $10.00 | None |
ENALAPRIL MALEATE-HCTZ 10MG-25MG TABLET (100 CT) |
1* |
Preferred Generic |
$5.00 | $10.00 | None |
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET (100 CT) |
1* |
Preferred Generic |
$5.00 | $10.00 | None |
ENBREL 25 MG/0.5 ML SYRINGE |
6* |
Specialty Tier |
33% | N/A | P Q:4 /28Days |
ENBREL 25MG KIT |
6* |
Specialty Tier |
33% | N/A | P Q:8 /28Days |
ENBREL 50mg/mL |
6* |
Specialty Tier |
33% | N/A | P Q:8 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENDOCET 10MG-325MG TABLET |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | Q:360 /30Days |
ENDOCET 5/325 TABLET |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | Q:360 /30Days |
ENDOCET 7.5-325MG TABLET |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | Q:360 /30Days |
ENDODAN TABLETS 325;4.8355MG;MG 100 BOT |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | Q:360 /30Days |
ENGERIX B INJECTION |
3 |
Preferred Brand |
$40.00 | $120.00 | P |
ENGERIX-B 10MCG 10 X 0.5ML VIALSD |
3 |
Preferred Brand |
$40.00 | $120.00 | P |
ENGERIX-B 20 MCG/ML SYRN |
3 |
Preferred Brand |
$40.00 | $120.00 | P |
ENOXAPARIN 100 MG/ML SYRINGE |
5* |
Injectable Drugs |
33% | 33% | None |
ENOXAPARIN 120 MG/0.8 ML SYR |
6* |
Specialty Tier |
33% | N/A | None |
ENOXAPARIN 150 MG/ML SYRINGE |
6* |
Specialty Tier |
33% | N/A | None |
ENOXAPARIN 30 MG/0.3 ML SYR |
5* |
Injectable Drugs |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENOXAPARIN 300 MG/3 ML VIAL |
5* |
Injectable Drugs |
33% | 33% | None |
ENOXAPARIN 40 MG/0.4 ML SYR |
5* |
Injectable Drugs |
33% | 33% | None |
ENOXAPARIN 60 MG/0.6 ML SYR |
5* |
Injectable Drugs |
33% | 33% | None |
ENOXAPARIN 80 MG/0.8 ML SYR |
5* |
Injectable Drugs |
33% | 33% | None |
entacapone 200 mg tablet [Comtan] |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
ENULOSE 10 GM/15 ML SOLUTION |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
Epinastine HCl 0.5mg/mL |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
EPIPEN 0.3MG AUTO-INJECTOR |
5* |
Injectable Drugs |
33% | 33% | Q:2 /1Days |
EPIPEN JR 0.15MG AUTO-INJCT |
5* |
Injectable Drugs |
33% | 33% | Q:2 /1Days |
EPIRUBICIN HCL INJECTION SOLUTION 2MG 1 X 25ML VIAL |
5* |
Injectable Drugs |
33% | 33% | P |
EPITOL 200MG TABLET |
1* |
Preferred Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPIVIR 10 MG/ML ORAL SOLUTION |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None |
EPIVIR HBV 100MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
EPIVIR HBV 25MG/5ML TUBEX |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
Eplerenone 25mg/1 90 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
Eplerenone 50mg/1 90 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
EPOGEN 10000U/ML VIAL MDV |
5* |
Injectable Drugs |
33% | 33% | P |
EPOGEN 2000[iU]/mL 10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL |
5* |
Injectable Drugs |
33% | 33% | P |
EPOGEN 3000U/ML VIAL SDV |
5* |
Injectable Drugs |
33% | 33% | P |
EPOGEN 4000U/ML VIAL SDV |
5* |
Injectable Drugs |
33% | 33% | P |
EPOGEN INJECTION 20000U 10 X 1ML CRTN |
5* |
Injectable Drugs |
33% | 33% | P |
EPROSARTAN MESYLATE 600 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPZICOM 600MG/300MG TABLETS |
6* |
Specialty Tier |
33% | N/A | None |
EQUETRO CAPSULES 200MG 120 BOT |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:240 /30Days |
EQUETRO CAPSULES 300MG 120 BOT |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:180 /30Days |
EQUETRO EXTENDED RELEASE CAPSULES 100MG 120 BOT |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:480 /30Days |
ERBITUX 100MG/50ML VIAL |
6* |
Specialty Tier |
33% | N/A | P |
ERGOMAR 2 MG TABLET SL |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ERIVEDGE 150 MG CAPSULE |
6* |
Specialty Tier |
33% | N/A | P |
ERRIN 0.35MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ERWINAZE 10,000 UNITS VIAL |
6* |
Specialty Tier |
33% | N/A | P |
ERY 2% PADS 2% 60 PADS JAR |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
ERYTHROCIN 500MG ADDVNT VL |
5* |
Injectable Drugs |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROCIN TAB 250MG |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
Erythromycin 2% solution |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
Erythromycin 20mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
ERYTHROMYCIN 500 MG FILMTAB |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
ERYTHROMYCIN ES 400 MG TAB |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
ERYTHROMYCIN OPHTHALMIC OINTMENT 0.5% 1 G BOX OF 50 TUBE |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
ERYTHROMYCIN TAB 250MG BS |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
ERYTHROMYCIN-BENZOYL PEROXIDE 3-5% GEL |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
ESCITALOPRAM 10 MG TABLET [Lexapro] |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | Q:60 /30Days |
ESCITALOPRAM 20 MG TABLET [Lexapro] |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | Q:30 /30Days |
ESCITALOPRAM 5 MG TABLET [Lexapro] |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro] |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | Q:600 /30Days |
ESOMEPRAZOLE SODIUM 20 MG VIAL [Nexium] |
5* |
Injectable Drugs |
33% | 33% | None |
ESOMEPRAZOLE SODIUM 40 MG VIAL [Nexium] |
5* |
Injectable Drugs |
33% | 33% | None |
ESTRADIOL 0.5MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | P |
ESTRADIOL 2MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | P |
ESTRADIOL TABLET 1MG (500 CT) |
3 |
Preferred Brand |
$40.00 | $120.00 | P |
ESTRADIOL TDS 0.025 MG/DAY |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:4 /28Days |
ESTRADIOL TDS 0.0375 MG/DAY |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:4 /28Days |
ESTRADIOL TDS 0.05 MG/DAY |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:4 /28Days |
ESTRADIOL TDS 0.06 MG/DAY |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:4 /28Days |
ESTRADIOL TDS 0.075 MG/DAY |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL TDS 0.1 MG/DAY |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:4 /28Days |
ESTRADIOL VALERATE 20mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
5* |
Injectable Drugs |
33% | 33% | None |
ESTRADIOL VALERATE 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
5* |
Injectable Drugs |
33% | 33% | None |
ETHAMBUTOL HCL 400 MG TABLET |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
Ethambutol Hydrochloride 100mg/1 |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21 |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
Ethosuximide 250mg 100 CAPSULE BOTTLE |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
ETHOSUXIMIDE 250MG/5ML SYRP |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
ETIDRONATE DISODIUM 400MG TABLET (60 CT) |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETODOLAC 200MG CAPSULE |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
Etodolac 300 mg capsule |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
ETODOLAC 400MG TABLET SR 24HR |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
Etodolac 400mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
ETODOLAC 500MG TABLET SR 24HR |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
Etodolac 500mg/1 500 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
ETODOLAC 600MG TABLET SR 24HR |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |
ETOPOPHOS 100MG VIAL |
5* |
Injectable Drugs |
33% | 33% | P |
Evista 60mg/1 100 TABLET BOTTLE |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days |
Exemestane 25mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
EXFORGE 10MG-160MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EXFORGE 10MG-320MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
EXFORGE 5MG-160MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
EXFORGE 5MG-320MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
Exforge HCT 10; 12.5; 160mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
Exforge HCT 10; 25; 160mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
Exforge HCT 10; 25; 320mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
Exforge HCT 5; 12.5; 160mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
Exforge HCT 5; 25; 160mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:30 /30Days |
EXJADE 125MG TABLET |
6* |
Specialty Tier |
33% | N/A | P |
EXJADE 250MG TABLET |
6* |
Specialty Tier |
33% | N/A | P |
EXJADE 500MG TABLET |
6* |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EXTAVIA 15 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
6* |
Specialty Tier |
33% | N/A | P |
EXTENDED PHENYTOIN SODIUM CAPSULES 300 MG |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None |