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2017 Medicare Part D Plan Formulary Information
EnvisionRxPlus (PDP) (S7694-029-0) Benefit Details
The EnvisionRxPlus (PDP) (S7694-029-0) Formulary Drugs Starting with the Letter E in CMS PDP Region 29 which includes: NV Plan Monthly Premium: $58.60 Deductible: $400 Qualifies for LIS: No
Drugs Starting with Letter E Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter E Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
E.E.S. 400 FILMTAB	4	Non-Preferred Drug	34%	34%	None
ECONAZOLE NITRATE 1% CREAM 85GM TUBE	4	Non-Preferred Drug	34%	34%	None
EDURANT 27.5mg/1	5	Specialty Tier	25%	N/A	Q:30 /30Days
EFFIENT 10 MG TABLET	4	Non-Preferred Drug	34%	34%	Q:36 /30Days
EFFIENT 5 MG TABLET	4	Non-Preferred Drug	34%	34%	Q:43 /30Days
ELIDEL 1% CREAM	4	Non-Preferred Drug	34%	34%	S
ELIMITE 5 % CREAM	4	Non-Preferred Drug	34%	34%	None
ELIQUIS 2.5 MG TABLET	4	Non-Preferred Drug	34%	34%	None
ELIQUIS 5 MG TABLET	4	Non-Preferred Drug	34%	34%	None
Elitek 3 KIT per CARTON / 1 KIT in 1 KIT	5	Specialty Tier	25%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ELITEK 7.5 MG VIAL	4	Non-Preferred Drug	34%	34%	P
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE	4	Non-Preferred Drug	34%	34%	None
EMCYT 140MG CAPSULE	4	Non-Preferred Drug	34%	34%	None
EMEND 125 MG POWDER PACKET	4	Non-Preferred Drug	34%	34%	P
EMEND 150 MG VIAL	4	Non-Preferred Drug	34%	34%	P
Emoquette 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	4	Non-Preferred Drug	34%	34%	None
EMPLICITI 300 MG VIAL	5	Specialty Tier	25%	N/A	P
EMPLICITI 400 MG VIAL	5	Specialty Tier	25%	N/A	P
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H	5	Specialty Tier	25%	N/A	S Q:30 /30Days
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H	5	Specialty Tier	25%	N/A	S Q:30 /30Days
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H	5	Specialty Tier	25%	N/A	S 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 Drug	34%	34%	Q:680 /28Days
EMTRIVA 200MG CAPSULE	4	Non-Preferred Drug	34%	34%	Q:30 /30Days
EMVERM 100 MG TABLET CHEW	4	Non-Preferred Drug	34%	34%	None
ENALAPRIL MALEATE 10MG TABLET (100 CT)	1	Preferred Generic	10%	10%	None
ENALAPRIL MALEATE 2.5 MG TAB	1	Preferred Generic	10%	10%	None
Enalapril Maleate 20mg/1 100 TABLET BOTTLE, PLASTIC	1	Preferred Generic	10%	10%	None
ENALAPRIL MALEATE 5 MG TABLET	1	Preferred Generic	10%	10%	None
Enalapril Maleate and Hydrochlorothiazide 10; 25mg/1; mg/1 100 TABLET BOTTLE, PLASTIC	1	Preferred Generic	10%	10%	None
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET	1	Preferred Generic	10%	10%	None
ENBREL 25 MG/0.5 ML SYRINGE	5	Specialty Tier	25%	N/A	P
ENBREL 25MG KIT	5	Specialty Tier	25%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENBREL 50 MG/ML SURECLICK SYR	5	Specialty Tier	25%	N/A	P
ENBREL 50mg/mL	5	Specialty Tier	25%	N/A	P
ENDOCET 10MG-325MG TABLET	4	Non-Preferred Drug	34%	34%	Q:370 /30Days
ENDOCET 5/325 TABLET	2	Generic	12%	12%	Q:370 /30Days
ENDOCET 7.5-325MG TABLET	4	Non-Preferred Drug	34%	34%	Q:370 /30Days
ENGERIX B INJECTION	4	Non-Preferred Drug	34%	34%	P
ENGERIX-B 10MCG 10 X 0.5ML VIALSD	4	Non-Preferred Drug	34%	34%	P
ENGERIX-B 20 MCG/ML SYRN	4	Non-Preferred Drug	34%	34%	P
ENOXAPARIN 100 MG/ML SYRINGE	5	Specialty Tier	25%	N/A	Q:60 /30Days
ENOXAPARIN 120 MG/0.8 ML SYRINGE	5	Specialty Tier	25%	N/A	Q:48 /30Days
ENOXAPARIN 150 MG/ML SYRINGE	5	Specialty Tier	25%	N/A	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENOXAPARIN 30 MG/0.3 ML SYRINGE	4	Non-Preferred Drug	34%	34%	Q:18 /30Days
ENOXAPARIN 300 MG/3 ML vial	4	Non-Preferred Drug	34%	34%	Q:180 /30Days
ENOXAPARIN 40 MG/0.4 ML SYRINGE	4	Non-Preferred Drug	34%	34%	Q:24 /30Days
ENOXAPARIN 60 MG/0.6 ML SYRINGE	4	Non-Preferred Drug	34%	34%	Q:36 /30Days
ENOXAPARIN 80 MG/0.8 ML SYRINGE	4	Non-Preferred Drug	34%	34%	Q:48 /30Days
ENTACAPONE 200 MG TABLET [Comtan Entacapone]	4	Non-Preferred Drug	34%	34%	None
ENTECAVIR 0.5 MG TABLET [Baraclude]	5	Specialty Tier	25%	N/A	Q:30 /30Days
ENTECAVIR 1 MG TABLET [Baraclude]	5	Specialty Tier	25%	N/A	Q:30 /30Days
ENTRESTO 24 MG-26 MG TABLET	3	Preferred Brand	15%	15%	P
ENTRESTO 49 MG-51 MG TABLET	3	Preferred Brand	15%	15%	P
ENTRESTO 97 MG-103 MG TABLET	3	Preferred Brand	15%	15%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENULOSE 10 GM/15 ML SOLUTION	1	Preferred Generic	10%	10%	None
ENVARSUS XR 0.75 MG TABLET	4	Non-Preferred Drug	34%	34%	P
ENVARSUS XR 1 MG TABLET	4	Non-Preferred Drug	34%	34%	P
ENVARSUS XR 4 MG TABLET	4	Non-Preferred Drug	34%	34%	P
EPCLUSA 400 MG-100 MG TABLET	5	Specialty Tier	25%	N/A	P
EPINEPHRINE 0.15 MG AUTO-INJCT	3	Preferred Brand	15%	15%	None
EPINEPHRINE 0.3 MG AUTO-INJECT	3	Preferred Brand	15%	15%	None
EPIPEN 0.3MG AUTO-INJECTOR	3	Preferred Brand	15%	15%	None
Epirubicin 200 mg/100 ml vial	4	Non-Preferred Drug	34%	34%	P
EPITOL 200MG TABLET	4	Non-Preferred Drug	34%	34%	None
EPIVIR HBV 25MG/5ML TUBEX	4	Non-Preferred Drug	34%	34%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Eplerenone 25mg/1 90 TABLET BOTTLE	4	Non-Preferred Drug	34%	34%	None
Eplerenone 50mg/1 90 TABLET BOTTLE	4	Non-Preferred Drug	34%	34%	None
EPZICOM 600MG/300MG TABLETS	5	Specialty Tier	25%	N/A	Q:30 /30Days
Ergotamine-caffeine 1-100mg tb	4	Non-Preferred Drug	34%	34%	Q:40 /28Days
ERIVEDGE 150 MG CAPSULE	5	Specialty Tier	25%	N/A	P Q:28 /28Days
Errin 0.35 mg tablet	4	Non-Preferred Drug	34%	34%	None
ERY 2% PADS 2% 60 PADS JAR	2	Generic	12%	12%	None
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE	4	Non-Preferred Drug	34%	34%	None
ERY-TAB TAB 250MG EC	4	Non-Preferred Drug	34%	34%	None
ERY-TAB TAB 333MG EC	4	Non-Preferred Drug	34%	34%	None
ERYTHROCIN 500MG ADDVNT VL	4	Non-Preferred Drug	34%	34%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ERYTHROCIN TAB 250MG	4	Non-Preferred Drug	34%	34%	None
Erythromycin 2% solution	4	Non-Preferred Drug	34%	34%	None
Erythromycin 20mg/g 1 TUBE per CARTON / 60 g in 1 TUBE	4	Non-Preferred Drug	34%	34%	None
ERYTHROMYCIN 500 MG FILMTAB	4	Non-Preferred Drug	34%	34%	None
ERYTHROMYCIN ES 400 MG TAB	4	Non-Preferred Drug	34%	34%	None
ERYTHROMYCIN OPHTHALMIC OINTMENT 0.5% 1 G BOX OF 50 TUBE	4	Non-Preferred Drug	34%	34%	None
ERYTHROMYCIN TAB 250MG BS	4	Non-Preferred Drug	34%	34%	None
ERYTHROMYCIN-BENZOYL PEROXIDE 3-5% GEL	4	Non-Preferred Drug	34%	34%	None
ESBRIET 267 MG CAPSULE	5	Specialty Tier	25%	N/A	P
ESBRIET 267 MG TABLET	5	Specialty Tier	25%	N/A	P
ESBRIET 801 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
ESCITALOPRAM 10 MG TABLET [Lexapro]	2	Generic	12%	12%	Q:45 /30Days
ESCITALOPRAM 20 MG TABLET [Lexapro]	2	Generic	12%	12%	Q:60 /30Days
ESCITALOPRAM 5 MG TABLET [Lexapro]	2	Generic	12%	12%	Q:30 /30Days
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro]	4	Non-Preferred Drug	34%	34%	Q:600 /30Days
ESOMEPRAZOLE SODIUM 40 MG VIAL [Nexium]	4	Non-Preferred Drug	34%	34%	None
ESTRACE VAG CREAM 0.1MG/GM	3	Preferred Brand	15%	15%	None
ESTRADIOL 0.5MG TABLET	2	Generic	12%	12%	P
ESTRADIOL 2MG TABLET	2	Generic	12%	12%	P
ESTRADIOL TABLET 1MG (500 CT)	2	Generic	12%	12%	P
ESTRADIOL TDS 0.025 MG/DAY	4	Non-Preferred Drug	34%	34%	P
ESTRADIOL TDS 0.0375 MG/DAY	4	Non-Preferred Drug	34%	34%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ESTRADIOL TDS 0.05 MG/DAY	4	Non-Preferred Drug	34%	34%	P
ESTRADIOL TDS 0.06 MG/DAY	4	Non-Preferred Drug	34%	34%	P
ESTRADIOL TDS 0.075 MG/DAY	4	Non-Preferred Drug	34%	34%	P
ESTRADIOL TDS 0.1 MG/DAY	4	Non-Preferred Drug	34%	34%	P
ETHAMBUTOL HCL 400 MG TABLET	4	Non-Preferred Drug	34%	34%	None
Ethambutol Hydrochloride 100mg/1	4	Non-Preferred Drug	34%	34%	None
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6	4	Non-Preferred Drug	34%	34%	None
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21	4	Non-Preferred Drug	34%	34%	None
ETHOSUXIMIDE 250 MG CAPSULE	4	Non-Preferred Drug	34%	34%	None
ETHOSUXIMIDE 250MG/5ML SYRP	4	Non-Preferred Drug	34%	34%	None
Etoposide 500 mg/25 ml vial	4	Non-Preferred Drug	34%	34%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EVOTAZ 300 MG-150 MG TABLET	5	Specialty Tier	25%	N/A	Q:30 /30Days
EXELON 13.3 MG/24HR PATCH	3	Preferred Brand	15%	15%	None
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS	3	Preferred Brand	15%	15%	None
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS	3	Preferred Brand	15%	15%	None
Exemestane 25mg/1 30 FILM COATED TABLETS in BOTTLE	4	Non-Preferred Drug	34%	34%	Q:60 /30Days
EXJADE 125MG TABLET	5	Specialty Tier	25%	N/A	P
EXJADE 250MG TABLET	5	Specialty Tier	25%	N/A	P
EXJADE 500MG TABLET	5	Specialty Tier	25%	N/A	P
Ezetimibe 10 mg tablet [Zetia]	4	Non-Preferred Drug	34%	34%	Q:30 /30Days

Chart Legend:

Below are a few notes to help you understand the above 2017 Medicare Part D EnvisionRxPlus (PDP) Plan Formulary.

Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).
Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.
Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $400 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.
Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
- Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
- No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.
Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
- Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
- Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
- Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $3700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2017 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
- Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
- None - This drug does not fall under any drug utilization management controls.
- P - Prior Authorization -This drug is subject to prior authorization.
- S - Step Therapy -This drug is subject to step therapy.
- Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.

(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2017 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.