2018 Medicare Part D Plan Formulary Information |
Select (HMO-POS SNP) (H1587-003-0)
Benefit Details
|
The Select (HMO-POS SNP) (H1587-003-0) Formulary Drugs Starting with the Letter E in Polk County, AR: CMS MA Region 15 which includes: AR Plan Monthly Premium: $128.00 Deductible: $0 |
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 |
Generic |
$8.00 | N/A | None |
EDURANT 27.5mg/1 |
5 |
Specialty Tier |
33% | N/A | None |
EFAVIRENZ 200 MG CAPSULE [Sustiva] |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
EFAVIRENZ 50 MG CAPSULE [Sustiva] |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
EFAVIRENZ 600 MG TABLET [Sustiva] |
5 |
Specialty Tier |
33% | N/A | None |
ELAPRASE 6mg/3mL 1 VIAL, GLASS in 1 BOX / 3 mL in 1 VIAL, GLASS |
5 |
Specialty Tier |
33% | N/A | P |
ELESTRIN 0.06 % Topical Gel |
3 |
Preferred Brand |
$47.00 | N/A | P |
ELETRIPTAN HBR 20 MG TABLET [Relpax] |
2 |
Generic |
$8.00 | N/A | Q:9 /30Days |
ELETRIPTAN HBR 40 MG TABLET [Relpax] |
2 |
Generic |
$8.00 | N/A | Q:9 /30Days |
ELIGARD 22.5 MG SYRINGE |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIGARD 30 MG SYRINGE KIT |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
ELIGARD 45 MG SYRINGE KIT |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
ELIGARD 7.5 MG SYRINGE KIT |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
ELIQUIS 2.5 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
ELIQUIS 5 MG STARTER PACK |
3 |
Preferred Brand |
$47.00 | N/A | None |
ELIQUIS 5 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
Elitek 3 KIT per CARTON / 1 KIT in 1 KIT |
5 |
Specialty Tier |
33% | N/A | P |
ELITEK 7.5 MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
EMCYT 140MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
EMEND 125 MG POWDER PACKET |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMEND 150 MG VIAL |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
Emoquette 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
1 |
Preferred Generic |
$2.00 | N/A | None |
Empagliflozin 5 MG / Metformin hydrochloride 500 MG Oral Tablet [Synjardy] |
3 |
Preferred Brand |
$47.00 | N/A | None |
EMPLICITI 300 MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
EMPLICITI 400 MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
5 |
Specialty Tier |
33% | N/A | P |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
5 |
Specialty Tier |
33% | N/A | P |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
5 |
Specialty Tier |
33% | N/A | P |
EMTRIVA 10MG/ML SOLUTION |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
EMTRIVA 200MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
EMVERM 100 MG TABLET CHEW |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENALAPRIL MALEATE 10 MG TAB |
1 |
Preferred Generic |
$2.00 | N/A | None |
ENALAPRIL MALEATE 2.5 MG TAB |
1 |
Preferred Generic |
$2.00 | N/A | None |
ENALAPRIL MALEATE 20 MG TAB |
1 |
Preferred Generic |
$2.00 | N/A | None |
ENALAPRIL MALEATE 5 MG TABLET |
1 |
Preferred Generic |
$2.00 | N/A | None |
Enalapril Maleate and Hydrochlorothiazide 10; 25mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$2.00 | N/A | None |
ENALAPRIL-HCTZ 5-12.5 MG TAB |
1 |
Preferred Generic |
$2.00 | N/A | None |
ENBREL 25 MG/0.5 ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | P |
ENBREL 25MG KIT |
5 |
Specialty Tier |
33% | N/A | P |
ENBREL 50 MG/ML SURECLICK SYR |
5 |
Specialty Tier |
33% | N/A | P |
ENBREL 50mg/mL |
5 |
Specialty Tier |
33% | N/A | P |
ENDARI 5 GRAM POWDER PACKET |
5 |
Specialty Tier |
33% | N/A | P Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENDOCET 10MG-325MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
ENDOCET 5/325 TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
ENDOCET 7.5-325MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
ENGERIX B INJECTION |
3 |
Preferred Brand |
$47.00 | N/A | P |
ENGERIX-B 20 MCG/ML SYRN |
3 |
Preferred Brand |
$47.00 | N/A | P |
ENOXAPARIN 100 MG/ML SYRINGE |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
ENOXAPARIN 120 MG/0.8 ML SYRINGE |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
ENOXAPARIN 150 MG/ML SYRINGE |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
ENOXAPARIN 30 MG/0.3 ML SYR |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
ENOXAPARIN 300 MG/3 ML VIAL |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
ENOXAPARIN 40 MG/0.4 ML SYR |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENOXAPARIN 60 MG/0.6 ML SYRINGE |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
ENOXAPARIN 80 MG/0.8 ML SYRINGE |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
ENSKYCE 28 TABLET |
2 |
Generic |
$8.00 | N/A | None |
ENTACAPONE 200 MG TABLET [Comtan Entacapone] |
2 |
Generic |
$8.00 | N/A | None |
ENTECAVIR 0.5 MG TABLET [Baraclude] |
5 |
Specialty Tier |
33% | N/A | P |
ENTECAVIR 1 MG TABLET [Baraclude] |
5 |
Specialty Tier |
33% | N/A | P |
ENTRESTO 24 MG-26 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | P |
ENTRESTO 49 MG-51 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | P |
ENTRESTO 97 MG-103 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | P |
ENULOSE 10 GM/15 ML SOLUTION |
1 |
Preferred Generic |
$2.00 | N/A | None |
ENVARSUS XR 0.75 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENVARSUS XR 1 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
ENVARSUS XR 4 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
EPCLUSA 400 MG-100 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
EPINASTINE HCL 0.05% EYE DROPS |
2 |
Generic |
$8.00 | N/A | None |
EPINEPHRINE 0.15 MG AUTO-INJCT |
1 |
Preferred Generic |
$2.00 | N/A | Q:2 /30Days |
EPINEPHRINE 0.3 MG AUTO-INJECT |
3 |
Preferred Brand |
$47.00 | N/A | Q:2 /30Days |
Epirubicin HCl 200 MG per 100 ML Injection |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
EPITOL 200MG TABLET |
2 |
Generic |
$8.00 | N/A | None |
EPIVIR HBV 25MG/5ML TUBEX |
3 |
Preferred Brand |
$47.00 | N/A | None |
Eplerenone 25mg/1 90 TABLET BOTTLE |
2 |
Generic |
$8.00 | N/A | None |
Eplerenone 50mg/1 90 TABLET BOTTLE |
2 |
Generic |
$8.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPOGEN 10000U/ML VIAL MDV |
3 |
Preferred Brand |
$47.00 | N/A | P |
EPOGEN 2000[iU]/mL 10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL |
3 |
Preferred Brand |
$47.00 | N/A | P |
EPOGEN 3000U/ML VIAL SDV |
3 |
Preferred Brand |
$47.00 | N/A | P |
EPOGEN 4000U/ML VIAL SDV |
3 |
Preferred Brand |
$47.00 | N/A | P |
EPOGEN INJECTION 20000U 10 X 1ML CRTN |
3 |
Preferred Brand |
$47.00 | N/A | P |
EPROSARTAN MESYLATE 600 MG TABLET |
2 |
Generic |
$8.00 | N/A | None |
ERAXIS 100mg/30mL 30 mL in 1 VIAL, SINGLE-USE |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
ERAXIS(WATER DIL) 50 MG VIAL |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
ERBITUX 100MG/50ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
ERGOLOID MESYLATES TABLETS 1MG 100 BOT |
2 |
Generic |
$8.00 | N/A | P |
Ergotamine-caffeine 1-100mg tb |
3 |
Preferred Brand |
$47.00 | N/A | Q:40 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERIVEDGE 150 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
ERLEADA 60 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
Errin 0.35 mg tablet |
1 |
Preferred Generic |
$2.00 | N/A | None |
ERWINAZE 10,000 UNITS VIAL |
5 |
Specialty Tier |
33% | N/A | P |
ERY 2% PADS 2% 60 PADS JAR |
1 |
Preferred Generic |
$2.00 | N/A | None |
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE |
3 |
Preferred Brand |
$47.00 | N/A | None |
ERYTHROCIN 500MG ADDVNT VL |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
ERYTHROCIN TAB 250MG |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
ERYTHROMYCIN 0.5% EYE OINTMENT |
1 |
Preferred Generic |
$2.00 | N/A | None |
ERYTHROMYCIN 2% SOLUTION |
1 |
Preferred Generic |
$2.00 | N/A | None |
ERYTHROMYCIN EC 250 MG CAP |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROMYCIN TAB 250MG BS |
2 |
Generic |
$8.00 | N/A | None |
ERYTHROMYCIN-BENZOYL GEL |
2 |
Generic |
$8.00 | N/A | None |
ESBRIET 267 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
ESBRIET 267 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
ESBRIET 801 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
ESCITALOPRAM 10 MG TABLET [Lexapro] |
2 |
Generic |
$8.00 | N/A | None |
ESCITALOPRAM 20 MG TABLET [Lexapro] |
2 |
Generic |
$8.00 | N/A | None |
ESCITALOPRAM 5 MG TABLET [Lexapro] |
2 |
Generic |
$8.00 | N/A | None |
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro] |
2 |
Generic |
$8.00 | N/A | None |
ESOMEPRAZOLE SODIUM 20 MG VIAL [Nexium] |
2 |
Generic |
$8.00 | N/A | P |
ESOMEPRAZOLE SODIUM 40 MG VIAL [Nexium] |
2 |
Generic |
$8.00 | N/A | P |
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 |
Preferred Generic |
$2.00 | N/A | None |
Estazolam 1mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$2.00 | N/A | None |
Estazolam 2mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$2.00 | N/A | None |
ESTRADIOL 0.01% CREAM |
3 |
Preferred Brand |
$47.00 | N/A | None |
Estradiol 0.025 mg patch |
2 |
Generic |
$8.00 | N/A | P |
Estradiol 0.0375 mg patch |
2 |
Generic |
$8.00 | N/A | P |
Estradiol 0.05 mg patch |
2 |
Generic |
$8.00 | N/A | P |
Estradiol 0.075 mg patch |
2 |
Generic |
$8.00 | N/A | P |
Estradiol 0.1 mg patch |
2 |
Generic |
$8.00 | N/A | P |
ESTRADIOL 0.5 MG TABLET |
1 |
Preferred Generic |
$2.00 | N/A | P |
ESTRADIOL 1 MG TABLET |
1 |
Preferred Generic |
$2.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL 10 MCG VAGINAL INSRT |
2 |
Generic |
$8.00 | N/A | None |
ESTRADIOL 2MG TABLET |
1 |
Preferred Generic |
$2.00 | N/A | P |
ESTRADIOL TDS 0.025 MG/DAY |
3 |
Preferred Brand |
$47.00 | N/A | P |
ESTRADIOL TDS 0.0375 MG/DAY |
3 |
Preferred Brand |
$47.00 | N/A | P |
ESTRADIOL TDS 0.05 MG/DAY |
3 |
Preferred Brand |
$47.00 | N/A | P |
ESTRADIOL TDS 0.06 MG/DAY |
3 |
Preferred Brand |
$47.00 | N/A | P |
ESTRADIOL TDS 0.075 MG/DAY |
3 |
Preferred Brand |
$47.00 | N/A | P |
ESTRADIOL TDS 0.1 MG/DAY |
3 |
Preferred Brand |
$47.00 | N/A | P |
ESTROPIPATE 0.625(0.75 MG) TABLET |
1 |
Preferred Generic |
$2.00 | N/A | P |
ESTROPIPATE 1.25(1.5 MG) TABLET |
1 |
Preferred Generic |
$2.00 | N/A | P |
ETHAMBUTOL HCL 400 MG TABLET |
1 |
Preferred Generic |
$2.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ethambutol Hydrochloride 100mg/1 |
1 |
Preferred Generic |
$2.00 | N/A | None |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 |
1 |
Preferred Generic |
$2.00 | N/A | None |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21 |
1 |
Preferred Generic |
$2.00 | N/A | None |
ETHOSUXIMIDE 250 MG CAPSULE |
2 |
Generic |
$8.00 | N/A | None |
ETHOSUXIMIDE 250 MG/5 ML SOLN |
2 |
Generic |
$8.00 | N/A | None |
ETHYNODIOL-ETH ESTRA 1MG-35MCG [ZOVIA] |
1 |
Preferred Generic |
$2.00 | N/A | None |
ethynodiol-eth estra 1mg-50mcg [ZOVIA] |
1 |
Preferred Generic |
$2.00 | N/A | None |
ETODOLAC 200 MG CAPSULE [LODINE] |
1 |
Preferred Generic |
$2.00 | N/A | None |
ETODOLAC 300 MG CAPSULE [LODINE] |
1 |
Preferred Generic |
$2.00 | N/A | None |
ETODOLAC 400 MG TABLET [LODINE] |
1 |
Preferred Generic |
$2.00 | N/A | None |
ETODOLAC 500 MG TABLET [LODINE] |
1 |
Preferred Generic |
$2.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETODOLAC ER 400 MG TABLET [LODINE] |
2 |
Generic |
$8.00 | N/A | None |
ETODOLAC ER 500 MG TABLET [LODINE] |
2 |
Generic |
$8.00 | N/A | None |
ETODOLAC ER 600 MG TABLET [LODINE] |
2 |
Generic |
$8.00 | N/A | None |
ETOPOPHOS 100MG VIAL |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
EVAMIST 1.53 MG/SPRAY |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
EVOTAZ 300 MG-150 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
EXEMESTANE 25 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
EXJADE 125MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
EXJADE 250MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
EXJADE 500MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
Ezetimibe 10 MG Oral Tablet [Zetia] |
3 |
Preferred Brand |
$47.00 | N/A | None |