2018 Medicare Part D Plan Formulary Information |
SCAN Plus (HMO) (H5425-045-0)
Benefit Details
|
The SCAN Plus (HMO) (H5425-045-0) Formulary Drugs Starting with the Letter E in San Francisco County, CA: CMS MA Region 24 which includes: CA Plan Monthly Premium: $35.50 Deductible: $405 |
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 |
4 |
Non-Preferred Drug |
25% | N/A | None |
EDURANT 27.5mg/1 |
5 |
Specialty Tier |
25% | N/A | None |
EFAVIRENZ 200 MG CAPSULE [Sustiva] |
4 |
Non-Preferred Drug |
25% | N/A | None |
EFAVIRENZ 50 MG CAPSULE [Sustiva] |
4 |
Non-Preferred Drug |
25% | N/A | None |
EFAVIRENZ 600 MG TABLET [Sustiva] |
5 |
Specialty Tier |
25% | N/A | None |
ELIDEL 1% CREAM |
4 |
Non-Preferred Drug |
25% | N/A | Q:200 /30Days |
ELIGARD 22.5 MG SYRINGE |
4 |
Non-Preferred Drug |
25% | N/A | P |
ELIGARD 30 MG SYRINGE KIT |
4 |
Non-Preferred Drug |
25% | N/A | P |
ELIGARD 45 MG SYRINGE KIT |
4 |
Non-Preferred Drug |
25% | N/A | P |
ELIGARD 7.5 MG SYRINGE KIT |
4 |
Non-Preferred Drug |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIQUIS 2.5 MG TABLET |
3 |
Preferred Brand |
25% | N/A | None |
ELIQUIS 5 MG STARTER PACK |
3 |
Preferred Brand |
25% | N/A | None |
ELIQUIS 5 MG TABLET |
3 |
Preferred Brand |
25% | N/A | None |
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE |
4 |
Non-Preferred Drug |
25% | N/A | None |
EMCYT 140MG CAPSULE |
3 |
Preferred Brand |
25% | N/A | None |
Emoquette 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2 |
Generic |
25% | N/A | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
4 |
Non-Preferred Drug |
25% | N/A | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
4 |
Non-Preferred Drug |
25% | N/A | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
4 |
Non-Preferred Drug |
25% | N/A | None |
EMTRIVA 10MG/ML SOLUTION |
4 |
Non-Preferred Drug |
25% | N/A | None |
EMTRIVA 200MG CAPSULE |
4 |
Non-Preferred Drug |
25% | 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 |
$0.00 | N/A | None |
ENALAPRIL MALEATE 2.5 MG TAB |
1* |
Preferred Generic |
$0.00 | N/A | None |
ENALAPRIL MALEATE 20 MG TAB |
1* |
Preferred Generic |
$0.00 | N/A | None |
ENALAPRIL MALEATE 5 MG TABLET |
1* |
Preferred Generic |
$0.00 | N/A | None |
Enalapril Maleate and Hydrochlorothiazide 10; 25mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1* |
Preferred Generic |
$0.00 | N/A | None |
ENALAPRIL-HCTZ 5-12.5 MG TAB |
1* |
Preferred Generic |
$0.00 | N/A | 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 |
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 |
3 |
Preferred Brand |
25% | N/A | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENDOCET 5/325 TABLET |
3 |
Preferred Brand |
25% | N/A | Q:360 /30Days |
ENDOCET 7.5-325MG TABLET |
3 |
Preferred Brand |
25% | N/A | Q:240 /30Days |
ENGERIX B INJECTION |
3 |
Preferred Brand |
25% | N/A | P |
ENGERIX-B 20 MCG/ML SYRN |
3 |
Preferred Brand |
25% | N/A | P |
ENOXAPARIN 100 MG/ML SYRINGE |
4 |
Non-Preferred Drug |
25% | N/A | None |
ENOXAPARIN 120 MG/0.8 ML SYRINGE |
4 |
Non-Preferred Drug |
25% | N/A | None |
ENOXAPARIN 150 MG/ML SYRINGE |
4 |
Non-Preferred Drug |
25% | N/A | None |
ENOXAPARIN 30 MG/0.3 ML SYR |
4 |
Non-Preferred Drug |
25% | N/A | None |
ENOXAPARIN 300 MG/3 ML VIAL |
4 |
Non-Preferred Drug |
25% | N/A | None |
ENOXAPARIN 40 MG/0.4 ML SYR |
4 |
Non-Preferred Drug |
25% | N/A | None |
ENOXAPARIN 60 MG/0.6 ML SYRINGE |
4 |
Non-Preferred Drug |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENOXAPARIN 80 MG/0.8 ML SYRINGE |
4 |
Non-Preferred Drug |
25% | N/A | None |
ENSKYCE 28 TABLET |
2 |
Generic |
25% | N/A | None |
ENTACAPONE 200 MG TABLET [Comtan Entacapone] |
4 |
Non-Preferred Drug |
25% | N/A | None |
ENTECAVIR 0.5 MG TABLET [Baraclude] |
5 |
Specialty Tier |
25% | N/A | None |
ENTECAVIR 1 MG TABLET [Baraclude] |
5 |
Specialty Tier |
25% | N/A | None |
ENTRESTO 24 MG-26 MG TABLET |
4 |
Non-Preferred Drug |
25% | N/A | P |
ENTRESTO 49 MG-51 MG TABLET |
4 |
Non-Preferred Drug |
25% | N/A | P |
ENTRESTO 97 MG-103 MG TABLET |
4 |
Non-Preferred Drug |
25% | N/A | P |
ENULOSE 10 GM/15 ML SOLUTION |
2 |
Generic |
25% | N/A | None |
EPCLUSA 400 MG-100 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
EPINEPHRINE 0.15 MG AUTO-INJCT |
3 |
Preferred Brand |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPINEPHRINE 0.3 MG AUTO-INJECT |
3 |
Preferred Brand |
25% | N/A | None |
EPITOL 200MG TABLET |
2 |
Generic |
25% | N/A | None |
EPIVIR HBV 25MG/5ML TUBEX |
4 |
Non-Preferred Drug |
25% | N/A | None |
Eplerenone 25mg/1 90 TABLET BOTTLE |
3 |
Preferred Brand |
25% | N/A | None |
Eplerenone 50mg/1 90 TABLET BOTTLE |
3 |
Preferred Brand |
25% | N/A | None |
ERGOLOID MESYLATES TABLETS 1MG 100 BOT |
3 |
Preferred Brand |
25% | N/A | P |
Ergotamine-caffeine 1-100mg tb |
4 |
Non-Preferred Drug |
25% | N/A | None |
ERIVEDGE 150 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
ERLEADA 60 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
ERWINAZE 10,000 UNITS VIAL |
5 |
Specialty Tier |
25% | N/A | P |
ERYTHROCIN 500MG ADDVNT VL |
4 |
Non-Preferred Drug |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROCIN TAB 250MG |
2 |
Generic |
25% | N/A | None |
ERYTHROMYCIN 0.5% EYE OINTMENT |
2 |
Generic |
25% | N/A | None |
ERYTHROMYCIN 2% GEL |
2 |
Generic |
25% | N/A | None |
ERYTHROMYCIN 2% SOLUTION |
2 |
Generic |
25% | N/A | None |
ERYTHROMYCIN 500 MG FILMTAB |
2 |
Generic |
25% | N/A | None |
ERYTHROMYCIN EC 250 MG CAP |
2 |
Generic |
25% | N/A | None |
ERYTHROMYCIN ES 400 MG TAB |
2 |
Generic |
25% | N/A | None |
ERYTHROMYCIN TAB 250MG BS |
2 |
Generic |
25% | N/A | 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 |
25% | N/A | None |
ESCITALOPRAM 20 MG TABLET [Lexapro] |
2 |
Generic |
25% | N/A | None |
ESCITALOPRAM 5 MG TABLET [Lexapro] |
2 |
Generic |
25% | N/A | None |
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro] |
2 |
Generic |
25% | N/A | None |
ESOMEPRAZOLE MAG DR 20 MG CAP [Nexium] |
3 |
Preferred Brand |
25% | N/A | S |
ESOMEPRAZOLE MAG DR 40 MG CAP [Nexium] |
3 |
Preferred Brand |
25% | N/A | S |
ESTARYLLA 0.25-0.035 MG TABLET [VyLibra] |
2 |
Generic |
25% | N/A | None |
Estazolam 1mg/1 100 TABLET BOTTLE |
2 |
Generic |
25% | N/A | None |
Estazolam 2mg/1 100 TABLET BOTTLE |
2 |
Generic |
25% | N/A | None |
ESTRACE VAG CREAM 0.1MG/GM |
3 |
Preferred Brand |
25% | N/A | None |
Estradiol / Norethindrone Acetate 0.5; 0.1mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, FILM C |
3 |
Preferred Brand |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL 0.01% CREAM |
3 |
Preferred Brand |
25% | N/A | None |
Estradiol 0.025 mg patch |
3 |
Preferred Brand |
25% | N/A | P |
Estradiol 0.0375 mg patch |
3 |
Preferred Brand |
25% | N/A | P |
Estradiol 0.05 mg patch |
3 |
Preferred Brand |
25% | N/A | P |
Estradiol 0.075 mg patch |
3 |
Preferred Brand |
25% | N/A | P |
Estradiol 0.1 mg patch |
3 |
Preferred Brand |
25% | N/A | P |
ESTRADIOL 0.5 MG TABLET |
2 |
Generic |
25% | N/A | P |
ESTRADIOL 1 MG TABLET |
2 |
Generic |
25% | N/A | P |
ESTRADIOL 10 MCG VAGINAL INSRT |
3 |
Preferred Brand |
25% | N/A | None |
ESTRADIOL 2MG TABLET |
2 |
Generic |
25% | N/A | P |
ESTRADIOL TDS 0.025 MG/DAY |
3 |
Preferred Brand |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL TDS 0.0375 MG/DAY |
3 |
Preferred Brand |
25% | N/A | P |
ESTRADIOL TDS 0.05 MG/DAY |
3 |
Preferred Brand |
25% | N/A | P |
ESTRADIOL TDS 0.06 MG/DAY |
3 |
Preferred Brand |
25% | N/A | P |
ESTRADIOL TDS 0.075 MG/DAY |
3 |
Preferred Brand |
25% | N/A | P |
ESTRADIOL TDS 0.1 MG/DAY |
3 |
Preferred Brand |
25% | N/A | P |
ESTRADIOL-NORETH 1.0-0.5MG TABLET |
3 |
Preferred Brand |
25% | N/A | P |
ESTROPIPATE 0.625(0.75 MG) TABLET |
2 |
Generic |
25% | N/A | P |
ESTROPIPATE 1.25(1.5 MG) TABLET |
2 |
Generic |
25% | N/A | P |
ETHAMBUTOL HCL 400 MG TABLET |
2 |
Generic |
25% | N/A | None |
Ethambutol Hydrochloride 100mg/1 |
2 |
Generic |
25% | N/A | None |
Ethinyl Estradiol 0.0025 MG / norethindrone acetate 0.5 MG Oral Tablet [Fyavolv] |
3 |
Preferred Brand |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 |
2 |
Generic |
25% | N/A | None |
ETHOSUXIMIDE 250 MG CAPSULE |
2 |
Generic |
25% | N/A | None |
ETHOSUXIMIDE 250 MG/5 ML SOLN |
2 |
Generic |
25% | N/A | None |
ETHYNODIOL-ETH ESTRA 1MG-35MCG [ZOVIA] |
2 |
Generic |
25% | N/A | None |
ethynodiol-eth estra 1mg-50mcg [ZOVIA] |
2 |
Generic |
25% | N/A | None |
ETIDRONATE DISODIUM 400MG TABLET (60 CT) |
2 |
Generic |
25% | N/A | None |
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT |
2 |
Generic |
25% | N/A | None |
ETODOLAC 200 MG CAPSULE [LODINE] |
2 |
Generic |
25% | N/A | None |
ETODOLAC 300 MG CAPSULE [LODINE] |
2 |
Generic |
25% | N/A | None |
ETODOLAC 400 MG TABLET [LODINE] |
2 |
Generic |
25% | N/A | None |
ETODOLAC 500 MG TABLET [LODINE] |
2 |
Generic |
25% | 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 |
25% | N/A | None |
ETODOLAC ER 500 MG TABLET [LODINE] |
2 |
Generic |
25% | N/A | None |
ETODOLAC ER 600 MG TABLET [LODINE] |
2 |
Generic |
25% | N/A | None |
EURAX 10% LOTION |
3 |
Preferred Brand |
25% | N/A | None |
Eurax Lotion and Cream 100mg/g 60 g in 1 TUBE |
3 |
Preferred Brand |
25% | N/A | None |
EVOTAZ 300 MG-150 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
EXEMESTANE 25 MG TABLET |
3 |
Preferred Brand |
25% | N/A | None |
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 Oral Tablet [Zetia] |
3 |
Preferred Brand |
25% | N/A | None |