2018 Medicare Part D Plan Formulary Information |
IU Health Plans Medicare Choice (HMO-POS) (H7220-004-0)
Benefit Details
|
The IU Health Plans Medicare Choice (HMO-POS) (H7220-004-0) Formulary Drugs Starting with the Letter E in Benton County, IN: CMS MA Region 13 which includes: IN Plan Monthly Premium: $78.00 Deductible: $200 |
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 |
E.E.S. 200 MG/5 ML GRANULES |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
E.E.S. 400 FILMTAB |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
ECONAZOLE NITRATE 1% CREAM 85GM TUBE |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
EDURANT 27.5mg/1 |
5 |
Specialty Tier |
29% | N/A | None |
EFAVIRENZ 200 MG CAPSULE [Sustiva] |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
EFAVIRENZ 50 MG CAPSULE [Sustiva] |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
EFAVIRENZ 600 MG TABLET [Sustiva] |
5 |
Specialty Tier |
29% | N/A | None |
EGRIFTA 2 MG VIAL |
5 |
Specialty Tier |
29% | N/A | P Q:60 /30Days |
ELAPRASE 6mg/3mL 1 VIAL, GLASS in 1 BOX / 3 mL in 1 VIAL, GLASS |
5 |
Specialty Tier |
29% | N/A | P |
ELELYSO 200 UNITS VIAL |
5 |
Specialty Tier |
29% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIDEL 1% CREAM |
4 |
Non-Preferred Brand |
$100.00 | N/A | P |
ELIGARD 22.5 MG SYRINGE |
4 |
Non-Preferred Brand |
$100.00 | N/A | P Q:1 /84Days |
ELIGARD 30 MG SYRINGE KIT |
4 |
Non-Preferred Brand |
$100.00 | N/A | P Q:1 /112Days |
ELIGARD 45 MG SYRINGE KIT |
4 |
Non-Preferred Brand |
$100.00 | N/A | P Q:1 /168Days |
ELIGARD 7.5 MG SYRINGE KIT |
4 |
Non-Preferred Brand |
$100.00 | N/A | P Q:1 /28Days |
ELIQUIS 2.5 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:60 /30Days |
ELIQUIS 5 MG STARTER PACK |
3 |
Preferred Brand |
$45.00 | N/A | Q:148 /365Days |
ELIQUIS 5 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:74 /30Days |
Elitek 3 KIT per CARTON / 1 KIT in 1 KIT |
5 |
Specialty Tier |
29% | N/A | None |
ELITEK 7.5 MG VIAL |
5 |
Specialty Tier |
29% | N/A | None |
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMADINE 0.05% EYE DROPS |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
EMCYT 140MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | N/A | P |
EMEND 125 MG POWDER PACKET |
4 |
Non-Preferred Brand |
$100.00 | N/A | P |
EMEND 150 MG VIAL |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
Emoquette 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2* |
Generic |
$12.00 | N/A | None |
Empagliflozin 5 MG / Metformin hydrochloride 500 MG Oral Tablet [Synjardy] |
3 |
Preferred Brand |
$45.00 | N/A | Q:60 /30Days |
EMPLICITI 300 MG VIAL |
5 |
Specialty Tier |
29% | N/A | P |
EMPLICITI 400 MG VIAL |
5 |
Specialty Tier |
29% | N/A | P |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
5 |
Specialty Tier |
29% | N/A | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
5 |
Specialty Tier |
29% | N/A | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
5 |
Specialty Tier |
29% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMTRIVA 10MG/ML SOLUTION |
3 |
Preferred Brand |
$45.00 | N/A | None |
EMTRIVA 200MG CAPSULE |
3 |
Preferred Brand |
$45.00 | N/A | None |
ENALAPRIL MALEATE 10 MG TAB |
1* |
Preferred Generic |
$6.00 | N/A | None |
ENALAPRIL MALEATE 2.5 MG TAB |
1* |
Preferred Generic |
$6.00 | N/A | None |
ENALAPRIL MALEATE 20 MG TAB |
1* |
Preferred Generic |
$6.00 | N/A | None |
ENALAPRIL MALEATE 5 MG TABLET |
1* |
Preferred Generic |
$6.00 | N/A | None |
Enalapril Maleate and Hydrochlorothiazide 10; 25mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
6* |
Select Care Drugs |
$0.00 | N/A | None |
ENALAPRIL-HCTZ 5-12.5 MG TAB |
6* |
Select Care Drugs |
$0.00 | N/A | None |
ENBREL 25 MG/0.5 ML SYRINGE |
5 |
Specialty Tier |
29% | N/A | P Q:8 /28Days |
ENBREL 25MG KIT |
5 |
Specialty Tier |
29% | N/A | P Q:16 /28Days |
ENBREL 50 MG/ML SURECLICK SYR |
5 |
Specialty Tier |
29% | N/A | P Q:8 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENBREL 50mg/mL |
5 |
Specialty Tier |
29% | N/A | P Q:8 /28Days |
ENDOCET 10MG-325MG TABLET |
2* |
Generic |
$12.00 | N/A | Q:360 /30Days |
ENDOCET 5/325 TABLET |
2* |
Generic |
$12.00 | N/A | Q:360 /30Days |
ENDOCET 7.5-325MG TABLET |
2* |
Generic |
$12.00 | N/A | Q:360 /30Days |
ENGERIX B INJECTION |
3 |
Preferred Brand |
$45.00 | N/A | P |
ENGERIX-B 20 MCG/ML SYRN |
3 |
Preferred Brand |
$45.00 | N/A | P |
ENOXAPARIN 100 MG/ML SYRINGE |
4 |
Non-Preferred Brand |
$100.00 | N/A | Q:120 /365Days |
ENOXAPARIN 120 MG/0.8 ML SYRINGE |
4 |
Non-Preferred Brand |
$100.00 | N/A | Q:96 /365Days |
ENOXAPARIN 150 MG/ML SYRINGE |
4 |
Non-Preferred Brand |
$100.00 | N/A | Q:120 /365Days |
ENOXAPARIN 30 MG/0.3 ML SYR |
4 |
Non-Preferred Brand |
$100.00 | N/A | Q:36 /365Days |
ENOXAPARIN 300 MG/3 ML VIAL |
4 |
Non-Preferred Brand |
$100.00 | N/A | Q:360 /365Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENOXAPARIN 40 MG/0.4 ML SYR |
4 |
Non-Preferred Brand |
$100.00 | N/A | Q:48 /365Days |
ENOXAPARIN 60 MG/0.6 ML SYRINGE |
4 |
Non-Preferred Brand |
$100.00 | N/A | Q:72 /365Days |
ENOXAPARIN 80 MG/0.8 ML SYRINGE |
4 |
Non-Preferred Brand |
$100.00 | N/A | Q:96 /365Days |
ENSKYCE 28 TABLET |
2* |
Generic |
$12.00 | N/A | None |
ENTACAPONE 200 MG TABLET [Comtan Entacapone] |
3 |
Preferred Brand |
$45.00 | N/A | None |
ENTECAVIR 0.5 MG TABLET [Baraclude] |
5 |
Specialty Tier |
29% | N/A | P |
ENTECAVIR 1 MG TABLET [Baraclude] |
5 |
Specialty Tier |
29% | N/A | P |
ENTRESTO 24 MG-26 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:60 /30Days |
ENTRESTO 49 MG-51 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:60 /30Days |
ENTRESTO 97 MG-103 MG TABLET |
3 |
Preferred Brand |
$45.00 | N/A | Q:60 /30Days |
ENULOSE 10 GM/15 ML SOLUTION |
2* |
Generic |
$12.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPCLUSA 400 MG-100 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P Q:28 /28Days |
EPINASTINE HCL 0.05% EYE DROPS |
2* |
Generic |
$12.00 | N/A | None |
EPINEPHRINE 0.15 MG AUTO-INJCT |
2* |
Generic |
$12.00 | N/A | None |
EPIPEN 0.3MG AUTO-INJECTOR |
3 |
Preferred Brand |
$45.00 | N/A | None |
EPIPEN JR 0.15MG AUTO-INJCT |
3 |
Preferred Brand |
$45.00 | N/A | None |
Epirubicin HCl 200 MG per 100 ML Injection |
2* |
Generic |
$12.00 | N/A | None |
EPITOL 200MG TABLET |
2* |
Generic |
$12.00 | N/A | None |
EPIVIR HBV 25MG/5ML TUBEX |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
Eplerenone 25mg/1 90 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
Eplerenone 50mg/1 90 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
EPOGEN 10000U/ML VIAL MDV |
4 |
Non-Preferred Brand |
$100.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPOGEN 2000[iU]/mL 10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL |
4 |
Non-Preferred Brand |
$100.00 | N/A | P |
EPOGEN 3000U/ML VIAL SDV |
4 |
Non-Preferred Brand |
$100.00 | N/A | P |
EPOGEN 4000U/ML VIAL SDV |
4 |
Non-Preferred Brand |
$100.00 | N/A | P |
EPOGEN INJECTION 20000U 10 X 1ML CRTN |
5 |
Specialty Tier |
29% | N/A | P |
EPROSARTAN MESYLATE 600 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
EQUETRO CAPSULES 200MG 120 BOT |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
EQUETRO CAPSULES 300MG 120 BOT |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
EQUETRO EXTENDED RELEASE CAPSULES 100MG 120 BOT |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
ERAXIS 100mg/30mL 30 mL in 1 VIAL, SINGLE-USE |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
ERAXIS(WATER DIL) 50 MG VIAL |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
ERBITUX 100MG/50ML VIAL |
5 |
Specialty Tier |
29% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERGOLOID MESYLATES TABLETS 1MG 100 BOT |
3 |
Preferred Brand |
$45.00 | N/A | None |
ERIVEDGE 150 MG CAPSULE |
5 |
Specialty Tier |
29% | N/A | P Q:30 /30Days |
ERLEADA 60 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P |
Errin 0.35 mg tablet |
2* |
Generic |
$12.00 | N/A | None |
ERWINAZE 10,000 UNITS VIAL |
5 |
Specialty Tier |
29% | N/A | None |
ERY 2% PADS 2% 60 PADS JAR |
2* |
Generic |
$12.00 | N/A | None |
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
ERY-TAB TAB 250MG EC |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
ERY-TAB TAB 333MG EC |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
ERYTHROCIN 500MG ADDVNT VL |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
ERYTHROCIN TAB 250MG |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Erythromycin 0.02 MG/MG Topical Gel [Erygel] |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
ERYTHROMYCIN 0.5% EYE OINTMENT |
1* |
Preferred Generic |
$6.00 | N/A | None |
ERYTHROMYCIN 2% GEL |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
ERYTHROMYCIN 2% SOLUTION |
2* |
Generic |
$12.00 | N/A | None |
ERYTHROMYCIN 500 MG FILMTAB |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
ERYTHROMYCIN EC 250 MG CAP |
2* |
Generic |
$12.00 | N/A | None |
ERYTHROMYCIN ES 400 MG TAB |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
Erythromycin Ethylsuccinate 40 MG/ML Oral Suspension |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
ERYTHROMYCIN TAB 250MG BS |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
ERYTHROMYCIN-BENZOYL GEL |
3 |
Preferred Brand |
$45.00 | N/A | None |
ESBRIET 267 MG CAPSULE |
5 |
Specialty Tier |
29% | N/A | P Q:270 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESBRIET 267 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P Q:270 /30Days |
ESBRIET 801 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P Q:90 /30Days |
ESCITALOPRAM 10 MG TABLET [Lexapro] |
2* |
Generic |
$12.00 | N/A | Q:60 /30Days |
ESCITALOPRAM 20 MG TABLET [Lexapro] |
2* |
Generic |
$12.00 | N/A | Q:30 /30Days |
ESCITALOPRAM 5 MG TABLET [Lexapro] |
2* |
Generic |
$12.00 | N/A | Q:120 /30Days |
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro] |
4 |
Non-Preferred Brand |
$100.00 | N/A | Q:600 /30Days |
ESTARYLLA 0.25-0.035 MG TABLET [VyLibra] |
2* |
Generic |
$12.00 | N/A | None |
ESTRACE VAG CREAM 0.1MG/GM |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
Estradiol / Norethindrone Acetate 0.5; 0.1mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, FILM C |
2* |
Generic |
$12.00 | N/A | None |
Estradiol 0.025 mg patch |
2* |
Generic |
$12.00 | N/A | Q:8 /28Days |
Estradiol 0.0375 mg patch |
2* |
Generic |
$12.00 | N/A | Q:8 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Estradiol 0.05 mg patch |
2* |
Generic |
$12.00 | N/A | Q:8 /28Days |
Estradiol 0.075 mg patch |
2* |
Generic |
$12.00 | N/A | Q:8 /28Days |
Estradiol 0.1 mg patch |
2* |
Generic |
$12.00 | N/A | Q:8 /28Days |
ESTRADIOL 0.5 MG TABLET |
2* |
Generic |
$12.00 | N/A | None |
ESTRADIOL 1 MG TABLET |
2* |
Generic |
$12.00 | N/A | None |
ESTRADIOL 10 MCG VAGINAL INSRT |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
ESTRADIOL 2MG TABLET |
2* |
Generic |
$12.00 | N/A | None |
ESTRADIOL TDS 0.025 MG/DAY |
2* |
Generic |
$12.00 | N/A | Q:4 /28Days |
ESTRADIOL TDS 0.0375 MG/DAY |
2* |
Generic |
$12.00 | N/A | Q:4 /28Days |
ESTRADIOL TDS 0.05 MG/DAY |
2* |
Generic |
$12.00 | N/A | Q:4 /28Days |
ESTRADIOL TDS 0.06 MG/DAY |
2* |
Generic |
$12.00 | N/A | Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL TDS 0.075 MG/DAY |
2* |
Generic |
$12.00 | N/A | Q:4 /28Days |
ESTRADIOL TDS 0.1 MG/DAY |
2* |
Generic |
$12.00 | N/A | Q:4 /28Days |
ESTRADIOL VALERATE 20mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
2* |
Generic |
$12.00 | N/A | None |
ESTRADIOL VALERATE 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
2* |
Generic |
$12.00 | N/A | None |
ESTRADIOL-NORETH 1.0-0.5MG TABLET |
2* |
Generic |
$12.00 | N/A | None |
ESTRING 2MG VAGINAL RING |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
ESTROPIPATE 0.625(0.75 MG) TABLET |
2* |
Generic |
$12.00 | N/A | None |
ESTROPIPATE 1.25(1.5 MG) TABLET |
2* |
Generic |
$12.00 | N/A | None |
ETHAMBUTOL HCL 400 MG TABLET |
2* |
Generic |
$12.00 | N/A | None |
Ethambutol Hydrochloride 100mg/1 |
2* |
Generic |
$12.00 | N/A | None |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 |
2* |
Generic |
$12.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21 |
2* |
Generic |
$12.00 | N/A | None |
ETHOSUXIMIDE 250 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
ETHOSUXIMIDE 250 MG/5 ML SOLN |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
ETHYNODIOL-ETH ESTRA 1MG-35MCG [ZOVIA] |
2* |
Generic |
$12.00 | N/A | None |
ethynodiol-eth estra 1mg-50mcg [ZOVIA] |
2* |
Generic |
$12.00 | N/A | None |
ETIDRONATE DISODIUM 400MG TABLET (60 CT) |
2* |
Generic |
$12.00 | N/A | None |
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT |
2* |
Generic |
$12.00 | N/A | None |
ETODOLAC 200 MG CAPSULE [LODINE] |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
ETODOLAC 300 MG CAPSULE [LODINE] |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
ETODOLAC 400 MG TABLET [LODINE] |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
ETODOLAC 500 MG TABLET [LODINE] |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETOPOPHOS 100MG VIAL |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
EUCRISA 2% OINTMENT |
4 |
Non-Preferred Brand |
$100.00 | N/A | P |
EVOTAZ 300 MG-150 MG TABLET |
5 |
Specialty Tier |
29% | N/A | None |
EXEMESTANE 25 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
EXJADE 125MG TABLET |
5 |
Specialty Tier |
29% | N/A | P |
EXJADE 250MG TABLET |
5 |
Specialty Tier |
29% | N/A | P |
EXJADE 500MG TABLET |
5 |
Specialty Tier |
29% | N/A | P |
Ezetimibe 10 MG Oral Tablet [Zetia] |
3 |
Preferred Brand |
$45.00 | N/A | None |