2018 Medicare Part D Plan Formulary Information |
Cigna-HealthSpring TotalCare (HMO SNP) (H9725-003-0)
Benefit Details
|
The Cigna-HealthSpring TotalCare (HMO SNP) (H9725-003-0) Formulary Drugs Starting with the Letter E in Polk County, NC: CMS MA Region 7 which includes: NC Plan Monthly Premium: $30.20 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 |
E.E.S. 400 FILMTAB |
1 |
Tier 1 |
15% | N/A | None |
ECONAZOLE NITRATE 1% CREAM 85GM TUBE |
1 |
Tier 1 |
15% | N/A | None |
EDARBI 40 MG TABLET |
1 |
Tier 1 |
15% | N/A | S |
EDARBI 80 MG TABLET |
1 |
Tier 1 |
15% | N/A | S |
EDARBYCLOR 40-12.5 MG TABLET |
1 |
Tier 1 |
15% | N/A | S |
EDARBYCLOR 40-25 MG TABLET |
1 |
Tier 1 |
15% | N/A | S |
EDURANT 27.5mg/1 |
1 |
Tier 1 |
15% | N/A | Q:30 /30Days |
EFAVIRENZ 200 MG CAPSULE [Sustiva] |
1 |
Tier 1 |
15% | N/A | Q:60 /30Days |
EFAVIRENZ 50 MG CAPSULE [Sustiva] |
1 |
Tier 1 |
15% | N/A | Q:90 /30Days |
EFAVIRENZ 600 MG TABLET [Sustiva] |
1 |
Tier 1 |
15% | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELAPRASE 6mg/3mL 1 VIAL, GLASS in 1 BOX / 3 mL in 1 VIAL, GLASS |
1 |
Tier 1 |
15% | N/A | P |
ELIDEL 1% CREAM |
1 |
Tier 1 |
15% | N/A | Q:100 /90Days |
ELIGARD 22.5 MG SYRINGE |
1 |
Tier 1 |
15% | N/A | P Q:1 /90Days |
ELIGARD 30 MG SYRINGE KIT |
1 |
Tier 1 |
15% | N/A | P Q:1 /120Days |
ELIGARD 45 MG SYRINGE KIT |
1 |
Tier 1 |
15% | N/A | P Q:1 /180Days |
ELIGARD 7.5 MG SYRINGE KIT |
1 |
Tier 1 |
15% | N/A | P Q:1 /30Days |
Elitek 3 KIT per CARTON / 1 KIT in 1 KIT |
1 |
Tier 1 |
15% | N/A | P |
ELITEK 7.5 MG VIAL |
1 |
Tier 1 |
15% | N/A | P |
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE |
1 |
Tier 1 |
15% | N/A | None |
EMCYT 140MG CAPSULE |
1 |
Tier 1 |
15% | N/A | None |
EMEND 125 MG POWDER PACKET |
1 |
Tier 1 |
15% | N/A | P Q:6 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Emoquette 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
1 |
Tier 1 |
15% | N/A | None |
Empagliflozin 5 MG / Metformin hydrochloride 500 MG Oral Tablet [Synjardy] |
1 |
Tier 1 |
15% | N/A | Q:60 /30Days |
EMPLICITI 300 MG VIAL |
1 |
Tier 1 |
15% | N/A | P |
EMPLICITI 400 MG VIAL |
1 |
Tier 1 |
15% | N/A | P |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
1 |
Tier 1 |
15% | N/A | Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
1 |
Tier 1 |
15% | N/A | Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
1 |
Tier 1 |
15% | N/A | Q:30 /30Days |
EMTRIVA 10MG/ML SOLUTION |
1 |
Tier 1 |
15% | N/A | Q:680 /28Days |
EMTRIVA 200MG CAPSULE |
1 |
Tier 1 |
15% | N/A | Q:30 /30Days |
ENABLEX 15 MG TABLET |
1 |
Tier 1 |
15% | N/A | S Q:30 /30Days |
ENABLEX 7.5 MG TABLET |
1 |
Tier 1 |
15% | N/A | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENALAPRIL MALEATE 10 MG TAB |
1 |
Tier 1 |
15% | N/A | Q:60 /30Days |
ENALAPRIL MALEATE 2.5 MG TAB |
1 |
Tier 1 |
15% | N/A | Q:60 /30Days |
ENALAPRIL MALEATE 20 MG TAB |
1 |
Tier 1 |
15% | N/A | Q:60 /30Days |
ENALAPRIL MALEATE 5 MG TABLET |
1 |
Tier 1 |
15% | N/A | Q:60 /30Days |
Enalapril Maleate and Hydrochlorothiazide 10; 25mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Tier 1 |
15% | N/A | Q:60 /30Days |
ENALAPRIL-HCTZ 5-12.5 MG TAB |
1 |
Tier 1 |
15% | N/A | Q:60 /30Days |
ENBREL 25 MG/0.5 ML SYRINGE |
1 |
Tier 1 |
15% | N/A | P Q:4 /28Days |
ENBREL 25MG KIT |
1 |
Tier 1 |
15% | N/A | P Q:8 /28Days |
ENBREL 50 MG/ML SURECLICK SYR |
1 |
Tier 1 |
15% | N/A | P Q:8 /28Days |
ENBREL 50mg/mL |
1 |
Tier 1 |
15% | N/A | P Q:8 /28Days |
ENDOCET 10MG-325MG TABLET |
1 |
Tier 1 |
15% | 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 |
1 |
Tier 1 |
15% | N/A | Q:360 /30Days |
ENDOCET 7.5-325MG TABLET |
1 |
Tier 1 |
15% | N/A | Q:240 /30Days |
ENGERIX B INJECTION |
1 |
Tier 1 |
15% | N/A | P Q:3 /365Days |
ENGERIX-B 20 MCG/ML SYRN |
1 |
Tier 1 |
15% | N/A | P Q:8 /365Days |
ENOXAPARIN 100 MG/ML SYRINGE |
1 |
Tier 1 |
15% | N/A | Q:30 /90Days |
ENOXAPARIN 120 MG/0.8 ML SYRINGE |
1 |
Tier 1 |
15% | N/A | Q:24 /90Days |
ENOXAPARIN 150 MG/ML SYRINGE |
1 |
Tier 1 |
15% | N/A | Q:30 /90Days |
ENOXAPARIN 30 MG/0.3 ML SYR |
1 |
Tier 1 |
15% | N/A | Q:9 /90Days |
ENOXAPARIN 300 MG/3 ML VIAL |
1 |
Tier 1 |
15% | N/A | Q:30 /90Days |
ENOXAPARIN 40 MG/0.4 ML SYR |
1 |
Tier 1 |
15% | N/A | Q:12 /90Days |
ENOXAPARIN 60 MG/0.6 ML SYRINGE |
1 |
Tier 1 |
15% | N/A | Q:18 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENOXAPARIN 80 MG/0.8 ML SYRINGE |
1 |
Tier 1 |
15% | N/A | Q:24 /90Days |
ENSKYCE 28 TABLET |
1 |
Tier 1 |
15% | N/A | None |
ENTACAPONE 200 MG TABLET [Comtan Entacapone] |
1 |
Tier 1 |
15% | N/A | Q:240 /30Days |
ENTECAVIR 0.5 MG TABLET [Baraclude] |
1 |
Tier 1 |
15% | N/A | Q:30 /30Days |
ENTECAVIR 1 MG TABLET [Baraclude] |
1 |
Tier 1 |
15% | N/A | Q:30 /30Days |
ENTRESTO 24 MG-26 MG TABLET |
1 |
Tier 1 |
15% | N/A | Q:60 /30Days |
ENTRESTO 49 MG-51 MG TABLET |
1 |
Tier 1 |
15% | N/A | Q:60 /30Days |
ENTRESTO 97 MG-103 MG TABLET |
1 |
Tier 1 |
15% | N/A | Q:60 /30Days |
ENULOSE 10 GM/15 ML SOLUTION |
1 |
Tier 1 |
15% | N/A | None |
ENVARSUS XR 0.75 MG TABLET |
1 |
Tier 1 |
15% | N/A | P |
ENVARSUS XR 1 MG TABLET |
1 |
Tier 1 |
15% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENVARSUS XR 4 MG TABLET |
1 |
Tier 1 |
15% | N/A | P |
EPCLUSA 400 MG-100 MG TABLET |
1 |
Tier 1 |
15% | N/A | P Q:28 /28Days |
EPINASTINE HCL 0.05% EYE DROPS |
1 |
Tier 1 |
15% | N/A | None |
EPINEPHRINE 0.15 MG AUTO-INJCT |
1 |
Tier 1 |
15% | N/A | Q:2 /30Days |
EPINEPHRINE 0.15 MG AUTO-INJECT |
1 |
Tier 1 |
15% | N/A | Q:2 /30Days |
EPINEPHRINE 0.3 MG AUTO-INJECT |
1 |
Tier 1 |
15% | N/A | Q:2 /30Days |
EPINEPHRINE 0.3 MG AUTO-INJECT |
1 |
Tier 1 |
15% | N/A | Q:2 /30Days |
EPIPEN 0.3MG AUTO-INJECTOR |
1 |
Tier 1 |
15% | N/A | Q:2 /30Days |
EPIPEN JR 0.15MG AUTO-INJCT |
1 |
Tier 1 |
15% | N/A | Q:2 /30Days |
Epirubicin HCl 200 MG per 100 ML Injection |
1 |
Tier 1 |
15% | N/A | P |
EPITOL 200MG TABLET |
1 |
Tier 1 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPIVIR HBV 25MG/5ML TUBEX |
1 |
Tier 1 |
15% | N/A | None |
ERBITUX 100MG/50ML VIAL |
1 |
Tier 1 |
15% | N/A | P |
ERGOLOID MESYLATES TABLETS 1MG 100 BOT |
1 |
Tier 1 |
15% | N/A | P |
Ergotamine-caffeine 1-100mg tb |
1 |
Tier 1 |
15% | N/A | Q:40 /28Days |
ERIVEDGE 150 MG CAPSULE |
1 |
Tier 1 |
15% | N/A | P Q:28 /28Days |
ERLEADA 60 MG TABLET |
1 |
Tier 1 |
15% | N/A | P Q:120 /30Days |
Errin 0.35 mg tablet |
1 |
Tier 1 |
15% | N/A | None |
ERWINAZE 10,000 UNITS VIAL |
1 |
Tier 1 |
15% | N/A | P Q:60 /28Days |
ERY 2% PADS 2% 60 PADS JAR |
1 |
Tier 1 |
15% | N/A | None |
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE |
1 |
Tier 1 |
15% | N/A | None |
ERY-TAB TAB 250MG EC |
1 |
Tier 1 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERY-TAB TAB 333MG EC |
1 |
Tier 1 |
15% | N/A | None |
ERYPED 400 MG/5 ML SUSPENSION |
1 |
Tier 1 |
15% | N/A | None |
ERYTHROCIN 500MG ADDVNT VL |
1 |
Tier 1 |
15% | N/A | None |
ERYTHROCIN TAB 250MG |
1 |
Tier 1 |
15% | N/A | None |
ERYTHROMYCIN 0.5% EYE OINTMENT |
1 |
Tier 1 |
15% | N/A | None |
ERYTHROMYCIN 2% GEL |
1 |
Tier 1 |
15% | N/A | None |
ERYTHROMYCIN 2% SOLUTION |
1 |
Tier 1 |
15% | N/A | None |
ERYTHROMYCIN 500 MG FILMTAB |
1 |
Tier 1 |
15% | N/A | None |
ERYTHROMYCIN ES 400 MG TAB |
1 |
Tier 1 |
15% | N/A | None |
Erythromycin Ethylsuccinate 40 MG/ML Oral Suspension |
1 |
Tier 1 |
15% | N/A | None |
ERYTHROMYCIN TAB 250MG BS |
1 |
Tier 1 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROMYCIN-BENZOYL GEL |
1 |
Tier 1 |
15% | N/A | None |
ESBRIET 267 MG CAPSULE |
1 |
Tier 1 |
15% | N/A | P Q:270 /30Days |
ESBRIET 267 MG TABLET |
1 |
Tier 1 |
15% | N/A | P Q:270 /30Days |
ESBRIET 801 MG TABLET |
1 |
Tier 1 |
15% | N/A | P Q:90 /30Days |
ESCITALOPRAM 10 MG TABLET [Lexapro] |
1 |
Tier 1 |
15% | N/A | Q:60 /30Days |
ESCITALOPRAM 20 MG TABLET [Lexapro] |
1 |
Tier 1 |
15% | N/A | Q:90 /30Days |
ESCITALOPRAM 5 MG TABLET [Lexapro] |
1 |
Tier 1 |
15% | N/A | Q:30 /30Days |
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro] |
1 |
Tier 1 |
15% | N/A | Q:600 /30Days |
ESOMEPRAZOLE MAG DR 20 MG CAP [Nexium] |
1 |
Tier 1 |
15% | N/A | Q:60 /30Days |
ESOMEPRAZOLE MAG DR 40 MG CAP [Nexium] |
1 |
Tier 1 |
15% | N/A | Q:60 /30Days |
ESOMEPRAZOLE SODIUM 20 MG VIAL [Nexium] |
1 |
Tier 1 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESOMEPRAZOLE SODIUM 40 MG VIAL [Nexium] |
1 |
Tier 1 |
15% | N/A | None |
ESTARYLLA 0.25-0.035 MG TABLET [VyLibra] |
1 |
Tier 1 |
15% | N/A | None |
ESTRADIOL 0.01% CREAM |
1 |
Tier 1 |
15% | N/A | None |
Estradiol 0.025 mg patch |
1 |
Tier 1 |
15% | N/A | P Q:8 /28Days |
Estradiol 0.0375 mg patch |
1 |
Tier 1 |
15% | N/A | P Q:8 /28Days |
Estradiol 0.05 mg patch |
1 |
Tier 1 |
15% | N/A | P Q:8 /28Days |
Estradiol 0.075 mg patch |
1 |
Tier 1 |
15% | N/A | P Q:8 /28Days |
Estradiol 0.1 mg patch |
1 |
Tier 1 |
15% | N/A | P Q:8 /28Days |
ESTRADIOL 0.5 MG TABLET |
1 |
Tier 1 |
15% | N/A | P |
ESTRADIOL 1 MG TABLET |
1 |
Tier 1 |
15% | N/A | P |
ESTRADIOL 10 MCG VAGINAL INSRT |
1 |
Tier 1 |
15% | N/A | Q:18 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL 2MG TABLET |
1 |
Tier 1 |
15% | N/A | P |
ESTRADIOL TDS 0.025 MG/DAY |
1 |
Tier 1 |
15% | N/A | P Q:4 /28Days |
ESTRADIOL TDS 0.0375 MG/DAY |
1 |
Tier 1 |
15% | N/A | P Q:4 /28Days |
ESTRADIOL TDS 0.05 MG/DAY |
1 |
Tier 1 |
15% | N/A | P Q:4 /28Days |
ESTRADIOL TDS 0.06 MG/DAY |
1 |
Tier 1 |
15% | N/A | P Q:4 /28Days |
ESTRADIOL TDS 0.075 MG/DAY |
1 |
Tier 1 |
15% | N/A | P Q:4 /28Days |
ESTRADIOL TDS 0.1 MG/DAY |
1 |
Tier 1 |
15% | N/A | P Q:4 /28Days |
ESTRADIOL VALERATE 20mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
1 |
Tier 1 |
15% | N/A | None |
ESTRADIOL VALERATE 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
1 |
Tier 1 |
15% | N/A | None |
ESTRING 2MG VAGINAL RING |
1 |
Tier 1 |
15% | N/A | Q:1 /90Days |
ETHACRYNATE SODIUM 50 MG VIAL [Edecrin] |
1 |
Tier 1 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETHAMBUTOL HCL 400 MG TABLET |
1 |
Tier 1 |
15% | N/A | None |
Ethambutol Hydrochloride 100mg/1 |
1 |
Tier 1 |
15% | N/A | None |
Ethinyl Estradiol 0.0025 MG / norethindrone acetate 0.5 MG Oral Tablet [Fyavolv] |
1 |
Tier 1 |
15% | N/A | P |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 |
1 |
Tier 1 |
15% | N/A | None |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21 |
1 |
Tier 1 |
15% | N/A | None |
ETHOSUXIMIDE 250 MG CAPSULE |
1 |
Tier 1 |
15% | N/A | None |
ETHOSUXIMIDE 250 MG/5 ML SOLN |
1 |
Tier 1 |
15% | N/A | None |
ethynodiol-eth estra 1mg-50mcg [ZOVIA] |
1 |
Tier 1 |
15% | N/A | None |
ETIDRONATE DISODIUM 400MG TABLET (60 CT) |
1 |
Tier 1 |
15% | N/A | None |
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT |
1 |
Tier 1 |
15% | N/A | None |
ETODOLAC 200 MG CAPSULE [LODINE] |
1 |
Tier 1 |
15% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETODOLAC 300 MG CAPSULE [LODINE] |
1 |
Tier 1 |
15% | N/A | None |
ETODOLAC 400 MG TABLET [LODINE] |
1 |
Tier 1 |
15% | N/A | None |
ETODOLAC 500 MG TABLET [LODINE] |
1 |
Tier 1 |
15% | N/A | None |
ETODOLAC ER 400 MG TABLET [LODINE] |
1 |
Tier 1 |
15% | N/A | None |
ETODOLAC ER 500 MG TABLET [LODINE] |
1 |
Tier 1 |
15% | N/A | None |
ETODOLAC ER 600 MG TABLET [LODINE] |
1 |
Tier 1 |
15% | N/A | None |
EVOTAZ 300 MG-150 MG TABLET |
1 |
Tier 1 |
15% | N/A | Q:30 /30Days |
EXEMESTANE 25 MG TABLET |
1 |
Tier 1 |
15% | N/A | Q:60 /30Days |
Ezetimibe 10 MG Oral Tablet [Zetia] |
1 |
Tier 1 |
15% | N/A | Q:30 /30Days |
Ezetimibe-Simvastatin 10-10 MG [Vytorin] |
1 |
Tier 1 |
15% | N/A | Q:30 /30Days |
Ezetimibe-Simvastatin 10-20 MG [Vytorin] |
1 |
Tier 1 |
15% | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ezetimibe-Simvastatin 10-40 MG [Vytorin] |
1 |
Tier 1 |
15% | N/A | Q:30 /30Days |
Ezetimibe-Simvastatin 10-80 MG [Vytorin] |
1 |
Tier 1 |
15% | N/A | Q:30 /30Days |