2018 Medicare Part D Plan Formulary Information |
Symphonix Value Rx (PDP) (S0522-024-0)
Benefit Details
 |
The Symphonix Value Rx (PDP) (S0522-024-0) Formulary Drugs Starting with the Letter E in CMS PDP Region 20 which includes: MS Plan Monthly Premium: $22.80 Deductible: $405 Qualifies for LIS: Yes |
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 Drug |
34% | 34% | None |
EDURANT 27.5mg/1  |
5 |
Specialty Tier |
25% | 25% | Q:60 /30Days |
EFAVIRENZ 200 MG CAPSULE [Sustiva] ![Compare how all Medicare Part D PDP plans in MS cover EFAVIRENZ 200 MG CAPSULE [Sustiva].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | 25% | Q:90 /30Days |
EFAVIRENZ 50 MG CAPSULE [Sustiva] ![Compare how all Medicare Part D PDP plans in MS cover EFAVIRENZ 50 MG CAPSULE [Sustiva].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
34% | 34% | Q:270 /30Days |
EFAVIRENZ 600 MG TABLET [Sustiva] ![Compare how all Medicare Part D PDP plans in MS cover EFAVIRENZ 600 MG TABLET [Sustiva].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | 25% | Q:60 /30Days |
EGRIFTA 2 MG VIAL  |
5 |
Specialty Tier |
25% | 25% | P |
ELAPRASE 6mg/3mL 1 VIAL, GLASS in 1 BOX / 3 mL in 1 VIAL, GLASS  |
5 |
Specialty Tier |
25% | 25% | None |
ELESTRIN 0.06 % Topical Gel  |
4 |
Non-Preferred Drug |
34% | 34% | None |
ELIDEL 1% CREAM  |
4 |
Non-Preferred Drug |
34% | 34% | S |
ELIQUIS 2.5 MG TABLET  |
3 |
Preferred Brand |
$28.00 | $84.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIQUIS 5 MG STARTER PACK  |
3 |
Preferred Brand |
$28.00 | $84.00 | Q:74 /30Days |
ELIQUIS 5 MG TABLET  |
3 |
Preferred Brand |
$28.00 | $84.00 | Q:60 /30Days |
Elitek 3 KIT per CARTON / 1 KIT in 1 KIT  |
5 |
Specialty Tier |
25% | 25% | None |
ELITEK 7.5 MG VIAL  |
5 |
Specialty Tier |
25% | 25% | None |
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE  |
4 |
Non-Preferred Drug |
34% | 34% | None |
EMBEDA ER 100-4 MG CAPSULE  |
3 |
Preferred Brand |
$28.00 | $84.00 | Q:90 /30Days |
EMBEDA ER 20-0.8 MG CAPSULE  |
3 |
Preferred Brand |
$28.00 | $84.00 | Q:120 /30Days |
EMBEDA ER 30-1.2 MG CAPSULE  |
3 |
Preferred Brand |
$28.00 | $84.00 | Q:60 /30Days |
EMBEDA ER 50-2 MG CAPSULE  |
3 |
Preferred Brand |
$28.00 | $84.00 | Q:60 /30Days |
EMBEDA ER 60-2.4 MG CAPSULE  |
3 |
Preferred Brand |
$28.00 | $84.00 | Q:180 /30Days |
EMBEDA ER 80-3.2 MG CAPSULE  |
3 |
Preferred Brand |
$28.00 | $84.00 | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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% | None |
Emoquette 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK  |
4 |
Non-Preferred Drug |
34% | 34% | None |
Empagliflozin 5 MG / Metformin hydrochloride 500 MG Oral Tablet [Synjardy] ![Compare how all Medicare Part D PDP plans in MS cover Empagliflozin 5 MG / Metformin hydrochloride 500 MG Oral Tablet [Synjardy].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$28.00 | $84.00 | Q:60 /30Days |
EMPLICITI 300 MG VIAL  |
5 |
Specialty Tier |
25% | 25% | P |
EMPLICITI 400 MG VIAL  |
5 |
Specialty Tier |
25% | 25% | P |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H  |
5 |
Specialty Tier |
25% | 25% | Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H  |
5 |
Specialty Tier |
25% | 25% | Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H  |
5 |
Specialty Tier |
25% | 25% | Q:30 /30Days |
EMTRIVA 10MG/ML SOLUTION  |
4 |
Non-Preferred Drug |
34% | 34% | Q:1275 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMTRIVA 200MG CAPSULE  |
4 |
Non-Preferred Drug |
34% | 34% | Q:60 /30Days |
ENALAPRIL MALEATE 10 MG TAB  |
2 |
Generic |
$3.00 | $9.00 | Q:60 /30Days |
ENALAPRIL MALEATE 2.5 MG TAB  |
2 |
Generic |
$3.00 | $9.00 | Q:60 /30Days |
ENALAPRIL MALEATE 20 MG TAB  |
2 |
Generic |
$3.00 | $9.00 | Q:60 /30Days |
ENALAPRIL MALEATE 5 MG TABLET  |
2 |
Generic |
$3.00 | $9.00 | Q:60 /30Days |
Enalapril Maleate and Hydrochlorothiazide 10; 25mg/1; mg/1 100 TABLET BOTTLE, PLASTIC  |
2 |
Generic |
$3.00 | $9.00 | Q:60 /30Days |
ENALAPRIL-HCTZ 5-12.5 MG TAB  |
2 |
Generic |
$3.00 | $9.00 | Q:30 /30Days |
ENDOCET 10MG-325MG TABLET  |
3 |
Preferred Brand |
$28.00 | $84.00 | Q:360 /30Days |
ENDOCET 5/325 TABLET  |
3 |
Preferred Brand |
$28.00 | $84.00 | Q:360 /30Days |
ENDOCET 7.5-325MG TABLET  |
3 |
Preferred Brand |
$28.00 | $84.00 | Q:360 /30Days |
ENGERIX B INJECTION  |
3 |
Preferred Brand |
$28.00 | $84.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENGERIX-B 20 MCG/ML SYRN  |
3 |
Preferred Brand |
$28.00 | $84.00 | P |
ENOXAPARIN 100 MG/ML SYRINGE  |
4 |
Non-Preferred Drug |
34% | 34% | Q:60 /30Days |
ENOXAPARIN 120 MG/0.8 ML SYRINGE  |
4 |
Non-Preferred Drug |
34% | 34% | Q:48 /30Days |
ENOXAPARIN 150 MG/ML SYRINGE  |
4 |
Non-Preferred Drug |
34% | 34% | Q:60 /30Days |
ENOXAPARIN 30 MG/0.3 ML SYR  |
4 |
Non-Preferred Drug |
34% | 34% | Q:18 /30Days |
ENOXAPARIN 300 MG/3 ML VIAL  |
4 |
Non-Preferred Drug |
34% | 34% | Q:90 /30Days |
ENOXAPARIN 40 MG/0.4 ML SYR  |
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 |
ENSKYCE 28 TABLET  |
4 |
Non-Preferred Drug |
34% | 34% | None |
ENTACAPONE 200 MG TABLET [Comtan Entacapone] ![Compare how all Medicare Part D PDP plans in MS cover ENTACAPONE 200 MG TABLET [Comtan Entacapone].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
34% | 34% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENTECAVIR 0.5 MG TABLET [Baraclude] ![Compare how all Medicare Part D PDP plans in MS cover ENTECAVIR 0.5 MG TABLET [Baraclude].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | 25% | None |
ENTECAVIR 1 MG TABLET [Baraclude] ![Compare how all Medicare Part D PDP plans in MS cover ENTECAVIR 1 MG TABLET [Baraclude].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | 25% | None |
ENTRESTO 24 MG-26 MG TABLET  |
3 |
Preferred Brand |
$28.00 | $84.00 | Q:60 /30Days |
ENTRESTO 49 MG-51 MG TABLET  |
3 |
Preferred Brand |
$28.00 | $84.00 | Q:60 /30Days |
ENTRESTO 97 MG-103 MG TABLET  |
3 |
Preferred Brand |
$28.00 | $84.00 | Q:60 /30Days |
ENULOSE 10 GM/15 ML SOLUTION  |
2 |
Generic |
$3.00 | $9.00 | 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% | 25% | P Q:28 /28Days |
EPINASTINE HCL 0.05% EYE DROPS  |
3 |
Preferred Brand |
$28.00 | $84.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPINEPHRINE 0.15 MG AUTO-INJCT  |
3 |
Preferred Brand |
$28.00 | $84.00 | Q:4 /30Days |
EPINEPHRINE 0.3 MG AUTO-INJECT  |
3 |
Preferred Brand |
$28.00 | $84.00 | Q:4 /30Days |
EPIPEN 0.3MG AUTO-INJECTOR  |
3 |
Preferred Brand |
$28.00 | $84.00 | Q:4 /30Days |
EPIPEN JR 0.15MG AUTO-INJCT  |
3 |
Preferred Brand |
$28.00 | $84.00 | Q:4 /30Days |
Epirubicin HCl 200 MG per 100 ML Injection  |
4 |
Non-Preferred Drug |
34% | 34% | None |
EPITOL 200MG TABLET  |
2 |
Generic |
$3.00 | $9.00 | None |
EPIVIR HBV 25MG/5ML TUBEX  |
3 |
Preferred Brand |
$28.00 | $84.00 | None |
ERBITUX 100MG/50ML VIAL  |
5 |
Specialty Tier |
25% | 25% | P |
Ergotamine-caffeine 1-100mg tb  |
3 |
Preferred Brand |
$28.00 | $84.00 | None |
ERIVEDGE 150 MG CAPSULE  |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
ERLEADA 60 MG TABLET  |
5 |
Specialty Tier |
25% | 25% | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Errin 0.35 mg tablet  |
3 |
Preferred Brand |
$28.00 | $84.00 | None |
ERWINAZE 10,000 UNITS VIAL  |
5 |
Specialty Tier |
25% | 25% | None |
ERY 2% PADS 2% 60 PADS JAR  |
3 |
Preferred Brand |
$28.00 | $84.00 | 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 |
ERYPED 200 MG/5 ML SUSPENSION  |
4 |
Non-Preferred Drug |
34% | 34% | None |
ERYPED 400 MG/5 ML SUSPENSION  |
4 |
Non-Preferred Drug |
34% | 34% | None |
ERYTHROCIN 500MG ADDVNT VL  |
4 |
Non-Preferred Drug |
34% | 34% | None |
ERYTHROMYCIN 0.5% EYE OINTMENT  |
2 |
Generic |
$3.00 | $9.00 | None |
ERYTHROMYCIN 2% GEL  |
4 |
Non-Preferred Drug |
34% | 34% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROMYCIN 2% SOLUTION  |
2 |
Generic |
$3.00 | $9.00 | None |
ERYTHROMYCIN 500 MG FILMTAB  |
4 |
Non-Preferred Drug |
34% | 34% | None |
ERYTHROMYCIN EC 250 MG CAP  |
4 |
Non-Preferred Drug |
34% | 34% | None |
ERYTHROMYCIN ES 400 MG TAB  |
4 |
Non-Preferred Drug |
34% | 34% | None |
Erythromycin Ethylsuccinate 40 MG/ML Oral Suspension  |
4 |
Non-Preferred Drug |
34% | 34% | None |
ERYTHROMYCIN TAB 250MG BS  |
4 |
Non-Preferred Drug |
34% | 34% | None |
ERYTHROMYCIN-BENZOYL GEL  |
4 |
Non-Preferred Drug |
34% | 34% | None |
ESBRIET 267 MG CAPSULE  |
5 |
Specialty Tier |
25% | 25% | P Q:270 /30Days |
ESBRIET 267 MG TABLET  |
5 |
Specialty Tier |
25% | 25% | P Q:270 /30Days |
ESBRIET 801 MG TABLET  |
5 |
Specialty Tier |
25% | 25% | P Q:90 /30Days |
ESCITALOPRAM 10 MG TABLET [Lexapro] ![Compare how all Medicare Part D PDP plans in MS cover ESCITALOPRAM 10 MG TABLET [Lexapro].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESCITALOPRAM 20 MG TABLET [Lexapro] ![Compare how all Medicare Part D PDP plans in MS cover ESCITALOPRAM 20 MG TABLET [Lexapro].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
ESCITALOPRAM 5 MG TABLET [Lexapro] ![Compare how all Medicare Part D PDP plans in MS cover ESCITALOPRAM 5 MG TABLET [Lexapro].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro] ![Compare how all Medicare Part D PDP plans in MS cover ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
ESTARYLLA 0.25-0.035 MG TABLET [VyLibra] ![Compare how all Medicare Part D PDP plans in MS cover ESTARYLLA 0.25-0.035 MG TABLET [VyLibra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
34% | 34% | None |
Estradiol / Norethindrone Acetate 0.5; 0.1mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, FILM C  |
3 |
Preferred Brand |
$28.00 | $84.00 | None |
ESTRADIOL 0.5 MG TABLET  |
2 |
Generic |
$3.00 | $9.00 | None |
ESTRADIOL 1 MG TABLET  |
2 |
Generic |
$3.00 | $9.00 | None |
ESTRADIOL 2MG TABLET  |
2 |
Generic |
$3.00 | $9.00 | None |
ESTRADIOL TDS 0.025 MG/DAY  |
2 |
Generic |
$3.00 | $9.00 | Q:4 /28Days |
ESTRADIOL TDS 0.0375 MG/DAY  |
2 |
Generic |
$3.00 | $9.00 | Q:4 /28Days |
ESTRADIOL TDS 0.05 MG/DAY  |
2 |
Generic |
$3.00 | $9.00 | Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL TDS 0.06 MG/DAY  |
2 |
Generic |
$3.00 | $9.00 | Q:4 /28Days |
ESTRADIOL TDS 0.075 MG/DAY  |
2 |
Generic |
$3.00 | $9.00 | Q:4 /28Days |
ESTRADIOL TDS 0.1 MG/DAY  |
2 |
Generic |
$3.00 | $9.00 | Q:4 /28Days |
ESTRADIOL VALERATE 20mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE  |
4 |
Non-Preferred Drug |
34% | 34% | None |
ESTRADIOL VALERATE 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE  |
4 |
Non-Preferred Drug |
34% | 34% | None |
ESTRADIOL-NORETH 1.0-0.5MG TABLET  |
3 |
Preferred Brand |
$28.00 | $84.00 | None |
ESTRING 2MG VAGINAL RING  |
4 |
Non-Preferred Drug |
34% | 34% | None |
ESTROPIPATE 0.625(0.75 MG) TABLET  |
2 |
Generic |
$3.00 | $9.00 | None |
ESTROPIPATE 1.25(1.5 MG) TABLET  |
2 |
Generic |
$3.00 | $9.00 | None |
ETHAMBUTOL HCL 400 MG TABLET  |
2 |
Generic |
$3.00 | $9.00 | None |
Ethambutol Hydrochloride 100mg/1  |
2 |
Generic |
$3.00 | $9.00 | None |
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  |
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  |
2 |
Generic |
$3.00 | $9.00 | None |
ETHOSUXIMIDE 250 MG/5 ML SOLN  |
2 |
Generic |
$3.00 | $9.00 | None |
ETHYNODIOL-ETH ESTRA 1MG-35MCG [ZOVIA] ![Compare how all Medicare Part D PDP plans in MS cover ETHYNODIOL-ETH ESTRA 1MG-35MCG [ZOVIA].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
34% | 34% | None |
ethynodiol-eth estra 1mg-50mcg [ZOVIA] ![Compare how all Medicare Part D PDP plans in MS cover ethynodiol-eth estra 1mg-50mcg [ZOVIA].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
34% | 34% | None |
ETOPOPHOS 100MG VIAL  |
4 |
Non-Preferred Drug |
34% | 34% | None |
EVOTAZ 300 MG-150 MG TABLET  |
5 |
Specialty Tier |
25% | 25% | Q:60 /30Days |
EXEMESTANE 25 MG TABLET  |
2 |
Generic |
$3.00 | $9.00 | None |
EXTAVIA 15 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK  |
5 |
Specialty Tier |
25% | 25% | None |
Ezetimibe 10 MG Oral Tablet [Zetia] ![Compare how all Medicare Part D PDP plans in MS cover Ezetimibe 10 MG Oral Tablet [Zetia].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$28.00 | $84.00 | Q:30 /30Days |