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2018 Medicare Part D Plan Formulary Information
Anthem Blue Cross MedicareRx Plus (PDP) (S5596-034-0) Benefit Details
The Anthem Blue Cross MedicareRx Plus (PDP) (S5596-034-0) Formulary Drugs Starting with the Letter E in CMS PDP Region 32 which includes: CA Plan Monthly Premium: $119.90 Deductible: $0 Qualifies for LIS: No
Drugs Starting with Letter E Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter E Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ECONAZOLE NITRATE 1% CREAM 85GM TUBE	3	Preferred Brand	$40.00	N/A	None
EDURANT 27.5mg/1	5	Specialty Tier	33%	N/A	Q:30 /30Days
EFAVIRENZ 200 MG CAPSULE [Sustiva]	4	Non-Preferred Drug	39%	N/A	Q:120 /30Days
EFAVIRENZ 50 MG CAPSULE [Sustiva]	4	Non-Preferred Drug	39%	N/A	Q:360 /30Days
EFAVIRENZ 600 MG TABLET [Sustiva]	5	Specialty Tier	33%	N/A	Q:30 /30Days
ELAPRASE 6mg/3mL 1 VIAL, GLASS in 1 BOX / 3 mL in 1 VIAL, GLASS	5	Specialty Tier	33%	N/A	P
ELIDEL 1% CREAM	4	Non-Preferred Drug	39%	N/A	P Q:100 /90Days
ELIQUIS 2.5 MG TABLET	3	Preferred Brand	$40.00	N/A	Q:60 /30Days
ELIQUIS 5 MG TABLET	3	Preferred Brand	$40.00	N/A	Q:74 /30Days
Elitek 3 KIT per CARTON / 1 KIT in 1 KIT	5	Specialty Tier	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ELITEK 7.5 MG VIAL	5	Specialty Tier	33%	N/A	P
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE	4	Non-Preferred Drug	39%	N/A	None
EMCYT 140MG CAPSULE	4	Non-Preferred Drug	39%	N/A	None
Emoquette 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	3	Preferred Brand	$40.00	N/A	None
Empagliflozin 5 MG / Metformin hydrochloride 500 MG Oral Tablet [Synjardy]	3	Preferred Brand	$40.00	N/A	Q:60 /30Days
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 Q:30 /30Days
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H	5	Specialty Tier	33%	N/A	P Q:30 /30Days
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H	5	Specialty Tier	33%	N/A	P Q:30 /30Days
EMTRIVA 10MG/ML SOLUTION	4	Non-Preferred Drug	39%	N/A	Q:850 /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	39%	N/A	Q:30 /30Days
ENALAPRIL MALEATE 10 MG TAB	6	Select Care Drugs	$0.00	N/A	None
ENALAPRIL MALEATE 2.5 MG TAB	6	Select Care Drugs	$0.00	N/A	None
ENALAPRIL MALEATE 20 MG TAB	6	Select Care Drugs	$0.00	N/A	None
ENALAPRIL MALEATE 5 MG TABLET	6	Select Care Drugs	$0.00	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	33%	N/A	P Q:4 /28Days
ENBREL 25MG KIT	5	Specialty Tier	33%	N/A	P Q:8 /28Days
ENBREL 50 MG/ML SURECLICK SYR	5	Specialty Tier	33%	N/A	P Q:8 /28Days
ENBREL 50mg/mL	5	Specialty Tier	33%	N/A	P Q:8 /28Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENDOCET 10MG-325MG TABLET	4	Non-Preferred Drug	39%	N/A	Q:360 /30Days
ENDOCET 5/325 TABLET	3	Preferred Brand	$40.00	N/A	Q:360 /30Days
ENDOCET 7.5-325MG TABLET	3	Preferred Brand	$40.00	N/A	Q:360 /30Days
ENGERIX B INJECTION	3	Preferred Brand	$40.00	N/A	P
ENGERIX-B 20 MCG/ML SYRN	3	Preferred Brand	$40.00	N/A	P
ENOXAPARIN 100 MG/ML SYRINGE	4	Non-Preferred Drug	39%	N/A	Q:28 /28Days
ENOXAPARIN 120 MG/0.8 ML SYRINGE	4	Non-Preferred Drug	39%	N/A	Q:22 /28Days
ENOXAPARIN 150 MG/ML SYRINGE	4	Non-Preferred Drug	39%	N/A	Q:28 /28Days
ENOXAPARIN 30 MG/0.3 ML SYR	4	Non-Preferred Drug	39%	N/A	Q:8 /28Days
ENOXAPARIN 300 MG/3 ML VIAL	4	Non-Preferred Drug	39%	N/A	Q:84 /28Days
ENOXAPARIN 40 MG/0.4 ML SYR	4	Non-Preferred Drug	39%	N/A	Q:11 /28Days
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	39%	N/A	Q:17 /28Days
ENOXAPARIN 80 MG/0.8 ML SYRINGE	4	Non-Preferred Drug	39%	N/A	Q:22 /28Days
ENTACAPONE 200 MG TABLET [Comtan Entacapone]	4	Non-Preferred Drug	39%	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	4	Non-Preferred Drug	39%	N/A	P
ENTRESTO 49 MG-51 MG TABLET	4	Non-Preferred Drug	39%	N/A	P
ENTRESTO 97 MG-103 MG TABLET	4	Non-Preferred Drug	39%	N/A	P
ENULOSE 10 GM/15 ML SOLUTION	2	Generic	$3.00	N/A	None
ENVARSUS XR 0.75 MG TABLET	4	Non-Preferred Drug	39%	N/A	P
ENVARSUS XR 1 MG TABLET	4	Non-Preferred Drug	39%	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	4	Non-Preferred Drug	39%	N/A	P
EPCLUSA 400 MG-100 MG TABLET	5	Specialty Tier	33%	N/A	P Q:30 /30Days
EPINEPHRINE 0.15 MG AUTO-INJCT	3	Preferred Brand	$40.00	N/A	Q:2 /28Days
EPINEPHRINE 0.3 MG AUTO-INJECT	3	Preferred Brand	$40.00	N/A	Q:2 /28Days
Epirubicin HCl 200 MG per 100 ML Injection	4	Non-Preferred Drug	39%	N/A	P
EPITOL 200MG TABLET	4	Non-Preferred Drug	39%	N/A	None
EPIVIR HBV 25MG/5ML TUBEX	3	Preferred Brand	$40.00	N/A	None
Eplerenone 25mg/1 90 TABLET BOTTLE	4	Non-Preferred Drug	39%	N/A	None
Eplerenone 50mg/1 90 TABLET BOTTLE	4	Non-Preferred Drug	39%	N/A	None
EPROSARTAN MESYLATE 600 MG TABLET	2	Generic	$3.00	N/A	None
EQUETRO CAPSULES 200MG 120 BOT	4	Non-Preferred Drug	39%	N/A	Q:240 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EQUETRO CAPSULES 300MG 120 BOT	4	Non-Preferred Drug	39%	N/A	Q:180 /30Days
EQUETRO EXTENDED RELEASE CAPSULES 100MG 120 BOT	4	Non-Preferred Drug	39%	N/A	Q:480 /30Days
ERBITUX 100MG/50ML VIAL	5	Specialty Tier	33%	N/A	P
ERGOLOID MESYLATES TABLETS 1MG 100 BOT	4	Non-Preferred Drug	39%	N/A	P
ERIVEDGE 150 MG CAPSULE	5	Specialty Tier	33%	N/A	P Q:30 /30Days
ERLEADA 60 MG TABLET	5	Specialty Tier	33%	N/A	P
Errin 0.35 mg tablet	3	Preferred Brand	$40.00	N/A	None
ERWINAZE 10,000 UNITS VIAL	5	Specialty Tier	33%	N/A	P
ERY 2% PADS 2% 60 PADS JAR	2	Generic	$3.00	N/A	None
ERYTHROCIN 500MG ADDVNT VL	4	Non-Preferred Drug	39%	N/A	None
ERYTHROCIN TAB 250MG	4	Non-Preferred Drug	39%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ERYTHROMYCIN 0.5% EYE OINTMENT	1	Preferred Generic	$1.00	N/A	None
ERYTHROMYCIN 2% GEL	2	Generic	$3.00	N/A	None
ERYTHROMYCIN 2% SOLUTION	2	Generic	$3.00	N/A	None
ERYTHROMYCIN 500 MG FILMTAB	4	Non-Preferred Drug	39%	N/A	None
ERYTHROMYCIN EC 250 MG CAP	4	Non-Preferred Drug	39%	N/A	None
ERYTHROMYCIN ES 400 MG TAB	4	Non-Preferred Drug	39%	N/A	None
ERYTHROMYCIN TAB 250MG BS	4	Non-Preferred Drug	39%	N/A	None
ERYTHROMYCIN-BENZOYL GEL	4	Non-Preferred Drug	39%	N/A	None
ESBRIET 267 MG CAPSULE	5	Specialty Tier	33%	N/A	P Q:270 /30Days
ESBRIET 267 MG TABLET	5	Specialty Tier	33%	N/A	P Q:270 /30Days
ESBRIET 801 MG TABLET	5	Specialty Tier	33%	N/A	P Q:90 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ESCITALOPRAM 10 MG TABLET [Lexapro]	2	Generic	$3.00	N/A	Q:60 /30Days
ESCITALOPRAM 20 MG TABLET [Lexapro]	2	Generic	$3.00	N/A	Q:30 /30Days
ESCITALOPRAM 5 MG TABLET [Lexapro]	2	Generic	$3.00	N/A	Q:120 /30Days
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro]	4	Non-Preferred Drug	39%	N/A	Q:600 /30Days
ESOMEPRAZOLE SODIUM 20 MG VIAL [Nexium]	4	Non-Preferred Drug	39%	N/A	None
ESOMEPRAZOLE SODIUM 40 MG VIAL [Nexium]	4	Non-Preferred Drug	39%	N/A	None
ESTARYLLA 0.25-0.035 MG TABLET [VyLibra]	4	Non-Preferred Drug	39%	N/A	None
ESTRACE VAG CREAM 0.1MG/GM	4	Non-Preferred Drug	39%	N/A	None
ESTRADIOL 0.01% CREAM	4	Non-Preferred Drug	39%	N/A	None
ESTRADIOL 0.5 MG TABLET	2	Generic	$3.00	N/A	P
ESTRADIOL 1 MG TABLET	2	Generic	$3.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ESTRADIOL 2MG TABLET	2	Generic	$3.00	N/A	P
ESTRADIOL TDS 0.025 MG/DAY	3	Preferred Brand	$40.00	N/A	P Q:4 /28Days
ESTRADIOL TDS 0.0375 MG/DAY	3	Preferred Brand	$40.00	N/A	P Q:4 /28Days
ESTRADIOL TDS 0.05 MG/DAY	3	Preferred Brand	$40.00	N/A	P Q:4 /28Days
ESTRADIOL TDS 0.06 MG/DAY	3	Preferred Brand	$40.00	N/A	P Q:4 /28Days
ESTRADIOL TDS 0.075 MG/DAY	3	Preferred Brand	$40.00	N/A	P Q:4 /28Days
ESTRADIOL TDS 0.1 MG/DAY	3	Preferred Brand	$40.00	N/A	P Q:4 /28Days
ESTRADIOL VALERATE 20mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE	4	Non-Preferred Drug	39%	N/A	None
ESTRADIOL VALERATE 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE	4	Non-Preferred Drug	39%	N/A	None
ESTRING 2MG VAGINAL RING	4	Non-Preferred Drug	39%	N/A	Q:1 /90Days
ESTROPIPATE 0.625(0.75 MG) TABLET	2	Generic	$3.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ESTROPIPATE 1.25(1.5 MG) TABLET	2	Generic	$3.00	N/A	P
ETHAMBUTOL HCL 400 MG TABLET	2	Generic	$3.00	N/A	None
Ethambutol Hydrochloride 100mg/1	2	Generic	$3.00	N/A	None
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6	3	Preferred Brand	$40.00	N/A	None
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21	3	Preferred Brand	$40.00	N/A	None
ETHOSUXIMIDE 250 MG CAPSULE	4	Non-Preferred Drug	39%	N/A	None
ETHOSUXIMIDE 250 MG/5 ML SOLN	3	Preferred Brand	$40.00	N/A	None
ETODOLAC 200 MG CAPSULE [LODINE]	4	Non-Preferred Drug	39%	N/A	None
ETODOLAC 300 MG CAPSULE [LODINE]	4	Non-Preferred Drug	39%	N/A	None
ETODOLAC 400 MG TABLET [LODINE]	2	Generic	$3.00	N/A	None
ETODOLAC 500 MG TABLET [LODINE]	2	Generic	$3.00	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	$3.00	N/A	None
ETODOLAC ER 500 MG TABLET [LODINE]	2	Generic	$3.00	N/A	None
ETODOLAC ER 600 MG TABLET [LODINE]	2	Generic	$3.00	N/A	None
ETOPOPHOS 100MG VIAL	5	Specialty Tier	33%	N/A	P
EVOTAZ 300 MG-150 MG TABLET	5	Specialty Tier	33%	N/A	Q:30 /30Days
EXEMESTANE 25 MG TABLET	4	Non-Preferred Drug	39%	N/A	Q:60 /30Days
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]	4	Non-Preferred Drug	39%	N/A	None

Chart Legend:

Below are a few notes to help you understand the above 2018 Medicare Part D Anthem Blue Cross MedicareRx Plus (PDP) Plan Formulary.

Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)
Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.
Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $405 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.
Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
- Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
- No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.
Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
- Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs. *Some Part D plans exclude one or more drug tiers from the deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
- Tier Description - This is the Medicare Part D plan’s description of this particular drug tier.
Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
- Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $3750) at a "Preferred" network pharmacy. In most cases, the "Preferred" network network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
- Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
- None - This drug does not fall under any drug utilization management controls.
- P - Prior Authorization -This drug is subject to prior authorization.
- S - Step Therapy -This drug is subject to step therapy.
- Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.

(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2018 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.