2019 Medicare Part D Plan Formulary Information |
Allwell Dual Medicare (HMO SNP) (H1664-005-0)
Benefit Details
|
The Allwell Dual Medicare (HMO SNP) (H1664-005-0) Formulary Drugs Starting with the Letter E in Polk County, MO: CMS MA Region 15 which includes: MO Plan Monthly Premium: $32.10 Deductible: $175 |
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 |
2 |
Generic |
$15.00 | $45.00 | None |
ECONAZOLE NITRATE 1% CREAM 85GM TUBE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
EDURANT 27.5mg/1 |
5 |
Specialty Tier |
29% | N/A | None |
EFAVIRENZ 200 MG CAPSULE [Sustiva] |
2 |
Generic |
$15.00 | $45.00 | None |
EFAVIRENZ 50 MG CAPSULE [Sustiva] |
2 |
Generic |
$15.00 | $45.00 | None |
EFAVIRENZ 600 MG TABLET [Sustiva] |
2 |
Generic |
$15.00 | $45.00 | None |
ELIGARD 22.5 MG SYRINGE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ELIGARD 30 MG SYRINGE KIT |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ELIGARD 45 MG SYRINGE KIT |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ELIGARD 7.5 MG SYRINGE KIT |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
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 |
$47.00 | $141.00 | None |
ELIQUIS 5 MG STARTER PACK |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
ELIQUIS 5 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
EMCYT 140MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
EMFLAZA 18 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P |
EMFLAZA 22.75 MG/ML ORAL SUSP |
5 |
Specialty Tier |
29% | N/A | P |
EMFLAZA 30 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P |
EMFLAZA 36 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P |
EMFLAZA 6 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P |
EMGALITY 120 MG/ML PEN INJCTR |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
EMGALITY 120 MG/ML SYRINGE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMOQUETTE 28 DAY TABLET [Solia] |
2 |
Generic |
$15.00 | $45.00 | None |
Empagliflozin 5 MG / Metformin hydrochloride 500 MG Oral Tablet [Synjardy] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
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 |
EMTRIVA 10MG/ML SOLUTION |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
EMTRIVA 200MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ENALAPRIL MALEATE 10 MG TAB |
6* |
Select Care Drugs |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 2.5 MG TAB |
6* |
Select Care Drugs |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 20 MG TAB |
6* |
Select Care Drugs |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 5 MG TABLET |
6* |
Select Care Drugs |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Enalapril Maleate and Hydrochlorothiazide 10; 25mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
6* |
Select Care Drugs |
$0.00 | $0.00 | None |
ENALAPRIL-HCTZ 5-12.5 MG TAB |
6* |
Select Care Drugs |
$0.00 | $0.00 | None |
ENBREL 25 MG/0.5 ML SYRINGE |
5 |
Specialty Tier |
29% | N/A | P |
ENBREL 25MG KIT |
5 |
Specialty Tier |
29% | N/A | P |
ENBREL 50 MG/ML SURECLICK SYR |
5 |
Specialty Tier |
29% | N/A | P |
ENBREL 50mg/mL |
5 |
Specialty Tier |
29% | N/A | P |
ENDARI 5 GRAM POWDER PACKET |
5 |
Specialty Tier |
29% | N/A | P |
ENDOCET 10MG-325MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
ENDOCET 5/325 TABLET |
2 |
Generic |
$15.00 | $45.00 | None |
ENDOCET 7.5-325MG TABLET |
2 |
Generic |
$15.00 | $45.00 | None |
ENGERIX B INJECTION |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENGERIX-B 20 MCG/ML SYRN |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
ENOXAPARIN 100 MG/ML SYRINGE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ENOXAPARIN 120 MG/0.8 ML SYRINGE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ENOXAPARIN 150 MG/ML SYRINGE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ENOXAPARIN 30 MG/0.3 ML SYR |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ENOXAPARIN 40 MG/0.4 ML SYR |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ENOXAPARIN 60 MG/0.6 ML SYRINGE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ENOXAPARIN 80 MG/0.8 ML SYRINGE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ENSKYCE 28 TABLET [Solia] |
2 |
Generic |
$15.00 | $45.00 | None |
ENTACAPONE 200 MG TABLET [Comtan Entacapone] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ENTECAVIR 0.5 MG TABLET [Baraclude] |
5 |
Specialty Tier |
29% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENTECAVIR 1 MG TABLET [Baraclude] |
5 |
Specialty Tier |
29% | N/A | None |
ENTRESTO 24 MG-26 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
ENTRESTO 49 MG-51 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
ENTRESTO 97 MG-103 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
ENULOSE 10 GM/15 ML SOLUTION |
2 |
Generic |
$15.00 | $45.00 | None |
ENVARSUS XR 0.75 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
ENVARSUS XR 1 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
ENVARSUS XR 4 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
EPCLUSA 400 MG-100 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P |
EPIDIOLEX 100 MG/ML SOLUTION |
5 |
Specialty Tier |
29% | N/A | P |
EPINASTINE HCL 0.05% EYE DROPS |
3 |
Preferred Brand |
$47.00 | $141.00 | 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 |
$47.00 | $141.00 | None |
EPINEPHRINE 0.15 MG AUTO-INJECT |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
EPINEPHRINE 0.3 MG AUTO-INJECT |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
EPINEPHRINE 0.3 MG AUTO-INJECT [Twinject] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
EPIPEN 0.3MG AUTO-INJECTOR |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
EPIPEN JR 0.15MG AUTO-INJCT |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
EPITOL 200MG TABLET |
2 |
Generic |
$15.00 | $45.00 | None |
EPIVIR HBV 25MG/5ML TUBEX |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
Eplerenone 25mg/1 90 TABLET BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
Eplerenone 50mg/1 90 TABLET BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
EPOGEN 10000U/ML VIAL MDV |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | 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 Drug |
$100.00 | $300.00 | P |
EPOGEN 3000U/ML VIAL SDV |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
EPOGEN 4000U/ML VIAL SDV |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
EPOGEN INJECTION 20000U 10 X 1ML CRTN |
5 |
Specialty Tier |
29% | N/A | P |
EPROSARTAN MESYLATE 600 MG TABLET |
6* |
Select Care Drugs |
$0.00 | $0.00 | None |
EQUETRO CAPSULES 200MG 120 BOT |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
EQUETRO CAPSULES 300MG 120 BOT |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
EQUETRO EXTENDED RELEASE CAPSULES 100MG 120 BOT |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ERAXIS 100mg/30mL 30 mL in 1 VIAL, SINGLE-USE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ERAXIS(WATER DIL) 50 MG VIAL |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ERGOLOID MESYLATES TABLETS 1MG 100 BOT |
2 |
Generic |
$15.00 | $45.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERIVEDGE 150 MG CAPSULE |
5 |
Specialty Tier |
29% | N/A | None |
ERLEADA 60 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P |
ERLOTINIB HCL 100 MG TABLET [Tarceva] |
5 |
Specialty Tier |
29% | N/A | P |
ERLOTINIB HCL 150 MG TABLET [Tarceva] |
5 |
Specialty Tier |
29% | N/A | P |
ERLOTINIB HCL 25 MG TABLET [Tarceva] |
5 |
Specialty Tier |
29% | N/A | P |
Errin 0.35 mg tablet |
2 |
Generic |
$15.00 | $45.00 | None |
ERTAPENEM 1 GRAM VIAL [Invanz] |
2 |
Generic |
$15.00 | $45.00 | None |
ERYTHROCIN 500MG ADDVNT VL |
2 |
Generic |
$15.00 | $45.00 | None |
ERYTHROMYCIN 0.5% EYE OINTMENT |
2 |
Generic |
$15.00 | $45.00 | None |
ERYTHROMYCIN 2% SOLUTION |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
ERYTHROMYCIN 500 MG FILMTAB |
2 |
Generic |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROMYCIN ES 400 MG TAB |
2 |
Generic |
$15.00 | $45.00 | None |
ERYTHROMYCIN TAB 250MG BS |
2 |
Generic |
$15.00 | $45.00 | None |
ERYTHROMYCIN-BENZOYL GEL |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ESBRIET 267 MG CAPSULE |
5 |
Specialty Tier |
29% | N/A | P |
ESBRIET 267 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P |
ESBRIET 801 MG TABLET |
5 |
Specialty Tier |
29% | N/A | P |
ESCITALOPRAM 10 MG TABLET [Lexapro] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ESCITALOPRAM 20 MG TABLET [Lexapro] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ESCITALOPRAM 5 MG TABLET [Lexapro] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ESOMEPRAZOLE MAG DR 20 MG CAP [Nexium] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESOMEPRAZOLE MAG DR 40 MG CAP [Nexium] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ESTARYLLA 0.25-0.035 MG TABLET [VyLibra] |
2 |
Generic |
$15.00 | $45.00 | None |
Estradiol / Norethindrone Acetate 0.5; 0.1mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, FILM C |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
ESTRADIOL 0.01% CREAM |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ESTRADIOL 0.5 MG TABLET |
2 |
Generic |
$15.00 | $45.00 | P |
ESTRADIOL 1 MG TABLET |
2 |
Generic |
$15.00 | $45.00 | P |
ESTRADIOL 2MG TABLET |
2 |
Generic |
$15.00 | $45.00 | P |
ESTRADIOL TDS 0.025 MG/DAY |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
ESTRADIOL TDS 0.0375 MG/DAY |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
ESTRADIOL TDS 0.05 MG/DAY |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
ESTRADIOL TDS 0.06 MG/DAY |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL TDS 0.075 MG/DAY |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
ESTRADIOL TDS 0.1 MG/DAY |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
ESTRADIOL VALERATE 20mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
ESTRADIOL VALERATE 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
ESTRADIOL-NORETH 1.0-0.5MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
ETHAMBUTOL HCL 400 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Ethambutol Hydrochloride 100mg/1 |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Ethinyl Estradiol 0.0025 MG / norethindrone acetate 0.5 MG Oral Tablet [Fyavolv] |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21 |
2 |
Generic |
$15.00 | $45.00 | None |
ETHOSUXIMIDE 250 MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETHOSUXIMIDE 250 MG/5 ML SOLN |
2 |
Generic |
$15.00 | $45.00 | None |
ETHYNODIOL-ETH ESTRA 1MG-35MCG [ZOVIA] |
2 |
Generic |
$15.00 | $45.00 | None |
ethynodiol-eth estra 1mg-50mcg [ZOVIA] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ETODOLAC 200 MG CAPSULE [LODINE] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
ETODOLAC 300 MG CAPSULE [LODINE] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
ETODOLAC 400 MG TABLET [LODINE] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
ETODOLAC 500 MG TABLET [LODINE] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
ETODOLAC ER 400 MG TABLET [LODINE] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ETODOLAC ER 500 MG TABLET [LODINE] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ETODOLAC ER 600 MG TABLET [LODINE] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
EVOTAZ 300 MG-150 MG TABLET |
5 |
Specialty Tier |
29% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EXEMESTANE 25 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
EZETIMIBE 10 MG TABLET [Zetia] |
2 |
Generic |
$15.00 | $45.00 | Q:1 /1Days |
Ezetimibe-Simvastatin 10-10 MG [Vytorin] |
2 |
Generic |
$15.00 | $45.00 | Q:8 /1Days |
Ezetimibe-Simvastatin 10-20 MG [Vytorin] |
2 |
Generic |
$15.00 | $45.00 | Q:4 /1Days |
Ezetimibe-Simvastatin 10-40 MG [Vytorin] |
2 |
Generic |
$15.00 | $45.00 | Q:2 /1Days |
Ezetimibe-Simvastatin 10-80 MG [Vytorin] |
2 |
Generic |
$15.00 | $45.00 | Q:1 /1Days |