2019 Medicare Part D Plan Formulary Information |
Community Care's Partnership Program Disabled (HMO SNP) (H2034-002-0)
Benefit Details
|
The Community Care's Partnership Program Disabled (HMO SNP) (H2034-002-0) Formulary Drugs Starting with the Letter E in Calumet County, WI: CMS MA Region 14 which includes: WI Plan Monthly Premium: $40.80 Deductible: $415 |
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 |
EDURANT 27.5mg/1 |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
EFAVIRENZ 200 MG CAPSULE [Sustiva] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
EFAVIRENZ 50 MG CAPSULE [Sustiva] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
EFAVIRENZ 600 MG TABLET [Sustiva] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ELIGARD 22.5 MG SYRINGE |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ELIGARD 30 MG SYRINGE KIT |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ELIGARD 45 MG SYRINGE KIT |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ELIGARD 7.5 MG SYRINGE KIT |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ELIQUIS 2.5 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ELIQUIS 5 MG STARTER PACK |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIQUIS 5 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
EMCYT 140MG CAPSULE |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
EMTRIVA 10MG/ML SOLUTION |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
EMTRIVA 200MG CAPSULE |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ENALAPRIL MALEATE 10 MG TAB |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ENALAPRIL MALEATE 2.5 MG TAB |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ENALAPRIL MALEATE 20 MG TAB |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENALAPRIL MALEATE 5 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
Enalapril Maleate and Hydrochlorothiazide 10; 25mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ENALAPRIL-HCTZ 5-12.5 MG TAB |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ENBREL 25 MG/0.5 ML SYRINGE |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ENBREL 25MG KIT |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ENBREL 50 MG/ML SURECLICK SYR |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ENBREL 50mg/mL |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ENGERIX B INJECTION |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ENGERIX-B 20 MCG/ML SYRN |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ENOXAPARIN 100 MG/ML SYRINGE |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ENOXAPARIN 120 MG/0.8 ML SYRINGE |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENOXAPARIN 150 MG/ML SYRINGE |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ENOXAPARIN 30 MG/0.3 ML SYR |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ENOXAPARIN 40 MG/0.4 ML SYR |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ENOXAPARIN 60 MG/0.6 ML SYRINGE |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ENOXAPARIN 80 MG/0.8 ML SYRINGE |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ENTACAPONE 200 MG TABLET [Comtan Entacapone] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ENTECAVIR 0.5 MG TABLET [Baraclude] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ENTECAVIR 1 MG TABLET [Baraclude] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ENTRESTO 24 MG-26 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ENTRESTO 49 MG-51 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ENTRESTO 97 MG-103 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENULOSE 10 GM/15 ML SOLUTION |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ENVARSUS XR 0.75 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ENVARSUS XR 1 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ENVARSUS XR 4 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
EPIDIOLEX 100 MG/ML SOLUTION |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
EPINEPHRINE 0.15 MG AUTO-INJCT |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:2 /30Days |
EPINEPHRINE 0.15 MG AUTO-INJECT |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:2 /30Days |
EPINEPHRINE 0.3 MG AUTO-INJECT |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:2 /30Days |
EPINEPHRINE 0.3 MG AUTO-INJECT [Twinject] |
1 |
All Formulary Drugs |
$0.00 | N/A | Q:2 /30Days |
EPIVIR HBV 25MG/5ML TUBEX |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
EPOGEN 10000U/ML VIAL MDV |
1 |
All Formulary Drugs |
$0.00 | 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 |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
EPOGEN 3000U/ML VIAL SDV |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
EPOGEN 4000U/ML VIAL SDV |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
EPOGEN INJECTION 20000U 10 X 1ML CRTN |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ERGOLOID MESYLATES TABLETS 1MG 100 BOT |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
Ergotamine-caffeine 1-100mg tb |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ERIVEDGE 150 MG CAPSULE |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ERLEADA 60 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ERLOTINIB HCL 100 MG TABLET [Tarceva] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ERLOTINIB HCL 150 MG TABLET [Tarceva] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ERLOTINIB HCL 25 MG TABLET [Tarceva] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERTAPENEM 1 GRAM VIAL [Invanz] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ERY 2% PADS 2% 60 PADS JAR |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ERYTHROCIN 500MG ADDVNT VL |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ERYTHROCIN TAB 250MG |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ERYTHROMYCIN 0.5% EYE OINTMENT |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ERYTHROMYCIN 2% GEL |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ERYTHROMYCIN 2% SOLUTION |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ERYTHROMYCIN 200 MG/5 ML GRAN Oral Suspension [EryPed] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ERYTHROMYCIN 400 MG/5 ML SUSP Oral Suspension [EryPed] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ERYTHROMYCIN 500 MG FILMTAB |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ERYTHROMYCIN EC 250 MG CAP |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROMYCIN ES 400 MG TAB |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ERYTHROMYCIN TAB 250MG BS |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ERYTHROMYCIN-BENZOYL GEL |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ESBRIET 267 MG CAPSULE |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ESBRIET 267 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ESBRIET 801 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | P |
ESCITALOPRAM 10 MG TABLET [Lexapro] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ESCITALOPRAM 20 MG TABLET [Lexapro] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ESCITALOPRAM 5 MG TABLET [Lexapro] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ESOMEPRAZOLE MAG DR 20 MG CAP [Nexium] |
1 |
All Formulary Drugs |
$0.00 | N/A | 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] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
Estradiol / Norethindrone Acetate 0.5; 0.1mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, FILM C |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ESTRADIOL 0.01% CREAM |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ESTRADIOL 0.5 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ESTRADIOL 1 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ESTRADIOL 10 MCG VAGINAL INSRT |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ESTRADIOL 2MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ESTRADIOL TDS 0.025 MG/DAY |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ESTRADIOL TDS 0.0375 MG/DAY |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ESTRADIOL TDS 0.05 MG/DAY |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ESTRADIOL TDS 0.06 MG/DAY |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL TDS 0.075 MG/DAY |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ESTRADIOL TDS 0.1 MG/DAY |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ESTRADIOL-NORETH 1.0-0.5MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ESTRING 2MG VAGINAL RING |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ETHAMBUTOL HCL 400 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
Ethambutol Hydrochloride 100mg/1 |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21 |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ETHOSUXIMIDE 250 MG CAPSULE |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ETHOSUXIMIDE 250 MG/5 ML SOLN |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ethynodiol-eth estra 1mg-50mcg [ZOVIA] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ETODOLAC 200 MG CAPSULE [LODINE] |
1 |
All Formulary Drugs |
$0.00 | 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 |
All Formulary Drugs |
$0.00 | N/A | None |
ETODOLAC 400 MG TABLET [LODINE] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ETODOLAC 500 MG TABLET [LODINE] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ETODOLAC ER 400 MG TABLET [LODINE] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ETODOLAC ER 500 MG TABLET [LODINE] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
ETODOLAC ER 600 MG TABLET [LODINE] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
EVOTAZ 300 MG-150 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
EXEMESTANE 25 MG TABLET |
1 |
All Formulary Drugs |
$0.00 | N/A | None |
EZETIMIBE 10 MG TABLET [Zetia] |
1 |
All Formulary Drugs |
$0.00 | N/A | None |