2019 Medicare Part D Plan Formulary Information |
WellSelect with Part D (PPO) (H9615-010-0)
Benefit Details
|
The WellSelect with Part D (PPO) (H9615-010-0) Formulary Drugs Starting with the Letter E in Sullivan County, NY: CMS MA Region 3 which includes: NY Plan Monthly Premium: $0.00 Deductible: $325 |
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 |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
EDURANT 27.5mg/1 |
5 |
Specialty Tier |
25% | N/A | None |
EFAVIRENZ 200 MG CAPSULE [Sustiva] |
2* |
Generic |
$11.00 | $22.00 | None |
EFAVIRENZ 50 MG CAPSULE [Sustiva] |
2* |
Generic |
$11.00 | $22.00 | None |
EFAVIRENZ 600 MG TABLET [Sustiva] |
2* |
Generic |
$11.00 | $22.00 | None |
ELETRIPTAN HBR 20 MG TABLET [Relpax] |
2* |
Generic |
$11.00 | $22.00 | Q:12 /30Days |
ELETRIPTAN HBR 40 MG TABLET [Relpax] |
2* |
Generic |
$11.00 | $22.00 | Q:8 /30Days |
ELIGARD 22.5 MG SYRINGE |
4 |
Non-Preferred Drug |
27% | 27% | None |
ELIGARD 30 MG SYRINGE KIT |
4 |
Non-Preferred Drug |
27% | 27% | None |
ELIGARD 45 MG SYRINGE KIT |
4 |
Non-Preferred Drug |
27% | 27% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIGARD 7.5 MG SYRINGE KIT |
4 |
Non-Preferred Drug |
27% | 27% | None |
ELIQUIS 2.5 MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
ELIQUIS 5 MG STARTER PACK |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
ELIQUIS 5 MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
EMCYT 140MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
EMOQUETTE 28 DAY TABLET [Solia] |
2* |
Generic |
$11.00 | $22.00 | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
5 |
Specialty Tier |
25% | N/A | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
5 |
Specialty Tier |
25% | N/A | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
5 |
Specialty Tier |
25% | N/A | None |
EMTRIVA 10MG/ML SOLUTION |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
EMTRIVA 200MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENALAPRIL MALEATE 10 MG TAB |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 2.5 MG TAB |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 20 MG TAB |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 5 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Enalapril Maleate and Hydrochlorothiazide 10; 25mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ENALAPRIL-HCTZ 5-12.5 MG TAB |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ENBREL 25 MG/0.5 ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P |
ENBREL 25MG KIT |
5 |
Specialty Tier |
25% | N/A | P |
ENBREL 50 MG/ML SURECLICK SYR |
5 |
Specialty Tier |
25% | N/A | P |
ENBREL 50mg/mL |
5 |
Specialty Tier |
25% | N/A | P |
ENDOCET 10MG-325MG TABLET |
2* |
Generic |
$11.00 | $22.00 | Q:360 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENDOCET 5/325 TABLET |
2* |
Generic |
$11.00 | $22.00 | Q:360 /30Days |
ENDOCET 7.5-325MG TABLET |
2* |
Generic |
$11.00 | $22.00 | Q:360 /30Days |
ENGERIX B INJECTION |
3 |
Preferred Brand |
$47.00 | $94.00 | P |
ENGERIX-B 20 MCG/ML SYRN |
3 |
Preferred Brand |
$47.00 | $94.00 | P |
ENOXAPARIN 100 MG/ML SYRINGE |
4 |
Non-Preferred Drug |
27% | 27% | None |
ENOXAPARIN 120 MG/0.8 ML SYRINGE |
4 |
Non-Preferred Drug |
27% | 27% | None |
ENOXAPARIN 150 MG/ML SYRINGE |
4 |
Non-Preferred Drug |
27% | 27% | None |
ENOXAPARIN 30 MG/0.3 ML SYR |
4 |
Non-Preferred Drug |
27% | 27% | None |
ENOXAPARIN 40 MG/0.4 ML SYR |
4 |
Non-Preferred Drug |
27% | 27% | None |
ENOXAPARIN 60 MG/0.6 ML SYRINGE |
4 |
Non-Preferred Drug |
27% | 27% | None |
ENOXAPARIN 80 MG/0.8 ML SYRINGE |
4 |
Non-Preferred Drug |
27% | 27% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENSKYCE 28 TABLET [Solia] |
2* |
Generic |
$11.00 | $22.00 | None |
ENTACAPONE 200 MG TABLET [Comtan Entacapone] |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
ENTECAVIR 0.5 MG TABLET [Baraclude] |
4 |
Non-Preferred Drug |
27% | 27% | None |
ENTECAVIR 1 MG TABLET [Baraclude] |
4 |
Non-Preferred Drug |
27% | 27% | None |
ENTRESTO 24 MG-26 MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
ENTRESTO 49 MG-51 MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
ENTRESTO 97 MG-103 MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
ENULOSE 10 GM/15 ML SOLUTION |
2* |
Generic |
$11.00 | $22.00 | None |
EPCLUSA 400 MG-100 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
EPIDIOLEX 100 MG/ML SOLUTION |
5 |
Specialty Tier |
25% | N/A | P |
EPINASTINE HCL 0.05% EYE DROPS |
2* |
Generic |
$11.00 | $22.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPINEPHRINE 0.15 MG AUTO-INJECT |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:4 /30Days |
EPINEPHRINE 0.3 MG AUTO-INJECT |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:4 /30Days |
EPINEPHRINE 0.3 MG AUTO-INJECT [Twinject] |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:4 /30Days |
EPITOL 200MG TABLET |
2* |
Generic |
$11.00 | $22.00 | None |
Eplerenone 25mg/1 90 TABLET BOTTLE |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Eplerenone 50mg/1 90 TABLET BOTTLE |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
EPOGEN 10000U/ML VIAL MDV |
4 |
Non-Preferred Drug |
27% | 27% | P Q:12 /30Days |
EPOGEN 2000[iU]/mL 10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL |
3 |
Preferred Brand |
$47.00 | $94.00 | P Q:12 /30Days |
EPOGEN 3000U/ML VIAL SDV |
3 |
Preferred Brand |
$47.00 | $94.00 | P Q:12 /30Days |
EPOGEN 4000U/ML VIAL SDV |
3 |
Preferred Brand |
$47.00 | $94.00 | P Q:12 /30Days |
EPOGEN INJECTION 20000U 10 X 1ML CRTN |
4 |
Non-Preferred Drug |
27% | 27% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPROSARTAN MESYLATE 600 MG TABLET |
2* |
Generic |
$11.00 | $22.00 | None |
ERGOLOID MESYLATES TABLETS 1MG 100 BOT |
2* |
Generic |
$11.00 | $22.00 | None |
Ergotamine-caffeine 1-100mg tb |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:43 /30Days |
ERIVEDGE 150 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | None |
ERLEADA 60 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
ERLOTINIB HCL 100 MG TABLET [Tarceva] |
5 |
Specialty Tier |
25% | N/A | None |
ERLOTINIB HCL 150 MG TABLET [Tarceva] |
5 |
Specialty Tier |
25% | N/A | None |
ERLOTINIB HCL 25 MG TABLET [Tarceva] |
5 |
Specialty Tier |
25% | N/A | None |
Errin 0.35 mg tablet |
2* |
Generic |
$11.00 | $22.00 | None |
ERTAPENEM 1 GRAM VIAL [Invanz] |
5 |
Specialty Tier |
25% | N/A | None |
ERY 2% PADS 2% 60 PADS JAR |
2* |
Generic |
$11.00 | $22.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
ERY-TAB TAB 250MG EC |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
ERY-TAB TAB 333MG EC |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
ERYTHROCIN 500MG ADDVNT VL |
4 |
Non-Preferred Drug |
27% | 27% | None |
ERYTHROCIN TAB 250MG |
2* |
Generic |
$11.00 | $22.00 | None |
ERYTHROMYCIN 0.5% EYE OINTMENT |
2* |
Generic |
$11.00 | $22.00 | None |
ERYTHROMYCIN 2% GEL |
2* |
Generic |
$11.00 | $22.00 | None |
ERYTHROMYCIN 2% SOLUTION |
2* |
Generic |
$11.00 | $22.00 | None |
ERYTHROMYCIN 500 MG FILMTAB |
2* |
Generic |
$11.00 | $22.00 | None |
ERYTHROMYCIN EC 250 MG CAP |
2* |
Generic |
$11.00 | $22.00 | None |
ERYTHROMYCIN ES 400 MG TAB |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROMYCIN TAB 250MG BS |
2* |
Generic |
$11.00 | $22.00 | None |
ERYTHROMYCIN-BENZOYL GEL |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
ESBRIET 267 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
ESBRIET 267 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
ESBRIET 801 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
ESCITALOPRAM 10 MG TABLET [Lexapro] |
2* |
Generic |
$11.00 | $22.00 | None |
ESCITALOPRAM 20 MG TABLET [Lexapro] |
2* |
Generic |
$11.00 | $22.00 | None |
ESCITALOPRAM 5 MG TABLET [Lexapro] |
2* |
Generic |
$11.00 | $22.00 | None |
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro] |
2* |
Generic |
$11.00 | $22.00 | None |
Estradiol / Norethindrone Acetate 0.5; 0.1mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, FILM C |
2* |
Generic |
$11.00 | $22.00 | None |
ESTRADIOL 0.01% CREAM |
2* |
Generic |
$11.00 | $22.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Estradiol 0.025 mg patch |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Estradiol 0.0375 mg patch |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Estradiol 0.05 mg patch |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Estradiol 0.075 mg patch |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Estradiol 0.1 mg patch |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
ESTRADIOL 0.5 MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
ESTRADIOL 1 MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
ESTRADIOL 10 MCG VAGINAL INSRT |
2* |
Generic |
$11.00 | $22.00 | None |
ESTRADIOL 2MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
ESTRADIOL TDS 0.025 MG/DAY |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
ESTRADIOL TDS 0.0375 MG/DAY |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL TDS 0.05 MG/DAY |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
ESTRADIOL TDS 0.06 MG/DAY |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
ESTRADIOL TDS 0.075 MG/DAY |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
ESTRADIOL TDS 0.1 MG/DAY |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
ESTRADIOL VALERATE 20mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
ESTRADIOL-NORETH 1.0-0.5MG TABLET |
2* |
Generic |
$11.00 | $22.00 | None |
ESTRING 2MG VAGINAL RING |
4 |
Non-Preferred Drug |
27% | 27% | None |
ETHAMBUTOL HCL 400 MG TABLET |
2* |
Generic |
$11.00 | $22.00 | None |
Ethambutol Hydrochloride 100mg/1 |
2* |
Generic |
$11.00 | $22.00 | None |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 |
2* |
Generic |
$11.00 | $22.00 | None |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21 |
2* |
Generic |
$11.00 | $22.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETHOSUXIMIDE 250 MG CAPSULE |
2* |
Generic |
$11.00 | $22.00 | None |
ETHOSUXIMIDE 250 MG/5 ML SOLN |
2* |
Generic |
$11.00 | $22.00 | None |
ETHYNODIOL-ETH ESTRA 1MG-35MCG [ZOVIA] |
2* |
Generic |
$11.00 | $22.00 | None |
ethynodiol-eth estra 1mg-50mcg [ZOVIA] |
2* |
Generic |
$11.00 | $22.00 | None |
ETIDRONATE DISODIUM 400MG TABLET (60 CT) |
2* |
Generic |
$11.00 | $22.00 | None |
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT |
2* |
Generic |
$11.00 | $22.00 | None |
EVOTAZ 300 MG-150 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
EXEMESTANE 25 MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
EXJADE 125MG TABLET |
4 |
Non-Preferred Drug |
27% | 27% | None |
EXJADE 250MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
EXJADE 500MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EZETIMIBE 10 MG TABLET [Zetia] |
2* |
Generic |
$11.00 | $22.00 | None |
Ezetimibe-Simvastatin 10-10 MG [Vytorin] |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Ezetimibe-Simvastatin 10-20 MG [Vytorin] |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Ezetimibe-Simvastatin 10-40 MG [Vytorin] |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
Ezetimibe-Simvastatin 10-80 MG [Vytorin] |
3 |
Preferred Brand |
$47.00 | $94.00 | None |