2020 Medicare Part D Plan Formulary Information |
Centers Plan for Medicare Advantage Care (HMO) (H6988-001-0)
Benefit Details
|
The Centers Plan for Medicare Advantage Care (HMO) (H6988-001-0) Formulary Drugs Starting with the Letter E in New York County, NY: CMS MA Region 3 which includes: NY Plan Monthly Premium: $0.00 Deductible: $395 |
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 |
ECONAZOLE NITRATE 1% CREAM (g) [Spectazole] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
EDARBI 40 MG TABLET |
3 |
Tier 3 |
$47.00 | $117.50 | None |
EDARBI 80 MG TABLET |
3 |
Tier 3 |
$47.00 | $117.50 | None |
EDARBYCLOR 40-12.5 MG TABLET |
3 |
Tier 3 |
$47.00 | $117.50 | None |
EDARBYCLOR 40-25 MG TABLET |
3 |
Tier 3 |
$47.00 | $117.50 | None |
EDURANT 27.5mg/1 |
5 |
Tier 5 |
25% | N/A | None |
EFAVIRENZ 200 MG CAPSULE [Sustiva] |
5 |
Tier 5 |
25% | N/A | None |
EFAVIRENZ 50 MG CAPSULE [Sustiva] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
EFAVIRENZ 600 MG TABLET [Sustiva] |
5 |
Tier 5 |
25% | N/A | None |
EGRIFTA 2 MG VIAL |
5 |
Tier 5 |
25% | N/A | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIGARD 22.5 MG SYRINGE |
4 |
Tier 4 |
$100.00 | $250.00 | None |
ELIGARD 30 MG SYRINGE KIT |
4 |
Tier 4 |
$100.00 | $250.00 | None |
ELIGARD 45 MG SYRINGE KIT |
4 |
Tier 4 |
$100.00 | $250.00 | None |
ELIGARD 7.5 MG SYRINGE KIT |
4 |
Tier 4 |
$100.00 | $250.00 | None |
ELIQUIS 2.5 MG TABLET |
3 |
Tier 3 |
$47.00 | $117.50 | Q:60 /30Days |
ELIQUIS 5 MG STARTER PACK |
3 |
Tier 3 |
$47.00 | $117.50 | None |
ELIQUIS 5 MG TABLET |
3 |
Tier 3 |
$47.00 | $117.50 | Q:60 /30Days |
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE |
4 |
Tier 4 |
$100.00 | $250.00 | Q:90 /30Days |
ELURYNG VAGINAL RING [NuvaRing] |
2* |
Tier 2 |
$15.00 | $37.50 | Q:1 /28Days |
EMCYT 140MG CAPSULE |
5 |
Tier 5 |
25% | N/A | None |
EMEND 125 MG POWDER PACKET |
4 |
Tier 4 |
$100.00 | $250.00 | P Q:6 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMFLAZA 18 MG TABLET |
5 |
Tier 5 |
25% | N/A | P Q:30 /30Days |
EMFLAZA 22.75 MG/ML ORAL SUSPENSION |
5 |
Tier 5 |
25% | N/A | P Q:91 /28Days |
EMFLAZA 30 MG TABLET |
5 |
Tier 5 |
25% | N/A | P Q:60 /30Days |
EMFLAZA 36 MG TABLET |
5 |
Tier 5 |
25% | N/A | P Q:60 /30Days |
EMFLAZA 6 MG TABLET |
5 |
Tier 5 |
25% | N/A | P Q:60 /30Days |
EMGALITY 120 MG/ML PEN INJCTR |
3 |
Tier 3 |
$47.00 | $117.50 | P Q:2 /30Days |
EMGALITY 120 MG/ML SYRINGE |
3 |
Tier 3 |
$47.00 | $117.50 | P Q:2 /30Days |
EMGALITY 300 MG (100 MG X3SYR) SYRINGE |
3 |
Tier 3 |
$47.00 | $117.50 | P Q:3 /30Days |
EMOQUETTE 28 DAY TABLET [Solia] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
Empagliflozin 5 MG / Metformin hydrochloride 500 MG Oral Tablet [Synjardy] |
3 |
Tier 3 |
$47.00 | $117.50 | S Q:60 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
5 |
Tier 5 |
25% | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
5 |
Tier 5 |
25% | N/A | Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
5 |
Tier 5 |
25% | N/A | Q:30 /30Days |
EMTRIVA 10MG/ML SOLUTION |
4 |
Tier 4 |
$100.00 | $250.00 | None |
EMTRIVA 200MG CAPSULE |
4 |
Tier 4 |
$100.00 | $250.00 | None |
ENALAPRIL MALEATE 10 MG TABLET |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ENALAPRIL MALEATE 2.5 MG TABLET |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ENALAPRIL MALEATE 20 MG TABLET |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ENALAPRIL MALEATE 5 MG TABLET |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ENALAPRIL-HCTZ 10-25 MG TABLET [Vaseretic] |
1* |
Tier 1 |
$3.00 | $0.00 | None |
ENALAPRIL-HCTZ 5-12.5 MG TABLET [Vaseretic] |
1* |
Tier 1 |
$3.00 | $0.00 | None |
ENBREL 25 MG/0.5 ML SYRINGE |
5 |
Tier 5 |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENBREL 25MG KIT |
5 |
Tier 5 |
25% | N/A | P |
ENBREL 50 MG/ML MINI CARTRIDGE |
5 |
Tier 5 |
25% | N/A | P |
ENBREL 50 MG/ML SURECLICK SYR |
5 |
Tier 5 |
25% | N/A | P |
ENBREL 50 MG/ML SYRINGE |
5 |
Tier 5 |
25% | N/A | P |
ENDARI 5 GRAM POWDER PACKET |
5 |
Tier 5 |
25% | N/A | P Q:180 /30Days |
ENDOCET 10MG-325MG TABLET |
2* |
Tier 2 |
$15.00 | $37.50 | Q:180 /30Days |
ENDOCET 5/325 TABLET |
2* |
Tier 2 |
$15.00 | $37.50 | Q:360 /30Days |
ENDOCET 7.5-325MG TABLET |
2* |
Tier 2 |
$15.00 | $37.50 | Q:240 /30Days |
ENGERIX B INJECTION |
3 |
Tier 3 |
$47.00 | $117.50 | P |
ENGERIX-B 20 MCG/ML SYRINGE |
3 |
Tier 3 |
$47.00 | $117.50 | P |
ENOXAPARIN 100 MG/ML SYRINGE [Lovenox] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENOXAPARIN 120 MG/0.8 ML SYRINGE [Lovenox] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ENOXAPARIN 150 MG/ML SYRINGE [Lovenox] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ENOXAPARIN 30 MG/0.3 ML SYRINGE [Lovenox] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ENOXAPARIN 40 MG/0.4 ML SYRINGE [Lovenox] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ENOXAPARIN 60 MG/0.6 ML SYRINGE [Lovenox] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ENOXAPARIN 80 MG/0.8 ML SYRINGE [Lovenox] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ENSKYCE 28 TABLET [Solia] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ENTACAPONE 200 MG TABLET [Comtan Entacapone] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ENTECAVIR 0.5 MG TABLET [Baraclude] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ENTECAVIR 1 MG TABLET [Baraclude] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ENTRESTO 24 MG-26 MG TABLET |
3 |
Tier 3 |
$47.00 | $117.50 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENTRESTO 49 MG-51 MG TABLET |
3 |
Tier 3 |
$47.00 | $117.50 | Q:60 /30Days |
ENTRESTO 97 MG-103 MG TABLET |
3 |
Tier 3 |
$47.00 | $117.50 | Q:60 /30Days |
ENULOSE 10 GM/15 ML SOLUTION |
2* |
Tier 2 |
$15.00 | $37.50 | None |
EPCLUSA 400 MG-100 MG TABLET |
5 |
Tier 5 |
25% | N/A | P Q:28 /28Days |
EPIDIOLEX 100 MG/ML SOLUTION |
5 |
Tier 5 |
25% | N/A | P |
EPINASTINE HCL 0.05% EYE DROPS |
2* |
Tier 2 |
$15.00 | $37.50 | None |
EPINEPHRINE 0.15 MG AUTO-INJECT [Twinject] |
2* |
Tier 2 |
$15.00 | $37.50 | Q:4 /30Days |
EPINEPHRINE 0.3 MG AUTO-INJECT [Twinject] |
2* |
Tier 2 |
$15.00 | $37.50 | Q:4 /30Days |
EPITOL 200MG TABLET |
2* |
Tier 2 |
$15.00 | $37.50 | None |
EPIVIR HBV 25MG/5ML TUBEX |
4 |
Tier 4 |
$100.00 | $250.00 | None |
EPLERENONE 25 MG TABLET [Inspra] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPLERENONE 50 MG TABLET [Inspra] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
EPOGEN 10000U/ML VIAL MDV |
3 |
Tier 3 |
$47.00 | $117.50 | P Q:12 /28Days |
EPOGEN 2000[iU]/mL 10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL |
3 |
Tier 3 |
$47.00 | $117.50 | P Q:12 /28Days |
EPOGEN 3000U/ML VIAL SDV |
3 |
Tier 3 |
$47.00 | $117.50 | P Q:12 /28Days |
EPOGEN 4000U/ML VIAL SDV |
3 |
Tier 3 |
$47.00 | $117.50 | P Q:12 /28Days |
EPOGEN INJECTION 20000U 10 X 1ML CRTN |
5 |
Tier 5 |
25% | N/A | P Q:12 /28Days |
ERGOLOID MESYLATES TABLETS 1MG 100 BOT |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ERIVEDGE 150 MG CAPSULE |
5 |
Tier 5 |
25% | N/A | P Q:30 /30Days |
ERLEADA 60 MG TABLET |
5 |
Tier 5 |
25% | N/A | P Q:120 /30Days |
ERLOTINIB HCL 100 MG TABLET [Tarceva] |
5 |
Tier 5 |
25% | N/A | P Q:60 /30Days |
ERLOTINIB HCL 150 MG TABLET [Tarceva] |
5 |
Tier 5 |
25% | N/A | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERLOTINIB HCL 25 MG TABLET [Tarceva] |
5 |
Tier 5 |
25% | N/A | P Q:60 /30Days |
ERRIN 0.35 MG TABLET [Sharobel 28-Day] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ERTAPENEM 1 GRAM VIAL [Invanz] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ERY 2% PADS 2% 60 PADS JAR |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ERYTHROMYCIN 0.5% EYE OINTMENT [Romycin] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ERYTHROMYCIN 2% GEL [Erygel] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ERYTHROMYCIN 2% SOLUTION |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ERYTHROMYCIN 200 MG/5 ML ORAL SUSPENSION [EryPed] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ERYTHROMYCIN 400 MG/5 ML SUSP Oral Suspension [EryPed] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ERYTHROMYCIN 500 MG FILMTAB |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ERYTHROMYCIN TABLET 250MG BS |
2* |
Tier 2 |
$15.00 | $37.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESBRIET 267 MG CAPSULE |
5 |
Tier 5 |
25% | N/A | P Q:270 /30Days |
ESBRIET 267 MG TABLET |
5 |
Tier 5 |
25% | N/A | P Q:270 /30Days |
ESBRIET 801 MG TABLET |
5 |
Tier 5 |
25% | N/A | P Q:90 /30Days |
ESCITALOPRAM 10 MG TABLET [Lexapro] |
1* |
Tier 1 |
$3.00 | $0.00 | None |
ESCITALOPRAM 20 MG TABLET [Lexapro] |
1* |
Tier 1 |
$3.00 | $0.00 | None |
ESCITALOPRAM 5 MG TABLET [Lexapro] |
1* |
Tier 1 |
$3.00 | $0.00 | None |
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ESTARYLLA 0.25-0.035 MG TABLET [VyLibra] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
Estradiol / Norethindrone Acetate 0.5; 0.1mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, FILM C |
2* |
Tier 2 |
$15.00 | $37.50 | P |
ESTRADIOL 0.01% CREAM |
2* |
Tier 2 |
$15.00 | $37.50 | None |
Estradiol 0.025 mg patch |
2* |
Tier 2 |
$15.00 | $37.50 | P Q:8 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Estradiol 0.0375 mg patch |
2* |
Tier 2 |
$15.00 | $37.50 | P Q:8 /28Days |
Estradiol 0.05 mg patch |
2* |
Tier 2 |
$15.00 | $37.50 | P Q:8 /28Days |
Estradiol 0.075 mg patch |
2* |
Tier 2 |
$15.00 | $37.50 | P Q:8 /28Days |
Estradiol 0.1 mg patch |
2* |
Tier 2 |
$15.00 | $37.50 | P Q:8 /28Days |
ESTRADIOL 0.5 MG TABLET |
1* |
Tier 1 |
$3.00 | $0.00 | P |
ESTRADIOL 1 MG TABLET |
1* |
Tier 1 |
$3.00 | $0.00 | P |
ESTRADIOL 10 MCG VAGINAL INSRT |
2* |
Tier 2 |
$15.00 | $37.50 | Q:18 /28Days |
ESTRADIOL 2MG TABLET |
1* |
Tier 1 |
$3.00 | $0.00 | P |
ESTRADIOL TDS 0.025 MG/DAY |
2* |
Tier 2 |
$15.00 | $37.50 | P Q:4 /28Days |
ESTRADIOL TDS 0.0375 MG/DAY |
2* |
Tier 2 |
$15.00 | $37.50 | P Q:4 /28Days |
ESTRADIOL TDS 0.05 MG/DAY |
2* |
Tier 2 |
$15.00 | $37.50 | P 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* |
Tier 2 |
$15.00 | $37.50 | P Q:4 /28Days |
ESTRADIOL TDS 0.075 MG/DAY |
2* |
Tier 2 |
$15.00 | $37.50 | P Q:4 /28Days |
ESTRADIOL TDS 0.1 MG/DAY |
2* |
Tier 2 |
$15.00 | $37.50 | P Q:4 /28Days |
ESTRADIOL VALERATE 20mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ESTRADIOL VALERATE 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ESZOPICLONE 1 MG TABLET [Lunesta] |
2* |
Tier 2 |
$15.00 | $37.50 | Q:30 /30Days |
ESZOPICLONE 2 MG TABLET [Lunesta] |
2* |
Tier 2 |
$15.00 | $37.50 | Q:30 /30Days |
ESZOPICLONE 3 MG TABLET [Lunesta] |
2* |
Tier 2 |
$15.00 | $37.50 | Q:30 /30Days |
ETHAMBUTOL HCL 400 MG TABLET |
2* |
Tier 2 |
$15.00 | $37.50 | None |
Ethambutol Hydrochloride 100mg/1 |
2* |
Tier 2 |
$15.00 | $37.50 | None |
Ethinyl Estradiol 0.0025 MG / norethindrone acetate 0.5 MG Oral Tablet [Fyavolv] |
2* |
Tier 2 |
$15.00 | $37.50 | P |
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 |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TABLET 21 |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ETHOSUXIMIDE 250 MG CAPSULE [Zarontin] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ETHOSUXIMIDE 250 MG/5 ML SOLN |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ETHYNODIOL-ETH ESTRA 1MG-35MCG [ZOVIA] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ETHYNODIOL-ETH ESTRA 1MG-50MCG [ZOVIA] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ETODOLAC 200 MG CAPSULE [Lodine] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ETODOLAC 300 MG CAPSULE [Lodine] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ETODOLAC 400 MG TABLET [Lodine] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ETODOLAC 500 MG TABLET [Lodine] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
ETONOGESTREL-EE VAGINAL RING [NuvaRing] |
2* |
Tier 2 |
$15.00 | $37.50 | Q:1 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EUCRISA 2% OINTMENT |
3 |
Tier 3 |
$47.00 | $117.50 | None |
EVENITY 210 MG DOSE-2 SYRINGES |
5 |
Tier 5 |
25% | N/A | P Q:2 /30Days |
EVEROLIMUS 0.25 MG TABLET [Zortress] |
2* |
Tier 2 |
$15.00 | $37.50 | P |
EVEROLIMUS 0.5 MG TABLET [Zortress] |
5 |
Tier 5 |
25% | N/A | P |
EVEROLIMUS 0.75 MG TABLET [Zortress] |
5 |
Tier 5 |
25% | N/A | P |
EVOTAZ 300 MG-150 MG TABLET |
5 |
Tier 5 |
25% | N/A | None |
EXEMESTANE 25 MG TABLET [Aromasin] |
2* |
Tier 2 |
$15.00 | $37.50 | None |
EXTAVIA 0.3 MG KIT |
5 |
Tier 5 |
25% | N/A | P Q:15 /30Days |
EZETIMIBE 10 MG TABLET [Zetia] |
2* |
Tier 2 |
$15.00 | $37.50 | Q:30 /30Days |