2020 Medicare Part D Plan Formulary Information |
Medicare Plus Blue PPO Essential (PPO) (H9572-004-3)
Benefit Details
|
The Medicare Plus Blue PPO Essential (PPO) (H9572-004-3) Formulary Drugs Starting with the Letter E in Charlevoix County, MI: CMS MA Region 11 which includes: MI Plan Monthly Premium: $18.00 Deductible: $200 |
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] |
4 |
Tier 4 |
50% | 50% | None |
EDARBI 40 MG TABLET |
4 |
Tier 4 |
50% | 50% | None |
EDARBI 80 MG TABLET |
4 |
Tier 4 |
50% | 50% | None |
EDARBYCLOR 40-12.5 MG TABLET |
4 |
Tier 4 |
50% | 50% | None |
EDARBYCLOR 40-25 MG TABLET |
4 |
Tier 4 |
50% | 50% | None |
EDURANT 27.5mg/1 |
5 |
Tier 5 |
29% | N/A | None |
EFAVIRENZ 200 MG CAPSULE [Sustiva] |
4 |
Tier 4 |
50% | 50% | None |
EFAVIRENZ 50 MG CAPSULE [Sustiva] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
EFAVIRENZ 600 MG TABLET [Sustiva] |
5 |
Tier 5 |
29% | N/A | None |
EGRIFTA 2 MG VIAL |
5 |
Tier 5 |
29% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELETRIPTAN HBR 20 MG TABLET [Relpax] |
4 |
Tier 4 |
50% | 50% | Q:18 /90Days |
ELETRIPTAN HBR 40 MG TABLET [Relpax] |
4 |
Tier 4 |
50% | 50% | Q:18 /90Days |
ELIQUIS 2.5 MG TABLET |
3 |
Tier 3 |
$42.00 | $126.00 | Q:180 /90Days |
ELIQUIS 5 MG STARTER PACK |
3 |
Tier 3 |
$42.00 | $126.00 | None |
ELIQUIS 5 MG TABLET |
3 |
Tier 3 |
$42.00 | $126.00 | Q:194 /90Days |
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE |
3 |
Tier 3 |
$42.00 | $126.00 | None |
ELURYNG VAGINAL RING [NuvaRing] |
4 |
Tier 4 |
50% | 50% | Q:3 /84Days |
EMCYT 140MG CAPSULE |
5 |
Tier 5 |
29% | N/A | None |
EMEND 125 MG POWDER PACKET |
4 |
Tier 4 |
50% | 50% | P |
EMOQUETTE 28 DAY TABLET [Solia] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
5 |
Tier 5 |
29% | N/A | None |
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 |
29% | N/A | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
5 |
Tier 5 |
29% | N/A | None |
EMTRIVA 10MG/ML SOLUTION |
3 |
Tier 3 |
$42.00 | $126.00 | None |
EMTRIVA 200MG CAPSULE |
3 |
Tier 3 |
$42.00 | $126.00 | None |
ENALAPRIL MALEATE 10 MG TABLET |
6* |
Tier 6 |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 2.5 MG TABLET |
6* |
Tier 6 |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 20 MG TABLET |
6* |
Tier 6 |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 5 MG TABLET |
6* |
Tier 6 |
$0.00 | $0.00 | None |
ENALAPRIL-HCTZ 10-25 MG TABLET [Vaseretic] |
6* |
Tier 6 |
$0.00 | $0.00 | None |
ENALAPRIL-HCTZ 5-12.5 MG TABLET [Vaseretic] |
6* |
Tier 6 |
$0.00 | $0.00 | None |
ENBREL 25 MG/0.5 ML SYRINGE |
5 |
Tier 5 |
29% | N/A | P Q:8 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENBREL 25MG KIT |
5 |
Tier 5 |
29% | N/A | P Q:16 /28Days |
ENBREL 50 MG/ML MINI CARTRIDGE |
5 |
Tier 5 |
29% | N/A | P Q:8 /28Days |
ENBREL 50 MG/ML SURECLICK SYR |
5 |
Tier 5 |
29% | N/A | P Q:8 /28Days |
ENBREL 50 MG/ML SYRINGE |
5 |
Tier 5 |
29% | N/A | P Q:8 /28Days |
ENDARI 5 GRAM POWDER PACKET |
5 |
Tier 5 |
29% | N/A | None |
ENDOCET 10MG-325MG TABLET |
2 |
Tier 2 |
$11.00 | $33.00 | Q:1080 /90Days |
ENDOCET 5/325 TABLET |
2 |
Tier 2 |
$11.00 | $33.00 | Q:1080 /90Days |
ENDOCET 7.5-325MG TABLET |
2 |
Tier 2 |
$11.00 | $33.00 | Q:1080 /90Days |
ENGERIX B INJECTION |
3 |
Tier 3 |
$42.00 | $126.00 | P |
ENGERIX-B 20 MCG/ML SYRINGE |
3 |
Tier 3 |
$42.00 | $126.00 | P |
ENOXAPARIN 100 MG/ML SYRINGE [Lovenox] |
4 |
Tier 4 |
50% | 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] |
4 |
Tier 4 |
50% | 50% | None |
ENOXAPARIN 150 MG/ML SYRINGE [Lovenox] |
4 |
Tier 4 |
50% | 50% | None |
ENOXAPARIN 30 MG/0.3 ML SYRINGE [Lovenox] |
4 |
Tier 4 |
50% | 50% | None |
ENOXAPARIN 40 MG/0.4 ML SYRINGE [Lovenox] |
4 |
Tier 4 |
50% | 50% | None |
ENOXAPARIN 60 MG/0.6 ML SYRINGE [Lovenox] |
4 |
Tier 4 |
50% | 50% | None |
ENOXAPARIN 80 MG/0.8 ML SYRINGE [Lovenox] |
4 |
Tier 4 |
50% | 50% | None |
ENSKYCE 28 TABLET [Solia] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ENTACAPONE 200 MG TABLET [Comtan Entacapone] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ENTECAVIR 0.5 MG TABLET [Baraclude] |
3 |
Tier 3 |
$42.00 | $126.00 | None |
ENTECAVIR 1 MG TABLET [Baraclude] |
3 |
Tier 3 |
$42.00 | $126.00 | None |
ENTRESTO 24 MG-26 MG TABLET |
4 |
Tier 4 |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENTRESTO 49 MG-51 MG TABLET |
4 |
Tier 4 |
50% | 50% | None |
ENTRESTO 97 MG-103 MG TABLET |
4 |
Tier 4 |
50% | 50% | None |
ENULOSE 10 GM/15 ML SOLUTION |
2 |
Tier 2 |
$11.00 | $33.00 | None |
EPCLUSA 400 MG-100 MG TABLET |
5 |
Tier 5 |
29% | N/A | P |
EPIDIOLEX 100 MG/ML SOLUTION |
5 |
Tier 5 |
29% | N/A | P |
EPINASTINE HCL 0.05% EYE DROPS |
2 |
Tier 2 |
$11.00 | $33.00 | None |
EPINEPHRINE 0.15 MG AUTO-INJECT |
3 |
Tier 3 |
$42.00 | $126.00 | None |
EPINEPHRINE 0.15 MG AUTO-INJECT [Twinject] |
3 |
Tier 3 |
$42.00 | $126.00 | None |
EPINEPHRINE 0.3 MG AUTO-INJECT |
3 |
Tier 3 |
$42.00 | $126.00 | None |
EPINEPHRINE 0.3 MG AUTO-INJECT [Twinject] |
3 |
Tier 3 |
$42.00 | $126.00 | None |
EPIPEN 0.3MG AUTO-INJECTOR |
4 |
Tier 4 |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPIPEN JR 0.15MG AUTO-INJCT |
3 |
Tier 3 |
$42.00 | $126.00 | None |
EPITOL 200MG TABLET |
2 |
Tier 2 |
$11.00 | $33.00 | None |
EPLERENONE 25 MG TABLET [Inspra] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
EPLERENONE 50 MG TABLET [Inspra] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
EPOGEN 10000U/ML VIAL MDV |
4 |
Tier 4 |
50% | 50% | P |
EPOGEN 2000[iU]/mL 10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL |
4 |
Tier 4 |
50% | 50% | P |
EPOGEN 3000U/ML VIAL SDV |
4 |
Tier 4 |
50% | 50% | P |
EPOGEN 4000U/ML VIAL SDV |
4 |
Tier 4 |
50% | 50% | P |
EPOGEN INJECTION 20000U 10 X 1ML CRTN |
4 |
Tier 4 |
50% | 50% | P |
ERAXIS 100mg/30mL 30 mL in 1 VIAL, SINGLE-USE |
4 |
Tier 4 |
50% | 50% | None |
ERAXIS(WATER DIL) 50 MG VIAL |
4 |
Tier 4 |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERGOLOID MESYLATES TABLETS 1MG 100 BOT |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ERIVEDGE 150 MG CAPSULE |
5 |
Tier 5 |
29% | N/A | P |
ERLEADA 60 MG TABLET |
5 |
Tier 5 |
29% | N/A | P |
ERLOTINIB HCL 100 MG TABLET [Tarceva] |
5 |
Tier 5 |
29% | N/A | P |
ERLOTINIB HCL 150 MG TABLET [Tarceva] |
5 |
Tier 5 |
29% | N/A | P |
ERLOTINIB HCL 25 MG TABLET [Tarceva] |
5 |
Tier 5 |
29% | N/A | P |
ERRIN 0.35 MG TABLET [Sharobel 28-Day] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ERTAPENEM 1 GRAM VIAL [Invanz] |
4 |
Tier 4 |
50% | 50% | None |
ERY 2% PADS 2% 60 PADS JAR |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ERY-TAB TABLET 250MG EC |
4 |
Tier 4 |
50% | 50% | None |
ERY-TAB TABLET 333MG EC |
4 |
Tier 4 |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYGEL 2% GEL |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ERYTHROCIN 250 MG FILMTAB TABLET |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ERYTHROMYCIN 0.5% EYE OINTMENT [Romycin] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ERYTHROMYCIN 2% GEL [Erygel] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ERYTHROMYCIN 2% SOLUTION |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ERYTHROMYCIN 200 MG/5 ML ORAL SUSPENSION [EryPed] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ERYTHROMYCIN 500 MG FILMTAB |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ERYTHROMYCIN DR 250 MG CAPSULE DR [ERYC] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ERYTHROMYCIN DR 250 MG TABLET DR [Ery-Tab] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ERYTHROMYCIN DR 333 MG TABLET DR [Ery-Tab] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ERYTHROMYCIN ES 400 MG TABLET |
2 |
Tier 2 |
$11.00 | $33.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROMYCIN TABLET 250MG BS |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ERYTHROMYCIN-BENZOYL GEL |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ESBRIET 267 MG TABLET |
5 |
Tier 5 |
29% | N/A | P Q:279 /31Days |
ESBRIET 801 MG TABLET |
5 |
Tier 5 |
29% | N/A | P Q:93 /31Days |
ESCITALOPRAM 10 MG TABLET [Lexapro] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ESCITALOPRAM 20 MG TABLET [Lexapro] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ESCITALOPRAM 5 MG TABLET [Lexapro] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ESOMEPRAZOLE MAG DR 20 MG CAPSULE [Nexium] |
4 |
Tier 4 |
50% | 50% | None |
ESOMEPRAZOLE MAG DR 40 MG CAPSULE [Nexium] |
4 |
Tier 4 |
50% | 50% | None |
ESTARYLLA 0.25-0.035 MG TABLET [VyLibra] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL 0.01% CREAM |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ESTRADIOL 0.5 MG TABLET |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ESTRADIOL 1 MG TABLET |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ESTRADIOL 10 MCG VAGINAL INSRT |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ESTRADIOL 2MG TABLET |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ESTRADIOL VALERATE 20mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
4 |
Tier 4 |
50% | 50% | None |
ESTRING 2MG VAGINAL RING |
3 |
Tier 3 |
$42.00 | $126.00 | Q:1 /90Days |
ETHAMBUTOL HCL 400 MG TABLET |
2 |
Tier 2 |
$11.00 | $33.00 | None |
Ethambutol Hydrochloride 100mg/1 |
2 |
Tier 2 |
$11.00 | $33.00 | None |
Ethinyl Estradiol 0.0025 MG / norethindrone acetate 0.5 MG Oral Tablet [Fyavolv] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ETHOSUXIMIDE 250 MG CAPSULE [Zarontin] |
2 |
Tier 2 |
$11.00 | $33.00 | 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 |
Tier 2 |
$11.00 | $33.00 | None |
ETHYNODIOL-ETH ESTRA 1MG-50MCG [ZOVIA] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ETODOLAC 200 MG CAPSULE [Lodine] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ETODOLAC 300 MG CAPSULE [Lodine] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ETODOLAC 400 MG TABLET [Lodine] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ETODOLAC 500 MG TABLET [Lodine] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ETODOLAC ER 400 MG TABLET [Lodine] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ETODOLAC ER 500 MG TABLET ER 24H [Lodine XL] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ETODOLAC ER 600 MG TABLET ER 24H [Lodine XL] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
ETONOGESTREL-EE VAGINAL RING [NuvaRing] |
4 |
Tier 4 |
50% | 50% | Q:3 /84Days |
EUTHYROX 100 MCG TABLET |
1* |
Tier 1 |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EUTHYROX 112 MCG TABLET |
1* |
Tier 1 |
$2.00 | $6.00 | None |
EUTHYROX 125 MCG TABLET |
1* |
Tier 1 |
$2.00 | $6.00 | None |
EUTHYROX 137 MCG TABLET |
1* |
Tier 1 |
$2.00 | $6.00 | None |
EUTHYROX 150 MCG TABLET |
1* |
Tier 1 |
$2.00 | $6.00 | None |
EUTHYROX 175 MCG TABLET |
1* |
Tier 1 |
$2.00 | $6.00 | None |
EUTHYROX 200 MCG TABLET |
1* |
Tier 1 |
$2.00 | $6.00 | None |
EUTHYROX 25 MCG TABLET |
1* |
Tier 1 |
$2.00 | $6.00 | None |
EUTHYROX 50 MCG TABLET |
1* |
Tier 1 |
$2.00 | $6.00 | None |
EUTHYROX 75 MCG TABLET |
1* |
Tier 1 |
$2.00 | $6.00 | None |
EUTHYROX 88 MCG TABLET |
1* |
Tier 1 |
$2.00 | $6.00 | None |
EVEROLIMUS 0.25 MG TABLET [Zortress] |
4 |
Tier 4 |
50% | 50% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EVEROLIMUS 0.5 MG TABLET [Zortress] |
5 |
Tier 5 |
29% | N/A | P |
EVEROLIMUS 0.75 MG TABLET [Zortress] |
5 |
Tier 5 |
29% | N/A | P |
EVEROLIMUS 2.5 MG TABLET [Afinitor] |
5 |
Tier 5 |
29% | N/A | P |
EVEROLIMUS 5 MG TABLET [Afinitor] |
5 |
Tier 5 |
29% | N/A | P |
EVEROLIMUS 7.5 MG TABLET [Afinitor] |
5 |
Tier 5 |
29% | N/A | P |
EVOTAZ 300 MG-150 MG TABLET |
5 |
Tier 5 |
29% | N/A | None |
EXEMESTANE 25 MG TABLET [Aromasin] |
2 |
Tier 2 |
$11.00 | $33.00 | None |
EXJADE 125MG TABLET |
5 |
Tier 5 |
29% | N/A | None |
EXJADE 250MG TABLET |
5 |
Tier 5 |
29% | N/A | None |
EXJADE 500MG TABLET |
5 |
Tier 5 |
29% | N/A | None |
EXTAVIA 0.3 MG KIT |
5 |
Tier 5 |
29% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EZALLOR SPRINKLE 10 MG CAPSULE |
4 |
Tier 4 |
50% | 50% | Q:90 /90Days |
EZALLOR SPRINKLE 20 MG CAPSULE |
4 |
Tier 4 |
50% | 50% | Q:90 /90Days |
EZALLOR SPRINKLE 40 MG CAPSULE |
4 |
Tier 4 |
50% | 50% | Q:90 /90Days |
EZALLOR SPRINKLE 5 MG CAPSULE |
4 |
Tier 4 |
50% | 50% | Q:90 /90Days |
EZETIMIBE 10 MG TABLET [Zetia] |
2 |
Tier 2 |
$11.00 | $33.00 | Q:90 /90Days |
EZETIMIBE-SIMVASTATIN 10-10 MG TABLET [Vytorin] |
2 |
Tier 2 |
$11.00 | $33.00 | Q:90 /90Days |
EZETIMIBE-SIMVASTATIN 10-20 MG TABLET [Vytorin] |
2 |
Tier 2 |
$11.00 | $33.00 | Q:90 /90Days |
EZETIMIBE-SIMVASTATIN 10-40 MG TABLET [Vytorin] |
2 |
Tier 2 |
$11.00 | $33.00 | Q:90 /90Days |
EZETIMIBE-SIMVASTATIN 10-80 MG TABLET [Vytorin] |
2 |
Tier 2 |
$11.00 | $33.00 | Q:90 /90Days |