2020 Medicare Part D Plan Formulary Information |
Virginia Premier Advantage Elite (HMO D-SNP) (H9877-001-0)
Benefit Details
|
The Virginia Premier Advantage Elite (HMO D-SNP) (H9877-001-0) Formulary Drugs Starting with the Letter E in Washington County, VA: CMS MA Region 7 which includes: VA Plan Monthly Premium: $27.90 Deductible: $435 |
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] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
EDURANT 27.5mg/1 |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
EFAVIRENZ 200 MG CAPSULE [Sustiva] |
1 |
Tier 1 |
$0.00 | $0.00 | Q:120 /30Days |
EFAVIRENZ 50 MG CAPSULE [Sustiva] |
1 |
Tier 1 |
$0.00 | $0.00 | Q:360 /30Days |
EFAVIRENZ 600 MG TABLET [Sustiva] |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
ELESTRIN 0.06% GEL MD PUMP |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ELETRIPTAN HBR 20 MG TABLET [Relpax] |
1 |
Tier 1 |
$0.00 | $0.00 | Q:9 /30Days |
ELETRIPTAN HBR 40 MG TABLET [Relpax] |
1 |
Tier 1 |
$0.00 | $0.00 | Q:9 /30Days |
ELIGARD 22.5 MG SYRINGE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ELIGARD 30 MG SYRINGE KIT |
1 |
Tier 1 |
$0.00 | $0.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIGARD 45 MG SYRINGE KIT |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ELIGARD 7.5 MG SYRINGE KIT |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ELIQUIS 2.5 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
ELIQUIS 5 MG STARTER PACK |
1 |
Tier 1 |
$0.00 | $0.00 | Q:74 /30Days |
ELIQUIS 5 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:74 /30Days |
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
EMCYT 140MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
EMGALITY 120 MG/ML PEN INJCTR |
1 |
Tier 1 |
$0.00 | $0.00 | P |
EMGALITY 120 MG/ML SYRINGE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
EMGALITY 300 MG (100 MG X3SYR) SYRINGE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
EMOQUETTE 28 DAY TABLET [Solia] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Empagliflozin 5 MG / Metformin hydrochloride 500 MG Oral Tablet [Synjardy] |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
1 |
Tier 1 |
$0.00 | $0.00 | P |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
1 |
Tier 1 |
$0.00 | $0.00 | P |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
1 |
Tier 1 |
$0.00 | $0.00 | P |
EMTRIVA 10MG/ML SOLUTION |
1 |
Tier 1 |
$0.00 | $0.00 | Q:720 /30Days |
EMTRIVA 200MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
EMVERM 100 MG TABLET CHEW |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 10 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 2.5 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 20 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 5 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENALAPRIL-HCTZ 10-25 MG TABLET [Vaseretic] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ENALAPRIL-HCTZ 5-12.5 MG TABLET [Vaseretic] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ENBREL 25 MG/0.5 ML SYRINGE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ENBREL 25MG KIT |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ENBREL 50 MG/ML MINI CARTRIDGE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ENBREL 50 MG/ML SURECLICK SYR |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ENBREL 50 MG/ML SYRINGE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ENDARI 5 GRAM POWDER PACKET |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ENGERIX B INJECTION |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ENGERIX-B 20 MCG/ML SYRINGE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ENOXAPARIN 100 MG/ML SYRINGE [Lovenox] |
1 |
Tier 1 |
$0.00 | $0.00 | 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] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ENOXAPARIN 150 MG/ML SYRINGE [Lovenox] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ENOXAPARIN 30 MG/0.3 ML SYRINGE [Lovenox] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ENOXAPARIN 40 MG/0.4 ML SYRINGE [Lovenox] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ENOXAPARIN 60 MG/0.6 ML SYRINGE [Lovenox] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ENOXAPARIN 80 MG/0.8 ML SYRINGE [Lovenox] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ENSKYCE 28 TABLET [Solia] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ENTACAPONE 200 MG TABLET [Comtan Entacapone] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ENTECAVIR 0.5 MG TABLET [Baraclude] |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ENTECAVIR 1 MG TABLET [Baraclude] |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ENTRESTO 24 MG-26 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENTRESTO 49 MG-51 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ENTRESTO 97 MG-103 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ENULOSE 10 GM/15 ML SOLUTION |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ENVARSUS XR 0.75 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ENVARSUS XR 1 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ENVARSUS XR 4 MG TABLET ER 24H |
1 |
Tier 1 |
$0.00 | $0.00 | P |
EPIDIOLEX 100 MG/ML SOLUTION |
1 |
Tier 1 |
$0.00 | $0.00 | P |
EPINASTINE HCL 0.05% EYE DROPS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
EPINEPHRINE 0.15 MG AUTO-INJECT [Twinject] |
1 |
Tier 1 |
$0.00 | $0.00 | Q:2 /30Days |
EPINEPHRINE 0.3 MG AUTO-INJECT [Twinject] |
1 |
Tier 1 |
$0.00 | $0.00 | Q:2 /30Days |
EPITOL 200MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPIVIR HBV 25MG/5ML TUBEX |
1 |
Tier 1 |
$0.00 | $0.00 | None |
EPLERENONE 25 MG TABLET [Inspra] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
EPLERENONE 50 MG TABLET [Inspra] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
EPOGEN 10000U/ML VIAL MDV |
1 |
Tier 1 |
$0.00 | $0.00 | P |
EPOGEN 2000[iU]/mL 10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | P |
EPOGEN 3000U/ML VIAL SDV |
1 |
Tier 1 |
$0.00 | $0.00 | P |
EPOGEN 4000U/ML VIAL SDV |
1 |
Tier 1 |
$0.00 | $0.00 | P |
EPOGEN INJECTION 20000U 10 X 1ML CRTN |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ERAXIS 100mg/30mL 30 mL in 1 VIAL, SINGLE-USE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ERAXIS(WATER DIL) 50 MG VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ERGOLOID MESYLATES TABLETS 1MG 100 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ergotamine-caffeine 1-100mg tablet |
1 |
Tier 1 |
$0.00 | $0.00 | Q:40 /28Days |
ERIVEDGE 150 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ERLEADA 60 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ERLOTINIB HCL 100 MG TABLET [Tarceva] |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ERLOTINIB HCL 150 MG TABLET [Tarceva] |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ERLOTINIB HCL 25 MG TABLET [Tarceva] |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ERRIN 0.35 MG TABLET [Sharobel 28-Day] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ERTAPENEM 1 GRAM VIAL [Invanz] |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ERY 2% PADS 2% 60 PADS JAR |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ERY-TAB TABLET 250MG EC |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERY-TAB TABLET 333MG EC |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ERYTHROCIN 500MG ADDVNT VL |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ERYTHROMYCIN 0.5% EYE OINTMENT [Romycin] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ERYTHROMYCIN 2% SOLUTION |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ERYTHROMYCIN 200 MG/5 ML ORAL SUSPENSION [EryPed] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ERYTHROMYCIN 400 MG/5 ML SUSP Oral Suspension [EryPed] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ERYTHROMYCIN 500 MG FILMTAB |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ERYTHROMYCIN DR 250 MG CAPSULE DR [ERYC] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ERYTHROMYCIN DR 250 MG TABLET DR [Ery-Tab] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ERYTHROMYCIN DR 333 MG TABLET DR [Ery-Tab] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ERYTHROMYCIN DR 500 MG TABLET DR [Ery-Tab] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROMYCIN TABLET 250MG BS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ERYTHROMYCIN-BENZOYL GEL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ESBRIET 267 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ESBRIET 801 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P |
ESCITALOPRAM 10 MG TABLET [Lexapro] |
1 |
Tier 1 |
$0.00 | $0.00 | Q:45 /30Days |
ESCITALOPRAM 20 MG TABLET [Lexapro] |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
ESCITALOPRAM 5 MG TABLET [Lexapro] |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro] |
1 |
Tier 1 |
$0.00 | $0.00 | Q:600 /30Days |
ESOMEPRAZOLE MAG DR 20 MG CAPSULE [Nexium] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ESOMEPRAZOLE MAG DR 40 MG CAPSULE [Nexium] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ESTARYLLA 0.25-0.035 MG TABLET [VyLibra] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Estazolam 1mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
ESTAZOLAM 2 MG TABLET [ProSom] |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
ESTRADIOL 0.01% CREAM |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Estradiol 0.025 mg patch |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Estradiol 0.0375 mg patch |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Estradiol 0.05 mg patch |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Estradiol 0.075 mg patch |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Estradiol 0.1 mg patch |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ESTRADIOL 0.5 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ESTRADIOL 1 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ESTRADIOL 10 MCG VAGINAL INSRT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL 2MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ESTRADIOL TDS 0.025 MG/DAY |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ESTRADIOL TDS 0.0375 MG/DAY |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ESTRADIOL TDS 0.05 MG/DAY |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ESTRADIOL TDS 0.06 MG/DAY |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ESTRADIOL TDS 0.075 MG/DAY |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ESTRADIOL TDS 0.1 MG/DAY |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ETHAMBUTOL HCL 400 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Ethambutol Hydrochloride 100mg/1 |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TABLET 21 |
1 |
Tier 1 |
$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 CAPSULE [Zarontin] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ETHOSUXIMIDE 250 MG/5 ML SOLN |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ETHYNODIOL-ETH ESTRA 1MG-35MCG [ZOVIA] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ETHYNODIOL-ETH ESTRA 1MG-50MCG [ZOVIA] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ETODOLAC 200 MG CAPSULE [Lodine] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ETODOLAC 300 MG CAPSULE [Lodine] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ETODOLAC 400 MG TABLET [Lodine] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ETODOLAC 500 MG TABLET [Lodine] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ETODOLAC ER 400 MG TABLET [Lodine] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ETODOLAC ER 500 MG TABLET ER 24H [Lodine XL] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
ETODOLAC ER 600 MG TABLET ER 24H [Lodine XL] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EUCRISA 2% OINTMENT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
EUTHYROX 100 MCG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
EUTHYROX 112 MCG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
EUTHYROX 125 MCG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
EUTHYROX 137 MCG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
EUTHYROX 150 MCG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
EUTHYROX 175 MCG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
EUTHYROX 200 MCG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
EUTHYROX 25 MCG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
EUTHYROX 50 MCG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
EUTHYROX 75 MCG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EUTHYROX 88 MCG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
EVAMIST 1.53 MG/SPRAY |
1 |
Tier 1 |
$0.00 | $0.00 | None |
EVEROLIMUS 0.25 MG TABLET [Zortress] |
1 |
Tier 1 |
$0.00 | $0.00 | P |
EVEROLIMUS 0.5 MG TABLET [Zortress] |
1 |
Tier 1 |
$0.00 | $0.00 | P |
EVEROLIMUS 0.75 MG TABLET [Zortress] |
1 |
Tier 1 |
$0.00 | $0.00 | P |
EVEROLIMUS 2.5 MG TABLET [Afinitor] |
1 |
Tier 1 |
$0.00 | $0.00 | P |
EVEROLIMUS 5 MG TABLET [Afinitor] |
1 |
Tier 1 |
$0.00 | $0.00 | P |
EVEROLIMUS 7.5 MG TABLET [Afinitor] |
1 |
Tier 1 |
$0.00 | $0.00 | P |
EVOTAZ 300 MG-150 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
EXEMESTANE 25 MG TABLET [Aromasin] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
EZETIMIBE 10 MG TABLET [Zetia] |
1 |
Tier 1 |
$0.00 | $0.00 | None |