2023 Medicare Part D Plan Formulary Information |
Kaiser Permanente Medicare Advantage Standard VA (HMO-POS) (H2172-009-0)
Benefit Details
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less. Call drug plan for more details. |
The Kaiser Permanente Medicare Advantage Standard VA (HMO-POS) (H2172-009-0) Formulary Drugs Starting with the Letter E in Fairfax County, VA: CMS MA Region 7 which includes: VA
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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 TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
ECONAZOLE NITRATE 1% CREAM (G) [Spectazole] |
2 |
Generic |
$10.00 | $0.00 | None |
EDURANT 27.5mg/1 |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
EFAVIR-EMTRI-TENOF 600-200-300 TABLET [Atripla] |
2 |
Generic |
$10.00 | $0.00 | None |
EFAVIRENZ 200 MG CAPSULE [Sustiva] |
2 |
Generic |
$10.00 | $0.00 | None |
EFAVIRENZ 50 MG CAPSULE [Sustiva] |
2 |
Generic |
$10.00 | $0.00 | None |
EFAVIRENZ 600 MG TABLET [Sustiva] |
2 |
Generic |
$10.00 | $0.00 | None |
EGRIFTA SV 2 MG VIAL |
5 |
Specialty Tier |
33% | 33% | None |
ELETRIPTAN HBR 20 MG TABLET [Relpax] |
2 |
Generic |
$10.00 | $0.00 | None |
ELETRIPTAN HBR 40 MG TABLET [Relpax] |
2 |
Generic |
$10.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIGARD 22.5 MG SYRINGE |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ELIGARD 30 MG SYRINGE KIT |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ELIGARD 45 MG SYRINGE KIT |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ELIGARD 7.5 MG SYRINGE KIT |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ELIQUIS 5 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE |
5 |
Specialty Tier |
33% | 33% | None |
ELURYNG VAGINAL RING [NuvaRing] |
2 |
Generic |
$10.00 | $0.00 | None |
EMCYT 140MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
EMFLAZA 18 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
EMFLAZA 22.75 MG/ML ORAL SUSPENSION |
5 |
Specialty Tier |
33% | 33% | None |
EMFLAZA 30 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMFLAZA 36 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
EMFLAZA 6 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
5 |
Specialty Tier |
33% | 33% | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
5 |
Specialty Tier |
33% | 33% | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
5 |
Specialty Tier |
33% | 33% | None |
EMTRICITABINE 200 MG CAPSULE [Emtriva] |
2 |
Generic |
$10.00 | $0.00 | None |
EMTRICITABINE-TENOFV 100-150MG TABLET [Truvada] |
2 |
Generic |
$10.00 | $0.00 | None |
EMTRICITABINE-TENOFV 133-200MG TABLET [Truvada] |
2 |
Generic |
$10.00 | $0.00 | None |
EMTRICITABINE-TENOFV 167-250MG TABLET [Truvada] |
2 |
Generic |
$10.00 | $0.00 | None |
EMTRICITABINE-TENOFV 200-300MG TABLET [Truvada] |
2 |
Generic |
$10.00 | $0.00 | None |
EMTRIVA 10MG/ML SOLUTION |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENALAPRIL MALEATE 10 MG TABLET [Vasotec] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 2.5 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 20 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 5 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ENBREL 25 MG/0.5 ML SYRINGE |
5 |
Specialty Tier |
33% | 33% | None |
ENBREL 25 MG/0.5 ML VIAL |
5 |
Specialty Tier |
33% | 33% | None |
ENBREL 50 MG/ML MINI CARTRIDGE |
5 |
Specialty Tier |
33% | 33% | None |
ENBREL 50 MG/ML SURECLICK PEN INJECTOR |
5 |
Specialty Tier |
33% | 33% | None |
ENBREL 50 MG/ML SYRINGE |
5 |
Specialty Tier |
33% | 33% | None |
ENDARI 5 GRAM POWDER PACKET |
5 |
Specialty Tier |
33% | 33% | None |
ENDOCET 5/325 TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENDOCET 7.5-325MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
ENGERIX B INJECTION |
6 |
Vaccines |
$0.00 | N/A | P |
ENGERIX-B 20 MCG/ML SYRINGE |
6 |
Vaccines |
$0.00 | N/A | P |
ENGERIX-B 20 MCG/ML VIAL |
6 |
Vaccines |
$0.00 | N/A | P |
ENOXAPARIN 100 MG/ML SYRINGE [Lovenox] |
2 |
Generic |
$10.00 | $0.00 | None |
ENOXAPARIN 120 MG/0.8 ML SYRINGE [Lovenox] |
2 |
Generic |
$10.00 | $0.00 | None |
ENOXAPARIN 150 MG/ML SYRINGE [Lovenox] |
2 |
Generic |
$10.00 | $0.00 | None |
ENOXAPARIN 30 MG/0.3 ML SYRINGE [Lovenox] |
2 |
Generic |
$10.00 | $0.00 | None |
ENOXAPARIN 40 MG/0.4 ML SYRINGE [Lovenox] |
2 |
Generic |
$10.00 | $0.00 | None |
ENOXAPARIN 60 MG/0.6 ML SYRINGE [Lovenox] |
2 |
Generic |
$10.00 | $0.00 | None |
ENOXAPARIN 80 MG/0.8 ML SYRINGE [Lovenox] |
2 |
Generic |
$10.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENSPRYNG 120 MG/ML SYRINGE |
5 |
Specialty Tier |
33% | 33% | None |
ENSTILAR 0.005%-0.064% FOAM |
5 |
Specialty Tier |
33% | 33% | None |
ENTACAPONE 200 MG TABLET [Comtan] |
2 |
Generic |
$10.00 | $0.00 | None |
ENTECAVIR 0.5 MG TABLET [Baraclude] |
2 |
Generic |
$10.00 | $0.00 | None |
ENTECAVIR 1 MG TABLET [Baraclude] |
2 |
Generic |
$10.00 | $0.00 | None |
ENTRESTO 24 MG-26 MG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
ENTRESTO 49 MG-51 MG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
ENTRESTO 97 MG-103 MG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
ENULOSE 10 GM/15 ML SOLUTION |
2 |
Generic |
$10.00 | $0.00 | None |
ENVARSUS XR 0.75 MG TABLET ER 24H |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | P |
ENVARSUS XR 1 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENVARSUS XR 4 MG TABLET ER 24H |
5 |
Specialty Tier |
33% | 33% | P |
EPCLUSA 150-37.5 MG PELLET PACK |
5 |
Specialty Tier |
33% | 33% | P |
EPCLUSA 200 MG-50 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
EPCLUSA 200-50 MG PELLET PACK |
5 |
Specialty Tier |
33% | 33% | P |
EPCLUSA 400 MG-100 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P |
EPIDIOLEX 100 MG/ML SOLUTION |
5 |
Specialty Tier |
33% | 33% | P |
EPINEPHRINE 0.15 MG AUTO-INJCT [Twinject] |
2 |
Generic |
$10.00 | $0.00 | None |
EPINEPHRINE 0.15 MG AUTO-INJECT |
2 |
Generic |
$10.00 | $0.00 | None |
EPINEPHRINE 0.3 MG AUTO-INJECT |
2 |
Generic |
$10.00 | $0.00 | None |
EPINEPHRINE 0.3 MG AUTO-INJECT [Twinject] |
2 |
Generic |
$10.00 | $0.00 | None |
EPLERENONE 25 MG TABLET [Inspra] |
2 |
Generic |
$10.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPRONTIA 25 MG/ML SOLUTION |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EQUETRO CAPSULES 200MG 120 BOTTLE |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EQUETRO CAPSULES 300MG 120 BOTTLE |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EQUETRO EXTENDED RELEASE CAPSULES 100MG 120 BOTTLE |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ERGOLOID MESYLATES TABLETS 1MG 100 BOTTLE |
2 |
Generic |
$10.00 | $0.00 | None |
Ergotamine-caffeine 1-100mg tablet |
2 |
Generic |
$10.00 | $0.00 | None |
ERIVEDGE 150 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
ERLEADA 240 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
ERLEADA 60 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
ERLOTINIB HCL 100 MG TABLET [Tarceva] |
5 |
Specialty Tier |
33% | 33% | None |
ERLOTINIB HCL 150 MG TABLET [Tarceva] |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERLOTINIB HCL 25 MG TABLET [Tarceva] |
5 |
Specialty Tier |
33% | 33% | None |
ERTAPENEM 1 GRAM VIAL [Invanz] |
2 |
Generic |
$10.00 | $0.00 | None |
ERY-TAB DR 250 MG TABLET DR |
2 |
Generic |
$10.00 | $0.00 | None |
ERY-TAB DR 333 MG TABLET DR |
2 |
Generic |
$10.00 | $0.00 | None |
ERY-TAB DR 500 MG TABLET DR |
2 |
Generic |
$10.00 | $0.00 | None |
ERYTHROCIN LACT 500 MG VIAL |
2 |
Generic |
$10.00 | $0.00 | None |
ERYTHROMYCIN 0.5% EYE OINTMENT [Romycin] |
2 |
Generic |
$10.00 | $0.00 | None |
ERYTHROMYCIN 2% GEL [Erygel] |
2 |
Generic |
$10.00 | $0.00 | None |
ERYTHROMYCIN 2% SOLUTION |
2 |
Generic |
$10.00 | $0.00 | None |
ERYTHROMYCIN 200 MG/5 ML ORAL SUSPENSION [EryPed] |
2 |
Generic |
$10.00 | $0.00 | None |
ERYTHROMYCIN 250 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROMYCIN 400 MG/5 ML ORAL SUSPENSION [EryPed] |
2 |
Generic |
$10.00 | $0.00 | None |
ERYTHROMYCIN 500 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ERYTHROMYCIN DR 250 MG CAPSULE DR [ERYC] |
2 |
Generic |
$10.00 | $0.00 | None |
ERYTHROMYCIN DR 250 MG TABLET DR [Ery-Tab] |
2 |
Generic |
$10.00 | $0.00 | None |
ERYTHROMYCIN-BENZOYL GEL [Benzamycin] |
2 |
Generic |
$10.00 | $0.00 | None |
ESCITALOPRAM 10 MG TABLET [Lexapro] |
2 |
Generic |
$10.00 | $0.00 | None |
ESCITALOPRAM 20 MG TABLET [Lexapro] |
2 |
Generic |
$10.00 | $0.00 | None |
ESCITALOPRAM 5 MG TABLET [Lexapro] |
2 |
Generic |
$10.00 | $0.00 | None |
ESCITALOPRAM OXALATE 5 MG/5 ML SOLUTION [Lexapro] |
2 |
Generic |
$10.00 | $0.00 | None |
ESOMEPRAZOLE MAG DR 40 MG CAPSULE DR [Nexium] |
2 |
Generic |
$10.00 | $0.00 | None |
ESTRACE VAGINAL CREAM 0.1MG/GM |
2 |
Generic |
$10.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL 0.01% CREAM/APPL [Estrace] |
2 |
Generic |
$10.00 | $0.00 | None |
Estradiol 0.025 mg patch |
2 |
Generic |
$10.00 | $0.00 | None |
ESTRADIOL 0.025 MG PATCH(1/WK) [FemPatch] |
2 |
Generic |
$10.00 | $0.00 | None |
ESTRADIOL 0.0375MG PATCH(1/WKClimara] |
2 |
Generic |
$10.00 | $0.00 | None |
ESTRADIOL 0.0375MG PATCH(2/WK) TDSW [Vivelle-Dot] |
2 |
Generic |
$10.00 | $0.00 | None |
Estradiol 0.05 mg patch |
2 |
Generic |
$10.00 | $0.00 | None |
ESTRADIOL 0.05 MG PATCH (1/WK) [Climara] |
2 |
Generic |
$10.00 | $0.00 | None |
ESTRADIOL 0.06 MG PATCH (1/WK) [Climara] |
2 |
Generic |
$10.00 | $0.00 | None |
Estradiol 0.075 mg patch |
2 |
Generic |
$10.00 | $0.00 | None |
ESTRADIOL 0.075 MG PATCH(1/WKClimara] |
2 |
Generic |
$10.00 | $0.00 | None |
Estradiol 0.1 mg patch |
2 |
Generic |
$10.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL 0.1 MG PATCH (1/WK) [Climara] |
2 |
Generic |
$10.00 | $0.00 | None |
ESTRADIOL 0.5 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
ESTRADIOL 1 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
ESTRADIOL 10 MCG VAGINAL INSRT |
2 |
Generic |
$10.00 | $0.00 | None |
ESTRADIOL 2MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
ESTRADIOL VALERATE 100 MG/5 ML VIAL [Gynogen LA] |
2 |
Generic |
$10.00 | $0.00 | None |
ESTRADIOL VALERATE 200 MG/5 ML VIAL [Delestrogen] |
2 |
Generic |
$10.00 | $0.00 | None |
ESTRING 7.5 MCG/DAY (2MG) VAG RING |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
ESZOPICLONE 1 MG TABLET [Lunesta] |
2 |
Generic |
$10.00 | $0.00 | None |
ESZOPICLONE 2 MG TABLET [Lunesta] |
2 |
Generic |
$10.00 | $0.00 | None |
ESZOPICLONE 3 MG TABLET [Lunesta] |
2 |
Generic |
$10.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETHACRYNIC ACID 25 MG TABLET [Edecrin] |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
ETHAMBUTOL HCL 400 MG TABLET |
2 |
Generic |
$10.00 | $0.00 | None |
Ethambutol Hydrochloride 100mg/1 |
2 |
Generic |
$10.00 | $0.00 | None |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TABLET 21 |
2 |
Generic |
$10.00 | $0.00 | None |
ETHOSUXIMIDE 250 MG CAPSULE [Zarontin] |
2 |
Generic |
$10.00 | $0.00 | None |
ETHOSUXIMIDE 250 MG/5 ML SOLUTION [Zarontin] |
2 |
Generic |
$10.00 | $0.00 | None |
ETHYNODIOL-ETH ESTRA 1MG-50MCG [ZOVIA] |
2 |
Generic |
$10.00 | $0.00 | None |
ETODOLAC 200 MG CAPSULE [Lodine] |
2 |
Generic |
$10.00 | $0.00 | None |
ETODOLAC 300 MG CAPSULE [Lodine] |
2 |
Generic |
$10.00 | $0.00 | None |
ETODOLAC 400 MG TABLET [Lodine] |
2 |
Generic |
$10.00 | $0.00 | None |
ETODOLAC 500 MG TABLET [Lodine] |
2 |
Generic |
$10.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETONOGESTREL-EE VAGINAL RING [NuvaRing] |
2 |
Generic |
$10.00 | $0.00 | None |
ETRAVIRINE 100 MG TABLET [INTELENCE] |
2 |
Generic |
$10.00 | $0.00 | None |
ETRAVIRINE 200 MG TABLET [INTELENCE] |
2 |
Generic |
$10.00 | $0.00 | None |
EVENITY 210 MG DOSE-2 SYRINGES |
5 |
Specialty Tier |
33% | 33% | None |
EVEROLIMUS 0.25 MG TABLET [Zortress] |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | P |
EVEROLIMUS 0.5 MG TABLET [Zortress] |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | P |
EVEROLIMUS 0.75 MG TABLET [Zortress] |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | P |
EVEROLIMUS 1 MG TABLET [Zortress] |
5 |
Specialty Tier |
33% | 33% | P |
EVEROLIMUS 10 MG TABLET [Afinitor] |
5 |
Specialty Tier |
33% | 33% | None |
EVEROLIMUS 2 MG TABLET FOR SUSP [Afinitor DISPERZ] |
5 |
Specialty Tier |
33% | 33% | None |
EVEROLIMUS 2.5 MG TABLET [Afinitor] |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EVEROLIMUS 3 MG TABLET FOR SUSP [Afinitor DISPERZ] |
5 |
Specialty Tier |
33% | 33% | None |
EVEROLIMUS 5 MG TABLET [Afinitor] |
5 |
Specialty Tier |
33% | 33% | None |
EVEROLIMUS 5 MG TABLET FOR SUSP [Afinitor DISPERZ] |
5 |
Specialty Tier |
33% | 33% | None |
EVEROLIMUS 7.5 MG TABLET [Afinitor] |
5 |
Specialty Tier |
33% | 33% | None |
EVOTAZ 300 MG-150 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None |
EVRYSDI 60 MG/80 ML(0.75MG/ML) SOLUTION RECON |
5 |
Specialty Tier |
33% | 33% | None |
EXEMESTANE 25 MG TABLET [Aromasin] |
2 |
Generic |
$10.00 | $0.00 | None |
EXKIVITY 40 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
EXSERVAN 50 MG FILM |
5 |
Specialty Tier |
33% | 33% | None |
EXTAVIA 0.3 MG KIT |
2 |
Generic |
$10.00 | $0.00 | None |
EZETIMIBE 10 MG TABLET [Zetia] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |