2015 Medicare Part D Plan Formulary Information |
Humana Preferred Rx Plan (PDP) (S5884-147-0)
Benefit Details
 |
The Humana Preferred Rx Plan (PDP) (S5884-147-0) Formulary Drugs Starting with the Letter E in CMS PDP Region 31 which includes: ID UT Plan Monthly Premium: $29.00 Deductible: $320 Qualifies for LIS: Yes |
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  |
4 |
Non-Preferred Brand |
35% | 35% | None |
E.E.S. GRAN SUS 200/5ML  |
4 |
Non-Preferred Brand |
35% | 35% | None |
ECONAZOLE NITRATE 1% CREAM 85GM TUBE  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
EDURANT 27.5mg/1  |
4 |
Non-Preferred Brand |
35% | 35% | Q:30 /30Days |
EFFIENT 10 MG TABLET  |
3 |
Preferred Brand |
20% | 17% | Q:30 /30Days |
EFFIENT 5 MG TABLET  |
3 |
Preferred Brand |
20% | 17% | Q:30 /30Days |
EGRIFTA 1 MG VIAL  |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
ELELYSO 200 UNITS VIAL  |
5 |
Specialty Tier |
25% | N/A | P Q:350 /30Days |
ELIDEL 1% CREAM  |
4 |
Non-Preferred Brand |
35% | 35% | None |
ELIQUIS 2.5 MG TABLET  |
3 |
Preferred Brand |
20% | 17% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIQUIS 5 MG TABLET  |
3 |
Preferred Brand |
20% | 17% | Q:74 /30Days |
Elitek 3 KIT per CARTON / 1 KIT in 1 KIT  |
5 |
Specialty Tier |
25% | N/A | P |
ELIXOPHYLLIN 80mg/15mL 473 mL in 1 BOTTLE  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
ELLA 30 MG TABLET  |
3 |
Preferred Brand |
20% | 17% | Q:1 /30Days |
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE  |
4 |
Non-Preferred Brand |
35% | 35% | None |
EMCYT 140MG CAPSULE  |
4 |
Non-Preferred Brand |
35% | 35% | None |
EMEND 40MG CAPSULE  |
4 |
Non-Preferred Brand |
35% | 35% | P Q:2 /28Days |
EMEND CAPSULES 125MG 6 BLPK  |
4 |
Non-Preferred Brand |
35% | 35% | P Q:2 /28Days |
EMEND CAPSULES 80MG 2 BLPK  |
4 |
Non-Preferred Brand |
35% | 35% | P Q:4 /28Days |
EMEND TRIFOLD PACK  |
4 |
Non-Preferred Brand |
35% | 35% | P Q:6 /28Days |
Emoquette 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK  |
4 |
Non-Preferred Brand |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H  |
4 |
Non-Preferred Brand |
35% | 35% | Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H  |
4 |
Non-Preferred Brand |
35% | 35% | Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H  |
4 |
Non-Preferred Brand |
35% | 35% | Q:30 /30Days |
EMTRIVA 10MG/ML SOLUTION  |
4 |
Non-Preferred Brand |
35% | 35% | Q:680 /28Days |
EMTRIVA 200MG CAPSULE  |
4 |
Non-Preferred Brand |
35% | 35% | Q:30 /30Days |
ENALAPRIL MALEATE 10MG TABLET (100 CT)  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
ENALAPRIL MALEATE 2.5 MG TAB  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
Enalapril Maleate 20mg/1 100 TABLET BOTTLE, PLASTIC  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
ENALAPRIL MALEATE 5 MG TABLET  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
Enalapril Maleate and Hydrochlorothiazide 10; 25mg/1; mg/1 100 TABLET BOTTLE, PLASTIC  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENBREL 25 MG/0.5 ML SYRINGE  |
5 |
Specialty Tier |
25% | N/A | P Q:8 /28Days |
ENBREL 25MG KIT  |
5 |
Specialty Tier |
25% | N/A | P Q:8 /28Days |
ENBREL 50 MG/ML SURECLICK SYR  |
5 |
Specialty Tier |
25% | N/A | P Q:8 /28Days |
ENBREL 50mg/mL  |
5 |
Specialty Tier |
25% | N/A | P Q:8 /28Days |
ENDOCET 10MG-325MG TABLET  |
3 |
Preferred Brand |
20% | 17% | Q:360 /30Days |
ENDOCET 5/325 TABLET  |
3 |
Preferred Brand |
20% | 17% | Q:360 /30Days |
ENDOCET 7.5-325MG TABLET  |
3 |
Preferred Brand |
20% | 17% | Q:360 /30Days |
ENGERIX B INJECTION  |
4 |
Non-Preferred Brand |
35% | 35% | P |
ENGERIX-B 10MCG 10 X 0.5ML VIALSD  |
4 |
Non-Preferred Brand |
35% | 35% | P |
ENGERIX-B 20 MCG/ML SYRN  |
4 |
Non-Preferred Brand |
35% | 35% | P |
ENOXAPARIN 100 MG/ML SYRINGE  |
4 |
Non-Preferred Brand |
35% | 35% | Q:28 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENOXAPARIN 120 MG/0.8 ML SYR  |
4 |
Non-Preferred Brand |
35% | 35% | Q:28 /28Days |
ENOXAPARIN 150 MG/ML SYRINGE  |
4 |
Non-Preferred Brand |
35% | 35% | Q:28 /28Days |
ENOXAPARIN 30 MG/0.3 ML SYR  |
4 |
Non-Preferred Brand |
35% | 35% | Q:28 /28Days |
ENOXAPARIN 300 MG/3 ML VIAL  |
4 |
Non-Preferred Brand |
35% | 35% | Q:14 /28Days |
ENOXAPARIN 40 MG/0.4 ML SYR  |
4 |
Non-Preferred Brand |
35% | 35% | Q:28 /28Days |
ENOXAPARIN 60 MG/0.6 ML SYR  |
4 |
Non-Preferred Brand |
35% | 35% | Q:28 /28Days |
ENOXAPARIN 80 MG/0.8 ML SYR  |
4 |
Non-Preferred Brand |
35% | 35% | Q:28 /28Days |
ENTACAPONE 200 MG TABLET [Comtan Entacapone] ![Compare how all Medicare Part D PDP plans in ID cover ENTACAPONE 200 MG TABLET [Comtan Entacapone].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
35% | 35% | Q:300 /30Days |
ENTECAVIR 0.5 MG TABLET [Baraclude] ![Compare how all Medicare Part D PDP plans in ID cover ENTECAVIR 0.5 MG TABLET [Baraclude].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
ENTECAVIR 1 MG TABLET [Baraclude] ![Compare how all Medicare Part D PDP plans in ID cover ENTECAVIR 1 MG TABLET [Baraclude].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
ENULOSE 10 GM/15 ML SOLUTION  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPINASTINE HCL 0.05% EYE DROPS  |
3 |
Preferred Brand |
20% | 17% | None |
EPIPEN 0.3MG AUTO-INJECTOR  |
4 |
Non-Preferred Brand |
35% | 35% | None |
EPIPEN JR 0.15MG AUTO-INJCT  |
4 |
Non-Preferred Brand |
35% | 35% | None |
EPIRUBICIN HCL INJECTION SOLUTION 2MG 1 X 25ML VIAL  |
4 |
Non-Preferred Brand |
35% | 35% | None |
EPITOL 200MG TABLET  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
EPIVIR 10 MG/ML ORAL SOLUTION  |
4 |
Non-Preferred Brand |
35% | 35% | Q:960 /30Days |
EPIVIR HBV 25MG/5ML TUBEX  |
4 |
Non-Preferred Brand |
35% | 35% | None |
Eplerenone 25mg/1 90 TABLET BOTTLE  |
4 |
Non-Preferred Brand |
35% | 35% | None |
Eplerenone 50mg/1 90 TABLET BOTTLE  |
4 |
Non-Preferred Brand |
35% | 35% | None |
EPOGEN 10000U/ML VIAL MDV  |
4 |
Non-Preferred Brand |
35% | 35% | P Q:14 /30Days |
EPOGEN 2000[iU]/mL 10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL ![Compare how all Medicare Part D PDP plans in ID cover EPOGEN 2000[iU]/mL 10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
35% | 35% | P Q:14 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPOGEN 3000U/ML VIAL SDV  |
4 |
Non-Preferred Brand |
35% | 35% | P Q:14 /30Days |
EPOGEN 4000U/ML VIAL SDV  |
4 |
Non-Preferred Brand |
35% | 35% | P Q:14 /30Days |
EPOGEN INJECTION 20000U 10 X 1ML CRTN  |
5 |
Specialty Tier |
25% | N/A | P Q:14 /30Days |
EPZICOM 600MG/300MG TABLETS  |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
EQUETRO CAPSULES 200MG 120 BOT  |
4 |
Non-Preferred Brand |
35% | 35% | None |
EQUETRO CAPSULES 300MG 120 BOT  |
4 |
Non-Preferred Brand |
35% | 35% | None |
EQUETRO EXTENDED RELEASE CAPSULES 100MG 120 BOT  |
4 |
Non-Preferred Brand |
35% | 35% | None |
ERAXIS 100mg/30mL 30 mL in 1 VIAL, SINGLE-USE  |
4 |
Non-Preferred Brand |
35% | 35% | None |
ERBITUX 100MG/50ML VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
ERGOMAR 2 MG TABLET SL  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
ERIVEDGE 150 MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERRIN 0.35MG TABLET  |
4 |
Non-Preferred Brand |
35% | 35% | None |
ERWINAZE 10,000 UNITS VIAL  |
5 |
Specialty Tier |
25% | N/A | P Q:60 /28Days |
ERY 2% PADS 2% 60 PADS JAR  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE  |
4 |
Non-Preferred Brand |
35% | 35% | None |
ERY-TAB TAB 250MG EC  |
4 |
Non-Preferred Brand |
35% | 35% | None |
ERY-TAB TAB 333MG EC  |
4 |
Non-Preferred Brand |
35% | 35% | None |
ERYPED 200 MG/5 ML SUSPENSION  |
4 |
Non-Preferred Brand |
35% | 35% | None |
ERYPED 400 MG/5 ML SUSPENSION  |
4 |
Non-Preferred Brand |
35% | 35% | None |
ERYTHROCIN 500MG ADDVNT VL  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
ERYTHROCIN TAB 250MG  |
3 |
Preferred Brand |
20% | 17% | None |
Erythromycin 2% solution  |
3 |
Preferred Brand |
20% | 17% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Erythromycin 20mg/g 1 TUBE per CARTON / 60 g in 1 TUBE  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
ERYTHROMYCIN ES 400 MG TAB  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
ERYTHROMYCIN OPHTHALMIC OINTMENT 0.5% 1 G BOX OF 50 TUBE  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
ERYTHROMYCIN-BENZOYL PEROXIDE 3-5% GEL  |
3 |
Preferred Brand |
20% | 17% | None |
ESCITALOPRAM 10 MG TABLET [Lexapro] ![Compare how all Medicare Part D PDP plans in ID cover ESCITALOPRAM 10 MG TABLET [Lexapro].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | Q:45 /30Days |
ESCITALOPRAM 20 MG TABLET [Lexapro] ![Compare how all Medicare Part D PDP plans in ID cover ESCITALOPRAM 20 MG TABLET [Lexapro].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days |
ESCITALOPRAM 5 MG TABLET [Lexapro] ![Compare how all Medicare Part D PDP plans in ID cover ESCITALOPRAM 5 MG TABLET [Lexapro].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days |
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro] ![Compare how all Medicare Part D PDP plans in ID cover ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
35% | 35% | Q:600 /30Days |
ESTRADIOL 0.5MG TABLET  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | P |
ESTRADIOL 2MG TABLET  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | P |
ESTRADIOL TABLET 1MG (500 CT)  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL TDS 0.025 MG/DAY  |
3 |
Preferred Brand |
20% | 17% | P Q:4 /28Days |
ESTRADIOL TDS 0.0375 MG/DAY  |
3 |
Preferred Brand |
20% | 17% | P Q:4 /28Days |
ESTRADIOL TDS 0.05 MG/DAY  |
3 |
Preferred Brand |
20% | 17% | P Q:4 /28Days |
ESTRADIOL TDS 0.06 MG/DAY  |
3 |
Preferred Brand |
20% | 17% | P Q:4 /28Days |
ESTRADIOL TDS 0.075 MG/DAY  |
3 |
Preferred Brand |
20% | 17% | P Q:4 /28Days |
ESTRADIOL TDS 0.1 MG/DAY  |
3 |
Preferred Brand |
20% | 17% | P Q:4 /28Days |
ETHAMBUTOL HCL 400 MG TABLET  |
4 |
Non-Preferred Brand |
35% | 35% | None |
Ethambutol Hydrochloride 100mg/1  |
4 |
Non-Preferred Brand |
35% | 35% | None |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6  |
4 |
Non-Preferred Brand |
35% | 35% | None |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21  |
4 |
Non-Preferred Brand |
35% | 35% | None |
Ethosuximide 250mg 100 CAPSULE BOTTLE  |
3 |
Preferred Brand |
20% | 17% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETHOSUXIMIDE 250MG/5ML SYRP  |
4 |
Non-Preferred Brand |
35% | 35% | None |
ETIDRONATE DISODIUM 400MG TABLET (60 CT)  |
4 |
Non-Preferred Brand |
35% | 35% | None |
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT  |
4 |
Non-Preferred Brand |
35% | 35% | None |
ETODOLAC 200MG CAPSULE  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
Etodolac 300 mg capsule  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
ETODOLAC 400 MG TABLET  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
ETODOLAC 400MG TABLET SR 24HR  |
4 |
Non-Preferred Brand |
35% | 35% | None |
ETODOLAC 500MG TABLET SR 24HR  |
4 |
Non-Preferred Brand |
35% | 35% | None |
Etodolac 500mg/1 500 TABLET BOTTLE  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
ETODOLAC 600MG TABLET SR 24HR  |
4 |
Non-Preferred Brand |
35% | 35% | None |
ETOPOPHOS 100MG VIAL  |
4 |
Non-Preferred Brand |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Etoposide 500 mg/25 ml vial  |
3 |
Preferred Brand |
20% | 17% | None |
Eurax Lotion and Cream 100mg/g 454 g in 1 BOTTLE  |
4 |
Non-Preferred Brand |
35% | 35% | None |
Eurax Lotion and Cream 100mg/g 60 g in 1 TUBE  |
4 |
Non-Preferred Brand |
35% | 35% | None |
EVOTAZ 300 MG-150 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
EXELON 13.3 MG/24HR PATCH  |
4 |
Non-Preferred Brand |
35% | 35% | Q:30 /30Days |
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS  |
4 |
Non-Preferred Brand |
35% | 35% | Q:30 /30Days |
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS  |
4 |
Non-Preferred Brand |
35% | 35% | Q:30 /30Days |
Exemestane 25mg/1 30 FILM COATED TABLETS in BOTTLE  |
4 |
Non-Preferred Brand |
35% | 35% | Q:60 /30Days |
EXJADE 125MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
EXJADE 250MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
EXJADE 500MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EXTENDED PHENYTOIN SODIUM CAPSULES 300 MG  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |