2016 Medicare Part D Plan Formulary Information |
MMM- Unico Extra (HMO) (H4003-015-0)
Benefit Details
|
The MMM- Unico Extra (HMO) (H4003-015-0) Formulary Drugs Starting with the Letter E in Yauco County, PR: CMS MA Region 30 which includes: PR Plan Monthly Premium: $0.00 Deductible: $90 |
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 |
$60.00 | $120.00 | None |
ECONAZOLE NITRATE 1% CREAM 85GM TUBE |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
EDURANT 27.5mg/1 |
5 |
Specialty Tier |
31% | 31% | None |
EFFIENT 10 MG TABLET |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | P |
EFFIENT 5 MG TABLET |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | P |
ELIDEL 1% CREAM |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | P |
ELIQUIS 2.5 MG TABLET |
3 |
Preferred Brand |
$25.00 | $50.00 | P |
ELIQUIS 5 MG TABLET |
3 |
Preferred Brand |
$25.00 | $50.00 | P |
Elitek 3 KIT per CARTON / 1 KIT in 1 KIT |
5 |
Specialty Tier |
31% | 31% | P |
ELIXOPHYLLIN 80mg/15mL 473 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
EMCYT 140MG CAPSULE |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
EMEND 150 MG VIAL |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | P |
EMEND 40MG CAPSULE |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | P Q:1 /30Days |
EMEND CAPSULES 125MG 6 BLPK |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | P Q:2 /30Days |
EMEND CAPSULES 80MG 2 BLPK |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | P Q:2 /2Days |
EMEND TRIFOLD PACK |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | P Q:3 /3Days |
Emoquette 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
EMPLICITI 300 MG VIAL |
5 |
Specialty Tier |
31% | 31% | P |
EMPLICITI 400 MG VIAL |
5 |
Specialty Tier |
31% | 31% | P |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
5 |
Specialty Tier |
31% | 31% | 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 |
Specialty Tier |
31% | 31% | Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
5 |
Specialty Tier |
31% | 31% | Q:30 /30Days |
EMTRIVA 10MG/ML SOLUTION |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
EMTRIVA 200MG CAPSULE |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
ENALAPRIL MALEATE 10MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
ENALAPRIL MALEATE 2.5 MG TAB |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Enalapril Maleate 20mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
ENALAPRIL MALEATE 5 MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Enalapril Maleate and Hydrochlorothiazide 10; 25mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
ENDOCET 10MG-325MG TABLET |
3 |
Preferred Brand |
$25.00 | $50.00 | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENDOCET 5/325 TABLET |
3 |
Preferred Brand |
$25.00 | $50.00 | Q:180 /30Days |
ENDOCET 7.5-325MG TABLET |
3 |
Preferred Brand |
$25.00 | $50.00 | Q:180 /30Days |
ENGERIX B INJECTION |
3 |
Preferred Brand |
$25.00 | $50.00 | P |
ENGERIX-B 10MCG 10 X 0.5ML VIALSD |
3 |
Preferred Brand |
$25.00 | $50.00 | P |
ENGERIX-B 20 MCG/ML SYRN |
3 |
Preferred Brand |
$25.00 | $50.00 | P |
ENOXAPARIN 100 MG/ML SYRINGE |
5 |
Specialty Tier |
31% | 31% | P Q:30 /30Days |
ENOXAPARIN 120 MG/0.8 ML SYR |
5 |
Specialty Tier |
31% | 31% | P Q:24 /30Days |
ENOXAPARIN 150 MG/ML SYRINGE |
5 |
Specialty Tier |
31% | 31% | P Q:30 /30Days |
ENOXAPARIN 30 MG/0.3 ML SYR |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | P Q:9 /30Days |
ENOXAPARIN 300 MG/3 ML VIAL |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | P Q:30 /30Days |
ENOXAPARIN 40 MG/0.4 ML SYR |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | P Q:12 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENOXAPARIN 60 MG/0.6 ML SYR |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | P Q:18 /30Days |
ENOXAPARIN 80 MG/0.8 ML SYR |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | P Q:24 /30Days |
ENTACAPONE 200 MG TABLET [Comtan Entacapone] |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
ENTECAVIR 0.5 MG TABLET [Baraclude] |
5 |
Specialty Tier |
31% | 31% | P |
ENTECAVIR 1 MG TABLET [Baraclude] |
5 |
Specialty Tier |
31% | 31% | P |
ENULOSE 10 GM/15 ML SOLUTION |
2 |
Generic |
$14.00 | $28.00 | None |
Epinephrine 0.3 mg auto-inject |
2 |
Generic |
$14.00 | $28.00 | None |
EPIPEN 0.3MG AUTO-INJECTOR |
3 |
Preferred Brand |
$25.00 | $50.00 | Q:4 /15Days |
EPIPEN JR 0.15MG AUTO-INJCT |
3 |
Preferred Brand |
$25.00 | $50.00 | Q:4 /2Days |
EPIRUBICIN HCL INJECTION SOLUTION 2MG 1 X 25ML VIAL |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | P |
EPITOL 200MG TABLET |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPIVIR HBV 25MG/5ML TUBEX |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
Eplerenone 25mg/1 90 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
Eplerenone 50mg/1 90 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
EPZICOM 600MG/300MG TABLETS |
5 |
Specialty Tier |
31% | 31% | None |
ERGOMAR 2 MG TABLET SL |
2 |
Generic |
$14.00 | $28.00 | None |
ERIVEDGE 150 MG CAPSULE |
5 |
Specialty Tier |
31% | 31% | P |
ERRIN 0.35MG TABLET |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
ERY 2% PADS 2% 60 PADS JAR |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
ERY-TAB TAB 250MG EC |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
ERY-TAB TAB 333MG EC |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROCIN 500MG ADDVNT VL |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | P |
ERYTHROCIN TAB 250MG |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
Erythromycin 2% solution |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
Erythromycin 20mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
ERYTHROMYCIN 500 MG FILMTAB |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
ERYTHROMYCIN EC 250 MG CAP |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
ERYTHROMYCIN ES 400 MG TAB |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
ERYTHROMYCIN OPHTHALMIC OINTMENT 0.5% 1 G BOX OF 50 TUBE |
2 |
Generic |
$14.00 | $28.00 | None |
ERYTHROMYCIN TAB 250MG BS |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
ERYTHROMYCIN-BENZOYL PEROXIDE 3-5% GEL |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
ESBRIET 267 MG CAPSULE |
5 |
Specialty Tier |
31% | 31% | P Q:270 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESCITALOPRAM 10 MG TABLET [Lexapro] |
2 |
Generic |
$14.00 | $28.00 | Q:60 /30Days |
ESCITALOPRAM 20 MG TABLET [Lexapro] |
2 |
Generic |
$14.00 | $28.00 | Q:30 /30Days |
ESCITALOPRAM 5 MG TABLET [Lexapro] |
2 |
Generic |
$14.00 | $28.00 | Q:120 /30Days |
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro] |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | Q:600 /30Days |
ESOMEPRAZOLE SODIUM 20 MG VIAL [Nexium] |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
ESOMEPRAZOLE SODIUM 40 MG VIAL [Nexium] |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
Estazolam 1mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:30 /30Days |
Estazolam 2mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | Q:30 /30Days |
ESTRACE VAG CREAM 0.1MG/GM |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
ESTRADIOL 0.5MG TABLET |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | P |
ESTRADIOL 2MG TABLET |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL TABLET 1MG (500 CT) |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | P |
ESTRADIOL TDS 0.025 MG/DAY |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | P |
ESTRADIOL TDS 0.0375 MG/DAY |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | P |
ESTRADIOL TDS 0.05 MG/DAY |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | P |
ESTRADIOL TDS 0.06 MG/DAY |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | P |
ESTRADIOL TDS 0.075 MG/DAY |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | P |
ESTRADIOL TDS 0.1 MG/DAY |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | P |
ESTRADIOL VALERATE 20mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
ESTRADIOL VALERATE 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
ESTROPIPATE 0.625(0.75 MG) TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
ESTROPIPATE 1.25(1.5 MG) TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETHAMBUTOL HCL 400 MG TABLET |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
Ethambutol Hydrochloride 100mg/1 |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 |
2 |
Generic |
$14.00 | $28.00 | None |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21 |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
ETHOSUXIMIDE 250 MG CAPSULE |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
ETHOSUXIMIDE 250MG/5ML SYRP |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
ETIDRONATE DISODIUM 400MG TABLET (60 CT) |
2 |
Generic |
$14.00 | $28.00 | None |
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT |
2 |
Generic |
$14.00 | $28.00 | None |
ETODOLAC 200MG CAPSULE |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
Etodolac 300 mg capsule |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
ETODOLAC 400 MG TABLET |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETODOLAC 400MG TABLET SR 24HR |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
ETODOLAC 500MG TABLET SR 24HR |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
Etodolac 500mg/1 500 TABLET BOTTLE |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
ETODOLAC 600MG TABLET SR 24HR |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
Etoposide 500 mg/25 ml vial |
3 |
Preferred Brand |
$25.00 | $50.00 | P |
Eurax Lotion and Cream 100mg/g 454 g in 1 BOTTLE |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
Eurax Lotion and Cream 100mg/g 60 g in 1 TUBE |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
EVOTAZ 300 MG-150 MG TABLET |
5 |
Specialty Tier |
31% | 31% | None |
EXELON 13.3 MG/24HR PATCH |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | P Q:30 /30Days |
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | P Q:30 /30Days |
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Exemestane 25mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
EXJADE 125MG TABLET |
5 |
Specialty Tier |
31% | 31% | P |
EXJADE 250MG TABLET |
5 |
Specialty Tier |
31% | 31% | P |
EXJADE 500MG TABLET |
5 |
Specialty Tier |
31% | 31% | P |