2016 Medicare Part D Plan Formulary Information |
Ambassador Plus (PPO) (H4738-002-0)
Benefit Details
|
The Ambassador Plus (PPO) (H4738-002-0) Formulary Drugs Starting with the Letter E in Greenville County, SC: CMS MA Region 8 which includes: SC Plan Monthly Premium: $80.00 Deductible: $0 |
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 85GM TUBE |
1 |
Generic |
$6.00 | $15.00 | None |
EDURANT 27.5mg/1 |
4 |
Specialty Tier |
33% | 33% | Q:30 /30Days |
EFFIENT 10 MG TABLET |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:30 /30Days |
EFFIENT 5 MG TABLET |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:30 /30Days |
EGRIFTA 2 MG VIAL |
4 |
Specialty Tier |
33% | 33% | None |
ELAPRASE 6mg/3mL 1 VIAL, GLASS in 1 BOX / 3 mL in 1 VIAL, GLASS |
4 |
Specialty Tier |
33% | 33% | P |
ELELYSO 200 UNITS VIAL |
4 |
Specialty Tier |
33% | 33% | P |
ELIDEL 1% CREAM |
2 |
Preferred Brand |
$45.00 | $112.50 | S |
ELIGARD 22.5 MG SYRINGE |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
ELIGARD 7.5 MG SYRINGE KIT |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Elitek 3 KIT per CARTON / 1 KIT in 1 KIT |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
ELITEK 7.5 MG VIAL |
4 |
Specialty Tier |
33% | 33% | P |
ELIXOPHYLLIN 80mg/15mL 473 mL in 1 BOTTLE |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
ELLENCE 2MG/ML VIAL |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
EMCYT 140MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
EMEND 150 MG VIAL |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
EMEND CAPSULES 125MG 6 BLPK |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | P Q:4 /30Days |
EMEND CAPSULES 80MG 2 BLPK |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | P Q:8 /30Days |
EMEND TRIFOLD PACK |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | P Q:12 /30Days |
EMPLICITI 300 MG VIAL |
4 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMPLICITI 400 MG VIAL |
4 |
Specialty Tier |
33% | 33% | P |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | P Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | P Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | P Q:30 /30Days |
EMTRIVA 10MG/ML SOLUTION |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
EMTRIVA 200MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
Enablex 15mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
Enablex 7.5mg EXTENDED RELEASE 90 TABLET BOTTLE |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ENALAPRIL MALEATE 10MG TABLET (100 CT) |
1 |
Generic |
$6.00 | $15.00 | None |
ENALAPRIL MALEATE 2.5 MG TAB |
1 |
Generic |
$6.00 | $15.00 | None |
Enalapril Maleate 20mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Generic |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENALAPRIL MALEATE 5 MG TABLET |
1 |
Generic |
$6.00 | $15.00 | None |
Enalapril Maleate and Hydrochlorothiazide 10; 25mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Generic |
$6.00 | $15.00 | None |
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET |
1 |
Generic |
$6.00 | $15.00 | None |
ENBREL 25MG KIT |
4 |
Specialty Tier |
33% | 33% | P |
ENBREL 50 MG/ML SURECLICK SYR |
4 |
Specialty Tier |
33% | 33% | P |
ENBREL 50mg/mL |
4 |
Specialty Tier |
33% | 33% | P |
ENDOCET 5/325 TABLET |
2 |
Preferred Brand |
$45.00 | $112.50 | Q:360 /30Days |
ENGERIX B INJECTION |
2 |
Preferred Brand |
$45.00 | $112.50 | P |
ENGERIX-B 10MCG 10 X 0.5ML VIALSD |
2 |
Preferred Brand |
$45.00 | $112.50 | P |
ENGERIX-B 20 MCG/ML SYRN |
2 |
Preferred Brand |
$45.00 | $112.50 | P |
ENJUVIA 0.3MG TABLET |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENJUVIA 0.45MG TABLET |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | P Q:30 /30Days |
ENJUVIA 0.9MG TABLET |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | P Q:30 /30Days |
ENOXAPARIN 100 MG/ML SYRINGE |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:28 /14Days |
ENOXAPARIN 120 MG/0.8 ML SYR |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:28 /14Days |
ENOXAPARIN 150 MG/ML SYRINGE |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:28 /14Days |
ENOXAPARIN 30 MG/0.3 ML SYR |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:28 /14Days |
ENOXAPARIN 300 MG/3 ML VIAL |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:28 /14Days |
ENOXAPARIN 40 MG/0.4 ML SYR |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:28 /14Days |
ENOXAPARIN 60 MG/0.6 ML SYR |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:28 /14Days |
ENOXAPARIN 80 MG/0.8 ML SYR |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:28 /14Days |
ENTACAPONE 200 MG TABLET [Comtan Entacapone] |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENTOCORT EC 3 MG CAPSULE |
4 |
Specialty Tier |
33% | 33% | None |
ENULOSE 10 GM/15 ML SOLUTION |
1 |
Generic |
$6.00 | $15.00 | None |
ENVARSUS XR 0.75 MG TABLET |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
ENVARSUS XR 1 MG TABLET |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
ENVARSUS XR 4 MG TABLET |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
EPINASTINE HCL 0.05% EYE DROPS |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
EPIPEN 0.3MG AUTO-INJECTOR |
2 |
Preferred Brand |
$45.00 | $112.50 | Q:2 /30Days |
EPIPEN JR 0.15MG AUTO-INJCT |
2 |
Preferred Brand |
$45.00 | $112.50 | Q:2 /30Days |
EPITOL 200MG TABLET |
1 |
Generic |
$6.00 | $15.00 | None |
EPIVIR 10 MG/ML ORAL SOLUTION |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
EPIVIR 150 MG TABLETS |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPIVIR 300mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
EPIVIR HBV 100MG TABLET |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
EPIVIR HBV 25MG/5ML TUBEX |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
Eplerenone 25mg/1 90 TABLET BOTTLE |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
Eplerenone 50mg/1 90 TABLET BOTTLE |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
EPOGEN 10000U/ML VIAL MDV |
2 |
Preferred Brand |
$45.00 | $112.50 | P |
EPOGEN 2000[iU]/mL 10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL |
2 |
Preferred Brand |
$45.00 | $112.50 | P |
EPOGEN 4000U/ML VIAL SDV |
2 |
Preferred Brand |
$45.00 | $112.50 | P |
EPOGEN INJECTION 20000U 10 X 1ML CRTN |
2 |
Preferred Brand |
$45.00 | $112.50 | P |
EPZICOM 600MG/300MG TABLETS |
4 |
Specialty Tier |
33% | 33% | None |
ERAXIS 100mg/30mL 30 mL in 1 VIAL, SINGLE-USE |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERBITUX 100MG/50ML VIAL |
4 |
Specialty Tier |
33% | 33% | P |
ERGOLOID MESYLATES TABLETS 1MG 100 BOT |
1 |
Generic |
$6.00 | $15.00 | P |
ERGOMAR 2 MG TABLET SL |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ERIVEDGE 150 MG CAPSULE |
4 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
ERRIN 0.35MG TABLET |
1 |
Generic |
$6.00 | $15.00 | None |
ERWINAZE 10,000 UNITS VIAL |
4 |
Specialty Tier |
33% | 33% | P |
ERY 2% PADS 2% 60 PADS JAR |
1 |
Generic |
$6.00 | $15.00 | None |
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
ERY-TAB TAB 250MG EC |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
ERY-TAB TAB 333MG EC |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
ERYPED 200 MG/5 ML SUSPENSION |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYPED 400 MG/5 ML SUSPENSION |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
ERYTHROCIN 500MG ADDVNT VL |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
ERYTHROCIN TAB 250MG |
1 |
Generic |
$6.00 | $15.00 | None |
Erythromycin 2% solution |
1 |
Generic |
$6.00 | $15.00 | None |
Erythromycin 20mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
1 |
Generic |
$6.00 | $15.00 | None |
ERYTHROMYCIN 500 MG FILMTAB |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
ERYTHROMYCIN ES 400 MG TAB |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
ERYTHROMYCIN OPHTHALMIC OINTMENT 0.5% 1 G BOX OF 50 TUBE |
1 |
Generic |
$6.00 | $15.00 | None |
ERYTHROMYCIN TAB 250MG BS |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
ERYTHROMYCIN-BENZOYL PEROXIDE 3-5% GEL |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
ESBRIET 267 MG CAPSULE |
4 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESCITALOPRAM 10 MG TABLET [Lexapro] |
1 |
Generic |
$6.00 | $15.00 | Q:30 /30Days |
ESCITALOPRAM 20 MG TABLET [Lexapro] |
1 |
Generic |
$6.00 | $15.00 | Q:30 /30Days |
ESCITALOPRAM 5 MG TABLET [Lexapro] |
1 |
Generic |
$6.00 | $15.00 | Q:30 /30Days |
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro] |
1 |
Generic |
$6.00 | $15.00 | Q:600 /30Days |
ESOMEPRAZOLE DR 49.3 MG CAPSULE [Nexium] |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
ESOMEPRAZOLE MAG DR 20 MG CAPSULE [Nexium] |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
ESOMEPRAZOLE SODIUM 20 MG VIAL [Nexium] |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
ESOMEPRAZOLE SODIUM 40 MG VIAL [Nexium] |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
Estazolam 1mg/1 100 TABLET BOTTLE |
1 |
Generic |
$6.00 | $15.00 | P |
Estazolam 2mg/1 100 TABLET BOTTLE |
1 |
Generic |
$6.00 | $15.00 | P |
ESTRACE VAG CREAM 0.1MG/GM |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL 0.5MG TABLET |
2 |
Preferred Brand |
$45.00 | $112.50 | P |
ESTRADIOL 2MG TABLET |
2 |
Preferred Brand |
$45.00 | $112.50 | P |
ESTRADIOL TABLET 1MG (500 CT) |
2 |
Preferred Brand |
$45.00 | $112.50 | P |
ESTRADIOL VALERATE 20mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
ESTRADIOL VALERATE 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
ETHAMBUTOL HCL 400 MG TABLET |
1 |
Generic |
$6.00 | $15.00 | None |
Ethambutol Hydrochloride 100mg/1 |
1 |
Generic |
$6.00 | $15.00 | None |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 |
1 |
Generic |
$6.00 | $15.00 | None |
ETHOSUXIMIDE 250 MG CAPSULE |
1 |
Generic |
$6.00 | $15.00 | None |
ETHOSUXIMIDE 250MG/5ML SYRP |
1 |
Generic |
$6.00 | $15.00 | None |
ETODOLAC 200MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Etodolac 300 mg capsule |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
ETODOLAC 400 MG TABLET |
1 |
Generic |
$6.00 | $15.00 | None |
ETODOLAC 400MG TABLET SR 24HR |
1 |
Generic |
$6.00 | $15.00 | None |
ETODOLAC 500MG TABLET SR 24HR |
1 |
Generic |
$6.00 | $15.00 | None |
Etodolac 500mg/1 500 TABLET BOTTLE |
1 |
Generic |
$6.00 | $15.00 | None |
ETODOLAC 600MG TABLET SR 24HR |
1 |
Generic |
$6.00 | $15.00 | None |
EVOTAZ 300 MG-150 MG TABLET |
4 |
Specialty Tier |
33% | 33% | None |
EVOXAC 30MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $112.50 | None |
EXELON 1.5MG CAPSULE |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:90 /30Days |
EXELON 13.3 MG/24HR PATCH |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:30 /30Days |
EXELON 3MG CAPSULE |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EXELON 4.5MG CAPSULE |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:60 /30Days |
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:30 /30Days |
EXELON 6MG CAPSULE |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:60 /30Days |
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:30 /30Days |
EXJADE 125MG TABLET |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
EXJADE 250MG TABLET |
4 |
Specialty Tier |
33% | 33% | P |
EXJADE 500MG TABLET |
4 |
Specialty Tier |
33% | 33% | P |