2016 Medicare Part D Plan Formulary Information |
Gold PPO with Part D (PPO) (H9615-007-0)
Benefit Details
|
The Gold PPO with Part D (PPO) (H9615-007-0) Formulary Drugs Starting with the Letter E in Fulton County, NY: CMS MA Region 3 which includes: NY Plan Monthly Premium: $151.00 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 |
E.E.S. 400 FILMTAB |
2 |
Generic |
$10.00 | $20.00 | None |
ECONAZOLE NITRATE 1% CREAM 85GM TUBE |
2 |
Generic |
$10.00 | $20.00 | None |
EDARBI 40 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
EDARBI 80 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
EDARBYCLOR 40-12.5 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
EDARBYCLOR 40-25 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
EDECRIN 25 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
EDURANT 27.5mg/1 |
5 |
Specialty Tier |
33% | N/A | None |
EFFIENT 10 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
EFFIENT 5 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIDEL 1% CREAM |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
ELIGARD 22.5 MG SYRINGE |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | P |
ELIGARD 30 MG SYRINGE KIT |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | P |
ELIGARD 45 MG SYRINGE KIT |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | P |
ELIGARD 7.5 MG SYRINGE KIT |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | P |
ELIPHOS TABLETS CALCIUM ACETATE TABLETS 667MG 200 BOT |
2 |
Generic |
$10.00 | $20.00 | None |
ELIQUIS 2.5 MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ELIQUIS 5 MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
Elitek 3 KIT per CARTON / 1 KIT in 1 KIT |
5 |
Specialty Tier |
33% | N/A | P |
ELIXOPHYLLIN 80mg/15mL 473 mL in 1 BOTTLE |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ELLENCE 2MG/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
EMADINE 0.05% EYE DROPS |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
EMCYT 140MG CAPSULE |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
EMEND 150 MG VIAL |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | P |
EMEND 40MG CAPSULE |
3 |
Preferred Brand |
$35.00 | $70.00 | P Q:1 /30Days |
EMEND CAPSULES 125MG 6 BLPK |
3 |
Preferred Brand |
$35.00 | $70.00 | P Q:2 /30Days |
EMEND CAPSULES 80MG 2 BLPK |
3 |
Preferred Brand |
$35.00 | $70.00 | P Q:8 /30Days |
EMEND TRIFOLD PACK |
3 |
Preferred Brand |
$35.00 | $70.00 | P Q:6 /30Days |
Emoquette 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2 |
Generic |
$10.00 | $20.00 | None |
EMPLICITI 300 MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
EMPLICITI 400 MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
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 |
$90.00 | $180.00 | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
EMTRIVA 10MG/ML SOLUTION |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
EMTRIVA 200MG CAPSULE |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ENALAPRIL MALEATE 10MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 2.5 MG TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Enalapril Maleate 20mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 5 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Enalapril Maleate and Hydrochlorothiazide 10; 25mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET |
1 |
Preferred Generic |
$0.00 | $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 |
33% | N/A | P |
ENBREL 25MG KIT |
5 |
Specialty Tier |
33% | N/A | P |
ENBREL 50 MG/ML SURECLICK SYR |
5 |
Specialty Tier |
33% | N/A | P |
ENBREL 50mg/mL |
5 |
Specialty Tier |
33% | N/A | P |
ENDOCET 10MG-325MG TABLET |
2 |
Generic |
$10.00 | $20.00 | Q:360 /30Days |
ENDOCET 5/325 TABLET |
2 |
Generic |
$10.00 | $20.00 | Q:360 /30Days |
ENDOCET 7.5-325MG TABLET |
2 |
Generic |
$10.00 | $20.00 | Q:360 /30Days |
ENGERIX B INJECTION |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | P |
ENGERIX-B 10MCG 10 X 0.5ML VIALSD |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | P |
ENGERIX-B 20 MCG/ML SYRN |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | P |
ENOXAPARIN 100 MG/ML SYRINGE |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENOXAPARIN 120 MG/0.8 ML SYR |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
ENOXAPARIN 150 MG/ML SYRINGE |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
ENOXAPARIN 30 MG/0.3 ML SYR |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
ENOXAPARIN 300 MG/3 ML VIAL |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
ENOXAPARIN 40 MG/0.4 ML SYR |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
ENOXAPARIN 60 MG/0.6 ML SYR |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
ENOXAPARIN 80 MG/0.8 ML SYR |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
ENTACAPONE 200 MG TABLET [Comtan Entacapone] |
2 |
Generic |
$10.00 | $20.00 | None |
ENTECAVIR 0.5 MG TABLET [Baraclude] |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
ENTECAVIR 1 MG TABLET [Baraclude] |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
ENTRESTO 24 MG-26 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENTRESTO 49 MG-51 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
ENTRESTO 97 MG-103 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
ENULOSE 10 GM/15 ML SOLUTION |
2 |
Generic |
$10.00 | $20.00 | None |
ENVARSUS XR 0.75 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | P |
ENVARSUS XR 1 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | P |
ENVARSUS XR 4 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | P |
EPINASTINE HCL 0.05% EYE DROPS |
2 |
Generic |
$10.00 | $20.00 | None |
Epinephrine 0.15 mg auto-injct |
2 |
Generic |
$10.00 | $20.00 | None |
Epinephrine 0.3 mg auto-inject |
2 |
Generic |
$10.00 | $20.00 | Q:1 /30Days |
EPIPEN 0.3MG AUTO-INJECTOR |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:1 /30Days |
EPIPEN JR 0.15MG AUTO-INJCT |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:1 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPIRUBICIN HCL INJECTION SOLUTION 2MG 1 X 25ML VIAL |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | P |
EPITOL 200MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
Eplerenone 25mg/1 90 TABLET BOTTLE |
2 |
Generic |
$10.00 | $20.00 | None |
Eplerenone 50mg/1 90 TABLET BOTTLE |
2 |
Generic |
$10.00 | $20.00 | None |
EPOGEN 10000U/ML VIAL MDV |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | P Q:12 /30Days |
EPOGEN 2000[iU]/mL 10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL |
3 |
Preferred Brand |
$35.00 | $70.00 | P Q:12 /30Days |
EPOGEN 3000U/ML VIAL SDV |
3 |
Preferred Brand |
$35.00 | $70.00 | P Q:12 /30Days |
EPOGEN 4000U/ML VIAL SDV |
3 |
Preferred Brand |
$35.00 | $70.00 | P Q:12 /30Days |
EPOGEN INJECTION 20000U 10 X 1ML CRTN |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | P |
EPROSARTAN MESYLATE 600 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
EPZICOM 600MG/300MG TABLETS |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EQUETRO CAPSULES 200MG 120 BOT |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
EQUETRO CAPSULES 300MG 120 BOT |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
EQUETRO EXTENDED RELEASE CAPSULES 100MG 120 BOT |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
ERBITUX 100MG/50ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
ERGOLOID MESYLATES TABLETS 1MG 100 BOT |
2 |
Generic |
$10.00 | $20.00 | None |
ERIVEDGE 150 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
ERRIN 0.35MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
ERWINAZE 10,000 UNITS VIAL |
5 |
Specialty Tier |
33% | N/A | P |
ERY 2% PADS 2% 60 PADS JAR |
2 |
Generic |
$10.00 | $20.00 | None |
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ERY-TAB TAB 250MG EC |
2 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERY-TAB TAB 333MG EC |
2 |
Generic |
$10.00 | $20.00 | None |
ERYTHROCIN 500MG ADDVNT VL |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
ERYTHROCIN TAB 250MG |
2 |
Generic |
$10.00 | $20.00 | None |
Erythromycin 2% solution |
2 |
Generic |
$10.00 | $20.00 | None |
Erythromycin 20mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2 |
Generic |
$10.00 | $20.00 | None |
ERYTHROMYCIN 500 MG FILMTAB |
2 |
Generic |
$10.00 | $20.00 | None |
ERYTHROMYCIN EC 250 MG CAP |
2 |
Generic |
$10.00 | $20.00 | None |
ERYTHROMYCIN ES 400 MG TAB |
2 |
Generic |
$10.00 | $20.00 | None |
ERYTHROMYCIN OPHTHALMIC OINTMENT 0.5% 1 G BOX OF 50 TUBE |
2 |
Generic |
$10.00 | $20.00 | None |
ERYTHROMYCIN TAB 250MG BS |
2 |
Generic |
$10.00 | $20.00 | None |
ERYTHROMYCIN-BENZOYL PEROXIDE 3-5% GEL |
2 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESBRIET 267 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
ESCITALOPRAM 10 MG TABLET [Lexapro] |
2 |
Generic |
$10.00 | $20.00 | None |
ESCITALOPRAM 20 MG TABLET [Lexapro] |
2 |
Generic |
$10.00 | $20.00 | None |
ESCITALOPRAM 5 MG TABLET [Lexapro] |
2 |
Generic |
$10.00 | $20.00 | None |
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro] |
2 |
Generic |
$10.00 | $20.00 | None |
ESOMEPRAZOLE SODIUM 20 MG VIAL [Nexium] |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | P |
ESOMEPRAZOLE SODIUM 40 MG VIAL [Nexium] |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | P |
ESTRACE VAG CREAM 0.1MG/GM |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
Estradiol / Norethindrone Acetate 0.5; 0.1mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, FILM C |
2 |
Generic |
$10.00 | $20.00 | None |
Estradiol 0.025 mg patch |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
Estradiol 0.0375 mg patch |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Estradiol 0.05 mg patch |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
Estradiol 0.075 mg patch |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
Estradiol 0.1 mg patch |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ESTRADIOL 0.5MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ESTRADIOL 2MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ESTRADIOL TABLET 1MG (500 CT) |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ESTRADIOL TDS 0.025 MG/DAY |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ESTRADIOL TDS 0.0375 MG/DAY |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ESTRADIOL TDS 0.05 MG/DAY |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ESTRADIOL TDS 0.06 MG/DAY |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ESTRADIOL TDS 0.075 MG/DAY |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL TDS 0.1 MG/DAY |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ESTRADIOL VALERATE 20mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ESTRADIOL-NORETH 1.0-0.5MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
ESTRING 2MG VAGINAL RING |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
ESTROPIPATE 0.625(0.75 MG) TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
ESTROPIPATE 1.25(1.5 MG) TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
ESTROPIPATE 2.5(3 MG) TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
ETHAMBUTOL HCL 400 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
Ethambutol Hydrochloride 100mg/1 |
2 |
Generic |
$10.00 | $20.00 | None |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 |
2 |
Generic |
$10.00 | $20.00 | None |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21 |
2 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETHOSUXIMIDE 250 MG CAPSULE |
2 |
Generic |
$10.00 | $20.00 | None |
ETHOSUXIMIDE 250MG/5ML SYRP |
2 |
Generic |
$10.00 | $20.00 | None |
ETIDRONATE DISODIUM 400MG TABLET (60 CT) |
2 |
Generic |
$10.00 | $20.00 | None |
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT |
2 |
Generic |
$10.00 | $20.00 | None |
ETODOLAC 200MG CAPSULE |
2 |
Generic |
$10.00 | $20.00 | None |
Etodolac 300 mg capsule |
2 |
Generic |
$10.00 | $20.00 | None |
ETODOLAC 400 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
Etodolac 500mg/1 500 TABLET BOTTLE |
2 |
Generic |
$10.00 | $20.00 | None |
ETOPOPHOS 100MG VIAL |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | P |
Etoposide 500 mg/25 ml vial |
2 |
Generic |
$10.00 | $20.00 | P |
Eurax Lotion and Cream 100mg/g 454 g in 1 BOTTLE |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Eurax Lotion and Cream 100mg/g 60 g in 1 TUBE |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
EVOTAZ 300 MG-150 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
EXELON 13.3 MG/24HR PATCH |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
Exemestane 25mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
EXJADE 125MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $180.00 | None |
EXJADE 250MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
EXJADE 500MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
EXTAVIA 15 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
5 |
Specialty Tier |
33% | N/A | None |