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2016 Medicare Part D Plan Formulary Information
Express Scripts Medicare - Choice (PDP) (S5660-181-0) Benefit Details
The Express Scripts Medicare - Choice (PDP) (S5660-181-0) Formulary Drugs Starting with the Letter E in CMS PDP Region 11 which includes: FL Plan Monthly Premium: $105.00 Deductible: $360 Qualifies for LIS: No
Drugs Starting with Letter E Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter E Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
E.E.S. 400 FILMTAB	3	Preferred Brand	$42.00	$126.00	None
E.E.S. GRAN SUS 200/5ML	3	Preferred Brand	$42.00	$126.00	None
ECONAZOLE NITRATE 1% CREAM 85GM TUBE	2*	Generic	$5.00	$5.00	None
EDECRIN 25 MG TABLET	4	Non-Preferred Brand	48%	50%	None
EDURANT 27.5mg/1	4	Non-Preferred Brand	48%	50%	None
EFFIENT 10 MG TABLET	3	Preferred Brand	$42.00	$126.00	None
EFFIENT 5 MG TABLET	3	Preferred Brand	$42.00	$126.00	None
ELAPRASE 6mg/3mL 1 VIAL, GLASS in 1 BOX / 3 mL in 1 VIAL, GLASS	5	Specialty Tier	25%	N/A	None
ELIPHOS TABLETS CALCIUM ACETATE TABLETS 667MG 200 BOT	2*	Generic	$5.00	$5.00	None
ELIQUIS 2.5 MG TABLET	3	Preferred Brand	$42.00	$126.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ELIQUIS 5 MG TABLET	3	Preferred Brand	$42.00	$126.00	None
ELIXOPHYLLIN 80mg/15mL 473 mL in 1 BOTTLE	4	Non-Preferred Brand	48%	50%	None
ELLENCE 2MG/ML VIAL	4	Non-Preferred Brand	48%	50%	None
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE	3	Preferred Brand	$42.00	$126.00	None
EMCYT 140MG CAPSULE	3	Preferred Brand	$42.00	$126.00	None
EMEND 150 MG VIAL	3	Preferred Brand	$42.00	$126.00	None
EMEND 40MG CAPSULE	3	Preferred Brand	$42.00	$126.00	P
EMEND CAPSULES 125MG 6 BLPK	3	Preferred Brand	$42.00	$126.00	P
EMEND CAPSULES 80MG 2 BLPK	3	Preferred Brand	$42.00	$126.00	P
EMEND TRIFOLD PACK	3	Preferred Brand	$42.00	$126.00	P
Emoquette 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	2*	Generic	$5.00	$5.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EMPLICITI 300 MG VIAL	4	Non-Preferred Brand	48%	50%	P
EMPLICITI 400 MG VIAL	4	Non-Preferred Brand	48%	50%	P
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H	4	Non-Preferred Brand	48%	50%	None
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H	4	Non-Preferred Brand	48%	50%	None
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H	4	Non-Preferred Brand	48%	50%	None
EMTRIVA 10MG/ML SOLUTION	3	Preferred Brand	$42.00	$126.00	None
EMTRIVA 200MG CAPSULE	3	Preferred Brand	$42.00	$126.00	None
EMVERM 100 MG TABLET CHEW	5	Specialty Tier	25%	N/A	None
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
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
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
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:4 /28Days
ENBREL 50mg/mL	5	Specialty Tier	25%	N/A	P Q:4 /28Days
ENDOCET 10MG-325MG TABLET	3	Preferred Brand	$42.00	$126.00	Q:372 /31Days
ENDOCET 5/325 TABLET	3	Preferred Brand	$42.00	$126.00	Q:372 /31Days
ENDOCET 7.5-325MG TABLET	3	Preferred Brand	$42.00	$126.00	Q:372 /31Days
ENGERIX B INJECTION	3	Preferred Brand	$42.00	$126.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENGERIX-B 10MCG 10 X 0.5ML VIALSD	3	Preferred Brand	$42.00	$126.00	P
ENGERIX-B 20 MCG/ML SYRN	3	Preferred Brand	$42.00	$126.00	P
ENOXAPARIN 100 MG/ML SYRINGE	3	Preferred Brand	$42.00	$126.00	None
ENOXAPARIN 120 MG/0.8 ML SYR	3	Preferred Brand	$42.00	$126.00	None
ENOXAPARIN 150 MG/ML SYRINGE	3	Preferred Brand	$42.00	$126.00	None
ENOXAPARIN 30 MG/0.3 ML SYR	3	Preferred Brand	$42.00	$126.00	None
ENOXAPARIN 300 MG/3 ML VIAL	5	Specialty Tier	25%	N/A	None
ENOXAPARIN 40 MG/0.4 ML SYR	3	Preferred Brand	$42.00	$126.00	None
ENOXAPARIN 60 MG/0.6 ML SYR	3	Preferred Brand	$42.00	$126.00	None
ENOXAPARIN 80 MG/0.8 ML SYR	3	Preferred Brand	$42.00	$126.00	None
ENTACAPONE 200 MG TABLET [Comtan Entacapone]	2*	Generic	$5.00	$5.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENTECAVIR 0.5 MG TABLET [Baraclude]	3	Preferred Brand	$42.00	$126.00	None
ENTECAVIR 1 MG TABLET [Baraclude]	3	Preferred Brand	$42.00	$126.00	None
ENTRESTO 24 MG-26 MG TABLET	3	Preferred Brand	$42.00	$126.00	P Q:62 /31Days
ENTRESTO 49 MG-51 MG TABLET	3	Preferred Brand	$42.00	$126.00	P Q:62 /31Days
ENTRESTO 97 MG-103 MG TABLET	3	Preferred Brand	$42.00	$126.00	P Q:62 /31Days
ENULOSE 10 GM/15 ML SOLUTION	1*	Preferred Generic	$1.00	$0.00	None
EPINASTINE HCL 0.05% EYE DROPS	2*	Generic	$5.00	$5.00	None
Epinephrine 0.15 mg auto-injct	2*	Generic	$5.00	$5.00	Q:4 /31Days
Epinephrine 0.3 mg auto-inject	2*	Generic	$5.00	$5.00	Q:4 /31Days
EPIPEN 0.3MG AUTO-INJECTOR	3	Preferred Brand	$42.00	$126.00	Q:4 /31Days
EPIPEN JR 0.15MG AUTO-INJCT	3	Preferred Brand	$42.00	$126.00	Q:4 /31Days
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	2*	Generic	$5.00	$5.00	None
EPITOL 200MG TABLET	1*	Preferred Generic	$1.00	$0.00	None
EPIVIR 10 MG/ML ORAL SOLUTION	3	Preferred Brand	$42.00	$126.00	None
EPIVIR HBV 25MG/5ML TUBEX	3	Preferred Brand	$42.00	$126.00	None
Eplerenone 25mg/1 90 TABLET BOTTLE	2*	Generic	$5.00	$5.00	None
Eplerenone 50mg/1 90 TABLET BOTTLE	2*	Generic	$5.00	$5.00	None
EPROSARTAN MESYLATE 600 MG TABLET	2*	Generic	$5.00	$5.00	None
EPZICOM 600MG/300MG TABLETS	5	Specialty Tier	25%	N/A	None
ERAXIS 100mg/30mL 30 mL in 1 VIAL, SINGLE-USE	4	Non-Preferred Brand	48%	50%	None
ERBITUX 100MG/50ML VIAL	5	Specialty Tier	25%	N/A	None
ERGOLOID MESYLATES TABLETS 1MG 100 BOT	2*	Generic	$5.00	$5.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ERIVEDGE 150 MG CAPSULE	5	Specialty Tier	25%	N/A	P Q:31 /31Days
ERRIN 0.35MG TABLET	2*	Generic	$5.00	$5.00	None
ERWINAZE 10,000 UNITS VIAL	5	Specialty Tier	25%	N/A	None
ERY 2% PADS 2% 60 PADS JAR	1*	Preferred Generic	$1.00	$0.00	None
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE	3	Preferred Brand	$42.00	$126.00	None
ERY-TAB TAB 250MG EC	3	Preferred Brand	$42.00	$126.00	None
ERY-TAB TAB 333MG EC	3	Preferred Brand	$42.00	$126.00	None
ERYGEL 2% GEL	2*	Generic	$5.00	$5.00	None
ERYTHROCIN 500MG ADDVNT VL	3	Preferred Brand	$42.00	$126.00	None
ERYTHROCIN TAB 250MG	3	Preferred Brand	$42.00	$126.00	None
Erythromycin 2% solution	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
Erythromycin 20mg/g 1 TUBE per CARTON / 60 g in 1 TUBE	1*	Preferred Generic	$1.00	$0.00	None
ERYTHROMYCIN 500 MG FILMTAB	3	Preferred Brand	$42.00	$126.00	None
ERYTHROMYCIN EC 250 MG CAP	3	Preferred Brand	$42.00	$126.00	None
ERYTHROMYCIN ES 400 MG TAB	3	Preferred Brand	$42.00	$126.00	None
ERYTHROMYCIN OPHTHALMIC OINTMENT 0.5% 1 G BOX OF 50 TUBE	1*	Preferred Generic	$1.00	$0.00	None
ERYTHROMYCIN TAB 250MG BS	4	Non-Preferred Brand	48%	50%	None
ERYTHROMYCIN-BENZOYL PEROXIDE 3-5% GEL	3	Preferred Brand	$42.00	$126.00	None
ESBRIET 267 MG CAPSULE	5	Specialty Tier	25%	N/A	P Q:279 /31Days
ESCITALOPRAM 10 MG TABLET [Lexapro]	3	Preferred Brand	$42.00	$126.00	Q:62 /31Days
ESCITALOPRAM 20 MG TABLET [Lexapro]	3	Preferred Brand	$42.00	$126.00	Q:31 /31Days
ESCITALOPRAM 5 MG TABLET [Lexapro]	3	Preferred Brand	$42.00	$126.00	Q:124 /31Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro]	4	Non-Preferred Brand	48%	50%	None
ESOMEPRAZOLE SODIUM 20 MG VIAL [Nexium]	2*	Generic	$5.00	$5.00	None
ESOMEPRAZOLE SODIUM 40 MG VIAL [Nexium]	2*	Generic	$5.00	$5.00	None
ESTRACE VAG CREAM 0.1MG/GM	3	Preferred Brand	$42.00	$126.00	None
Estradiol / Norethindrone Acetate 0.5; 0.1mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, FILM C	2*	Generic	$5.00	$5.00	None
Estradiol 0.025 mg patch	1*	Preferred Generic	$1.00	$0.00	Q:8 /28Days
Estradiol 0.0375 mg patch	1*	Preferred Generic	$1.00	$0.00	Q:8 /28Days
Estradiol 0.05 mg patch	1*	Preferred Generic	$1.00	$0.00	Q:8 /28Days
Estradiol 0.075 mg patch	1*	Preferred Generic	$1.00	$0.00	Q:8 /28Days
Estradiol 0.1 mg patch	1*	Preferred Generic	$1.00	$0.00	Q:8 /28Days
ESTRADIOL 0.5MG 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
ESTRADIOL 2MG TABLET	1*	Preferred Generic	$1.00	$0.00	None
ESTRADIOL TABLET 1MG (500 CT)	1*	Preferred Generic	$1.00	$0.00	None
ESTRADIOL TDS 0.025 MG/DAY	1*	Preferred Generic	$1.00	$0.00	Q:4 /28Days
ESTRADIOL TDS 0.0375 MG/DAY	1*	Preferred Generic	$1.00	$0.00	Q:4 /28Days
ESTRADIOL TDS 0.05 MG/DAY	1*	Preferred Generic	$1.00	$0.00	Q:4 /28Days
ESTRADIOL TDS 0.06 MG/DAY	1*	Preferred Generic	$1.00	$0.00	Q:4 /28Days
ESTRADIOL TDS 0.075 MG/DAY	1*	Preferred Generic	$1.00	$0.00	Q:4 /28Days
ESTRADIOL TDS 0.1 MG/DAY	1*	Preferred Generic	$1.00	$0.00	Q:4 /28Days
ESTRADIOL VALERATE 20mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE	2*	Generic	$5.00	$5.00	None
ESTRADIOL VALERATE 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE	2*	Generic	$5.00	$5.00	None
ESTRADIOL-NORETH 1.0-0.5MG TABLET	2*	Generic	$5.00	$5.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ESTRING 2MG VAGINAL RING	4	Non-Preferred Brand	48%	50%	None
ESTROPIPATE 0.625(0.75 MG) TABLET	2*	Generic	$5.00	$5.00	None
ESTROPIPATE 1.25(1.5 MG) TABLET	2*	Generic	$5.00	$5.00	None
ESTROPIPATE 2.5(3 MG) TABLET	2*	Generic	$5.00	$5.00	None
ETHAMBUTOL HCL 400 MG TABLET	2*	Generic	$5.00	$5.00	None
Ethambutol Hydrochloride 100mg/1	2*	Generic	$5.00	$5.00	None
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6	2*	Generic	$5.00	$5.00	None
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21	2*	Generic	$5.00	$5.00	None
ETHOSUXIMIDE 250 MG CAPSULE	3	Preferred Brand	$42.00	$126.00	None
ETHOSUXIMIDE 250MG/5ML SYRP	3	Preferred Brand	$42.00	$126.00	None
ETIDRONATE DISODIUM 400MG TABLET (60 CT)	4	Non-Preferred Brand	48%	50%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT	4	Non-Preferred Brand	48%	50%	None
ETODOLAC 200MG CAPSULE	2*	Generic	$5.00	$5.00	None
Etodolac 300 mg capsule	2*	Generic	$5.00	$5.00	None
ETODOLAC 400 MG TABLET	2*	Generic	$5.00	$5.00	None
ETODOLAC 400MG TABLET SR 24HR	2*	Generic	$5.00	$5.00	None
ETODOLAC 500MG TABLET SR 24HR	2*	Generic	$5.00	$5.00	None
Etodolac 500mg/1 500 TABLET BOTTLE	2*	Generic	$5.00	$5.00	None
ETODOLAC 600MG TABLET SR 24HR	2*	Generic	$5.00	$5.00	None
ETOPOPHOS 100MG VIAL	4	Non-Preferred Brand	48%	50%	None
Etoposide 500 mg/25 ml vial	2*	Generic	$5.00	$5.00	None
Eurax Lotion and Cream 100mg/g 454 g in 1 BOTTLE	3	Preferred Brand	$42.00	$126.00	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	3	Preferred Brand	$42.00	$126.00	None
Evista 60mg/1 100 TABLET BOTTLE	3	Preferred Brand	$42.00	$126.00	None
EVOTAZ 300 MG-150 MG TABLET	4	Non-Preferred Brand	48%	50%	None
EXELON 13.3 MG/24HR PATCH	4	Non-Preferred Brand	48%	50%	None
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS	4	Non-Preferred Brand	48%	50%	None
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS	4	Non-Preferred Brand	48%	50%	None
Exemestane 25mg/1 30 FILM COATED TABLETS in BOTTLE	3	Preferred Brand	$42.00	$126.00	None
EXJADE 125MG TABLET	5	Specialty Tier	25%	N/A	None
EXJADE 250MG TABLET	5	Specialty Tier	25%	N/A	None
EXJADE 500MG TABLET	5	Specialty Tier	25%	N/A	None

Chart Legend:

Below are a few notes to help you understand the above 2016 Medicare Part D Express Scripts Medicare - Choice (PDP) Plan Formulary.

Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).
Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.
Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $360 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.
Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
- Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
- No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.
Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
- Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
- Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
- Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $3310) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2016 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
- Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
- None - This drug does not fall under any drug utilization management controls.
- P - Prior Authorization -This drug is subject to prior authorization.
- S - Step Therapy -This drug is subject to step therapy.
- Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.

(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2016 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.