2017 Medicare Part D Plan Formulary Information |
Express Scripts Medicare - Value (PDP) (S5660-105-0)
Benefit Details
|
The Express Scripts Medicare - Value (PDP) (S5660-105-0) Formulary Drugs Starting with the Letter E in CMS PDP Region 2 which includes: CT MA RI VT Plan Monthly Premium: $43.10 Deductible: $400 Qualifies for LIS: No |
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 Drug |
48% | N/A | None |
ECONAZOLE NITRATE 1% CREAM 85GM TUBE |
4 |
Non-Preferred Drug |
48% | N/A | None |
EDURANT 27.5mg/1 |
4 |
Non-Preferred Drug |
48% | N/A | None |
EFFIENT 10 MG TABLET |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
EFFIENT 5 MG TABLET |
3 |
Preferred Brand |
$36.00 | $108.00 | 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 |
4 |
Non-Preferred Drug |
48% | N/A | None |
ELIQUIS 2.5 MG TABLET |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
ELIQUIS 5 MG TABLET |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
ELLENCE 2MG/ML VIAL |
4 |
Non-Preferred Drug |
48% | N/A | 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 |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
EMCYT 140MG CAPSULE |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
EMEND 125 MG POWDER PACKET |
3 |
Preferred Brand |
$36.00 | $108.00 | P |
EMEND 150 MG VIAL |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
EMEND 40MG CAPSULE |
3 |
Preferred Brand |
$36.00 | $108.00 | P |
EMEND CAPSULES 125MG 6 BLPK |
3 |
Preferred Brand |
$36.00 | $108.00 | P |
EMEND CAPSULES 80MG 2 BLPK |
3 |
Preferred Brand |
$36.00 | $108.00 | P |
EMEND TRIFOLD PACK |
3 |
Preferred Brand |
$36.00 | $108.00 | P |
Emoquette 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2 |
Generic |
$3.00 | $6.00 | None |
EMPLICITI 300 MG VIAL |
4 |
Non-Preferred Drug |
48% | N/A | P |
EMPLICITI 400 MG VIAL |
4 |
Non-Preferred Drug |
48% | 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 Drug |
48% | N/A | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
4 |
Non-Preferred Drug |
48% | N/A | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
4 |
Non-Preferred Drug |
48% | N/A | None |
EMTRIVA 10MG/ML SOLUTION |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
EMTRIVA 200MG CAPSULE |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
EMVERM 100 MG TABLET CHEW |
5 |
Specialty Tier |
25% | N/A | None |
ENALAPRIL MALEATE 10MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $3.00 | None |
ENALAPRIL MALEATE 2.5 MG TAB |
1 |
Preferred Generic |
$0.00 | $3.00 | None |
Enalapril Maleate 20mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $3.00 | None |
ENALAPRIL MALEATE 5 MG TABLET |
1 |
Preferred Generic |
$0.00 | $3.00 | None |
Enalapril Maleate and Hydrochlorothiazide 10; 25mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $3.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET |
1 |
Preferred Generic |
$0.00 | $3.00 | 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:8 /28Days |
ENBREL 50mg/mL |
5 |
Specialty Tier |
25% | N/A | P Q:8 /28Days |
ENDOCET 10MG-325MG TABLET |
4 |
Non-Preferred Drug |
48% | N/A | Q:372 /31Days |
ENDOCET 5/325 TABLET |
4 |
Non-Preferred Drug |
48% | N/A | Q:372 /31Days |
ENDOCET 7.5-325MG TABLET |
4 |
Non-Preferred Drug |
48% | N/A | Q:372 /31Days |
ENGERIX B INJECTION |
3 |
Preferred Brand |
$36.00 | $108.00 | P |
ENGERIX-B 10MCG 10 X 0.5ML VIALSD |
3 |
Preferred Brand |
$36.00 | $108.00 | P |
ENGERIX-B 20 MCG/ML SYRN |
3 |
Preferred Brand |
$36.00 | $108.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENOXAPARIN 100 MG/ML SYRINGE |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
ENOXAPARIN 120 MG/0.8 ML SYRINGE |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
ENOXAPARIN 150 MG/ML SYRINGE |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
ENOXAPARIN 30 MG/0.3 ML SYRINGE |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
ENOXAPARIN 300 MG/3 ML vial |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
ENOXAPARIN 40 MG/0.4 ML SYRINGE |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
ENOXAPARIN 60 MG/0.6 ML SYRINGE |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
ENOXAPARIN 80 MG/0.8 ML SYRINGE |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
ENTACAPONE 200 MG TABLET [Comtan Entacapone] |
2 |
Generic |
$3.00 | $6.00 | None |
ENTECAVIR 0.5 MG TABLET [Baraclude] |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
ENTECAVIR 1 MG TABLET [Baraclude] |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENTRESTO 24 MG-26 MG TABLET |
3 |
Preferred Brand |
$36.00 | $108.00 | Q:62 /31Days |
ENTRESTO 49 MG-51 MG TABLET |
3 |
Preferred Brand |
$36.00 | $108.00 | Q:62 /31Days |
ENTRESTO 97 MG-103 MG TABLET |
3 |
Preferred Brand |
$36.00 | $108.00 | Q:62 /31Days |
ENULOSE 10 GM/15 ML SOLUTION |
2 |
Generic |
$3.00 | $6.00 | None |
EPCLUSA 400 MG-100 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
EPINASTINE HCL 0.05% EYE DROPS |
4 |
Non-Preferred Drug |
48% | N/A | None |
EPINEPHRINE 0.15 MG AUTO-INJCT |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
EPINEPHRINE 0.15 MG AUTO-INJECT |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
EPINEPHRINE 0.3 MG AUTO-INJECT |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
EPINEPHRINE 0.3 MG AUTO-INJECT |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
EPIPEN 0.3MG AUTO-INJECTOR |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPIPEN JR 0.15MG AUTO-INJCT |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
Epirubicin 200 mg/100 ml vial |
4 |
Non-Preferred Drug |
48% | N/A | None |
EPITOL 200MG TABLET |
2 |
Generic |
$3.00 | $6.00 | None |
EPIVIR HBV 25MG/5ML TUBEX |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
Eplerenone 25mg/1 90 TABLET BOTTLE |
4 |
Non-Preferred Drug |
48% | N/A | None |
Eplerenone 50mg/1 90 TABLET BOTTLE |
4 |
Non-Preferred Drug |
48% | N/A | None |
EPROSARTAN MESYLATE 600 MG TABLET |
4 |
Non-Preferred Drug |
48% | N/A | None |
EPZICOM 600MG/300MG TABLETS |
5 |
Specialty Tier |
25% | N/A | None |
ERBITUX 100MG/50ML VIAL |
5 |
Specialty Tier |
25% | N/A | None |
ERGOLOID MESYLATES TABLETS 1MG 100 BOT |
2 |
Generic |
$3.00 | $6.00 | None |
Ergotamine-caffeine 1-100mg tb |
3 |
Preferred Brand |
$36.00 | $108.00 | 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 0.35 mg tablet |
2 |
Generic |
$3.00 | $6.00 | None |
ERWINAZE 10,000 UNITS VIAL |
5 |
Specialty Tier |
25% | N/A | None |
ERY 2% PADS 2% 60 PADS JAR |
4 |
Non-Preferred Drug |
48% | N/A | None |
ERYGEL 2% GEL |
2 |
Generic |
$3.00 | $6.00 | None |
ERYTHROCIN 500MG ADDVNT VL |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
ERYTHROCIN TAB 250MG |
4 |
Non-Preferred Drug |
48% | N/A | None |
Erythromycin 2% solution |
2 |
Generic |
$3.00 | $6.00 | None |
Erythromycin 20mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2 |
Generic |
$3.00 | $6.00 | None |
ERYTHROMYCIN 500 MG FILMTAB |
4 |
Non-Preferred Drug |
48% | N/A | None |
ERYTHROMYCIN EC 250 MG CAP |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROMYCIN ES 400 MG TAB |
4 |
Non-Preferred Drug |
48% | N/A | None |
Erythromycin Ethylsuccinate 40 MG/ML Oral Suspension |
4 |
Non-Preferred Drug |
48% | N/A | None |
ERYTHROMYCIN OPHTHALMIC OINTMENT 0.5% 1 G BOX OF 50 TUBE |
1 |
Preferred Generic |
$0.00 | $3.00 | None |
ERYTHROMYCIN TAB 250MG BS |
4 |
Non-Preferred Drug |
48% | N/A | None |
ERYTHROMYCIN-BENZOYL PEROXIDE 3-5% GEL |
4 |
Non-Preferred Drug |
48% | N/A | None |
ESBRIET 267 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:279 /31Days |
ESBRIET 267 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:279 /31Days |
ESBRIET 801 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:93 /31Days |
ESCITALOPRAM 10 MG TABLET [Lexapro] |
1 |
Preferred Generic |
$0.00 | $3.00 | Q:62 /31Days |
ESCITALOPRAM 20 MG TABLET [Lexapro] |
1 |
Preferred Generic |
$0.00 | $3.00 | Q:31 /31Days |
ESCITALOPRAM 5 MG TABLET [Lexapro] |
1 |
Preferred Generic |
$0.00 | $3.00 | 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 Drug |
48% | N/A | None |
ESOMEPRAZOLE SODIUM 20 MG VIAL [Nexium] |
2 |
Generic |
$3.00 | $6.00 | None |
ESOMEPRAZOLE SODIUM 40 MG VIAL [Nexium] |
2 |
Generic |
$3.00 | $6.00 | None |
ESTRACE VAG CREAM 0.1MG/GM |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
Estradiol / Norethindrone Acetate 0.5; 0.1mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, FILM C |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
Estradiol 0.025 mg patch |
2 |
Generic |
$3.00 | $6.00 | P Q:8 /28Days |
Estradiol 0.0375 mg patch |
2 |
Generic |
$3.00 | $6.00 | P Q:8 /28Days |
Estradiol 0.05 mg patch |
2 |
Generic |
$3.00 | $6.00 | P Q:8 /28Days |
Estradiol 0.075 mg patch |
2 |
Generic |
$3.00 | $6.00 | P Q:8 /28Days |
Estradiol 0.1 mg patch |
2 |
Generic |
$3.00 | $6.00 | P Q:8 /28Days |
ESTRADIOL 0.5MG TABLET |
2 |
Generic |
$3.00 | $6.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL 2MG TABLET |
2 |
Generic |
$3.00 | $6.00 | P |
ESTRADIOL TABLET 1MG (500 CT) |
2 |
Generic |
$3.00 | $6.00 | P |
ESTRADIOL TDS 0.025 MG/DAY |
2 |
Generic |
$3.00 | $6.00 | P Q:4 /28Days |
ESTRADIOL TDS 0.0375 MG/DAY |
2 |
Generic |
$3.00 | $6.00 | P Q:4 /28Days |
ESTRADIOL TDS 0.05 MG/DAY |
2 |
Generic |
$3.00 | $6.00 | P Q:4 /28Days |
ESTRADIOL TDS 0.06 MG/DAY |
2 |
Generic |
$3.00 | $6.00 | P Q:4 /28Days |
ESTRADIOL TDS 0.075 MG/DAY |
2 |
Generic |
$3.00 | $6.00 | P Q:4 /28Days |
ESTRADIOL TDS 0.1 MG/DAY |
2 |
Generic |
$3.00 | $6.00 | P Q:4 /28Days |
ESTRADIOL VALERATE 20mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
2 |
Generic |
$3.00 | $6.00 | None |
ESTRADIOL VALERATE 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
2 |
Generic |
$3.00 | $6.00 | None |
ESTRADIOL-NORETH 1.0-0.5MG TABLET |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTROPIPATE 0.625(0.75 MG) TABLET |
2 |
Generic |
$3.00 | $6.00 | P |
ESTROPIPATE 1.25(1.5 MG) TABLET |
2 |
Generic |
$3.00 | $6.00 | P |
ESTROPIPATE 2.5(3 MG) TABLET |
2 |
Generic |
$3.00 | $6.00 | P |
Ethacrynic Acid 25 MG Oral Tablet [Edecrin] |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
ETHAMBUTOL HCL 400 MG TABLET |
4 |
Non-Preferred Drug |
48% | N/A | None |
Ethambutol Hydrochloride 100mg/1 |
2 |
Generic |
$3.00 | $6.00 | None |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 |
2 |
Generic |
$3.00 | $6.00 | None |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21 |
2 |
Generic |
$3.00 | $6.00 | None |
ETHOSUXIMIDE 250 MG CAPSULE |
4 |
Non-Preferred Drug |
48% | N/A | None |
ETHOSUXIMIDE 250MG/5ML SYRP |
4 |
Non-Preferred Drug |
48% | N/A | None |
ethynodiol-eth estra 1mg-50mcg [ZOVIA] |
2 |
Generic |
$3.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETIDRONATE DISODIUM 400MG TABLET (60 CT) |
4 |
Non-Preferred Drug |
48% | N/A | None |
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT |
4 |
Non-Preferred Drug |
48% | N/A | None |
ETODOLAC 200MG CAPSULE |
2 |
Generic |
$3.00 | $6.00 | None |
Etodolac 300 mg capsule |
2 |
Generic |
$3.00 | $6.00 | None |
ETODOLAC 400 MG TABLET |
2 |
Generic |
$3.00 | $6.00 | None |
ETODOLAC 400MG TABLET SR 24HR |
4 |
Non-Preferred Drug |
48% | N/A | None |
ETODOLAC 500 MG TABLET |
2 |
Generic |
$3.00 | $6.00 | None |
ETODOLAC 500MG TABLET SR 24HR |
4 |
Non-Preferred Drug |
48% | N/A | None |
ETODOLAC 600MG TABLET SR 24HR |
4 |
Non-Preferred Drug |
48% | N/A | None |
ETOPOPHOS 100MG VIAL |
4 |
Non-Preferred Drug |
48% | N/A | None |
Etoposide 500 mg/25 ml vial |
2 |
Generic |
$3.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Eurax Lotion and Cream 100mg/g 454 g in 1 BOTTLE |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
Eurax Lotion and Cream 100mg/g 60 g in 1 TUBE |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
EVOTAZ 300 MG-150 MG TABLET |
4 |
Non-Preferred Drug |
48% | N/A | None |
Exemestane 25mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$36.00 | $108.00 | 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 |
Ezetimibe-Simvastatin 10-10 MG [Vytorin] |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
Ezetimibe-Simvastatin 10-20 MG [Vytorin] |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
Ezetimibe-Simvastatin 10-40 MG [Vytorin] |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
Ezetimibe-Simvastatin 10-80 MG [Vytorin] |
3 |
Preferred Brand |
$36.00 | $108.00 | None |