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2018 Medicare Part D Plan Formulary Information
Express Scripts Medicare - Value (PDP) (S5660-113-0) Benefit Details
The Express Scripts Medicare - Value (PDP) (S5660-113-0) Formulary Drugs Starting with the Letter E in CMS PDP Region 11 which includes: FL Plan Monthly Premium: $61.30 Deductible: $405 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	4	Non-Preferred Drug	46%	N/A	None
EDARBI 40 MG TABLET	4	Non-Preferred Drug	46%	N/A	None
EDARBI 80 MG TABLET	4	Non-Preferred Drug	46%	N/A	None
EDARBYCLOR 40-12.5 MG TABLET	4	Non-Preferred Drug	46%	N/A	None
EDARBYCLOR 40-25 MG TABLET	4	Non-Preferred Drug	46%	N/A	None
EDURANT 27.5mg/1	4	Non-Preferred Drug	46%	N/A	None
EFAVIRENZ 200 MG CAPSULE [Sustiva]	5	Specialty Tier	25%	N/A	None
EFAVIRENZ 50 MG CAPSULE [Sustiva]	3	Preferred Brand	$18.00	$54.00	None
EFAVIRENZ 600 MG TABLET [Sustiva]	5	Specialty Tier	25%	N/A	None
ELAPRASE 6mg/3mL 1 VIAL, GLASS in 1 BOX / 3 mL in 1 VIAL, GLASS	5	Specialty Tier	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ELIQUIS 2.5 MG TABLET	3	Preferred Brand	$18.00	$54.00	None
ELIQUIS 5 MG STARTER PACK	3	Preferred Brand	$18.00	$54.00	None
ELIQUIS 5 MG TABLET	3	Preferred Brand	$18.00	$54.00	None
ELLENCE 2MG/ML VIAL	4	Non-Preferred Drug	46%	N/A	P
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE	3	Preferred Brand	$18.00	$54.00	None
EMCYT 140MG CAPSULE	3	Preferred Brand	$18.00	$54.00	None
EMEND 125 MG POWDER PACKET	3	Preferred Brand	$18.00	$54.00	P
EMEND 150 MG VIAL	3	Preferred Brand	$18.00	$54.00	None
EMEND 40 MG CAPSULE	3	Preferred Brand	$18.00	$54.00	P
EMEND CAPSULES 125MG 6 BLPK	3	Preferred Brand	$18.00	$54.00	P
EMEND CAPSULES 80MG 2 BLPK	3	Preferred Brand	$18.00	$54.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Emoquette 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	4	Non-Preferred Drug	46%	N/A	None
Empagliflozin 5 MG / Metformin hydrochloride 500 MG Oral Tablet [Synjardy]	3	Preferred Brand	$18.00	$54.00	Q:124 /31Days
EMPLICITI 300 MG VIAL	4	Non-Preferred Drug	46%	N/A	P
EMPLICITI 400 MG VIAL	4	Non-Preferred Drug	46%	N/A	P
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H	4	Non-Preferred Drug	46%	N/A	None
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H	4	Non-Preferred Drug	46%	N/A	None
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H	4	Non-Preferred Drug	46%	N/A	None
EMTRIVA 10MG/ML SOLUTION	3	Preferred Brand	$18.00	$54.00	None
EMTRIVA 200MG CAPSULE	3	Preferred Brand	$18.00	$54.00	None
EMVERM 100 MG TABLET CHEW	5	Specialty Tier	25%	N/A	None
ENALAPRIL MALEATE 10 MG TAB	1	Preferred Generic	$1.00	$3.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENALAPRIL MALEATE 2.5 MG TAB	1	Preferred Generic	$1.00	$3.00	None
ENALAPRIL MALEATE 20 MG TAB	1	Preferred Generic	$1.00	$3.00	None
ENALAPRIL MALEATE 5 MG TABLET	1	Preferred Generic	$1.00	$3.00	None
Enalapril Maleate and Hydrochlorothiazide 10; 25mg/1; mg/1 100 TABLET BOTTLE, PLASTIC	1	Preferred Generic	$1.00	$3.00	None
ENALAPRIL-HCTZ 5-12.5 MG TAB	1	Preferred Generic	$1.00	$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:16 /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	3	Preferred Brand	$18.00	$54.00	Q:372 /31Days
ENDOCET 5/325 TABLET	3	Preferred Brand	$18.00	$54.00	Q:372 /31Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENDOCET 7.5-325MG TABLET	3	Preferred Brand	$18.00	$54.00	Q:372 /31Days
ENGERIX B INJECTION	3	Preferred Brand	$18.00	$54.00	P
ENGERIX-B 20 MCG/ML SYRN	3	Preferred Brand	$18.00	$54.00	P
ENOXAPARIN 100 MG/ML SYRINGE	4	Non-Preferred Drug	46%	N/A	None
ENOXAPARIN 120 MG/0.8 ML SYRINGE	4	Non-Preferred Drug	46%	N/A	None
ENOXAPARIN 150 MG/ML SYRINGE	4	Non-Preferred Drug	46%	N/A	None
ENOXAPARIN 30 MG/0.3 ML SYR	4	Non-Preferred Drug	46%	N/A	None
ENOXAPARIN 300 MG/3 ML VIAL	4	Non-Preferred Drug	46%	N/A	None
ENOXAPARIN 40 MG/0.4 ML SYR	4	Non-Preferred Drug	46%	N/A	None
ENOXAPARIN 60 MG/0.6 ML SYRINGE	4	Non-Preferred Drug	46%	N/A	None
ENOXAPARIN 80 MG/0.8 ML SYRINGE	4	Non-Preferred Drug	46%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENTACAPONE 200 MG TABLET [Comtan Entacapone]	3	Preferred Brand	$18.00	$54.00	None
ENTECAVIR 0.5 MG TABLET [Baraclude]	3	Preferred Brand	$18.00	$54.00	None
ENTECAVIR 1 MG TABLET [Baraclude]	3	Preferred Brand	$18.00	$54.00	None
ENTRESTO 24 MG-26 MG TABLET	3	Preferred Brand	$18.00	$54.00	Q:62 /31Days
ENTRESTO 49 MG-51 MG TABLET	3	Preferred Brand	$18.00	$54.00	Q:62 /31Days
ENTRESTO 97 MG-103 MG TABLET	3	Preferred Brand	$18.00	$54.00	Q:62 /31Days
ENULOSE 10 GM/15 ML SOLUTION	2	Generic	$3.00	$9.00	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	46%	N/A	None
EPINEPHRINE 0.15 MG AUTO-INJCT	3	Preferred Brand	$18.00	$54.00	None
EPINEPHRINE 0.3 MG AUTO-INJECT	3	Preferred Brand	$18.00	$54.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EPINEPHRINE 0.3 MG AUTO-INJECT	3	Preferred Brand	$18.00	$54.00	None
EPIPEN 0.3MG AUTO-INJECTOR	3	Preferred Brand	$18.00	$54.00	None
EPIPEN JR 0.15MG AUTO-INJCT	3	Preferred Brand	$18.00	$54.00	None
Epirubicin HCl 200 MG per 100 ML Injection	4	Non-Preferred Drug	46%	N/A	P
EPITOL 200MG TABLET	2	Generic	$3.00	$9.00	None
EPIVIR HBV 25MG/5ML TUBEX	3	Preferred Brand	$18.00	$54.00	None
Eplerenone 25mg/1 90 TABLET BOTTLE	4	Non-Preferred Drug	46%	N/A	None
Eplerenone 50mg/1 90 TABLET BOTTLE	4	Non-Preferred Drug	46%	N/A	None
EPROSARTAN MESYLATE 600 MG TABLET	4	Non-Preferred Drug	46%	N/A	None
ERBITUX 100MG/50ML VIAL	5	Specialty Tier	25%	N/A	P
Ergotamine-caffeine 1-100mg tb	3	Preferred Brand	$18.00	$54.00	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
ERLEADA 60 MG TABLET	5	Specialty Tier	25%	N/A	P
Errin 0.35 mg tablet	2	Generic	$3.00	$9.00	None
ERWINAZE 10,000 UNITS VIAL	5	Specialty Tier	25%	N/A	P
ERY 2% PADS 2% 60 PADS JAR	4	Non-Preferred Drug	46%	N/A	None
ERYTHROCIN 500MG ADDVNT VL	3	Preferred Brand	$18.00	$54.00	None
ERYTHROCIN TAB 250MG	4	Non-Preferred Drug	46%	N/A	None
Erythromycin 0.02 MG/MG Topical Gel [Erygel]	2	Generic	$3.00	$9.00	None
ERYTHROMYCIN 0.5% EYE OINTMENT	1	Preferred Generic	$1.00	$3.00	None
ERYTHROMYCIN 2% GEL	2	Generic	$3.00	$9.00	None
ERYTHROMYCIN 2% SOLUTION	2	Generic	$3.00	$9.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ERYTHROMYCIN 500 MG FILMTAB	4	Non-Preferred Drug	46%	N/A	None
ERYTHROMYCIN EC 250 MG CAP	3	Preferred Brand	$18.00	$54.00	None
ERYTHROMYCIN ES 400 MG TAB	4	Non-Preferred Drug	46%	N/A	None
Erythromycin Ethylsuccinate 40 MG/ML Oral Suspension	4	Non-Preferred Drug	46%	N/A	None
ERYTHROMYCIN TAB 250MG BS	4	Non-Preferred Drug	46%	N/A	None
ERYTHROMYCIN-BENZOYL GEL	4	Non-Preferred Drug	46%	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	$1.00	$3.00	Q:62 /31Days
ESCITALOPRAM 20 MG TABLET [Lexapro]	1	Preferred Generic	$1.00	$3.00	Q:31 /31Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ESCITALOPRAM 5 MG TABLET [Lexapro]	1	Preferred Generic	$1.00	$3.00	Q:124 /31Days
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro]	4	Non-Preferred Drug	46%	N/A	None
ESOMEPRAZOLE SODIUM 20 MG VIAL [Nexium]	4	Non-Preferred Drug	46%	N/A	None
ESOMEPRAZOLE SODIUM 40 MG VIAL [Nexium]	4	Non-Preferred Drug	46%	N/A	None
ESTARYLLA 0.25-0.035 MG TABLET [VyLibra]	4	Non-Preferred Drug	46%	N/A	None
ESTRACE VAG CREAM 0.1MG/GM	3	Preferred Brand	$18.00	$54.00	None
Estradiol / Norethindrone Acetate 0.5; 0.1mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, FILM C	3	Preferred Brand	$18.00	$54.00	None
ESTRADIOL 0.01% CREAM	3	Preferred Brand	$18.00	$54.00	None
ESTRADIOL 0.5 MG TABLET	4	Non-Preferred Drug	46%	N/A	P
ESTRADIOL 1 MG TABLET	4	Non-Preferred Drug	46%	N/A	P
ESTRADIOL 10 MCG VAGINAL INSRT	3	Preferred Brand	$18.00	$54.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ESTRADIOL 2MG TABLET	4	Non-Preferred Drug	46%	N/A	P
ESTRADIOL TDS 0.025 MG/DAY	2	Generic	$3.00	$9.00	P Q:4 /28Days
ESTRADIOL TDS 0.0375 MG/DAY	2	Generic	$3.00	$9.00	P Q:4 /28Days
ESTRADIOL TDS 0.05 MG/DAY	2	Generic	$3.00	$9.00	P Q:4 /28Days
ESTRADIOL TDS 0.06 MG/DAY	2	Generic	$3.00	$9.00	P Q:4 /28Days
ESTRADIOL TDS 0.075 MG/DAY	2	Generic	$3.00	$9.00	P Q:4 /28Days
ESTRADIOL TDS 0.1 MG/DAY	2	Generic	$3.00	$9.00	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	$9.00	None
ESTRADIOL VALERATE 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE	2	Generic	$3.00	$9.00	None
ESTRADIOL-NORETH 1.0-0.5MG TABLET	3	Preferred Brand	$18.00	$54.00	None
ESTROPIPATE 0.625(0.75 MG) TABLET	2	Generic	$3.00	$9.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ESTROPIPATE 1.25(1.5 MG) TABLET	2	Generic	$3.00	$9.00	P
ETHACRYNIC ACID 25 MG TABLET [Edecrin]	4	Non-Preferred Drug	46%	N/A	None
ETHAMBUTOL HCL 400 MG TABLET	4	Non-Preferred Drug	46%	N/A	None
Ethambutol Hydrochloride 100mg/1	2	Generic	$3.00	$9.00	None
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6	4	Non-Preferred Drug	46%	N/A	None
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21	4	Non-Preferred Drug	46%	N/A	None
ETHOSUXIMIDE 250 MG CAPSULE	4	Non-Preferred Drug	46%	N/A	None
ETHOSUXIMIDE 250 MG/5 ML SOLN	4	Non-Preferred Drug	46%	N/A	None
ETHYNODIOL-ETH ESTRA 1MG-35MCG [ZOVIA]	4	Non-Preferred Drug	46%	N/A	None
ethynodiol-eth estra 1mg-50mcg [ZOVIA]	4	Non-Preferred Drug	46%	N/A	None
ETOPOPHOS 100MG VIAL	4	Non-Preferred Drug	46%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EURAX 10% LOTION	3	Preferred Brand	$18.00	$54.00	None
Eurax Lotion and Cream 100mg/g 60 g in 1 TUBE	3	Preferred Brand	$18.00	$54.00	None
EVOTAZ 300 MG-150 MG TABLET	4	Non-Preferred Drug	46%	N/A	None
EXEMESTANE 25 MG TABLET	3	Preferred Brand	$18.00	$54.00	None
Ezetimibe 10 MG Oral Tablet [Zetia]	3	Preferred Brand	$18.00	$54.00	None
Ezetimibe-Simvastatin 10-10 MG [Vytorin]	3	Preferred Brand	$18.00	$54.00	Q:31 /31Days
Ezetimibe-Simvastatin 10-20 MG [Vytorin]	3	Preferred Brand	$18.00	$54.00	Q:31 /31Days
Ezetimibe-Simvastatin 10-40 MG [Vytorin]	3	Preferred Brand	$18.00	$54.00	Q:31 /31Days
Ezetimibe-Simvastatin 10-80 MG [Vytorin]	3	Preferred Brand	$18.00	$54.00	Q:31 /31Days

Chart Legend:

Below are a few notes to help you understand the above 2018 Medicare Part D Express Scripts Medicare - Value (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). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)
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 $405 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 five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs. *Some Part D plans exclude one or more drug tiers from the deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
- Tier 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 $3750) at a "Preferred" network pharmacy. In most cases, the "Preferred" network network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
- 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 2018 )

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.