2019 Medicare Part D Plan Formulary Information |
Optimo Plus (PPO) (H4005-004-0)
Benefit Details
|
The Optimo Plus (PPO) (H4005-004-0) Formulary Drugs Starting with the Letter E in Naguabo County, PR: CMS MA Region 30 which includes: PR Plan Monthly Premium: $121.00 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. 200 MG/5 ML GRANULES |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
EDURANT 27.5mg/1 |
5 |
Specialty Tier |
25% | 25% | None |
EFAVIRENZ 200 MG CAPSULE [Sustiva] |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
EFAVIRENZ 50 MG CAPSULE [Sustiva] |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
EFAVIRENZ 600 MG TABLET [Sustiva] |
5 |
Specialty Tier |
25% | 25% | None |
EFUDEX 5% CREAM |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
ELETRIPTAN HBR 20 MG TABLET [Relpax] |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | S Q:12 /30Days |
ELETRIPTAN HBR 40 MG TABLET [Relpax] |
3 |
Preferred Brand |
$25.00 | $50.00 | S Q:6 /30Days |
ELIDEL 1% CREAM |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | S |
ELIGARD 22.5 MG SYRINGE |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | P Q:1 /84Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIGARD 30 MG SYRINGE KIT |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | P Q:1 /120Days |
ELIGARD 45 MG SYRINGE KIT |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | P Q:1 /180Days |
ELIGARD 7.5 MG SYRINGE KIT |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | P Q:1 /28Days |
ELIQUIS 2.5 MG TABLET |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
ELIQUIS 5 MG STARTER PACK |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
ELIQUIS 5 MG TABLET |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
ELOCON 0.1% CREAM |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
ELOCON 0.1% OINTMENT |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
EMCYT 140MG CAPSULE |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
EMEND 125 MG POWDER PACKET |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | P Q:3 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Empagliflozin 5 MG / Metformin hydrochloride 500 MG Oral Tablet [Synjardy] |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
5 |
Specialty Tier |
25% | 25% | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
5 |
Specialty Tier |
25% | 25% | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
5 |
Specialty Tier |
25% | 25% | None |
EMTRIVA 10MG/ML SOLUTION |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
EMTRIVA 200MG CAPSULE |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
ENALAPRIL MALEATE 10 MG TAB |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 2.5 MG TAB |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 20 MG TAB |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 5 MG TABLET |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
Enalapril Maleate and Hydrochlorothiazide 10; 25mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENALAPRIL-HCTZ 5-12.5 MG TAB |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
ENBREL 25 MG/0.5 ML SYRINGE |
5 |
Specialty Tier |
25% | 25% | P Q:4 /28Days |
ENBREL 25MG KIT |
5 |
Specialty Tier |
25% | 25% | P Q:8 /28Days |
ENBREL 50 MG/ML SURECLICK SYR |
5 |
Specialty Tier |
25% | 25% | P Q:8 /28Days |
ENBREL 50mg/mL |
5 |
Specialty Tier |
25% | 25% | P Q:8 /28Days |
ENDOCET 10MG-325MG TABLET |
2 |
Generic |
$10.00 | $20.00 | Q:180 /30Days |
ENDOCET 5/325 TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | Q:360 /30Days |
ENDOCET 7.5-325MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | Q:240 /30Days |
ENGERIX B INJECTION |
3 |
Preferred Brand |
$25.00 | $50.00 | P |
ENGERIX-B 20 MCG/ML SYRN |
3 |
Preferred Brand |
$25.00 | $50.00 | P |
ENOXAPARIN 100 MG/ML SYRINGE |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENOXAPARIN 120 MG/0.8 ML SYRINGE |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | Q:24 /30Days |
ENOXAPARIN 150 MG/ML SYRINGE |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | Q:30 /30Days |
ENOXAPARIN 30 MG/0.3 ML SYR |
3 |
Preferred Brand |
$25.00 | $50.00 | Q:9 /30Days |
ENOXAPARIN 40 MG/0.4 ML SYR |
3 |
Preferred Brand |
$25.00 | $50.00 | Q:12 /30Days |
ENOXAPARIN 60 MG/0.6 ML SYRINGE |
3 |
Preferred Brand |
$25.00 | $50.00 | Q:18 /30Days |
ENOXAPARIN 80 MG/0.8 ML SYRINGE |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | Q:24 /30Days |
ENTACAPONE 200 MG TABLET [Comtan Entacapone] |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
ENTECAVIR 0.5 MG TABLET [Baraclude] |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | P |
ENTECAVIR 1 MG TABLET [Baraclude] |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | P |
ENTOCORT EC 3 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | None |
ENTRESTO 24 MG-26 MG TABLET |
3 |
Preferred Brand |
$25.00 | $50.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENTRESTO 49 MG-51 MG TABLET |
3 |
Preferred Brand |
$25.00 | $50.00 | P |
ENTRESTO 97 MG-103 MG TABLET |
3 |
Preferred Brand |
$25.00 | $50.00 | P |
ENULOSE 10 GM/15 ML SOLUTION |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
EPCLUSA 400 MG-100 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
EPIDIOLEX 100 MG/ML SOLUTION |
5 |
Specialty Tier |
25% | 25% | None |
EPINEPHRINE 0.15 MG AUTO-INJCT |
3 |
Preferred Brand |
$25.00 | $50.00 | Q:2 /30Days |
EPINEPHRINE 0.15 MG AUTO-INJECT |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | Q:2 /30Days |
EPINEPHRINE 0.3 MG AUTO-INJECT |
3 |
Preferred Brand |
$25.00 | $50.00 | Q:2 /30Days |
EPIPEN 0.3MG AUTO-INJECTOR |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | Q:2 /30Days |
EPIPEN JR 0.15MG AUTO-INJCT |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | Q:2 /30Days |
EPIVIR HBV 25MG/5ML TUBEX |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Eplerenone 25mg/1 90 TABLET BOTTLE |
3 |
Preferred Brand |
$25.00 | $50.00 | S |
Eplerenone 50mg/1 90 TABLET BOTTLE |
3 |
Preferred Brand |
$25.00 | $50.00 | S |
ERAXIS 100mg/30mL 30 mL in 1 VIAL, SINGLE-USE |
5 |
Specialty Tier |
25% | 25% | P |
ERAXIS(WATER DIL) 50 MG VIAL |
5 |
Specialty Tier |
25% | 25% | P |
Ergotamine-caffeine 1-100mg tb |
3 |
Preferred Brand |
$25.00 | $50.00 | Q:40 /30Days |
ERIVEDGE 150 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
ERLEADA 60 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
ERLOTINIB HCL 100 MG TABLET [Tarceva] |
5 |
Specialty Tier |
25% | 25% | P |
ERLOTINIB HCL 150 MG TABLET [Tarceva] |
5 |
Specialty Tier |
25% | 25% | P |
ERLOTINIB HCL 25 MG TABLET [Tarceva] |
5 |
Specialty Tier |
25% | 25% | P |
ERTAPENEM 1 GRAM VIAL [Invanz] |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERY 2% PADS 2% 60 PADS JAR |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
ERYTHROCIN 500MG ADDVNT VL |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | P |
ERYTHROMYCIN 0.5% EYE OINTMENT |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
ERYTHROMYCIN 2% GEL |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
ERYTHROMYCIN 2% SOLUTION |
2 |
Generic |
$10.00 | $20.00 | None |
ERYTHROMYCIN ES 400 MG TAB |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
ERYTHROMYCIN-BENZOYL GEL |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
ESBRIET 267 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
ESBRIET 267 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
ESBRIET 801 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESCITALOPRAM 10 MG TABLET [Lexapro] |
1 |
Preferred Generic |
$5.00 | $10.00 | Q:60 /30Days |
ESCITALOPRAM 20 MG TABLET [Lexapro] |
1 |
Preferred Generic |
$5.00 | $10.00 | Q:30 /30Days |
ESCITALOPRAM 5 MG TABLET [Lexapro] |
1 |
Preferred Generic |
$5.00 | $10.00 | Q:60 /30Days |
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro] |
3 |
Preferred Brand |
$25.00 | $50.00 | Q:600 /30Days |
Estazolam 1mg/1 100 TABLET BOTTLE |
2 |
Generic |
$10.00 | $20.00 | Q:30 /30Days |
Estazolam 2mg/1 100 TABLET BOTTLE |
2 |
Generic |
$10.00 | $20.00 | Q:30 /30Days |
Estradiol / Norethindrone Acetate 0.5; 0.1mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, FILM C |
3 |
Preferred Brand |
$25.00 | $50.00 | P |
ESTRADIOL 0.01% CREAM |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
ESTRADIOL 0.5 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | P |
ESTRADIOL 1 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | P |
ESTRADIOL 10 MCG VAGINAL INSRT |
3 |
Preferred Brand |
$25.00 | $50.00 | Q:18 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL 2MG TABLET |
2 |
Generic |
$10.00 | $20.00 | P |
ESTRADIOL VALERATE 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
2 |
Generic |
$10.00 | $20.00 | None |
ESTRADIOL-NORETH 1.0-0.5MG TABLET |
3 |
Preferred Brand |
$25.00 | $50.00 | P |
ETHAMBUTOL HCL 400 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
Ethambutol Hydrochloride 100mg/1 |
2 |
Generic |
$10.00 | $20.00 | None |
ETHOSUXIMIDE 250 MG CAPSULE |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
ETHOSUXIMIDE 250 MG/5 ML SOLN |
2 |
Generic |
$10.00 | $20.00 | None |
ETODOLAC 200 MG CAPSULE [LODINE] |
2 |
Generic |
$10.00 | $20.00 | None |
ETODOLAC 300 MG CAPSULE [LODINE] |
2 |
Generic |
$10.00 | $20.00 | None |
ETODOLAC 400 MG TABLET [LODINE] |
2 |
Generic |
$10.00 | $20.00 | None |
ETODOLAC 500 MG TABLET [LODINE] |
2 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETODOLAC ER 400 MG TABLET [LODINE] |
2 |
Generic |
$10.00 | $20.00 | None |
ETODOLAC ER 500 MG TABLET [LODINE] |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
ETODOLAC ER 600 MG TABLET [LODINE] |
3 |
Preferred Brand |
$25.00 | $50.00 | None |
EURAX 10% LOTION |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
Eurax Lotion and Cream 100mg/g 60 g in 1 TUBE |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
EVOTAZ 300 MG-150 MG TABLET |
5 |
Specialty Tier |
25% | 25% | None |
EVOXAC 30MG CAPSULE |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
EXEMESTANE 25 MG TABLET |
4 |
Non-Preferred Drug |
$40.00 | $80.00 | None |
EZETIMIBE 10 MG TABLET [Zetia] |
2 |
Generic |
$10.00 | $20.00 | None |