2019 Medicare Part D Plan Formulary Information |
Optimum Emerald Partial (HMO SNP) (H5594-016-0)
Benefit Details
|
The Optimum Emerald Partial (HMO SNP) (H5594-016-0) Formulary Drugs Starting with the Letter E in Pasco County, FL: CMS MA Region 9 which includes: FL Plan Monthly Premium: $30.30 Deductible: $415 |
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 |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
ECONAZOLE NITRATE 1% CREAM 85GM TUBE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
EDURANT 27.5mg/1 |
4 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
EFAVIRENZ 200 MG CAPSULE [Sustiva] |
4 |
Specialty Tier |
25% | N/A | None |
EFAVIRENZ 50 MG CAPSULE [Sustiva] |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
EFAVIRENZ 600 MG TABLET [Sustiva] |
4 |
Specialty Tier |
25% | N/A | None |
EGRIFTA 2 MG VIAL |
4 |
Specialty Tier |
25% | N/A | P |
ELIDEL 1% CREAM |
2 |
Preferred Brand |
$45.00 | $135.00 | S |
ELIGARD 22.5 MG SYRINGE |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:1 /90Days |
ELIGARD 7.5 MG SYRINGE KIT |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:1 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIQUIS 2.5 MG TABLET |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
ELIQUIS 5 MG STARTER PACK |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:74 /30Days |
ELIQUIS 5 MG TABLET |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
EMCYT 140MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
EMEND 125 MG POWDER PACKET |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:4 /30Days |
EMGALITY 120 MG/ML PEN INJCTR |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:2 /30Days |
EMGALITY 120 MG/ML SYRINGE |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:2 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
4 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
4 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
4 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMTRIVA 10MG/ML SOLUTION |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
EMTRIVA 200MG CAPSULE |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
EMVERM 100 MG TABLET CHEW |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
ENALAPRIL MALEATE 10 MG TAB |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 2.5 MG TAB |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 20 MG TAB |
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-HCTZ 5-12.5 MG TAB |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ENBREL 25 MG/0.5 ML SYRINGE |
4 |
Specialty Tier |
25% | N/A | P |
ENBREL 25MG KIT |
4 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENBREL 50 MG/ML SURECLICK SYR |
4 |
Specialty Tier |
25% | N/A | P |
ENBREL 50mg/mL |
4 |
Specialty Tier |
25% | N/A | P |
ENDOCET 10MG-325MG TABLET |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:360 /30Days |
ENDOCET 5/325 TABLET |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:360 /30Days |
ENDOCET 7.5-325MG TABLET |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:360 /30Days |
ENGERIX B INJECTION |
2 |
Preferred Brand |
$45.00 | $135.00 | P |
ENGERIX-B 20 MCG/ML SYRN |
2 |
Preferred Brand |
$45.00 | $135.00 | P |
ENOXAPARIN 100 MG/ML SYRINGE |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:28 /14Days |
ENOXAPARIN 120 MG/0.8 ML SYRINGE |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:28 /14Days |
ENOXAPARIN 150 MG/ML SYRINGE |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:28 /14Days |
ENOXAPARIN 30 MG/0.3 ML SYR |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:28 /14Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENOXAPARIN 40 MG/0.4 ML SYR |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:28 /14Days |
ENOXAPARIN 60 MG/0.6 ML SYRINGE |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:28 /14Days |
ENOXAPARIN 80 MG/0.8 ML SYRINGE |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:28 /14Days |
ENSKYCE 28 TABLET [Solia] |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
ENTACAPONE 200 MG TABLET [Comtan Entacapone] |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
ENTECAVIR 0.5 MG TABLET [Baraclude] |
4 |
Specialty Tier |
25% | N/A | P |
ENTECAVIR 1 MG TABLET [Baraclude] |
4 |
Specialty Tier |
25% | N/A | P |
ENTRESTO 24 MG-26 MG TABLET |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:60 /30Days |
ENTRESTO 49 MG-51 MG TABLET |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:60 /30Days |
ENTRESTO 97 MG-103 MG TABLET |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:60 /30Days |
ENULOSE 10 GM/15 ML SOLUTION |
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 |
ENVARSUS XR 0.75 MG TABLET |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | P |
ENVARSUS XR 1 MG TABLET |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | P |
ENVARSUS XR 4 MG TABLET |
4 |
Specialty Tier |
25% | N/A | P |
EPCLUSA 400 MG-100 MG TABLET |
4 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
EPIDIOLEX 100 MG/ML SOLUTION |
4 |
Specialty Tier |
25% | N/A | None |
EPINASTINE HCL 0.05% EYE DROPS |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
EPINEPHRINE 0.15 MG AUTO-INJCT |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:2 /30Days |
EPINEPHRINE 0.15 MG AUTO-INJECT |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:2 /30Days |
EPINEPHRINE 0.3 MG AUTO-INJECT |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:2 /30Days |
EPINEPHRINE 0.3 MG AUTO-INJECT [Twinject] |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:2 /30Days |
EPIPEN JR 0.15MG AUTO-INJCT |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:2 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPITOL 200MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
EPIVIR HBV 25MG/5ML TUBEX |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
Eplerenone 25mg/1 90 TABLET BOTTLE |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
Eplerenone 50mg/1 90 TABLET BOTTLE |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
EPOGEN 10000U/ML VIAL MDV |
2 |
Preferred Brand |
$45.00 | $135.00 | P |
EPOGEN 2000[iU]/mL 10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL |
2 |
Preferred Brand |
$45.00 | $135.00 | P |
EPOGEN 4000U/ML VIAL SDV |
2 |
Preferred Brand |
$45.00 | $135.00 | P |
EPOGEN INJECTION 20000U 10 X 1ML CRTN |
2 |
Preferred Brand |
$45.00 | $135.00 | P |
ERAXIS 100mg/30mL 30 mL in 1 VIAL, SINGLE-USE |
4 |
Specialty Tier |
25% | N/A | None |
ERAXIS(WATER DIL) 50 MG VIAL |
4 |
Specialty Tier |
25% | N/A | None |
ERGOLOID MESYLATES TABLETS 1MG 100 BOT |
1* |
Preferred Generic |
$0.00 | $0.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERIVEDGE 150 MG CAPSULE |
4 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
ERLEADA 60 MG TABLET |
4 |
Specialty Tier |
25% | N/A | None |
ERLOTINIB HCL 100 MG TABLET [Tarceva] |
4 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
ERLOTINIB HCL 150 MG TABLET [Tarceva] |
4 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
ERLOTINIB HCL 25 MG TABLET [Tarceva] |
4 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
Errin 0.35 mg tablet |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ERTAPENEM 1 GRAM VIAL [Invanz] |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | P |
ERY 2% PADS 2% 60 PADS JAR |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
ERY-TAB TAB 250MG EC |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
ERY-TAB TAB 333MG EC |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYPED 400 MG/5 ML SUSPENSION |
4 |
Specialty Tier |
25% | N/A | None |
ERYTHROCIN 500MG ADDVNT VL |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | P |
ERYTHROCIN TAB 250MG |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
ERYTHROMYCIN 0.5% EYE OINTMENT |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ERYTHROMYCIN 2% GEL |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ERYTHROMYCIN 2% SOLUTION |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ERYTHROMYCIN 200 MG/5 ML GRAN Oral Suspension [EryPed] |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
ERYTHROMYCIN 500 MG FILMTAB |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
ERYTHROMYCIN ES 400 MG TAB |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
ERYTHROMYCIN TAB 250MG BS |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
ERYTHROMYCIN-BENZOYL GEL |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESBRIET 267 MG CAPSULE |
4 |
Specialty Tier |
25% | N/A | P |
ESBRIET 267 MG TABLET |
4 |
Specialty Tier |
25% | N/A | P |
ESBRIET 801 MG TABLET |
4 |
Specialty Tier |
25% | N/A | P |
ESCITALOPRAM 10 MG TABLET [Lexapro] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
ESCITALOPRAM 20 MG TABLET [Lexapro] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
ESCITALOPRAM 5 MG TABLET [Lexapro] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:600 /30Days |
ESOMEPRAZOLE MAG DR 20 MG CAP [Nexium] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ESOMEPRAZOLE MAG DR 40 MG CAP [Nexium] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ESTARYLLA 0.25-0.035 MG TABLET [VyLibra] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Estazolam 1mg/1 100 TABLET BOTTLE |
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 |
Estazolam 2mg/1 100 TABLET BOTTLE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ESTRADIOL 0.01% CREAM |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
Estradiol 0.025 mg patch |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:10 /30Days |
Estradiol 0.0375 mg patch |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:10 /30Days |
Estradiol 0.05 mg patch |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:10 /30Days |
Estradiol 0.075 mg patch |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:10 /30Days |
Estradiol 0.1 mg patch |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:10 /30Days |
ESTRADIOL 0.5 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | P |
ESTRADIOL 1 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | P |
ESTRADIOL 10 MCG VAGINAL INSRT |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
ESTRADIOL 2MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL VALERATE 20mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
ESTRADIOL VALERATE 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
ESZOPICLONE 1 MG TABLET [Lunesta] |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days |
ESZOPICLONE 2 MG TABLET [Lunesta] |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days |
ESZOPICLONE 3 MG TABLET [Lunesta] |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days |
ETHACRYNIC ACID 25 MG TABLET [Edecrin] |
4 |
Specialty Tier |
25% | N/A | None |
ETHAMBUTOL HCL 400 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Ethambutol Hydrochloride 100mg/1 |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ETHOSUXIMIDE 250 MG CAPSULE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ETHOSUXIMIDE 250 MG/5 ML SOLN |
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 |
ETODOLAC 200 MG CAPSULE [LODINE] |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
ETODOLAC 300 MG CAPSULE [LODINE] |
2 |
Preferred Brand |
$45.00 | $135.00 | None |
ETODOLAC 400 MG TABLET [LODINE] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ETODOLAC 500 MG TABLET [LODINE] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ETODOLAC ER 400 MG TABLET [LODINE] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ETODOLAC ER 500 MG TABLET [LODINE] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ETODOLAC ER 600 MG TABLET [LODINE] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
EVOTAZ 300 MG-150 MG TABLET |
4 |
Specialty Tier |
25% | N/A | None |
EXEMESTANE 25 MG TABLET |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
EXJADE 125MG TABLET |
4 |
Specialty Tier |
25% | N/A | P |
EXJADE 250MG TABLET |
4 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EXJADE 500MG TABLET |
4 |
Specialty Tier |
25% | N/A | P |
EZETIMIBE 10 MG TABLET [Zetia] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
Ezetimibe-Simvastatin 10-10 MG [Vytorin] |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
Ezetimibe-Simvastatin 10-20 MG [Vytorin] |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
Ezetimibe-Simvastatin 10-40 MG [Vytorin] |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
Ezetimibe-Simvastatin 10-80 MG [Vytorin] |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |