2009 Medicare Part D Plan Formulary Information |
Windsor Rx (S2505-001-0)
Benefit Details
|
The Windsor Rx (S2505-001-0) Formulary Drugs Starting with the Letter E in CMS PDP Region 12 which includes: AL TN
|
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 TABLET 400MG |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ECONAZOLE NITRATE 1% CREAM 85GM TUBE |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ED K+10 TABLET |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
EFFEXOR 37.5MG CAPSULE ER (90 CT) |
3 |
Tier 3 - NonPreferred Brand, NonPreferred Generic |
$50.00 | N/A | None |
EFFEXOR XR 150MG CAPSULE ER 15 CAPSULES BOT |
3 |
Tier 3 - NonPreferred Brand, NonPreferred Generic |
$50.00 | N/A | None |
EFFEXOR XR 75MG CAPSULE ER 15 CAPSULES BOT |
3 |
Tier 3 - NonPreferred Brand, NonPreferred Generic |
$50.00 | N/A | None |
ELAPRASE 6MG/3ML VIAL |
4 |
Tier 4 - Speciality (Brand or Generic) |
25% | N/A | P |
ELESTAT 0.05% EYE DROPS |
3 |
Tier 3 - NonPreferred Brand, NonPreferred Generic |
$50.00 | N/A | None |
ELIDEL 1% CREAM |
3 |
Tier 3 - NonPreferred Brand, NonPreferred Generic |
$50.00 | N/A | S |
ELITEK 1.5MG VIAL |
4 |
Tier 4 - Speciality (Brand or Generic) |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELITEK 7.5MG VIAL |
4 |
Tier 4 - Speciality (Brand or Generic) |
25% | N/A | P |
ELMIRON 100MG CAPSULE |
3 |
Tier 3 - NonPreferred Brand, NonPreferred Generic |
$50.00 | N/A | None |
ELOXATIN 100MG/20ML VIAL |
4 |
Tier 4 - Speciality (Brand or Generic) |
25% | N/A | P |
ELOXATIN 50MG/10ML VIAL |
4 |
Tier 4 - Speciality (Brand or Generic) |
25% | N/A | P |
ELSPAR INJ 10000UNT |
2 |
Tier 2 - Preferred Brand |
$25.00 | N/A | P |
EMCYT 140MG CAPSULE |
2 |
Tier 2 - Preferred Brand |
$25.00 | N/A | None |
EMEND 125MG CAPSULE |
3 |
Tier 3 - NonPreferred Brand, NonPreferred Generic |
$50.00 | N/A | Q:6 /23Days |
EMEND 40MG CAPSULE |
3 |
Tier 3 - NonPreferred Brand, NonPreferred Generic |
$50.00 | N/A | Q:6 /23Days |
EMEND 80MG CAPSULE |
3 |
Tier 3 - NonPreferred Brand, NonPreferred Generic |
$50.00 | N/A | Q:6 /23Days |
EMEND TRIFOLD PACK |
3 |
Tier 3 - NonPreferred Brand, NonPreferred Generic |
$50.00 | N/A | Q:6 /23Days |
EMSAM 12MG/24 HOURS PATCH |
3 |
Tier 3 - NonPreferred Brand, NonPreferred Generic |
$50.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMSAM 6MG/24 HOURS PATCH |
3 |
Tier 3 - NonPreferred Brand, NonPreferred Generic |
$50.00 | N/A | None |
EMSAM 9MG/24 HOURS PATCH |
3 |
Tier 3 - NonPreferred Brand, NonPreferred Generic |
$50.00 | N/A | None |
EMTRIVA 10MG/ML SOLUTION |
2 |
Tier 2 - Preferred Brand |
$25.00 | N/A | None |
EMTRIVA 200MG CAPSULE |
2 |
Tier 2 - Preferred Brand |
$25.00 | N/A | None |
ENALAPRIL MALEATE 10MG TABLET (100 CT) |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ENALAPRIL MALEATE 2.5MG TABLET |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ENALAPRIL MALEATE 20MG TABLET (1000 CT) |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ENALAPRIL MALEATE 5MG TABLET |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ENALAPRIL MALEATE-HCTZ 10MG-25MG TABLET (100 CT) |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET (100 CT) |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ENBREL 50MG/ML SURECLICK SYR |
4 |
Tier 4 - Speciality (Brand or Generic) |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENBREL INJECTION 50MG/ML SYR |
4 |
Tier 4 - Speciality (Brand or Generic) |
25% | N/A | P |
ENBREL INJECTION KIT 25MG 1 DOSE TRAY PKGCOM |
4 |
Tier 4 - Speciality (Brand or Generic) |
25% | N/A | P |
ENDOCET 10/650MG TABLET |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | Q:180 /30Days |
ENDOCET 10MG-325MG TABLET |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | Q:360 /30Days |
ENDOCET 5/325 TABLET |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | Q:360 /25Days |
ENDOCET 7.5-325MG TABLET |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | Q:360 /30Days |
ENDOCET 7.5/500MG TABLET |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | Q:240 /30Days |
ENGERIX-B 10MCG/0.5ML SYRN |
3 |
Tier 3 - NonPreferred Brand, NonPreferred Generic |
$50.00 | N/A | P |
ENGERIX-B 20MCG/ML SYRINGE |
3 |
Tier 3 - NonPreferred Brand, NonPreferred Generic |
$50.00 | N/A | P |
ENPRESSE-28 TABLET |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | Q:28 /21Days |
EPIPEN 0.3MG AUTO-INJECTOR |
3 |
Tier 3 - NonPreferred Brand, NonPreferred Generic |
$50.00 | N/A | Q:12 /300Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPIPEN JR 0.15MG AUTO-INJCT |
3 |
Tier 3 - NonPreferred Brand, NonPreferred Generic |
$50.00 | N/A | Q:12 /300Days |
EPIRUBICIN HCL INJECTION SOLUTION 2MG 1 X 25ML VIAL |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | P |
EPITOL 200MG TABLET |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
EPIVIR 10MG/ML ORAL SOLUTION |
2 |
Tier 2 - Preferred Brand |
$25.00 | N/A | None |
EPIVIR 150MG TABLET |
2 |
Tier 2 - Preferred Brand |
$25.00 | N/A | None |
EPIVIR 300MG TABLET |
2 |
Tier 2 - Preferred Brand |
$25.00 | N/A | None |
EPIVIR HBV 100MG TABLET |
2 |
Tier 2 - Preferred Brand |
$25.00 | N/A | None |
EPIVIR HBV 25MG/5ML TUBEX |
2 |
Tier 2 - Preferred Brand |
$25.00 | N/A | None |
EPOGEN 10000U/ML VIAL MDV |
4 |
Tier 4 - Speciality (Brand or Generic) |
25% | N/A | P |
EPOGEN 2000U/ML VIAL SDV |
3 |
Tier 3 - NonPreferred Brand, NonPreferred Generic |
$50.00 | N/A | P |
EPOGEN 3000U/ML VIAL SDV |
3 |
Tier 3 - NonPreferred Brand, NonPreferred Generic |
$50.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPOGEN 4000U/ML VIAL SDV |
3 |
Tier 3 - NonPreferred Brand, NonPreferred Generic |
$50.00 | N/A | P |
EPOGEN INJECTION 20000U 10 X 1ML CRTN |
4 |
Tier 4 - Speciality (Brand or Generic) |
25% | N/A | P |
EPOGEN INJECTION 40000U 10 X 4ML VIALS VIALSD |
4 |
Tier 4 - Speciality (Brand or Generic) |
25% | N/A | P |
EPZICOM TABLET |
4 |
Tier 4 - Speciality (Brand or Generic) |
25% | N/A | None |
ERBITUX 100MG/50ML VIAL |
4 |
Tier 4 - Speciality (Brand or Generic) |
25% | N/A | P |
ERGOLOID MESYLATES 1MG TABLET (500 CT) |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ERGOTAMINE-CAFFEINE 1-100MG TABLET |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ERRIN 0.35MG TABLET |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | Q:28 /21Days |
ERY-TAB 250MG TABLET EC |
2 |
Tier 2 - Preferred Brand |
$25.00 | N/A | None |
ERY-TAB 333MG TABLET EC |
2 |
Tier 2 - Preferred Brand |
$25.00 | N/A | None |
ERY-TAB 500MG TABLET EC |
2 |
Tier 2 - Preferred Brand |
$25.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROMYCIN 2% SOLUTION |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ERYTHROMYCIN 200MG/5ML SUSP |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ERYTHROMYCIN 250MG FILMTAB |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ERYTHROMYCIN 400MG/5ML SUSP |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ERYTHROMYCIN 500MG FILMTAB |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ERYTHROMYCIN ETHYLSUCCINATE 400MG TABLET (500 CT) |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ERYTHROMYCIN OPHTHALMIC OINTMENT 5MG 1/8 OZ TUBE |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ERYTHROMYCIN-BENZOYL PEROXIDE 3-5% GEL |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ERYTHROMYCIN/SULFISOX SUSP |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ESTRADIOL .025MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ESTRADIOL .0375MG/24 PATCH TRANSDERMAL WEEKLY |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL .075MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ESTRADIOL 0.05MG/DAY PATCH |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ESTRADIOL 0.06MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ESTRADIOL 0.1MG/DAY PATCH |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ESTRADIOL 0.5MG TABLET |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ESTRADIOL 2MG TABLET |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ESTRADIOL TABLET 1MG (500 CT) |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ESTRADIOL-NORETH 1.0-0.5MG TABLET |
3 |
Tier 3 - NonPreferred Brand, NonPreferred Generic |
$50.00 | N/A | None |
ESTROPIPATE 0.625 TABLET |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ESTROPIPATE 1.25 TABLET |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ESTROPIPATE 2.5 TABLET |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETHAMBUTOL HCL 100MG TABLET |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ETHAMBUTOL HCL 400MG TABLET (100 CT) |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ETHOSUXIMIDE 250MG CAPSULE |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ETHOSUXIMIDE 250MG/5ML SYRP |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ETIDRONATE DISODIUM 200MG TABLET |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ETIDRONATE DISODIUM 400MG TABLET (60 CT) |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ETODOLAC 200MG CAPSULE |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ETODOLAC 300MG CAPSULE |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ETODOLAC 400MG TABLET (500 CT) |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ETODOLAC 400MG TABLET SR 24HR |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ETODOLAC 500MG TABLET (100 CT) |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | Q:180 /25Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETODOLAC 500MG TABLET SR 24HR |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ETODOLAC 600MG TABLET SR 24HR |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | None |
ETOPOPHOS 100MG VIAL |
4 |
Tier 4 - Speciality (Brand or Generic) |
25% | N/A | P |
ETOPOSIDE INJECTION 20MG 25ML VIALMD |
1 |
Tier 1 - Preferred Generics |
$10.00 | N/A | P |
EVISTA 60MG TABLET (30 CT) |
2 |
Tier 2 - Preferred Brand |
$25.00 | N/A | None |
EXELON 1.5MG CAPSULE |
2 |
Tier 2 - Preferred Brand |
$25.00 | N/A | None |
EXELON 2MG/ML ORAL SOLUTION |
2 |
Tier 2 - Preferred Brand |
$25.00 | N/A | None |
EXELON 3MG CAPSULE |
2 |
Tier 2 - Preferred Brand |
$25.00 | N/A | None |
EXELON 4.5MG CAPSULE |
2 |
Tier 2 - Preferred Brand |
$25.00 | N/A | None |
EXELON 6MG CAPSULE |
2 |
Tier 2 - Preferred Brand |
$25.00 | N/A | None |
EXFORGE 10MG-160MG TABLET |
2 |
Tier 2 - Preferred Brand |
$25.00 | N/A | Q:60 /23Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EXFORGE 10MG-320MG TABLET |
2 |
Tier 2 - Preferred Brand |
$25.00 | N/A | Q:60 /23Days |
EXFORGE 5MG-160MG TABLET |
2 |
Tier 2 - Preferred Brand |
$25.00 | N/A | Q:60 /23Days |
EXFORGE 5MG-320MG TABLET |
2 |
Tier 2 - Preferred Brand |
$25.00 | N/A | None |
EXJADE 125MG TABLET |
4 |
Tier 4 - Speciality (Brand or Generic) |
25% | N/A | P |
EXJADE 250MG TABLET |
4 |
Tier 4 - Speciality (Brand or Generic) |
25% | N/A | P |
EXJADE 500MG TABLET |
4 |
Tier 4 - Speciality (Brand or Generic) |
25% | N/A | P |