2009 Medicare Part D Plan Formulary Information |
Blue MedicareRx Value (S5596-029-0)
Sanctioned Plan
|
The Blue MedicareRx Value (S5596-029-0) Formulary Drugs Starting with the Letter E in CMS PDP Region 29 which includes: NV
|
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. 200MG/5ML SUSPENSION |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:1440 /30Days |
E.E.S. 400 TABLET 400MG |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
E.E.S. 400MG/5ML SUSPENSION |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:1440 /30Days |
ECONAZOLE NITRATE 1% CREAM 85GM TUBE |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ED DOXY-CAPS 100MG CAPSULE |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:60 /1Days |
ED K+10 TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
EDECRIN SODIUM 50MG VIAL |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
ELAPRASE 6MG/3ML VIAL |
5 |
Tier 5. |
29% | N/A | None |
ELIGARD 22.5MG SYRINGE |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | P |
ELIGARD 30MG SYRINGE |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIGARD 45MG SYRINGE |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | P |
ELIGARD 7.5MG SYRINGE |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | P |
ELITEK 1.5MG VIAL |
5 |
Tier 5. |
29% | N/A | None |
ELITEK 7.5MG VIAL |
5 |
Tier 5. |
29% | N/A | None |
ELIXOPHYLLIN 80MG/15ML ELIX |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | None |
ELLENCE 2MG/ML VIAL |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
ELOXATIN 100MG/20ML VIAL |
5 |
Tier 5. |
29% | N/A | None |
ELOXATIN 50MG/10ML VIAL |
5 |
Tier 5. |
29% | N/A | None |
ELSPAR INJ 10000UNT |
5 |
Tier 5. |
29% | N/A | None |
EMCYT 140MG CAPSULE |
5 |
Tier 5. |
29% | N/A | None |
EMEND 125MG CAPSULE |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | P Q:4 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMEND 40MG CAPSULE |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | P Q:1 /1Days |
EMEND 80MG CAPSULE |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | P Q:8 /30Days |
EMEND TRIFOLD PACK |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | P Q:12 /30Days |
EMSAM 12MG/24 HOURS PATCH |
3 |
Tier 3 Non-Preferred Brand or Generic |
$85.00 | $212.50 | Q:30 /30Days |
EMSAM 6MG/24 HOURS PATCH |
3 |
Tier 3 Non-Preferred Brand or Generic |
$85.00 | $212.50 | Q:30 /30Days |
EMSAM 9MG/24 HOURS PATCH |
3 |
Tier 3 Non-Preferred Brand or Generic |
$85.00 | $212.50 | Q:30 /30Days |
EMTRIVA 10MG/ML SOLUTION |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | None |
EMTRIVA 200MG CAPSULE |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | None |
ENALAPRIL MALEATE 10MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ENALAPRIL MALEATE 2.5MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ENALAPRIL MALEATE 20MG TABLET (1000 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENALAPRIL MALEATE 5MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ENALAPRIL MALEATE-HCTZ 10MG-25MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ENBREL 50MG/ML SURECLICK SYR |
5 |
Tier 5. |
29% | N/A | P Q:8 /28Days |
ENBREL INJECTION 50MG/ML SYR |
5 |
Tier 5. |
29% | N/A | P Q:8 /28Days |
ENBREL INJECTION KIT 25MG 1 DOSE TRAY PKGCOM |
5 |
Tier 5. |
29% | N/A | P Q:8 /28Days |
ENDOCET 10/650MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:180 /30Days |
ENDOCET 10MG-325MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:360 /30Days |
ENDOCET 5/325 TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:360 /30Days |
ENDOCET 7.5-325MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:360 /30Days |
ENDOCET 7.5/500MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENGERIX-B 10MCG 10 X 0.5ML VIALSD |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | P |
ENGERIX-B 10MCG/0.5ML SYRN |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | P |
ENGERIX-B 20MCG/ML SYRINGE |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | P |
ENPRESSE-28 TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:28 /28Days |
ENTOCORT EC 3MG CAPSULE |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | None |
ENULOSE SYRUP 10GM/15ML 1 PINT BOTPL |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
EPINEPHRINE 0.1MG/ML ABBJCT |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
EPIPEN 0.3MG AUTO-INJECTOR |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | Q:2 /1Days |
EPIPEN JR 0.15MG AUTO-INJCT |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | Q:2 /1Days |
EPIRUBICIN HCL INJECTION SOLUTION 2MG 1 X 25ML VIAL |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
EPITOL 200MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPIVIR 10MG/ML ORAL SOLUTION |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | None |
EPIVIR 150MG TABLET |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | None |
EPIVIR 300MG TABLET |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | None |
EPIVIR HBV 100MG TABLET |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | None |
EPIVIR HBV 25MG/5ML TUBEX |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | None |
EPLERENONE 25MG TABS |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:45 /30Days |
EPLERENONE 50MG TABS |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:60 /30Days |
EPOGEN 10000U/ML VIAL MDV |
5 |
Tier 5. |
29% | N/A | P |
EPOGEN 2000U/ML VIAL SDV |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | P |
EPOGEN 3000U/ML VIAL SDV |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | P |
EPOGEN 4000U/ML VIAL SDV |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPOGEN INJECTION 20000U 10 X 1ML CRTN |
5 |
Tier 5. |
29% | N/A | P |
EPOGEN INJECTION 40000U 10 X 4ML VIALS VIALSD |
5 |
Tier 5. |
29% | N/A | P |
EPZICOM TABLET |
5 |
Tier 5. |
29% | N/A | None |
EQUETRO 100MG CAPSULE |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | Q:240 /30Days |
EQUETRO 200MG CAPSULE |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | Q:240 /30Days |
EQUETRO 300MG CAPSULE |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | Q:180 /30Days |
ERBITUX 100MG/50ML VIAL |
5 |
Tier 5. |
29% | N/A | P |
ERGOLOID MESYLATES 1MG TABLET (500 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:90 /30Days |
ERGOTAMINE-CAFFEINE 1-100MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ERRIN 0.35MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:28 /28Days |
ERY 2% SWAB MEDICATED |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYDERM 2% TOP SOLUTION |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ERYTHROCIN 250MG FILMTAB |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ERYTHROCIN 500MG ADDVNT VL |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
ERYTHROCIN 500MG FILMTAB |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ERYTHROCIN 500MG VIAL |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
ERYTHROCIN LACTOBIONATE IV POWDER FOR INJECTION |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
ERYTHROMYCIN 2% GEL |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ERYTHROMYCIN 2% SOLUTION |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ERYTHROMYCIN 200MG/5ML SUSP |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:1440 /30Days |
ERYTHROMYCIN 250MG CAP EC |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ERYTHROMYCIN 250MG FILMTAB |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROMYCIN 400MG/5ML SUSP |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:1440 /30Days |
ERYTHROMYCIN 500MG FILMTAB |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ERYTHROMYCIN ETHYLSUCCINATE 400MG TABLET (500 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ERYTHROMYCIN OPHTHALMIC OINTMENT 5MG 1/8 OZ TUBE |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:8 /30Days |
ERYTHROMYCIN-BENZOYL PEROXIDE 3-5% GEL |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:47 /30Days |
ERYTHROMYCIN/SULFISOX SUSP |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:600 /1Days |
ESTRADIOL .025MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:4 /28Days |
ESTRADIOL .0375MG/24 PATCH TRANSDERMAL WEEKLY |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:4 /28Days |
ESTRADIOL .075MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:4 /28Days |
ESTRADIOL 0.05MG/DAY PATCH |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:4 /28Days |
ESTRADIOL 0.06MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL 0.1MG/DAY PATCH |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:4 /28Days |
ESTRADIOL 0.5MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ESTRADIOL 2MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ESTRADIOL TABLET 1MG (500 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ESTRADIOL VALERATE INJECTION |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
ESTRADIOL VALERATE INJECTION |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
ESTRADIOL VALERATE INJECTION |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
ESTRADIOL-NORETH 1.0-0.5MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ESTROPIPATE 0.625 TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ESTROPIPATE 1.25 TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ESTROPIPATE 2.5 TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | 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 Generic |
$10.00 | $15.00 | None |
ETHAMBUTOL HCL 400MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ETHOSUXIMIDE 250MG CAPSULE |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ETHOSUXIMIDE 250MG/5ML SYRP |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ETHYOL POWDER FOR INJECTION 500MG 3 X 10ML VILSU CRTN |
5 |
Tier 5. |
29% | N/A | None |
ETIDRONATE DISODIUM 200MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ETIDRONATE DISODIUM 400MG TABLET (60 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ETODOLAC 200MG CAPSULE |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ETODOLAC 300MG CAPSULE |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ETODOLAC 400MG TABLET (500 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ETODOLAC 400MG TABLET SR 24HR |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETODOLAC 500MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ETODOLAC 500MG TABLET SR 24HR |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ETODOLAC 600MG TABLET SR 24HR |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
ETOPOPHOS 100MG VIAL |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
ETOPOSIDE INJECTION 20MG 25ML VIALMD |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
EVISTA 60MG TABLET (30 CT) |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | Q:30 /30Days |
EXELON 1.5MG CAPSULE |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | Q:60 /30Days |
EXELON 2MG/ML ORAL SOLUTION |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | Q:180 /30Days |
EXELON 3MG CAPSULE |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | Q:60 /30Days |
EXELON 4.5MG CAPSULE |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | Q:60 /30Days |
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EXELON 6MG CAPSULE |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | Q:60 /30Days |
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | Q:30 /30Days |
EXFORGE 10MG-160MG TABLET |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | None |
EXFORGE 10MG-320MG TABLET |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | None |
EXFORGE 5MG-160MG TABLET |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | None |
EXFORGE 5MG-320MG TABLET |
2 |
Tier 2 Preferred Brand |
$43.00 | $107.50 | None |
EXJADE 125MG TABLET |
5 |
Tier 5. |
29% | N/A | None |
EXJADE 250MG TABLET |
5 |
Tier 5. |
29% | N/A | None |
EXJADE 500MG TABLET |
5 |
Tier 5. |
29% | N/A | None |