Q1Medicare.com 2009 Medicare Part D or Medicare Advantage Plan Formulary Browser

2009 Medicare Part D Plan Formulary Information
Advantage Freedom Plan by RxAmerica (S5644-059-0) Benefit Details
The Advantage Freedom Plan by RxAmerica (S5644-059-0) Formulary Drugs Starting with the Letter E in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
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
ECONAZOLE NITRATE 1% CREAM 85GM TUBE	1	Preferred Generic	$5.00	$0.00	None
ED DOXY-CAPS 100MG CAPSULE	1	Preferred Generic	$5.00	$0.00	None
ED K+10 TABLET	1	Preferred Generic	$5.00	$0.00	None
EFFEXOR 37.5MG CAPSULE ER (90 CT)	2	Preferred Brand	35%	40%	None
EFFEXOR XR 150MG CAPSULE ER 15 CAPSULES BOT	2	Preferred Brand	35%	40%	None
EFFEXOR XR 75MG CAPSULE ER 15 CAPSULES BOT	2	Preferred Brand	35%	40%	None
EFUDEX 5% CREAM	2	Preferred Brand	35%	40%	None
ELAPRASE 6MG/3ML VIAL	2	Preferred Brand	35%	40%	P
ELIDEL 1% CREAM	2	Preferred Brand	35%	40%	P
ELIGARD 22.5MG SYRINGE	4	Non-Preferred	45%	45%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ELIGARD 30MG SYRINGE	2	Preferred Brand	35%	40%	P
ELIGARD 45MG SYRINGE	2	Preferred Brand	35%	40%	P
ELIGARD 7.5MG SYRINGE	4	Non-Preferred	45%	45%	P
ELITEK 1.5MG VIAL	2	Preferred Brand	35%	40%	P
ELITEK 7.5MG VIAL	2	Preferred Brand	35%	40%	P
ELIXOPHYLLIN 80MG/15ML ELIX	2	Preferred Brand	35%	40%	None
ELLENCE 2MG/ML VIAL	3	Specialty	33%	N/A	None
ELOXATIN 100MG/20ML VIAL	3	Specialty	33%	N/A	P
ELOXATIN 50MG/10ML VIAL	3	Specialty	33%	N/A	P
EMCYT 140MG CAPSULE	2	Preferred Brand	35%	40%	None
EMEND 125MG CAPSULE	2	Preferred Brand	35%	40%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EMEND 80MG CAPSULE	2	Preferred Brand	35%	40%	P
EMEND TRIFOLD PACK	2	Preferred Brand	35%	40%	P
EMSAM 12MG/24 HOURS PATCH	2	Preferred Brand	35%	40%	P
EMSAM 6MG/24 HOURS PATCH	2	Preferred Brand	35%	40%	P
EMSAM 9MG/24 HOURS PATCH	2	Preferred Brand	35%	40%	P
EMTRIVA 10MG/ML SOLUTION	2	Preferred Brand	35%	40%	None
EMTRIVA 200MG CAPSULE	2	Preferred Brand	35%	40%	None
ENALAPRIL MALEATE 10MG TABLET (100 CT)	1	Preferred Generic	$5.00	$0.00	None
ENALAPRIL MALEATE 2.5MG TABLET	1	Preferred Generic	$5.00	$0.00	None
ENALAPRIL MALEATE 20MG TABLET (1000 CT)	1	Preferred Generic	$5.00	$0.00	None
ENALAPRIL MALEATE 5MG TABLET	1	Preferred Generic	$5.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENALAPRIL MALEATE-HCTZ 10MG-25MG TABLET (100 CT)	1	Preferred Generic	$5.00	$0.00	None
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET (100 CT)	1	Preferred Generic	$5.00	$0.00	None
ENBREL INJECTION 50MG/ML SYR	3	Specialty	33%	N/A	P
ENBREL INJECTION KIT 25MG 1 DOSE TRAY PKGCOM	3	Specialty	33%	N/A	P
ENDOCET 5/325 TABLET	1	Preferred Generic	$5.00	$0.00	None
ENGERIX-B 10MCG 10 X 0.5ML VIALSD	2	Preferred Brand	35%	40%	P
ENGERIX-B 10MCG/0.5ML SYRN	2	Preferred Brand	35%	40%	P
ENGERIX-B 20MCG/ML SYRINGE	2	Preferred Brand	35%	40%	P
ENPRESSE-28 TABLET	1	Preferred Generic	$5.00	$0.00	None
ENULOSE SYRUP 10GM/15ML 1 PINT BOTPL	1	Preferred Generic	$5.00	$0.00	None
EPINEPHRINE 0.1MG/ML ABBJCT	1	Preferred Generic	$5.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EPIPEN 0.3MG AUTO-INJECTOR	2	Preferred Brand	35%	40%	None
EPIPEN JR 0.15MG AUTO-INJCT	2	Preferred Brand	35%	40%	None
EPIRUBICIN HCL INJECTION SOLUTION 2MG 1 X 25ML VIAL	1	Preferred Generic	$5.00	$0.00	P
EPITOL 200MG TABLET	1	Preferred Generic	$5.00	$0.00	None
EPIVIR 10MG/ML ORAL SOLUTION	2	Preferred Brand	35%	40%	None
EPIVIR 150MG TABLET	2	Preferred Brand	35%	40%	None
EPIVIR 300MG TABLET	2	Preferred Brand	35%	40%	None
EPIVIR HBV 100MG TABLET	2	Preferred Brand	35%	40%	None
EPIVIR HBV 25MG/5ML TUBEX	2	Preferred Brand	35%	40%	None
EPLERENONE 25MG TABS	1	Preferred Generic	$5.00	$0.00	P
EPLERENONE 50MG TABS	1	Preferred Generic	$5.00	$0.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EPOGEN 10000U/ML VIAL MDV	3	Specialty	33%	N/A	P
EPOGEN 2000U/ML VIAL SDV	2	Preferred Brand	35%	40%	P Q:12 /30Days
EPOGEN 3000U/ML VIAL SDV	2	Preferred Brand	35%	40%	P Q:12 /30Days
EPOGEN 4000U/ML VIAL SDV	2	Preferred Brand	35%	40%	P Q:12 /30Days
EPOGEN INJECTION 20000U 10 X 1ML CRTN	3	Specialty	33%	N/A	P
EPOGEN INJECTION 40000U 10 X 4ML VIALS VIALSD	3	Specialty	33%	N/A	P
EPZICOM TABLET	2	Preferred Brand	35%	40%	None
ERAXIS 100MG VIAL	2	Preferred Brand	35%	40%	None
ERAXIS 50MG VIAL	2	Preferred Brand	35%	40%	P
ERGOLOID MESYLATES 1MG TABLET (500 CT)	1	Preferred Generic	$5.00	$0.00	None
ERGOTAMINE-CAFFEINE 1-100MG TABLET	1	Preferred Generic	$5.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ERRIN 0.35MG TABLET	1	Preferred Generic	$5.00	$0.00	None
ERY 2% SWAB MEDICATED	1	Preferred Generic	$5.00	$0.00	None
ERY-TAB 250MG TABLET EC	2	Preferred Brand	35%	40%	None
ERY-TAB 500MG TABLET EC	2	Preferred Brand	35%	40%	None
ERYDERM 2% TOP SOLUTION	1	Preferred Generic	$5.00	$0.00	None
ERYTHROCIN 500MG ADDVNT VL	2	Preferred Brand	35%	40%	None
ERYTHROCIN 500MG VIAL	1	Preferred Generic	$5.00	$0.00	None
ERYTHROCIN LACTOBIONATE IV POWDER FOR INJECTION	2	Preferred Brand	35%	40%	None
ERYTHROMYCIN 2% GEL	1	Preferred Generic	$5.00	$0.00	None
ERYTHROMYCIN 2% SOLUTION	1	Preferred Generic	$5.00	$0.00	None
ERYTHROMYCIN 250MG CAP EC	1	Preferred Generic	$5.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ERYTHROMYCIN 250MG FILMTAB	1	Preferred Generic	$5.00	$0.00	None
ERYTHROMYCIN 500MG FILMTAB	1	Preferred Generic	$5.00	$0.00	None
ERYTHROMYCIN OPHTHALMIC OINTMENT 5MG 1/8 OZ TUBE	1	Preferred Generic	$5.00	$0.00	None
ESTRADERM 0.05MG/24H PATCH TRANSDERMAL SEMIWEEKLY	2	Preferred Brand	35%	40%	None
ESTRADERM 0.1MG/24HR PATCH TRANSDERMAL SEMIWEEKLY	2	Preferred Brand	35%	40%	None
ESTRADIOL .025MG/24H PATCH TRANSDERMAL WEEKLY	1	Preferred Generic	$5.00	$0.00	None
ESTRADIOL .075MG/24H PATCH TRANSDERMAL WEEKLY	1	Preferred Generic	$5.00	$0.00	None
ESTRADIOL 0.05MG/DAY PATCH	1	Preferred Generic	$5.00	$0.00	None
ESTRADIOL 0.1MG/DAY PATCH	1	Preferred Generic	$5.00	$0.00	None
ESTRADIOL 0.5MG TABLET	1	Preferred Generic	$5.00	$0.00	None
ESTRADIOL 2MG TABLET	1	Preferred Generic	$5.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ESTRADIOL TABLET 1MG (500 CT)	1	Preferred Generic	$5.00	$0.00	None
ESTRASORB 2.5MG 56 POU	2	Preferred Brand	35%	40%	None
ESTROGEL 0.06% GEL	2	Preferred Brand	35%	40%	None
ESTROPIPATE 0.625 TABLET	1	Preferred Generic	$5.00	$0.00	None
ESTROPIPATE 1.25 TABLET	1	Preferred Generic	$5.00	$0.00	None
ESTROPIPATE 2.5 TABLET	1	Preferred Generic	$5.00	$0.00	None
ESTROSTEP FE-28 TABLET	2	Preferred Brand	35%	40%	None
ETHAMBUTOL HCL 100MG TABLET	1	Preferred Generic	$5.00	$0.00	None
ETHAMBUTOL HCL 400MG TABLET (100 CT)	1	Preferred Generic	$5.00	$0.00	None
ETHOSUXIMIDE 250MG CAPSULE	1	Preferred Generic	$5.00	$0.00	None
ETHOSUXIMIDE 250MG/5ML SYRP	1	Preferred Generic	$5.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ETHYOL POWDER FOR INJECTION 500MG 3 X 10ML VILSU CRTN	3	Specialty	33%	N/A	P
ETODOLAC 200MG CAPSULE	1	Preferred Generic	$5.00	$0.00	None
ETODOLAC 300MG CAPSULE	1	Preferred Generic	$5.00	$0.00	None
ETODOLAC 400MG TABLET (500 CT)	1	Preferred Generic	$5.00	$0.00	None
ETODOLAC 400MG TABLET SR 24HR	1	Preferred Generic	$5.00	$0.00	None
ETODOLAC 500MG TABLET (100 CT)	1	Preferred Generic	$5.00	$0.00	None
ETODOLAC 500MG TABLET SR 24HR	1	Preferred Generic	$5.00	$0.00	None
ETODOLAC 600MG TABLET SR 24HR	1	Preferred Generic	$5.00	$0.00	None
ETOPOSIDE INJECTION 20MG 25ML VIALMD	1	Preferred Generic	$5.00	$0.00	None
EURAX 10% CREAM	2	Preferred Brand	35%	40%	None
EURAX 10% LOTION	2	Preferred Brand	35%	40%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EVISTA 60MG TABLET (30 CT)	2	Preferred Brand	35%	40%	None
EVOCLIN 1% FOAM	2	Preferred Brand	35%	40%	None
EXELDERM 1% CREAM	2	Preferred Brand	35%	40%	None
EXELDERM 1% SOLUTION	2	Preferred Brand	35%	40%	None
EXELON 1.5MG CAPSULE	2	Preferred Brand	35%	40%	P
EXELON 2MG/ML ORAL SOLUTION	2	Preferred Brand	35%	40%	P
EXELON 3MG CAPSULE	2	Preferred Brand	35%	40%	P
EXELON 4.5MG CAPSULE	2	Preferred Brand	35%	40%	P
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS	2	Preferred Brand	35%	40%	None
EXELON 6MG CAPSULE	2	Preferred Brand	35%	40%	P
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS	2	Preferred Brand	35%	40%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EXJADE 125MG TABLET	2	Preferred Brand	35%	40%	P
EXJADE 250MG TABLET	2	Preferred Brand	35%	40%	P
EXJADE 500MG TABLET	2	Preferred Brand	35%	40%	P

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D Advantage Freedom Plan by RxAmerica 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).
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 $295 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 four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
- Drug 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 initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
- 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 October 2009 )

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.