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MedicareBlue Rx Option 1 (S5743-001-0)
Tier 1 (1877)
Tier 2 (398)
Tier 3 (462)
Tier 4 (324)

Requires Prior Authorization:
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Uses Step Therapy:
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2009 Medicare Part D Plan Formulary Information
MedicareBlue Rx Option 1 (S5743-001-0)
Benefit Details  
The MedicareBlue Rx Option 1 (S5743-001-0)
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
Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order
E.E.S. 200MG/5ML SUSPENSION   1 Level 1: Covered Generic 10%10%None
E.E.S. 400 TABLET 400MG   1 Level 1: Covered Generic 10%10%None
E.E.S. 400MG/5ML SUSPENSION   1 Level 1: Covered Generic 10%10%None
ECONAZOLE NITRATE 1% CREAM 85GM TUBE   1 Level 1: Covered Generic 10%10%None
ED DOXY-CAPS 100MG CAPSULE   1 Level 1: Covered Generic 10%10%None
ED K+10 TABLET   1 Level 1: Covered Generic 10%10%None
EFFEXOR 37.5MG CAPSULE ER (90 CT)   3 Level 3: Covered Brand 50%50%S
EFFEXOR XR 150MG CAPSULE ER 15 CAPSULES BOT   3 Level 3: Covered Brand 50%50%S
EFFEXOR XR 75MG CAPSULE ER 15 CAPSULES BOT   3 Level 3: Covered Brand 50%50%S
ELAPRASE 6MG/3ML VIAL   4 Covered Specialty 25%25%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ELIGARD 22.5MG SYRINGE   3 Level 3: Covered Brand 50%50%None
ELIGARD 30MG SYRINGE   3 Level 3: Covered Brand 50%50%None
ELIGARD 45MG SYRINGE   3 Level 3: Covered Brand 50%50%None
ELIGARD 7.5MG SYRINGE   3 Level 3: Covered Brand 50%50%None
ELITEK 1.5MG VIAL   4 Covered Specialty 25%25%None
ELITEK 7.5MG VIAL   4 Covered Specialty 25%25%None
ELLENCE 2MG/ML VIAL   4 Covered Specialty 25%25%None
ELOXATIN 100MG/20ML VIAL   4 Covered Specialty 25%25%None
ELOXATIN 50MG/10ML VIAL   4 Covered Specialty 25%25%None
ELSPAR INJ 10000UNT   4 Covered Specialty 25%25%None
EMCYT 140MG CAPSULE   4 Covered Specialty 25%25%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
EMEND 125MG CAPSULE   2 Level 2: Covered Preferred Brand 22%22%P
EMEND 40MG CAPSULE   2 Level 2: Covered Preferred Brand 22%22%P
EMEND 80MG CAPSULE   2 Level 2: Covered Preferred Brand 22%22%P
EMEND TRIFOLD PACK   2 Level 2: Covered Preferred Brand 22%22%P
EMSAM 12MG/24 HOURS PATCH   3 Level 3: Covered Brand 50%50%None
EMSAM 6MG/24 HOURS PATCH   3 Level 3: Covered Brand 50%50%None
EMSAM 9MG/24 HOURS PATCH   3 Level 3: Covered Brand 50%50%None
EMTRIVA 10MG/ML SOLUTION   3 Level 3: Covered Brand 50%50%None
EMTRIVA 200MG CAPSULE   3 Level 3: Covered Brand 50%50%None
ENABLEX 15MG TABLET   2 Level 2: Covered Preferred Brand 22%22%Q:30
/30Days
ENABLEX 7.5MG TABLET   2 Level 2: Covered Preferred Brand 22%22%Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ENALAPRIL MALEATE 10MG TABLET (100 CT)   1 Level 1: Covered Generic 10%10%None
ENALAPRIL MALEATE 2.5MG TABLET   1 Level 1: Covered Generic 10%10%None
ENALAPRIL MALEATE 20MG TABLET (1000 CT)   1 Level 1: Covered Generic 10%10%None
ENALAPRIL MALEATE 5MG TABLET   1 Level 1: Covered Generic 10%10%None
ENALAPRIL MALEATE-HCTZ 10MG-25MG TABLET (100 CT)   1 Level 1: Covered Generic 10%10%None
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET (100 CT)   1 Level 1: Covered Generic 10%10%None
ENBREL 50MG/ML SURECLICK SYR   4 Covered Specialty 25%25%S
ENBREL INJECTION 50MG/ML SYR   4 Covered Specialty 25%25%S
ENBREL INJECTION KIT 25MG 1 DOSE TRAY PKGCOM   4 Covered Specialty 25%25%S
ENDOCET 10/650MG TABLET   1 Level 1: Covered Generic 10%10%None
ENDOCET 10MG-325MG TABLET   1 Level 1: Covered Generic 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ENDOCET 5/325 TABLET   1 Level 1: Covered Generic 10%10%None
ENDOCET 7.5-325MG TABLET   1 Level 1: Covered Generic 10%10%None
ENDOCET 7.5/500MG TABLET   1 Level 1: Covered Generic 10%10%None
ENGERIX-B 10MCG 10 X 0.5ML VIALSD   3 Level 3: Covered Brand 50%50%P
ENGERIX-B 10MCG/0.5ML SYRN   3 Level 3: Covered Brand 50%50%P
ENGERIX-B 20MCG/ML SYRINGE   3 Level 3: Covered Brand 50%50%P
ENPRESSE-28 TABLET   1 Level 1: Covered Generic 10%10%None
ENTOCORT EC 3MG CAPSULE   2 Level 2: Covered Preferred Brand 22%22%None
ENULOSE SYRUP 10GM/15ML 1 PINT BOTPL   1 Level 1: Covered Generic 10%10%None
EPIPEN 0.3MG AUTO-INJECTOR   2 Level 2: Covered Preferred Brand 22%22%None
EPIPEN JR 0.15MG AUTO-INJCT   2 Level 2: Covered Preferred Brand 22%22%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
EPIRUBICIN HCL INJECTION SOLUTION 2MG 1 X 25ML VIAL   4 Covered Specialty 25%25%None
EPITOL 200MG TABLET   1 Level 1: Covered Generic 10%10%None
EPIVIR 10MG/ML ORAL SOLUTION   2 Level 2: Covered Preferred Brand 22%22%None
EPIVIR 150MG TABLET   2 Level 2: Covered Preferred Brand 22%22%None
EPIVIR 300MG TABLET   2 Level 2: Covered Preferred Brand 22%22%None
EPIVIR HBV 100MG TABLET   2 Level 2: Covered Preferred Brand 22%22%None
EPIVIR HBV 25MG/5ML TUBEX   2 Level 2: Covered Preferred Brand 22%22%None
EPOGEN 10000U/ML VIAL MDV   4 Covered Specialty 25%25%P
EPOGEN 2000U/ML VIAL SDV   2 Level 2: Covered Preferred Brand 22%22%P
EPOGEN 3000U/ML VIAL SDV   3 Level 3: Covered Brand 50%50%P
EPOGEN 4000U/ML VIAL SDV   3 Level 3: Covered Brand 50%50%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   4 Covered Specialty 25%25%P
EPOGEN INJECTION 40000U 10 X 4ML VIALS VIALSD   4 Covered Specialty 25%25%P
EPZICOM TABLET   2 Level 2: Covered Preferred Brand 22%22%None
EQUETRO 100MG CAPSULE   3 Level 3: Covered Brand 50%50%None
EQUETRO 200MG CAPSULE   3 Level 3: Covered Brand 50%50%None
EQUETRO 300MG CAPSULE   3 Level 3: Covered Brand 50%50%None
ERBITUX 100MG/50ML VIAL   4 Covered Specialty 25%25%None
ERGOTAMINE-CAFFEINE 1-100MG TABLET   1 Level 1: Covered Generic 10%10%None
ERRIN 0.35MG TABLET   1 Level 1: Covered Generic 10%10%None
ERY 2% SWAB MEDICATED   1 Level 1: Covered Generic 10%10%None
ERYDERM 2% TOP SOLUTION   1 Level 1: Covered Generic 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ERYTHROCIN 250MG FILMTAB   1 Level 1: Covered Generic 10%10%None
ERYTHROCIN 500MG ADDVNT VL   3 Level 3: Covered Brand 50%50%None
ERYTHROCIN 500MG FILMTAB   1 Level 1: Covered Generic 10%10%None
ERYTHROCIN 500MG VIAL   3 Level 3: Covered Brand 50%50%None
ERYTHROCIN LACTOBIONATE IV POWDER FOR INJECTION   3 Level 3: Covered Brand 50%50%None
ERYTHROMYCIN 2% GEL   1 Level 1: Covered Generic 10%10%None
ERYTHROMYCIN 2% SOLUTION   1 Level 1: Covered Generic 10%10%None
ERYTHROMYCIN 200MG/5ML SUSP   1 Level 1: Covered Generic 10%10%None
ERYTHROMYCIN 400MG/5ML SUSP   1 Level 1: Covered Generic 10%10%None
ERYTHROMYCIN ETHYLSUCCINATE 400MG TABLET (500 CT)   1 Level 1: Covered Generic 10%10%None
ERYTHROMYCIN OPHTHALMIC OINTMENT 5MG 1/8 OZ TUBE   1 Level 1: Covered Generic 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ERYTHROMYCIN-BENZOYL PEROXIDE 3-5% GEL   1 Level 1: Covered Generic 10%10%None
ESTRADERM 0.05MG/24H PATCH TRANSDERMAL SEMIWEEKLY   2 Level 2: Covered Preferred Brand 22%22%None
ESTRADERM 0.1MG/24HR PATCH TRANSDERMAL SEMIWEEKLY   2 Level 2: Covered Preferred Brand 22%22%None
ESTRADIOL .025MG/24H PATCH TRANSDERMAL WEEKLY   1 Level 1: Covered Generic 10%10%None
ESTRADIOL .0375MG/24 PATCH TRANSDERMAL WEEKLY   1 Level 1: Covered Generic 10%10%None
ESTRADIOL .075MG/24H PATCH TRANSDERMAL WEEKLY   1 Level 1: Covered Generic 10%10%None
ESTRADIOL 0.05MG/DAY PATCH   1 Level 1: Covered Generic 10%10%None
ESTRADIOL 0.06MG/24H PATCH TRANSDERMAL WEEKLY   1 Level 1: Covered Generic 10%10%None
ESTRADIOL 0.1MG/DAY PATCH   1 Level 1: Covered Generic 10%10%None
ESTRADIOL 0.5MG TABLET   1 Level 1: Covered Generic 10%10%None
ESTRADIOL 2MG TABLET   1 Level 1: Covered Generic 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ESTRADIOL TABLET 1MG (500 CT)   1 Level 1: Covered Generic 10%10%None
ESTRADIOL-NORETH 1.0-0.5MG TABLET   1 Level 1: Covered Generic 10%10%None
ESTROPIPATE 0.625 TABLET   1 Level 1: Covered Generic 10%10%None
ESTROPIPATE 1.25 TABLET   1 Level 1: Covered Generic 10%10%None
ESTROPIPATE 2.5 TABLET   1 Level 1: Covered Generic 10%10%None
ETHAMBUTOL HCL 100MG TABLET   1 Level 1: Covered Generic 10%10%None
ETHAMBUTOL HCL 400MG TABLET (100 CT)   1 Level 1: Covered Generic 10%10%None
ETHOSUXIMIDE 250MG CAPSULE   1 Level 1: Covered Generic 10%10%None
ETHOSUXIMIDE 250MG/5ML SYRP   1 Level 1: Covered Generic 10%10%None
ETIDRONATE DISODIUM 200MG TABLET   1 Level 1: Covered Generic 10%10%None
ETIDRONATE DISODIUM 400MG TABLET (60 CT)   1 Level 1: Covered Generic 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ETODOLAC 200MG CAPSULE   1 Level 1: Covered Generic 10%10%None
ETODOLAC 300MG CAPSULE   1 Level 1: Covered Generic 10%10%None
ETODOLAC 400MG TABLET (500 CT)   1 Level 1: Covered Generic 10%10%None
ETODOLAC 400MG TABLET SR 24HR   1 Level 1: Covered Generic 10%10%None
ETODOLAC 500MG TABLET (100 CT)   1 Level 1: Covered Generic 10%10%None
ETODOLAC 500MG TABLET SR 24HR   1 Level 1: Covered Generic 10%10%None
ETODOLAC 600MG TABLET SR 24HR   1 Level 1: Covered Generic 10%10%None
ETOPOPHOS 100MG VIAL   3 Level 3: Covered Brand 50%50%None
ETOPOSIDE INJECTION 20MG 25ML VIALMD   1 Level 1: Covered Generic 10%10%None
EVISTA 60MG TABLET (30 CT)   2 Level 2: Covered Preferred Brand 22%22%None
EXELON 1.5MG CAPSULE   2 Level 2: Covered Preferred Brand 22%22%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
EXELON 2MG/ML ORAL SOLUTION   2 Level 2: Covered Preferred Brand 22%22%None
EXELON 3MG CAPSULE   2 Level 2: Covered Preferred Brand 22%22%None
EXELON 4.5MG CAPSULE   2 Level 2: Covered Preferred Brand 22%22%None
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS   2 Level 2: Covered Preferred Brand 22%22%None
EXELON 6MG CAPSULE   2 Level 2: Covered Preferred Brand 22%22%None
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS   2 Level 2: Covered Preferred Brand 22%22%None
EXFORGE 10MG-160MG TABLET   2 Level 2: Covered Preferred Brand 22%22%S
EXFORGE 10MG-320MG TABLET   2 Level 2: Covered Preferred Brand 22%22%S
EXFORGE 5MG-160MG TABLET   2 Level 2: Covered Preferred Brand 22%22%S
EXFORGE 5MG-320MG TABLET   2 Level 2: Covered Preferred Brand 22%22%S
EXJADE 125MG TABLET   4 Covered Specialty 25%25%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
EXJADE 250MG TABLET   4 Covered Specialty 25%25%None
EXJADE 500MG TABLET   4 Covered Specialty 25%25%None

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D MedicareBlue Rx Option 1 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.