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2009 Medicare Part D Plan Formulary Information
Community CCRx Basic (S5803-094-0) Benefit Details
The Community CCRx Basic (S5803-094-0) 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
E.E.S. 200MG/5ML SUSPENSION	1	Generic	$0.00	N/A	None
E.E.S. 400 TABLET 400MG	1	Generic	$0.00	N/A	None
E.E.S. 400MG/5ML SUSPENSION	1	Generic	$0.00	N/A	None
ECONAZOLE NITRATE 1% CREAM 85GM TUBE	1	Generic	$0.00	N/A	None
ED DOXY-CAPS 100MG CAPSULE	1	Generic	$0.00	N/A	None
ED K+10 TABLET	1	Generic	$0.00	N/A	None
EDECRIN 25MG TABLET (100 CT)	3	Non-Preferred Brand	50%	N/A	None
EDECRIN SODIUM 50MG VIAL	2	Preferred Brand	30%	N/A	None
EFFEXOR 37.5MG CAPSULE ER (90 CT)	3	Non-Preferred Brand	50%	N/A	S Q:30 /30Days
EFFEXOR XR 150MG CAPSULE ER 15 CAPSULES BOT	3	Non-Preferred Brand	50%	N/A	S Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EFFEXOR XR 75MG CAPSULE ER 15 CAPSULES BOT	3	Non-Preferred Brand	50%	N/A	S Q:30 /30Days
ELESTAT 0.05% EYE DROPS	3	Non-Preferred Brand	50%	N/A	Q:5 /25Days
ELIDEL 1% CREAM	3	Non-Preferred Brand	50%	N/A	Q:60 /30Days
ELIGARD 22.5MG SYRINGE	2	Preferred Brand	30%	N/A	P Q:1 /84Days
ELIGARD 7.5MG SYRINGE	2	Preferred Brand	30%	N/A	P Q:1 /30Days
ELITEK 1.5MG VIAL	3	Non-Preferred Brand	50%	N/A	P
ELITEK 7.5MG VIAL	3	Non-Preferred Brand	50%	N/A	P
ELIXOPHYLLIN 80MG/15ML ELIX	2	Preferred Brand	30%	N/A	None
ELMIRON 100MG CAPSULE	3	Non-Preferred Brand	50%	N/A	Q:90 /30Days
EMCYT 140MG CAPSULE	2	Preferred Brand	30%	N/A	None
EMEND 125MG CAPSULE	2	Preferred Brand	30%	N/A	P Q:6 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EMEND 80MG CAPSULE	2	Preferred Brand	30%	N/A	P Q:6 /30Days
EMEND TRIFOLD PACK	2	Preferred Brand	30%	N/A	P Q:6 /30Days
EMSAM 12MG/24 HOURS PATCH	3	Non-Preferred Brand	50%	N/A	P Q:30 /30Days
EMSAM 6MG/24 HOURS PATCH	3	Non-Preferred Brand	50%	N/A	P Q:30 /30Days
EMSAM 9MG/24 HOURS PATCH	3	Non-Preferred Brand	50%	N/A	P Q:30 /30Days
EMTRIVA 10MG/ML SOLUTION	2	Preferred Brand	30%	N/A	None
EMTRIVA 200MG CAPSULE	2	Preferred Brand	30%	N/A	None
ENABLEX 15MG TABLET	2	Preferred Brand	30%	N/A	Q:30 /30Days
ENABLEX 7.5MG TABLET	2	Preferred Brand	30%	N/A	Q:30 /30Days
ENALAPRIL MALEATE 10MG TABLET (100 CT)	1	Generic	$0.00	N/A	None
ENALAPRIL MALEATE 2.5MG TABLET	1	Generic	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENALAPRIL MALEATE 20MG TABLET (1000 CT)	1	Generic	$0.00	N/A	None
ENALAPRIL MALEATE 5MG TABLET	1	Generic	$0.00	N/A	None
ENALAPRIL MALEATE-HCTZ 10MG-25MG TABLET (100 CT)	1	Generic	$0.00	N/A	None
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET (100 CT)	1	Generic	$0.00	N/A	None
ENBREL 50MG/ML SURECLICK SYR	3	Non-Preferred Brand	50%	N/A	P Q:7 /28Days
ENBREL INJECTION 50MG/ML SYR	3	Non-Preferred Brand	50%	N/A	P Q:7 /28Days
ENBREL INJECTION KIT 25MG 1 DOSE TRAY PKGCOM	3	Non-Preferred Brand	50%	N/A	P Q:16 /28Days
ENDOCET 10/650MG TABLET	1	Generic	$0.00	N/A	Q:180 /30Days
ENDOCET 10MG-325MG TABLET	1	Generic	$0.00	N/A	Q:360 /30Days
ENDOCET 5/325 TABLET	1	Generic	$0.00	N/A	Q:360 /30Days
ENDOCET 7.5-325MG TABLET	1	Generic	$0.00	N/A	Q:360 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENDOCET 7.5/500MG TABLET	1	Generic	$0.00	N/A	Q:240 /30Days
ENGERIX-B 10MCG 10 X 0.5ML VIALSD	3	Non-Preferred Brand	50%	N/A	P
ENGERIX-B 10MCG/0.5ML SYRN	3	Non-Preferred Brand	50%	N/A	P
ENGERIX-B 20MCG/ML SYRINGE	3	Non-Preferred Brand	50%	N/A	P
ENPRESSE-28 TABLET	1	Generic	$0.00	N/A	Q:28 /28Days
ENTOCORT EC 3MG CAPSULE	2	Preferred Brand	30%	N/A	S
ENULOSE SYRUP 10GM/15ML 1 PINT BOTPL	1	Generic	$0.00	N/A	None
ENZYMAX 500MG TABLET	2	Preferred Brand	30%	N/A	None
EPINEPHRINE 0.1MG/ML ABBJCT	1	Generic	$0.00	N/A	None
EPIPEN 0.3MG AUTO-INJECTOR	3	Non-Preferred Brand	50%	N/A	Q:2 /30Days
EPIPEN JR 0.15MG AUTO-INJCT	3	Non-Preferred Brand	50%	N/A	Q:2 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EPITOL 200MG TABLET	1	Generic	$0.00	N/A	None
EPIVIR 10MG/ML ORAL SOLUTION	2	Preferred Brand	30%	N/A	None
EPIVIR 150MG TABLET	2	Preferred Brand	30%	N/A	None
EPIVIR 300MG TABLET	2	Preferred Brand	30%	N/A	None
EPIVIR HBV 100MG TABLET	2	Preferred Brand	30%	N/A	P
EPIVIR HBV 25MG/5ML TUBEX	2	Preferred Brand	30%	N/A	P
EPZICOM TABLET	2	Preferred Brand	30%	N/A	None
EQUETRO 100MG CAPSULE	3	Non-Preferred Brand	50%	N/A	None
EQUETRO 200MG CAPSULE	3	Non-Preferred Brand	50%	N/A	None
EQUETRO 300MG CAPSULE	3	Non-Preferred Brand	50%	N/A	None
ERAXIS 100MG VIAL	3	Non-Preferred Brand	50%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ERAXIS 50MG VIAL	3	Non-Preferred Brand	50%	N/A	P
ERGOMAR SUBLINGUAL TABLET 2MG	2	Preferred Brand	30%	N/A	None
ERRIN 0.35MG TABLET	1	Generic	$0.00	N/A	Q:28 /28Days
ERY 2% SWAB MEDICATED	1	Generic	$0.00	N/A	None
ERY-TAB 250MG TABLET EC	2	Preferred Brand	30%	N/A	None
ERY-TAB 333MG TABLET EC	2	Preferred Brand	30%	N/A	None
ERY-TAB 500MG TABLET EC	2	Preferred Brand	30%	N/A	None
ERYDERM 2% TOP SOLUTION	1	Generic	$0.00	N/A	None
ERYTHROCIN 250MG FILMTAB	1	Generic	$0.00	N/A	None
ERYTHROCIN 500MG ADDVNT VL	2	Preferred Brand	30%	N/A	None
ERYTHROCIN 500MG FILMTAB	1	Generic	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ERYTHROCIN 500MG VIAL	2	Preferred Brand	30%	N/A	None
ERYTHROCIN LACTOBIONATE IV POWDER FOR INJECTION	2	Preferred Brand	30%	N/A	None
ERYTHROMYCIN 2% GEL	1	Generic	$0.00	N/A	None
ERYTHROMYCIN 2% SOLUTION	1	Generic	$0.00	N/A	None
ERYTHROMYCIN 200MG/5ML SUSP	1	Generic	$0.00	N/A	None
ERYTHROMYCIN 250MG CAP EC	2	Preferred Brand	30%	N/A	None
ERYTHROMYCIN 250MG FILMTAB	2	Preferred Brand	30%	N/A	None
ERYTHROMYCIN 400MG/5ML SUSP	1	Generic	$0.00	N/A	None
ERYTHROMYCIN 500MG FILMTAB	2	Preferred Brand	30%	N/A	None
ERYTHROMYCIN ETHYLSUCCINATE 400MG TABLET (500 CT)	1	Generic	$0.00	N/A	None
ERYTHROMYCIN OPHTHALMIC OINTMENT 5MG 1/8 OZ TUBE	1	Generic	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ERYTHROMYCIN/SULFISOX SUSP	1	Generic	$0.00	N/A	None
ESTRACE VAG CREAM 0.1MG/GM	3	Non-Preferred Brand	50%	N/A	Q:85 /28Days
ESTRADERM 0.05MG/24H PATCH TRANSDERMAL SEMIWEEKLY	3	Non-Preferred Brand	50%	N/A	Q:8 /28Days
ESTRADERM 0.1MG/24HR PATCH TRANSDERMAL SEMIWEEKLY	3	Non-Preferred Brand	50%	N/A	Q:8 /28Days
ESTRADIOL .025MG/24H PATCH TRANSDERMAL WEEKLY	1	Generic	$0.00	N/A	Q:4 /28Days
ESTRADIOL .0375MG/24 PATCH TRANSDERMAL WEEKLY	1	Generic	$0.00	N/A	Q:4 /28Days
ESTRADIOL .075MG/24H PATCH TRANSDERMAL WEEKLY	1	Generic	$0.00	N/A	Q:4 /28Days
ESTRADIOL 0.05MG/DAY PATCH	1	Generic	$0.00	N/A	Q:4 /28Days
ESTRADIOL 0.06MG/24H PATCH TRANSDERMAL WEEKLY	1	Generic	$0.00	N/A	Q:4 /28Days
ESTRADIOL 0.1MG/DAY PATCH	1	Generic	$0.00	N/A	Q:4 /28Days
ESTRADIOL 0.5MG TABLET	1	Generic	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ESTRADIOL 2MG TABLET	1	Generic	$0.00	N/A	None
ESTRADIOL TABLET 1MG (500 CT)	1	Generic	$0.00	N/A	None
ESTRADIOL VALERATE INJECTION	3	Non-Preferred Brand	50%	N/A	None
ESTRADIOL VALERATE INJECTION	3	Non-Preferred Brand	50%	N/A	None
ESTRADIOL VALERATE INJECTION	3	Non-Preferred Brand	50%	N/A	None
ESTROPIPATE 0.625 TABLET	1	Generic	$0.00	N/A	None
ESTROPIPATE 1.25 TABLET	1	Generic	$0.00	N/A	None
ESTROPIPATE 2.5 TABLET	1	Generic	$0.00	N/A	None
ETHAMBUTOL HCL 100MG TABLET	1	Generic	$0.00	N/A	None
ETHAMBUTOL HCL 400MG TABLET (100 CT)	1	Generic	$0.00	N/A	None
ETHOSUXIMIDE 250MG CAPSULE	2	Preferred Brand	30%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ETHOSUXIMIDE 250MG/5ML SYRP	1	Generic	$0.00	N/A	None
ETODOLAC 200MG CAPSULE	1	Generic	$0.00	N/A	None
ETODOLAC 300MG CAPSULE	1	Generic	$0.00	N/A	None
ETODOLAC 400MG TABLET (500 CT)	1	Generic	$0.00	N/A	None
ETODOLAC 400MG TABLET SR 24HR	1	Generic	$0.00	N/A	None
ETODOLAC 500MG TABLET (100 CT)	1	Generic	$0.00	N/A	None
ETODOLAC 500MG TABLET SR 24HR	1	Generic	$0.00	N/A	None
ETODOLAC 600MG TABLET SR 24HR	1	Generic	$0.00	N/A	None
EURAX 10% CREAM	2	Preferred Brand	30%	N/A	None
EURAX 10% LOTION	2	Preferred Brand	30%	N/A	None
EVISTA 60MG TABLET (30 CT)	2	Preferred Brand	30%	N/A	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EXELON 1.5MG CAPSULE	3	Non-Preferred Brand	50%	N/A	Q:60 /30Days
EXELON 2MG/ML ORAL SOLUTION	3	Non-Preferred Brand	50%	N/A	Q:180 /30Days
EXELON 3MG CAPSULE	3	Non-Preferred Brand	50%	N/A	Q:60 /30Days
EXELON 4.5MG CAPSULE	3	Non-Preferred Brand	50%	N/A	Q:60 /30Days
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS	3	Non-Preferred Brand	50%	N/A	Q:30 /30Days
EXELON 6MG CAPSULE	3	Non-Preferred Brand	50%	N/A	Q:60 /30Days
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS	3	Non-Preferred Brand	50%	N/A	Q:30 /30Days
EXFORGE 10MG-160MG TABLET	2	Preferred Brand	30%	N/A	Q:30 /30Days
EXFORGE 10MG-320MG TABLET	2	Preferred Brand	30%	N/A	Q:30 /30Days
EXFORGE 5MG-160MG TABLET	2	Preferred Brand	30%	N/A	Q:30 /30Days
EXFORGE 5MG-320MG TABLET	2	Preferred Brand	30%	N/A	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EXJADE 125MG TABLET	3	Non-Preferred Brand	50%	N/A	P
EXJADE 250MG TABLET	3	Non-Preferred Brand	50%	N/A	P
EXJADE 500MG TABLET	3	Non-Preferred Brand	50%	N/A	P

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D Community CCRx Basic 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.