2010 Medicare Part D Plan Formulary Information |
MedicareRx Rewards Standard (PDP) (S5960-137-0)
Benefit Details
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The MedicareRx Rewards Standard (PDP) (S5960-137-0) Formulary Drugs Starting with the Letter E in CMS PDP Region 31 which includes: ID UT
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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 |
ECONAZOLE NITRATE 1% CREAM 85GM TUBE |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ED DOXY-CAPS 100MG CAPSULE |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ED K+10 TABLET |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
EES 400 TABLET 400MG 100 BOT |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ELAPRASE 6MG/3ML VIAL |
4 |
Tier 4 Specialty Drugs |
25% | N/A | None |
ELIGARD 22.5MG SYRINGE |
3 |
Tier 3 Non-Specialty Injectable Drugs |
25% | 25% | P |
ELIGARD 30MG SYRINGE |
3 |
Tier 3 Non-Specialty Injectable Drugs |
25% | 25% | P |
ELIGARD 45MG SYRINGE |
3 |
Tier 3 Non-Specialty Injectable Drugs |
25% | 25% | P |
ELIGARD 7.5MG SYRINGE |
3 |
Tier 3 Non-Specialty Injectable Drugs |
25% | 25% | P |
ELITEK 1.5MG VIAL |
4 |
Tier 4 Specialty Drugs |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIXOPHYLLIN 80MG/15ML ELIX |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | None |
ELLENCE 2MG/ML VIAL |
3 |
Tier 3 Non-Specialty Injectable Drugs |
25% | 25% | None |
ELOXATIN 100MG/20ML VIAL |
4 |
Tier 4 Specialty Drugs |
25% | N/A | P |
ELSPAR INJ 10000UNT |
4 |
Tier 4 Specialty Drugs |
25% | N/A | None |
EMCYT 140MG CAPSULE |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | None |
EMEND 40MG CAPSULE |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | P Q:1 /1Days |
EMEND CAPSULES 125MG 6 BLPK |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | P Q:4 /30Days |
EMEND CAPSULES 80MG 2 BLPK |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | P Q:8 /30Days |
EMEND TRIFOLD PACK |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | P Q:12 /30Days |
EMSAM 12MG/24 HOURS PATCH |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | Q:30 /30Days |
EMSAM 6MG/24 HOURS PATCH |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMSAM 9MG/24 HOURS PATCH |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | Q:30 /30Days |
EMTRIVA 10MG/ML SOLUTION |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | None |
EMTRIVA 200MG CAPSULE |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | None |
ENALAPRIL MALEATE 10MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ENALAPRIL MALEATE 2.5MG TABLET |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ENALAPRIL MALEATE 20MG TABLET (1000 CT) |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ENALAPRIL MALEATE TABLETS 5MG |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ENALAPRIL MALEATE-HCTZ 10MG-25MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ENBREL 50MG/ML SURECLICK SYR |
4 |
Tier 4 Specialty Drugs |
25% | N/A | P Q:8 /28Days |
ENBREL INJECTION 50MG/ML SYR |
4 |
Tier 4 Specialty Drugs |
25% | N/A | P Q:8 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENBREL INJECTION KIT 25MG 1 DOSE TRAY PKGCOM |
4 |
Tier 4 Specialty Drugs |
25% | N/A | P Q:8 /28Days |
ENDOCET 10/650MG TABLET |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | Q:180 /30Days |
ENDOCET 10MG-325MG TABLET |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | Q:360 /30Days |
ENDOCET 5/325 TABLET |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | Q:360 /30Days |
ENDOCET 7.5-325MG TABLET |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | Q:360 /30Days |
ENDOCET 7.5/500MG TABLET |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | Q:240 /30Days |
ENDODAN TABLETS 325;4.8355MG;MG 100 BOT |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ENGERIX-B 10MCG 10 X 0.5ML VIALSD |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | P |
ENGERIX-B 10MCG/0.5ML SYRN |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | P |
ENGERIX-B 20MCG/ML SYRINGE |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | P |
ENPRESSE-28 TABLET |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | Q:28 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENTOCORT EC 3MG CAPSULE |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | None |
ENULOSE SYRUP 10GM/15ML 1 PINT BOTPL |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
EPINEPHRINE 0.1MG/ML ABBJCT |
3 |
Tier 3 Non-Specialty Injectable Drugs |
25% | 25% | None |
EPIPEN 0.3MG AUTO-INJECTOR |
3 |
Tier 3 Non-Specialty Injectable Drugs |
25% | 25% | Q:2 /1Days |
EPIPEN JR 0.15MG AUTO-INJCT |
3 |
Tier 3 Non-Specialty Injectable Drugs |
25% | 25% | Q:2 /1Days |
EPIRUBICIN HCL INJECTION SOLUTION 2MG 1 X 25ML VIAL |
3 |
Tier 3 Non-Specialty Injectable Drugs |
25% | 25% | None |
EPITOL 200MG TABLET |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
EPIVIR 10MG/ML ORAL SOLUTION |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | None |
EPIVIR 150MG TABLET |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | None |
EPIVIR 300MG TABLET |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | None |
EPIVIR HBV 100MG TABLET |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPIVIR HBV 25MG/5ML TUBEX |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | None |
EPLERENONE 25MG TABS |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | Q:45 /30Days |
EPLERENONE 50MG TABS |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | Q:60 /30Days |
EPOGEN 10000U/ML VIAL MDV |
4 |
Tier 4 Specialty Drugs |
25% | N/A | P |
EPOGEN 2000U/ML VIAL SDV |
3 |
Tier 3 Non-Specialty Injectable Drugs |
25% | 25% | P |
EPOGEN 3000U/ML VIAL SDV |
3 |
Tier 3 Non-Specialty Injectable Drugs |
25% | 25% | P |
EPOGEN 4000U/ML VIAL SDV |
3 |
Tier 3 Non-Specialty Injectable Drugs |
25% | 25% | P |
EPOGEN INJECTION 20000U 10 X 1ML CRTN |
4 |
Tier 4 Specialty Drugs |
25% | N/A | P |
EPOGEN INJECTION 40000U 10 X 4ML VIALS VIALSD |
4 |
Tier 4 Specialty Drugs |
25% | N/A | P |
EPZICOM TABLET |
4 |
Tier 4 Specialty Drugs |
25% | N/A | None |
EQUETRO CAPSULES 200MG 120 BOT |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EQUETRO CAPSULES 300MG 120 BOT |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | Q:180 /30Days |
EQUETRO EXTENDED RELEASE CAPSULES 100MG 120 BOT |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | Q:240 /30Days |
ERBITUX 100MG/50ML VIAL |
4 |
Tier 4 Specialty Drugs |
25% | N/A | P |
ERGOLOID MESYLATES TABLETS 1MG 100 BOT |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ERGOTAMINE-CAFFEINE 1-100MG TABLET |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ERRIN 0.35MG TABLET |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | Q:28 /28Days |
ERY 2% PADS 2% 60 PADS JAR |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ERYTHROCIN 500MG ADDVNT VL |
3 |
Tier 3 Non-Specialty Injectable Drugs |
25% | 25% | None |
ERYTHROCIN 500MG FILMTAB |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ERYTHROCIN STEARATE TABLETS 250MG 100 BOT |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ERYTHROMYCIN 2% SOLUTION |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROMYCIN 250MG 100 BOT |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ERYTHROMYCIN 500MG FILMTAB |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ERYTHROMYCIN ETHYLSUCCINATE AND SULFISOXAZOLE ACETYL POWDER FOR ORAL SUSPENSION 200;600MG/5ML;MG/ 10 |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ERYTHROMYCIN GEL TOPICAL USP 2% 60 GM TUBE |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ERYTHROMYCIN OPHTHALMIC OINTMENT 0.5% 1 G BOX OF 50 TUBE |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ERYTHROMYCIN-BENZOYL PEROXIDE 3-5% GEL |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ESTRADIOL .025MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | Q:4 /28Days |
ESTRADIOL .0375MG/24 PATCH TRANSDERMAL WEEKLY |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | Q:4 /28Days |
ESTRADIOL .075MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | Q:4 /28Days |
ESTRADIOL 0.05MG/DAY PATCH |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | Q:4 /28Days |
ESTRADIOL 0.06MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | 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 Drugs |
$6.50 | $9.75 | Q:4 /28Days |
ESTRADIOL 0.5MG TABLET |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ESTRADIOL 2MG TABLET |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ESTRADIOL TABLET 1MG (500 CT) |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ESTRADIOL VALERATE INJECTION |
3 |
Tier 3 Non-Specialty Injectable Drugs |
25% | 25% | None |
ESTRADIOL VALERATE INJECTION |
3 |
Tier 3 Non-Specialty Injectable Drugs |
25% | 25% | None |
ESTRADIOL VALERATE INJECTION |
3 |
Tier 3 Non-Specialty Injectable Drugs |
25% | 25% | None |
ESTRADIOL-NORETH 1.0-0.5MG TABLET |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ESTROPIPATE 0.625 TABLET |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ESTROPIPATE 1.25 TABLET |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ESTROPIPATE 2.5 TABLET |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | 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 Drugs |
$6.50 | $9.75 | None |
ETHAMBUTOL HCL 400MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ETHOSUXIMIDE 250MG CAPSULE |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ETHOSUXIMIDE 250MG/5ML SYRP |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ETHYOL POWDER FOR INJECTION 500MG 3 X 10ML VILSU CRTN |
4 |
Tier 4 Specialty Drugs |
25% | N/A | None |
ETIDRONATE DISODIUM 400MG TABLET (60 CT) |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ETODOLAC 200MG CAPSULE |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ETODOLAC 300MG CAPSULE |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ETODOLAC 400MG TABLET (500 CT) |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ETODOLAC 400MG TABLET SR 24HR |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | 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 Drugs |
$6.50 | $9.75 | None |
ETODOLAC 500MG TABLET SR 24HR |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ETODOLAC 600MG TABLET SR 24HR |
1 |
Tier 1 Preferred Generic Drugs |
$6.50 | $9.75 | None |
ETOPOPHOS 100MG VIAL |
3 |
Tier 3 Non-Specialty Injectable Drugs |
25% | 25% | None |
ETOPOSIDE INJECTION 20MG 25ML VIALMD |
3 |
Tier 3 Non-Specialty Injectable Drugs |
25% | 25% | None |
EVISTA TABLETS 60MG |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | Q:30 /30Days |
EXELON 1.5MG CAPSULE |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | Q:60 /30Days |
EXELON 2MG/ML ORAL SOLUTION |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | Q:180 /30Days |
EXELON 3MG CAPSULE |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | Q:60 /30Days |
EXELON 4.5MG CAPSULE |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | Q:60 /30Days |
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | 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 Certain Generic Drugs |
25% | 25% | Q:60 /30Days |
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | Q:30 /30Days |
EXFORGE 10MG-160MG TABLET |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | None |
EXFORGE 10MG-320MG TABLET |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | None |
EXFORGE 5MG-160MG TABLET |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | None |
EXFORGE 5MG-320MG TABLET |
2 |
Tier 2 Preferred Brand Certain Generic Drugs |
25% | 25% | None |
EXJADE 125MG TABLET |
4 |
Tier 4 Specialty Drugs |
25% | N/A | None |
EXJADE 250MG TABLET |
4 |
Tier 4 Specialty Drugs |
25% | N/A | None |
EXJADE 500MG TABLET |
4 |
Tier 4 Specialty Drugs |
25% | N/A | None |