2011 Medicare Part D Plan Formulary Information |
Community CCRx Choice (PDP) (S5803-162-0)
Benefit Details
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The Community CCRx Choice (PDP) (S5803-162-0) Formulary Drugs Starting with the Letter E in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
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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 |
E.E.S. 200MG/5ML GRANULES |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
ECONAZOLE NITRATE 1% CREAM 85GM TUBE |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ED K+10 TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
EDECRIN 25MG TABLET (100 CT) |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | None |
EES 400 TABLET 400MG 100 BOT |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
EFFEXOR 37.5MG CAPSULE ER (90 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:30 /30Days |
EFFEXOR XR 150MG CAPSULE ER 15 CAPSULES BOT |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:60 /30Days |
EFFEXOR XR 75MG CAPSULE ER 15 CAPSULES BOT |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:30 /30Days |
ELIDEL 1% CREAM |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | Q:60 /30Days |
ELITEK 1.5MG VIAL |
4 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIXOPHYLLIN 80MG/15ML ELIX |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
ELMIRON CAPSULES 100MG |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | None |
EMBEDA 20-0.8 MG CAPSULE |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:60 /30Days |
EMBEDA 30-1.2 MG CAPSULE |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:60 /30Days |
EMBEDA 50-2 MG CAPSULE |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:60 /30Days |
EMBEDA CAPSULES EXTENDED RELEASE |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:360 /30Days |
EMBEDA CAPSULES EXTENDED RELEASE |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:60 /30Days |
EMBEDA CAPSULES EXTENDED RELEASE |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:60 /30Days |
EMCYT 140MG CAPSULE |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
EMEND CAPSULES 125MG 6 BLPK |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | P Q:6 /30Days |
EMEND CAPSULES 80MG 2 BLPK |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | P Q:6 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMEND TRIFOLD PACK |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | P Q:6 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | P Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | P Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | P Q:30 /30Days |
EMTRIVA 10MG/ML SOLUTION |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | None |
EMTRIVA 200MG CAPSULE |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | None |
ENABLEX 15MG TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:30 /30Days |
ENABLEX 7.5MG TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:30 /30Days |
ENALAPRIL MALEATE 10MG TABLET (100 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ENALAPRIL MALEATE 2.5MG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ENALAPRIL MALEATE 20MG TABLET (1000 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENALAPRIL MALEATE TABLETS 5MG |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ENALAPRIL MALEATE-HCTZ 10MG-25MG TABLET (100 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET (100 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ENBREL 25 MG/0.5 ML SYRINGE |
4 |
Specialty Tier |
33% | N/A | P Q:4 /28Days |
ENBREL 25MG KIT |
4 |
Specialty Tier |
33% | N/A | P Q:16 /28Days |
ENBREL INJECTION 50MG/ML SYR |
4 |
Specialty Tier |
33% | N/A | P Q:8 /28Days |
ENDOCET 10/650MG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:180 /30Days |
ENDOCET 10MG-325MG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:360 /30Days |
ENDOCET 5/325 TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:360 /30Days |
ENDOCET 7.5-325MG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:360 /30Days |
ENDOCET 7.5/500MG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENDODAN TABLETS 325;4.8355MG;MG 100 BOT |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:360 /30Days |
ENGERIX B INJECTION |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | P |
ENGERIX B INJECTION 20MCG/ML |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | P |
ENGERIX-B 10MCG 10 X 0.5ML VIALSD |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | P |
ENOXAPARIN SODIUM INJECTION |
4 |
Specialty Tier |
33% | N/A | Q:24 /30Days |
ENOXAPARIN SODIUM INJECTION |
4 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
ENOXAPARIN SODIUM INJECTION |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | Q:9 /30Days |
ENOXAPARIN SODIUM INJECTION |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | Q:12 /30Days |
ENOXAPARIN SODIUM INJECTION |
4 |
Specialty Tier |
33% | N/A | Q:18 /30Days |
ENOXAPARIN SODIUM INJECTION |
4 |
Specialty Tier |
33% | N/A | Q:24 /30Days |
ENOXAPARIN SODIUM INJECTION |
4 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENTOCORT EC 3MG CAPSULE |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | S |
ENULOSE SYRUP 10GM/15ML 1 PINT BOTPL |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
EPINEPHRINE 0.1MG/ML ABBJCT |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
EPIPEN 0.3MG AUTO-INJECTOR |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | Q:2 /30Days |
EPIPEN JR 0.15MG AUTO-INJCT |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | Q:2 /30Days |
EPITOL 200MG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
EPIVIR 300MG TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
EPIVIR HBV 100MG TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
EPIVIR HBV 25MG/5ML TUBEX |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
EPIVIR ORAL SOLUTION |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
EPIVIR TABLETS |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPZICOM TABLETS |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
EQUETRO CAPSULES 200MG 120 BOT |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | None |
EQUETRO CAPSULES 300MG 120 BOT |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | None |
EQUETRO EXTENDED RELEASE CAPSULES 100MG 120 BOT |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | None |
ERGOMAR SUBLINGUAL TABLET 2MG |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
ERRIN 0.35MG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:28 /28Days |
ERY 2% PADS 2% 60 PADS JAR |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ERY DELAYED RELEASE TABLETS 250MG 100 BOT |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ERY TAB TABLETS 333MG 100 BOT |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ERY-TAB 500MG TABLET EC |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ERYTHROCIN 500MG ADDVNT VL |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROCIN 500MG FILMTAB |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ERYTHROCIN STEARATE TABLETS 250MG 100 BOT |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ERYTHROMYCIN 2% SOLUTION |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ERYTHROMYCIN 250MG 100 BOT |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ERYTHROMYCIN 500MG FILMTAB |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ERYTHROMYCIN ETHYLSUCCINATE AND SULFISOXAZOLE ACETYL POWDER FOR ORAL SUSPENSION 200;600MG/5ML;MG/ 10 |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ERYTHROMYCIN GEL TOPICAL USP 2% 60 GM TUBE |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ERYTHROMYCIN OPHTHALMIC OINTMENT 0.5% 1 G BOX OF 50 TUBE |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ESTRACE VAG CREAM 0.1MG/GM |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | None |
ESTRADERM 0.05MG/24H PATCH TRANSDERMAL SEMIWEEKLY |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | Q:8 /28Days |
ESTRADERM 0.1MG/24HR PATCH TRANSDERMAL SEMIWEEKLY |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | Q:8 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL .025MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:4 /28Days |
ESTRADIOL .0375MG/24 PATCH TRANSDERMAL WEEKLY |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:4 /28Days |
ESTRADIOL .075MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:4 /28Days |
ESTRADIOL 0.05MG/DAY PATCH |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:4 /28Days |
ESTRADIOL 0.06MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:4 /28Days |
ESTRADIOL 0.1MG/DAY PATCH |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:4 /28Days |
ESTRADIOL 0.5MG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ESTRADIOL 2MG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ESTRADIOL TABLET 1MG (500 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ESTRADIOL VALERATE INJECTION |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ESTRADIOL VALERATE INJECTION |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL VALERATE INJECTION |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ESTROPIPATE 0.625 TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ESTROPIPATE 1.25 TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ESTROPIPATE 2.5 TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ETHAMBUTOL HCL 100MG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ETHAMBUTOL HCL 400MG TABLET (100 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:28 /28Days |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21 |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:28 /28Days |
ETHOSUXIMIDE 250MG CAPSULE |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ETHOSUXIMIDE 250MG/5ML SYRP |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ETODOLAC 200MG CAPSULE |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETODOLAC 300MG CAPSULE |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ETODOLAC 400MG TABLET (500 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ETODOLAC 400MG TABLET SR 24HR |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ETODOLAC 500MG TABLET (100 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ETODOLAC 500MG TABLET SR 24HR |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
ETODOLAC 600MG TABLET SR 24HR |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
EURAX 10% CREAM 60GM |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
EURAX 10% LOTION 454ML |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
EXELON 2MG/ML ORAL SOLUTION |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | Q:180 /30Days |
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | Q:30 /30Days |
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EXFORGE 10MG-160MG TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:30 /30Days |
EXFORGE 10MG-320MG TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:30 /30Days |
EXFORGE 5MG-160MG TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:30 /30Days |
EXFORGE 5MG-320MG TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:30 /30Days |
EXJADE 125MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
EXJADE 250MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
EXJADE 500MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
EXTENDED PHENYTOIN SODIUM CAPSULES 300 MG |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |