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WellCare Signature (PDP) (S5967-042-0)
Tier 1 (1636)
Tier 2 (356)
Tier 3 (285)
Tier 4 (186)

Requires Prior Authorization:
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2011 Medicare Part D Plan Formulary Information
WellCare Signature (PDP) (S5967-042-0)
Benefit Details           
The WellCare Signature (PDP) (S5967-042-0)
Formulary Drugs Starting with the Letter E

in CMS PDP Region 8 which includes: NC
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 Generic $0.00$0.00None
EES 400 TABLET 400MG 100 BOT   1 Generic $0.00$0.00None
EGG YOLK PHOSPHOLIPIDS 12 MG/ML / GLYCERIN 25 MG/ML / SAFFLOWER OIL 100 MG/ML / SOYBEAN OIL 100 MG/M   2 Preferred Brand $38.00$95.00None
EGG YOLK PHOSPHOLIPIDS 12 MG/ML / GLYCERIN 25 MG/ML / SOYBEAN OIL 100 MG/ML INJECTABLE SUSPENSION [L   2 Preferred Brand $38.00$95.00None
EGG YOLK PHOSPHOLIPIDS 12 MG/ML / GLYCERIN 25 MG/ML / SOYBEAN OIL 200 MG/ML INJECTABLE SUSPENSION [L   2 Preferred Brand $38.00$95.00None
ELAPRASE 6MG/3ML VIAL   4 Specialty Tier 33%N/AP
ELIPHOS TABLETS CALCIUM ACETATE TABLETS 667MG 200 BOT   1 Generic $0.00$0.00None
ELITEK 1.5MG VIAL   4 Specialty Tier 33%N/AP
EMCYT 140MG CAPSULE   3 Non-Preferred Brand $70.00$175.00P
EMEND 40MG CAPSULE   3 Non-Preferred Brand $70.00$175.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
EMEND CAPSULES 125MG 6 BLPK   3 Non-Preferred Brand $70.00$175.00P
EMEND CAPSULES 80MG 2 BLPK   3 Non-Preferred Brand $70.00$175.00P
EMEND TRIFOLD PACK   3 Non-Preferred Brand $70.00$175.00P
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H   3 Non-Preferred Brand $70.00$175.00P
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H   3 Non-Preferred Brand $70.00$175.00P
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H   3 Non-Preferred Brand $70.00$175.00P
EMTRIVA 10MG/ML SOLUTION   2 Preferred Brand $38.00$95.00None
EMTRIVA 200MG CAPSULE   2 Preferred Brand $38.00$95.00None
ENABLEX 15MG TABLET   2 Preferred Brand $38.00$95.00None
ENABLEX 7.5MG TABLET   2 Preferred Brand $38.00$95.00None
ENALAPRIL MALEATE 10MG TABLET (100 CT)   1 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ENALAPRIL MALEATE 2.5MG TABLET   1 Generic $0.00$0.00None
ENALAPRIL MALEATE 20MG TABLET (1000 CT)   1 Generic $0.00$0.00None
ENALAPRIL MALEATE TABLETS 5MG   1 Generic $0.00$0.00None
ENALAPRIL MALEATE-HCTZ 10MG-25MG TABLET (100 CT)   1 Generic $0.00$0.00None
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET (100 CT)   1 Generic $0.00$0.00None
ENDOCET 10/650MG TABLET   1 Generic $0.00$0.00Q:248
/31Days
ENDOCET 10MG-325MG TABLET   1 Generic $0.00$0.00Q:248
/31Days
ENDOCET 5/325 TABLET   1 Generic $0.00$0.00Q:248
/31Days
ENDOCET 7.5-325MG TABLET   1 Generic $0.00$0.00Q:248
/31Days
ENDOCET 7.5/500MG TABLET   1 Generic $0.00$0.00Q:248
/31Days
ENGERIX B INJECTION   2 Preferred Brand $38.00$95.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ENGERIX B INJECTION 20MCG/ML   2 Preferred Brand $38.00$95.00P
ENGERIX-B 10MCG 10 X 0.5ML VIALSD   2 Preferred Brand $38.00$95.00P
ENJUVIA 0.3MG TABLET   2 Preferred Brand $38.00$95.00None
ENJUVIA 0.45MG TABLET   2 Preferred Brand $38.00$95.00None
ENJUVIA 0.625MG TABLET   2 Preferred Brand $38.00$95.00None
ENJUVIA 0.9MG TABLET   2 Preferred Brand $38.00$95.00None
ENJUVIA 1.25MG TABLET   2 Preferred Brand $38.00$95.00None
ENOXAPARIN SODIUM INJECTION   1 Generic $0.00$0.00Q:22
/31Days
ENOXAPARIN SODIUM INJECTION   1 Generic $0.00$0.00Q:28
/31Days
ENOXAPARIN SODIUM INJECTION   1 Generic $0.00$0.00Q:8
/31Days
ENOXAPARIN SODIUM INJECTION   1 Generic $0.00$0.00Q:8
/31Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ENOXAPARIN SODIUM INJECTION   1 Generic $0.00$0.00Q:17
/31Days
ENOXAPARIN SODIUM INJECTION   1 Generic $0.00$0.00Q:22
/31Days
ENOXAPARIN SODIUM INJECTION   1 Generic $0.00$0.00Q:28
/31Days
ENTOCORT EC 3MG CAPSULE   3 Non-Preferred Brand $70.00$175.00None
ENULOSE SYRUP 10GM/15ML 1 PINT BOTPL   1 Generic $0.00$0.00None
EPIPEN 0.3MG AUTO-INJECTOR   2 Preferred Brand $38.00$95.00None
EPITOL 200MG TABLET   1 Generic $0.00$0.00None
EPIVIR 300MG TABLET   3 Non-Preferred Brand $70.00$175.00None
EPIVIR HBV 100MG TABLET   3 Non-Preferred Brand $70.00$175.00None
EPIVIR HBV 25MG/5ML TUBEX   3 Non-Preferred Brand $70.00$175.00None
EPIVIR ORAL SOLUTION   3 Non-Preferred Brand $70.00$175.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
EPIVIR TABLETS   3 Non-Preferred Brand $70.00$175.00None
EPZICOM TABLETS   2 Preferred Brand $38.00$95.00None
ERGOLOID MESYLATES TABLETS 1MG 100 BOT   1 Generic $0.00$0.00None
ERGOTAMINE-CAFFEINE 1-100MG TABLET   1 Generic $0.00$0.00None
ERRIN 0.35MG TABLET   1 Generic $0.00$0.00None
ERY DELAYED RELEASE TABLETS 250MG 100 BOT   1 Generic $0.00$0.00None
ERY TAB TABLETS 333MG 100 BOT   1 Generic $0.00$0.00None
ERY-TAB 500MG TABLET EC   1 Generic $0.00$0.00None
ERYTHROCIN 500MG ADDVNT VL   1 Generic $0.00$0.00None
ERYTHROCIN 500MG FILMTAB   1 Generic $0.00$0.00None
ERYTHROCIN STEARATE TABLETS 250MG 100 BOT   1 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ERYTHROMYCIN 2% SOLUTION   1 Generic $0.00$0.00None
ERYTHROMYCIN 250MG 100 BOT   1 Generic $0.00$0.00None
ERYTHROMYCIN 500MG FILMTAB   1 Generic $0.00$0.00None
ERYTHROMYCIN ETHYLSUCCINATE AND SULFISOXAZOLE ACETYL POWDER FOR ORAL SUSPENSION 200;600MG/5ML;MG/ 10   1 Generic $0.00$0.00None
ERYTHROMYCIN GEL TOPICAL USP 2% 60 GM TUBE   1 Generic $0.00$0.00None
ERYTHROMYCIN OPHTHALMIC OINTMENT 0.5% 1 G BOX OF 50 TUBE   1 Generic $0.00$0.00None
ERYTHROMYCIN-BENZOYL PEROXIDE 3-5% GEL   1 Generic $0.00$0.00None
ESTRACE 0.5MG TABLET   2 Preferred Brand $38.00$95.00None
ESTRACE 2MG TABLET   2 Preferred Brand $38.00$95.00None
ESTRACE TABLET 1MG (100 CT)   2 Preferred Brand $38.00$95.00None
ESTRACE VAG CREAM 0.1MG/GM   3 Non-Preferred Brand $70.00$175.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ESTRADERM 0.05MG/24H PATCH TRANSDERMAL SEMIWEEKLY   2 Preferred Brand $38.00$95.00None
ESTRADERM 0.1MG/24HR PATCH TRANSDERMAL SEMIWEEKLY   2 Preferred Brand $38.00$95.00None
ESTRADIOL .025MG/24H PATCH TRANSDERMAL WEEKLY   1 Generic $0.00$0.00None
ESTRADIOL .0375MG/24 PATCH TRANSDERMAL WEEKLY   1 Generic $0.00$0.00None
ESTRADIOL .075MG/24H PATCH TRANSDERMAL WEEKLY   1 Generic $0.00$0.00None
ESTRADIOL 0.05MG/DAY PATCH   1 Generic $0.00$0.00None
ESTRADIOL 0.06MG/24H PATCH TRANSDERMAL WEEKLY   1 Generic $0.00$0.00None
ESTRADIOL 0.1MG/DAY PATCH   1 Generic $0.00$0.00None
ESTRADIOL 0.5MG TABLET   1 Generic $0.00$0.00None
ESTRADIOL 2MG TABLET   1 Generic $0.00$0.00None
ESTRADIOL TABLET 1MG (500 CT)   1 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ESTROPIPATE 0.625 TABLET   1 Generic $0.00$0.00None
ESTROPIPATE 1.25 TABLET   1 Generic $0.00$0.00None
ESTROPIPATE 2.5 TABLET   1 Generic $0.00$0.00None
ETHAMBUTOL HCL 100MG TABLET   1 Generic $0.00$0.00None
ETHAMBUTOL HCL 400MG TABLET (100 CT)   1 Generic $0.00$0.00None
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6   1 Generic $0.00$0.00None
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21   1 Generic $0.00$0.00None
ETHOSUXIMIDE 250MG CAPSULE   1 Generic $0.00$0.00None
ETHOSUXIMIDE 250MG/5ML SYRP   1 Generic $0.00$0.00None
ETIDRONATE DISODIUM 400MG TABLET (60 CT)   1 Generic $0.00$0.00None
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT   1 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ETODOLAC 200MG CAPSULE   1 Generic $0.00$0.00None
ETODOLAC 300MG CAPSULE   1 Generic $0.00$0.00None
ETODOLAC 400MG TABLET (500 CT)   1 Generic $0.00$0.00None
ETODOLAC 400MG TABLET SR 24HR   1 Generic $0.00$0.00None
ETODOLAC 500MG TABLET (100 CT)   1 Generic $0.00$0.00None
ETODOLAC 500MG TABLET SR 24HR   1 Generic $0.00$0.00None
ETODOLAC 600MG TABLET SR 24HR   1 Generic $0.00$0.00None
EURAX 10% CREAM 60GM   3 Non-Preferred Brand $70.00$175.00None
EURAX 10% LOTION 454ML   3 Non-Preferred Brand $70.00$175.00None
EXELON 1.5MG CAPSULE   2 Preferred Brand $38.00$95.00None
EXELON 2MG/ML ORAL SOLUTION   2 Preferred Brand $38.00$95.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
EXELON 3MG CAPSULE   2 Preferred Brand $38.00$95.00None
EXELON 4.5MG CAPSULE   2 Preferred Brand $38.00$95.00None
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS   2 Preferred Brand $38.00$95.00None
EXELON 6MG CAPSULE   2 Preferred Brand $38.00$95.00None
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS   2 Preferred Brand $38.00$95.00None
EXJADE 125MG TABLET   4 Specialty Tier 33%N/AP
EXJADE 250MG TABLET   4 Specialty Tier 33%N/AP
EXJADE 500MG TABLET   4 Specialty Tier 33%N/AP
EXTENDED PHENYTOIN SODIUM CAPSULES 300 MG   1 Generic $0.00$0.00None

Chart Legend:

Below are a few notes to help you understand the above 2011 Medicare Part D WellCare Signature (PDP) 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 $310 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 intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $(2840)) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, on the 2011 Humana Walmart-Preferred Rx Plan the pricing 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 2011 )

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.







Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.