2012 Medicare Part D Plan Formulary Information |
WellCare Signature (PDP) (S5967-064-0)
Benefit Details
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The WellCare Signature (PDP) (S5967-064-0) Formulary Drugs Starting with the Letter E in CMS PDP Region 30 which includes: OR WA
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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. GRAN SUS 200/5ML |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
ECONAZOLE NITRATE 1% CREAM 85GM TUBE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
EDURANT 27.5mg/1 |
5 |
Specialty Tier Drugs |
33% | N/A | Q:31 /31Days |
EES 400 TABLET 400MG 100 BOT |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
EGG YOLK PHOSPHOLIPIDS 12 MG/ML / GLYCERIN 25 MG/ML / SAFFLOWER OIL 100 MG/ML / SOYBEAN OIL 100 MG/M |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
ELAPRASE 6mg/3mL 1 VIAL, GLASS in 1 BOX / 3 mL in 1 VIAL, GLASS |
5 |
Specialty Tier Drugs |
33% | N/A | P |
ELIGARD 1 KIT in 1 CARTON |
4 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | P |
ELIGARD 1 KIT in 1 CARTON |
4 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | P |
ELIGARD 1 KIT in 1 CARTON |
4 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | P |
ELIGARD 1 KIT in 1 CARTON |
5 |
Specialty Tier Drugs |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIPHOS TABLETS CALCIUM ACETATE TABLETS 667MG 200 BOT |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
Elitek 3 KIT in 1 CARTON / 1 KIT in 1 KIT |
5 |
Specialty Tier Drugs |
33% | N/A | P |
EMCYT 140MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | P |
EMEND 40MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | P |
EMEND CAPSULES 125MG 6 BLPK |
4 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | P |
EMEND CAPSULES 80MG 2 BLPK |
4 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | P |
EMEND TRIFOLD PACK |
4 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | P |
Emoquette 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
4 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | P |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
4 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | P |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
4 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMTRIVA 10MG/ML SOLUTION |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
EMTRIVA 200MG CAPSULE |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
ENALAPRIL MALEATE 10MG TABLET (100 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Enalapril Maleate 2.5mg/1 100 TABLET in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Enalapril Maleate 20mg/1 500 TABLET in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Enalapril Maleate 5mg/1 1000 TABLET in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE-HCTZ 10MG-25MG TABLET (100 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET (100 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ENBREL 25 MG/0.5 ML SYRINGE |
5 |
Specialty Tier Drugs |
33% | N/A | P |
ENBREL 25MG KIT |
5 |
Specialty Tier Drugs |
33% | N/A | P |
ENBREL 50mg/mL |
5 |
Specialty Tier Drugs |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENDOCET 10/650MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | Q:186 /31Days |
ENDOCET 10MG-325MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | Q:248 /31Days |
ENDOCET 5/325 TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | Q:248 /31Days |
ENDOCET 7.5-325MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | Q:248 /31Days |
ENDOCET 7.5/500MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | Q:248 /31Days |
ENGERIX B INJECTION |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | P |
ENGERIX B INJECTION 20MCG/ML |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | P |
ENGERIX-B 10MCG 10 X 0.5ML VIALSD |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | P |
ENOXAPARIN SODIUM INJECTION |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | Q:22 /31Days |
ENOXAPARIN SODIUM INJECTION |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | Q:28 /31Days |
ENOXAPARIN SODIUM INJECTION |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | Q:8 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENOXAPARIN SODIUM INJECTION |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | Q:8 /31Days |
ENOXAPARIN SODIUM INJECTION |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | Q:17 /31Days |
ENOXAPARIN SODIUM INJECTION |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | Q:22 /31Days |
ENOXAPARIN SODIUM INJECTION |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | Q:28 /31Days |
ENTOCORT EC 3MG CAPSULE |
4 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | None |
ENULOSE SYRUP 10GM/15ML 1 PINT BOTPL |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
EPIPEN 0.3MG AUTO-INJECTOR |
4 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | None |
EPITOL 200MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
EPIVIR 300mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | None |
EPIVIR HBV 100MG TABLET |
4 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | None |
EPIVIR HBV 25MG/5ML TUBEX |
4 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPIVIR ORAL SOLUTION |
4 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | None |
EPIVIR TABLETS |
4 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | None |
EPZICOM TABLETS |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
ERGOLOID MESYLATES TABLETS 1MG 100 BOT |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
ERGOTAMINE-CAFFEINE TABLET 100 CT Bottle |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ERIVEDGE 150 MG CAPSULE |
5 |
Specialty Tier Drugs |
33% | N/A | P Q:31 /31Days |
ERRIN 0.35MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ERY-TAB TAB 250MG EC |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ERY-TAB TAB 333MG EC |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ERYTHROCIN 500MG ADDVNT VL |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROCIN TAB 250MG |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ERYTHROMYCIN 2% SOLUTION |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Erythromycin 20mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ERYTHROMYCIN 500 MG FILMTAB |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ERYTHROMYCIN ETHYLSUCCINATE AND SULFISOXAZOLE ACETYL POWDER FOR ORAL SUSPENSION 200;600MG/5ML;MG/ 10 |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ERYTHROMYCIN ETHYLSUCCINATE TABLETS 400 MG 100 BOT |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ERYTHROMYCIN OPHTHALMIC OINTMENT 0.5% 1 G BOX OF 50 TUBE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ERYTHROMYCIN TAB 250MG BS |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ERYTHROMYCIN-BENZOYL PEROXIDE 3-5% GEL |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ESCITALOPRAM 10 MG TABLET |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | Q:31 /31Days |
ESCITALOPRAM 20 MG TABLET |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | Q:31 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESCITALOPRAM 5 MG TABLET |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | Q:31 /31Days |
ESCITALOPRAM OXALATE 5 MG/5 ML |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
ESTRACE VAG CREAM 0.1MG/GM |
4 |
Non-Preferred Brand Drugs |
$95.00 | $237.50 | None |
ESTRADERM 0.05MG/24H PATCH TRANSDERMAL SEMIWEEKLY |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
ESTRADERM 0.1MG/24HR PATCH TRANSDERMAL SEMIWEEKLY |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
ESTRADIOL .025MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ESTRADIOL .0375MG/24 PATCH TRANSDERMAL WEEKLY |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ESTRADIOL .075MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ESTRADIOL 0.05MG/DAY PATCH |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ESTRADIOL 0.06MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ESTRADIOL 0.1MG/DAY PATCH |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL 0.5MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ESTRADIOL 2MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ESTRADIOL TABLET 1MG (500 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ESTROPIPATE 0.625 TABLET |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
ESTROPIPATE 1.25 TABLET |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
ESTROPIPATE 2.5 TABLET |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
ETHAMBUTOL HCL 400MG TABLET (100 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Ethambutol Hydrochloride 100mg/1 |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21 |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Ethosuximide 250mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETHOSUXIMIDE 250MG/5ML SYRP |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ETIDRONATE DISODIUM 400MG TABLET (60 CT) |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
ETODOLAC 200MG CAPSULE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ETODOLAC 300 MG CAPSULE |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ETODOLAC 400MG TABLET (500 CT) |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ETODOLAC 400MG TABLET SR 24HR |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ETODOLAC 500MG TABLET SR 24HR |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ETODOLAC 500mg/1 |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
ETODOLAC 600MG TABLET SR 24HR |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |
Evista 60mg/1 100 TABLET in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | Q:31 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EXELON 2MG/ML ORAL SOLUTION |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS |
3 |
Preferred Brand Drugs |
$45.00 | $112.50 | None |
Exemestane 25mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$20.00 | $50.00 | None |
EXJADE 125MG TABLET |
5 |
Specialty Tier Drugs |
33% | N/A | P |
EXJADE 250MG TABLET |
5 |
Specialty Tier Drugs |
33% | N/A | P |
EXJADE 500MG TABLET |
5 |
Specialty Tier Drugs |
33% | N/A | P |
EXTAVIA 15 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
5 |
Specialty Tier Drugs |
33% | N/A | P |
EXTENDED PHENYTOIN SODIUM CAPSULES 300 MG |
1 |
Preferred Generic Drugs |
$0.00 | $0.00 | None |