2012 Medicare Part D Plan Formulary Information |
PICA Alante (PDP) (S5775-002-0)
Benefit Details
|
The PICA Alante (PDP) (S5775-002-0) Formulary Drugs Starting with the Letter E in CMS PDP Region 38 which includes: PR
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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 |
EDURANT 27.5mg/1 |
4 |
Specialty Tier Drugs |
27% | 27% | None |
EES 400 TABLET 400MG 100 BOT |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
EFFEXOR 37.5MG CAPSULE ER (90 CT) |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
EFFEXOR XR 150MG CAPSULE ER 15 CAPSULES BOT |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
EFFEXOR XR 75MG CAPSULE ER 15 CAPSULES BOT |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
Effient 10mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
Effient 5mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
EFUDEX 5% CREAM |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
Egrifta 1 KIT in 1 CARTON |
4 |
Specialty Tier Drugs |
27% | 27% | P |
ELDEPRYL 5 MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELIDEL 1% CREAM |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
ELIGARD 1 KIT in 1 CARTON |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
ELIGARD 1 KIT in 1 CARTON |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
ELIGARD 1 KIT in 1 CARTON |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
ELIGARD 1 KIT in 1 CARTON |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
Elitek 3 KIT in 1 CARTON / 1 KIT in 1 KIT |
4 |
Specialty Tier Drugs |
27% | 27% | P |
ELIXOPHYLLIN 80mg/15mL 473 mL in 1 BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ELMIRON 100mg/1 100 CAPSULE, GELATIN COATED in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
ELOCON 0.1% CREAM |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
ELOCON 0.1% LOTION |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
ELOCON 0.1% OINTMENT |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMCYT 140MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
EMEND CAPSULES 125MG 6 BLPK |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | P Q:1 /1Days |
EMEND CAPSULES 80MG 2 BLPK |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | P Q:2 /2Days |
EMEND TRIFOLD PACK |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | P Q:3 /3Days |
EMLA CREAM 2.5%/2.5% 30 GM TUBE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
EMTRIVA 10MG/ML SOLUTION |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
EMTRIVA 200MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
ENABLEX 15MG TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Enablex 7.5mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
ENALAPRIL MALEATE 10MG TABLET (100 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Enalapril Maleate 2.5mg/1 100 TABLET in 1 BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Enalapril Maleate 20mg/1 500 TABLET in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Enalapril Maleate 5mg/1 1000 TABLET in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ENALAPRIL MALEATE-HCTZ 10MG-25MG TABLET (100 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET (100 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ENBREL 25 MG/0.5 ML SYRINGE |
4 |
Specialty Tier Drugs |
27% | 27% | P Q:9 /30Days |
ENBREL 25MG KIT |
4 |
Specialty Tier Drugs |
27% | 27% | P |
ENBREL 50mg/mL |
4 |
Specialty Tier Drugs |
27% | 27% | P |
ENDOCET 10/650MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENDOCET 10MG-325MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ENDOCET 5/325 TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ENDOCET 7.5-325MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ENDOCET 7.5/500MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ENGERIX B INJECTION |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
ENGERIX B INJECTION 20MCG/ML |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
ENGERIX-B 10MCG 10 X 0.5ML VIALSD |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
ENTOCORT EC 3MG CAPSULE |
4 |
Specialty Tier Drugs |
27% | 27% | None |
ENULOSE SYRUP 10GM/15ML 1 PINT BOTPL |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Epinephrine 0.1mg/mL |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
EPIPEN 0.3MG AUTO-INJECTOR |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPIVIR 300mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
EPIVIR HBV 100MG TABLET |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
EPIVIR HBV 25MG/5ML TUBEX |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
EPIVIR ORAL SOLUTION |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
EPIVIR TABLETS |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
Eplerenone 25mg/1 30 TABLET in 1 BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Eplerenone 50mg/1 30 TABLET in 1 BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
EPOGEN 10000U/ML VIAL MDV |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P Q:11 /30Days |
EPOGEN 2000[iU]/mL 10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P Q:55 /30Days |
EPOGEN 3000U/ML VIAL SDV |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P Q:37 /30Days |
EPOGEN 4000U/ML VIAL SDV |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P Q:27 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPOGEN INJECTION 20000U 10 X 1ML CRTN |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P Q:5 /30Days |
EPZICOM TABLETS |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
ERBITUX 100MG/50ML VIAL |
4 |
Specialty Tier Drugs |
27% | 27% | P |
ERGOLOID MESYLATES TABLETS 1MG 100 BOT |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ERGOMAR SUBLINGUAL TABLET 2MG |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
ERGOTAMINE-CAFFEINE TABLET 100 CT Bottle |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ERIVEDGE 150 MG CAPSULE |
4 |
Specialty Tier Drugs |
27% | 27% | None |
ERY 2% PADS 2% 60 PADS JAR |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ERY-TAB TAB 250MG EC |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ERY-TAB TAB 333MG EC |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYPED 200MG/5ML 100 ML BOT |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
ERYPED POWDER FOR ORAL SOLUTION 400MG/5ML 100 ML BOT |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
ERYTHROCIN 500MG ADDVNT VL |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
ERYTHROCIN TAB 250MG |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
ERYTHROMYCIN 2% SOLUTION |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Erythromycin 20mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ERYTHROMYCIN 500 MG FILMTAB |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ERYTHROMYCIN ETHYLSUCCINATE AND SULFISOXAZOLE ACETYL POWDER FOR ORAL SUSPENSION 200;600MG/5ML;MG/ 10 |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ERYTHROMYCIN OPHTHALMIC OINTMENT 0.5% 1 G BOX OF 50 TUBE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ERYTHROMYCIN TAB 250MG BS |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ESCITALOPRAM 10 MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESCITALOPRAM 20 MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ESCITALOPRAM 5 MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ESCITALOPRAM OXALATE 5 MG/5 ML |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ESTRACE 0.5MG TABLET |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
ESTRACE 2MG TABLET |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
ESTRACE TABLET 1MG (100 CT) |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
ESTRACE VAG CREAM 0.1MG/GM |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
ESTRADIOL .025MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ESTRADIOL .0375MG/24 PATCH TRANSDERMAL WEEKLY |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ESTRADIOL .075MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ESTRADIOL 0.05MG/DAY PATCH |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL 0.06MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ESTRADIOL 0.1MG/DAY PATCH |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ESTRADIOL 0.5MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ESTRADIOL 2MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ESTRADIOL TABLET 1MG (500 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ESTRING 2MG VAGINAL RING |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ESTROPIPATE 0.625 TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ESTROPIPATE 1.25 TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ESTROPIPATE 2.5 TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ETHAMBUTOL 400 MG ORAL TABLET [MYAMBUTOL] |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
ETHAMBUTOL HCL 400MG TABLET (100 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ethambutol Hydrochloride 100mg/1 |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Ethosuximide 250mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ETHOSUXIMIDE 250MG/5ML SYRP |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ETHYOL POWDER FOR INJECTION 500MG 3 X 10ML VILSU CRTN |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
ETODOLAC 200MG CAPSULE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ETODOLAC 300 MG CAPSULE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ETODOLAC 400MG TABLET (500 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ETODOLAC 400MG TABLET SR 24HR |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ETODOLAC 500MG TABLET SR 24HR |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ETODOLAC 500mg/1 |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
ETODOLAC 600MG TABLET SR 24HR |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Etoposide 20mg/mL 1 VIAL in 1 BOX, UNIT-DOSE / 50 mL in 1 VIAL |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
Eurax Lotion and Cream 100mg/g 454 g in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
Eurax Lotion and Cream 100mg/g 60 g in 1 TUBE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
Evista 60mg/1 100 TABLET in 1 BOTTLE |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
EVOCLIN 1% FOAM |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
EXELON 1.5MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | S Q:60 /30Days |
EXELON 2MG/ML ORAL SOLUTION |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | S Q:180 /30Days |
EXELON 3MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | S Q:60 /30Days |
EXELON 4.5MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | S Q:60 /30Days |
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
EXELON 6MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | S Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
Exemestane 25mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
EXFORGE 10MG-160MG TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
EXFORGE 10MG-320MG TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
EXFORGE 5MG-160MG TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
EXFORGE 5MG-320MG TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
Exforge HCT 10; 12.5; 160mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
Exforge HCT 10; 25; 160mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
Exforge HCT 10; 25; 320mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
Exforge HCT 5; 12.5; 160mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
Exforge HCT 5; 25; 160mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EXJADE 125MG TABLET |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
EXJADE 250MG TABLET |
4 |
Specialty Tier Drugs |
27% | 27% | None |
EXJADE 500MG TABLET |
4 |
Specialty Tier Drugs |
27% | 27% | None |