2013 Medicare Part D Plan Formulary Information |
Coventry Total Care (HMO) (H3144-001-0)
Benefit Details
|
The Coventry Total Care (HMO) (H3144-001-0) Formulary Drugs Starting with the Letter E in BOONE County, IL: CMS MA Region 14 which includes: IL
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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. 400 FILMTAB |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
E.E.S. GRAN SUS 200/5ML |
2 |
Preferred Brand |
$40.00 | $120.00 | None |
ECONAZOLE NITRATE 1% CREAM 85GM TUBE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
EDURANT 27.5mg/1 |
4 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
EFFIENT 10 MG TABLET |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | Q:30 /30Days |
EFFIENT 5 MG TABLET |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | Q:30 /30Days |
Egrifta 1 KIT in 1 CARTON |
4 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
ELAPRASE 6mg/3mL 1 VIAL, GLASS in 1 BOX / 3 mL in 1 VIAL, GLASS |
4 |
Specialty Tier |
33% | N/A | P |
ELELYSO 200 UNITS VIAL |
4 |
Specialty Tier |
33% | N/A | P |
ELIDEL 1% CREAM |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | S Q:30 /30Days |
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 |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ELIQUIS 2.5 MG TABLET |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | Q:60 /30Days |
ELIQUIS 5 MG TABLET |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | Q:60 /30Days |
Elitek 3 KIT in 1 CARTON / 1 KIT in 1 KIT |
4 |
Specialty Tier |
33% | N/A | P |
ELIXOPHYLLIN 80mg/15mL 473 mL in 1 BOTTLE |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
EMADINE 0.05% EYE DROPS |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
EMCYT 140MG CAPSULE |
2 |
Preferred Brand |
$40.00 | $120.00 | None |
EMEND 40MG CAPSULE |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | Q:1 /30Days |
EMEND CAPSULES 125MG 6 BLPK |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | P Q:6 /30Days |
EMEND CAPSULES 80MG 2 BLPK |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | P Q:6 /30Days |
EMEND TRIFOLD PACK |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | P Q:6 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Emoquette 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | S Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | S Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | S Q:30 /30Days |
EMTRIVA 10MG/ML SOLUTION |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
EMTRIVA 200MG CAPSULE |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
Enablex 15mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | Q:30 /30Days |
Enablex 7.5mg EXTENDED RELEASE 90 TABLET BOTTLE |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | Q:30 /30Days |
ENALAPRIL MALEATE 10MG TABLET (100 CT) |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ENALAPRIL MALEATE 2.5 MG TAB |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Enalapril Maleate 20mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENALAPRIL MALEATE 5 MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ENALAPRIL MALEATE-HCTZ 10MG-25MG TABLET (100 CT) |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET (100 CT) |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ENBREL 25 MG/0.5 ML SYRINGE |
4 |
Specialty Tier |
33% | N/A | P Q:16 /30Days |
ENBREL 25MG KIT |
4 |
Specialty Tier |
33% | N/A | P Q:16 /30Days |
ENBREL 50mg/mL |
4 |
Specialty Tier |
33% | N/A | P Q:8 /28Days |
ENDOCET 10/650MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | Q:180 /30Days |
ENDOCET 10MG-325MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | Q:360 /30Days |
ENDOCET 5/325 TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | Q:360 /30Days |
ENDOCET 7.5-325MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | Q:360 /30Days |
ENDOCET 7.5/500MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | 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 |
Preferred Generic |
$5.00 | $15.00 | Q:360 /30Days |
ENGERIX B INJECTION |
2 |
Preferred Brand |
$40.00 | $120.00 | P |
ENGERIX B INJECTION 20MCG/ML |
2 |
Preferred Brand |
$40.00 | $120.00 | P |
ENGERIX-B 10MCG 10 X 0.5ML VIALSD |
2 |
Preferred Brand |
$40.00 | $120.00 | P |
ENOXAPARIN 100 MG/ML SYRINGE |
1 |
Preferred Generic |
$5.00 | $15.00 | P |
ENOXAPARIN 120 MG/0.8 ML SYR |
1 |
Preferred Generic |
$5.00 | $15.00 | P |
ENOXAPARIN 150 MG/ML SYRINGE |
1 |
Preferred Generic |
$5.00 | $15.00 | P |
ENOXAPARIN 30 MG/0.3 ML SYR |
1 |
Preferred Generic |
$5.00 | $15.00 | P |
ENOXAPARIN 40 MG/0.4 ML SYR |
1 |
Preferred Generic |
$5.00 | $15.00 | P |
ENOXAPARIN 60 MG/0.6 ML SYR |
1 |
Preferred Generic |
$5.00 | $15.00 | P |
ENOXAPARIN 80 MG/0.8 ML SYR |
1 |
Preferred Generic |
$5.00 | $15.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
entacapone 200 mg tablet |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ENULOSE 10 GM/15 ML SOLUTION |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Epinephrine 0.1mg/mL |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
EPIPEN 0.3MG AUTO-INJECTOR |
2 |
Preferred Brand |
$40.00 | $120.00 | Q:2 /30Days |
EPIPEN JR 0.15MG AUTO-INJCT |
2 |
Preferred Brand |
$40.00 | $120.00 | Q:2 /30Days |
EPITOL 200MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
EPIVIR HBV 100MG TABLET |
2 |
Preferred Brand |
$40.00 | $120.00 | None |
EPIVIR HBV 25MG/5ML TUBEX |
2 |
Preferred Brand |
$40.00 | $120.00 | None |
EPIVIR ORAL SOLUTION |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
Eplerenone 25mg/1 90 TABLET BOTTLE |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
Eplerenone 50mg/1 90 TABLET BOTTLE |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EPROSARTAN MESYLATE 600 MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | Q:30 /30Days |
EPZICOM TABLETS |
4 |
Specialty Tier |
33% | N/A | None |
EQUETRO CAPSULES 200MG 120 BOT |
2 |
Preferred Brand |
$40.00 | $120.00 | None |
EQUETRO CAPSULES 300MG 120 BOT |
2 |
Preferred Brand |
$40.00 | $120.00 | None |
EQUETRO EXTENDED RELEASE CAPSULES 100MG 120 BOT |
2 |
Preferred Brand |
$40.00 | $120.00 | None |
ERAXIS 100mg/30mL 30 mL in 1 VIAL, SINGLE-USE |
4 |
Specialty Tier |
33% | N/A | P |
ERGOLOID MESYLATES TABLETS 1MG 100 BOT |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ERIVEDGE 150 MG CAPSULE |
4 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
ERRIN 0.35MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ERY 2% PADS 2% 60 PADS JAR |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE |
2 |
Preferred Brand |
$40.00 | $120.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERY-TAB TAB 250MG EC |
2 |
Preferred Brand |
$40.00 | $120.00 | None |
ERY-TAB TAB 333MG EC |
2 |
Preferred Brand |
$40.00 | $120.00 | None |
ERYPED 200 MG/5 ML SUSPENSION |
2 |
Preferred Brand |
$40.00 | $120.00 | None |
ERYPED 400 MG/5 ML SUSPENSION |
2 |
Preferred Brand |
$40.00 | $120.00 | None |
ERYTHROCIN 500MG ADDVNT VL |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
ERYTHROCIN TAB 250MG |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Erythromycin 2% solution |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Erythromycin 20mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ERYTHROMYCIN 500 MG FILMTAB |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ERYTHROMYCIN ES 400 MG TAB |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ERYTHROMYCIN OPHTHALMIC OINTMENT 0.5% 1 G BOX OF 50 TUBE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROMYCIN TAB 250MG BS |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ESCITALOPRAM 10 MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | Q:45 /30Days |
ESCITALOPRAM 20 MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | Q:45 /30Days |
ESCITALOPRAM 5 MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | Q:45 /30Days |
ESCITALOPRAM OXALATE 5 MG/5 ML |
1 |
Preferred Generic |
$5.00 | $15.00 | Q:600 /30Days |
ESTRACE 0.5MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ESTRACE 2MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ESTRACE TABLET 1MG (100 CT) |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ESTRACE VAG CREAM 0.1MG/GM |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
ESTRADIOL .025MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ESTRADIOL .0375MG/24 PATCH TRANSDERMAL WEEKLY |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL .075MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Estradiol / Norethindrone Acetate 0.5; 0.1mg/1; mg/1 1 BLISTER PACK in 1 CARTON / 28 TABLET, FILM C |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
ESTRADIOL 0.05MG/DAY PATCH |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ESTRADIOL 0.06MG/24H PATCH TRANSDERMAL WEEKLY |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ESTRADIOL 0.1MG/DAY PATCH |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ESTRADIOL 0.5MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ESTRADIOL 2MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ESTRADIOL TABLET 1MG (500 CT) |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ESTRADIOL-NORETH 1.0-0.5MG TABLET |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
ESTRING 2MG VAGINAL RING |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | Q:1 /90Days |
ETHAMBUTOL HCL 400 MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ethambutol Hydrochloride 100mg/1 |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21 |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
Ethosuximide 250mg 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ETHOSUXIMIDE 250MG/5ML SYRP |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ETIDRONATE DISODIUM 400MG TABLET (60 CT) |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
ETODOLAC 200MG CAPSULE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Etodolac 300 mg capsule |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ETODOLAC 400MG TABLET SR 24HR |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
Etodolac 400mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETODOLAC 500MG TABLET SR 24HR |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
Etodolac 500mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
ETODOLAC 600MG TABLET SR 24HR |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
Etoposide 20mg/mL 1 VIAL in 1 BOX, UNIT-DOSE / 25 mL in 1 VIAL |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | P |
Eurax Lotion and Cream 100mg/g 454 g in 1 BOTTLE |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
Eurax Lotion and Cream 100mg/g 60 g in 1 TUBE |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
EVAMIST 1.53/SPRAY SPRAY NON-AEROSOL |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | Q:16 /30Days |
Evista 60mg/1 100 TABLET BOTTLE |
2 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days |
EXALGO 12mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2 |
Preferred Brand |
$40.00 | $120.00 | Q:150 /30Days |
EXALGO 16mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2 |
Preferred Brand |
$40.00 | $120.00 | Q:120 /30Days |
EXALGO 8mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2 |
Preferred Brand |
$40.00 | $120.00 | Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Exelderm 10mg/g 30 g in 1 TUBE |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
Exelderm 10mg/mL 30 mL in 1 BOTTLE, PLASTIC |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
EXELON 13.3 MG/24HR PATCH |
2 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days |
EXELON 2MG/ML ORAL SOLUTION |
2 |
Preferred Brand |
$40.00 | $120.00 | Q:180 /30Days |
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS |
2 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days |
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS |
2 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days |
Exemestane 25mg/1 30 FILM COATED TABLETS in BOTTLE |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
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 |
EXTAVIA 15 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
4 |
Specialty Tier |
33% | N/A | P Q:15 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EXTENDED PHENYTOIN SODIUM CAPSULES 300 MG |
1 |
Preferred Generic |
$5.00 | $15.00 | None |