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2013 Medicare Part D Plan Formulary Information
EnvisionRxPlus Gold (PDP) (S7694-094-0) Benefit Details
The EnvisionRxPlus Gold (PDP) (S7694-094-0) Formulary Drugs Starting with the Letter E in CMS PDP Region 24 which includes: KS
Drugs Starting with Letter E Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter E Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ECONAZOLE NITRATE 1% CREAM 85GM TUBE	2	Non-Preferred Generic	1%	1%	None
edarbi 40mg/1	4	Non-Preferred Brand	30%	30%	S
edarbi 80mg/1	4	Non-Preferred Brand	30%	30%	S
EDARBYCLOR 40-12.5 MG TABLET	4	Non-Preferred Brand	30%	30%	S
EDARBYCLOR 40-25 MG TABLET	4	Non-Preferred Brand	30%	30%	S
EDURANT 27.5mg/1	4	Non-Preferred Brand	30%	30%	None
EFFIENT 10 MG TABLET	4	Non-Preferred Brand	30%	30%	None
EFFIENT 5 MG TABLET	4	Non-Preferred Brand	30%	30%	None
Egrifta 1 KIT in 1 CARTON	5	Specialty Tier	29%	N/A	P
ELAPRASE 6mg/3mL 1 VIAL, GLASS in 1 BOX / 3 mL in 1 VIAL, GLASS	5	Specialty Tier	29%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ELIDEL 1% CREAM	4	Non-Preferred Brand	30%	30%	None
ELIGARD 1 KIT in 1 CARTON	4	Non-Preferred Brand	30%	30%	P
ELIGARD 1 KIT in 1 CARTON	4	Non-Preferred Brand	30%	30%	P
ELIGARD 1 KIT in 1 CARTON	4	Non-Preferred Brand	30%	30%	P
ELIGARD 1 KIT in 1 CARTON	4	Non-Preferred Brand	30%	30%	P
Elitek 3 KIT in 1 CARTON / 1 KIT in 1 KIT	5	Specialty Tier	29%	N/A	None
Ella 30mg/1 1 BLISTER PACK in 1 CARTON / 1 TABLET in 1 BLISTER PACK	4	Non-Preferred Brand	30%	30%	None
ELLENCE 2MG/ML VIAL	4	Non-Preferred Brand	30%	30%	P
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE	3	Preferred Brand	1%	1%	None
ELOXATIN 100MG/20ML VIAL	4	Non-Preferred Brand	30%	30%	P
ELSPAR INJ 10000UNT	4	Non-Preferred Brand	30%	30%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EMCYT 140MG CAPSULE	4	Non-Preferred Brand	30%	30%	None
EMEND 40MG CAPSULE	4	Non-Preferred Brand	30%	30%	P Q:30 /30Days
EMEND CAPSULES 125MG 6 BLPK	4	Non-Preferred Brand	30%	30%	P Q:30 /30Days
EMEND CAPSULES 80MG 2 BLPK	3	Preferred Brand	1%	1%	P Q:30 /30Days
EMEND TRIFOLD PACK	4	Non-Preferred Brand	30%	30%	P Q:12 /30Days
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H	4	Non-Preferred Brand	30%	30%	None
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H	4	Non-Preferred Brand	30%	30%	None
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H	4	Non-Preferred Brand	30%	30%	None
EMTRIVA 10MG/ML SOLUTION	3	Preferred Brand	1%	1%	None
EMTRIVA 200MG CAPSULE	4	Non-Preferred Brand	30%	30%	None
ENALAPRIL MALEATE 10MG TABLET (100 CT)	1	Preferred Generic	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENALAPRIL MALEATE 2.5 MG TAB	1	Preferred Generic	1%	1%	None
Enalapril Maleate 20mg/1 100 TABLET BOTTLE, PLASTIC	1	Preferred Generic	1%	1%	None
ENALAPRIL MALEATE 5 MG TABLET	1	Preferred Generic	1%	1%	None
ENALAPRIL MALEATE-HCTZ 10MG-25MG TABLET (100 CT)	2	Non-Preferred Generic	1%	1%	None
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET (100 CT)	1	Preferred Generic	1%	1%	None
ENBREL 25 MG/0.5 ML SYRINGE	5	Specialty Tier	29%	N/A	None
ENBREL 25MG KIT	5	Specialty Tier	29%	N/A	None
ENBREL 50mg/mL	5	Specialty Tier	29%	N/A	None
ENDOCET 10/650MG TABLET	2	Non-Preferred Generic	1%	1%	Q:185 /30Days
ENDOCET 10MG-325MG TABLET	2	Non-Preferred Generic	1%	1%	Q:370 /30Days
ENDOCET 5/325 TABLET	2	Non-Preferred Generic	1%	1%	Q:370 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENDOCET 7.5-325MG TABLET	2	Non-Preferred Generic	1%	1%	Q:370 /30Days
ENDOCET 7.5/500MG TABLET	2	Non-Preferred Generic	1%	1%	Q:240 /30Days
ENGERIX B INJECTION	4	Non-Preferred Brand	30%	30%	P
ENGERIX B INJECTION 20MCG/ML	4	Non-Preferred Brand	30%	30%	P
ENGERIX-B 10MCG 10 X 0.5ML VIALSD	4	Non-Preferred Brand	30%	30%	P
ENOXAPARIN 100 MG/ML SYRINGE	2	Non-Preferred Generic	1%	1%	None
ENOXAPARIN 120 MG/0.8 ML SYR	2	Non-Preferred Generic	1%	1%	None
ENOXAPARIN 150 MG/ML SYRINGE	2	Non-Preferred Generic	1%	1%	None
ENOXAPARIN 30 MG/0.3 ML SYR	2	Non-Preferred Generic	1%	1%	None
ENOXAPARIN 300 MG/3 ML VIAL	2	Non-Preferred Generic	1%	1%	None
ENOXAPARIN 40 MG/0.4 ML SYR	2	Non-Preferred Generic	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENOXAPARIN 60 MG/0.6 ML SYR	2	Non-Preferred Generic	1%	1%	None
ENOXAPARIN 80 MG/0.8 ML SYR	2	Non-Preferred Generic	1%	1%	None
entacapone 200 mg tablet	2	Non-Preferred Generic	1%	1%	None
ENTOCORT EC 3 MG CAPSULE	4	Non-Preferred Brand	30%	30%	None
ENULOSE 10 GM/15 ML SOLUTION	1	Preferred Generic	1%	1%	None
EPIPEN 0.3MG AUTO-INJECTOR	3	Preferred Brand	1%	1%	None
EPIPEN JR 0.15MG AUTO-INJCT	3	Preferred Brand	1%	1%	None
EPIRUBICIN HCL INJECTION SOLUTION 2MG 1 X 25ML VIAL	2	Non-Preferred Generic	1%	1%	P
EPITOL 200MG TABLET	2	Non-Preferred Generic	1%	1%	None
EPIVIR HBV 100MG TABLET	4	Non-Preferred Brand	30%	30%	None
EPIVIR HBV 25MG/5ML TUBEX	3	Preferred Brand	1%	1%	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	30%	30%	None
Eplerenone 25mg/1 90 TABLET BOTTLE	2	Non-Preferred Generic	1%	1%	None
Eplerenone 50mg/1 90 TABLET BOTTLE	2	Non-Preferred Generic	1%	1%	None
EPZICOM TABLETS	5	Specialty Tier	29%	N/A	None
ERAXIS 100mg/30mL 30 mL in 1 VIAL, SINGLE-USE	4	Non-Preferred Brand	30%	30%	None
ERBITUX 100MG/50ML VIAL	4	Non-Preferred Brand	30%	30%	P
ERGOLOID MESYLATES TABLETS 1MG 100 BOT	2	Non-Preferred Generic	1%	1%	None
ERIVEDGE 150 MG CAPSULE	5	Specialty Tier	29%	N/A	None
ERYTHROCIN TAB 250MG	2	Non-Preferred Generic	1%	1%	None
Erythromycin 2% solution	2	Non-Preferred Generic	1%	1%	None
Erythromycin 20mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE	2	Non-Preferred Generic	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ERYTHROMYCIN ES 400 MG TAB	1	Preferred Generic	1%	1%	None
ERYTHROMYCIN OPHTHALMIC OINTMENT 0.5% 1 G BOX OF 50 TUBE	1	Preferred Generic	1%	1%	None
ERYTHROMYCIN-BENZOYL PEROXIDE 3-5% GEL	2	Non-Preferred Generic	1%	1%	None
ESCITALOPRAM 10 MG TABLET	2	Non-Preferred Generic	1%	1%	None
ESCITALOPRAM 20 MG TABLET	2	Non-Preferred Generic	1%	1%	None
ESCITALOPRAM 5 MG TABLET	2	Non-Preferred Generic	1%	1%	None
ESCITALOPRAM OXALATE 5 MG/5 ML	2	Non-Preferred Generic	1%	1%	None
Estazolam 1mg/1 100 TABLET BOTTLE	1	Preferred Generic	1%	1%	Q:60 /30Days
Estazolam 2mg/1 100 TABLET BOTTLE	1	Preferred Generic	1%	1%	Q:30 /30Days
ESTRADIOL .025MG/24H PATCH TRANSDERMAL WEEKLY	2	Non-Preferred Generic	1%	1%	None
ESTRADIOL .0375MG/24 PATCH TRANSDERMAL WEEKLY	2	Non-Preferred Generic	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ESTRADIOL .075MG/24H PATCH TRANSDERMAL WEEKLY	2	Non-Preferred Generic	1%	1%	None
ESTRADIOL 0.05MG/DAY PATCH	2	Non-Preferred Generic	1%	1%	None
ESTRADIOL 0.06MG/24H PATCH TRANSDERMAL WEEKLY	1	Preferred Generic	1%	1%	None
ESTRADIOL 0.1MG/DAY PATCH	2	Non-Preferred Generic	1%	1%	None
ESTRADIOL 0.5MG TABLET	1	Preferred Generic	1%	1%	None
ESTRADIOL 2MG TABLET	1	Preferred Generic	1%	1%	None
ESTRADIOL TABLET 1MG (500 CT)	1	Preferred Generic	1%	1%	None
ETHAMBUTOL HCL 400 MG TABLET	2	Non-Preferred Generic	1%	1%	None
Ethambutol Hydrochloride 100mg/1	2	Non-Preferred Generic	1%	1%	None
Ethosuximide 250mg 100 CAPSULE BOTTLE	2	Non-Preferred Generic	1%	1%	None
ETHOSUXIMIDE 250MG/5ML SYRP	1	Preferred Generic	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ETODOLAC 200MG CAPSULE	2	Non-Preferred Generic	1%	1%	None
Etodolac 300 mg capsule	2	Non-Preferred Generic	1%	1%	None
ETODOLAC 400MG TABLET SR 24HR	2	Non-Preferred Generic	1%	1%	None
Etodolac 400mg/1 100 TABLET BOTTLE	2	Non-Preferred Generic	1%	1%	None
ETODOLAC 500MG TABLET SR 24HR	2	Non-Preferred Generic	1%	1%	None
Etodolac 500mg/1 500 TABLET BOTTLE	2	Non-Preferred Generic	1%	1%	None
ETODOLAC 600MG TABLET SR 24HR	2	Non-Preferred Generic	1%	1%	None
ETOPOPHOS 100MG VIAL	4	Non-Preferred Brand	30%	30%	P
Etoposide 20mg/mL 1 VIAL in 1 BOX, UNIT-DOSE / 25 mL in 1 VIAL	2	Non-Preferred Generic	1%	1%	P
Eurax Lotion and Cream 100mg/g 60 g in 1 TUBE	4	Non-Preferred Brand	30%	30%	None
Evista 60mg/1 100 TABLET BOTTLE	3	Preferred Brand	1%	1%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EXELON 13.3 MG/24HR PATCH	3	Preferred Brand	1%	1%	None
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS	3	Preferred Brand	1%	1%	None
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS	3	Preferred Brand	1%	1%	None
Exemestane 25mg/1 30 FILM COATED TABLETS in BOTTLE	2	Non-Preferred Generic	1%	1%	None
EXJADE 125MG TABLET	4	Non-Preferred Brand	30%	30%	None
EXJADE 250MG TABLET	5	Specialty Tier	29%	N/A	None
EXJADE 500MG TABLET	5	Specialty Tier	29%	N/A	None
EXTAVIA 15 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK	5	Specialty Tier	29%	N/A	None
EXTENDED PHENYTOIN SODIUM CAPSULES 300 MG	2	Non-Preferred Generic	1%	1%	None

Chart Legend:

Below are a few notes to help you understand the above 2013 Medicare Part D EnvisionRxPlus Gold (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 $325 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 $2970) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 Humana Walmart-Preferred Rx Plan the cost-sharing 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 2013 )

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.