Q1Medicare.com 2013 Medicare Part D or Medicare Advantage Plan Formulary Browser

2013 Medicare Part D Plan Formulary Information
Security Blue ValueRx (HMO) (H3957-032-0) Benefit Details
The Security Blue ValueRx (HMO) (H3957-032-0) Formulary Drugs Starting with the Letter E in JEFFERSON County, PA: CMS MA Region 6 which includes: PA
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
E.E.S. 400 FILMTAB	1	Generic	$10.00	$25.00	None
E.E.S. GRAN SUS 200/5ML	3	Non-Preferred Brand	$95.00	$237.50	None
EC-NAPROSYN 375MG TABLET EC	3	Non-Preferred Brand	$95.00	$237.50	None
EC-NAPROSYN 500MG TABLET EC	3	Non-Preferred Brand	$95.00	$237.50	None
ECONAZOLE NITRATE 1% CREAM 85GM TUBE	1	Generic	$10.00	$25.00	None
edarbi 40mg/1	3	Non-Preferred Brand	$95.00	$237.50	None
edarbi 80mg/1	3	Non-Preferred Brand	$95.00	$237.50	None
EDARBYCLOR 40-12.5 MG TABLET	3	Non-Preferred Brand	$95.00	$237.50	None
EDARBYCLOR 40-25 MG TABLET	3	Non-Preferred Brand	$95.00	$237.50	None
EDECRIN 25MG TABLET (100 CT)	2	Preferred Brand	$45.00	$112.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Edluar 10mg/1 3 BLISTER PACK in 1 CARTON / 10 TABLET in 1 BLISTER PACK	3	Non-Preferred Brand	$95.00	$237.50	None
Edluar 5mg/1 3 BLISTER PACK in 1 CARTON / 10 TABLET in 1 BLISTER PACK	3	Non-Preferred Brand	$95.00	$237.50	None
EDURANT 27.5mg/1	3	Non-Preferred Brand	$95.00	$237.50	None
EFFEXOR 37.5MG CAPSULE ER (90 CT)	3	Non-Preferred Brand	$95.00	$237.50	None
EFFEXOR XR 150MG CAPSULE ER 15 CAPSULES BOT	3	Non-Preferred Brand	$95.00	$237.50	None
EFFEXOR XR 75MG CAPSULE ER 15 CAPSULES BOT	3	Non-Preferred Brand	$95.00	$237.50	None
EFFIENT 10 MG TABLET	2	Preferred Brand	$45.00	$112.50	None
EFFIENT 5 MG TABLET	2	Preferred Brand	$45.00	$112.50	None
EFUDEX 5% CREAM	3	Non-Preferred Brand	$95.00	$237.50	None
Egrifta 1 KIT in 1 CARTON	4	Specialty Tier	33%	33%	P
ELAPRASE 6mg/3mL 1 VIAL, GLASS in 1 BOX / 3 mL in 1 VIAL, GLASS	4	Specialty Tier	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ELDEPRYL 5 MG CAPSULE	3	Non-Preferred Brand	$95.00	$237.50	None
ELELYSO 200 UNITS VIAL	4	Specialty Tier	33%	33%	None
ELESTAT 0.5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER	3	Non-Preferred Brand	$95.00	$237.50	None
Elestrin 0.6mg/g 2 BOTTLE, PUMP in 1 CARTON / 35 g in 1 BOTTLE, PUMP	3	Non-Preferred Brand	$95.00	$237.50	None
ELIDEL 1% CREAM	3	Non-Preferred Brand	$95.00	$237.50	None
ELIGARD 1 KIT in 1 CARTON	3	Non-Preferred Brand	$95.00	$237.50	None
ELIGARD 1 KIT in 1 CARTON	3	Non-Preferred Brand	$95.00	$237.50	None
ELIGARD 1 KIT in 1 CARTON	3	Non-Preferred Brand	$95.00	$237.50	None
ELIGARD 1 KIT in 1 CARTON	3	Non-Preferred Brand	$95.00	$237.50	None
ELIPHOS TABLETS CALCIUM ACETATE TABLETS 667MG 200 BOT	1	Generic	$10.00	$25.00	None
ELIQUIS 2.5 MG TABLET	3	Non-Preferred Brand	$95.00	$237.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ELIQUIS 5 MG TABLET	3	Non-Preferred Brand	$95.00	$237.50	None
Elitek 3 KIT in 1 CARTON / 1 KIT in 1 KIT	4	Specialty Tier	33%	33%	None
ELIXOPHYLLIN 80mg/15mL 473 mL in 1 BOTTLE	2	Preferred Brand	$45.00	$112.50	None
Ella 30mg/1 1 BLISTER PACK in 1 CARTON / 1 TABLET in 1 BLISTER PACK	3	Non-Preferred Brand	$95.00	$237.50	None
ELLENCE 2MG/ML VIAL	3	Non-Preferred Brand	$95.00	$237.50	None
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE	2	Preferred Brand	$45.00	$112.50	None
ELOCON 0.1% CREAM	3	Non-Preferred Brand	$95.00	$237.50	None
ELOCON 0.1% LOTION	3	Non-Preferred Brand	$95.00	$237.50	None
ELOCON 0.1% OINTMENT	3	Non-Preferred Brand	$95.00	$237.50	None
ELOXATIN 100MG/20ML VIAL	3	Non-Preferred Brand	$95.00	$237.50	None
ELSPAR INJ 10000UNT	3	Non-Preferred Brand	$95.00	$237.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EMADINE 0.05% EYE DROPS	3	Non-Preferred Brand	$95.00	$237.50	None
EMCYT 140MG CAPSULE	2	Preferred Brand	$45.00	$112.50	None
EMEND 40MG CAPSULE	3	Non-Preferred Brand	$95.00	$237.50	P
EMEND CAPSULES 125MG 6 BLPK	3	Non-Preferred Brand	$95.00	$237.50	P
EMEND CAPSULES 80MG 2 BLPK	3	Non-Preferred Brand	$95.00	$237.50	P
EMEND TRIFOLD PACK	3	Non-Preferred Brand	$95.00	$237.50	P
EMLA CREAM	3	Non-Preferred Brand	$95.00	$237.50	None
Emoquette 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK	1	Generic	$10.00	$25.00	None
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H	3	Non-Preferred Brand	$95.00	$237.50	None
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H	3	Non-Preferred Brand	$95.00	$237.50	None
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H	3	Non-Preferred Brand	$95.00	$237.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EMTRIVA 10MG/ML SOLUTION	2	Preferred Brand	$45.00	$112.50	None
EMTRIVA 200MG CAPSULE	2	Preferred Brand	$45.00	$112.50	None
Enablex 15mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE	3	Non-Preferred Brand	$95.00	$237.50	None
Enablex 7.5mg EXTENDED RELEASE 90 TABLET BOTTLE	3	Non-Preferred Brand	$95.00	$237.50	None
ENALAPRIL MALEATE 10MG TABLET (100 CT)	1	Generic	$10.00	$25.00	None
ENALAPRIL MALEATE 2.5 MG TAB	1	Generic	$10.00	$25.00	None
Enalapril Maleate 20mg/1 100 TABLET BOTTLE, PLASTIC	1	Generic	$10.00	$25.00	None
ENALAPRIL MALEATE 5 MG TABLET	1	Generic	$10.00	$25.00	None
ENALAPRIL MALEATE-HCTZ 10MG-25MG TABLET (100 CT)	1	Generic	$10.00	$25.00	None
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET (100 CT)	1	Generic	$10.00	$25.00	None
ENBREL 25 MG/0.5 ML SYRINGE	4	Specialty Tier	33%	33%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENBREL 25MG KIT	4	Specialty Tier	33%	33%	P
ENBREL 50mg/mL	4	Specialty Tier	33%	33%	P
ENDOCET 10/650MG TABLET	1	Generic	$10.00	$25.00	Q:180 /25Days
ENDOCET 10MG-325MG TABLET	1	Generic	$10.00	$25.00	Q:360 /25Days
ENDOCET 5/325 TABLET	1	Generic	$10.00	$25.00	Q:360 /25Days
ENDOCET 7.5-325MG TABLET	1	Generic	$10.00	$25.00	Q:360 /25Days
ENDOCET 7.5/500MG TABLET	1	Generic	$10.00	$25.00	Q:240 /25Days
ENDODAN TABLETS 325;4.8355MG;MG 100 BOT	1	Generic	$10.00	$25.00	None
Endometrin 100mg/1 1 CARTON in 1 CARTON / 21 BLISTER PACK in 1 CARTON / 1 INSERT in 1 BLISTER PACK	3	Non-Preferred Brand	$95.00	$237.50	None
ENGERIX B INJECTION	2	Preferred Brand	$45.00	$112.50	None
ENGERIX B INJECTION 20MCG/ML	2	Preferred Brand	$45.00	$112.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENGERIX-B 10MCG 10 X 0.5ML VIALSD	2	Preferred Brand	$45.00	$112.50	None
ENJUVIA 0.3MG TABLET	3	Non-Preferred Brand	$95.00	$237.50	None
ENJUVIA 0.45MG TABLET	3	Non-Preferred Brand	$95.00	$237.50	None
ENJUVIA 0.625MG TABLET	3	Non-Preferred Brand	$95.00	$237.50	None
ENJUVIA 0.9MG TABLET	3	Non-Preferred Brand	$95.00	$237.50	None
ENJUVIA 1.25MG TABLET	3	Non-Preferred Brand	$95.00	$237.50	None
ENOXAPARIN 100 MG/ML SYRINGE	1	Generic	$10.00	$25.00	None
ENOXAPARIN 120 MG/0.8 ML SYR	4	Specialty Tier	33%	33%	None
ENOXAPARIN 150 MG/ML SYRINGE	4	Specialty Tier	33%	33%	None
ENOXAPARIN 30 MG/0.3 ML SYR	1	Generic	$10.00	$25.00	None
ENOXAPARIN 300 MG/3 ML VIAL	4	Specialty Tier	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENOXAPARIN 40 MG/0.4 ML SYR	1	Generic	$10.00	$25.00	None
ENOXAPARIN 60 MG/0.6 ML SYR	1	Generic	$10.00	$25.00	None
ENOXAPARIN 80 MG/0.8 ML SYR	1	Generic	$10.00	$25.00	None
entacapone 200 mg tablet	1	Generic	$10.00	$25.00	None
ENTOCORT EC 3 MG CAPSULE	3	Non-Preferred Brand	$95.00	$237.50	None
ENULOSE 10 GM/15 ML SOLUTION	1	Generic	$10.00	$25.00	None
EPIDUO GEL 0.1;2.5%;% 45 TRADE SIZE TUBE	3	Non-Preferred Brand	$95.00	$237.50	None
Epinastine HCl 0.5mg/mL	1	Generic	$10.00	$25.00	None
Epinephrine 0.1mg/mL	1	Generic	$10.00	$25.00	None
EPIPEN 0.3MG AUTO-INJECTOR	2	Preferred Brand	$45.00	$112.50	None
EPIPEN JR 0.15MG AUTO-INJCT	2	Preferred Brand	$45.00	$112.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EPIRUBICIN HCL INJECTION SOLUTION 2MG 1 X 25ML VIAL	1	Generic	$10.00	$25.00	None
EPITOL 200MG TABLET	1	Generic	$10.00	$25.00	None
EPIVIR 300mg/1 30 FILM COATED TABLETS in BOTTLE	2	Preferred Brand	$45.00	$112.50	None
EPIVIR HBV 100MG TABLET	2	Preferred Brand	$45.00	$112.50	None
EPIVIR HBV 25MG/5ML TUBEX	2	Preferred Brand	$45.00	$112.50	None
EPIVIR ORAL SOLUTION	2	Preferred Brand	$45.00	$112.50	None
EPIVIR TABLETS	2	Preferred Brand	$45.00	$112.50	None
Eplerenone 25mg/1 90 TABLET BOTTLE	1	Generic	$10.00	$25.00	None
Eplerenone 50mg/1 90 TABLET BOTTLE	1	Generic	$10.00	$25.00	None
EPOGEN 10000U/ML VIAL MDV	2	Preferred Brand	$45.00	$112.50	P
EPOGEN 2000[iU]/mL 10 VIAL in 1 PACKAGE / 1 mL in 1 VIAL	2	Preferred Brand	$45.00	$112.50	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EPOGEN 3000U/ML VIAL SDV	2	Preferred Brand	$45.00	$112.50	P
EPOGEN 4000U/ML VIAL SDV	2	Preferred Brand	$45.00	$112.50	P
EPOGEN INJECTION 20000U 10 X 1ML CRTN	2	Preferred Brand	$45.00	$112.50	P
EPROSARTAN MESYLATE 600 MG TABLET	1	Generic	$10.00	$25.00	None
EPZICOM TABLETS	2	Preferred Brand	$45.00	$112.50	None
EQUETRO CAPSULES 200MG 120 BOT	3	Non-Preferred Brand	$95.00	$237.50	None
EQUETRO CAPSULES 300MG 120 BOT	3	Non-Preferred Brand	$95.00	$237.50	None
EQUETRO EXTENDED RELEASE CAPSULES 100MG 120 BOT	3	Non-Preferred Brand	$95.00	$237.50	None
ERAXIS 100mg/30mL 30 mL in 1 VIAL, SINGLE-USE	3	Non-Preferred Brand	$95.00	$237.50	None
ERBITUX 100MG/50ML VIAL	3	Non-Preferred Brand	$95.00	$237.50	None
ERGOLOID MESYLATES TABLETS 1MG 100 BOT	1	Generic	$10.00	$25.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ERGOMAR 2 MG TABLET SL	2	Preferred Brand	$45.00	$112.50	None
ERIVEDGE 150 MG CAPSULE	4	Specialty Tier	33%	33%	P
ERRIN 0.35MG TABLET	1	Generic	$10.00	$25.00	None
ERTACZO 2% CREAM	3	Non-Preferred Brand	$95.00	$237.50	None
ERY 2% PADS 2% 60 PADS JAR	1	Generic	$10.00	$25.00	None
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE	2	Preferred Brand	$45.00	$112.50	None
ERY-TAB TAB 250MG EC	1	Generic	$10.00	$25.00	None
ERY-TAB TAB 333MG EC	1	Generic	$10.00	$25.00	None
ERYPED 200 MG/5 ML SUSPENSION	3	Non-Preferred Brand	$95.00	$237.50	None
ERYPED 400 MG/5 ML SUSPENSION	2	Preferred Brand	$45.00	$112.50	None
ERYTHROCIN 500MG ADDVNT VL	2	Preferred Brand	$45.00	$112.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ERYTHROCIN TAB 250MG	1	Generic	$10.00	$25.00	None
Erythromycin 2% solution	1	Generic	$10.00	$25.00	None
Erythromycin 20mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE	1	Generic	$10.00	$25.00	None
ERYTHROMYCIN 500 MG FILMTAB	1	Generic	$10.00	$25.00	None
ERYTHROMYCIN ES 400 MG TAB	1	Generic	$10.00	$25.00	None
ERYTHROMYCIN OPHTHALMIC OINTMENT 0.5% 1 G BOX OF 50 TUBE	1	Generic	$10.00	$25.00	None
ERYTHROMYCIN TAB 250MG BS	1	Generic	$10.00	$25.00	None
ERYTHROMYCIN-BENZOYL PEROXIDE 3-5% GEL	1	Generic	$10.00	$25.00	None
ESCITALOPRAM 10 MG TABLET	1	Generic	$10.00	$25.00	None
ESCITALOPRAM 20 MG TABLET	1	Generic	$10.00	$25.00	None
ESCITALOPRAM 5 MG TABLET	1	Generic	$10.00	$25.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ESCITALOPRAM OXALATE 5 MG/5 ML	1	Generic	$10.00	$25.00	None
Estazolam 1mg/1 100 TABLET BOTTLE	1	Generic	$10.00	$25.00	None
Estazolam 2mg/1 100 TABLET BOTTLE	1	Generic	$10.00	$25.00	None
ESTRACE 0.5MG TABLET	3	Non-Preferred Brand	$95.00	$237.50	None
ESTRACE 2MG TABLET	3	Non-Preferred Brand	$95.00	$237.50	None
ESTRACE TABLET 1MG (100 CT)	3	Non-Preferred Brand	$95.00	$237.50	None
ESTRACE VAG CREAM 0.1MG/GM	3	Non-Preferred Brand	$95.00	$237.50	None
ESTRADIOL .025MG/24H PATCH TRANSDERMAL WEEKLY	1	Generic	$10.00	$25.00	None
ESTRADIOL .0375MG/24 PATCH TRANSDERMAL WEEKLY	1	Generic	$10.00	$25.00	None
ESTRADIOL .075MG/24H PATCH TRANSDERMAL WEEKLY	1	Generic	$10.00	$25.00	None
Estradiol / Norethindrone Acetate 0.5; 0.1mg/1; mg/1 1 BLISTER PACK in 1 CARTON / 28 TABLET, FILM C	1	Generic	$10.00	$25.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ESTRADIOL 0.05MG/DAY PATCH	1	Generic	$10.00	$25.00	None
ESTRADIOL 0.06MG/24H PATCH TRANSDERMAL WEEKLY	1	Generic	$10.00	$25.00	None
ESTRADIOL 0.1MG/DAY PATCH	1	Generic	$10.00	$25.00	None
ESTRADIOL 0.5MG TABLET	1	Generic	$10.00	$25.00	None
ESTRADIOL 2MG TABLET	1	Generic	$10.00	$25.00	None
ESTRADIOL TABLET 1MG (500 CT)	1	Generic	$10.00	$25.00	None
ESTRADIOL VALERATE 20mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 5 mL in 1 VIAL, MULTI-DOSE	1	Generic	$10.00	$25.00	None
ESTRADIOL VALERATE 40mg/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 5 mL in 1 VIAL, MULTI-DOSE	1	Generic	$10.00	$25.00	None
ESTRADIOL VALERATE INJECTION	1	Generic	$10.00	$25.00	None
ESTRADIOL-NORETH 1.0-0.5MG TABLET	1	Generic	$10.00	$25.00	None
ESTRING 2MG VAGINAL RING	3	Non-Preferred Brand	$95.00	$237.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ESTROPIPATE 0.625(0.75 MG) TABLET	1	Generic	$10.00	$25.00	None
ESTROPIPATE 1.25(1.5 MG) TABLET	1	Generic	$10.00	$25.00	None
ESTROPIPATE 2.5 TABLET	1	Generic	$10.00	$25.00	None
ESTROSTEP TABLETS 1;.02MG;MG 28 BLPK	3	Non-Preferred Brand	$95.00	$237.50	None
ETHAMBUTOL HCL 400 MG TABLET	1	Generic	$10.00	$25.00	None
Ethambutol Hydrochloride 100mg/1	1	Generic	$10.00	$25.00	None
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6	1	Generic	$10.00	$25.00	None
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21	1	Generic	$10.00	$25.00	None
Ethosuximide 250mg 100 CAPSULE BOTTLE	1	Generic	$10.00	$25.00	None
ETHOSUXIMIDE 250MG/5ML SYRP	1	Generic	$10.00	$25.00	None
ETIDRONATE DISODIUM 400MG TABLET (60 CT)	1	Generic	$10.00	$25.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT	1	Generic	$10.00	$25.00	None
ETODOLAC 200MG CAPSULE	1	Generic	$10.00	$25.00	None
Etodolac 300 mg capsule	1	Generic	$10.00	$25.00	None
ETODOLAC 400MG TABLET SR 24HR	1	Generic	$10.00	$25.00	None
Etodolac 400mg/1 100 TABLET BOTTLE	1	Generic	$10.00	$25.00	None
ETODOLAC 500MG TABLET SR 24HR	1	Generic	$10.00	$25.00	None
Etodolac 500mg/1 500 TABLET BOTTLE	1	Generic	$10.00	$25.00	None
ETODOLAC 600MG TABLET SR 24HR	1	Generic	$10.00	$25.00	None
ETOPOPHOS 100MG VIAL	3	Non-Preferred Brand	$95.00	$237.50	None
Etoposide 20mg/mL 1 VIAL in 1 BOX, UNIT-DOSE / 25 mL in 1 VIAL	1	Generic	$10.00	$25.00	None
Eurax Lotion and Cream 100mg/g 454 g in 1 BOTTLE	3	Non-Preferred Brand	$95.00	$237.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Eurax Lotion and Cream 100mg/g 60 g in 1 TUBE	2	Preferred Brand	$45.00	$112.50	None
EVAMIST 1.53/SPRAY SPRAY NON-AEROSOL	3	Non-Preferred Brand	$95.00	$237.50	None
Evista 60mg/1 100 TABLET BOTTLE	2	Preferred Brand	$45.00	$112.50	None
EVOCLIN 10mg/g 1 CAN in 1 CARTON / 100 g in 1 CAN	3	Non-Preferred Brand	$95.00	$237.50	None
EVOXAC 30MG CAPSULE	2	Preferred Brand	$45.00	$112.50	None
EXALGO 12mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE	3	Non-Preferred Brand	$95.00	$237.50	Q:60 /25Days
EXALGO 16mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE	3	Non-Preferred Brand	$95.00	$237.50	Q:60 /25Days
EXALGO 8mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE	3	Non-Preferred Brand	$95.00	$237.50	Q:60 /25Days
Exelderm 10mg/g 30 g in 1 TUBE	3	Non-Preferred Brand	$95.00	$237.50	None
Exelderm 10mg/mL 30 mL in 1 BOTTLE, PLASTIC	3	Non-Preferred Brand	$95.00	$237.50	None
EXELON 1.5MG CAPSULE	3	Non-Preferred Brand	$95.00	$237.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EXELON 13.3 MG/24HR PATCH	2	Preferred Brand	$45.00	$112.50	None
EXELON 2MG/ML ORAL SOLUTION	2	Preferred Brand	$45.00	$112.50	None
EXELON 3MG CAPSULE	3	Non-Preferred Brand	$95.00	$237.50	None
EXELON 4.5MG CAPSULE	3	Non-Preferred Brand	$95.00	$237.50	None
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS	2	Preferred Brand	$45.00	$112.50	None
EXELON 6MG CAPSULE	3	Non-Preferred Brand	$95.00	$237.50	None
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS	2	Preferred Brand	$45.00	$112.50	None
Exemestane 25mg/1 30 FILM COATED TABLETS in BOTTLE	1	Generic	$10.00	$25.00	None
EXFORGE 10MG-160MG TABLET	3	Non-Preferred Brand	$95.00	$237.50	None
EXFORGE 10MG-320MG TABLET	3	Non-Preferred Brand	$95.00	$237.50	None
EXFORGE 5MG-160MG TABLET	3	Non-Preferred Brand	$95.00	$237.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EXFORGE 5MG-320MG TABLET	3	Non-Preferred Brand	$95.00	$237.50	None
Exforge HCT 10; 12.5; 160mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE	3	Non-Preferred Brand	$95.00	$237.50	None
Exforge HCT 10; 25; 160mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE	3	Non-Preferred Brand	$95.00	$237.50	None
Exforge HCT 10; 25; 320mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE	3	Non-Preferred Brand	$95.00	$237.50	None
Exforge HCT 5; 12.5; 160mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE	3	Non-Preferred Brand	$95.00	$237.50	None
Exforge HCT 5; 25; 160mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE	3	Non-Preferred Brand	$95.00	$237.50	None
EXJADE 125MG TABLET	2	Preferred Brand	$45.00	$112.50	None
EXJADE 250MG TABLET	4	Specialty Tier	33%	33%	None
EXJADE 500MG TABLET	4	Specialty Tier	33%	33%	None
EXTAVIA 15 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK	4	Specialty Tier	33%	33%	None
EXTENDED PHENYTOIN SODIUM CAPSULES 300 MG	1	Generic	$10.00	$25.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EXTINA 2% FOAM	3	Non-Preferred Brand	$95.00	$237.50	None

Chart Legend:

Below are a few notes to help you understand the above 2013 Medicare Part D Security Blue ValueRx (HMO) 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.