2015 Medicare Part D Plan Formulary Information |
WellCare Extra (PDP) (S5967-174-0)
Benefit Details
|
The WellCare Extra (PDP) (S5967-174-0) Formulary Drugs Starting with the Letter E in CMS PDP Region 2 which includes: CT MA RI VT Plan Monthly Premium: $52.70 Deductible: $0 Qualifies for LIS: No |
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 |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
E.E.S. GRAN SUS 200/5ML |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ECONAZOLE NITRATE 1% CREAM 85GM TUBE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
EDARBI 40 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:30 /30Days |
EDARBI 80 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:30 /30Days |
EDARBYCLOR 40-12.5 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:30 /30Days |
EDARBYCLOR 40-25 MG TABLET |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:30 /30Days |
EDURANT 27.5mg/1 |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
EFFIENT 10 MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
EFFIENT 5 MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EGRIFTA 1 MG VIAL |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
ELAPRASE 6mg/3mL 1 VIAL, GLASS in 1 BOX / 3 mL in 1 VIAL, GLASS |
5 |
Specialty Tier |
33% | N/A | P |
ELIDEL 1% CREAM |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
ELIGARD 22.5 MG SYRINGE |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
ELIGARD 30 MG SYRINGE |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
ELIGARD 45 MG SYRINGE |
5 |
Specialty Tier |
33% | N/A | P |
ELIGARD 7.5 MG SYRINGE |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
ELIPHOS TABLETS CALCIUM ACETATE TABLETS 667MG 200 BOT |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ELIQUIS 2.5 MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
ELIQUIS 5 MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
Elitek 3 KIT per CARTON / 1 KIT in 1 KIT |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ELLA 30 MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:1 /30Days |
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
EMCYT 140MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
EMEND 40MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
EMEND CAPSULES 125MG 6 BLPK |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
EMEND CAPSULES 80MG 2 BLPK |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
EMEND TRIFOLD PACK |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | P |
Emoquette 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EMTRIVA 10MG/ML SOLUTION |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
EMTRIVA 200MG CAPSULE |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
ENALAPRIL MALEATE 10MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 2.5 MG TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Enalapril Maleate 20mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
ENALAPRIL MALEATE 5 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Enalapril Maleate and Hydrochlorothiazide 10; 25mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ENBREL 25 MG/0.5 ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | P Q:8 /28Days |
ENBREL 25MG KIT |
5 |
Specialty Tier |
33% | N/A | P Q:8 /28Days |
ENBREL 50 MG/ML SURECLICK SYR |
5 |
Specialty Tier |
33% | N/A | P Q:8 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENBREL 50mg/mL |
5 |
Specialty Tier |
33% | N/A | P Q:8 /28Days |
ENDOCET 10MG-325MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | Q:360 /30Days |
ENDOCET 5/325 TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | Q:360 /30Days |
ENDOCET 7.5-325MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | Q:360 /30Days |
ENGERIX B INJECTION |
3 |
Preferred Brand |
$40.00 | $100.00 | P |
ENGERIX-B 10MCG 10 X 0.5ML VIALSD |
3 |
Preferred Brand |
$40.00 | $100.00 | P |
ENGERIX-B 20 MCG/ML SYRN |
3 |
Preferred Brand |
$40.00 | $100.00 | P |
ENOXAPARIN 100 MG/ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | Q:28 /30Days |
ENOXAPARIN 120 MG/0.8 ML SYR |
5 |
Specialty Tier |
33% | N/A | Q:22 /30Days |
ENOXAPARIN 150 MG/ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | Q:28 /30Days |
ENOXAPARIN 30 MG/0.3 ML SYR |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | Q:8 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ENOXAPARIN 300 MG/3 ML VIAL |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | Q:24 /30Days |
ENOXAPARIN 40 MG/0.4 ML SYR |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | Q:8 /30Days |
ENOXAPARIN 60 MG/0.6 ML SYR |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | Q:17 /30Days |
ENOXAPARIN 80 MG/0.8 ML SYR |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | Q:22 /30Days |
ENTACAPONE 200 MG TABLET [Comtan Entacapone] |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ENTECAVIR 0.5 MG TABLET [Baraclude] |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
ENTECAVIR 1 MG TABLET [Baraclude] |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
ENULOSE 10 GM/15 ML SOLUTION |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
EPITOL 200MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
EPIVIR HBV 25MG/5ML TUBEX |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
EPZICOM 600MG/300MG TABLETS |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERGOLOID MESYLATES TABLETS 1MG 100 BOT |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ERIVEDGE 150 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
ERRIN 0.35MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ERY-TAB TAB 250MG EC |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ERY-TAB TAB 333MG EC |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ERYPED 200 MG/5 ML SUSPENSION |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
ERYTHROCIN 500MG ADDVNT VL |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ERYTHROCIN TAB 250MG |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Erythromycin 2% solution |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Erythromycin 20mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ERYTHROMYCIN 500 MG FILMTAB |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ERYTHROMYCIN ES 400 MG TAB |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ERYTHROMYCIN OPHTHALMIC OINTMENT 0.5% 1 G BOX OF 50 TUBE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ERYTHROMYCIN TAB 250MG BS |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ERYTHROMYCIN-BENZOYL PEROXIDE 3-5% GEL |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ESCITALOPRAM 10 MG TABLET [Lexapro] |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | Q:30 /30Days |
ESCITALOPRAM 20 MG TABLET [Lexapro] |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | Q:30 /30Days |
ESCITALOPRAM 5 MG TABLET [Lexapro] |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | Q:30 /30Days |
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro] |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ESOMEPRAZOLE SODIUM 20 MG VIAL [Nexium] |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ESOMEPRAZOLE SODIUM 40 MG VIAL [Nexium] |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Estazolam 1mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Estazolam 2mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ESTRACE VAG CREAM 0.1MG/GM |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None |
Estradiol / Norethindrone Acetate 0.5; 0.1mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, FILM C |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Estradiol 0.025 mg patch |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Estradiol 0.0375 mg patch |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Estradiol 0.05 mg patch |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Estradiol 0.075 mg patch |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Estradiol 0.1 mg patch |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ESTRADIOL 0.5MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ESTRADIOL 2MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ESTRADIOL TABLET 1MG (500 CT) |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ESTRADIOL TDS 0.025 MG/DAY |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ESTRADIOL TDS 0.0375 MG/DAY |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ESTRADIOL TDS 0.05 MG/DAY |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ESTRADIOL TDS 0.06 MG/DAY |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ESTRADIOL TDS 0.075 MG/DAY |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ESTRADIOL TDS 0.1 MG/DAY |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ESTRADIOL-NORETH 1.0-0.5MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ESTROPIPATE 0.625(0.75 MG) TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ESTROPIPATE 1.25(1.5 MG) TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ESTROPIPATE 2.5(3 MG) TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETHAMBUTOL HCL 400 MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Ethambutol Hydrochloride 100mg/1 |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21 |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Ethosuximide 250mg 100 CAPSULE BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ETHOSUXIMIDE 250MG/5ML SYRP |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ETIDRONATE DISODIUM 400MG TABLET (60 CT) |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ETODOLAC 200MG CAPSULE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Etodolac 300 mg capsule |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ETODOLAC 400 MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ETODOLAC 400MG TABLET SR 24HR |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ETODOLAC 500MG TABLET SR 24HR |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
Etodolac 500mg/1 500 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
ETODOLAC 600MG TABLET SR 24HR |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
EVOTAZ 300 MG-150 MG TABLET |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
EXELON 13.3 MG/24HR PATCH |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:30 /30Days |
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:30 /30Days |
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:30 /30Days |
Exemestane 25mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |
EXJADE 125MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
EXJADE 250MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
EXJADE 500MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
EXTAVIA 15 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
5 |
Specialty Tier |
33% | N/A | P |
EXTENDED PHENYTOIN SODIUM CAPSULES 300 MG |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None |