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2015 Medicare Part D Plan Formulary Information
Blue Shield Medicare Basic Plan (PDP) (S2468-003-0) Benefit Details
The Blue Shield Medicare Basic Plan (PDP) (S2468-003-0) Formulary Drugs Starting with the Letter E in CMS PDP Region 32 which includes: CA Plan Monthly Premium: $47.60 Deductible: $320 Qualifies for LIS: No
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	$5.00	$10.00	None
EDARBI 40 MG TABLET	3	Preferred Brand	$40.00	$80.00	S
EDARBI 80 MG TABLET	3	Preferred Brand	$40.00	$80.00	S
EDARBYCLOR 40-12.5 MG TABLET	3	Preferred Brand	$40.00	$80.00	S
EDARBYCLOR 40-25 MG TABLET	3	Preferred Brand	$40.00	$80.00	S
EDURANT 27.5mg/1	6	Specialty Tier	25%	25%	None
EFFIENT 10 MG TABLET	4	Non-Preferred Brand	$90.00	$180.00	Q:30 /30Days
EFFIENT 5 MG TABLET	4	Non-Preferred Brand	$90.00	$180.00	Q:30 /30Days
EGRIFTA 1 MG VIAL	6	Specialty Tier	25%	25%	P
ELAPRASE 6mg/3mL 1 VIAL, GLASS in 1 BOX / 3 mL in 1 VIAL, GLASS	6	Specialty Tier	25%	25%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ELIDEL 1% CREAM	4	Non-Preferred Brand	$90.00	$180.00	S Q:100 /30Days
ELIGARD 22.5 MG SYRINGE	5	Injectable Drugs	25%	25%	None
ELIGARD 7.5 MG SYRINGE	5	Injectable Drugs	25%	25%	None
ELIPHOS TABLETS CALCIUM ACETATE TABLETS 667MG 200 BOT	3	Preferred Brand	$40.00	$80.00	None
ELIQUIS 2.5 MG TABLET	3	Preferred Brand	$40.00	$80.00	Q:70 /180Days
ELIQUIS 5 MG TABLET	3	Preferred Brand	$40.00	$80.00	Q:60 /30Days
Elitek 3 KIT per CARTON / 1 KIT in 1 KIT	6	Specialty Tier	25%	25%	None
ELLA 30 MG TABLET	3	Preferred Brand	$40.00	$80.00	Q:1 /2Days
ELLENCE 2MG/ML VIAL	5	Injectable Drugs	25%	25%	P
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE	4	Non-Preferred Brand	$90.00	$180.00	None
EMCYT 140MG CAPSULE	3	Preferred Brand	$40.00	$80.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EMEND 40MG CAPSULE	4	Non-Preferred Brand	$90.00	$180.00	P Q:1 /30Days
EMEND CAPSULES 125MG 6 BLPK	4	Non-Preferred Brand	$90.00	$180.00	P
EMEND CAPSULES 80MG 2 BLPK	4	Non-Preferred Brand	$90.00	$180.00	P
EMEND TRIFOLD PACK	4	Non-Preferred Brand	$90.00	$180.00	P
Emoquette 6 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	2	Non-Preferred Generic	$5.00	$10.00	None
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H	6	Specialty Tier	25%	25%	P
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H	6	Specialty Tier	25%	25%	P
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H	6	Specialty Tier	25%	25%	P
EMTRIVA 10MG/ML SOLUTION	4	Non-Preferred Brand	$90.00	$180.00	None
EMTRIVA 200MG CAPSULE	4	Non-Preferred Brand	$90.00	$180.00	None
ENALAPRIL MALEATE 10MG TABLET (100 CT)	1	Preferred Generic	$0.00	$0.00	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	$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	1	Preferred Generic	$0.00	$0.00	None
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET	1	Preferred Generic	$0.00	$0.00	None
ENBREL 25 MG/0.5 ML SYRINGE	6	Specialty Tier	25%	25%	P
ENBREL 25MG KIT	6	Specialty Tier	25%	25%	P
ENBREL 50 MG/ML SURECLICK SYR	6	Specialty Tier	25%	25%	P
ENBREL 50mg/mL	6	Specialty Tier	25%	25%	P
ENDOCET 10MG-325MG TABLET	3	Preferred Brand	$40.00	$80.00	Q:360 /30Days
ENDOCET 5/325 TABLET	3	Preferred Brand	$40.00	$80.00	Q:360 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENDOCET 7.5-325MG TABLET	3	Preferred Brand	$40.00	$80.00	Q:360 /30Days
ENGERIX B INJECTION	5	Injectable Drugs	25%	25%	P
ENGERIX-B 10MCG 10 X 0.5ML VIALSD	5	Injectable Drugs	25%	25%	P
ENGERIX-B 20 MCG/ML SYRN	5	Injectable Drugs	25%	25%	P
ENOXAPARIN 100 MG/ML SYRINGE	6	Specialty Tier	25%	25%	Q:28 /60Days
ENOXAPARIN 120 MG/0.8 ML SYR	6	Specialty Tier	25%	25%	Q:22 /60Days
ENOXAPARIN 150 MG/ML SYRINGE	6	Specialty Tier	25%	25%	Q:28 /60Days
ENOXAPARIN 30 MG/0.3 ML SYR	5	Injectable Drugs	25%	25%	Q:8 /60Days
ENOXAPARIN 300 MG/3 ML VIAL	5	Injectable Drugs	25%	25%	Q:28 /60Days
ENOXAPARIN 40 MG/0.4 ML SYR	5	Injectable Drugs	25%	25%	Q:11 /60Days
ENOXAPARIN 60 MG/0.6 ML SYR	5	Injectable Drugs	25%	25%	Q:17 /60Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ENOXAPARIN 80 MG/0.8 ML SYR	5	Injectable Drugs	25%	25%	Q:22 /60Days
ENTACAPONE 200 MG TABLET [Comtan Entacapone]	4	Non-Preferred Brand	$90.00	$180.00	None
ENTECAVIR 0.5 MG TABLET [Baraclude]	6	Specialty Tier	25%	25%	Q:30 /30Days
ENTECAVIR 1 MG TABLET [Baraclude]	6	Specialty Tier	25%	25%	Q:30 /30Days
ENULOSE 10 GM/15 ML SOLUTION	2	Non-Preferred Generic	$5.00	$10.00	None
EPINASTINE HCL 0.05% EYE DROPS	3	Preferred Brand	$40.00	$80.00	None
Epinephrine 0.15 mg auto-injct	3	Preferred Brand	$40.00	$80.00	Q:4 /2Days
Epinephrine 0.3 mg auto-inject	3	Preferred Brand	$40.00	$80.00	Q:4 /2Days
EPIPEN 0.3MG AUTO-INJECTOR	3	Preferred Brand	$40.00	$80.00	Q:4 /2Days
EPIPEN JR 0.15MG AUTO-INJCT	3	Preferred Brand	$40.00	$80.00	Q:4 /2Days
EPIRUBICIN HCL INJECTION SOLUTION 2MG 1 X 25ML VIAL	5	Injectable Drugs	25%	25%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
EPITOL 200MG TABLET	2	Non-Preferred Generic	$5.00	$10.00	None
EPIVIR HBV 25MG/5ML TUBEX	3	Preferred Brand	$40.00	$80.00	P
Eplerenone 25mg/1 90 TABLET BOTTLE	4	Non-Preferred Brand	$90.00	$180.00	None
Eplerenone 50mg/1 90 TABLET BOTTLE	4	Non-Preferred Brand	$90.00	$180.00	None
EPROSARTAN MESYLATE 600 MG TABLET	3	Preferred Brand	$40.00	$80.00	S Q:30 /30Days
EPZICOM 600MG/300MG TABLETS	6	Specialty Tier	25%	25%	None
ERBITUX 100MG/50ML VIAL	6	Specialty Tier	25%	25%	P
ERGOLOID MESYLATES TABLETS 1MG 100 BOT	3	Preferred Brand	$40.00	$80.00	P
ERIVEDGE 150 MG CAPSULE	6	Specialty Tier	25%	25%	P Q:30 /30Days
ERRIN 0.35MG TABLET	2	Non-Preferred Generic	$5.00	$10.00	None
ERWINAZE 10,000 UNITS VIAL	6	Specialty Tier	25%	25%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ERY 2% PADS 2% 60 PADS JAR	2	Non-Preferred Generic	$5.00	$10.00	None
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE	3	Preferred Brand	$40.00	$80.00	None
ERY-TAB TAB 250MG EC	3	Preferred Brand	$40.00	$80.00	None
ERY-TAB TAB 333MG EC	3	Preferred Brand	$40.00	$80.00	None
ERYTHROCIN 500MG ADDVNT VL	5	Injectable Drugs	25%	25%	None
ERYTHROCIN TAB 250MG	3	Preferred Brand	$40.00	$80.00	None
Erythromycin 2% solution	2	Non-Preferred Generic	$5.00	$10.00	None
Erythromycin 20mg/g 1 TUBE per CARTON / 60 g in 1 TUBE	2	Non-Preferred Generic	$5.00	$10.00	None
ERYTHROMYCIN 500 MG FILMTAB	2	Non-Preferred Generic	$5.00	$10.00	None
ERYTHROMYCIN ES 400 MG TAB	2	Non-Preferred Generic	$5.00	$10.00	None
ERYTHROMYCIN OPHTHALMIC OINTMENT 0.5% 1 G BOX OF 50 TUBE	2	Non-Preferred Generic	$5.00	$10.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ERYTHROMYCIN TAB 250MG BS	2	Non-Preferred Generic	$5.00	$10.00	None
ERYTHROMYCIN-BENZOYL PEROXIDE 3-5% GEL	2	Non-Preferred Generic	$5.00	$10.00	None
ESBRIET 267 MG CAPSULE	6	Specialty Tier	25%	25%	P Q:270 /30Days
ESCITALOPRAM 10 MG TABLET [Lexapro]	2	Non-Preferred Generic	$5.00	$10.00	None
ESCITALOPRAM 20 MG TABLET [Lexapro]	2	Non-Preferred Generic	$5.00	$10.00	None
ESCITALOPRAM 5 MG TABLET [Lexapro]	2	Non-Preferred Generic	$5.00	$10.00	None
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro]	3	Preferred Brand	$40.00	$80.00	None
ESOMEPRAZOLE SODIUM 20 MG VIAL [Nexium]	5	Injectable Drugs	25%	25%	None
ESOMEPRAZOLE SODIUM 40 MG VIAL [Nexium]	5	Injectable Drugs	25%	25%	None
Estradiol / Norethindrone Acetate 0.5; 0.1mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, FILM C	3	Preferred Brand	$40.00	$80.00	P
Estradiol 0.025 mg patch	2	Non-Preferred Generic	$5.00	$10.00	P Q:16 /28Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Estradiol 0.0375 mg patch	2	Non-Preferred Generic	$5.00	$10.00	P Q:16 /28Days
Estradiol 0.05 mg patch	2	Non-Preferred Generic	$5.00	$10.00	P Q:16 /28Days
Estradiol 0.075 mg patch	2	Non-Preferred Generic	$5.00	$10.00	P Q:16 /28Days
Estradiol 0.1 mg patch	2	Non-Preferred Generic	$5.00	$10.00	P Q:16 /28Days
ESTRADIOL 0.5MG TABLET	2	Non-Preferred Generic	$5.00	$10.00	P
ESTRADIOL 2MG TABLET	2	Non-Preferred Generic	$5.00	$10.00	P
ESTRADIOL TABLET 1MG (500 CT)	2	Non-Preferred Generic	$5.00	$10.00	P
ESTRADIOL TDS 0.025 MG/DAY	2	Non-Preferred Generic	$5.00	$10.00	P Q:16 /28Days
ESTRADIOL TDS 0.0375 MG/DAY	2	Non-Preferred Generic	$5.00	$10.00	P Q:16 /28Days
ESTRADIOL TDS 0.05 MG/DAY	2	Non-Preferred Generic	$5.00	$10.00	P Q:16 /28Days
ESTRADIOL TDS 0.06 MG/DAY	2	Non-Preferred Generic	$5.00	$10.00	P Q:16 /28Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ESTRADIOL TDS 0.075 MG/DAY	2	Non-Preferred Generic	$5.00	$10.00	P Q:16 /28Days
ESTRADIOL TDS 0.1 MG/DAY	2	Non-Preferred Generic	$5.00	$10.00	P Q:16 /28Days
ESTRADIOL-NORETH 1.0-0.5MG TABLET	3	Preferred Brand	$40.00	$80.00	P
ESTROPIPATE 0.625(0.75 MG) TABLET	2	Non-Preferred Generic	$5.00	$10.00	P
ESTROPIPATE 1.25(1.5 MG) TABLET	2	Non-Preferred Generic	$5.00	$10.00	P
ESTROPIPATE 2.5(3 MG) TABLET	2	Non-Preferred Generic	$5.00	$10.00	P
ESZOPICLONE 1 MG TABLET [Lunesta]	2	Non-Preferred Generic	$5.00	$10.00	P Q:30 /30Days
ESZOPICLONE 2 MG TABLET [Lunesta]	2	Non-Preferred Generic	$5.00	$10.00	P Q:30 /30Days
ESZOPICLONE 3 MG TABLET [Lunesta]	2	Non-Preferred Generic	$5.00	$10.00	P Q:30 /30Days
ETHAMBUTOL HCL 400 MG TABLET	2	Non-Preferred Generic	$5.00	$10.00	None
Ethambutol Hydrochloride 100mg/1	2	Non-Preferred Generic	$5.00	$10.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6	2	Non-Preferred Generic	$5.00	$10.00	None
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21	2	Non-Preferred Generic	$5.00	$10.00	None
Ethosuximide 250mg 100 CAPSULE BOTTLE	2	Non-Preferred Generic	$5.00	$10.00	None
ETHOSUXIMIDE 250MG/5ML SYRP	2	Non-Preferred Generic	$5.00	$10.00	None
ETIDRONATE DISODIUM 400MG TABLET (60 CT)	3	Preferred Brand	$40.00	$80.00	None
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT	3	Preferred Brand	$40.00	$80.00	None
ETODOLAC 200MG CAPSULE	2	Non-Preferred Generic	$5.00	$10.00	None
Etodolac 300 mg capsule	2	Non-Preferred Generic	$5.00	$10.00	None
ETODOLAC 400 MG TABLET	2	Non-Preferred Generic	$5.00	$10.00	None
ETODOLAC 400MG TABLET SR 24HR	3	Preferred Brand	$40.00	$80.00	None
ETODOLAC 500MG TABLET SR 24HR	3	Preferred Brand	$40.00	$80.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Etodolac 500mg/1 500 TABLET BOTTLE	2	Non-Preferred Generic	$5.00	$10.00	None
ETODOLAC 600MG TABLET SR 24HR	3	Preferred Brand	$40.00	$80.00	None
ETOPOPHOS 100MG VIAL	3	Preferred Brand	$40.00	$80.00	P
Etoposide 500 mg/25 ml vial	5	Injectable Drugs	25%	25%	P
EVOTAZ 300 MG-150 MG TABLET	6	Specialty Tier	25%	25%	None
Exemestane 25mg/1 30 FILM COATED TABLETS in BOTTLE	3	Preferred Brand	$40.00	$80.00	None
EXJADE 125MG TABLET	6	Specialty Tier	25%	25%	None
EXJADE 250MG TABLET	6	Specialty Tier	25%	25%	None
EXJADE 500MG TABLET	6	Specialty Tier	25%	25%	None
EXTAVIA 15 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	6	Specialty Tier	25%	25%	P Q:15 /30Days
EXTENDED PHENYTOIN SODIUM CAPSULES 300 MG	2	Non-Preferred Generic	$5.00	$10.00	None

Chart Legend:

Below are a few notes to help you understand the above 2015 Medicare Part D Blue Shield Medicare Basic Plan (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 $320 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 $2960) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2016 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 September 2015 )

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.