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MedicareBlue Rx Option 1 (S5743-001-0)
Tier 1 (1877)
Tier 2 (398)
Tier 3 (462)
Tier 4 (324)

Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
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Cick on the first letter of your drug name to browse the formulary:

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2009 Medicare Part D Plan Formulary Information
MedicareBlue Rx Option 1 (S5743-001-0)
Benefit Details  
The MedicareBlue Rx Option 1 (S5743-001-0)
Formulary Drugs Starting with the Letter B
in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
Drugs Starting with Letter B

Drug Name		 Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order
BACITRACIN 500U/GM EYE OINT   1 Level 1: Covered Generic 10%10%None
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT   1 Level 1: Covered Generic 10%10%None
BACLOFEN 10MG TABLET   1 Level 1: Covered Generic 10%10%None
BACLOFEN 20MG TABLET   1 Level 1: Covered Generic 10%10%None
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT)   1 Level 1: Covered Generic 10%10%None
BALZIVA 0.4-0.035 TABLET   1 Level 1: Covered Generic 10%10%None
BANZEL TABLET   3 Level 3: Covered Brand 50%50%None
BANZEL TABLET   3 Level 3: Covered Brand 50%50%None
BARACLUDE 0.05MG/ML SOLUTION   2 Level 2: Covered Preferred Brand 22%22%None
BARACLUDE 0.5MG TABLET   2 Level 2: Covered Preferred Brand 22%22%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
BARACLUDE 1MG TABLET   2 Level 2: Covered Preferred Brand 22%22%None
BD INSULIN SYRINGE ULT-FINE II   2 Level 2: Covered Preferred Brand 22%22%None
BD INSULIN SYRINGE ULT-FINE II   2 Level 2: Covered Preferred Brand 22%22%None
BD INSULIN SYRINGE ULTRA-FINE SYRING   2 Level 2: Covered Preferred Brand 22%22%None
BD ORGINAL PEN NEEDLES 29G   2 Level 2: Covered Preferred Brand 22%22%None
BENAZEPRIL HCL 10MG TABLET   1 Level 1: Covered Generic 10%10%None
BENAZEPRIL HCL 20MG TABLET (100 CT)   1 Level 1: Covered Generic 10%10%None
BENAZEPRIL HCL 40MG TABLET   1 Level 1: Covered Generic 10%10%None
BENAZEPRIL HCL 5MG TABLET   1 Level 1: Covered Generic 10%10%None
BENAZEPRIL HCL-HCTZ TABLET 10-12.5MG (100 CT)   1 Level 1: Covered Generic 10%10%None
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT)   1 Level 1: Covered Generic 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
BENAZEPRIL HCL-HCTZ TABLET 20-25MG (100 CT)   1 Level 1: Covered Generic 10%10%None
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT)   1 Level 1: Covered Generic 10%10%None
BENICAR 20MG TABLET   3 Level 3: Covered Brand 50%50%S
BENICAR 40MG TABLET   3 Level 3: Covered Brand 50%50%S
BENICAR 5MG TABLET   3 Level 3: Covered Brand 50%50%S
BENICAR HCT 20-12.5MG TABLET   3 Level 3: Covered Brand 50%50%S
BENICAR HCT 40-25MG TABLET   3 Level 3: Covered Brand 50%50%S
BENICAR HCT TABLET 12.5-40MG (30 CT)   3 Level 3: Covered Brand 50%50%S
BENZTROPINE MES 0.5MG TABLET   1 Level 1: Covered Generic 10%10%None
BENZTROPINE MES TABLET 1MG (1000 CT)   1 Level 1: Covered Generic 10%10%None
BENZTROPINE MES TABLET 2MG (1000 CT)   1 Level 1: Covered Generic 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
BETA-VAL 0.1% CREAM   1 Level 1: Covered Generic 10%10%None
BETA-VAL 0.1% LOTION   1 Level 1: Covered Generic 10%10%None
BETAMETHASONE DIPROPIONATE 0.05% CREAM   1 Level 1: Covered Generic 10%10%None
BETAMETHASONE DIPROPIONATE 0.05% GEL   1 Level 1: Covered Generic 10%10%None
BETAMETHASONE DIPROPIONATE 0.05% GEL   1 Level 1: Covered Generic 10%10%None
BETAMETHASONE DIPROPIONATE 0.05% OINT   1 Level 1: Covered Generic 10%10%None
BETAMETHASONE DIPROPIONATE LOTION 60ML   1 Level 1: Covered Generic 10%10%None
BETAMETHASONE DP 0.05% CREAM   1 Level 1: Covered Generic 10%10%None
BETAMETHASONE DP 0.05% LOTION   1 Level 1: Covered Generic 10%10%None
BETAMETHASONE DP 0.05% OINTMENT   1 Level 1: Covered Generic 10%10%None
BETAMETHASONE VA 0.1% CREAM   1 Level 1: Covered Generic 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
BETAMETHASONE VA 0.1% LOTION   1 Level 1: Covered Generic 10%10%None
BETAMETHASONE VA 0.1% OINTMENT   1 Level 1: Covered Generic 10%10%None
BETASERON 0.3MG VIAL   4 Covered Specialty 25%25%None
BETAXOLOL 10MG TABLET   1 Level 1: Covered Generic 10%10%None
BETAXOLOL 20MG TABLET   1 Level 1: Covered Generic 10%10%None
BETAXOLOL HCL 0.5% EYE DROP   1 Level 1: Covered Generic 10%10%None
BETHANECHOL CHLORIDE 10MG TABLET (100 CT)   1 Level 1: Covered Generic 10%10%None
BETHANECHOL CHLORIDE 25MG TABLET (100 CT)   1 Level 1: Covered Generic 10%10%None
BETHANECHOL CHLORIDE 50MG TABLET (100 CT)   1 Level 1: Covered Generic 10%10%None
BETHANECHOL CHLORIDE 5MG TABLET   1 Level 1: Covered Generic 10%10%None
BETOPTIC S 0.25% EYE DROPS   3 Level 3: Covered Brand 50%50%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
BICNU 100MG VIAL   3 Level 3: Covered Brand 50%50%None
BILTRICIDE 600MG TABLET   3 Level 3: Covered Brand 50%50%None
BISOPROLOL FUMARATE 10MG TABLET (100 CT)   1 Level 1: Covered Generic 10%10%None
BISOPROLOL FUMARATE 5MG TABLET (100 CT)   1 Level 1: Covered Generic 10%10%None
BISOPROLOL FUMARATE-HCTZ TABLET 10-6.25MG (500 CT)   1 Level 1: Covered Generic 10%10%None
BISOPROLOL FUMARATE-HCTZ TABLET 2.5-6.25MG (100 CT)   1 Level 1: Covered Generic 10%10%None
BISOPROLOL FUMARATE-HCTZ TABLET 5-6.25MG (100 CT)   1 Level 1: Covered Generic 10%10%None
BLENOXANE 15 UNITS VIAL   4 Covered Specialty 25%25%P
BLEOMYCIN FOR INJECTION USP 15UNITS 1 X 10ML VIALSD   4 Covered Specialty 25%25%P
BLEOMYCIN SULFATE 30UNITS VIA   4 Covered Specialty 25%25%P
BONIVA 150MG TABLET   2 Level 2: Covered Preferred Brand 22%22%S Q:1
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
BONIVA 2.5MG TABLET   2 Level 2: Covered Preferred Brand 22%22%S Q:30
/30Days
BONIVA 3MG/3ML SYRINGE   3 Level 3: Covered Brand 50%50%S Q:1
/90Days
BOOSTRIX INJECTION SUSPENSION 2.5UNT-5ML 5 X .5ML SYR   3 Level 3: Covered Brand 50%50%None
BOROFAIR SOL 2% OTIC   1 Level 1: Covered Generic 10%10%None
BRIMONIDINE TARTRATE OPHTHALMIC SOLUTION 0.2% 10ML BOTPL   1 Level 1: Covered Generic 10%10%None
BROMOCRIPTINE MESYLATE 2.5MG TABLET   1 Level 1: Covered Generic 10%10%None
BROMOCRIPTINE MESYLATE 5MG CAPSULE   1 Level 1: Covered Generic 10%10%None
BUDEPRION SR 100MG TABLET SA   1 Level 1: Covered Generic 10%10%None
BUDEPRION SR 150MG TABLET SA   1 Level 1: Covered Generic 10%10%None
BUDEPRION XL 300MG TABLET SR 24HR   1 Level 1: Covered Generic 10%10%None
BUDEPRION XL TABLETS 150MG 500 TABLETS BOT   1 Level 1: Covered Generic 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
BUMETANIDE 0.25MG/ML VIAL   1 Level 1: Covered Generic 10%10%None
BUMETANIDE 0.5MG TABLET USP (500 CT)   1 Level 1: Covered Generic 10%10%None
BUMETANIDE 1MG TABLET USP (500 CT)   1 Level 1: Covered Generic 10%10%None
BUMETANIDE 2MG TABLET USP (500 CT)   1 Level 1: Covered Generic 10%10%None
BUPHENYL 500MG TABLET   4 Covered Specialty 25%25%None
BUPHENYL POWDER   4 Covered Specialty 25%25%None
BUPROBAN ER TABLET   1 Level 1: Covered Generic 10%10%None
BUPROPION HCL 100MG ER TABLET (60 CT)   1 Level 1: Covered Generic 10%10%None
BUPROPION HCL 75MG TABLET   1 Level 1: Covered Generic 10%10%None
BUPROPION HCL SR 200MG TABLET SA   1 Level 1: Covered Generic 10%10%None
BUPROPION HCL TABLET 100MG   1 Level 1: Covered Generic 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
BUPROPION HCL TABLET SUSTAINED RELEASE   1 Level 1: Covered Generic 10%10%None
BUSPIRONE HCL 10MG TABLET   1 Level 1: Covered Generic 10%10%None
BUSPIRONE HCL 15MG TABLET (180 CT)   1 Level 1: Covered Generic 10%10%None
BUSPIRONE HCL 30MG TABLET (60 CT)   1 Level 1: Covered Generic 10%10%None
BUSPIRONE HCL 5MG TABLET   1 Level 1: Covered Generic 10%10%None
BUSPIRONE HCL 7.5MG TABLET   1 Level 1: Covered Generic 10%10%None
BUSULFEX 6MG/ML AMPUL   4 Covered Specialty 25%25%None
BUTALBITAL ASPIRIN CAFFEINE CODEINE PHOSPHATE 325-50-40MG (500 CT)   1 Level 1: Covered Generic 10%10%None
BUTALBITAL/CAFF/APAP/COD CP   1 Level 1: Covered Generic 10%10%None
BUTORPHANOL 10MG/ML SPRAY   1 Level 1: Covered Generic 10%10%None
BYETTA 10MCG/0.04ML PEN INJ   2 Level 2: Covered Preferred Brand 22%22%S
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
BYETTA 5MCG/0.02ML PEN INJ   2 Level 2: Covered Preferred Brand 22%22%S

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D MedicareBlue Rx Option 1 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 $295 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 initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2700) 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 2009 )

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.