2010 Medicare Part D Plan Formulary Information |
Simply Prescriptions Rx 3 (PDP) (S3521-003-0)
Benefit Details
|
The Simply Prescriptions Rx 3 (PDP) (S3521-003-0) Formulary Drugs Starting with the Letter B in CMS PDP Region 3 which includes: NY
|
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 |
BACIIM POWDER FOR INJECTION SOLUTION 50000UNT/VIAL |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BACITRACIN 500U/GM EYE OINT |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BACITRACIN INJ 50000UNT |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BACLOFEN 10MG TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BACLOFEN 20MG TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BACTRIM 400-80MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BACTRIM DS TABLET 800-160 |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BACTROBAN 2% CREAM |
2 |
Tier 2 |
$30.00 | $75.00 | None |
BACTROBAN 2% OINTMENT |
3 |
Tier 3 |
$75.00 | $187.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BACTROBAN NASAL 2% OINTMENT |
2 |
Tier 2 |
$30.00 | $75.00 | None |
BALACET 325 TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BALZIVA 0.4-0.035 TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | Q:30 /30Days |
BANZEL TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | Q:240 /30Days |
BANZEL TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | Q:480 /30Days |
BARACLUDE 0.05MG/ML SOLUTION |
3 |
Tier 3 |
$75.00 | $187.50 | P Q:600 /30Days |
BARACLUDE 0.5MG TABLET |
4 |
Tier 4 |
25% | 25% | P Q:30 /30Days |
BARACLUDE 1MG TABLET |
4 |
Tier 4 |
25% | 25% | P Q:30 /30Days |
BECONASE AQ 0.042% SPRAY |
3 |
Tier 3 |
$75.00 | $187.50 | S Q:50 /30Days |
BENAZEPRIL HCL 10MG TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BENAZEPRIL HCL 20MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BENAZEPRIL HCL 40MG TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BENAZEPRIL HCL 5MG TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BENAZEPRIL HCL-HCTZ TABLET 10-12.5MG (100 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BENAZEPRIL HCL-HCTZ TABLET 20-25MG (100 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BENICAR 20MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | Q:30 /30Days |
BENICAR 40MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | Q:30 /30Days |
BENICAR 5MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | Q:30 /30Days |
BENICAR HCT 20-12.5MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BENICAR HCT 40-25MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | Q:30 /30Days |
BENICAR HCT TABLET 12.5-40MG (30 CT) |
3 |
Tier 3 |
$75.00 | $187.50 | Q:30 /30Days |
BENTYL 10MG CAPSULE |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BENTYL 10MG/5ML SYRUP |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BENTYL 20MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BENTYL INJECTION 20MG/2ML AMP |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BENZACLIN CARE KIT 50;10MG;MG 50 GM PUMP W/VISCONTOUR PKGCOM |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BENZAMYCIN GEL |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BENZTROPINE MES 0.5MG TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BENZTROPINE MES TABLET 1MG (1000 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BENZTROPINE MES TABLET 2MG (1000 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BESIVANCE BESIFLOACIN OPTHALMIC SUSPENSION 0.6% 5 ML BOTDR |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BETA-VAL 0.1% CREAM |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BETA-VAL 0.1% LOTION |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BETAGAN 0.25% EYE DROPS |
3 |
Tier 3 |
$75.00 | $187.50 | Q:20 /30Days |
BETAGAN 0.5% EYE DROPS |
3 |
Tier 3 |
$75.00 | $187.50 | Q:15 /30Days |
BETAMETHASONE DIPROPIONATE 0.05% CREAM |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BETAMETHASONE DIPROPIONATE 0.05% GEL |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BETAMETHASONE DIPROPIONATE 0.05% GEL |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BETAMETHASONE DIPROPIONATE 0.05% OINT |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BETAMETHASONE DIPROPIONATE LOTION 60ML |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BETAMETHASONE DP 0.05% CREAM |
1 |
Tier 1 |
$5.00 | $12.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETAMETHASONE DP 0.05% OINTMENT |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BETAMETHASONE VA 0.1% CREAM |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BETAMETHASONE VA 0.1% LOTION |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BETAMETHASONE VA 0.1% OINTMENT |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BETAPACE 120MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BETAPACE 160MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BETAPACE 240MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BETAPACE AF 80MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BETASERON KIT 0.3MG/VIAL 14 TRAY BOX PKGCOM |
4 |
Tier 4 |
25% | 25% | P Q:15 /30Days |
BETAXOLOL HCL 0.5% EYE DROP |
3 |
Tier 3 |
$75.00 | $187.50 | Q:20 /30Days |
BETAXOLOL TABLETS 10MG 100 BOT |
1 |
Tier 1 |
$5.00 | $12.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETAXOLOL TABLETS 20MG 100 BOT |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BETHANECHOL CHLORIDE 10MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BETHANECHOL CHLORIDE 25MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BETHANECHOL CHLORIDE 50MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BETHANECHOL CHLORIDE 5MG TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BETIMOL 0.5% EYE DROPS |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BETIMOL SOLUTION 2.5MG 5 ML BOT |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BETOPTIC S OPHTHALMIC SUSPENSION 0.25% 10 ML BOT |
3 |
Tier 3 |
$75.00 | $187.50 | Q:20 /30Days |
BIAXIN 125MG/5ML SUSPENSION |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BIAXIN 250MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BIAXIN 250MG/5ML SUSPENSION |
3 |
Tier 3 |
$75.00 | $187.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BIAXIN 500MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BIAXIN XL 500MG TABLET 56 BOX |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BIAXIN XL 500MG TABLET SA |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BICALUTAMIDE TABLETS 50MG 100 BOT |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BICILL LA PFS 600MU 1ML PED |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BICILLIN C-R 1.2MM UNITS SYR 2ML x 10 |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BICILLIN C-R 900/300 SYRINGE 2ML x 10 |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BICILLIN LA PFS 1200MU 2ML |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BICILLIN LA. 600000UNIT/ML 1ML |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BICNU INJECTION 100MG/VIL |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BIDIL TABLET 20MG/37.5MG |
3 |
Tier 3 |
$75.00 | $187.50 | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BILTRICIDE 600MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BISOPROLOL FUMARATE 10MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BISOPROLOL FUMARATE 5MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BISOPROLOL FUMARATE-HCTZ TABLET 10-6.25MG (500 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BISOPROLOL FUMARATE-HCTZ TABLET 2.5-6.25MG (100 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BISOPROLOL FUMARATE-HCTZ TABLET 5-6.25MG (100 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BLEOMYCIN SULFATE 30UNITS VIA |
4 |
Tier 4 |
25% | 25% | P |
BLEPH-10 10% EYE DROPS |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BLEPHAMIDE 0.2% EYE DROPS |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BLEPHAMIDE 10-0.2% EYE OINT |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BONIVA 150MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | 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 |
3 |
Tier 3 |
$75.00 | $187.50 | S Q:30 /30Days |
BONIVA 3MG/3ML SYRINGE |
3 |
Tier 3 |
$75.00 | $187.50 | P |
BOOSTRIX INJECTION SUSPENSION 2.5UNT-5ML 5 X .5ML SYR |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BOROFAIR SOL 2% OTIC |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BRETHINE 1MG/ML VIAL |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BRETHINE 2.5MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BRETHINE 5MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BREVICON TABLET 0.5/35 |
3 |
Tier 3 |
$75.00 | $187.50 | Q:30 /30Days |
BRIMONIDINE TARTRATE OPHTHALMIC SOLUTION 0.2% 10ML BOTPL |
1 |
Tier 1 |
$5.00 | $12.50 | Q:10 /30Days |
BROMOCRIPTINE MESYLATE 2.5MG TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BROMOCRIPTINE MESYLATE 5MG CAPSULE |
1 |
Tier 1 |
$5.00 | $12.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BROVANA 15MCG/2ML VIAL NEBULIZER |
3 |
Tier 3 |
$75.00 | $187.50 | P |
BUDEPRION SR 100MG TABLET SA |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BUDEPRION SR 150MG TABLET SA |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BUDEPRION XL 300MG TABLET SR 24HR |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BUDEPRION XL TABLETS 150MG 500 TABLETS BOT |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BUMETANIDE 0.25MG/ML VIAL |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BUMETANIDE 0.5MG TABLET USP (500 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BUMETANIDE 1MG TABLET USP (500 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BUMETANIDE 2MG TABLET USP (500 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BUMEX 0.5MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BUMEX 2MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUPHENYL 500MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
BUPHENYL POWDER |
4 |
Tier 4 |
25% | 25% | None |
BUPRENEX 0.3MG/ML AMPUL |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BUPRENORPHINE 0.3MG/ML SYRN |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BUPROBAN ER TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BUPROPION HCL 100MG ER TABLET (60 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BUPROPION HCL 75MG TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BUPROPION HCL SR 200MG TABLET SA |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BUPROPION HCL TABLET 100MG |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BUPROPION HCL TABLET SUSTAINED RELEASE |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BUSPAR 15MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUSPAR 30MG DIVIDOSE TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BUSPAR TABLETS 10MG 100 BOT |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BUSPAR TABLETS 5MG 100 BOT |
3 |
Tier 3 |
$75.00 | $187.50 | None |
BUSPIRONE HCL 10MG TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BUSPIRONE HCL 15MG TABLET (180 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BUSPIRONE HCL 30MG TABLET (60 CT) |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BUSPIRONE HCL 5MG TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BUSPIRONE HCL 7.5MG TABLET |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BUTALBITAL/CAFF/APAP/COD CP |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BUTORPHANOL 10MG/ML SPRAY |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BUTORPHANOL TARTRATE INJECTION 1MG 10 X 1ML VIAL |
1 |
Tier 1 |
$5.00 | $12.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUTORPHANOL TARTRATE INJECTION 2MG 10 X 1ML VIAL |
1 |
Tier 1 |
$5.00 | $12.50 | None |
BYETTA 10MCG/0.04ML PEN INJ |
2 |
Tier 2 |
$30.00 | $75.00 | Q:2 /30Days |
BYSTOLIC 10MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | S Q:120 /30Days |
BYSTOLIC 5MG TABLET |
3 |
Tier 3 |
$75.00 | $187.50 | S Q:30 /30Days |
BYSTOLIC NEBIVOLOL HCL 2.5MG TABLET ORAL |
3 |
Tier 3 |
$75.00 | $187.50 | S Q:30 /30Days |
BYSTOLIC TABLETS 20MG 100 BOT |
3 |
Tier 3 |
$75.00 | $187.50 | S Q:60 /30Days |