2010 Medicare Part D Plan Formulary Information |
AmeriHealth Rx Option II (PDP) (S2321-002-0)
Benefit Details
|
The AmeriHealth Rx Option II (PDP) (S2321-002-0) Formulary Drugs Starting with the Letter B in CMS PDP Region 6 which includes: PA WV
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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 |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BACITRACIN 500U/GM EYE OINT |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BACLOFEN 10MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BACLOFEN 20MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BACTRIM 400-80MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BACTRIM DS TABLET 800-160 |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BACTROBAN 2% CREAM |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
BACTROBAN 2% OINTMENT |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BACTROBAN NASAL 2% OINTMENT |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT) |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BALZIVA 0.4-0.035 TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BANZEL TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BANZEL TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BARACLUDE 0.05MG/ML SOLUTION |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
BARACLUDE 0.5MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
BARACLUDE 1MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None |
BENAZEPRIL HCL 10MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
BENAZEPRIL HCL 20MG TABLET (100 CT) |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
BENAZEPRIL HCL 40MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
BENAZEPRIL HCL 5MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BENAZEPRIL HCL-HCTZ TABLET 10-12.5MG (100 CT) |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT) |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
BENAZEPRIL HCL-HCTZ TABLET 20-25MG (100 CT) |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT) |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
BENICAR 20MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | P |
BENICAR 40MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | P |
BENICAR 5MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | P |
BENICAR HCT 20-12.5MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | P |
BENICAR HCT 40-25MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | P |
BENICAR HCT TABLET 12.5-40MG (30 CT) |
3 |
Preferred Brand |
$35.00 | $70.00 | P |
BENTYL 10MG CAPSULE |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BENTYL 10MG/5ML SYRUP |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BENTYL 20MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BENZAMYCIN GEL |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BENZTROPINE MES 0.5MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BENZTROPINE MES TABLET 1MG (1000 CT) |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BENZTROPINE MES TABLET 2MG (1000 CT) |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BETA-VAL 0.1% CREAM |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BETA-VAL 0.1% LOTION |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BETAGAN 0.25% EYE DROPS |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BETAGAN 0.5% EYE DROPS |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BETAMETHASONE DIPROPIONATE 0.05% CREAM |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETAMETHASONE DIPROPIONATE 0.05% GEL |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BETAMETHASONE DIPROPIONATE 0.05% GEL |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BETAMETHASONE DIPROPIONATE 0.05% OINT |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BETAMETHASONE DIPROPIONATE LOTION 60ML |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BETAMETHASONE DP 0.05% CREAM |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BETAMETHASONE DP 0.05% OINTMENT |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BETAMETHASONE VA 0.1% CREAM |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BETAMETHASONE VA 0.1% LOTION |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BETAMETHASONE VA 0.1% OINTMENT |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BETAPACE 120MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BETAPACE 160MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETAPACE 240MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BETAPACE AF 80MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BETASERON KIT 0.3MG/VIAL 14 TRAY BOX PKGCOM |
5 |
Specialty |
30% | 30% | Q:15 /30Days |
BETAXOLOL HCL 0.5% EYE DROP |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BETAXOLOL TABLETS 10MG 100 BOT |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
BETAXOLOL TABLETS 20MG 100 BOT |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
BETHANECHOL CHLORIDE 10MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BETHANECHOL CHLORIDE 25MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BETHANECHOL CHLORIDE 50MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BETHANECHOL CHLORIDE 5MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BETIMOL 0.5% EYE DROPS |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETIMOL SOLUTION 2.5MG 5 ML BOT |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
BETOPTIC S OPHTHALMIC SUSPENSION 0.25% 10 ML BOT |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
BIAXIN 125MG/5ML SUSPENSION |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BIAXIN 250MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BIAXIN 250MG/5ML SUSPENSION |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BIAXIN 500MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BIAXIN XL 500MG TABLET 56 BOX |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BIAXIN XL 500MG TABLET SA |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BICALUTAMIDE TABLETS 50MG 100 BOT |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BIDIL TABLET 20MG/37.5MG |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BISOPROLOL FUMARATE 10MG TABLET (100 CT) |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BISOPROLOL FUMARATE 5MG TABLET (100 CT) |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
BISOPROLOL FUMARATE-HCTZ TABLET 10-6.25MG (500 CT) |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
BISOPROLOL FUMARATE-HCTZ TABLET 2.5-6.25MG (100 CT) |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
BISOPROLOL FUMARATE-HCTZ TABLET 5-6.25MG (100 CT) |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
BLEOMYCIN SULFATE 30UNITS VIA |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BLEPH-10 10% EYE DROPS |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BLEPHAMIDE 0.2% EYE DROPS |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
BLEPHAMIDE 10-0.2% EYE OINT |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
BOOSTRIX INJECTION SUSPENSION 2.5UNT-5ML 5 X .5ML SYR |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
BOROFAIR SOL 2% OTIC |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BRETHINE 1MG/ML VIAL |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BRETHINE 2.5MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BRETHINE 5MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BREVICON TABLET 0.5/35 |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
BRIMONIDINE TARTRATE OPHTHALMIC SOLUTION 0.2% 10ML BOTPL |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BROMOCRIPTINE MESYLATE 2.5MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BROMOCRIPTINE MESYLATE 5MG CAPSULE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BUDEPRION SR 100MG TABLET SA |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BUDEPRION SR 150MG TABLET SA |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BUDEPRION XL 300MG TABLET SR 24HR |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BUDEPRION XL TABLETS 150MG 500 TABLETS BOT |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
BUMETANIDE 0.25MG/ML VIAL |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUMETANIDE 0.5MG TABLET USP (500 CT) |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BUMETANIDE 1MG TABLET USP (500 CT) |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BUMETANIDE 2MG TABLET USP (500 CT) |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BUMEX 0.5MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BUMEX 2MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BUPHENYL 500MG TABLET |
5 |
Specialty |
30% | 30% | None |
BUPHENYL POWDER |
5 |
Specialty |
30% | 30% | None |
BUPRENORPHINE 0.3MG/ML SYRN |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BUPROBAN ER TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
BUPROPION HCL 100MG ER TABLET (60 CT) |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
BUPROPION HCL 75MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUPROPION HCL SR 200MG TABLET SA |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
BUPROPION HCL TABLET 100MG |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
BUPROPION HCL TABLET SUSTAINED RELEASE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
BUSPAR 15MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BUSPAR 30MG DIVIDOSE TABLET |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BUSPAR TABLETS 10MG 100 BOT |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BUSPAR TABLETS 5MG 100 BOT |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P |
BUSPIRONE HCL 10MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
BUSPIRONE HCL 15MG TABLET (180 CT) |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
BUSPIRONE HCL 30MG TABLET (60 CT) |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
BUSPIRONE HCL 5MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUSPIRONE HCL 7.5MG TABLET |
1 |
Preferred Generic |
$7.00 | $14.00 | None |
BUTALBITAL/CAFF/APAP/COD CP |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | Q:180 /30Days |
BUTORPHANOL 10MG/ML SPRAY |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | Q:8 /30Days |
BYETTA 10MCG/0.04ML PEN INJ |
3 |
Preferred Brand |
$35.00 | $70.00 | P Q:3 /30Days |
BYSTOLIC 10MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
BYSTOLIC 5MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
BYSTOLIC NEBIVOLOL HCL 2.5MG TABLET ORAL |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
BYSTOLIC TABLETS 20MG 100 BOT |
3 |
Preferred Brand |
$35.00 | $70.00 | None |