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2010 Medicare Part D Plan (PDP Only) Formulary Browser

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EnvisionRxPlus Gold (PDP) (S7694-066-0)
Tier 1 (1359)
Tier 2 (198)
Tier 3 (298)
Tier 4 (365)
Tier 5 (116)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
  *required
 
Cick on the first letter of your drug name to browse the formulary:

A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2010 Medicare Part D Plan Formulary Information
EnvisionRxPlus Gold (PDP) (S7694-066-0)
Benefit Details  
The EnvisionRxPlus Gold (PDP) (S7694-066-0)
Formulary Drugs Starting with the Letter B

in CMS PDP Region 32 which includes: CA
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 Preferred Generic $4.00$12.00None
BACITRACIN 500U/GM EYE OINT   1 Tier 1 Preferred Generic $4.00$12.00None
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT   1 Tier 1 Preferred Generic $4.00$12.00None
BACLOFEN 10MG TABLET   1 Tier 1 Preferred Generic $4.00$12.00None
BACLOFEN 20MG TABLET   1 Tier 1 Preferred Generic $4.00$12.00None
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT)   2 Tier 2 NonPreferred Generics $30.00$90.00None
BANZEL TABLET   4 Tier 4 NonPreferred Brand 25%25%None
BANZEL TABLET   4 Tier 4 NonPreferred Brand 25%25%None
BARACLUDE 0.05MG/ML SOLUTION   4 Tier 4 NonPreferred Brand 25%25%None
BARACLUDE 0.5MG TABLET   5 Tier 5 Specialty 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BARACLUDE 1MG TABLET   5 Tier 5 Specialty 25%N/ANone
BENAZEPRIL HCL 10MG TABLET   1 Tier 1 Preferred Generic $4.00$12.00None
BENAZEPRIL HCL 20MG TABLET (100 CT)   1 Tier 1 Preferred Generic $4.00$12.00None
BENAZEPRIL HCL 40MG TABLET   1 Tier 1 Preferred Generic $4.00$12.00None
BENAZEPRIL HCL 5MG TABLET   1 Tier 1 Preferred Generic $4.00$12.00None
BENAZEPRIL HCL-HCTZ TABLET 10-12.5MG (100 CT)   1 Tier 1 Preferred Generic $4.00$12.00None
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT)   1 Tier 1 Preferred Generic $4.00$12.00None
BENAZEPRIL HCL-HCTZ TABLET 20-25MG (100 CT)   1 Tier 1 Preferred Generic $4.00$12.00None
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT)   1 Tier 1 Preferred Generic $4.00$12.00None
BENZTROPINE MES 0.5MG TABLET   1 Tier 1 Preferred Generic $4.00$12.00None
BENZTROPINE MES TABLET 1MG (1000 CT)   1 Tier 1 Preferred Generic $4.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BENZTROPINE MES TABLET 2MG (1000 CT)   1 Tier 1 Preferred Generic $4.00$12.00None
BETA-VAL 0.1% CREAM   1 Tier 1 Preferred Generic $4.00$12.00None
BETA-VAL 0.1% LOTION   1 Tier 1 Preferred Generic $4.00$12.00None
BETAMETHASONE DIPROPIONATE 0.05% GEL   1 Tier 1 Preferred Generic $4.00$12.00None
BETAMETHASONE DIPROPIONATE LOTION 60ML   1 Tier 1 Preferred Generic $4.00$12.00None
BETAMETHASONE DP 0.05% CREAM   1 Tier 1 Preferred Generic $4.00$12.00None
BETAMETHASONE DP 0.05% OINTMENT   1 Tier 1 Preferred Generic $4.00$12.00None
BETAMETHASONE VA 0.1% CREAM   1 Tier 1 Preferred Generic $4.00$12.00None
BETAMETHASONE VA 0.1% LOTION   1 Tier 1 Preferred Generic $4.00$12.00None
BETAMETHASONE VA 0.1% OINTMENT   1 Tier 1 Preferred Generic $4.00$12.00None
BETASERON KIT 0.3MG/VIAL 14 TRAY BOX PKGCOM   5 Tier 5 Specialty 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BETAXOLOL HCL 0.5% EYE DROP   1 Tier 1 Preferred Generic $4.00$12.00None
BETAXOLOL TABLETS 10MG 100 BOT   1 Tier 1 Preferred Generic $4.00$12.00None
BETAXOLOL TABLETS 20MG 100 BOT   1 Tier 1 Preferred Generic $4.00$12.00None
BICALUTAMIDE TABLETS 50MG 100 BOT   2 Tier 2 NonPreferred Generics $30.00$90.00None
BISOPROLOL FUMARATE 10MG TABLET (100 CT)   1 Tier 1 Preferred Generic $4.00$12.00None
BISOPROLOL FUMARATE 5MG TABLET (100 CT)   1 Tier 1 Preferred Generic $4.00$12.00None
BISOPROLOL FUMARATE-HCTZ TABLET 10-6.25MG (500 CT)   1 Tier 1 Preferred Generic $4.00$12.00None
BISOPROLOL FUMARATE-HCTZ TABLET 2.5-6.25MG (100 CT)   1 Tier 1 Preferred Generic $4.00$12.00None
BISOPROLOL FUMARATE-HCTZ TABLET 5-6.25MG (100 CT)   1 Tier 1 Preferred Generic $4.00$12.00None
BLEOMYCIN SULFATE 30UNITS VIA   2 Tier 2 NonPreferred Generics $30.00$90.00None
BOOSTRIX INJECTION SUSPENSION 2.5UNT-5ML 5 X .5ML SYR   3 Tier 3 Preferred Brand $25.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BOROFAIR SOL 2% OTIC   1 Tier 1 Preferred Generic $4.00$12.00None
BRIMONIDINE TARTRATE OPHTHALMIC SOLUTION 0.2% 10ML BOTPL   1 Tier 1 Preferred Generic $4.00$12.00None
BROMOCRIPTINE MESYLATE 2.5MG TABLET   2 Tier 2 NonPreferred Generics $30.00$90.00None
BROMOCRIPTINE MESYLATE 5MG CAPSULE   2 Tier 2 NonPreferred Generics $30.00$90.00None
BUDEPRION SR 100MG TABLET SA   1 Tier 1 Preferred Generic $4.00$12.00None
BUDEPRION SR 150MG TABLET SA   1 Tier 1 Preferred Generic $4.00$12.00None
BUDEPRION XL 300MG TABLET SR 24HR   2 Tier 2 NonPreferred Generics $30.00$90.00None
BUMETANIDE 0.25MG/ML VIAL   1 Tier 1 Preferred Generic $4.00$12.00None
BUMETANIDE 0.5MG TABLET USP (500 CT)   1 Tier 1 Preferred Generic $4.00$12.00None
BUMETANIDE 1MG TABLET USP (500 CT)   1 Tier 1 Preferred Generic $4.00$12.00None
BUMETANIDE 2MG TABLET USP (500 CT)   1 Tier 1 Preferred Generic $4.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BUPHENYL 500MG TABLET   4 Tier 4 NonPreferred Brand 25%25%None
BUPHENYL POWDER   4 Tier 4 NonPreferred Brand 25%25%None
BUPRENORPHINE 0.3MG/ML SYRN   1 Tier 1 Preferred Generic $4.00$12.00None
BUPROPION HCL 100MG ER TABLET (60 CT)   1 Tier 1 Preferred Generic $4.00$12.00None
BUPROPION HCL 75MG TABLET   1 Tier 1 Preferred Generic $4.00$12.00None
BUPROPION HCL SR 200MG TABLET SA   1 Tier 1 Preferred Generic $4.00$12.00None
BUPROPION HCL TABLET 100MG   1 Tier 1 Preferred Generic $4.00$12.00None
BUPROPION HCL TABLET SUSTAINED RELEASE   1 Tier 1 Preferred Generic $4.00$12.00None
BUSPIRONE HCL 10MG TABLET   1 Tier 1 Preferred Generic $4.00$12.00None
BUSPIRONE HCL 15MG TABLET (180 CT)   1 Tier 1 Preferred Generic $4.00$12.00None
BUSPIRONE HCL 30MG TABLET (60 CT)   1 Tier 1 Preferred Generic $4.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BUSPIRONE HCL 5MG TABLET   1 Tier 1 Preferred Generic $4.00$12.00None
BUSPIRONE HCL 7.5MG TABLET   1 Tier 1 Preferred Generic $4.00$12.00None
BUTALBITAL/CAFF/APAP/COD CP   1 Tier 1 Preferred Generic $4.00$12.00None
BUTORPHANOL 10MG/ML SPRAY   1 Tier 1 Preferred Generic $4.00$12.00None
BUTORPHANOL TARTRATE INJECTION 1MG 10 X 1ML VIAL   1 Tier 1 Preferred Generic $4.00$12.00None
BUTORPHANOL TARTRATE INJECTION 2MG 10 X 1ML VIAL   1 Tier 1 Preferred Generic $4.00$12.00None
BYETTA 10MCG/0.04ML PEN INJ   4 Tier 4 NonPreferred Brand 25%25%None
BYSTOLIC 10MG TABLET   3 Tier 3 Preferred Brand $25.00$75.00None
BYSTOLIC 5MG TABLET   3 Tier 3 Preferred Brand $25.00$75.00None
BYSTOLIC NEBIVOLOL HCL 2.5MG TABLET ORAL   3 Tier 3 Preferred Brand $25.00$75.00None
BYSTOLIC TABLETS 20MG 100 BOT   3 Tier 3 Preferred Brand $25.00$75.00None

Chart Legend:

Below are a few notes to help you understand the above 2010 Medicare Part D EnvisionRxPlus Gold (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 the standard $310 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 wit 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 which tier the drug is in. 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 $2830) 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 2010 )

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.







Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.