2011 Medicare Part D Plan Formulary Information |
CIGNA Medicare Rx Plan One (PDP) (S5617-123-0)
Benefit Details
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The CIGNA Medicare Rx Plan One (PDP) (S5617-123-0) Formulary Drugs Starting with the Letter B in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
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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/Preferred Brand |
$28.00 | $70.00 | None |
BACITRACIN 500U/GM EYE OINT |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BACITRACIN INJ 50000UNT |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | None |
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BACLOFEN 10MG TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BACLOFEN 20MG TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT) |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | None |
BALZIVA 0.4-0.035 TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | None |
BANZEL TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$84.00 | $210.00 | P |
BANZEL TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$84.00 | $210.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BARACLUDE 0.05MG/ML SOLUTION |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$84.00 | $210.00 | None |
BARACLUDE 0.5MG TABLET |
4 |
Specialty Tier |
25% | 25% | None |
BARACLUDE 1MG TABLET |
4 |
Specialty Tier |
25% | 25% | None |
BENAZEPRIL HCL 10MG TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BENAZEPRIL HCL 20MG TABLET (100 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BENAZEPRIL HCL 40MG TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BENAZEPRIL HCL 5MG TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BENAZEPRIL HCL-HCTZ TABLET 10-12.5MG (100 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BENAZEPRIL HCL-HCTZ TABLET 20-25MG (100 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BENZTROPINE MES TABLET 1MG (1000 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BENZTROPINE MES TABLET 2MG (1000 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BENZTROPINE MESYLATE INJECTION 2MG/2ML |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | None |
BENZTROPINE MESYLATE TABLETS |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BETA-VAL 0.1% CREAM |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BETAMETHASONE DIPROPIONATE 0.05% CREAM |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BETAMETHASONE DIPROPIONATE 0.05% GEL |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BETAMETHASONE DIPROPIONATE CREAM USP |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BETAMETHASONE DIPROPIONATE LOTION |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BETAMETHASONE DIPROPIONATE LOTION 60ML |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BETAMETHASONE DIPROPIONATE OINTMENT AUGMENTED |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETAMETHASONE DP 0.05% OINTMENT |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BETAMETHASONE VA 0.1% LOTION |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BETAMETHASONE VALERATE CREAM USP |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BETAMETHASONE VALERATE OINTMENT USP |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BETASERON KIT 0.3MG/VIAL 14 TRAY BOX PKGCOM |
4 |
Specialty Tier |
25% | 25% | P |
BETAXOLOL HCL 0.5% EYE DROP |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BETHANECHOL CHLORICDE TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BETHANECHOL CHLORIDE 50MG TABLET (100 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BETHANECHOL CHLORIDE 5MG TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BETHANECHOL CHLORIDE TABLETS |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BETIMOL 0.5% EYE DROPS |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $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 |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | None |
BETOPTIC S OPHTHALMIC SUSPENSION 0.25% 10 ML BOT |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | None |
BICALUTAMIDE TABLETS 50MG 100 BOT |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | None |
BICILL LA PFS 600MU 1ML PED |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$84.00 | $210.00 | None |
BICILLIN C-R 1.2MM UNITS SYR 2ML x 10 |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | None |
BICILLIN C-R 900/300 SYRINGE 2ML x 10 |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | None |
BICILLIN LA PFS 1200MU 2ML |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$84.00 | $210.00 | None |
BICILLIN LA. 600000UNIT/ML 1ML |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$84.00 | $210.00 | None |
BICNU INJECTION 100MG/VIL |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | P |
BILTRICIDE 600MG TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | None |
BISOPROLOL FUMARATE 10MG TABLET (100 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | 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/Preferred Brand |
$3.00 | $7.50 | None |
BISOPROLOL FUMARATE-HCTZ TABLET 10-6.25MG (500 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BISOPROLOL FUMARATE-HCTZ TABLET 2.5-6.25MG (100 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BISOPROLOL FUMARATE-HCTZ TABLET 5-6.25MG (100 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BLEOMYCIN SULFATE 30UNITS VIA |
4 |
Specialty Tier |
25% | 25% | P |
BLEPHAMIDE 10-0.2% EYE OINT |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$84.00 | $210.00 | None |
BONIVA 150MG TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | Q:1 /30Days |
BONIVA 3MG/3ML SYRINGE |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | P Q:3 /90Days |
BOOSTRIX INJECTION |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | None |
BOROFAIR SOL 2% OTIC |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BRIMONIDINE TARTRATE OPHTHALMIC SOLUTION 0.2% 10ML BOTPL |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BROMOCRIPTINE MESYLATE 2.5MG TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | None |
BROMOCRIPTINE MESYLATE 5MG CAPSULE |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | None |
BUDEPRION SR 100MG TABLET SA |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | Q:60 /30Days |
BUDEPRION SR 150MG TABLET SA |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | Q:60 /30Days |
BUDEPRION XL 300MG TABLET SR 24HR |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | Q:30 /30Days |
BUDEPRION XL TABLETS 150MG 500 TABLETS BOT |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | Q:30 /30Days |
BUDESONIDE 0.25 MG/2 ML SUSP |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | P |
BUDESONIDE 0.5 MG/2 ML SUSP |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | P |
BUMETANIDE 0.25MG/ML VIAL |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BUMETANIDE 0.5MG TABLET USP (500 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BUMETANIDE 1MG TABLET USP (500 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUMETANIDE 2MG TABLET USP (500 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BUPHENYL 500MG TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | None |
BUPHENYL POWDER |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | None |
BUPRENORPHINE 0.3MG/ML SYRN |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BUPRENORPHINE 2 MG SUBLINGUAL TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | None |
BUPRENORPHINE 8 MG SUBLINGUAL TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | None |
BUPROBAN ER TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | Q:60 /30Days |
BUPROPION HCL 150 MG TABLET SA |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | Q:60 /30Days |
BUPROPION HCL 75MG TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BUPROPION HCL SR 100 MG TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | Q:60 /30Days |
BUPROPION HCL SR 200MG TABLET SA |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUPROPION HCL TABLET 100MG |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BUSPIRONE HCL 15MG TABLET (180 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BUSPIRONE HCL 30MG TABLET (60 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BUSPIRONE HCL 5 MG TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BUSPIRONE HCL 7.5MG TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BUSPIRONE HYDROCHLORIDE TABLETS |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BUTALBITAL/CAFF/APAP/COD CP |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BUTORPHANOL 10MG/ML SPRAY |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | Q:5 /30Days |
BUTORPHANOL TARTRATE INJECTION 1MG 10 X 1ML VIAL |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BUTORPHANOL TARTRATE INJECTION 2MG 10 X 1ML VIAL |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
BYETTA 10MCG/0.04ML PEN INJ |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | Q:3 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BYETTA 5MCG/0.02ML PEN INJ |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | Q:3 /30Days |
BYSTOLIC 10MG TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | Q:120 /30Days |
BYSTOLIC 5MG TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | Q:90 /30Days |
BYSTOLIC NEBIVOLOL HCL 2.5MG TABLET ORAL |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | Q:90 /30Days |
BYSTOLIC TABLETS 20MG 100 BOT |
2 |
Non-Preferred Generic/Preferred Brand |
$28.00 | $70.00 | Q:60 /30Days |