2011 Medicare Part D Plan Formulary Information |
Health Net Value Orange Option 2 (PDP) (S5678-015-0)
Sanctioned Plan
|
The Health Net Value Orange Option 2 (PDP) (S5678-015-0) Formulary Drugs Starting with the Letter B in CMS PDP Region 5 which includes: DC DE MD
|
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 |
4 |
Tier 4 Injectable |
33% | 33% | None |
BACITRACIN 500U/GM EYE OINT |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BACITRACIN INJ 50000UNT |
4 |
Tier 4 Injectable |
33% | 33% | None |
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BACLOFEN 10MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BACLOFEN 20MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BACTROBAN 2% CREAM |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$64.00 | $160.00 | None |
BACTROBAN NASAL 2% OINTMENT |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$64.00 | $160.00 | None |
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BALZIVA 0.4-0.035 TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BANZEL TABLET |
2 |
Tier 2 Preferred Brand |
$32.00 | $64.00 | Q:16 /1Days |
BANZEL TABLET |
2 |
Tier 2 Preferred Brand |
$32.00 | $64.00 | Q:8 /1Days |
BARACLUDE 0.05MG/ML SOLUTION |
2 |
Tier 2 Preferred Brand |
$32.00 | $64.00 | None |
BARACLUDE 0.5MG TABLET |
5 |
Tier 5 Specialty |
33% | 33% | None |
BARACLUDE 1MG TABLET |
5 |
Tier 5 Specialty |
33% | 33% | None |
BENAZEPRIL HCL 10MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:2 /1Days |
BENAZEPRIL HCL 20MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:2 /1Days |
BENAZEPRIL HCL 40MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:2 /1Days |
BENAZEPRIL HCL 5MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:2 /1Days |
BENAZEPRIL HCL-HCTZ TABLET 10-12.5MG (100 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:2 /1Days |
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:2 /1Days |
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 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:2 /1Days |
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:2 /1Days |
BENICAR 20MG TABLET |
2 |
Tier 2 Preferred Brand |
$32.00 | $64.00 | Q:1 /1Days |
BENICAR 40MG TABLET |
2 |
Tier 2 Preferred Brand |
$32.00 | $64.00 | Q:1 /1Days |
BENICAR 5MG TABLET |
2 |
Tier 2 Preferred Brand |
$32.00 | $64.00 | Q:1 /1Days |
BENICAR HCT 20-12.5MG TABLET |
2 |
Tier 2 Preferred Brand |
$32.00 | $64.00 | Q:1 /1Days |
BENICAR HCT 40-25MG TABLET |
2 |
Tier 2 Preferred Brand |
$32.00 | $64.00 | Q:1 /1Days |
BENICAR HCT TABLET 12.5-40MG (30 CT) |
2 |
Tier 2 Preferred Brand |
$32.00 | $64.00 | Q:1 /1Days |
BENTYL INJECTION 20MG/2ML AMP |
4 |
Tier 4 Injectable |
33% | 33% | None |
BENZOYL PEROXIDE 0.05 MG/MG / CLINDAMYCIN 0.01 MG/MG TOPICAL GEL |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$64.00 | $160.00 | None |
BENZTROPINE MES 0.5MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | 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 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BENZTROPINE MES TABLET 2MG (1000 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BENZTROPINE MESYLATE INJECTION 2MG/2ML |
4 |
Tier 4 Injectable |
33% | 33% | None |
BENZYL ALCOHOL 50 ML/ML TOPICAL LOTION [ULESFIA] |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$64.00 | $160.00 | None |
BEPREVE 1.5% EYE DROPS |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$64.00 | $160.00 | None |
BESIVANCE BESIFLOACIN OPTHALMIC SUSPENSION 0.6% 5 ML BOTDR |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$64.00 | $160.00 | S Q:5 /7Days |
BETA-VAL 0.1% CREAM |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BETAMETHASONE 0.0005 MG/MG AUGMENTED TOPICAL OINTMENT |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BETAMETHASONE DIPROPIONATE 0.05% CREAM |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BETAMETHASONE DIPROPIONATE 0.05% GEL |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BETAMETHASONE DIPROPIONATE LOTION 60ML |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETAMETHASONE DP 0.05% CREAM |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BETAMETHASONE DP 0.05% OINTMENT |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BETAMETHASONE VA 0.1% CREAM |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BETAMETHASONE VA 0.1% LOTION |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BETAMETHASONE VA 0.1% OINTMENT |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BETASERON KIT 0.3MG/VIAL 14 TRAY BOX PKGCOM |
5 |
Tier 5 Specialty |
33% | 33% | P |
BETAXOLOL HCL 0.5% EYE DROP |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BETAXOLOL TABLETS 10MG 100 BOT |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$64.00 | $160.00 | None |
BETAXOLOL TABLETS 20MG 100 BOT |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$64.00 | $160.00 | None |
BETHANECHOL CHLORIDE 10MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BETHANECHOL CHLORIDE 25MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETHANECHOL CHLORIDE 50MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BETHANECHOL CHLORIDE 5MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BETIMOL 0.5% EYE DROPS |
2 |
Tier 2 Preferred Brand |
$32.00 | $64.00 | None |
BETIMOL SOLUTION 2.5MG 5 ML BOT |
2 |
Tier 2 Preferred Brand |
$32.00 | $64.00 | None |
BETOPTIC S OPHTHALMIC SUSPENSION 0.25% 10 ML BOT |
2 |
Tier 2 Preferred Brand |
$32.00 | $64.00 | Q:1 /1Days |
BICALUTAMIDE TABLETS 50MG 100 BOT |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BICILL LA PFS 600MU 1ML PED |
4 |
Tier 4 Injectable |
33% | 33% | None |
BICILLIN C-R 1.2MM UNITS SYR 2ML x 10 |
4 |
Tier 4 Injectable |
33% | 33% | None |
BICILLIN C-R 900/300 SYRINGE 2ML x 10 |
4 |
Tier 4 Injectable |
33% | 33% | None |
BICILLIN LA PFS 1200MU 2ML |
4 |
Tier 4 Injectable |
33% | 33% | None |
BICILLIN LA. 600000UNIT/ML 1ML |
4 |
Tier 4 Injectable |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BICNU INJECTION 100MG/VIL |
4 |
Tier 4 Injectable |
33% | 33% | None |
BILTRICIDE 600MG TABLET |
2 |
Tier 2 Preferred Brand |
$32.00 | $64.00 | None |
BISOPROLOL FUMARATE 10MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BISOPROLOL FUMARATE 5MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BISOPROLOL FUMARATE-HCTZ TABLET 10-6.25MG (500 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BISOPROLOL FUMARATE-HCTZ TABLET 2.5-6.25MG (100 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BISOPROLOL FUMARATE-HCTZ TABLET 5-6.25MG (100 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BLEOMYCIN SULFATE 30UNITS VIA |
4 |
Tier 4 Injectable |
33% | 33% | None |
BLEPHAMIDE 0.2% EYE DROPS |
2 |
Tier 2 Preferred Brand |
$32.00 | $64.00 | Q:10 /10Days |
BLEPHAMIDE 10-0.2% EYE OINT |
2 |
Tier 2 Preferred Brand |
$32.00 | $64.00 | None |
BONIVA 150MG TABLET |
2 |
Tier 2 Preferred Brand |
$32.00 | $64.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BONIVA 3MG/3ML SYRINGE |
4 |
Tier 4 Injectable |
33% | 33% | None |
BOOSTRIX INJECTION SUSPENSION 2.5UNT-5ML 5 X .5ML SYR |
4 |
Tier 4 Injectable |
33% | 33% | None |
BOROFAIR SOL 2% OTIC |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BOTOX 100UNITS VIAL |
4 |
Tier 4 Injectable |
33% | 33% | P |
BRIMONIDINE TARTRATE OPHTHALMIC SOLUTION 0.2% 10ML BOTPL |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BROMOCRIPTINE MESYLATE 2.5MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BROMOCRIPTINE MESYLATE 5MG CAPSULE |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BUDEPRION SR 100MG TABLET SA |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:4 /1Days |
BUDEPRION SR 150MG TABLET SA |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:2 /1Days |
BUDEPRION XL 300MG TABLET SR 24HR |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$64.00 | $160.00 | Q:1 /1Days |
BUDEPRION XL TABLETS 150MG 500 TABLETS BOT |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUDESONIDE 0.25 MG/2 ML SUSP |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | P Q:4 /1Days |
BUDESONIDE 0.5 MG/2 ML SUSP |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | P Q:4 /1Days |
BUMETANIDE 0.25MG/ML VIAL |
4 |
Tier 4 Injectable |
33% | 33% | None |
BUMETANIDE 0.5MG TABLET USP (500 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BUMETANIDE 1MG TABLET USP (500 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BUMETANIDE 2MG TABLET USP (500 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BUPHENYL 500MG TABLET |
5 |
Tier 5 Specialty |
33% | 33% | None |
BUPHENYL POWDER |
5 |
Tier 5 Specialty |
33% | 33% | None |
BUPRENEX 0.3MG/ML AMPUL |
4 |
Tier 4 Injectable |
33% | 33% | None |
BUPRENORPHINE 0.3MG/ML SYRN |
4 |
Tier 4 Injectable |
33% | 33% | None |
BUPROBAN ER TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUPROPION HCL 150 MG TABLET SA |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:2 /1Days |
BUPROPION HCL 75MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:6 /1Days |
BUPROPION HCL SR 100 MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:4 /1Days |
BUPROPION HCL SR 200MG TABLET SA |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:2 /1Days |
BUPROPION HCL TABLET 100MG |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:4 /1Days |
BUSPIRONE HCL 10MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BUSPIRONE HCL 15MG TABLET (180 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BUSPIRONE HCL 30MG TABLET (60 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BUSPIRONE HCL 5 MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BUSPIRONE HCL 7.5MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
BUTALBITAL/CAFF/APAP/COD CP |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$64.00 | $160.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUTORPHANOL TARTRATE INJECTION 1MG 10 X 1ML VIAL |
4 |
Tier 4 Injectable |
33% | 33% | None |
BUTORPHANOL TARTRATE INJECTION 2MG 10 X 1ML VIAL |
4 |
Tier 4 Injectable |
33% | 33% | None |
BYETTA 10MCG/0.04ML PEN INJ |
4 |
Tier 4 Injectable |
33% | 33% | P |
BYETTA 5MCG/0.02ML PEN INJ |
4 |
Tier 4 Injectable |
33% | 33% | P |
BYSTOLIC 10MG TABLET |
2 |
Tier 2 Preferred Brand |
$32.00 | $64.00 | Q:4 /1Days |
BYSTOLIC 5MG TABLET |
2 |
Tier 2 Preferred Brand |
$32.00 | $64.00 | Q:1 /1Days |
BYSTOLIC NEBIVOLOL HCL 2.5MG TABLET ORAL |
2 |
Tier 2 Preferred Brand |
$32.00 | $64.00 | Q:1 /1Days |
BYSTOLIC TABLETS 20MG 100 BOT |
2 |
Tier 2 Preferred Brand |
$32.00 | $64.00 | Q:2 /1Days |