2012 Medicare Part D Plan Formulary Information |
Blue MedicareRx Premier (PDP) (S2893-003-0)
Benefit Details
|
The Blue MedicareRx Premier (PDP) (S2893-003-0) Formulary Drugs Starting with the Letter B in CMS PDP Region 2 which includes: CT MA RI VT
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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 |
BACITRACIN 500[iU]/g 1 TUBE in 1 CARTON / 3.5 g in 1 TUBE |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BACLOFEN 10MG TABLET |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
Baclofen 20mg/1 500 TABLET in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BACTROBAN 2% CREAM |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | None |
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT) |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
Balziva 6 POUCH in 1 CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER PACK |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
Banzel 200mg/1 |
4 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | P |
Banzel 40mg/mL |
4 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | P |
BANZEL TABLET 400MG |
4 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BARACLUDE 0.05mg/mL 1 BOTTLE in 1 CARTON / 210 mL in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | None |
BARACLUDE 0.5MG TABLET |
5 |
Specialty Tier Drugs |
33% | N/A | None |
BARACLUDE 1MG TABLET |
5 |
Specialty Tier Drugs |
33% | N/A | None |
BENAZEPRIL HCL 10MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $4.00 | None |
BENAZEPRIL HCL 20mg/1 100 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$4.00 | $4.00 | None |
BENAZEPRIL HCL 40MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $4.00 | None |
BENAZEPRIL HCL 5MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $4.00 | None |
BENAZEPRIL HCL-HCTZ TABLET 10-12.5MG (100 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $4.00 | None |
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $4.00 | None |
BENAZEPRIL HCL-HCTZ TABLET 20-25MG (100 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $4.00 | None |
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $4.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BENICAR 20MG TABLET |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | None |
BENICAR 40MG TABLET |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | None |
BENICAR 5MG TABLET |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | None |
BENICAR HCT 20-12.5MG TABLET |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | Q:45 /30Days |
BENICAR HCT 40-25MG TABLET |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | None |
BENICAR HCT TABLET 12.5-40MG (30 CT) |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | None |
Benztropine Mesylate 1mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic Drugs |
$4.00 | $4.00 | None |
Benztropine Mesylate 2mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic Drugs |
$4.00 | $4.00 | None |
BENZTROPINE MESYLATE INJECTION 2MG/2ML |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BENZTROPINE MESYLATE TABLETS |
1 |
Preferred Generic Drugs |
$4.00 | $4.00 | None |
BEPREVE 1.5% EYE DROPS |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETAMETHASONE DIPROPIONATE 0.05% CREAM |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
Betamethasone Dipropionate 0.60mg/mL 60 mL in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$4.00 | $4.00 | None |
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE |
1 |
Preferred Generic Drugs |
$4.00 | $4.00 | None |
Betamethasone Dipropionate 0.64mg/mL 60 mL in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BETAMETHASONE DP 0.05% OINTMENT |
1 |
Preferred Generic Drugs |
$4.00 | $4.00 | None |
BETAMETHASONE VA 0.1% LOTION |
1 |
Preferred Generic Drugs |
$4.00 | $4.00 | None |
BETAMETHASONE VALERATE CREAM |
1 |
Preferred Generic Drugs |
$4.00 | $4.00 | None |
BETAMETHASONE VALERATE OINTMENT USP |
1 |
Preferred Generic Drugs |
$4.00 | $4.00 | None |
BETASERON KIT 0.3MG/VIAL 14 TRAY BOX PKGCOM |
5 |
Specialty Tier Drugs |
33% | N/A | P Q:14 /28Days |
BETAXOLOL HCL 0.5% EYE DROP |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BETHANECHOL CHLORICDE TABLET |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETHANECHOL CHLORIDE 50MG TABLET (100 CT) |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BETHANECHOL CHLORIDE 5MG TABLET |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BETHANECHOL CHLORIDE TABLETS |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BETIMOL 0.5% EYE DROPS |
4 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
BETIMOL SOLUTION 2.5MG 5 ML BOT |
4 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
BETOPTIC S OPHTHALMIC SUSPENSION 0.25% 10 ML BOT |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | None |
BICALUTAMIDE TABLETS 50MG 100 BOT |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BICILL LA PFS 600MU 1ML PED |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | None |
BICILLIN C-R 1.2MM UNITS SYR 2ML x 10 |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | None |
BICILLIN C-R 900/300 SYRINGE 2ML x 10 |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | None |
BICILLIN LA PFS 1200MU 2ML |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BICILLIN LA. 600000UNIT/ML 1ML |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | None |
BICNU 1 KIT in 1 CARTON |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | P |
BIDIL TABLET 20MG/37.5MG |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | None |
BISOPROLOL FUMARATE 10MG TABLET (100 CT) |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BISOPROLOL FUMARATE 5MG TABLET (100 CT) |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BISOPROLOL FUMARATE-HCTZ TABLET 10-6.25MG (500 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $4.00 | None |
BISOPROLOL FUMARATE-HCTZ TABLET 2.5-6.25MG (100 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $4.00 | None |
BISOPROLOL FUMARATE-HCTZ TABLET 5-6.25MG (100 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $4.00 | None |
BLEOMYCIN SULFATE 30UNITS VIA |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | P |
BLEPHAMIDE 10-0.2% EYE OINT |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | None |
BONIVA 3MG/3ML SYRINGE |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BOOSTRIX 8; 2.5; 8; 5; 2.5ug/0.5mL; ug/0.5mL; ug/0.5mL; [iU]/0.5mL; [iU]/0.5mL |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | None |
BOOSTRIX 8; 2.5; 8; 5; 2.5ug/0.5mL; ug/0.5mL; ug/0.5mL; [iU]/0.5mL; [iU]/0.5mL |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | None |
BRIELLYN |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BRILINTA 90mg/1 60 TABLET in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | P |
Brimonidine Tartrate 1.5mg/mL |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BRIMONIDINE TARTRATE OPHTHALMIC SOLUTION 0.2% 10ML BOTPL |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
Bromday 0.9mg/mL |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | None |
Bromfenac 1.035mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 2.5 mL in 1 BOTTLE, DROPPER |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
Bromocriptine mesylate 2.5mg/1 24 BOTTLE in 1 CARTON / 100 TABLET in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BROMOCRIPTINE MESYLATE 5MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BUDEPRION SR 100MG TABLET SA |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUDEPRION SR 150MG TABLET SA |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BUDEPRION XL 300MG TABLET SR 24HR |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BUDEPRION XL TABLETS 150MG 500 TABLETS BOT |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BUDESONIDE 0.25 MG/2 ML SUSP |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | P |
BUDESONIDE 0.5 MG/2 ML SUSP |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | P |
Budesonide 3mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BUMETANIDE 0.25MG/ML VIAL |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BUMETANIDE 0.5MG TABLET USP (500 CT) |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BUMETANIDE 1MG TABLET USP (500 CT) |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BUMETANIDE 2MG TABLET USP (500 CT) |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BUPHENYL 500MG TABLET |
5 |
Specialty Tier Drugs |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Buprenorphine HCl 2mg/1 30 TABLET in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | P |
Buprenorphine HCl 8mg/1 30 TABLET in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | P |
BUPROBAN ER TABLET |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BUPROPION HCL 75MG TABLET |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BUPROPION HCL SR 100 MG TABLET |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BUPROPION HCL SR 200MG TABLET SA |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BUPROPION HCL TABLET 100MG |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
Bupropion Hydrochloride 150mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BUSPIRONE HCL 15MG TABLET (180 CT) |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BUSPIRONE HCL 30MG TABLET (60 CT) |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BUSPIRONE HCL 5 MG TABLET |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUSPIRONE HCL 7.5MG TABLET |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BUSPIRONE HYDROCHLORIDE TABLETS |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BUSULFEX 6mg/mL |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | P |
BUTALBITAL/CAFF/APAP/COD CP |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
Butorphanol Tartrate 1mg/mL 10 VIAL in 1 BOX / 1 mL in 1 VIAL |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
Butorphanol Tartrate 2mg/mL 10 VIAL in 1 BOX / 2 mL in 1 VIAL |
2 |
Non-Preferred Generic Drugs |
$9.00 | $22.50 | None |
BYDUREON 2 MG VIAL |
4 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | P Q:4 /30Days |
BYETTA 10ug/0.04mL |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | P Q:2 /30Days |
BYETTA 5MCG/0.02ML PEN INJ |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | P Q:1 /30Days |
Bystolic 10mg/1 100 TABLET in 1 BLISTER PACK |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | None |
Bystolic 2.5mg/1 100 TABLET in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Bystolic 5mg/1 30 TABLET in 1 BOTTLE |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | None |
BYSTOLIC TABLETS 20MG 100 BOT |
3 |
Preferred Brand Drugs |
$30.00 | $75.00 | None |