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2012 Medicare Part D Plan Formulary Information
Blue Cross MedicareRx Standard (PDP) (S5596-033-0) Benefit Details
The Blue Cross MedicareRx Standard (PDP) (S5596-033-0) 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
Drugs Starting with Letter B Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BACiiM 500001/1 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL	5	Injectable Drug	25%	25%	None
BACITRACIN 500[iU]/g 1 TUBE in 1 CARTON / 3.5 g in 1 TUBE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
BACITRACIN INJ 50000UNT	5	Injectable Drug	25%	25%	None
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT	1*	Preferred Generic Drugs	$2.00	$3.00	None
BACLOFEN 10MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Baclofen 20mg/1 500 TABLET in 1 BOTTLE, PLASTIC	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Balziva 6 POUCH in 1 CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER PACK	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Banzel 200mg/1	4	Non-Preferred Brand Drugs	$90.00	$225.00	None
Banzel 40mg/mL	4	Non-Preferred Brand Drugs	$90.00	$225.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BANZEL TABLET 400MG	4	Non-Preferred Brand Drugs	$90.00	$225.00	None
BARACLUDE 0.05mg/mL 1 BOTTLE in 1 CARTON / 210 mL in 1 BOTTLE	4	Non-Preferred Brand Drugs	$90.00	$225.00	None
BARACLUDE 0.5MG TABLET	6	Specialty Tier Drugs	25%	N/A	None
BARACLUDE 1MG TABLET	6	Specialty Tier Drugs	25%	N/A	None
BENAZEPRIL HCL 10MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
BENAZEPRIL HCL 20mg/1 100 TABLET, FILM COATED in 1 BOTTLE, PLASTIC	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
BENAZEPRIL HCL 40MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
BENAZEPRIL HCL 5MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
BENAZEPRIL HCL-HCTZ TABLET 10-12.5MG (100 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
BENAZEPRIL HCL-HCTZ TABLET 20-25MG (100 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
BENLYSTA 120mg/1.5mL 1 VIAL in 1 CARTON / 1.5 mL in 1 VIAL	6	Specialty Tier Drugs	25%	N/A	P
BENTYL INJECTION 20MG/2ML AMP	5	Injectable Drug	25%	25%	None
Benztropine Mesylate 1mg/1 100 TABLET BOTTLE	1*	Preferred Generic Drugs	$2.00	$3.00	None
Benztropine Mesylate 2mg/1 100 TABLET BOTTLE	1*	Preferred Generic Drugs	$2.00	$3.00	None
BENZTROPINE MESYLATE INJECTION 2MG/2ML	5	Injectable Drug	25%	25%	None
BENZTROPINE MESYLATE TABLETS	1*	Preferred Generic Drugs	$2.00	$3.00	None
BETAMETHASONE DIPROPIONATE 0.05% CREAM	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Betamethasone Dipropionate 0.60mg/mL 60 mL in 1 BOTTLE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Betamethasone Dipropionate 0.64mg/mL 60 mL in 1 BOTTLE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BETAMETHASONE DP 0.05% OINTMENT	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
BETAMETHASONE VA 0.1% LOTION	1*	Preferred Generic Drugs	$2.00	$3.00	None
BETAMETHASONE VALERATE CREAM	1*	Preferred Generic Drugs	$2.00	$3.00	None
BETAMETHASONE VALERATE OINTMENT USP	1*	Preferred Generic Drugs	$2.00	$3.00	None
BETASERON KIT 0.3MG/VIAL 14 TRAY BOX PKGCOM	6	Specialty Tier Drugs	25%	N/A	P
BETAXOLOL HCL 0.5% EYE DROP	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
BETHANECHOL CHLORICDE TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
BETHANECHOL CHLORIDE 50MG TABLET (100 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
BETHANECHOL CHLORIDE 5MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
BETHANECHOL CHLORIDE TABLETS	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
BICALUTAMIDE TABLETS 50MG 100 BOT	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BICILL LA PFS 600MU 1ML PED	5	Injectable Drug	25%	25%	None
BICILLIN C-R 1.2MM UNITS SYR 2ML x 10	5	Injectable Drug	25%	25%	None
BICILLIN C-R 900/300 SYRINGE 2ML x 10	5	Injectable Drug	25%	25%	None
BICILLIN LA PFS 1200MU 2ML	5	Injectable Drug	25%	25%	None
BICILLIN LA. 600000UNIT/ML 1ML	5	Injectable Drug	25%	25%	None
BICNU 1 KIT in 1 CARTON	5	Injectable Drug	25%	25%	P
BIDIL TABLET 20MG/37.5MG	3	Preferred Brand Drugs	$40.00	$100.00	None
BISOPROLOL FUMARATE-HCTZ TABLET 10-6.25MG (500 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
BISOPROLOL FUMARATE-HCTZ TABLET 2.5-6.25MG (100 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
BISOPROLOL FUMARATE-HCTZ TABLET 5-6.25MG (100 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
BLEOMYCIN SULFATE 30UNITS VIA	5	Injectable Drug	25%	25%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BONIVA 3MG/3ML SYRINGE	5	Injectable Drug	25%	25%	P
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	$40.00	$100.00	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	$40.00	$100.00	None
BOTOX 100UNITS VIAL	5	Injectable Drug	25%	25%	P
BRIELLYN	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Brimonidine Tartrate 1.5mg/mL	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
BRIMONIDINE TARTRATE OPHTHALMIC SOLUTION 0.2% 10ML BOTPL	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Bromocriptine mesylate 2.5mg/1 24 BOTTLE in 1 CARTON / 100 TABLET in 1 BOTTLE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
BROMOCRIPTINE MESYLATE 5MG CAPSULE	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
BROVANA 15MCG/2ML VIAL NEBULIZER	4	Non-Preferred Brand Drugs	$90.00	$225.00	P Q:120 /30Days
BUDEPRION SR 100MG TABLET SA	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:60 /30Days
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	$7.00	$10.50	Q:60 /30Days
BUDEPRION XL 300MG TABLET SR 24HR	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:30 /30Days
BUDEPRION XL TABLETS 150MG 500 TABLETS BOT	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:90 /30Days
BUDESONIDE 0.25 MG/2 ML SUSP	4	Non-Preferred Brand Drugs	$90.00	$225.00	P Q:120 /30Days
BUDESONIDE 0.5 MG/2 ML SUSP	4	Non-Preferred Brand Drugs	$90.00	$225.00	P Q:120 /30Days
Budesonide 3mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
BUMETANIDE 0.25MG/ML VIAL	5	Injectable Drug	25%	25%	None
BUMETANIDE 0.5MG TABLET USP (500 CT)	1*	Preferred Generic Drugs	$2.00	$3.00	None
BUMETANIDE 1MG TABLET USP (500 CT)	1*	Preferred Generic Drugs	$2.00	$3.00	None
BUMETANIDE 2MG TABLET USP (500 CT)	1*	Preferred Generic Drugs	$2.00	$3.00	None
BUPHENYL 500MG TABLET	6	Specialty Tier Drugs	25%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BUPHENYL POWDER	6	Specialty Tier Drugs	25%	N/A	P
BUPRENEX 0.3MG/ML AMPUL	5	Injectable Drug	25%	25%	None
BUPRENORPHINE 0.3MG/ML SYRN	5	Injectable Drug	25%	25%	None
Buprenorphine HCl 2mg/1 30 TABLET in 1 BOTTLE	2	Non-Preferred Generic Drugs	$7.00	$10.50	P Q:240 /30Days
Buprenorphine HCl 8mg/1 30 TABLET in 1 BOTTLE	2	Non-Preferred Generic Drugs	$7.00	$10.50	P Q:60 /30Days
BUPROBAN ER TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:60 /30Days
BUPROPION HCL 75MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:120 /30Days
BUPROPION HCL SR 100 MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:60 /30Days
BUPROPION HCL SR 200MG TABLET SA	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:60 /30Days
BUPROPION HCL TABLET 100MG	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:120 /30Days
Bupropion Hydrochloride 150mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BUSPIRONE HCL 15MG TABLET (180 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
BUSPIRONE HCL 30MG TABLET (60 CT)	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
BUSPIRONE HCL 5 MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
BUSPIRONE HCL 7.5MG TABLET	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
BUSPIRONE HYDROCHLORIDE TABLETS	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
BUSULFEX 6mg/mL	5	Injectable Drug	25%	25%	P
BUTALBITAL/CAFF/APAP/COD CP	2	Non-Preferred Generic Drugs	$7.00	$10.50	Q:180 /30Days
BUTORPHANOL 10MG/ML SPRAY	2	Non-Preferred Generic Drugs	$7.00	$10.50	None
Butorphanol Tartrate 1mg/mL 10 VIAL in 1 BOX / 1 mL in 1 VIAL	5	Injectable Drug	25%	25%	None
Butorphanol Tartrate 2mg/mL 10 VIAL in 1 BOX / 2 mL in 1 VIAL	5	Injectable Drug	25%	25%	None
BYETTA 10ug/0.04mL	3	Preferred Brand Drugs	$40.00	$100.00	S 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	3	Preferred Brand Drugs	$40.00	$100.00	S Q:2 /30Days
Bystolic 10mg/1 100 TABLET in 1 BLISTER PACK	3	Preferred Brand Drugs	$40.00	$100.00	None
Bystolic 2.5mg/1 100 TABLET in 1 BOTTLE	3	Preferred Brand Drugs	$40.00	$100.00	None
Bystolic 5mg/1 30 TABLET in 1 BOTTLE	3	Preferred Brand Drugs	$40.00	$100.00	None
BYSTOLIC TABLETS 20MG 100 BOT	3	Preferred Brand Drugs	$40.00	$100.00	None

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D Blue Cross MedicareRx Standard (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 standard $320 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 with 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 the drug’s tier. 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 intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2930) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2012 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 September 2012 )

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.