2013 Medicare Part D Plan Formulary Information |
United American - Enhanced (PDP) (S5755-006-0)
Benefit Details
|
The United American - Enhanced (PDP) (S5755-006-0) 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 |
$7.00 | $30.00 | None |
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
BACLOFEN 10MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
baclofen 20 mg tablet |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
BACTROBAN 2% CREAM |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
BACTROBAN NASAL 2% OINTMENT |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT) |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
Balziva 6 POUCH in 1 CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER PACK |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
Banzel 200mg/1 |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
Banzel 40mg/mL |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BANZEL TABLET 400MG |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
BARACLUDE 0.05mg/mL 1 BOTTLE in 1 CARTON / 210 mL in 1 BOTTLE |
3 |
Preferred Brand |
$40.00 | $90.00 | Q:1890 /90Days |
BARACLUDE 0.5MG TABLET |
3 |
Preferred Brand |
$40.00 | $90.00 | Q:90 /90Days |
BARACLUDE 1MG TABLET |
3 |
Preferred Brand |
$40.00 | $90.00 | Q:90 /90Days |
BENAZEPRIL HCL 10MG TABLET |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
BENAZEPRIL HCL 20mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
BENAZEPRIL HCL 40MG TABLET |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
BENAZEPRIL HCL 5MG TABLET |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
BENAZEPRIL HCL-HCTZ TABLET 10-12.5MG (100 CT) |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:720 /90Days |
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT) |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:360 /90Days |
BENAZEPRIL HCL-HCTZ TABLET 20-25MG (100 CT) |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:360 /90Days |
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 |
$7.00 | $30.00 | Q:1440 /90Days |
BENICAR 20MG TABLET |
3 |
Preferred Brand |
$40.00 | $90.00 | Q:90 /90Days |
BENICAR 40MG TABLET |
3 |
Preferred Brand |
$40.00 | $90.00 | Q:90 /90Days |
BENICAR 5MG TABLET |
3 |
Preferred Brand |
$40.00 | $90.00 | Q:180 /90Days |
BENICAR HCT 20-12.5MG TABLET |
3 |
Preferred Brand |
$40.00 | $90.00 | Q:90 /90Days |
BENICAR HCT 40-25MG TABLET |
3 |
Preferred Brand |
$40.00 | $90.00 | Q:90 /90Days |
BENICAR HCT TABLET 12.5-40MG (30 CT) |
3 |
Preferred Brand |
$40.00 | $90.00 | Q:90 /90Days |
Benztropine Mesylate 1mg 100 TABLET BOTTLE |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
Benztropine Mesylate 1mg/mL 5 VIAL, SINGLE-USE in 1 CARTON / 2 mL in 1 VIAL, SINGLE-USE |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
Benztropine Mesylate 2mg/1 100 TABLET BOTTLE |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
BENZTROPINE MESYLATE TABLETS |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BENZYL ALCOHOL 50 ML/ML TOPICAL LOTION [ULESFIA] |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
BEPREVE 1.5% EYE DROPS |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
BESIVANCE BESIFLOACIN OPTHALMIC SUSPENSION 0.6% 5 ML BOTDR |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
BETAMETHASONE DIPROPIONATE 0.05% CREAM |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
Betamethasone Dipropionate 0.60mg/mL 60 mL in 1 BOTTLE |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
Betamethasone Dipropionate 0.64mg/mL 60 mL in 1 BOTTLE |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
Betamethasone DP 0.05% ointment |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
BETAMETHASONE DP AUG 0.05% GEL |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
betamethasone valer 0.12% foam |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
BETAMETHASONE VALERATE 0.1% lotion |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETAMETHASONE VALERATE CREAM |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
BETAMETHASONE VALERATE OINTMENT USP |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
BETASERON KIT 0.3MG/VIAL 14 TRAY BOX PKGCOM |
5 |
Specialty |
29% | 29% | P Q:45 /90Days |
Betaxolol 10mg/1 |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
Betaxolol 20mg/1 100 FILM COATED TABLETS in BOTTLE |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
betaxolol hcl 0.5% eye drop |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
BETHANECHOL 10 MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
BETHANECHOL CHLORIDE 25MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
BETHANECHOL CHLORIDE 50MG TABLET (100 CT) |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
BETHANECHOL CHLORIDE 5MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
BETOPTIC S OPHTHALMIC SUSPENSION 0.25% 10 ML BOT |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BICALUTAMIDE TABLETS 50MG 100 BOT |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
BICILL LA PFS 600MU 1ML PED |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
BICILLIN C-R 1.2MM UNITS SYR 2ML x 10 |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
BICILLIN C-R 900/300 SYRINGE 2ML x 10 |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
BICILLIN LA PFS 1200MU 2ML |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
BICILLIN LA. 600000UNIT/ML 1ML |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
BICNU 1 KIT in 1 CARTON |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
BIDIL TABLET |
3 |
Preferred Brand |
$40.00 | $90.00 | Q:540 /90Days |
BILTRICIDE 600MG TABLET |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
BISOPROLOL FUMARATE 10MG TABLET (100 CT) |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
BISOPROLOL FUMARATE 5MG TABLET (100 CT) |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BISOPROLOL FUMARATE-HCTZ TABLET 10-6.25MG (500 CT) |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
BISOPROLOL FUMARATE-HCTZ TABLET 2.5-6.25MG (100 CT) |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
BISOPROLOL FUMARATE-HCTZ TABLET 5-6.25MG (100 CT) |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
BLEOMYCIN SULFATE 30UNITS VIA |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
BLEPH-10 10% EYE DROPS |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
BLEPHAMIDE 0.2% EYE DROPS |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
BLEPHAMIDE 10-0.2% EYE OINT |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | 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 |
$40.00 | $90.00 | 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 |
$40.00 | $90.00 | None |
BOSULIF 100 MG TABLET |
5 |
Specialty |
29% | 29% | P Q:360 /90Days |
BOSULIF 500 MG TABLET |
5 |
Specialty |
29% | 29% | P Q:90 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BRIELLYN |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
BRILINTA 90mg/1 60 TABLET BOTTLE |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
Brimonidine Tartrate 1.5mg/mL |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
BRIMONIDINE TARTRATE OPHTHALMIC SOLUTION 0.2% 10ML BOTPL |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
BROMDAY 0.09% EYE DROPS |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
Bromfenac 1.035mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 2.5 mL in 1 BOTTLE, DROPPER |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
Bromocriptine mesylate 2.5mg/1 24 BOTTLE in 1 CARTON / 100 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
BROMOCRIPTINE MESYLATE 5MG CAPSULE |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
BUDEPRION SR 100MG TABLET SA |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:180 /90Days |
BUDEPRION SR 150MG TABLET SA |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:180 /90Days |
BUDESONIDE 0.25 MG/2 ML SUSP |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUDESONIDE 0.5 MG/2 ML SUSP |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | P |
Budesonide 3mg 100 CAPSULE BOTTLE |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
BUMETANIDE 0.25MG/ML VIAL |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
BUMETANIDE 0.5MG TABLET USP (500 CT) |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
BUMETANIDE 1MG TABLET USP (500 CT) |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
BUMETANIDE 2MG TABLET USP (500 CT) |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
BUPHENYL 500MG TABLET |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
BUPHENYL POWDER |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
BUPRENEX 0.3MG/ML AMPUL |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
buprenorphin-naloxon 2-0.5 mg tb |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
buprenorphin-naloxon 8-2 mg tb |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUPRENORPHINE 0.3MG/ML SYRN |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
Buprenorphine HCl 2mg/1 30 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
Buprenorphine HCl 8mg/1 30 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
BUPROBAN ER TABLET |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | P Q:180 /90Days |
BUPROPION HCL 75MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
BUPROPION HCL SR 100 MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:180 /90Days |
BUPROPION HCL SR 200MG TABLET SA |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:180 /90Days |
BUPROPION HCL TABLET 100MG |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
BUPROPION HCL XL 150 MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:270 /90Days |
Bupropion Hydrochloride 150mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:180 /90Days |
Bupropion Hydrochloride XL 300mg/1 500 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | Q:90 /90Days |
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 |
$7.00 | $30.00 | None |
BUSPIRONE HCL 30MG TABLET (60 CT) |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
BUSPIRONE HCL 5 MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
BUSPIRONE HCL 7.5MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
BUSPIRONE HYDROCHLORIDE TABLETS |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | None |
BUSULFEX 6mg/mL |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
BUTORPHANOL 10MG/ML SPRAY |
2* |
Non-Preferred Generic |
$7.00 | $30.00 | P Q:30 /90Days |
Butrans 10ug/h |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
Butrans 20ug/h |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
Butrans 5ug/h |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
BYDUREON 2 MG VIAL |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BYETTA 10ug/0.04mL |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
BYETTA 5MCG/0.02ML PEN INJ |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
Bystolic 10mg 100 TABLET in BLISTER PACK |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
Bystolic 2.5mg 100 TABLETBOTTLE |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
Bystolic 5mg 30 TABLET BOTTLE |
3 |
Preferred Brand |
$40.00 | $90.00 | None |
BYSTOLIC TABLETS 20MG 100 BOT |
3 |
Preferred Brand |
$40.00 | $90.00 | None |