Q1Medicare.com 2013 Medicare Part D or Medicare Advantage Plan Formulary Browser

2013 Medicare Part D Plan Formulary Information
SilverScript Basic (PDP) (S5601-008-0) Sanctioned Plan
The SilverScript Basic (PDP) (S5601-008-0) Formulary Drugs Starting with the Letter B in CMS PDP Region 4 which includes: NJ
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
BACITRACIN 500[iU]/g 1 TUBE in 1 CARTON / 3.5 g in 1 TUBE	2	Preferred Brands	21%	21%	None
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT	1	Generics	$2.00	$5.00	None
BACLOFEN 10MG TABLET	1	Generics	$2.00	$5.00	None
Baclofen 20mg/1 500 TABLET in 1 BOTTLE, PLASTIC	1	Generics	$2.00	$5.00	None
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT)	2	Preferred Brands	21%	21%	None
Balziva 6 POUCH in 1 CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER PACK	1	Generics	$2.00	$5.00	None
Banzel 200mg/1	3	Non-Preferred Brand Drugs	42%	42%	None
Banzel 40mg/mL	3	Non-Preferred Brand Drugs	42%	42%	None
BANZEL TABLET 400MG	3	Non-Preferred Brand Drugs	42%	42%	None
BARACLUDE 0.05mg/mL 1 BOTTLE in 1 CARTON / 210 mL in 1 BOTTLE	2	Preferred Brands	21%	21%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BARACLUDE 0.5MG TABLET	2	Preferred Brands	21%	21%	None
BARACLUDE 1MG TABLET	2	Preferred Brands	21%	21%	None
BENAZEPRIL HCL 10MG TABLET	1	Generics	$2.00	$5.00	None
BENAZEPRIL HCL 20mg/1 100 TABLET, FILM COATED in 1 BOTTLE, PLASTIC	1	Generics	$2.00	$5.00	None
BENAZEPRIL HCL 40MG TABLET	1	Generics	$2.00	$5.00	None
BENAZEPRIL HCL 5MG TABLET	1	Generics	$2.00	$5.00	None
BENAZEPRIL HCL-HCTZ TABLET 10-12.5MG (100 CT)	1	Generics	$2.00	$5.00	None
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT)	1	Generics	$2.00	$5.00	None
BENAZEPRIL HCL-HCTZ TABLET 20-25MG (100 CT)	1	Generics	$2.00	$5.00	None
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT)	1	Generics	$2.00	$5.00	None
BENICAR 20MG TABLET	2	Preferred Brands	21%	21%	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BENICAR 40MG TABLET	2	Preferred Brands	21%	21%	Q:30 /30Days
BENICAR 5MG TABLET	2	Preferred Brands	21%	21%	Q:60 /30Days
BENICAR HCT 20-12.5MG TABLET	2	Preferred Brands	21%	21%	Q:30 /30Days
BENICAR HCT 40-25MG TABLET	2	Preferred Brands	21%	21%	Q:30 /30Days
BENICAR HCT TABLET 12.5-40MG (30 CT)	2	Preferred Brands	21%	21%	Q:30 /30Days
Benztropine Mesylate 1mg 100 TABLET BOTTLE	1	Generics	$2.00	$5.00	None
Benztropine Mesylate 2mg/1 100 TABLET BOTTLE	1	Generics	$2.00	$5.00	None
BENZTROPINE MESYLATE INJECTION 2MG/2ML	3	Non-Preferred Brand Drugs	42%	42%	None
BENZTROPINE MESYLATE TABLETS	1	Generics	$2.00	$5.00	None
BEPREVE 1.5% EYE DROPS	2	Preferred Brands	21%	21%	None
BESIVANCE BESIFLOACIN OPTHALMIC SUSPENSION 0.6% 5 ML BOTDR	2	Preferred Brands	21%	21%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BETAMETHASONE DIPROPIONATE 0.05% CREAM	1	Generics	$2.00	$5.00	None
Betamethasone Dipropionate 0.60mg/mL 60 mL in 1 BOTTLE	1	Generics	$2.00	$5.00	None
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE	1	Generics	$2.00	$5.00	None
Betamethasone Dipropionate 0.64mg/g 45 g in 1 TUBE	1	Generics	$2.00	$5.00	None
Betamethasone Dipropionate 0.64mg/mL 60 mL in 1 BOTTLE	2	Preferred Brands	21%	21%	None
BETAMETHASONE VALERATE 0.1% lotion	1	Generics	$2.00	$5.00	None
BETAMETHASONE VALERATE CREAM	1	Generics	$2.00	$5.00	None
BETAMETHASONE VALERATE OINTMENT USP	1	Generics	$2.00	$5.00	None
BETASERON KIT 0.3MG/VIAL 14 TRAY BOX PKGCOM	4	Specialty	25%	25%	P Q:14 /28Days
betaxolol hcl 0.5% eye drop	1	Generics	$2.00	$5.00	None
BETHANECHOL CHLORICDE TABLET	1	Generics	$2.00	$5.00	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	Generics	$2.00	$5.00	None
BETHANECHOL CHLORIDE 5MG TABLET	1	Generics	$2.00	$5.00	None
BETHANECHOL CHLORIDE TABLETS	1	Generics	$2.00	$5.00	None
BETOPTIC S OPHTHALMIC SUSPENSION 0.25% 10 ML BOT	3	Non-Preferred Brand Drugs	42%	42%	None
BICALUTAMIDE TABLETS 50MG 100 BOT	2	Preferred Brands	21%	21%	Q:30 /30Days
BICILL LA PFS 600MU 1ML PED	3	Non-Preferred Brand Drugs	42%	42%	None
BICILLIN C-R 1.2MM UNITS SYR 2ML x 10	3	Non-Preferred Brand Drugs	42%	42%	None
BICILLIN C-R 900/300 SYRINGE 2ML x 10	3	Non-Preferred Brand Drugs	42%	42%	None
BICILLIN LA PFS 1200MU 2ML	3	Non-Preferred Brand Drugs	42%	42%	None
BICILLIN LA. 600000UNIT/ML 1ML	3	Non-Preferred Brand Drugs	42%	42%	None
BICNU 1 KIT in 1 CARTON	3	Non-Preferred Brand Drugs	42%	42%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BILTRICIDE 600MG TABLET	2	Preferred Brands	21%	21%	None
BISOPROLOL FUMARATE 10MG TABLET (100 CT)	1	Generics	$2.00	$5.00	None
BISOPROLOL FUMARATE 5MG TABLET (100 CT)	1	Generics	$2.00	$5.00	None
BISOPROLOL FUMARATE-HCTZ TABLET 10-6.25MG (500 CT)	1	Generics	$2.00	$5.00	None
BISOPROLOL FUMARATE-HCTZ TABLET 2.5-6.25MG (100 CT)	1	Generics	$2.00	$5.00	None
BISOPROLOL FUMARATE-HCTZ TABLET 5-6.25MG (100 CT)	1	Generics	$2.00	$5.00	None
BLEOMYCIN SULFATE 30UNITS VIA	2	Preferred Brands	21%	21%	P
BLEPHAMIDE 10-0.2% EYE OINT	2	Preferred Brands	21%	21%	None
BONIVA 3mg/3mL SYRINGE	3	Non-Preferred Brand Drugs	42%	42%	P Q:3 /90Days
BOOSTRIX 8; 2.5; 8; 5; 2.5ug/0.5mL; ug/0.5mL; ug/0.5mL; [iU]/0.5mL; [iU]/0.5mL	2	Preferred Brands	21%	21%	None
BOOSTRIX 8; 2.5; 8; 5; 2.5ug/0.5mL; ug/0.5mL; ug/0.5mL; [iU]/0.5mL; [iU]/0.5mL	2	Preferred Brands	21%	21%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BRIELLYN	1	Generics	$2.00	$5.00	None
BRILINTA 90mg/1 60 TABLET in 1 BOTTLE	3	Non-Preferred Brand Drugs	42%	42%	P
BRIMONIDINE TARTRATE OPHTHALMIC SOLUTION 0.2% 10ML BOTPL	1	Generics	$2.00	$5.00	None
Bromday 0.9mg/mL	2	Preferred Brands	21%	21%	None
Bromocriptine mesylate 2.5mg/1 24 BOTTLE in 1 CARTON / 100 TABLET in 1 BOTTLE	2	Preferred Brands	21%	21%	None
BROMOCRIPTINE MESYLATE 5MG CAPSULE	2	Preferred Brands	21%	21%	None
BUDEPRION SR 100MG TABLET SA	2	Preferred Brands	21%	21%	None
BUDEPRION SR 150MG TABLET SA	2	Preferred Brands	21%	21%	None
BUDEPRION XL 300MG TABLET SR 24HR	2	Preferred Brands	21%	21%	Q:30 /30Days
BUDEPRION XL TABLETS 150MG 500 TABLETS BOT	2	Preferred Brands	21%	21%	Q:90 /30Days
BUDESONIDE 0.25 MG/2 ML SUSP	3	Non-Preferred Brand Drugs	42%	42%	P Q:120 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BUDESONIDE 0.5 MG/2 ML SUSP	3	Non-Preferred Brand Drugs	42%	42%	P Q:120 /30Days
Budesonide 3mg 100 CAPSULE BOTTLE	4	Specialty	25%	25%	None
BUMETANIDE 0.25MG/ML VIAL	1	Generics	$2.00	$5.00	None
BUMETANIDE 0.5MG TABLET USP (500 CT)	1	Generics	$2.00	$5.00	None
BUMETANIDE 1MG TABLET USP (500 CT)	1	Generics	$2.00	$5.00	None
BUMETANIDE 2MG TABLET USP (500 CT)	1	Generics	$2.00	$5.00	None
BUPHENYL 500MG TABLET	4	Specialty	25%	25%	None
BUPHENYL POWDER	4	Specialty	25%	25%	None
Buprenorphine HCl 2mg/1 30 TABLET in 1 BOTTLE	3	Non-Preferred Brand Drugs	42%	42%	P
Buprenorphine HCl 8mg/1 30 TABLET in 1 BOTTLE	3	Non-Preferred Brand Drugs	42%	42%	P
BUPROBAN ER TABLET	1	Generics	$2.00	$5.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BUPROPION HCL 75MG TABLET	1	Generics	$2.00	$5.00	None
BUPROPION HCL SR 100 MG TABLET	2	Preferred Brands	21%	21%	None
BUPROPION HCL SR 200MG TABLET SA	2	Preferred Brands	21%	21%	None
BUPROPION HCL TABLET 100MG	1	Generics	$2.00	$5.00	None
Bupropion Hydrochloride 150mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE	2	Preferred Brands	21%	21%	None
BUSPIRONE HCL 15MG TABLET (180 CT)	1	Generics	$2.00	$5.00	None
BUSPIRONE HCL 30MG TABLET (60 CT)	1	Generics	$2.00	$5.00	None
BUSPIRONE HCL 5 MG TABLET	1	Generics	$2.00	$5.00	None
BUSPIRONE HCL 7.5MG TABLET	1	Generics	$2.00	$5.00	None
BUSPIRONE HYDROCHLORIDE TABLETS	1	Generics	$2.00	$5.00	None
BUSULFEX 6mg/mL	3	Non-Preferred Brand Drugs	42%	42%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Butorphanol Tartrate 1mg/mL 10 VIAL in 1 BOX / 1 mL in 1 VIAL	2	Preferred Brands	21%	21%	None
Butorphanol Tartrate 2mg/mL 10 VIAL in 1 BOX / 2 mL in 1 VIAL	2	Preferred Brands	21%	21%	None
BYETTA 10ug/0.04mL	3	Non-Preferred Brand Drugs	42%	42%	P Q:2 /30Days
BYETTA 5MCG/0.02ML PEN INJ	3	Non-Preferred Brand Drugs	42%	42%	P Q:1 /30Days
Bystolic 10mg 100 TABLET in BLISTER PACK	2	Preferred Brands	21%	21%	None
Bystolic 2.5mg 100 TABLETBOTTLE	2	Preferred Brands	21%	21%	None
Bystolic 5mg 30 TABLET BOTTLE	2	Preferred Brands	21%	21%	None
BYSTOLIC TABLETS 20MG 100 BOT	2	Preferred Brands	21%	21%	None

Chart Legend:

Below are a few notes to help you understand the above 2013 Medicare Part D SilverScript Basic (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 $325 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 $2970) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 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 October 2013 )

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.