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2013 Medicare Part D Plan Formulary Information
Aetna CVS/pharmacy Prescription Drug Plan (PDP) (S5810-035-0) Benefit Details
The Aetna CVS/pharmacy Prescription Drug Plan (PDP) (S5810-035-0) Formulary Drugs Starting with the Letter B in CMS PDP Region 01 which includes: ME NH
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	1	Preferred generic	$2.00	$5.00	None
BACITRACIN 500[iU]/g 1 TUBE in 1 CARTON / 3.5 g in 1 TUBE	1	Preferred generic	$2.00	$5.00	None
BACITRACIN INJ 50000UNT	1	Preferred generic	$2.00	$5.00	None
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT	1	Preferred generic	$2.00	$5.00	None
BACLOFEN 10MG TABLET	1	Preferred generic	$2.00	$5.00	None
baclofen 20 mg tablet	1	Preferred generic	$2.00	$5.00	None
BACTROBAN 2% CREAM	4	Non-preferred brand	48%	48%	None
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT)	2	Non-preferred generic	$5.00	$15.00	None
Balziva 6 POUCH in 1 CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER PACK	1	Preferred generic	$2.00	$5.00	None
Banzel 200mg/1	4	Non-preferred brand	48%	48%	P Q:3 /1Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Banzel 40mg/mL	5	Specialty	25%	25%	P Q:80 /1Days
BANZEL TABLET 400MG	4	Non-preferred brand	48%	48%	P Q:8 /1Days
BARACLUDE 0.05mg/mL 1 BOTTLE in 1 CARTON / 210 mL in 1 BOTTLE	3	Preferred brand	$40.00	$120.00	P Q:21 /1Days
BARACLUDE 0.5MG TABLET	5	Specialty	25%	25%	P Q:1 /1Days
BARACLUDE 1MG TABLET	5	Specialty	25%	25%	P Q:1 /1Days
BENAZEPRIL HCL 10MG TABLET	1	Preferred generic	$2.00	$5.00	None
BENAZEPRIL HCL 20mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC	1	Preferred generic	$2.00	$5.00	None
BENAZEPRIL HCL 40MG TABLET	1	Preferred generic	$2.00	$5.00	None
BENAZEPRIL HCL 5MG TABLET	1	Preferred generic	$2.00	$5.00	None
BENAZEPRIL HCL-HCTZ TABLET 10-12.5MG (100 CT)	1	Preferred generic	$2.00	$5.00	None
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT)	1	Preferred generic	$2.00	$5.00	None
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	Preferred generic	$2.00	$5.00	None
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT)	1	Preferred generic	$2.00	$5.00	None
BENICAR 20MG TABLET	4	Non-preferred brand	48%	48%	Q:1 /1Days
BENICAR 40MG TABLET	4	Non-preferred brand	48%	48%	None
BENICAR 5MG TABLET	4	Non-preferred brand	48%	48%	Q:1 /1Days
BENICAR HCT 20-12.5MG TABLET	4	Non-preferred brand	48%	48%	Q:1 /1Days
BENICAR HCT 40-25MG TABLET	4	Non-preferred brand	48%	48%	None
BENICAR HCT TABLET 12.5-40MG (30 CT)	4	Non-preferred brand	48%	48%	None
BENLYSTA 120mg/1.5mL 1 VIAL in 1 CARTON / 1.5 mL in 1 VIAL	4	Non-preferred brand	48%	48%	P
Benztropine Mesylate 1mg 100 TABLET BOTTLE	1	Preferred generic	$2.00	$5.00	None
Benztropine Mesylate 1mg/mL 5 VIAL, SINGLE-USE in 1 CARTON / 2 mL in 1 VIAL, SINGLE-USE	2	Non-preferred generic	$5.00	$15.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Benztropine Mesylate 2mg/1 100 TABLET BOTTLE	1	Preferred generic	$2.00	$5.00	None
BENZTROPINE MESYLATE TABLETS	1	Preferred generic	$2.00	$5.00	None
BETAMETHASONE DIPROPIONATE 0.05% CREAM	1	Preferred generic	$2.00	$5.00	None
Betamethasone Dipropionate 0.60mg/mL 60 mL in 1 BOTTLE	1	Preferred generic	$2.00	$5.00	None
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE	1	Preferred generic	$2.00	$5.00	None
Betamethasone Dipropionate 0.64mg/mL 60 mL in 1 BOTTLE	2	Non-preferred generic	$5.00	$15.00	None
Betamethasone DP 0.05% ointment	1	Preferred generic	$2.00	$5.00	None
BETAMETHASONE DP AUG 0.05% GEL	1	Preferred generic	$2.00	$5.00	None
BETAMETHASONE VALERATE 0.1% lotion	1	Preferred generic	$2.00	$5.00	None
BETAMETHASONE VALERATE CREAM	1	Preferred generic	$2.00	$5.00	None
BETAMETHASONE VALERATE OINTMENT USP	1	Preferred generic	$2.00	$5.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Betaxolol 10mg/1	1	Preferred generic	$2.00	$5.00	None
Betaxolol 20mg/1 100 FILM COATED TABLETS in BOTTLE	1	Preferred generic	$2.00	$5.00	None
betaxolol hcl 0.5% eye drop	1	Preferred generic	$2.00	$5.00	None
BETHANECHOL 10 MG TABLET	1	Preferred generic	$2.00	$5.00	None
BETHANECHOL CHLORIDE 25MG TABLET	1	Preferred generic	$2.00	$5.00	None
BETHANECHOL CHLORIDE 50MG TABLET (100 CT)	1	Preferred generic	$2.00	$5.00	None
BETHANECHOL CHLORIDE 5MG TABLET	1	Preferred generic	$2.00	$5.00	None
BICALUTAMIDE TABLETS 50MG 100 BOT	1	Preferred generic	$2.00	$5.00	Q:1 /1Days
BICNU 1 KIT in 1 CARTON	4	Non-preferred brand	48%	48%	None
BISOPROLOL FUMARATE 10MG TABLET (100 CT)	1	Preferred generic	$2.00	$5.00	None
BISOPROLOL FUMARATE 5MG TABLET (100 CT)	1	Preferred generic	$2.00	$5.00	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	$2.00	$5.00	None
BISOPROLOL FUMARATE-HCTZ TABLET 2.5-6.25MG (100 CT)	1	Preferred generic	$2.00	$5.00	None
BISOPROLOL FUMARATE-HCTZ TABLET 5-6.25MG (100 CT)	1	Preferred generic	$2.00	$5.00	None
BLEOMYCIN SULFATE 30UNITS VIA	2	Non-preferred generic	$5.00	$15.00	P
BLEPH-10 10% EYE DROPS	4	Non-preferred brand	48%	48%	None
BLEPHAMIDE 10-0.2% EYE OINT	4	Non-preferred brand	48%	48%	None
BONIVA 150MG TABLET	4	Non-preferred brand	48%	48%	P Q:3 /90Days
BONIVA 3mg/3mL SYRINGE	3	Preferred brand	$40.00	$120.00	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	4	Non-preferred brand	48%	48%	None
BOOSTRIX 8; 2.5; 8; 5; 2.5ug/0.5mL; ug/0.5mL; ug/0.5mL; [iU]/0.5mL; [iU]/0.5mL	4	Non-preferred brand	48%	48%	None
BOSULIF 100 MG TABLET	5	Specialty	25%	25%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BOSULIF 500 MG TABLET	5	Specialty	25%	25%	P
BRIELLYN	1	Preferred generic	$2.00	$5.00	None
BRILINTA 90mg/1 60 TABLET BOTTLE	3	Preferred brand	$40.00	$120.00	None
Brimonidine Tartrate 1.5mg/mL	2	Non-preferred generic	$5.00	$15.00	None
BRIMONIDINE TARTRATE OPHTHALMIC SOLUTION 0.2% 10ML BOTPL	1	Preferred generic	$2.00	$5.00	None
Bromocriptine mesylate 2.5mg/1 24 BOTTLE in 1 CARTON / 100 TABLET BOTTLE	2	Non-preferred generic	$5.00	$15.00	None
BROMOCRIPTINE MESYLATE 5MG CAPSULE	2	Non-preferred generic	$5.00	$15.00	None
BUDEPRION SR 100MG TABLET SA	1	Preferred generic	$2.00	$5.00	Q:2 /1Days
BUDEPRION SR 150MG TABLET SA	1	Preferred generic	$2.00	$5.00	Q:2 /1Days
BUDESONIDE 0.25 MG/2 ML SUSP	2	Non-preferred generic	$5.00	$15.00	P
BUDESONIDE 0.5 MG/2 ML SUSP	2	Non-preferred generic	$5.00	$15.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Budesonide 3mg 100 CAPSULE BOTTLE	2	Non-preferred generic	$5.00	$15.00	None
BUMETANIDE 0.25MG/ML VIAL	1	Preferred generic	$2.00	$5.00	None
BUMETANIDE 0.5MG TABLET USP (500 CT)	1	Preferred generic	$2.00	$5.00	None
BUMETANIDE 1MG TABLET USP (500 CT)	1	Preferred generic	$2.00	$5.00	None
BUMETANIDE 2MG TABLET USP (500 CT)	1	Preferred generic	$2.00	$5.00	None
BUPHENYL 500MG TABLET	5	Specialty	25%	25%	None
BUPHENYL POWDER	5	Specialty	25%	25%	None
buprenorphin-naloxon 2-0.5 mg tb	2	Non-preferred generic	$5.00	$15.00	P Q:3 /1Days
buprenorphin-naloxon 8-2 mg tb	2	Non-preferred generic	$5.00	$15.00	P Q:3 /1Days
BUPRENORPHINE 0.3MG/ML SYRN	1	Preferred generic	$2.00	$5.00	None
Buprenorphine HCl 2mg/1 30 TABLET BOTTLE	2	Non-preferred generic	$5.00	$15.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Buprenorphine HCl 8mg/1 30 TABLET BOTTLE	2	Non-preferred generic	$5.00	$15.00	P
BUPROBAN ER TABLET	1	Preferred generic	$2.00	$5.00	Q:2 /1Days
BUPROPION HCL 75MG TABLET	1	Preferred generic	$2.00	$5.00	Q:6 /1Days
BUPROPION HCL SR 100 MG TABLET	1	Preferred generic	$2.00	$5.00	Q:2 /1Days
BUPROPION HCL SR 200MG TABLET SA	1	Preferred generic	$2.00	$5.00	Q:2 /1Days
BUPROPION HCL TABLET 100MG	1	Preferred generic	$2.00	$5.00	Q:6 /1Days
BUPROPION HCL XL 150 MG TABLET	1	Preferred generic	$2.00	$5.00	Q:1 /1Days
Bupropion Hydrochloride 150mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE	1	Preferred generic	$2.00	$5.00	Q:2 /1Days
Bupropion Hydrochloride XL 300mg/1 500 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE	1	Preferred generic	$2.00	$5.00	Q:1 /1Days
BUSPIRONE HCL 15MG TABLET (180 CT)	1	Preferred generic	$2.00	$5.00	None
BUSPIRONE HCL 30MG TABLET (60 CT)	1	Preferred generic	$2.00	$5.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BUSPIRONE HCL 5 MG TABLET	1	Preferred generic	$2.00	$5.00	None
BUSPIRONE HCL 7.5MG TABLET	1	Preferred generic	$2.00	$5.00	None
BUSPIRONE HYDROCHLORIDE TABLETS	1	Preferred generic	$2.00	$5.00	None
BUSULFEX 6mg/mL	5	Specialty	25%	25%	None
BUTALBITAL/CAFF/APAP/COD CP	1	Preferred generic	$2.00	$5.00	Q:6 /1Days
BUTORPHANOL 10MG/ML SPRAY	2	Non-preferred generic	$5.00	$15.00	Q:50 /30Days
Butorphanol Tartrate 1mg/mL 10 VIAL in 1 BOX / 1 mL in 1 VIAL	2	Non-preferred generic	$5.00	$15.00	None
Butorphanol Tartrate 2mg/mL 10 VIAL in 1 BOX / 2 mL in 1 VIAL	2	Non-preferred generic	$5.00	$15.00	None
BYDUREON 2 MG VIAL	3	Preferred brand	$40.00	$120.00	None
BYETTA 10ug/0.04mL	4	Non-preferred brand	48%	48%	None
BYETTA 5MCG/0.02ML PEN INJ	4	Non-preferred brand	48%	48%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Bystolic 10mg 100 TABLET in BLISTER PACK	3	Preferred brand	$40.00	$120.00	None
Bystolic 2.5mg 100 TABLETBOTTLE	3	Preferred brand	$40.00	$120.00	None
Bystolic 5mg 30 TABLET BOTTLE	3	Preferred brand	$40.00	$120.00	None
BYSTOLIC TABLETS 20MG 100 BOT	3	Preferred brand	$40.00	$120.00	None

Chart Legend:

Below are a few notes to help you understand the above 2013 Medicare Part D Aetna CVS/pharmacy Prescription Drug Plan (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.