2015 Medicare Part D Plan Formulary Information |
Medica Prime Solution Thrift with Part D Option 1 (Cost) (H2450-007-0)
Benefit Details
|
The Medica Prime Solution Thrift with Part D Option 1 (Cost) (H2450-007-0) Formulary Drugs Starting with the Letter B in MINER County, SD: CMS MA Region 19 which includes: SD Plan Monthly Premium: $65.80 Deductible: $320 |
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 |
BACiiM 500001/1 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL |
2 |
Tier 2 |
25% | 25% | None |
Bacitracin 500 unit/gm Eye Ointment |
2 |
Tier 2 |
25% | 25% | None |
BACITRACIN INJ 50000UNT |
2 |
Tier 2 |
25% | 25% | None |
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT |
2 |
Tier 2 |
25% | 25% | None |
BACLOFEN 10MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
BACLOFEN 20 MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
BACTRIM 400-80MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
BACTRIM DS TABLET 800-160 |
4 |
Tier 4 |
25% | 25% | None |
BACTROBAN 2% CREAM |
4 |
Tier 4 |
25% | 25% | None |
BACTROBAN 20mg/g 22 g in 1 TUBE |
4 |
Tier 4 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BACTROBAN NASAL 2% OINTMENT |
4 |
Tier 4 |
25% | 25% | None |
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT) |
2 |
Tier 2 |
25% | 25% | None |
Balziva 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK |
2 |
Tier 2 |
25% | 25% | None |
Banzel 200mg/1 |
4 |
Tier 4 |
25% | 25% | None |
Banzel 40mg/mL |
4 |
Tier 4 |
25% | 25% | None |
BANZEL TABLET 400MG |
4 |
Tier 4 |
25% | 25% | None |
BARACLUDE 0.05mg/mL 1 BOTTLE per CARTON / 210 mL in 1 BOTTLE |
4 |
Tier 4 |
25% | 25% | None |
BARACLUDE 0.5MG TABLET |
5 |
Tier 5 |
25% | 25% | None |
BARACLUDE 1MG TABLET |
5 |
Tier 5 |
25% | 25% | None |
BCG VACCINE 50mg/1 1 VIAL per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL |
3 |
Tier 3 |
25% | 25% | P |
BECONASE AQ 0.042% SPRAY |
4 |
Tier 4 |
25% | 25% | Q:50 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BELEODAQ 500 MG VIAL |
5 |
Tier 5 |
25% | 25% | P |
BELSOMRA 10 MG TABLET |
4 |
Tier 4 |
25% | 25% | P Q:30 /30Days |
BELSOMRA 15 MG TABLET |
4 |
Tier 4 |
25% | 25% | P Q:30 /30Days |
BELSOMRA 20 MG TABLET |
4 |
Tier 4 |
25% | 25% | P Q:30 /30Days |
BELSOMRA 5 MG TABLET |
4 |
Tier 4 |
25% | 25% | P Q:30 /30Days |
BENAZEPRIL HCL 10MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BENAZEPRIL HCL 20mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Tier 1 |
25% | 25% | None |
BENAZEPRIL HCL 40MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BENAZEPRIL HCL 5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BENAZEPRIL HCL-HCTZ TABLET 10-12.5MG (100 CT) |
2 |
Tier 2 |
25% | 25% | None |
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT) |
2 |
Tier 2 |
25% | 25% | 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) |
2 |
Tier 2 |
25% | 25% | None |
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT) |
2 |
Tier 2 |
25% | 25% | None |
BENICAR 20MG TABLET |
3 |
Tier 3 |
25% | 25% | S |
BENICAR 40MG TABLET |
3 |
Tier 3 |
25% | 25% | S |
BENICAR 5MG TABLET |
3 |
Tier 3 |
25% | 25% | S |
BENICAR HCT 20-12.5MG TABLET |
3 |
Tier 3 |
25% | 25% | S |
BENICAR HCT 40-25MG TABLET |
3 |
Tier 3 |
25% | 25% | S |
BENICAR HCT TABLET 12.5-40MG (30 CT) |
3 |
Tier 3 |
25% | 25% | S |
BENLYSTA 120mg/1.5mL 1 VIAL per CARTON / 1.5 mL in 1 VIAL |
5 |
Tier 5 |
25% | 25% | P |
BENTYL 10MG CAPSULE |
4 |
Tier 4 |
25% | 25% | None |
BENTYL 20MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BENTYL INJECTION 20MG/2ML AMP |
4 |
Tier 4 |
25% | 25% | None |
BENZACLIN GEL |
4 |
Tier 4 |
25% | 25% | None |
BENZAMYCIN GEL |
4 |
Tier 4 |
25% | 25% | None |
BENZTROPINE 2 MG/2 ML VIAL |
2 |
Tier 2 |
25% | 25% | P |
Benztropine mes 2 mg tablet |
2 |
Tier 2 |
25% | 25% | P |
BENZTROPINE MESYLATE 0.5 MG TABLETS |
2 |
Tier 2 |
25% | 25% | P |
Benztropine Mesylate 1mg 100 TABLET BOTTLE |
2 |
Tier 2 |
25% | 25% | P |
BEPREVE 1.5% EYE DROPS |
4 |
Tier 4 |
25% | 25% | S |
BERINERT 500 UNIT KIT |
5 |
Tier 5 |
25% | 25% | P Q:3 /30Days |
BESIVANCE BESIFLOACIN OPTHALMIC SUSPENSION 0.6% 5 ML BOTDR |
4 |
Tier 4 |
25% | 25% | S |
BETAGAN 0.5% EYE DROPS |
4 |
Tier 4 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Betamethasone Dipropionate 0.5mg/g 1 TUBE in 1 CARTON / 50 g in 1 TUBE |
2 |
Tier 2 |
25% | 25% | None |
Betamethasone Dipropionate 0.60mg/mL 60 mL in 1 BOTTLE |
2 |
Tier 2 |
25% | 25% | None |
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE |
2 |
Tier 2 |
25% | 25% | None |
Betamethasone Dipropionate 0.64mg/mL 60 mL in 1 BOTTLE |
2 |
Tier 2 |
25% | 25% | None |
Betamethasone DP 0.05% ointment |
2 |
Tier 2 |
25% | 25% | None |
BETAMETHASONE DP AUG 0.05% GEL |
2 |
Tier 2 |
25% | 25% | None |
BETAMETHASONE VALERATE 0.1% LOTION |
2 |
Tier 2 |
25% | 25% | None |
BETAMETHASONE VALERATE 0.12% FOAM |
2 |
Tier 2 |
25% | 25% | None |
BETAMETHASONE VALERATE CREAM |
2 |
Tier 2 |
25% | 25% | None |
BETAMETHASONE VALERATE OINTMENT USP |
2 |
Tier 2 |
25% | 25% | None |
Betapace AF 120mg/1 1 PACKAGE in 1 PACKAGE / 1 BOTTLE in 1 PACKAGE / 60 BOTTLE, PLASTIC in 1 BOTTLE |
4 |
Tier 4 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Betapace AF 160mg/1 1 PACKAGE in 1 PACKAGE / 1 BOTTLE in 1 PACKAGE / 60 BOTTLE, PLASTIC in 1 BOTTLE |
4 |
Tier 4 |
25% | 25% | None |
BETAPACE AF 80MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
BETASERON KIT 0.3MG/VIAL 14 TRAY BOX PKGCOM |
5 |
Tier 5 |
25% | 25% | S |
Betaxolol 10mg/1 |
2 |
Tier 2 |
25% | 25% | None |
Betaxolol 20mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Tier 2 |
25% | 25% | None |
Betaxolol hcl 0.5% eye drop |
2 |
Tier 2 |
25% | 25% | None |
BETHANECHOL 10 MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
BETHANECHOL 5 MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
BETHANECHOL CHLORIDE 25MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
BETHANECHOL CHLORIDE 50MG TABLET (100 CT) |
2 |
Tier 2 |
25% | 25% | None |
BETHKIS 300 MG/4 ML AMPULE |
5 |
Tier 5 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETIMOL 0.5% EYE DROPS |
4 |
Tier 4 |
25% | 25% | None |
BETOPTIC S OPHTHALMIC SUSPENSION 0.25% 10 ML BOT |
4 |
Tier 4 |
25% | 25% | None |
BEXSERO PREFILLED SYRINGE |
3 |
Tier 3 |
25% | 25% | None |
Beyaz 3 BLISTER PACK in 1 PACKAGE / 1 KIT per BLISTER PACK |
4 |
Tier 4 |
25% | 25% | None |
BIAXIN 250MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
BIAXIN 250MG/5ML SUSPENSION |
4 |
Tier 4 |
25% | 25% | None |
BIAXIN 500MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
Bicalutamide 50mL/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Tier 2 |
25% | 25% | None |
BICILL LA PFS 600MU 1ML PED |
4 |
Tier 4 |
25% | 25% | None |
BICILLIN C-R 1.2MM UNITS SYR 2ML x 10 |
4 |
Tier 4 |
25% | 25% | None |
BICILLIN C-R 900/300 SYRINGE 2ML x 10 |
4 |
Tier 4 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BICILLIN LA PFS 1200MU 2ML |
4 |
Tier 4 |
25% | 25% | None |
BICILLIN LA. 600000UNIT/ML 1ML |
4 |
Tier 4 |
25% | 25% | None |
BICNU 100 MG VIAL |
4 |
Tier 4 |
25% | 25% | None |
BIDIL TABLET |
4 |
Tier 4 |
25% | 25% | None |
Biltricide 600mg/1 6 FILM COATED TABLETS in BOTTLE |
4 |
Tier 4 |
25% | 25% | None |
BIMATOPROST 0.03% EYE DROPS [Lumigan] |
2 |
Tier 2 |
25% | 25% | None |
BINOSTO 70 MG TABLET EFF |
4 |
Tier 4 |
25% | 25% | Q:4 /28Days |
BISOPROLOL FUMARATE 10MG TABLET (100 CT) |
2 |
Tier 2 |
25% | 25% | None |
BISOPROLOL FUMARATE 5MG TABLET (100 CT) |
2 |
Tier 2 |
25% | 25% | None |
BISOPROLOL FUMARATE-HCTZ TABLET 10-6.25MG (500 CT) |
2 |
Tier 2 |
25% | 25% | None |
BISOPROLOL FUMARATE-HCTZ TABLET 2.5-6.25MG (100 CT) |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BISOPROLOL FUMARATE-HCTZ TABLET 5-6.25MG (100 CT) |
2 |
Tier 2 |
25% | 25% | None |
BIVIGAM LIQUID 10% VIAL |
5 |
Tier 5 |
25% | 25% | P |
BLEOMYCIN SULFATE 30UNITS VIA |
2 |
Tier 2 |
25% | 25% | P |
BLEPH-10 10% EYE DROPS |
2 |
Tier 2 |
25% | 25% | None |
BLEPHAMIDE 0.2% EYE DROPS |
3 |
Tier 3 |
25% | 25% | None |
BLEPHAMIDE 10-0.2% EYE OINT |
3 |
Tier 3 |
25% | 25% | None |
BONIVA 150MG TABLET |
4 |
Tier 4 |
25% | 25% | Q:1 /28Days |
BONIVA 3mg/3mL SYRINGE |
4 |
Tier 4 |
25% | 25% | P Q:3 /84Days |
BOOSTRIX TDAP VACCINE SYRINGE |
3 |
Tier 3 |
25% | 25% | None |
BOOSTRIX TDAP VACCINE VIAL |
3 |
Tier 3 |
25% | 25% | None |
BOSULIF 100 MG TABLET |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BOSULIF 500 MG TABLET |
5 |
Tier 5 |
25% | 25% | P Q:30 /30Days |
BOTOX 100UNITS VIAL |
4 |
Tier 4 |
25% | 25% | P Q:4 /90Days |
BOTOX 200[USP'U]/1 1 VIAL in 1 CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL |
4 |
Tier 4 |
25% | 25% | P Q:1 /90Days |
BREO ELLIPTA 100-25 MCG INH |
3 |
Tier 3 |
25% | 25% | Q:60 /30Days |
BREO ELLIPTA 200-25 MCG INH |
3 |
Tier 3 |
25% | 25% | Q:60 /30Days |
BREVICON TABLET 0.5/35 |
4 |
Tier 4 |
25% | 25% | None |
BRIELLYN TABLET |
2 |
Tier 2 |
25% | 25% | None |
BRILINTA 90mg/1 60 TABLET BOTTLE |
3 |
Tier 3 |
25% | 25% | None |
Brimonidine Tartrate 1.5mg/mL |
2 |
Tier 2 |
25% | 25% | None |
BRIMONIDINE TARTRATE OPHTHALMIC SOLUTION 0.2% 10ML BOTPL |
2 |
Tier 2 |
25% | 25% | None |
BRINTELLIX 10 MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BRINTELLIX 20 MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
BRINTELLIX 5 MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
BRISDELLE 7.5 MG CAPSULE |
4 |
Tier 4 |
25% | 25% | None |
Bromfenac 1.035mg/mL 1 BOTTLE, DROPPER per CARTON / 2.5 mL in 1 BOTTLE, DROPPER |
2 |
Tier 2 |
25% | 25% | None |
Bromocriptine mesylate 2.5mg/1 24 BOTTLE per CARTON / 100 TABLET BOTTLE |
2 |
Tier 2 |
25% | 25% | None |
BROMOCRIPTINE MESYLATE 5MG CAPSULE |
2 |
Tier 2 |
25% | 25% | None |
Budesonide 32 mcg nasal spray |
2 |
Tier 2 |
25% | 25% | Q:17 /30Days |
Budesonide 3mg 100 CAPSULE BOTTLE |
5 |
Tier 5 |
25% | 25% | None |
BUMETANIDE 0.25MG/ML VIAL |
2 |
Tier 2 |
25% | 25% | None |
Bumetanide 0.5mg/1 100 TABLET BOTTLE |
2 |
Tier 2 |
25% | 25% | None |
Bumetanide 1mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET in 1 BLISTER PACK |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Bumetanide 2mg/1 100 TABLET BOTTLE |
2 |
Tier 2 |
25% | 25% | None |
BUNAVAIL 2.1-0.3 MG FILM |
4 |
Tier 4 |
25% | 25% | P Q:60 /30Days |
BUNAVAIL 4.2-0.7 MG FILM |
4 |
Tier 4 |
25% | 25% | P Q:60 /30Days |
BUNAVAIL 6.3-1 MG FILM |
4 |
Tier 4 |
25% | 25% | P Q:60 /30Days |
BUPRENEX 0.3 MG/ML AMPUL |
4 |
Tier 4 |
25% | 25% | None |
buprenorphin-naloxon 2-0.5 mg tb |
2 |
Tier 2 |
25% | 25% | P Q:90 /30Days |
buprenorphin-naloxon 8-2 mg tb |
2 |
Tier 2 |
25% | 25% | P Q:90 /30Days |
BUPRENORPHINE 0.3MG/ML SYRN |
2 |
Tier 2 |
25% | 25% | None |
Buprenorphine HCl 2mg/1 30 TABLET BOTTLE |
2 |
Tier 2 |
25% | 25% | P Q:90 /30Days |
Buprenorphine HCl 8mg/1 30 TABLET BOTTLE |
2 |
Tier 2 |
25% | 25% | P Q:90 /30Days |
BUPROBAN ER 150 MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUPROPION HCL SR 100 MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
BUPROPION HCL SR 200MG TABLET SA |
2 |
Tier 2 |
25% | 25% | None |
BUPROPION HCL XL 150 MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
BUPROPION HCL XL 300 MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
Bupropion Hydrochloride 100mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Tier 2 |
25% | 25% | None |
Bupropion Hydrochloride 150mg/1 100 TABLET, ER in 1 BOTTLE |
2 |
Tier 2 |
25% | 25% | None |
BUPROPION HYDROCHLORIDE 75mg/1 1000 TABLET BOTTLE |
2 |
Tier 2 |
25% | 25% | None |
BUSPIRONE HCL 15MG TABLET (180 CT) |
2 |
Tier 2 |
25% | 25% | None |
BUSPIRONE HCL 30MG TABLET (60 CT) |
2 |
Tier 2 |
25% | 25% | None |
BUSPIRONE HCL 5 MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
BUSPIRONE HCL 7.5MG TABLET |
2 |
Tier 2 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUSPIRONE HYDROCHLORIDE 10 MG TABLETS |
2 |
Tier 2 |
25% | 25% | None |
BUSULFEX 6mg/mL |
5 |
Tier 5 |
25% | 25% | None |
BUTALBITAL-ASA-CAFFEINE CAPSULE |
2 |
Tier 2 |
25% | 25% | P Q:180 /30Days |
BUTALBITAL/ACETAMINOPHEN 325; 50mg/1; mg/1 100 TABLET BOTTLE |
2 |
Tier 2 |
25% | 25% | P Q:180 /30Days |
BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50-325-40 |
2 |
Tier 2 |
25% | 25% | P Q:180 /30Days |
BUTALBITAL/CAFFEINE/ACETAMINOPH/CODEIN |
2 |
Tier 2 |
25% | 25% | P Q:180 /30Days |
Butisol Sodium 30mg/1 100 TABLET BOTTLE |
4 |
Tier 4 |
25% | 25% | Q:120 /30Days |
Butorphanol 1 mg/ml vial |
2 |
Tier 2 |
25% | 25% | None |
BUTORPHANOL 10MG/ML SPRAY |
2 |
Tier 2 |
25% | 25% | Q:5 /28Days |
Butorphanol 2 mg/ml vial |
2 |
Tier 2 |
25% | 25% | None |
Butrans 10ug/h |
3 |
Tier 3 |
25% | 25% | Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUTRANS 15 MCG/HR PATCH |
3 |
Tier 3 |
25% | 25% | Q:4 /28Days |
Butrans 20ug/h |
3 |
Tier 3 |
25% | 25% | Q:4 /28Days |
Butrans 5ug/h |
3 |
Tier 3 |
25% | 25% | Q:4 /28Days |
BUTRANS 7.5 MCG/HR PATCH |
3 |
Tier 3 |
25% | 25% | Q:4 /28Days |
BYDUREON 2 MG PEN INJECT |
3 |
Tier 3 |
25% | 25% | Q:4 /28Days |
BYDUREON 2 MG VIAL |
3 |
Tier 3 |
25% | 25% | Q:4 /28Days |
BYETTA 10 MCG DOSE PEN INJ |
3 |
Tier 3 |
25% | 25% | Q:2 /28Days |
BYETTA 5 MCG DOSE PEN INJ |
3 |
Tier 3 |
25% | 25% | Q:1 /28Days |
Bystolic 10mg/1 30 TABLET BOTTLE |
3 |
Tier 3 |
25% | 25% | None |
Bystolic 2.5mg/1 30 TABLET BOTTLE |
3 |
Tier 3 |
25% | 25% | None |
BYSTOLIC 20 MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Bystolic 5mg 30 TABLET BOTTLE |
3 |
Tier 3 |
25% | 25% | None |