2016 Medicare Part D Plan Formulary Information |
Aetna Medicare Prime Plan (HMO) (H3931-093-0)
Benefit Details
|
The Aetna Medicare Prime Plan (HMO) (H3931-093-0) Formulary Drugs Starting with the Letter B in Boulder County, CO: CMS MA Region 20 which includes: CO Plan Monthly Premium: $0.00 Deductible: $125 |
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 |
4 |
Non-Preferred Brand |
40% | 40% | None |
Bacitracin 500 unit/gm Eye Ointment |
2* |
Generic |
$10.00 | $45.00 | None |
BACITRACIN INJ 50000UNT |
4 |
Non-Preferred Brand |
40% | 40% | None |
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT |
2* |
Generic |
$10.00 | $45.00 | None |
BACLOFEN 10MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
BACLOFEN 20 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT) |
2* |
Generic |
$10.00 | $45.00 | None |
Balziva 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK |
4 |
Non-Preferred Brand |
40% | 40% | None |
Banzel 200mg/1 |
4 |
Non-Preferred Brand |
40% | 40% | P |
Banzel 40mg/mL |
4 |
Non-Preferred Brand |
40% | 40% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BANZEL TABLET 400MG |
4 |
Non-Preferred Brand |
40% | 40% | P |
BARACLUDE 0.05mg/mL 1 BOTTLE per CARTON / 210 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
40% | 40% | Q:630 /30Days |
BARACLUDE 0.5MG TABLET |
4 |
Non-Preferred Brand |
40% | 40% | Q:30 /30Days |
BARACLUDE 1MG TABLET |
4 |
Non-Preferred Brand |
40% | 40% | Q:30 /30Days |
BCG VACCINE 50mg/1 1 VIAL per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL |
2* |
Generic |
$10.00 | $45.00 | None |
BEKYREE 28 DAY TABLET |
4 |
Non-Preferred Brand |
40% | 40% | None |
BELEODAQ 500 MG VIAL |
4 |
Non-Preferred Brand |
40% | 40% | P |
BENAZEPRIL HCL 10MG TABLET |
1* |
Preferred Generic |
$3.00 | $24.00 | None |
BENAZEPRIL HCL 20mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1* |
Preferred Generic |
$3.00 | $24.00 | None |
BENAZEPRIL HCL 40MG TABLET |
1* |
Preferred Generic |
$3.00 | $24.00 | None |
BENAZEPRIL HCL 5MG TABLET |
1* |
Preferred Generic |
$3.00 | $24.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BENAZEPRIL HCL-HCTZ TABLET 10-12.5MG (100 CT) |
1* |
Preferred Generic |
$3.00 | $24.00 | None |
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT) |
1* |
Preferred Generic |
$3.00 | $24.00 | None |
BENAZEPRIL HCL-HCTZ TABLET 20-25MG (100 CT) |
1* |
Preferred Generic |
$3.00 | $24.00 | None |
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT) |
1* |
Preferred Generic |
$3.00 | $24.00 | None |
BENLYSTA 120mg/1.5mL 1 VIAL per CARTON / 1.5 mL in 1 VIAL |
4 |
Non-Preferred Brand |
40% | 40% | P |
BENLYSTA 400 MG VIAL |
4 |
Non-Preferred Brand |
40% | 40% | P |
BENZTROPINE 2 MG/2 ML VIAL |
4 |
Non-Preferred Brand |
40% | 40% | P |
BENZTROPINE MESYLATE 0.5 MG TABLETS |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
Benztropine Mesylate 1mg 100 TABLET BOTTLE |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
BENZTROPINE MESYLATE 2 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
BESIVANCE BESIFLOACIN OPTHALMIC SUSPENSION 0.6% 5 ML BOTDR |
4 |
Non-Preferred Brand |
40% | 40% | 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* |
Generic |
$10.00 | $45.00 | None |
Betamethasone Dipropionate 0.60mg/mL 60 mL in 1 BOTTLE |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Betamethasone Dipropionate 0.64mg/mL 60 mL in 1 BOTTLE |
2* |
Generic |
$10.00 | $45.00 | None |
Betamethasone DP 0.05% ointment |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
BETAMETHASONE DP AUG 0.05% GEL |
2* |
Generic |
$10.00 | $45.00 | None |
BETAMETHASONE DP AUG 0.05% OIN |
2* |
Generic |
$10.00 | $45.00 | None |
BETAMETHASONE VALERATE 0.1% LOTION |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
BETAMETHASONE VALERATE 0.12% FOAM |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
BETAMETHASONE VALERATE CREAM |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
BETAMETHASONE VALERATE OINTMENT USP |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Betaxolol 10mg/1 |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Betaxolol 20mg/1 100 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Betaxolol hcl 0.5% eye drop |
1* |
Preferred Generic |
$3.00 | $24.00 | None |
Bethanechol 10 mg tablet |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Bethanechol 5 mg tablet |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
BETHANECHOL CHLORIDE 25MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
BETHANECHOL CHLORIDE 50MG TABLET (100 CT) |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
BETIMOL 0.25% EYE DROPS |
4 |
Non-Preferred Brand |
40% | 40% | None |
BETIMOL 0.5% EYE DROPS |
4 |
Non-Preferred Brand |
40% | 40% | None |
BETOPTIC S OPHTHALMIC SUSPENSION 0.25% 10 ML BOT |
4 |
Non-Preferred Brand |
40% | 40% | None |
BEXAROTENE 75 MG CAPSULE [Targretin] |
4 |
Non-Preferred Brand |
40% | 40% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BEXSERO PREFILLED SYRINGE |
4 |
Non-Preferred Brand |
40% | 40% | None |
Bicalutamide 50mL/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
BICILL LA PFS 600MU 1ML PED |
4 |
Non-Preferred Brand |
40% | 40% | None |
BICILLIN LA PFS 1200MU 2ML |
4 |
Non-Preferred Brand |
40% | 40% | None |
BICILLIN LA. 600000UNIT/ML 1ML |
4 |
Non-Preferred Brand |
40% | 40% | None |
BICNU 100 MG VIAL |
4 |
Non-Preferred Brand |
40% | 40% | None |
BISOPROLOL FUMARATE 10MG TABLET (100 CT) |
2* |
Generic |
$10.00 | $45.00 | None |
BISOPROLOL FUMARATE 5MG TABLET (100 CT) |
2* |
Generic |
$10.00 | $45.00 | None |
BISOPROLOL FUMARATE-HCTZ TABLET 10-6.25MG (500 CT) |
2* |
Generic |
$10.00 | $45.00 | None |
BISOPROLOL FUMARATE-HCTZ TABLET 2.5-6.25MG (100 CT) |
2* |
Generic |
$10.00 | $45.00 | None |
BISOPROLOL FUMARATE-HCTZ TABLET 5-6.25MG (100 CT) |
2* |
Generic |
$10.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BLEOMYCIN SULFATE 30UNITS VIA |
4 |
Non-Preferred Brand |
40% | 40% | P |
BLISOVI 24 FE TABLET |
4 |
Non-Preferred Brand |
40% | 40% | None |
BLISOVI FE 1-20 TABLET |
4 |
Non-Preferred Brand |
40% | 40% | None |
BLISOVI FE 1.5-30 TABLET |
4 |
Non-Preferred Brand |
40% | 40% | None |
BOOSTRIX TDAP VACCINE SYRINGE |
4 |
Non-Preferred Brand |
40% | 40% | None |
BOOSTRIX TDAP VACCINE VIAL |
4 |
Non-Preferred Brand |
40% | 40% | None |
BOSULIF 100 MG TABLET |
4 |
Non-Preferred Brand |
40% | 40% | P |
BOSULIF 500 MG TABLET |
4 |
Non-Preferred Brand |
40% | 40% | P |
BREO ELLIPTA 100-25 MCG INH |
4 |
Non-Preferred Brand |
40% | 40% | Q:60 /30Days |
BREO ELLIPTA 200-25 MCG INH |
4 |
Non-Preferred Brand |
40% | 40% | Q:60 /30Days |
BRIELLYN TABLET |
4 |
Non-Preferred Brand |
40% | 40% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BRILINTA 60 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
BRILINTA 90mg/1 60 TABLET BOTTLE |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
Brimonidine Tartrate 1.5mg/mL |
2* |
Generic |
$10.00 | $45.00 | None |
BRIMONIDINE TARTRATE OPHTHALMIC SOLUTION 0.2% 10ML BOTPL |
2* |
Generic |
$10.00 | $45.00 | None |
BRIVIACT 10 MG TABLET |
4 |
Non-Preferred Brand |
40% | 40% | P Q:60 /30Days |
BRIVIACT 10 MG/ML ORAL SOLN |
4 |
Non-Preferred Brand |
40% | 40% | P Q:600 /30Days |
BRIVIACT 100 MG TABLET |
4 |
Non-Preferred Brand |
40% | 40% | P Q:60 /30Days |
BRIVIACT 25 MG TABLET |
4 |
Non-Preferred Brand |
40% | 40% | P Q:60 /30Days |
BRIVIACT 50 MG TABLET |
4 |
Non-Preferred Brand |
40% | 40% | P Q:60 /30Days |
BRIVIACT 50 MG/5 ML VIAL |
4 |
Non-Preferred Brand |
40% | 40% | P |
BRIVIACT 75 MG TABLET |
4 |
Non-Preferred Brand |
40% | 40% | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Bromocriptine mesylate 2.5mg/1 24 BOTTLE per CARTON / 100 TABLET BOTTLE |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
BROMOCRIPTINE MESYLATE 5MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
BUDESONIDE 0.25 MG/2 ML SUSP |
4 |
Non-Preferred Brand |
40% | 40% | P |
BUDESONIDE 0.5 MG/2 ML SUSP |
4 |
Non-Preferred Brand |
40% | 40% | P |
BUDESONIDE 1 MG/2 ML INH SUSP |
4 |
Non-Preferred Brand |
40% | 40% | P |
Budesonide 32 mcg nasal spray |
4 |
Non-Preferred Brand |
40% | 40% | None |
Budesonide 3mg 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
40% | 40% | None |
BUMETANIDE 0.25MG/ML VIAL |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
BUMETANIDE 0.5 MG 100 TABLET BOTTLE |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
BUMETANIDE 1 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
BUMETANIDE 2 MG 100 TABLET BOTTLE |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUPHENYL 500 MG TABLET |
4 |
Non-Preferred Brand |
40% | 40% | P |
Buprenorphine HCl 2mg/1 30 TABLET BOTTLE |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:90 /30Days |
Buprenorphine HCl 8mg/1 30 TABLET BOTTLE |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:90 /30Days |
BUPRENORPHINE-NALOXONE 2-0.5 MG SL |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:90 /30Days |
BUPRENORPHINE-NALOXONE 8-2 MG SL |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:90 /30Days |
BUPROBAN ER 150 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
BUPROPION HCL SR 100 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
BUPROPION HCL SR 200MG TABLET SA |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
BUPROPION HCL XL 150 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
BUPROPION HCL XL 300 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
Bupropion Hydrochloride 100mg/1 100 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Bupropion Hydrochloride 150mg/1 100 TABLET, ER in 1 BOTTLE |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
BUPROPION HYDROCHLORIDE 75mg/1 1000 TABLET BOTTLE |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:180 /30Days |
BUSPIRONE HCL 15MG TABLET (180 CT) |
2* |
Generic |
$10.00 | $45.00 | None |
BUSPIRONE HCL 30MG TABLET (60 CT) |
2* |
Generic |
$10.00 | $45.00 | None |
BUSPIRONE HCL 5 MG TABLET |
2* |
Generic |
$10.00 | $45.00 | None |
BUSPIRONE HCL 7.5MG TABLET |
2* |
Generic |
$10.00 | $45.00 | None |
BUSPIRONE HYDROCHLORIDE 10 MG TABLETS |
2* |
Generic |
$10.00 | $45.00 | None |
BUSULFEX 6mg/mL |
4 |
Non-Preferred Brand |
40% | 40% | None |
BUTALBITAL COMP-CODEINE #3 CAP |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:180 /30Days |
BUTALBITAL-ASA-CAFFEINE CAPSULE |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:180 /30Days |
BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50-300-40 |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50-325-40 |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:180 /30Days |
BUTALBITAL/ACETAMINOPHEN/CAFFEINE CP |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:180 /30Days |
BUTALBITAL/CAFFEINE/ACETAMINOPH/CODEIN |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:180 /30Days |