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2016 Medicare Part D Plan Formulary Information
Symphonix Value Rx (PDP) (S0522-032-0) Benefit Details
The Symphonix Value Rx (PDP) (S0522-032-0) Formulary Drugs Starting with the Letter B in CMS PDP Region 31 which includes: ID UT Plan Monthly Premium: $37.80 Deductible: $360 Qualifies for LIS: Yes
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	4	Non-Preferred Brand	35%	35%	None
Bacitracin 500 unit/gm Eye Ointment	3	Preferred Brand	20%	20%	None
BACITRACIN INJ 50000UNT	4	Non-Preferred Brand	35%	35%	None
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT	2	Generic	$2.00	$6.00	None
BACLOFEN 10MG TABLET	2	Generic	$2.00	$6.00	None
BACLOFEN 20 MG TABLET	2	Generic	$2.00	$6.00	None
BACTROBAN NASAL 2% OINTMENT	4	Non-Preferred Brand	35%	35%	None
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT)	4	Non-Preferred Brand	35%	35%	None
Balziva 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK	2	Generic	$2.00	$6.00	None
Banzel 200mg/1	5	Specialty Tier	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Banzel 40mg/mL	5	Specialty Tier	25%	N/A	None
BANZEL TABLET 400MG	5	Specialty Tier	25%	N/A	None
BARACLUDE 0.05mg/mL 1 BOTTLE per CARTON / 210 mL in 1 BOTTLE	5	Specialty Tier	25%	N/A	None
BARACLUDE 0.5MG TABLET	5	Specialty Tier	25%	N/A	None
BARACLUDE 1MG TABLET	5	Specialty Tier	25%	N/A	None
BEKYREE 28 DAY TABLET	2	Generic	$2.00	$6.00	None
BELEODAQ 500 MG VIAL	5	Specialty Tier	25%	N/A	P
BELSOMRA 10 MG TABLET	3	Preferred Brand	20%	20%	Q:30 /30Days
BELSOMRA 15 MG TABLET	3	Preferred Brand	20%	20%	Q:30 /30Days
BELSOMRA 20 MG TABLET	3	Preferred Brand	20%	20%	Q:30 /30Days
BELSOMRA 5 MG TABLET	3	Preferred Brand	20%	20%	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BENAZEPRIL HCL 10MG TABLET	1	Preferred Generic	$1.00	$3.00	None
BENAZEPRIL HCL 20mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC	1	Preferred Generic	$1.00	$3.00	None
BENAZEPRIL HCL 40MG TABLET	1	Preferred Generic	$1.00	$3.00	None
BENAZEPRIL HCL 5MG TABLET	1	Preferred Generic	$1.00	$3.00	None
BENAZEPRIL HCL-HCTZ TABLET 10-12.5MG (100 CT)	3	Preferred Brand	20%	20%	None
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT)	3	Preferred Brand	20%	20%	None
BENAZEPRIL HCL-HCTZ TABLET 20-25MG (100 CT)	3	Preferred Brand	20%	20%	None
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT)	3	Preferred Brand	20%	20%	None
BENICAR 20MG TABLET	3	Preferred Brand	20%	20%	Q:30 /30Days
BENICAR 40MG TABLET	3	Preferred Brand	20%	20%	Q:30 /30Days
BENICAR 5MG TABLET	3	Preferred Brand	20%	20%	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BENICAR HCT 20-12.5MG TABLET	3	Preferred Brand	20%	20%	Q:30 /30Days
BENICAR HCT 40-25MG TABLET	3	Preferred Brand	20%	20%	Q:30 /30Days
BENICAR HCT TABLET 12.5-40MG (30 CT)	3	Preferred Brand	20%	20%	Q:30 /30Days
BENLYSTA 120mg/1.5mL 1 VIAL per CARTON / 1.5 mL in 1 VIAL	5	Specialty Tier	25%	N/A	P
BENLYSTA 400 MG VIAL	5	Specialty Tier	25%	N/A	P
BENZTROPINE 2 MG/2 ML VIAL	4	Non-Preferred Brand	35%	35%	None
BENZTROPINE MESYLATE 0.5 MG TABLETS	2	Generic	$2.00	$6.00	None
Benztropine Mesylate 1mg 100 TABLET BOTTLE	2	Generic	$2.00	$6.00	None
BENZTROPINE MESYLATE 2 MG TABLET	2	Generic	$2.00	$6.00	None
BEPREVE 1.5% EYE DROPS	4	Non-Preferred Brand	35%	35%	None
BERINERT 500 UNIT KIT	5	Specialty Tier	25%	N/A	P
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	$2.00	$6.00	None
Betamethasone Dipropionate 0.60mg/mL 60 mL in 1 BOTTLE	3	Preferred Brand	20%	20%	None
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE	3	Preferred Brand	20%	20%	None
Betamethasone Dipropionate 0.64mg/mL 60 mL in 1 BOTTLE	4	Non-Preferred Brand	35%	35%	None
Betamethasone DP 0.05% ointment	3	Preferred Brand	20%	20%	None
BETAMETHASONE DP AUG 0.05% GEL	4	Non-Preferred Brand	35%	35%	None
BETAMETHASONE DP AUG 0.05% OIN	4	Non-Preferred Brand	35%	35%	None
BETAMETHASONE VALERATE 0.1% LOTION	3	Preferred Brand	20%	20%	None
BETAMETHASONE VALERATE 0.12% FOAM	4	Non-Preferred Brand	35%	35%	None
BETAMETHASONE VALERATE CREAM	2	Generic	$2.00	$6.00	None
BETAMETHASONE VALERATE OINTMENT USP	2	Generic	$2.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BETASERON KIT 0.3MG/VIAL 14 TRAY BOX PKGCOM	5	Specialty Tier	25%	N/A	P
Betaxolol 10mg/1	2	Generic	$2.00	$6.00	None
Betaxolol 20mg/1 100 FILM COATED TABLETS in BOTTLE	3	Preferred Brand	20%	20%	None
Betaxolol hcl 0.5% eye drop	3	Preferred Brand	20%	20%	None
Bethanechol 10 mg tablet	2	Generic	$2.00	$6.00	None
Bethanechol 5 mg tablet	2	Generic	$2.00	$6.00	None
BETHANECHOL CHLORIDE 25MG TABLET	2	Generic	$2.00	$6.00	None
BETHANECHOL CHLORIDE 50MG TABLET (100 CT)	3	Preferred Brand	20%	20%	None
BETHKIS 300 MG/4 ML AMPULE	5	Specialty Tier	25%	N/A	P
BETIMOL 0.25% EYE DROPS	4	Non-Preferred Brand	35%	35%	None
BETIMOL 0.5% EYE DROPS	4	Non-Preferred Brand	35%	35%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BEXAROTENE 75 MG CAPSULE [Targretin]	5	Specialty Tier	25%	N/A	P
BEXSERO PREFILLED SYRINGE	3	Preferred Brand	20%	20%	None
Bicalutamide 50mL/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC	2	Generic	$2.00	$6.00	None
BICILL LA PFS 600MU 1ML PED	4	Non-Preferred Brand	35%	35%	None
BICILLIN C-R 1.2MM UNITS SYR 2ML x 10	4	Non-Preferred Brand	35%	35%	None
BICILLIN C-R 900/300 SYRINGE 2ML x 10	4	Non-Preferred Brand	35%	35%	None
BICILLIN LA PFS 1200MU 2ML	4	Non-Preferred Brand	35%	35%	None
BICILLIN LA. 600000UNIT/ML 1ML	4	Non-Preferred Brand	35%	35%	None
BICNU 100 MG VIAL	5	Specialty Tier	25%	N/A	None
Biltricide 600mg/1 6 FILM COATED TABLETS in BOTTLE	4	Non-Preferred Brand	35%	35%	None
BIMATOPROST 0.03% EYE DROPS [Lumigan]	3	Preferred Brand	20%	20%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BINOSTO 70 MG TABLET EFF	4	Non-Preferred Brand	35%	35%	Q:4 /28Days
BISOPROLOL FUMARATE 10MG TABLET (100 CT)	2	Generic	$2.00	$6.00	None
BISOPROLOL FUMARATE 5MG TABLET (100 CT)	2	Generic	$2.00	$6.00	None
BISOPROLOL FUMARATE-HCTZ TABLET 10-6.25MG (500 CT)	2	Generic	$2.00	$6.00	None
BISOPROLOL FUMARATE-HCTZ TABLET 2.5-6.25MG (100 CT)	1	Preferred Generic	$1.00	$3.00	None
BISOPROLOL FUMARATE-HCTZ TABLET 5-6.25MG (100 CT)	2	Generic	$2.00	$6.00	None
BIVIGAM LIQUID 10% VIAL	5	Specialty Tier	25%	N/A	P
BLEOMYCIN SULFATE 30UNITS VIA	4	Non-Preferred Brand	35%	35%	P
BLEPHAMIDE 0.2% EYE DROPS	4	Non-Preferred Brand	35%	35%	None
BLEPHAMIDE 10-0.2% EYE OINT	4	Non-Preferred Brand	35%	35%	None
BLISOVI 24 FE TABLET	2	Generic	$2.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BLISOVI FE 1-20 TABLET	2	Generic	$2.00	$6.00	None
BLISOVI FE 1.5-30 TABLET	2	Generic	$2.00	$6.00	None
BOOSTRIX TDAP VACCINE SYRINGE	3	Preferred Brand	20%	20%	None
BOOSTRIX TDAP VACCINE VIAL	3	Preferred Brand	20%	20%	None
BOSULIF 100 MG TABLET	5	Specialty Tier	25%	N/A	P
BOSULIF 500 MG TABLET	5	Specialty Tier	25%	N/A	P
BOTOX 100UNITS VIAL	4	Non-Preferred Brand	35%	35%	P
BOTOX 200[USP'U]/1 1 VIAL in 1 CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL	4	Non-Preferred Brand	35%	35%	P
BRIELLYN TABLET	2	Generic	$2.00	$6.00	None
BRILINTA 60 MG TABLET	3	Preferred Brand	20%	20%	Q:60 /30Days
BRILINTA 90mg/1 60 TABLET BOTTLE	3	Preferred Brand	20%	20%	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Brimonidine Tartrate 1.5mg/mL	4	Non-Preferred Brand	35%	35%	None
BRIMONIDINE TARTRATE OPHTHALMIC SOLUTION 0.2% 10ML BOTPL	2	Generic	$2.00	$6.00	None
BRIVIACT 10 MG TABLET	4	Non-Preferred Brand	35%	35%	Q:60 /30Days
BRIVIACT 10 MG/ML ORAL SOLN	4	Non-Preferred Brand	35%	35%	Q:600 /30Days
BRIVIACT 100 MG TABLET	4	Non-Preferred Brand	35%	35%	Q:60 /30Days
BRIVIACT 25 MG TABLET	4	Non-Preferred Brand	35%	35%	Q:60 /30Days
BRIVIACT 50 MG TABLET	4	Non-Preferred Brand	35%	35%	Q:60 /30Days
BRIVIACT 50 MG/5 ML VIAL	4	Non-Preferred Brand	35%	35%	Q:600 /30Days
BRIVIACT 75 MG TABLET	4	Non-Preferred Brand	35%	35%	Q:60 /30Days
BROMFENAC SODIUM 0.09% EYE DRP	4	Non-Preferred Brand	35%	35%	None
Bromocriptine mesylate 2.5mg/1 24 BOTTLE per CARTON / 100 TABLET BOTTLE	4	Non-Preferred Brand	35%	35%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BROMOCRIPTINE MESYLATE 5MG CAPSULE	4	Non-Preferred Brand	35%	35%	None
BUDESONIDE 0.25 MG/2 ML SUSP	4	Non-Preferred Brand	35%	35%	P
BUDESONIDE 0.5 MG/2 ML SUSP	4	Non-Preferred Brand	35%	35%	P
BUDESONIDE 1 MG/2 ML INH SUSP	4	Non-Preferred Brand	35%	35%	P
BUMETANIDE 0.25MG/ML VIAL	2	Generic	$2.00	$6.00	None
BUMETANIDE 0.5 MG 100 TABLET BOTTLE	2	Generic	$2.00	$6.00	None
BUMETANIDE 1 MG TABLET	2	Generic	$2.00	$6.00	None
BUMETANIDE 2 MG 100 TABLET BOTTLE	2	Generic	$2.00	$6.00	None
BUPHENYL 500 MG TABLET	5	Specialty Tier	25%	N/A	None
BUPHENYL POWDER	5	Specialty Tier	25%	N/A	None
BUPRENORPHINE 0.3MG/ML SYRN	4	Non-Preferred Brand	35%	35%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Buprenorphine HCl 2mg/1 30 TABLET BOTTLE	4	Non-Preferred Brand	35%	35%	Q:90 /30Days
Buprenorphine HCl 8mg/1 30 TABLET BOTTLE	4	Non-Preferred Brand	35%	35%	Q:90 /30Days
BUPROBAN ER 150 MG TABLET	2	Generic	$2.00	$6.00	None
BUPROPION HCL SR 100 MG TABLET	2	Generic	$2.00	$6.00	None
BUPROPION HCL SR 200MG TABLET SA	2	Generic	$2.00	$6.00	None
BUPROPION HCL XL 150 MG TABLET	3	Preferred Brand	20%	20%	None
BUPROPION HCL XL 300 MG TABLET	2	Generic	$2.00	$6.00	None
Bupropion Hydrochloride 100mg/1 100 FILM COATED TABLETS in BOTTLE	3	Preferred Brand	20%	20%	None
Bupropion Hydrochloride 150mg/1 100 TABLET, ER in 1 BOTTLE	2	Generic	$2.00	$6.00	None
BUPROPION HYDROCHLORIDE 75mg/1 1000 TABLET BOTTLE	2	Generic	$2.00	$6.00	None
BUSPIRONE HCL 15MG TABLET (180 CT)	2	Generic	$2.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BUSPIRONE HCL 30MG TABLET (60 CT)	3	Preferred Brand	20%	20%	None
BUSPIRONE HCL 5 MG TABLET	2	Generic	$2.00	$6.00	None
BUSPIRONE HCL 7.5MG TABLET	3	Preferred Brand	20%	20%	None
BUSPIRONE HYDROCHLORIDE 10 MG TABLETS	2	Generic	$2.00	$6.00	None
BUSULFEX 6mg/mL	5	Specialty Tier	25%	N/A	None
BUTALBITAL-ASA-CAFFEINE CAPSULE	3	Preferred Brand	20%	20%	Q:180 /30Days
BUTALBITAL/ACETAMINOPHEN 325; 50mg/1; mg/1 100 TABLET BOTTLE	3	Preferred Brand	20%	20%	P Q:180 /30Days
BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50-325-40	3	Preferred Brand	20%	20%	Q:180 /30Days
Butorphanol 1 mg/ml vial	4	Non-Preferred Brand	35%	35%	None
BUTORPHANOL 10MG/ML SPRAY	4	Non-Preferred Brand	35%	35%	None
Butorphanol 2 mg/ml vial	4	Non-Preferred Brand	35%	35%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BYDUREON 2 MG PEN INJECT	3	Preferred Brand	20%	20%	S Q:4 /28Days
BYDUREON 2 MG VIAL	3	Preferred Brand	20%	20%	S Q:4 /28Days
BYETTA 10 MCG DOSE PEN INJ	4	Non-Preferred Brand	35%	35%	S Q:2 /30Days
BYETTA 5 MCG DOSE PEN INJ	4	Non-Preferred Brand	35%	35%	S Q:1 /30Days

Chart Legend:

Below are a few notes to help you understand the above 2016 Medicare Part D Symphonix Value Rx (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 $360 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 $3310) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2016 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 September 2016 )

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.