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2016 Medicare Part D Plan Formulary Information
Aetna Medicare Rx Saver (PDP) (S5810-059-0) Benefit Details
The Aetna Medicare Rx Saver (PDP) (S5810-059-0) Formulary Drugs Starting with the Letter B in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY Plan Monthly Premium: $25.70 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	2	Generic	$2.00	$21.00	None
BACITRACIN INJ 50000UNT	4	Non-Preferred Brand	35%	35%	None
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT	2	Generic	$2.00	$21.00	None
BACLOFEN 10MG TABLET	2	Generic	$2.00	$21.00	None
BACLOFEN 20 MG TABLET	2	Generic	$2.00	$21.00	None
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT)	2	Generic	$2.00	$21.00	None
Balziva 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK	2	Generic	$2.00	$21.00	None
Banzel 200mg/1	4	Non-Preferred Brand	35%	35%	P
Banzel 40mg/mL	5	Specialty Tier	25%	N/A	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	35%	35%	P
BARACLUDE 0.05mg/mL 1 BOTTLE per CARTON / 210 mL in 1 BOTTLE	4	Non-Preferred Brand	35%	35%	Q:630 /30Days
BARACLUDE 0.5MG TABLET	5	Specialty Tier	25%	N/A	Q:30 /30Days
BARACLUDE 1MG TABLET	5	Specialty Tier	25%	N/A	Q:30 /30Days
BCG VACCINE 50mg/1 1 VIAL per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL	2	Generic	$2.00	$21.00	None
BEKYREE 28 DAY TABLET	2	Generic	$2.00	$21.00	None
BELEODAQ 500 MG VIAL	5	Specialty Tier	25%	N/A	P
BENAZEPRIL HCL 10MG TABLET	2	Generic	$2.00	$21.00	None
BENAZEPRIL HCL 20mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC	2	Generic	$2.00	$21.00	None
BENAZEPRIL HCL 40MG TABLET	2	Generic	$2.00	$21.00	None
BENAZEPRIL HCL 5MG TABLET	2	Generic	$2.00	$21.00	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)	2	Generic	$2.00	$21.00	None
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT)	2	Generic	$2.00	$21.00	None
BENAZEPRIL HCL-HCTZ TABLET 20-25MG (100 CT)	2	Generic	$2.00	$21.00	None
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT)	2	Generic	$2.00	$21.00	None
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	2	Generic	$2.00	$21.00	P
BENZTROPINE MESYLATE 0.5 MG TABLETS	2	Generic	$2.00	$21.00	P
Benztropine Mesylate 1mg 100 TABLET BOTTLE	2	Generic	$2.00	$21.00	P
BENZTROPINE MESYLATE 2 MG TABLET	2	Generic	$2.00	$21.00	P
BESIVANCE BESIFLOACIN OPTHALMIC SUSPENSION 0.6% 5 ML BOTDR	4	Non-Preferred Brand	35%	35%	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	$2.00	$21.00	None
Betamethasone Dipropionate 0.60mg/mL 60 mL in 1 BOTTLE	2	Generic	$2.00	$21.00	None
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE	2	Generic	$2.00	$21.00	None
Betamethasone Dipropionate 0.64mg/mL 60 mL in 1 BOTTLE	2	Generic	$2.00	$21.00	None
Betamethasone DP 0.05% ointment	2	Generic	$2.00	$21.00	None
BETAMETHASONE DP AUG 0.05% GEL	2	Generic	$2.00	$21.00	None
BETAMETHASONE DP AUG 0.05% OIN	2	Generic	$2.00	$21.00	None
BETAMETHASONE VALERATE 0.1% LOTION	2	Generic	$2.00	$21.00	None
BETAMETHASONE VALERATE 0.12% FOAM	2	Generic	$2.00	$21.00	None
BETAMETHASONE VALERATE CREAM	2	Generic	$2.00	$21.00	None
BETAMETHASONE VALERATE OINTMENT USP	2	Generic	$2.00	$21.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Betaxolol 10mg/1	2	Generic	$2.00	$21.00	None
Betaxolol 20mg/1 100 FILM COATED TABLETS in BOTTLE	2	Generic	$2.00	$21.00	None
Betaxolol hcl 0.5% eye drop	2	Generic	$2.00	$21.00	None
Bethanechol 10 mg tablet	2	Generic	$2.00	$21.00	None
Bethanechol 5 mg tablet	2	Generic	$2.00	$21.00	None
BETHANECHOL CHLORIDE 25MG TABLET	2	Generic	$2.00	$21.00	None
BETHANECHOL CHLORIDE 50MG TABLET (100 CT)	2	Generic	$2.00	$21.00	None
BETIMOL 0.25% EYE DROPS	4	Non-Preferred Brand	35%	35%	None
BETIMOL 0.5% EYE DROPS	4	Non-Preferred Brand	35%	35%	None
BETOPTIC S OPHTHALMIC SUSPENSION 0.25% 10 ML BOT	4	Non-Preferred Brand	35%	35%	None
BEXAROTENE 75 MG CAPSULE [Targretin]	5	Specialty Tier	25%	N/A	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	35%	35%	None
Bicalutamide 50mL/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC	3	Preferred Brand	$35.00	$105.00	None
BICILL LA PFS 600MU 1ML PED	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	4	Non-Preferred Brand	35%	35%	None
BISOPROLOL FUMARATE 10MG TABLET (100 CT)	2	Generic	$2.00	$21.00	None
BISOPROLOL FUMARATE 5MG TABLET (100 CT)	2	Generic	$2.00	$21.00	None
BISOPROLOL FUMARATE-HCTZ TABLET 10-6.25MG (500 CT)	2	Generic	$2.00	$21.00	None
BISOPROLOL FUMARATE-HCTZ TABLET 2.5-6.25MG (100 CT)	2	Generic	$2.00	$21.00	None
BISOPROLOL FUMARATE-HCTZ TABLET 5-6.25MG (100 CT)	2	Generic	$2.00	$21.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BLEOMYCIN SULFATE 30UNITS VIA	3	Preferred Brand	$35.00	$105.00	P
BLISOVI 24 FE TABLET	2	Generic	$2.00	$21.00	None
BLISOVI FE 1-20 TABLET	2	Generic	$2.00	$21.00	None
BLISOVI FE 1.5-30 TABLET	2	Generic	$2.00	$21.00	None
BOOSTRIX TDAP VACCINE SYRINGE	4	Non-Preferred Brand	35%	35%	None
BOOSTRIX TDAP VACCINE VIAL	4	Non-Preferred Brand	35%	35%	None
BOSULIF 100 MG TABLET	5	Specialty Tier	25%	N/A	P
BOSULIF 500 MG TABLET	5	Specialty Tier	25%	N/A	P
BREO ELLIPTA 100-25 MCG INH	4	Non-Preferred Brand	35%	35%	Q:60 /30Days
BREO ELLIPTA 200-25 MCG INH	4	Non-Preferred Brand	35%	35%	Q:60 /30Days
BRIELLYN TABLET	2	Generic	$2.00	$21.00	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	$35.00	$105.00	Q:60 /30Days
BRILINTA 90mg/1 60 TABLET BOTTLE	3	Preferred Brand	$35.00	$105.00	Q:60 /30Days
Brimonidine Tartrate 1.5mg/mL	2	Generic	$2.00	$21.00	None
BRIMONIDINE TARTRATE OPHTHALMIC SOLUTION 0.2% 10ML BOTPL	2	Generic	$2.00	$21.00	None
BRIVIACT 10 MG TABLET	5	Specialty Tier	25%	N/A	P Q:60 /30Days
BRIVIACT 10 MG/ML ORAL SOLN	5	Specialty Tier	25%	N/A	P Q:600 /30Days
BRIVIACT 100 MG TABLET	5	Specialty Tier	25%	N/A	P Q:60 /30Days
BRIVIACT 25 MG TABLET	5	Specialty Tier	25%	N/A	P Q:60 /30Days
BRIVIACT 50 MG TABLET	5	Specialty Tier	25%	N/A	P Q:60 /30Days
BRIVIACT 50 MG/5 ML VIAL	4	Non-Preferred Brand	35%	35%	P
BRIVIACT 75 MG TABLET	5	Specialty Tier	25%	N/A	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	2	Generic	$2.00	$21.00	None
BROMOCRIPTINE MESYLATE 5MG CAPSULE	2	Generic	$2.00	$21.00	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
Budesonide 32 mcg nasal spray	4	Non-Preferred Brand	35%	35%	None
Budesonide 3mg 100 CAPSULE BOTTLE	5	Specialty Tier	25%	N/A	None
BUMETANIDE 0.25MG/ML VIAL	2	Generic	$2.00	$21.00	None
BUMETANIDE 0.5 MG 100 TABLET BOTTLE	2	Generic	$2.00	$21.00	None
BUMETANIDE 1 MG TABLET	2	Generic	$2.00	$21.00	None
BUMETANIDE 2 MG 100 TABLET BOTTLE	2	Generic	$2.00	$21.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BUPHENYL 500 MG TABLET	5	Specialty Tier	25%	N/A	P
Buprenorphine HCl 2mg/1 30 TABLET BOTTLE	2	Generic	$2.00	$21.00	P Q:90 /30Days
Buprenorphine HCl 8mg/1 30 TABLET BOTTLE	2	Generic	$2.00	$21.00	P Q:90 /30Days
BUPRENORPHINE-NALOXONE 2-0.5 MG SL	2	Generic	$2.00	$21.00	P Q:90 /30Days
BUPRENORPHINE-NALOXONE 8-2 MG SL	2	Generic	$2.00	$21.00	P Q:90 /30Days
BUPROBAN ER 150 MG TABLET	2	Generic	$2.00	$21.00	Q:60 /30Days
BUPROPION HCL SR 100 MG TABLET	3	Preferred Brand	$35.00	$105.00	Q:60 /30Days
BUPROPION HCL SR 200MG TABLET SA	3	Preferred Brand	$35.00	$105.00	Q:60 /30Days
BUPROPION HCL XL 150 MG TABLET	3	Preferred Brand	$35.00	$105.00	Q:30 /30Days
BUPROPION HCL XL 300 MG TABLET	3	Preferred Brand	$35.00	$105.00	Q:30 /30Days
Bupropion Hydrochloride 100mg/1 100 FILM COATED TABLETS in BOTTLE	3	Preferred Brand	$35.00	$105.00	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	$35.00	$105.00	Q:60 /30Days
BUPROPION HYDROCHLORIDE 75mg/1 1000 TABLET BOTTLE	3	Preferred Brand	$35.00	$105.00	Q:180 /30Days
BUSPIRONE HCL 15MG TABLET (180 CT)	2	Generic	$2.00	$21.00	None
BUSPIRONE HCL 30MG TABLET (60 CT)	2	Generic	$2.00	$21.00	None
BUSPIRONE HCL 5 MG TABLET	2	Generic	$2.00	$21.00	None
BUSPIRONE HCL 7.5MG TABLET	2	Generic	$2.00	$21.00	None
BUSPIRONE HYDROCHLORIDE 10 MG TABLETS	2	Generic	$2.00	$21.00	None
BUSULFEX 6mg/mL	5	Specialty Tier	25%	N/A	None
BUTALBITAL COMP-CODEINE #3 CAP	2	Generic	$2.00	$21.00	P Q:180 /30Days
BUTALBITAL-ASA-CAFFEINE CAPSULE	2	Generic	$2.00	$21.00	P Q:180 /30Days
BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50-300-40	2	Generic	$2.00	$21.00	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	2	Generic	$2.00	$21.00	P Q:180 /30Days
BUTALBITAL/ACETAMINOPHEN/CAFFEINE CP	2	Generic	$2.00	$21.00	P Q:180 /30Days
BUTALBITAL/CAFFEINE/ACETAMINOPH/CODEIN	2	Generic	$2.00	$21.00	P Q:180 /30Days

Chart Legend:

Below are a few notes to help you understand the above 2016 Medicare Part D Aetna Medicare Rx Saver (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.