2018 Medicare Part D Plan Formulary Information |
Aetna Medicare Rx Select (PDP) (S5810-292-0)
Benefit Details
 |
The Aetna Medicare Rx Select (PDP) (S5810-292-0) Formulary Drugs Starting with the Letter B in CMS PDP Region 21 which includes: LA Plan Monthly Premium: $17.70 Deductible: $405 Qualifies for LIS: No |
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 Drug |
37% | N/A | None |
Bacitracin 500 unit/gm Eye Ointment  |
4 |
Non-Preferred Drug |
37% | N/A | None |
BACITRACIN INJ 50000UNT  |
4 |
Non-Preferred Drug |
37% | N/A | None |
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT  |
2* |
Generic |
$3.00 | N/A | None |
BACLOFEN 10 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
BACLOFEN 20 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
BACLOFEN 5 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
BACTRIM 400-80 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
BACTRIM DS 800-160 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
BACTROBAN 2% CREAM  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BACTROBAN NASAL 2% OINTMENT  |
4 |
Non-Preferred Drug |
37% | N/A | None |
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT)  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Balziva 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Banzel 200mg/1  |
5 |
Specialty Tier |
25% | N/A | P |
Banzel 40mg/mL  |
5 |
Specialty Tier |
25% | N/A | P |
BANZEL TABLET 400MG  |
5 |
Specialty Tier |
25% | N/A | P |
BARACLUDE 0.05mg/mL 1 BOTTLE per CARTON / 210 mL in 1 BOTTLE  |
5 |
Specialty Tier |
25% | N/A | None |
BAVENCIO 200 MG/10 ML VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
BCG VACCINE 50mg/1 1 VIAL per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL  |
3 |
Preferred Brand |
$46.00 | N/A | None |
BECONASE AQ 0.042% SPRAY  |
4 |
Non-Preferred Drug |
37% | N/A | Q:50 /30Days |
BEKYREE 28 DAY TABLET [VIORELE] ![Compare how all Medicare Part D PDP plans in LA cover BEKYREE 28 DAY TABLET [VIORELE].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$46.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BELEODAQ 500 MG VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
BENAZEPRIL HCL 10 MG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
BENAZEPRIL HCL 20 MG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
BENAZEPRIL HCL 40 MG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
BENAZEPRIL HCL 5 MG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
BENAZEPRIL HCL-HCTZ TABLET 10-12.5MG (100 CT)  |
2* |
Generic |
$3.00 | N/A | None |
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT)  |
2* |
Generic |
$3.00 | N/A | None |
BENAZEPRIL HCL-HCTZ TABLET 20-25MG (100 CT)  |
2* |
Generic |
$3.00 | N/A | None |
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT)  |
2* |
Generic |
$3.00 | N/A | None |
BENICAR 20 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
BENICAR 40 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BENICAR 5MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
BENICAR HCT 20-12.5 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
BENICAR HCT 40-25 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
BENICAR HCT TABLET 12.5-40MG (30 CT)  |
4 |
Non-Preferred Drug |
37% | N/A | S 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 200 MG/ML AUTOINJECT  |
5 |
Specialty Tier |
25% | N/A | P |
BENLYSTA 200 MG/ML SYRINGE  |
5 |
Specialty Tier |
25% | N/A | P |
BENLYSTA 400 MG VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
BENTYL INJECTION 20MG/2ML AMP  |
4 |
Non-Preferred Drug |
37% | N/A | None |
BENZTROPINE 2 MG/2 ML AMPULE [Cogentin] ![Compare how all Medicare Part D PDP plans in LA cover BENZTROPINE 2 MG/2 ML AMPULE [Cogentin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$3.00 | N/A | P |
BENZTROPINE MES 0.5 MG Tablet [Cogentin] ![Compare how all Medicare Part D PDP plans in LA cover BENZTROPINE MES 0.5 MG Tablet [Cogentin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$3.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BENZTROPINE MES 1 MG TABLET [Cogentin] ![Compare how all Medicare Part D PDP plans in LA cover BENZTROPINE MES 1 MG TABLET [Cogentin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$3.00 | N/A | P |
BENZTROPINE MES 2 MG TABLET [Cogentin] ![Compare how all Medicare Part D PDP plans in LA cover BENZTROPINE MES 2 MG TABLET [Cogentin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$3.00 | N/A | P |
BEPREVE 1.5% EYE DROPS  |
3 |
Preferred Brand |
$46.00 | N/A | None |
BESIVANCE BESIFLOACIN OPTHALMIC SUSPENSION 0.6% 5 ML BOTDR  |
3 |
Preferred Brand |
$46.00 | N/A | None |
BETAGAN 0.5% EYE DROPS  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
BETAMETHASONE DP 0.05% LOT  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Betamethasone DP 0.05% ointment  |
4 |
Non-Preferred Drug |
37% | N/A | None |
BETAMETHASONE DP AUG 0.05% CRM  |
3 |
Preferred Brand |
$46.00 | N/A | None |
BETAMETHASONE DP AUG 0.05% GEL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
BETAMETHASONE DP AUG 0.05% LOT  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETAMETHASONE DP AUG 0.05% OIN  |
4 |
Non-Preferred Drug |
37% | N/A | None |
BETAMETHASONE VA 0.1% CREAM  |
3 |
Preferred Brand |
$46.00 | N/A | None |
BETAMETHASONE VALERATE 0.1% LOTION  |
3 |
Preferred Brand |
$46.00 | N/A | None |
BETAMETHASONE VALERATE 0.12% FOAM  |
4 |
Non-Preferred Drug |
37% | N/A | None |
BETAMETHASONE VALERATE OINTMENT USP  |
3 |
Preferred Brand |
$46.00 | N/A | None |
BETASERON 0.3 MG KIT  |
5 |
Specialty Tier |
25% | N/A | P Q:14 /28Days |
BETAXOLOL 10 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
BETAXOLOL 20 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Betaxolol 5 MG/ML Ophthalmic Solution  |
3 |
Preferred Brand |
$46.00 | N/A | None |
BETHANECHOL 10 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
BETHANECHOL 25 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETHANECHOL 5 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
BETHANECHOL 50 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
BETHKIS 300 MG/4 ML AMPULE  |
5 |
Specialty Tier |
25% | N/A | P Q:224 /56Days |
BETIMOL 0.25% EYE DROPS  |
4 |
Non-Preferred Drug |
37% | N/A | None |
BETIMOL 0.5% EYE DROPS  |
4 |
Non-Preferred Drug |
37% | N/A | None |
BETOPTIC S OPHTHALMIC SUSPENSION 0.25% 10 ML BOT  |
3 |
Preferred Brand |
$46.00 | N/A | None |
BEVESPI AEROSPHERE INHALER  |
3 |
Preferred Brand |
$46.00 | N/A | Q:11 /30Days |
BEXAROTENE 75 MG CAPSULE [Targretin] ![Compare how all Medicare Part D PDP plans in LA cover BEXAROTENE 75 MG CAPSULE [Targretin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P |
BEXSERO PREFILLED SYRINGE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
BICALUTAMIDE 50 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
BICILL LA PFS 600MU 1ML PED  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BICILLIN LA PFS 1200MU 2ML  |
4 |
Non-Preferred Drug |
37% | N/A | None |
BICILLIN LA. 600000UNIT/ML 1ML  |
4 |
Non-Preferred Drug |
37% | N/A | None |
BICNU 100 MG VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
BIDIL TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
BIKTARVY 50-200-25 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
Biltricide 600mg/1 6 FILM COATED TABLETS in BOTTLE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
BINOSTO 70 MG TABLET EFF  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:4 /28Days |
BISOPROLOL FUMARATE 10 MG TAB  |
2* |
Generic |
$3.00 | N/A | None |
BISOPROLOL FUMARATE 5 MG TAB  |
2* |
Generic |
$3.00 | N/A | None |
BISOPROLOL-HCTZ 10-6.25 MG TAB  |
1* |
Preferred Generic |
$0.00 | N/A | None |
BISOPROLOL-HCTZ 2.5-6.25 MG TB  |
1* |
Preferred Generic |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BISOPROLOL-HCTZ 5-6.25 MG TAB  |
1* |
Preferred Generic |
$0.00 | N/A | None |
BIVIGAM LIQUID 10% VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
BLEOMYCIN SULFATE 30 UNIT VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | P |
BLEPH-10 10% EYE DROPS  |
4 |
Non-Preferred Drug |
37% | N/A | None |
BLEPHAMIDE 10-0.2% EYE OINT  |
4 |
Non-Preferred Drug |
37% | N/A | None |
BLEPHAMIDE EYE DROPS  |
4 |
Non-Preferred Drug |
37% | N/A | None |
BLISOVI 24 FE TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
BLISOVI FE 1-20 TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
BLISOVI FE 1.5-30 TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
BONIVA 150 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:1 /30Days |
BONIVA 3mg/3mL SYRINGE  |
4 |
Non-Preferred Drug |
37% | N/A | Q:3 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BOOSTRIX TDAP VACCINE SYRINGE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
BOOSTRIX TDAP VACCINE VIAL  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Bortezomib 3.5 Mg Intravenous Solution  |
5 |
Specialty Tier |
25% | N/A | P |
BOSULIF 100 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
BOSULIF 400 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 Drug |
37% | N/A | P Q:4 /70Days |
BOTOX 200[USP'U]/1 1 VIAL in 1 CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL ![Compare how all Medicare Part D PDP plans in LA cover BOTOX 200[USP'U]/1 1 VIAL in 1 CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | P Q:2 /70Days |
BREO ELLIPTA 100-25 MCG INH  |
3 |
Preferred Brand |
$46.00 | N/A | Q:60 /30Days |
BREO ELLIPTA 200-25 MCG INH  |
3 |
Preferred Brand |
$46.00 | N/A | Q:60 /30Days |
BRIELLYN TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | 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 |
$46.00 | N/A | None |
BRILINTA 90mg/1 60 TABLET BOTTLE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
BRIMONIDINE 0.2% EYE DROP  |
3 |
Preferred Brand |
$46.00 | N/A | None |
BRIMONIDINE TARTRATE 0.15% DRP  |
3 |
Preferred Brand |
$46.00 | N/A | None |
BRIVIACT 10 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
BRIVIACT 10 MG/ML ORAL SOLN  |
5 |
Specialty Tier |
25% | N/A | P |
BRIVIACT 100 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
BRIVIACT 25 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
BRIVIACT 50 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
BRIVIACT 50 MG/5 ML VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | P |
BRIVIACT 75 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BROMOCRIPTINE 2.5 MG TABLET [Parlodel] ![Compare how all Medicare Part D PDP plans in LA cover BROMOCRIPTINE 2.5 MG TABLET [Parlodel].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | None |
BROMOCRIPTINE MESYLATE 5MG CAPSULE [Parlodel] ![Compare how all Medicare Part D PDP plans in LA cover BROMOCRIPTINE MESYLATE 5MG CAPSULE [Parlodel].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | None |
BROVANA 15MCG/2ML VIAL NEBULIZER  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:120 /30Days |
BUDESONIDE 0.25 MG/2 ML SUSP AMPUL-NEB [Pulmicort] ![Compare how all Medicare Part D PDP plans in LA cover BUDESONIDE 0.25 MG/2 ML SUSP AMPUL-NEB [Pulmicort].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | P |
BUDESONIDE 0.5 MG/2 ML SUSP AMPUL-NEB [Pulmicort] ![Compare how all Medicare Part D PDP plans in LA cover BUDESONIDE 0.5 MG/2 ML SUSP AMPUL-NEB [Pulmicort].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | P |
BUDESONIDE 1 MG/2 ML INH SUSP AMPUL-NEB [Pulmicort] ![Compare how all Medicare Part D PDP plans in LA cover BUDESONIDE 1 MG/2 ML INH SUSP AMPUL-NEB [Pulmicort].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | P |
BUDESONIDE EC 3 MG CAPSULE CAPDR - ER [Entocort EC] ![Compare how all Medicare Part D PDP plans in LA cover BUDESONIDE EC 3 MG CAPSULE CAPDR - ER [Entocort EC].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | None |
BUDESONIDE ER 9 MG TABLET DR - ER [UCERIS] ![Compare how all Medicare Part D PDP plans in LA cover BUDESONIDE ER 9 MG TABLET DR - ER [UCERIS].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | None |
BUMETANIDE 0.25MG/ML VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
BUMETANIDE 0.5 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
BUMETANIDE 1 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUMETANIDE 2 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
BUPAP 50 MG-300 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:180 /30Days |
BUPHENYL 500 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
BUPRENORPHIN-NALOXON 2-0.5 MG SL [Suboxone] ![Compare how all Medicare Part D PDP plans in LA cover BUPRENORPHIN-NALOXON 2-0.5 MG SL [Suboxone].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$46.00 | N/A | P Q:90 /30Days |
BUPRENORPHIN-NALOXON 8-2 MG SL [Suboxone] ![Compare how all Medicare Part D PDP plans in LA cover BUPRENORPHIN-NALOXON 8-2 MG SL [Suboxone].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$46.00 | N/A | P Q:90 /30Days |
BUPRENORPHINE 10 MCG/HR PATCH [Butrans] ![Compare how all Medicare Part D PDP plans in LA cover BUPRENORPHINE 10 MCG/HR PATCH [Butrans].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | S Q:4 /28Days |
BUPRENORPHINE 15 MCG/HR PATCH [Butrans] ![Compare how all Medicare Part D PDP plans in LA cover BUPRENORPHINE 15 MCG/HR PATCH [Butrans].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | S Q:4 /28Days |
BUPRENORPHINE 2 MG TABLET Subligual [Subutex] ![Compare how all Medicare Part D PDP plans in LA cover BUPRENORPHINE 2 MG TABLET Subligual [Subutex].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$46.00 | N/A | P Q:90 /30Days |
BUPRENORPHINE 20 MCG/HR PATCH [Butrans] ![Compare how all Medicare Part D PDP plans in LA cover BUPRENORPHINE 20 MCG/HR PATCH [Butrans].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | S Q:4 /28Days |
BUPRENORPHINE 5 MCG/HR PATCH [Butrans] ![Compare how all Medicare Part D PDP plans in LA cover BUPRENORPHINE 5 MCG/HR PATCH [Butrans].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | S Q:4 /28Days |
BUPRENORPHINE 8 MG TABLET Subligual [Subutex] ![Compare how all Medicare Part D PDP plans in LA cover BUPRENORPHINE 8 MG TABLET Subligual [Subutex].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$46.00 | N/A | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUPROPION HCL 100 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | Q:180 /30Days |
BUPROPION HCL 75 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | Q:180 /30Days |
BUPROPION HCL SR 100 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | Q:60 /30Days |
BUPROPION HCL SR 150 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | Q:60 /30Days |
BUPROPION HCL SR 150 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | Q:60 /30Days |
BUPROPION HCL SR 200 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | Q:60 /30Days |
BUPROPION HCL XL 150 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | Q:30 /30Days |
BUPROPION HCL XL 300 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | Q:30 /30Days |
BUSPIRONE HCL 15 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
BUSPIRONE HCL 30 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
BUSPIRONE HCL 5 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUSPIRONE HCL 7.5 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
BUSPIRONE HYDROCHLORIDE 10 MG TABLETS  |
2* |
Generic |
$3.00 | N/A | None |
Busulfan 60 mg/10 ml vial [Busulfex] ![Compare how all Medicare Part D PDP plans in LA cover Busulfan 60 mg/10 ml vial [Busulfex].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P |
BUSULFEX 6mg/mL  |
5 |
Specialty Tier |
25% | N/A | P |
BUTALB-ACETAMIN-CAFF 50-325-40  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:180 /30Days |
BUTALB-CAFF-ACETAMINOPH-CODEIN  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:180 /30Days |
BUTALBITAL COMP-CODEINE #3 CAP  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:180 /30Days |
BUTALBITAL-ASA-CAFFEINE CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:180 /30Days |
BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50-300-40  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:180 /30Days |
BUTALBITAL/ACETAMINOPHEN/CAFFEINE CP  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:180 /30Days |
BUTORPHANOL 10MG/ML SPRAY  |
4 |
Non-Preferred Drug |
37% | N/A | Q:5 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUTORPHANOL 1MG/ML VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
BUTORPHANOL 2MG/ML VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Butrans 10ug/h  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:4 /28Days |
BUTRANS 15 MCG/HR PATCH  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:4 /28Days |
Butrans 20ug/h  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:4 /28Days |
Butrans 5ug/h  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:4 /28Days |
BUTRANS 7.5 MCG/HR PATCH  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:4 /28Days |
BYDUREON 2 MG PEN INJECT  |
3 |
Preferred Brand |
$46.00 | N/A | Q:4 /28Days |
BYDUREON 2 MG VIAL  |
3 |
Preferred Brand |
$46.00 | N/A | Q:4 /28Days |
BYDUREON BCISE 2 MG AUTOINJECT  |
3 |
Preferred Brand |
$46.00 | N/A | Q:4 /28Days |
BYETTA 10 MCG DOSE PEN INJ  |
4 |
Non-Preferred Drug |
37% | N/A | Q:2 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BYETTA 5 MCG DOSE PEN INJ  |
4 |
Non-Preferred Drug |
37% | N/A | Q:1 /30Days |
Bystolic 10mg/1 30 TABLET BOTTLE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Bystolic 2.5mg/1 30 TABLET BOTTLE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
BYSTOLIC 20 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Bystolic 5mg 30 TABLET BOTTLE  |
4 |
Non-Preferred Drug |
37% | N/A | None |