2019 Medicare Part D Plan Formulary Information |
Blue Shield 65 Plus Choice Plan (HMO) (H0504-021-0)
Benefit Details
|
The Blue Shield 65 Plus Choice Plan (HMO) (H0504-021-0) Formulary Drugs Starting with the Letter B in LOS ANGELES County, CA: CMS MA Region 24 which includes: CA Plan Monthly Premium: $0.00 Deductible: $0 |
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 |
Bacitracin 500 unit/gm Eye Ointment |
2 |
Generic |
$10.00 | $15.00 | None |
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT |
2 |
Generic |
$10.00 | $15.00 | None |
BACLOFEN 10 MG TABLET |
2 |
Generic |
$10.00 | $15.00 | Q:8 /1Days |
BACLOFEN 20 MG TABLET |
2 |
Generic |
$10.00 | $15.00 | Q:4 /1Days |
BACLOFEN 5 MG TABLET |
2 |
Generic |
$10.00 | $15.00 | Q:3 /1Days |
BACTROBAN NASAL 2% OINTMENT |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | None |
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT) |
2 |
Generic |
$10.00 | $15.00 | None |
BALVERSA 3 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P Q:3 /1Days |
BALVERSA 4 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P Q:2 /1Days |
BALVERSA 5 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Balziva 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK |
2 |
Generic |
$10.00 | $15.00 | None |
Banzel 200mg/1 |
6 |
Specialty Tier |
33% | N/A | S Q:2 /1Days |
Banzel 40mg/mL |
6 |
Specialty Tier |
33% | N/A | S Q:80 /1Days |
BANZEL TABLET 400MG |
6 |
Specialty Tier |
33% | N/A | S Q:8 /1Days |
BARACLUDE 0.05mg/mL 1 BOTTLE per CARTON / 210 mL in 1 BOTTLE |
6 |
Specialty Tier |
33% | N/A | Q:21 /1Days |
BAXDELA 300 MG VIAL |
6 |
Specialty Tier |
33% | N/A | Q:28 /30Days |
BAXDELA 450 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P Q:28 /30Days |
BCG VACCINE 50mg/1 1 VIAL per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
BENAZEPRIL HCL 10 MG TABLET |
1 |
Preferred Generic |
$3.00 | $4.50 | Q:1 /1Days |
BENAZEPRIL HCL 20 MG TABLET |
1 |
Preferred Generic |
$3.00 | $4.50 | Q:1 /1Days |
BENAZEPRIL HCL 40 MG TABLET |
1 |
Preferred Generic |
$3.00 | $4.50 | Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BENAZEPRIL HCL 5 MG TABLET |
1 |
Preferred Generic |
$3.00 | $4.50 | Q:1 /1Days |
BENAZEPRIL HCL-HCTZ TABLET 10-12.5MG (100 CT) |
1 |
Preferred Generic |
$3.00 | $4.50 | None |
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT) |
1 |
Preferred Generic |
$3.00 | $4.50 | None |
BENAZEPRIL HCL-HCTZ TABLET 20-25MG (100 CT) |
1 |
Preferred Generic |
$3.00 | $4.50 | None |
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT) |
1 |
Preferred Generic |
$3.00 | $4.50 | None |
BENLYSTA 200 MG/ML AUTOINJECT |
6 |
Specialty Tier |
33% | N/A | P Q:4 /28Days |
BENLYSTA 200 MG/ML SYRINGE |
6 |
Specialty Tier |
33% | N/A | P Q:4 /28Days |
BENZNIDAZOLE 100 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:240 /365Days |
BENZNIDAZOLE 12.5 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:720 /365Days |
BENZTROPINE MES 0.5 MG Tablet [Cogentin] |
2 |
Generic |
$10.00 | $15.00 | None |
BENZTROPINE MES 1 MG TABLET [Cogentin] |
2 |
Generic |
$10.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BENZTROPINE MES 2 MG TABLET [Cogentin] |
2 |
Generic |
$10.00 | $15.00 | None |
BEPREVE 1.5% EYE DROPS |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | None |
BERINERT 500 UNIT KIT |
6 |
Specialty Tier |
33% | N/A | P |
BESIVANCE BESIFLOACIN OPTHALMIC SUSPENSION 0.6% 5 ML BOTDR |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE |
2 |
Generic |
$10.00 | $15.00 | None |
BETAMETHASONE DP 0.05% LOT |
2 |
Generic |
$10.00 | $15.00 | None |
Betamethasone DP 0.05% ointment |
2 |
Generic |
$10.00 | $15.00 | None |
BETAMETHASONE DP AUG 0.05% CRM |
2 |
Generic |
$10.00 | $15.00 | None |
BETAMETHASONE DP AUG 0.05% GEL |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
BETAMETHASONE DP AUG 0.05% LOT |
2 |
Generic |
$10.00 | $15.00 | None |
BETAMETHASONE DP AUG 0.05% OIN |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETAMETHASONE VA 0.1% CREAM |
2 |
Generic |
$10.00 | $15.00 | None |
BETAMETHASONE VALERATE 0.1% LOTION |
2 |
Generic |
$10.00 | $15.00 | None |
BETAMETHASONE VALERATE OINTMENT USP |
2 |
Generic |
$10.00 | $15.00 | None |
BETASERON 0.3 MG KIT |
6 |
Specialty Tier |
33% | N/A | P Q:15 /30Days |
BETAXOLOL 10 MG TABLET |
2 |
Generic |
$10.00 | $15.00 | None |
BETAXOLOL 20 MG TABLET |
2 |
Generic |
$10.00 | $15.00 | None |
Betaxolol 5 MG/ML Ophthalmic Solution |
2 |
Generic |
$10.00 | $15.00 | None |
BETHANECHOL 10 MG TABLET |
2 |
Generic |
$10.00 | $15.00 | None |
BETHANECHOL 25 MG TABLET |
2 |
Generic |
$10.00 | $15.00 | None |
BETHANECHOL 5 MG TABLET |
2 |
Generic |
$10.00 | $15.00 | None |
BETHANECHOL 50 MG TABLET |
2 |
Generic |
$10.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETHKIS 300 MG/4 ML AMPULE |
6 |
Specialty Tier |
33% | N/A | P Q:224 /28Days |
BETIMOL 0.25% EYE DROPS |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
BETIMOL 0.5% EYE DROPS |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
BETOPTIC S OPHTHALMIC SUSPENSION 0.25% 10 ML BOT |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
BEVESPI AEROSPHERE INHALER |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:11 /28Days |
BEXAROTENE 75 MG CAPSULE [Targretin] |
6 |
Specialty Tier |
33% | N/A | P Q:10 /1Days |
BEXSERO PREFILLED SYRINGE |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
BICALUTAMIDE 50 MG TABLET |
2 |
Generic |
$10.00 | $15.00 | None |
BICILL LA PFS 600MU 1ML PED |
5 |
Injectable Drugs |
31% | 31% | None |
BICILLIN C-R 1.2MM UNITS SYR 2ML x 10 |
5 |
Injectable Drugs |
31% | 31% | None |
BICILLIN C-R 900/300 SYRINGE 2ML x 10 |
5 |
Injectable Drugs |
31% | 31% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BICILLIN LA PFS 1200MU 2ML |
5 |
Injectable Drugs |
31% | 31% | None |
BICILLIN LA. 600000UNIT/ML 1ML |
5 |
Injectable Drugs |
31% | 31% | None |
BIDIL TABLET |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | P Q:6 /1Days |
BIKTARVY 50-200-25 MG TABLET |
6 |
Specialty Tier |
33% | N/A | Q:1 /1Days |
BIMATOPROST 0.03% EYE DROPS [Lumigan] |
3 |
Preferred Brand |
$40.00 | $100.00 | S Q:5 /30Days |
BISOPROLOL FUMARATE 10 MG TAB |
2 |
Generic |
$10.00 | $15.00 | None |
BISOPROLOL FUMARATE 5 MG TAB |
2 |
Generic |
$10.00 | $15.00 | None |
BISOPROLOL-HCTZ 10-6.25 MG TAB |
1 |
Preferred Generic |
$3.00 | $4.50 | None |
BISOPROLOL-HCTZ 2.5-6.25 MG TB |
1 |
Preferred Generic |
$3.00 | $4.50 | None |
BISOPROLOL-HCTZ 5-6.25 MG TAB |
1 |
Preferred Generic |
$3.00 | $4.50 | None |
BIVIGAM LIQUID 10% VIAL |
6 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BLEPHAMIDE 10-0.2% EYE OINT |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
BLEPHAMIDE EYE DROPS |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | None |
BLISOVI 24 FE TABLET |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | None |
BLISOVI FE 1.5-30 TABLET |
2 |
Generic |
$10.00 | $15.00 | None |
BOOSTRIX TDAP VACCINE SYRINGE |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
BOOSTRIX TDAP VACCINE VIAL |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
BOSENTAN 125 MG TABLET [Tracleer] |
6 |
Specialty Tier |
33% | N/A | P Q:2 /1Days |
BOSENTAN 62.5 MG TABLET [Tracleer] |
6 |
Specialty Tier |
33% | N/A | P Q:4 /1Days |
BOSULIF 100 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P Q:4 /1Days |
BOSULIF 400 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P Q:1 /1Days |
BOSULIF 500 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BRAFTOVI 50 MG CAPSULE |
6 |
Specialty Tier |
33% | N/A | P Q:4 /1Days |
BRAFTOVI 75 MG CAPSULE |
6 |
Specialty Tier |
33% | N/A | P Q:6 /1Days |
BREO ELLIPTA 100-25 MCG INH |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:60 /30Days |
BREO ELLIPTA 200-25 MCG INH |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:60 /30Days |
BRIELLYN TABLET |
2 |
Generic |
$10.00 | $15.00 | None |
BRILINTA 60 MG TABLET |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:2 /1Days |
BRILINTA 90mg/1 60 TABLET BOTTLE |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:2 /1Days |
BRIMONIDINE 0.2% EYE DROP |
2 |
Generic |
$10.00 | $15.00 | None |
BRIMONIDINE TARTRATE 0.15% DRP |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
BRIVIACT 10 MG TABLET |
6 |
Specialty Tier |
33% | N/A | S Q:2 /1Days |
BRIVIACT 10 MG/ML ORAL SOLN |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | S Q:20 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BRIVIACT 100 MG TABLET |
6 |
Specialty Tier |
33% | N/A | S Q:2 /1Days |
BRIVIACT 25 MG TABLET |
6 |
Specialty Tier |
33% | N/A | S Q:2 /1Days |
BRIVIACT 50 MG TABLET |
6 |
Specialty Tier |
33% | N/A | S Q:2 /1Days |
BRIVIACT 75 MG TABLET |
6 |
Specialty Tier |
33% | N/A | S Q:2 /1Days |
BROMOCRIPTINE 2.5 MG TABLET [Parlodel] |
2 |
Generic |
$10.00 | $15.00 | None |
BROMOCRIPTINE MESYLATE 5MG CAPSULE [Parlodel] |
2 |
Generic |
$10.00 | $15.00 | None |
BUDESONIDE 0.25 MG/2 ML SUSP AMPUL-NEB [Pulmicort] |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:120 /30Days |
BUDESONIDE 0.5 MG/2 ML SUSP AMPUL-NEB [Pulmicort] |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:120 /30Days |
BUDESONIDE 1 MG/2 ML INH SUSP AMPUL-NEB [Pulmicort] |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:60 /30Days |
BUDESONIDE EC 3 MG CAPSULE CAPDR - ER [Entocort EC] |
6 |
Specialty Tier |
33% | N/A | P |
BUMETANIDE 0.25MG/ML VIAL |
5 |
Injectable Drugs |
31% | 31% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUMETANIDE 0.5 MG TABLET |
1 |
Preferred Generic |
$3.00 | $4.50 | None |
BUMETANIDE 1 MG TABLET |
1 |
Preferred Generic |
$3.00 | $4.50 | None |
BUMETANIDE 2 MG TABLET |
1 |
Preferred Generic |
$3.00 | $4.50 | None |
BUPRENORP-NALOX 12-3 MG SL FILM [Suboxone] |
2 |
Generic |
$10.00 | $15.00 | Q:2 /1Days |
BUPRENORP-NALOX 2-0.5 MG SL FILM [Suboxone] |
2 |
Generic |
$10.00 | $15.00 | Q:5 /1Days |
BUPRENORP-NALOX 4-1 MG SL FILM [Suboxone] |
2 |
Generic |
$10.00 | $15.00 | Q:5 /1Days |
BUPRENORP-NALOX 8-2 MG SL FILM [Suboxone] |
2 |
Generic |
$10.00 | $15.00 | Q:3 /1Days |
BUPRENORPHIN-NALOXON 2-0.5 MG SL [Suboxone] |
2 |
Generic |
$10.00 | $15.00 | Q:12 /1Days |
BUPRENORPHIN-NALOXON 8-2 MG SL [Suboxone] |
2 |
Generic |
$10.00 | $15.00 | Q:3 /1Days |
BUPRENORPHINE 10 MCG/HR PATCH [Butrans] |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | P Q:4 /28Days |
BUPRENORPHINE 15 MCG/HR PATCH [Butrans] |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | P Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUPRENORPHINE 2 MG TABLET Subligual [Subutex] |
2 |
Generic |
$10.00 | $15.00 | Q:84 /90Days |
BUPRENORPHINE 20 MCG/HR PATCH [Butrans] |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | P Q:4 /28Days |
BUPRENORPHINE 5 MCG/HR PATCH [Butrans] |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | P Q:4 /28Days |
BUPRENORPHINE 7.5 MCG/HR PATCH Patch [Butrans] |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | P Q:4 /28Days |
BUPRENORPHINE 8 MG TABLET Subligual [Subutex] |
2 |
Generic |
$10.00 | $15.00 | Q:21 /90Days |
BUPROPION HCL 100 MG TABLET |
2 |
Generic |
$10.00 | $15.00 | Q:4 /1Days |
BUPROPION HCL 75 MG TABLET |
2 |
Generic |
$10.00 | $15.00 | Q:6 /1Days |
BUPROPION HCL SR 100 MG TABLET |
2 |
Generic |
$10.00 | $15.00 | Q:4 /1Days |
BUPROPION HCL SR 150 MG TABLET |
2 |
Generic |
$10.00 | $15.00 | Q:2 /1Days |
BUPROPION HCL SR 150 MG TABLET |
2 |
Generic |
$10.00 | $15.00 | Q:3 /1Days |
BUPROPION HCL SR 200 MG TABLET |
2 |
Generic |
$10.00 | $15.00 | Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUPROPION HCL XL 150 MG TABLET |
2 |
Generic |
$10.00 | $15.00 | Q:3 /1Days |
BUPROPION HCL XL 300 MG TABLET |
2 |
Generic |
$10.00 | $15.00 | Q:1 /1Days |
BUSPIRONE HCL 15 MG TABLET |
2 |
Generic |
$10.00 | $15.00 | None |
BUSPIRONE HCL 30 MG TABLET |
2 |
Generic |
$10.00 | $15.00 | None |
BUSPIRONE HCL 5 MG TABLET |
2 |
Generic |
$10.00 | $15.00 | None |
BUSPIRONE HCL 7.5 MG TABLET |
2 |
Generic |
$10.00 | $15.00 | None |
BUSPIRONE HYDROCHLORIDE 10 MG TABLETS |
2 |
Generic |
$10.00 | $15.00 | None |
BUTALB-ACETAMIN-CAFF 50-325-40 |
2 |
Generic |
$10.00 | $15.00 | P Q:6 /1Days |
BUTALB-CAFF-ACETAMINOPH-CODEIN |
2 |
Generic |
$10.00 | $15.00 | P Q:6 /1Days |
BUTALBITAL-ASA-CAFFEINE CAPSULE |
2 |
Generic |
$10.00 | $15.00 | P Q:6 /1Days |
BUTALBITAL/ACETAMINOPHEN 325; 50mg/1; mg/1 100 TABLET BOTTLE |
2 |
Generic |
$10.00 | $15.00 | P Q:6 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUTALBITAL/ACETAMINOPHEN/CAFFEINE CP |
2 |
Generic |
$10.00 | $15.00 | P Q:6 /1Days |
BUTORPHANOL 10MG/ML SPRAY |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:15 /28Days |
BYETTA 10 MCG DOSE PEN INJ |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:2 /28Days |
BYETTA 5 MCG DOSE PEN INJ |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:1 /28Days |
Bystolic 10mg/1 30 TABLET BOTTLE |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | None |
Bystolic 2.5mg/1 30 TABLET BOTTLE |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | None |
BYSTOLIC 20 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | None |
Bystolic 5mg 30 TABLET BOTTLE |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | None |
BYVALSON 5 MG-80 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:1 /1Days |