2019 Medicare Part D Plan Formulary Information |
Cigna-HealthSpring Rx Secure-Extra (PDP) (S5617-256-0)
Benefit Details
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The Cigna-HealthSpring Rx Secure-Extra (PDP) (S5617-256-0) Formulary Drugs Starting with the Letter B in CMS PDP Region 11 which includes: FL Plan Monthly Premium: $61.70 Deductible: $100 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 |
Bacitracin 500 unit/gm Eye Ointment  |
4 |
Non-Preferred Drug |
50% | 50% | None |
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT  |
2* |
Generic |
$10.00 | $25.00 | None |
BACLOFEN 10 MG TABLET  |
2* |
Generic |
$10.00 | $25.00 | None |
BACLOFEN 20 MG TABLET  |
2* |
Generic |
$10.00 | $25.00 | None |
BACLOFEN 5 MG TABLET  |
2* |
Generic |
$10.00 | $25.00 | None |
BACTROBAN NASAL 2% OINTMENT  |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT)  |
4 |
Non-Preferred Drug |
50% | 50% | None |
BALVERSA 3 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | P Q:90 /30Days |
BALVERSA 4 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | P Q:60 /30Days |
BALVERSA 5 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
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 | $25.00 | None |
Banzel 200mg/1  |
5 |
Specialty Tier |
31% | N/A | P Q:60 /30Days |
Banzel 40mg/mL  |
5 |
Specialty Tier |
31% | N/A | P Q:2400 /30Days |
BANZEL TABLET 400MG  |
5 |
Specialty Tier |
31% | N/A | P Q:240 /30Days |
BARACLUDE 0.05mg/mL 1 BOTTLE per CARTON / 210 mL in 1 BOTTLE  |
4 |
Non-Preferred Drug |
50% | 50% | Q:630 /30Days |
BAXDELA 300 MG VIAL  |
4 |
Non-Preferred Drug |
50% | 50% | None |
BAXDELA 450 MG TABLET  |
4 |
Non-Preferred Drug |
50% | 50% | None |
BCG VACCINE 50mg/1 1 VIAL per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL  |
4 |
Non-Preferred Drug |
50% | 50% | None |
BENAZEPRIL HCL 10 MG TABLET  |
1* |
Preferred Generic |
$4.00 | $10.00 | Q:60 /30Days |
BENAZEPRIL HCL 20 MG TABLET  |
1* |
Preferred Generic |
$4.00 | $10.00 | Q:60 /30Days |
BENAZEPRIL HCL 40 MG TABLET  |
1* |
Preferred Generic |
$4.00 | $10.00 | Q:60 /30Days |
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 |
$4.00 | $10.00 | Q:60 /30Days |
BENAZEPRIL HCL-HCTZ TABLET 10-12.5MG (100 CT)  |
2* |
Generic |
$10.00 | $25.00 | Q:30 /30Days |
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT)  |
2* |
Generic |
$10.00 | $25.00 | Q:60 /30Days |
BENAZEPRIL HCL-HCTZ TABLET 20-25MG (100 CT)  |
2* |
Generic |
$10.00 | $25.00 | Q:30 /30Days |
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT)  |
2* |
Generic |
$10.00 | $25.00 | Q:30 /30Days |
BENZTROPINE MES 0.5 MG Tablet [Cogentin] ![Compare how all Medicare Part D PDP plans in FL cover BENZTROPINE MES 0.5 MG Tablet [Cogentin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $25.00 | P |
BENZTROPINE MES 1 MG TABLET [Cogentin] ![Compare how all Medicare Part D PDP plans in FL cover BENZTROPINE MES 1 MG TABLET [Cogentin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $25.00 | P |
BENZTROPINE MES 2 MG TABLET [Cogentin] ![Compare how all Medicare Part D PDP plans in FL cover BENZTROPINE MES 2 MG TABLET [Cogentin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $25.00 | P |
BESIVANCE BESIFLOACIN OPTHALMIC SUSPENSION 0.6% 5 ML BOTDR  |
4 |
Non-Preferred Drug |
50% | 50% | None |
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE  |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
BETAMETHASONE DP 0.05% LOT  |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Betamethasone DP 0.05% ointment  |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
BETAMETHASONE DP AUG 0.05% CRM  |
2* |
Generic |
$10.00 | $25.00 | None |
BETAMETHASONE DP AUG 0.05% GEL  |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
BETAMETHASONE DP AUG 0.05% LOT  |
4 |
Non-Preferred Drug |
50% | 50% | None |
BETAMETHASONE DP AUG 0.05% OIN  |
4 |
Non-Preferred Drug |
50% | 50% | None |
BETAMETHASONE VA 0.1% CREAM  |
2* |
Generic |
$10.00 | $25.00 | None |
BETAMETHASONE VALERATE 0.1% LOTION  |
2* |
Generic |
$10.00 | $25.00 | None |
BETAMETHASONE VALERATE 0.12% FOAM  |
4 |
Non-Preferred Drug |
50% | 50% | None |
BETAMETHASONE VALERATE OINTMENT USP  |
2* |
Generic |
$10.00 | $25.00 | None |
BETASERON 0.3 MG KIT  |
5 |
Specialty Tier |
31% | N/A | P Q:14 /28Days |
BETAXOLOL 10 MG TABLET  |
2* |
Generic |
$10.00 | $25.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETAXOLOL 20 MG TABLET  |
2* |
Generic |
$10.00 | $25.00 | None |
Betaxolol 5 MG/ML Ophthalmic Solution  |
4 |
Non-Preferred Drug |
50% | 50% | None |
BETHANECHOL 10 MG TABLET  |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
BETHANECHOL 25 MG TABLET  |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
BETHANECHOL 5 MG TABLET  |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
BETHANECHOL 50 MG TABLET  |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
BEXAROTENE 75 MG CAPSULE [Targretin] ![Compare how all Medicare Part D PDP plans in FL cover BEXAROTENE 75 MG CAPSULE [Targretin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
31% | N/A | None |
BEXSERO PREFILLED SYRINGE  |
4 |
Non-Preferred Drug |
50% | 50% | None |
BICALUTAMIDE 50 MG TABLET  |
3* |
Preferred Brand |
$42.00 | $105.00 | Q:30 /30Days |
BICILL LA PFS 600MU 1ML PED  |
4 |
Non-Preferred Drug |
50% | 50% | None |
BICILLIN LA PFS 1200MU 2ML  |
4 |
Non-Preferred Drug |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BICILLIN LA. 600000UNIT/ML 1ML  |
4 |
Non-Preferred Drug |
50% | 50% | None |
BIDIL TABLET  |
3* |
Preferred Brand |
$42.00 | $105.00 | Q:180 /30Days |
BIKTARVY 50-200-25 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | Q:30 /30Days |
Biltricide 600mg/1 6 FILM COATED TABLETS in BOTTLE  |
4 |
Non-Preferred Drug |
50% | 50% | None |
BIMATOPROST 0.03% EYE DROPS [Lumigan] ![Compare how all Medicare Part D PDP plans in FL cover BIMATOPROST 0.03% EYE DROPS [Lumigan].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$10.00 | $25.00 | Q:5 /30Days |
BINOSTO 70 MG TABLET EFF  |
4 |
Non-Preferred Drug |
50% | 50% | None |
BISOPROLOL FUMARATE 10 MG TAB  |
2* |
Generic |
$10.00 | $25.00 | None |
BISOPROLOL FUMARATE 5 MG TAB  |
2* |
Generic |
$10.00 | $25.00 | None |
BISOPROLOL-HCTZ 10-6.25 MG TAB  |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
BISOPROLOL-HCTZ 2.5-6.25 MG TB  |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
BISOPROLOL-HCTZ 5-6.25 MG TAB  |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BLEPHAMIDE 10-0.2% EYE OINT  |
4 |
Non-Preferred Drug |
50% | 50% | None |
BLEPHAMIDE EYE DROPS  |
4 |
Non-Preferred Drug |
50% | 50% | None |
BLISOVI FE 1.5-30 TABLET  |
2* |
Generic |
$10.00 | $25.00 | None |
BOOSTRIX TDAP VACCINE SYRINGE  |
4 |
Non-Preferred Drug |
50% | 50% | Q:1 /365Days |
BOOSTRIX TDAP VACCINE VIAL  |
4 |
Non-Preferred Drug |
50% | 50% | Q:1 /365Days |
BOSENTAN 125 MG TABLET [Tracleer] ![Compare how all Medicare Part D PDP plans in FL cover BOSENTAN 125 MG TABLET [Tracleer].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
31% | N/A | P Q:60 /30Days |
BOSENTAN 62.5 MG TABLET [Tracleer] ![Compare how all Medicare Part D PDP plans in FL cover BOSENTAN 62.5 MG TABLET [Tracleer].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
31% | N/A | P Q:60 /30Days |
BOSULIF 100 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | P Q:120 /30Days |
BOSULIF 400 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
BOSULIF 500 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
BRAFTOVI 50 MG CAPSULE  |
5 |
Specialty Tier |
31% | N/A | P Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BRAFTOVI 75 MG CAPSULE  |
5 |
Specialty Tier |
31% | N/A | P Q:180 /30Days |
BREO ELLIPTA 100-25 MCG INH  |
3* |
Preferred Brand |
$42.00 | $105.00 | Q:60 /30Days |
BREO ELLIPTA 200-25 MCG INH  |
3* |
Preferred Brand |
$42.00 | $105.00 | Q:60 /30Days |
BRIELLYN TABLET  |
2* |
Generic |
$10.00 | $25.00 | None |
BRILINTA 60 MG TABLET  |
3* |
Preferred Brand |
$42.00 | $105.00 | Q:60 /30Days |
BRILINTA 90mg/1 60 TABLET BOTTLE  |
3* |
Preferred Brand |
$42.00 | $105.00 | Q:60 /30Days |
BRIMONIDINE 0.2% EYE DROP  |
2* |
Generic |
$10.00 | $25.00 | None |
BRIMONIDINE TARTRATE 0.15% DRP  |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
BRIVIACT 10 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | Q:60 /30Days |
BRIVIACT 10 MG/ML ORAL SOLN  |
5 |
Specialty Tier |
31% | N/A | Q:1200 /30Days |
BRIVIACT 100 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BRIVIACT 25 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | Q:60 /30Days |
BRIVIACT 50 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | Q:60 /30Days |
BRIVIACT 75 MG TABLET  |
5 |
Specialty Tier |
31% | N/A | Q:60 /30Days |
BROMFENAC SODIUM 0.09% EYE DROPS [Xibrom] ![Compare how all Medicare Part D PDP plans in FL cover BROMFENAC SODIUM 0.09% EYE DROPS [Xibrom].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | None |
BROMOCRIPTINE 2.5 MG TABLET [Parlodel] ![Compare how all Medicare Part D PDP plans in FL cover BROMOCRIPTINE 2.5 MG TABLET [Parlodel].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | None |
BROMOCRIPTINE MESYLATE 5MG CAPSULE [Parlodel] ![Compare how all Medicare Part D PDP plans in FL cover BROMOCRIPTINE MESYLATE 5MG CAPSULE [Parlodel].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | None |
BUDESONIDE 0.25 MG/2 ML SUSP AMPUL-NEB [Pulmicort] ![Compare how all Medicare Part D PDP plans in FL 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 |
50% | 50% | P Q:120 /30Days |
BUDESONIDE 0.5 MG/2 ML SUSP AMPUL-NEB [Pulmicort] ![Compare how all Medicare Part D PDP plans in FL 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 |
50% | 50% | P Q:120 /30Days |
BUDESONIDE 1 MG/2 ML INH SUSP AMPUL-NEB [Pulmicort] ![Compare how all Medicare Part D PDP plans in FL 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 |
50% | 50% | P Q:120 /30Days |
BUDESONIDE EC 3 MG CAPSULE CAPDR - ER [Entocort EC] ![Compare how all Medicare Part D PDP plans in FL cover BUDESONIDE EC 3 MG CAPSULE CAPDR - ER [Entocort EC].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | None |
BUMETANIDE 0.25MG/ML VIAL  |
4 |
Non-Preferred Drug |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUMETANIDE 0.5 MG TABLET  |
2* |
Generic |
$10.00 | $25.00 | None |
BUMETANIDE 1 MG TABLET  |
2* |
Generic |
$10.00 | $25.00 | None |
BUMETANIDE 2 MG TABLET  |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
BUPRENORP-NALOX 12-3 MG SL FILM [Suboxone] ![Compare how all Medicare Part D PDP plans in FL cover BUPRENORP-NALOX 12-3 MG SL FILM [Suboxone].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:90 /30Days |
BUPRENORP-NALOX 2-0.5 MG SL FILM [Suboxone] ![Compare how all Medicare Part D PDP plans in FL cover BUPRENORP-NALOX 2-0.5 MG SL FILM [Suboxone].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:90 /30Days |
BUPRENORP-NALOX 4-1 MG SL FILM [Suboxone] ![Compare how all Medicare Part D PDP plans in FL cover BUPRENORP-NALOX 4-1 MG SL FILM [Suboxone].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:90 /30Days |
BUPRENORP-NALOX 8-2 MG SL FILM [Suboxone] ![Compare how all Medicare Part D PDP plans in FL cover BUPRENORP-NALOX 8-2 MG SL FILM [Suboxone].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:90 /30Days |
BUPRENORPHIN-NALOXON 2-0.5 MG SL [Suboxone] ![Compare how all Medicare Part D PDP plans in FL cover BUPRENORPHIN-NALOXON 2-0.5 MG SL [Suboxone].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:90 /30Days |
BUPRENORPHIN-NALOXON 8-2 MG SL [Suboxone] ![Compare how all Medicare Part D PDP plans in FL cover BUPRENORPHIN-NALOXON 8-2 MG SL [Suboxone].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:90 /30Days |
BUPRENORPHINE 2 MG TABLET Subligual [Subutex] ![Compare how all Medicare Part D PDP plans in FL cover BUPRENORPHINE 2 MG TABLET Subligual [Subutex].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | P Q:90 /30Days |
BUPRENORPHINE 8 MG TABLET Subligual [Subutex] ![Compare how all Medicare Part D PDP plans in FL cover BUPRENORPHINE 8 MG TABLET Subligual [Subutex].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | 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  |
2* |
Generic |
$10.00 | $25.00 | Q:120 /30Days |
BUPROPION HCL 75 MG TABLET  |
2* |
Generic |
$10.00 | $25.00 | Q:180 /30Days |
BUPROPION HCL SR 100 MG TABLET  |
2* |
Generic |
$10.00 | $25.00 | Q:60 /30Days |
BUPROPION HCL SR 150 MG TABLET  |
2* |
Generic |
$10.00 | $25.00 | Q:60 /30Days |
BUPROPION HCL SR 150 MG TABLET  |
2* |
Generic |
$10.00 | $25.00 | Q:60 /30Days |
BUPROPION HCL SR 200 MG TABLET  |
2* |
Generic |
$10.00 | $25.00 | Q:60 /30Days |
BUPROPION HCL XL 150 MG TABLET  |
2* |
Generic |
$10.00 | $25.00 | Q:30 /30Days |
BUPROPION HCL XL 300 MG TABLET  |
2* |
Generic |
$10.00 | $25.00 | Q:30 /30Days |
BUSPIRONE HCL 15 MG TABLET  |
2* |
Generic |
$10.00 | $25.00 | None |
BUSPIRONE HCL 30 MG TABLET  |
2* |
Generic |
$10.00 | $25.00 | None |
BUSPIRONE HCL 5 MG TABLET  |
2* |
Generic |
$10.00 | $25.00 | 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 |
$10.00 | $25.00 | None |
BUSPIRONE HYDROCHLORIDE 10 MG TABLETS  |
2* |
Generic |
$10.00 | $25.00 | None |
BUTALB-ACETAMIN-CAFF 50-325-40  |
4 |
Non-Preferred Drug |
50% | 50% | P Q:180 /30Days |
BUTALB-CAFF-ACETAMINOPH-CODEIN  |
3* |
Preferred Brand |
$42.00 | $105.00 | P Q:180 /30Days |
BUTALBITAL COMP-CODEINE #3 CAP  |
4 |
Non-Preferred Drug |
50% | 50% | P Q:180 /30Days |
BUTALBITAL-ASA-CAFFEINE CAPSULE  |
4 |
Non-Preferred Drug |
50% | 50% | P Q:180 /30Days |
BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50-300-40  |
4 |
Non-Preferred Drug |
50% | 50% | P Q:180 /30Days |
BUTALBITAL/ACETAMINOPHEN/CAFFEINE CP  |
4 |
Non-Preferred Drug |
50% | 50% | P Q:180 /30Days |
BUTORPHANOL 10MG/ML SPRAY  |
4 |
Non-Preferred Drug |
50% | 50% | Q:5 /30Days |
BYDUREON 2 MG PEN INJECT  |
4 |
Non-Preferred Drug |
50% | 50% | Q:4 /28Days |
BYDUREON BCISE 2 MG AUTOINJECT  |
4 |
Non-Preferred Drug |
50% | 50% | Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BYETTA 10 MCG DOSE PEN INJ  |
4 |
Non-Preferred Drug |
50% | 50% | Q:2 /30Days |
BYETTA 5 MCG DOSE PEN INJ  |
4 |
Non-Preferred Drug |
50% | 50% | Q:1 /30Days |
Bystolic 10mg/1 30 TABLET BOTTLE  |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
Bystolic 2.5mg/1 30 TABLET BOTTLE  |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
BYSTOLIC 20 MG TABLET  |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
Bystolic 5mg 30 TABLET BOTTLE  |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |