2023 Medicare Part D Plan Formulary Information |
RiverSpring Star (HMO I-SNP) (H6776-001-0)
Benefit Details
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less. Call drug plan for more details. |
The RiverSpring Star (HMO I-SNP) (H6776-001-0) Formulary Drugs Starting with the Letter B in Bronx County, NY: CMS MA Region 3 which includes: NY
|
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 |
1 |
Tier 1 |
25% | 25% | None |
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT |
1 |
Tier 1 |
25% | 25% | None |
BACLOFEN 10 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BACLOFEN 20 MG TABLET [Lioresal] |
1 |
Tier 1 |
25% | 25% | None |
BACLOFEN 25 MG/5 ML ORAL SUSPENSION [FLEQSUVY] |
1 |
Tier 1 |
25% | 25% | None |
BACLOFEN 5 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BACTRIM 400-80 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BACTRIM DS 800-160 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BAFIERTAM DR 95 MG CAPSULE DR |
1 |
Tier 1 |
25% | 25% | P Q:120 /30Days |
BALCOLTRA TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BALSALAZIDE DISODIUM 750 MG CAPSULE [Colazal] |
1 |
Tier 1 |
25% | 25% | None |
BALVERSA 3 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
BALVERSA 4 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
BALVERSA 5 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
Balziva 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK |
1 |
Tier 1 |
25% | 25% | None |
Banzel 200mg/1 |
1 |
Tier 1 |
25% | 25% | P |
BANZEL 400MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
Banzel 40mg/mL |
1 |
Tier 1 |
25% | 25% | P |
BAQSIMI 3 MG SPRAY ONE PACK |
1 |
Tier 1 |
25% | 25% | None |
BARACLUDE 0.05mg/mL 1 BOTTLE per CARTON / 210 mL in 1 BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
BARACLUDE 0.5MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BARACLUDE 1MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BASAGLAR 100 UNIT/ML KWIKPEN |
1 |
Tier 1 |
$35 max* | 25% | S |
BASAGLAR TEMPO PEN 100 UNIT/ML INSULIN PEN [Semglee] |
1 |
Tier 1 |
$35 max* | 25% | S |
BAXDELA 300 MG VIAL |
1 |
Tier 1 |
25% | 25% | P |
BAXDELA 450 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BCG VACCINE 50mg/1 1 VIAL per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL |
1 |
Tier 1 |
25% | 25% | None |
BECONASE AQ 0.042% SPRAY |
1 |
Tier 1 |
25% | 25% | S Q:50 /30Days |
BELBUCA 150 MCG FILM |
1 |
Tier 1 |
25% | 25% | P Q:60 /30Days |
BELBUCA 300 MCG FILM |
1 |
Tier 1 |
25% | 25% | P Q:60 /30Days |
BELBUCA 450 MCG FILM |
1 |
Tier 1 |
25% | 25% | P Q:60 /30Days |
BELBUCA 600 MCG FILM |
1 |
Tier 1 |
25% | 25% | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BELBUCA 75 MCG FILM |
1 |
Tier 1 |
25% | 25% | P Q:60 /30Days |
BELBUCA 750 MCG FILM |
1 |
Tier 1 |
25% | 25% | P Q:60 /30Days |
BELBUCA 900 MCG FILM |
1 |
Tier 1 |
25% | 25% | P Q:60 /30Days |
BELSOMRA 10 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
BELSOMRA 15 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
BELSOMRA 20 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
BELSOMRA 5 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
BENAZEPRIL HCL 10 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BENAZEPRIL HCL 20 MG TABLET [Lotensin] |
1 |
Tier 1 |
25% | 25% | None |
BENAZEPRIL HCL 40 MG TABLET [Lotensin] |
1 |
Tier 1 |
25% | 25% | None |
BENAZEPRIL HCL 5 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BENAZEPRIL-HCTZ 10-12.5 MG TABLET [Lotensin HCT] |
1 |
Tier 1 |
25% | 25% | None |
BENAZEPRIL-HCTZ 20-12.5 MG TABLET [Lotensin HCT] |
1 |
Tier 1 |
25% | 25% | None |
BENAZEPRIL-HCTZ 20-25 MG TABLET [Lotensin HCT] |
1 |
Tier 1 |
25% | 25% | None |
BENAZEPRIL-HCTZ 5-6.25 MG TABLET [Lotensin HCT] |
1 |
Tier 1 |
25% | 25% | None |
BENICAR 20 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
BENICAR 40 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
BENICAR 5 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
BENICAR HCT 20-12.5 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
BENICAR HCT 40-12.5 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
BENICAR HCT 40-25 MG TABLET |
1 |
Tier 1 |
25% | 25% | S |
BENLYSTA 200 MG/ML AUTOINJECT |
1 |
Tier 1 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BENLYSTA 200 MG/ML SYRINGE |
1 |
Tier 1 |
25% | 25% | P |
BENZAMYCIN GEL |
1 |
Tier 1 |
25% | 25% | None |
BENZNIDAZOLE 100 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BENZNIDAZOLE 12.5 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BENZTROPINE MES 0.5 MG TABLET [Cogentin] |
1 |
Tier 1 |
25% | 25% | P |
BENZTROPINE MES 1 MG TABLET [Cogentin] |
1 |
Tier 1 |
25% | 25% | P |
BENZTROPINE MES 2 MG TABLET [Cogentin] |
1 |
Tier 1 |
25% | 25% | P |
BEPOTASTINE 1.5% EYE DROPS [Bepreve] |
1 |
Tier 1 |
25% | 25% | None |
BEPREVE 1.5% EYE DROPS |
1 |
Tier 1 |
25% | 25% | None |
BERINERT 500 UNIT KIT |
1 |
Tier 1 |
25% | 25% | P |
BESIVANCE BESIFLOACIN OPTHALMIC SUSPENSION 0.6% 5 ML BOTDR |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BESREMI 500 MCG/ML SYRINGE |
1 |
Tier 1 |
25% | 25% | P |
BETAINE 1 GRAM/SCOOP POWDER [Cystadane] |
1 |
Tier 1 |
25% | 25% | None |
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE |
1 |
Tier 1 |
25% | 25% | None |
BETAMETHASONE DP 0.05% LOTION |
1 |
Tier 1 |
25% | 25% | None |
BETAMETHASONE DP 0.05% OINTMENT [Maxivate] |
1 |
Tier 1 |
25% | 25% | None |
BETAMETHASONE DP AUG 0.05% CREAM (g) [RRB Pak] |
1 |
Tier 1 |
25% | 25% | None |
BETAMETHASONE DP AUG 0.05% GEL |
1 |
Tier 1 |
25% | 25% | None |
BETAMETHASONE DP AUG 0.05% LOTION [Diprolene] |
1 |
Tier 1 |
25% | 25% | None |
BETAMETHASONE DP AUG 0.05% OINTMENT [Diprolene] |
1 |
Tier 1 |
25% | 25% | None |
BETAMETHASONE VA 0.1% CREAM (G) [Valisone] |
1 |
Tier 1 |
25% | 25% | None |
BETAMETHASONE VALER 0.1% LOTION [Valisone] |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETAMETHASONE VALER 0.1% OINTMENT [Valisone] |
1 |
Tier 1 |
25% | 25% | None |
BETAMETHASONE VALER 0.12% FOAM [Luxiq Foam] |
1 |
Tier 1 |
25% | 25% | None |
BETAPACE AF 120 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BETAPACE AF 160 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BETAPACE AF 80 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BETASERON 0.3 MG KIT |
1 |
Tier 1 |
25% | 25% | P Q:14 /28Days |
BETAXOLOL 10 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BETAXOLOL 20 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BETAXOLOL HCL 0.5% EYE DROPS |
1 |
Tier 1 |
25% | 25% | None |
BETHANECHOL 10 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BETHANECHOL 25 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETHANECHOL 5 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BETHANECHOL 50 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BETHKIS 300 MG/4 ML AMPULE |
1 |
Tier 1 |
25% | 25% | P Q:224 /28Days |
BETIMOL 0.25% EYE DROPS |
1 |
Tier 1 |
25% | 25% | None |
BETIMOL 0.5% EYE DROPS |
1 |
Tier 1 |
25% | 25% | None |
BETOPTIC S 0.25% EYE DROP EYE DROPPER |
1 |
Tier 1 |
25% | 25% | None |
BEVESPI AEROSPHERE INHALER |
1 |
Tier 1 |
25% | 25% | Q:11 /30Days |
BEXAROTENE 1% GEL [Targretin] |
1 |
Tier 1 |
25% | 25% | P |
BEXAROTENE 75 MG CAPSULE [Targretin] |
1 |
Tier 1 |
25% | 25% | P |
BEXSERO PREFILLED SYRINGE |
1 |
Tier 1 |
25% | 25% | None |
Beyaz 3 BLISTER PACK in 1 PACKAGE / 1 KIT per BLISTER PACK |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BICALUTAMIDE 50 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BICILL LA PFS 600MU 1ML PED |
1 |
Tier 1 |
25% | 25% | P |
BICILLIN C-R 1.2MM UNITS SYRINGE 2ML x 10 |
1 |
Tier 1 |
25% | 25% | P |
BICILLIN C-R 900/300 SYRINGE 2ML x 10 |
1 |
Tier 1 |
25% | 25% | P |
BICILLIN LA PFS 1200MU 2ML |
1 |
Tier 1 |
25% | 25% | P |
BICILLIN LA. 600000UNIT/ML 1ML |
1 |
Tier 1 |
25% | 25% | P |
BIDIL 20 MG-37.5 MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:180 /30Days |
BIJUVA 1 MG-100 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P |
BIKTARVY 30-120-15 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BIKTARVY 50-200-25 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Biltricide 600mg/1 6 FILM COATED TABLETS in BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BIMATOPROST 0.03% EYE DROPS [Lumigan] |
1 |
Tier 1 |
25% | 25% | None |
BINOSTO 70 MG EFFERVESCENT TABLET |
1 |
Tier 1 |
25% | 25% | S Q:4 /28Days |
BISMUTH-METRO-TETR 140-125-125 CAPSULE [Pylera] |
1 |
Tier 1 |
25% | 25% | Q:120 /180Days |
BISOPROLOL FUMARATE 10 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BISOPROLOL FUMARATE 5 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BISOPROLOL-HCTZ 10-6.25 MG TABLET [Ziac] |
1 |
Tier 1 |
25% | 25% | None |
BISOPROLOL-HCTZ 2.5-6.25 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BISOPROLOL-HCTZ 5-6.25 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BIVIGAM 10% VIAL [Panzyga] |
1 |
Tier 1 |
25% | 25% | P |
BLISOVI 24 FE TABLET [Tarina Fe 1/20] |
1 |
Tier 1 |
25% | 25% | None |
BLISOVI FE 1.5-30 TABLET [Microgestin Fe 1.5/30] |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BONJESTA ER 20-20 MG TABLET IR DR |
1 |
Tier 1 |
25% | 25% | None |
BOOSTRIX TDAP VACCINE SYRINGE |
1 |
Tier 1 |
25% | 25% | None |
BOOSTRIX TDAP VACCINE VIAL |
1 |
Tier 1 |
25% | 25% | None |
BOSENTAN 125 MG TABLET [Tracleer] |
1 |
Tier 1 |
25% | 25% | P |
BOSENTAN 62.5 MG TABLET [Tracleer] |
1 |
Tier 1 |
25% | 25% | P |
BOSULIF 100 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:90 /30Days |
BOSULIF 400 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
BOSULIF 500 MG TABLET |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days |
BRAFTOVI 75 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P Q:180 /30Days |
BREO ELLIPTA 100-25 MCG INH |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
BREO ELLIPTA 200-25 MCG INH |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BREZTRI AEROSPHERE INHALER HFA AER AD |
1 |
Tier 1 |
25% | 25% | Q:11 /30Days |
BRIELLYN TABLET |
1 |
Tier 1 |
25% | 25% | None |
BRILINTA 60 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BRILINTA 90mg/1 60 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
BRIMONIDINE 0.2% EYE DROPS [Alphagan] |
1 |
Tier 1 |
25% | 25% | None |
BRIMONIDINE 0.33% GEL PUMP [Mirvaso] |
1 |
Tier 1 |
25% | 25% | P |
BRIMONIDINE TARTRATE 0.15% DROPS [Alphagan P] |
1 |
Tier 1 |
25% | 25% | None |
BRIMONIDINE-TIMOLOL 0.2%-0.5% DROPS [Combigan] |
1 |
Tier 1 |
25% | 25% | None |
BRINZOLAMIDE 1% EYE DROPS/EYE DROPPER [Azopt] |
1 |
Tier 1 |
25% | 25% | None |
BRIVIACT 10 MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
BRIVIACT 10 MG/ML ORAL SOLUTION |
1 |
Tier 1 |
25% | 25% | Q:600 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BRIVIACT 100 MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
BRIVIACT 25 MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
BRIVIACT 50 MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
BRIVIACT 75 MG TABLET |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
BROMFENAC SODIUM 0.09% EYE DROPS [Xibrom] |
1 |
Tier 1 |
25% | 25% | None |
BROMOCRIPTINE 2.5 MG TABLET [Parlodel] |
1 |
Tier 1 |
25% | 25% | None |
BROMOCRIPTINE 5 MG CAPSULE [Parlodel] |
1 |
Tier 1 |
25% | 25% | None |
BROMSITE 0.075% EYE DROPS |
1 |
Tier 1 |
25% | 25% | None |
BRONCHITOL 40 MG INHALE CAPSULE W/DEV |
1 |
Tier 1 |
25% | 25% | P |
BROVANA 15MCG/2ML VIAL NEBULIZER |
1 |
Tier 1 |
25% | 25% | P |
BRUKINSA 80 MG CAPSULE |
1 |
Tier 1 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BRYHALI 0.01% LOTION |
1 |
Tier 1 |
25% | 25% | None |
BUDESONIDE 0.25 MG/2 ML SUSP AMPUL-NEB [Pulmicort] |
1 |
Tier 1 |
25% | 25% | P Q:120 /30Days |
BUDESONIDE 0.5 MG/2 ML SUSP AMPUL-NEB [Pulmicort] |
1 |
Tier 1 |
25% | 25% | P Q:120 /30Days |
BUDESONIDE 1 MG/2 ML INH SUSP AMPUL-NEB [Pulmicort] |
1 |
Tier 1 |
25% | 25% | P Q:60 /30Days |
BUDESONIDE 2 MG RECTAL FOAM/APPL [UCERIS Rectal] |
1 |
Tier 1 |
25% | 25% | None |
BUDESONIDE EC 3 MG CAPSULE DR - ER [Entocort EC] |
1 |
Tier 1 |
25% | 25% | None |
BUDESONIDE ER 9 MG TABLET ER [UCERIS] |
1 |
Tier 1 |
25% | 25% | None |
BUDESONIDE-FORMOTEROL 160-4.5 HFA AER AD [Symbicort] |
1 |
Tier 1 |
25% | 25% | S Q:10 /30Days |
BUDESONIDE-FORMOTEROL 80-4.5 HFA AER AD [Symbicort] |
1 |
Tier 1 |
25% | 25% | S Q:10 /30Days |
BUMETANIDE 0.5 MG TABLET [Bumex] |
1 |
Tier 1 |
25% | 25% | None |
BUMETANIDE 1 MG TABLET [Bumex] |
1 |
Tier 1 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUMETANIDE 1 MG/4 ML VIAL |
1 |
Tier 1 |
25% | 25% | None |
BUMETANIDE 2 MG TABLET [Bumex] |
1 |
Tier 1 |
25% | 25% | None |
BUPHENYL 500 MG TABLET |
1 |
Tier 1 |
25% | 25% | P |
BUPHENYL POWDER |
1 |
Tier 1 |
25% | 25% | P |
BUPRENORP-NALOX 12-3 MG SL FILM [Suboxone] |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
BUPRENORPHIN-NALOXON 8-2 MG SL SUSLIGUAL TABLET [Suboxone] |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
BUPRENORPHINE 10 MCG/HR PATCH [Butrans] |
1 |
Tier 1 |
25% | 25% | P Q:4 /28Days |
BUPRENORPHINE 15 MCG/HR PATCH [Butrans] |
1 |
Tier 1 |
25% | 25% | P Q:4 /28Days |
BUPRENORPHINE 2 MG SUBLIGUAL TABLET [Subutex] |
1 |
Tier 1 |
25% | 25% | None |
BUPRENORPHINE 20 MCG/HR PATCH [Butrans] |
1 |
Tier 1 |
25% | 25% | P Q:4 /28Days |
BUPRENORPHINE 5 MCG/HR PATCH [Butrans] |
1 |
Tier 1 |
25% | 25% | P Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUPRENORPHINE 7.5 MCG/HR PATCH [Butrans] |
1 |
Tier 1 |
25% | 25% | P Q:4 /28Days |
BUPRENORPHINE 8 MG TABLET SUSLIGUAL [Subutex] |
1 |
Tier 1 |
25% | 25% | None |
BUPRENORPHINE-NALOX 2-0.5MG FILM [Suboxone] |
1 |
Tier 1 |
25% | 25% | Q:360 /30Days |
BUPRENORPHINE-NALOX 4-1MG FILM [Suboxone] |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
BUPRENORPHINE-NALOX 8-2MG FILM [Suboxone] |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
BUPRENORPHN-NALOXN 2-0.5 MG TABLET SUSLIGUAL [Suboxone] |
1 |
Tier 1 |
25% | 25% | Q:360 /30Days |
BUPROPION HCL 100 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BUPROPION HCL 75 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BUPROPION HCL SR 100 MG TABLET SR 12H [Wellbutrin SR] |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
BUPROPION HCL SR 150 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BUPROPION HCL SR 150 MG TABLET SR 12H [Wellbutrin SR] |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUPROPION HCL SR 200 MG TABLET SR 12H [Wellbutrin SR] |
1 |
Tier 1 |
25% | 25% | Q:60 /30Days |
BUPROPION HCL XL 150 MG TABLET ER 24H [Wellbutrin XL] |
1 |
Tier 1 |
25% | 25% | Q:90 /30Days |
BUPROPION HCL XL 300 MG TABLET ER 24H [Wellbutrin XL] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
BUPROPION HCL XL 450 MG TABLET ER 24H [Forfivo XL] |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days |
BUSPIRONE HCL 15 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BUSPIRONE HCL 30 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BUSPIRONE HCL 5 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BUSPIRONE HCL 7.5 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BUSPIRONE HYDROCHLORIDE 10 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
BUTORPHANOL 10 MG/ML SPRAY [Stadol NS] |
1 |
Tier 1 |
25% | 25% | Q:10 /28Days |
Butrans 10ug/h |
1 |
Tier 1 |
25% | 25% | P Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUTRANS 15 MCG/HR PATCH |
1 |
Tier 1 |
25% | 25% | P Q:4 /28Days |
Butrans 20ug/h |
1 |
Tier 1 |
25% | 25% | P Q:4 /28Days |
Butrans 5ug/h |
1 |
Tier 1 |
25% | 25% | P Q:4 /28Days |
BUTRANS 7.5 MCG/HR PATCH |
1 |
Tier 1 |
25% | 25% | P Q:4 /28Days |
BYDUREON BCISE 2 MG AUTOINJECT |
1 |
Tier 1 |
25% | 25% | P Q:4 /28Days |
BYETTA 10 MCG DOSE PEN INJ |
1 |
Tier 1 |
25% | 25% | P Q:2 /30Days |
BYETTA 5 MCG DOSE PEN INJ |
1 |
Tier 1 |
25% | 25% | P Q:1 /30Days |
BYLVAY 1,200 MCG CAPSULE |
1 |
Tier 1 |
25% | 25% | P |
BYLVAY 200 MCG PELLET DSP CP |
1 |
Tier 1 |
25% | 25% | P |
BYLVAY 400 MCG CAPSULE |
1 |
Tier 1 |
25% | 25% | P |
BYLVAY 600 MCG PELLET DSP CP |
1 |
Tier 1 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Bystolic 10mg/1 30 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
Bystolic 2.5mg/1 30 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | None |
BYSTOLIC 20 MG TABLET |
1 |
Tier 1 |
25% | 25% | None |
Bystolic 5mg 30 TABLET BOTTLE |
1 |
Tier 1 |
25% | 25% | None |