Q1Medicare.com 2009 Medicare Part D or Medicare Advantage Plan Formulary Browser

2009 Medicare Part D Plan Formulary Information
First Health Part D-Premier (S5768-009-0) Benefit Details
The First Health Part D-Premier (S5768-009-0) Formulary Drugs Starting with the Letter B in CMS PDP Region 6 which includes: PA WV
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
BACITRACIN 500U/GM EYE OINT	1	Preferred Generic	$7.00	N/A	None
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT	1	Preferred Generic	$7.00	N/A	None
BACLOFEN 10MG TABLET	1	Preferred Generic	$7.00	N/A	None
BACLOFEN 20MG TABLET	1	Preferred Generic	$7.00	N/A	None
BACTROBAN 2% CREAM	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	None
BACTROBAN NASAL 2% OINTMENT	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	None
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT)	1	Preferred Generic	$7.00	N/A	None
BALZIVA 0.4-0.035 TABLET	1	Preferred Generic	$7.00	N/A	None
BANZEL TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	P Q:240 /30Days
BANZEL TABLET	4	Specialty-Generic and Brand	33%	N/A	P Q:240 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BARACLUDE 0.05MG/ML SOLUTION	4	Specialty-Generic and Brand	33%	N/A	Q:630 /30Days
BARACLUDE 0.5MG TABLET	4	Specialty-Generic and Brand	33%	N/A	Q:30 /30Days
BARACLUDE 1MG TABLET	4	Specialty-Generic and Brand	33%	N/A	Q:30 /30Days
BD INSULIN SYRINGE ULT-FINE II	2	Preferred Brand	$27.00	N/A	None
BD INSULIN SYRINGE ULT-FINE II	2	Preferred Brand	$27.00	N/A	None
BD INSULIN SYRINGE ULTRA-FINE SYRING	2	Preferred Brand	$27.00	N/A	None
BD ORGINAL PEN NEEDLES 29G	2	Preferred Brand	$27.00	N/A	None
BECONASE AQ 0.042% SPRAY	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	Q:50 /30Days
BENAZEPRIL HCL 10MG TABLET	1	Preferred Generic	$7.00	N/A	None
BENAZEPRIL HCL 20MG TABLET (100 CT)	1	Preferred Generic	$7.00	N/A	None
BENAZEPRIL HCL 40MG TABLET	1	Preferred Generic	$7.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BENAZEPRIL HCL 5MG TABLET	1	Preferred Generic	$7.00	N/A	None
BENAZEPRIL HCL-HCTZ TABLET 10-12.5MG (100 CT)	1	Preferred Generic	$7.00	N/A	None
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT)	1	Preferred Generic	$7.00	N/A	None
BENAZEPRIL HCL-HCTZ TABLET 20-25MG (100 CT)	1	Preferred Generic	$7.00	N/A	None
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT)	1	Preferred Generic	$7.00	N/A	None
BENICAR 20MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	Q:30 /30Days
BENICAR 40MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	Q:30 /30Days
BENICAR 5MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	Q:30 /30Days
BENICAR HCT 20-12.5MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	Q:30 /30Days
BENICAR HCT 40-25MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	Q:30 /30Days
BENICAR HCT TABLET 12.5-40MG (30 CT)	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BENZACLIN GEL 1-5%	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	None
BENZTROPINE MES 0.5MG TABLET	1	Preferred Generic	$7.00	N/A	None
BENZTROPINE MES TABLET 1MG (1000 CT)	1	Preferred Generic	$7.00	N/A	None
BENZTROPINE MES TABLET 2MG (1000 CT)	1	Preferred Generic	$7.00	N/A	None
BETAMETHASONE DIPROPIONATE 0.05% CREAM	1	Preferred Generic	$7.00	N/A	None
BETAMETHASONE DIPROPIONATE 0.05% GEL	1	Preferred Generic	$7.00	N/A	None
BETAMETHASONE DIPROPIONATE 0.05% OINT	1	Preferred Generic	$7.00	N/A	None
BETAMETHASONE DIPROPIONATE LOTION 60ML	1	Preferred Generic	$7.00	N/A	None
BETAMETHASONE DP 0.05% CREAM	1	Preferred Generic	$7.00	N/A	None
BETAMETHASONE DP 0.05% LOTION	1	Preferred Generic	$7.00	N/A	None
BETAMETHASONE DP 0.05% OINTMENT	1	Preferred Generic	$7.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BETAMETHASONE VA 0.1% CREAM	1	Preferred Generic	$7.00	N/A	None
BETAMETHASONE VA 0.1% LOTION	1	Preferred Generic	$7.00	N/A	None
BETAMETHASONE VA 0.1% OINTMENT	1	Preferred Generic	$7.00	N/A	None
BETASERON 0.3MG VIAL	4	Specialty-Generic and Brand	33%	N/A	P S Q:15 /30Days
BETAXOLOL 10MG TABLET	1	Preferred Generic	$7.00	N/A	None
BETAXOLOL 20MG TABLET	1	Preferred Generic	$7.00	N/A	None
BETAXOLOL HCL 0.5% EYE DROP	1	Preferred Generic	$7.00	N/A	None
BETHANECHOL CHLORIDE 10MG TABLET (100 CT)	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	None
BETHANECHOL CHLORIDE 25MG TABLET (100 CT)	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	None
BETHANECHOL CHLORIDE 50MG TABLET (100 CT)	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	None
BETHANECHOL CHLORIDE 5MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BETIMOL 0.25% EYE DROPS	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	None
BETIMOL 0.5% EYE DROPS	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	None
BETOPTIC S 0.25% EYE DROPS	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	None
BILTRICIDE 600MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	None
BISOPROLOL FUMARATE 10MG TABLET (100 CT)	1	Preferred Generic	$7.00	N/A	None
BISOPROLOL FUMARATE 5MG TABLET (100 CT)	1	Preferred Generic	$7.00	N/A	None
BISOPROLOL FUMARATE-HCTZ TABLET 10-6.25MG (500 CT)	1	Preferred Generic	$7.00	N/A	None
BISOPROLOL FUMARATE-HCTZ TABLET 2.5-6.25MG (100 CT)	1	Preferred Generic	$7.00	N/A	None
BISOPROLOL FUMARATE-HCTZ TABLET 5-6.25MG (100 CT)	1	Preferred Generic	$7.00	N/A	None
BLEOMYCIN FOR INJECTION USP 15UNITS 1 X 10ML VIALSD	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	P
BLEOMYCIN SULFATE 30UNITS VIA	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BLEPHAMIDE 0.2% EYE DROPS	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	None
BLEPHAMIDE 10-0.2% EYE OINT	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	None
BONIVA 150MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	Q:1 /30Days
BONIVA 2.5MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	Q:30 /30Days
BOOSTRIX INJECTION SUSPENSION 2.5UNT-5ML 5 X .5ML SYR	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	None
BOROFAIR SOL 2% OTIC	1	Preferred Generic	$7.00	N/A	None
BOTOX 100UNITS VIAL	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	P
BRIMONIDINE TARTRATE OPHTHALMIC SOLUTION 0.2% 10ML BOTPL	1	Preferred Generic	$7.00	N/A	None
BROMOCRIPTINE MESYLATE 2.5MG TABLET	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	None
BROMOCRIPTINE MESYLATE 5MG CAPSULE	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	None
BROVANA 15MCG/2ML VIAL NEBULIZER	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	P Q:120 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BUDEPRION SR 100MG TABLET SA	1	Preferred Generic	$7.00	N/A	None
BUDEPRION SR 150MG TABLET SA	1	Preferred Generic	$7.00	N/A	None
BUDEPRION XL 300MG TABLET SR 24HR	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	Q:30 /30Days
BUDEPRION XL TABLETS 150MG 500 TABLETS BOT	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	S Q:30 /30Days
BUMETANIDE 0.25MG/ML VIAL	1	Preferred Generic	$7.00	N/A	None
BUMETANIDE 0.5MG TABLET USP (500 CT)	1	Preferred Generic	$7.00	N/A	None
BUMETANIDE 1MG TABLET USP (500 CT)	1	Preferred Generic	$7.00	N/A	None
BUMETANIDE 2MG TABLET USP (500 CT)	1	Preferred Generic	$7.00	N/A	None
BUPHENYL 500MG TABLET	4	Specialty-Generic and Brand	33%	N/A	P
BUPROBAN ER TABLET	1	Preferred Generic	$7.00	N/A	None
BUPROPION HCL 100MG ER TABLET (60 CT)	1	Preferred Generic	$7.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BUPROPION HCL 75MG TABLET	1	Preferred Generic	$7.00	N/A	None
BUPROPION HCL SR 200MG TABLET SA	1	Preferred Generic	$7.00	N/A	None
BUPROPION HCL TABLET 100MG	1	Preferred Generic	$7.00	N/A	None
BUPROPION HCL TABLET SUSTAINED RELEASE	1	Preferred Generic	$7.00	N/A	None
BUSPIRONE HCL 10MG TABLET	1	Preferred Generic	$7.00	N/A	None
BUSPIRONE HCL 15MG TABLET (180 CT)	1	Preferred Generic	$7.00	N/A	None
BUSPIRONE HCL 30MG TABLET (60 CT)	1	Preferred Generic	$7.00	N/A	None
BUSPIRONE HCL 5MG TABLET	1	Preferred Generic	$7.00	N/A	None
BUSPIRONE HCL 7.5MG TABLET	1	Preferred Generic	$7.00	N/A	None
BUTALBITAL ASPIRIN CAFFEINE CODEINE PHOSPHATE 325-50-40MG (500 CT)	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	None
BUTALBITAL/CAFF/APAP/COD CP	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BUTORPHANOL 10MG/ML SPRAY	3	Non-Preferred Generic/Non-Preferred Brand	$52.00	N/A	None
BYETTA 10MCG/0.04ML PEN INJ	2	Preferred Brand	$27.00	N/A	S Q:2 /30Days
BYETTA 5MCG/0.02ML PEN INJ	2	Preferred Brand	$27.00	N/A	S Q:1 /30Days
BYSTOLIC 10MG TABLET	2	Preferred Brand	$27.00	N/A	Q:120 /30Days
BYSTOLIC 5MG TABLET	2	Preferred Brand	$27.00	N/A	Q:30 /30Days
BYSTOLIC NEBIVOLOL HCL 2.5MG TABLET ORAL	2	Preferred Brand	$27.00	N/A	Q:30 /30Days

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D First Health Part D-Premier 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 $295 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 initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 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 October 2009 )

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.