2013 Medicare Part D Plan Formulary Information |
First Health Part D Value Plus (PDP) (S5768-150-0)
Benefit Details
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The First Health Part D Value Plus (PDP) (S5768-150-0) Formulary Drugs Starting with the Letter B in CMS PDP Region 27 which includes: CO
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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 |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | None |
BACITRACIN 500[iU]/g 1 TUBE in 1 CARTON / 3.5 g in 1 TUBE |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BACLOFEN 10MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
baclofen 20 mg tablet |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BACTROBAN NASAL 2% OINTMENT |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | None |
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT) |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
Balziva 6 POUCH in 1 CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER PACK |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | None |
Banzel 200mg/1 |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | P Q:240 /30Days |
Banzel 40mg/mL |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | P Q:2400 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BANZEL TABLET 400MG |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | P Q:240 /30Days |
BARACLUDE 0.05mg/mL 1 BOTTLE in 1 CARTON / 210 mL in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | Q:630 /30Days |
BARACLUDE 0.5MG TABLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | Q:30 /30Days |
BARACLUDE 1MG TABLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | Q:30 /30Days |
BECONASE AQ 0.042% SPRAY |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | Q:50 /30Days |
BENAZEPRIL HCL 10MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BENAZEPRIL HCL 20mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BENAZEPRIL HCL 40MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BENAZEPRIL HCL 5MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BENAZEPRIL HCL-HCTZ TABLET 10-12.5MG (100 CT) |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT) |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BENAZEPRIL HCL-HCTZ TABLET 20-25MG (100 CT) |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT) |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BENICAR 20MG TABLET |
2 |
Preferred Brand Drugs |
$35.00 | N/A | Q:30 /30Days |
BENICAR 40MG TABLET |
2 |
Preferred Brand Drugs |
$35.00 | N/A | Q:30 /30Days |
BENICAR 5MG TABLET |
2 |
Preferred Brand Drugs |
$35.00 | N/A | Q:30 /30Days |
BENICAR HCT 20-12.5MG TABLET |
2 |
Preferred Brand Drugs |
$35.00 | N/A | Q:30 /30Days |
BENICAR HCT 40-25MG TABLET |
2 |
Preferred Brand Drugs |
$35.00 | N/A | Q:30 /30Days |
BENICAR HCT TABLET 12.5-40MG (30 CT) |
2 |
Preferred Brand Drugs |
$35.00 | N/A | Q:30 /30Days |
BENLYSTA 120mg/1.5mL 1 VIAL in 1 CARTON / 1.5 mL in 1 VIAL |
4 |
Specialty Tier Drugs |
33% | N/A | P |
Benztropine Mesylate 1mg 100 TABLET BOTTLE |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
Benztropine Mesylate 1mg/mL 5 VIAL, SINGLE-USE in 1 CARTON / 2 mL in 1 VIAL, SINGLE-USE |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Benztropine Mesylate 2mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BENZTROPINE MESYLATE TABLETS |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BENZYL ALCOHOL 50 ML/ML TOPICAL LOTION [ULESFIA] |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | None |
BEPREVE 1.5% EYE DROPS |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | Q:10 /30Days |
BESIVANCE BESIFLOACIN OPTHALMIC SUSPENSION 0.6% 5 ML BOTDR |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | Q:5 /30Days |
BETAMETHASONE DIPROPIONATE 0.05% CREAM |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
Betamethasone Dipropionate 0.60mg/mL 60 mL in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
Betamethasone Dipropionate 0.64mg/mL 60 mL in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
Betamethasone DP 0.05% ointment |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BETAMETHASONE DP AUG 0.05% GEL |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETAMETHASONE VALERATE 0.1% lotion |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BETAMETHASONE VALERATE CREAM |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BETAMETHASONE VALERATE OINTMENT USP |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BETASERON KIT 0.3MG/VIAL 14 TRAY BOX PKGCOM |
4 |
Specialty Tier Drugs |
33% | N/A | P Q:15 /30Days |
Betaxolol 10mg/1 |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
Betaxolol 20mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
betaxolol hcl 0.5% eye drop |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BETHANECHOL 10 MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BETHANECHOL CHLORIDE 25MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BETHANECHOL CHLORIDE 50MG TABLET (100 CT) |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BETHANECHOL CHLORIDE 5MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETIMOL 0.5% EYE DROPS |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | None |
BETIMOL SOLUTION 2.5MG 5 ML BOT |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | None |
BETOPTIC S OPHTHALMIC SUSPENSION 0.25% 10 ML BOT |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | None |
BICALUTAMIDE TABLETS 50MG 100 BOT |
1 |
Preferred Generic Drugs |
$0.00 | N/A | Q:30 /30Days |
BILTRICIDE 600MG TABLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | None |
BISOPROLOL FUMARATE 10MG TABLET (100 CT) |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BISOPROLOL FUMARATE 5MG TABLET (100 CT) |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BISOPROLOL FUMARATE-HCTZ TABLET 10-6.25MG (500 CT) |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BISOPROLOL FUMARATE-HCTZ TABLET 2.5-6.25MG (100 CT) |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BISOPROLOL FUMARATE-HCTZ TABLET 5-6.25MG (100 CT) |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BLEOMYCIN SULFATE 30UNITS VIA |
3 |
Non-Preferred Brand Drugs |
$70.00 | 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 |
2 |
Preferred Brand Drugs |
$35.00 | N/A | None |
BLEPHAMIDE 10-0.2% EYE OINT |
2 |
Preferred Brand Drugs |
$35.00 | N/A | None |
BONIVA 3mg/3mL SYRINGE |
2 |
Preferred Brand Drugs |
$35.00 | N/A | P Q:3 /90Days |
BOOSTRIX 8; 2.5; 8; 5; 2.5ug/0.5mL; ug/0.5mL; ug/0.5mL; [iU]/0.5mL; [iU]/0.5mL |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | None |
BOOSTRIX 8; 2.5; 8; 5; 2.5ug/0.5mL; ug/0.5mL; ug/0.5mL; [iU]/0.5mL; [iU]/0.5mL |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | None |
BOSULIF 100 MG TABLET |
4 |
Specialty Tier Drugs |
33% | N/A | P |
BOSULIF 500 MG TABLET |
4 |
Specialty Tier Drugs |
33% | N/A | P |
BRIELLYN |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | None |
BRILINTA 90mg/1 60 TABLET BOTTLE |
2 |
Preferred Brand Drugs |
$35.00 | N/A | Q:60 /30Days |
Brimonidine Tartrate 1.5mg/mL |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | None |
BRIMONIDINE TARTRATE OPHTHALMIC SOLUTION 0.2% 10ML BOTPL |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BROMDAY 0.09% EYE DROPS |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | Q:2 /30Days |
Bromfenac 1.035mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 2.5 mL in 1 BOTTLE, DROPPER |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | Q:3 /30Days |
Bromocriptine mesylate 2.5mg/1 24 BOTTLE in 1 CARTON / 100 TABLET BOTTLE |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BROMOCRIPTINE MESYLATE 5MG CAPSULE |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BROVANA 15MCG/2ML VIAL NEBULIZER |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | P Q:120 /30Days |
BUDEPRION SR 100MG TABLET SA |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BUDEPRION SR 150MG TABLET SA |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BUDESONIDE 0.25 MG/2 ML SUSP |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | P Q:120 /30Days |
BUDESONIDE 0.5 MG/2 ML SUSP |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | P Q:120 /30Days |
Budesonide 3mg 100 CAPSULE BOTTLE |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | None |
BUMETANIDE 0.25MG/ML VIAL |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUMETANIDE 0.5MG TABLET USP (500 CT) |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BUMETANIDE 1MG TABLET USP (500 CT) |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BUMETANIDE 2MG TABLET USP (500 CT) |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BUPHENYL 500MG TABLET |
4 |
Specialty Tier Drugs |
33% | N/A | P |
BUPROBAN ER TABLET |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BUPROPION HCL 75MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BUPROPION HCL SR 100 MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BUPROPION HCL SR 200MG TABLET SA |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BUPROPION HCL TABLET 100MG |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BUPROPION HCL XL 150 MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | N/A | Q:30 /30Days |
Bupropion Hydrochloride 150mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Bupropion Hydrochloride XL 300mg/1 500 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$0.00 | N/A | Q:30 /30Days |
BUSPIRONE HCL 15MG TABLET (180 CT) |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BUSPIRONE HCL 30MG TABLET (60 CT) |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BUSPIRONE HCL 5 MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BUSPIRONE HCL 7.5MG TABLET |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BUSPIRONE HYDROCHLORIDE TABLETS |
1 |
Preferred Generic Drugs |
$0.00 | N/A | None |
BUTALBITAL/CAFF/APAP/COD CP |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | Q:180 /30Days |
BUTORPHANOL 10MG/ML SPRAY |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | None |
BYETTA 10ug/0.04mL |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | P Q:2 /30Days |
BYETTA 5MCG/0.02ML PEN INJ |
3 |
Non-Preferred Brand Drugs |
$70.00 | N/A | P Q:1 /30Days |
Bystolic 10mg 100 TABLET in BLISTER PACK |
2 |
Preferred Brand Drugs |
$35.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Bystolic 2.5mg 100 TABLETBOTTLE |
2 |
Preferred Brand Drugs |
$35.00 | N/A | Q:30 /30Days |
Bystolic 5mg 30 TABLET BOTTLE |
2 |
Preferred Brand Drugs |
$35.00 | N/A | Q:30 /30Days |
BYSTOLIC TABLETS 20MG 100 BOT |
2 |
Preferred Brand Drugs |
$35.00 | N/A | Q:60 /30Days |