2014 Medicare Part D Plan Formulary Information |
First+Plus Advantage Plus (PPO) (H4011-003-0)
Benefit Details
|
The First+Plus Advantage Plus (PPO) (H4011-003-0) Formulary Drugs Starting with the Letter B in GUAYANILLA County, PR: CMS MA Region 30 which includes: PR 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 |
BACiiM 500001/1 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | P |
Bacitracin 500 unit/gm Eye Ointment |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
BACITRACIN INJ 50000UNT |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | P |
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
BACLOFEN 10MG TABLET |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
baclofen 20 mg tablet |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
BACTROBAN 2% CREAM |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | None |
BACTROBAN NASAL 2% OINTMENT |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | None |
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT) |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
Balziva 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Banzel 200mg/1 |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | None |
Banzel 40mg/mL |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | None |
BANZEL TABLET 400MG |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | None |
BARACLUDE 0.05mg/mL 1 BOTTLE per CARTON / 210 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | P |
BARACLUDE 0.5MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
BARACLUDE 1MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
BECONASE AQ 0.042% SPRAY |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | None |
BENAZEPRIL HCL 10MG TABLET |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
BENAZEPRIL HCL 20mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
BENAZEPRIL HCL 40MG TABLET |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
BENAZEPRIL HCL 5MG TABLET |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BENAZEPRIL HCL-HCTZ TABLET 10-12.5MG (100 CT) |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT) |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
BENAZEPRIL HCL-HCTZ TABLET 20-25MG (100 CT) |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT) |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
BENICAR 20MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
BENICAR 40MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
BENICAR 5MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
BENICAR HCT 20-12.5MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
BENICAR HCT 40-25MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
BENICAR HCT TABLET 12.5-40MG (30 CT) |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
BENLYSTA 120mg/1.5mL 1 VIAL per CARTON / 1.5 mL in 1 VIAL |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BENZTROPINE MESYLATE 0.5 MG TABLETS |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
Benztropine Mesylate 1mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
Benztropine Mesylate 1mg/mL 5 VIAL, SINGLE-USE per CARTON / 2 mL in 1 VIAL, SINGLE-USE |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
Benztropine Mesylate 2mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
BETAGAN 0.5% EYE DROPS |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | None |
BETAMETHASONE DIPROPIONATE 0.05% CREAM |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
Betamethasone Dipropionate 0.60mg/mL 60 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
Betamethasone Dipropionate 0.64mg/mL 60 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
Betamethasone DP 0.05% ointment |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
BETAMETHASONE VALERATE 0.1% lotion |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETAMETHASONE VALERATE CREAM |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
BETAMETHASONE VALERATE OINTMENT USP |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
BETASERON KIT 0.3MG/VIAL 14 TRAY BOX PKGCOM |
5 |
Specialty Tier |
25% | N/A | P Q:14 /28Days |
Betaxolol 10mg/1 |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
Betaxolol 20mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
betaxolol hcl 0.5% eye drop |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
BETHANECHOL 10 MG TABLET |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
BETHANECHOL CHLORIDE 25MG TABLET |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
BETHANECHOL CHLORIDE 50MG TABLET (100 CT) |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
BETHANECHOL CHLORIDE 5MG TABLET |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
Bicalutamide 50 mg tablet |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BICILL LA PFS 600MU 1ML PED |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | None |
BICILLIN C-R 1.2MM UNITS SYR 2ML x 10 |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | None |
BICILLIN C-R 900/300 SYRINGE 2ML x 10 |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | None |
BICILLIN LA PFS 1200MU 2ML |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | None |
BICILLIN LA. 600000UNIT/ML 1ML |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | None |
BICNU 1 KIT per CARTON |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | P |
Biltricide 600mg/1 6 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
BISOPROLOL FUMARATE 10MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
BISOPROLOL FUMARATE 5MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
BISOPROLOL FUMARATE-HCTZ TABLET 10-6.25MG (500 CT) |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
BISOPROLOL FUMARATE-HCTZ TABLET 2.5-6.25MG (100 CT) |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BISOPROLOL FUMARATE-HCTZ TABLET 5-6.25MG (100 CT) |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
BLEOMYCIN SULFATE 30UNITS VIA |
1 |
Preferred Generic |
$6.00 | $12.00 | P |
BOOSTRIX 8; 2.5; 8; 5; 2.5ug/0.5mL; ug/0.5mL; ug/0.5mL; [iU]/0.5mL; [iU]/0.5mL |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | None |
BOOSTRIX 8; 2.5; 8; 5; 2.5ug/0.5mL; ug/0.5mL; ug/0.5mL; [iU]/0.5mL; [iU]/0.5mL |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | None |
BOSULIF 100 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
BOSULIF 500 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
BOTOX 100UNITS VIAL |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | P |
BREVICON TABLET 0.5/35 |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
BRIELLYN |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
Brimonidine Tartrate 1.5mg/mL |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
BRIMONIDINE TARTRATE OPHTHALMIC SOLUTION 0.2% 10ML BOTPL |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BRINTELLIX 10 MG TABLET |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | None |
BRINTELLIX 20 MG TABLET |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | None |
BRINTELLIX 5 MG TABLET |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | None |
Bromocriptine mesylate 2.5mg/1 24 BOTTLE per CARTON / 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
BROMOCRIPTINE MESYLATE 5MG CAPSULE |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
BUDEPRION SR 100MG TABLET SA |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
BUDEPRION SR 150MG TABLET SA |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
BUDESONIDE 0.25 MG/2 ML SUSP |
1 |
Preferred Generic |
$6.00 | $12.00 | P |
BUDESONIDE 0.5 MG/2 ML SUSP |
1 |
Preferred Generic |
$6.00 | $12.00 | P |
Budesonide 3mg 100 CAPSULE BOTTLE |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
BUMETANIDE 0.25MG/ML VIAL |
1 |
Preferred Generic |
$6.00 | $12.00 | 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 |
$6.00 | $12.00 | None |
BUMETANIDE 1 MG TABLET |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
BUMETANIDE 2 MG TABLET |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
BUPHENYL 500MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
BUPHENYL POWDER |
5 |
Specialty Tier |
25% | N/A | P |
buprenorphin-naloxon 2-0.5 mg tb |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | P Q:90 /30Days |
buprenorphin-naloxon 8-2 mg tb |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | P Q:90 /30Days |
Buprenorphine HCl 2mg/1 30 TABLET BOTTLE |
1 |
Preferred Generic |
$6.00 | $12.00 | P |
Buprenorphine HCl 8mg/1 30 TABLET BOTTLE |
1 |
Preferred Generic |
$6.00 | $12.00 | P |
BUPROBAN ER 150 MG TABLET |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
BUPROPION HCL 100 MG TABLET |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUPROPION HCL 75 MG TABLET |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
BUPROPION HCL SR 100 MG TABLET |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
BUPROPION HCL SR 200MG TABLET SA |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
BUPROPION HCL XL 150 MG TABLET |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
BUPROPION HCL XL 300 MG TABLET |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
Bupropion Hydrochloride 150mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
BUSPIRONE HCL 15MG TABLET (180 CT) |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
BUSPIRONE HCL 30MG TABLET (60 CT) |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
BUSPIRONE HCL 5 MG TABLET |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
BUSPIRONE HCL 7.5MG TABLET |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
BUSPIRONE HYDROCHLORIDE 10 MG TABLETS |
1 |
Preferred Generic |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUSULFEX 6mg/mL |
5 |
Specialty Tier |
25% | N/A | P |
BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50-325-40 |
1 |
Preferred Generic |
$6.00 | $12.00 | Q:90 /30Days |
Butisol Sodium 30mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | None |
Butisol Sodium 30mg/5mL 473 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | None |
Butisol Sodium 50mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$55.00 | $110.00 | None |
Butorphanol 1 mg/ml vial |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
BUTORPHANOL 10MG/ML SPRAY |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | Q:10 /30Days |
Butorphanol 2 mg/ml vial |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None |
BYDUREON 2 MG VIAL |
3 |
Preferred Brand |
$35.00 | $70.00 | S |
BYETTA 10ug/0.04mL |
3 |
Preferred Brand |
$35.00 | $70.00 | S Q:2 /30Days |
BYETTA 5MCG/0.02ML PEN INJ |
3 |
Preferred Brand |
$35.00 | $70.00 | S Q:1 /30Days |