2014 Medicare Part D Plan Formulary Information |
HumanaChoice R5826-008 (Regional PPO) (R5826-008-0)
Benefit Details
|
The HumanaChoice R5826-008 (Regional PPO) (R5826-008-0) Formulary Drugs Starting with the Letter B in Statewide County, KY: CMS MA Region 13 which includes: IN KY Plan Monthly Premium: $38.10 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 |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
Bacitracin 500 unit/gm Eye Ointment |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
BACITRACIN INJ 50000UNT |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | None |
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | None |
BACLOFEN 10MG TABLET |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | None |
baclofen 20 mg tablet |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | None |
BACTROBAN 2% CREAM |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
BACTROBAN 20mg/g 22 g in 1 TUBE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
BACTROBAN NASAL 2% OINTMENT |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT) |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
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 |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
Banzel 200mg/1 |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P Q:480 /30Days |
Banzel 40mg/mL |
5 |
Specialty Tier |
33% | N/A | P Q:2760 /30Days |
BANZEL TABLET 400MG |
5 |
Specialty Tier |
33% | N/A | P Q:240 /30Days |
BARACLUDE 0.05mg/mL 1 BOTTLE per CARTON / 210 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:630 /30Days |
BARACLUDE 0.5MG TABLET |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
BARACLUDE 1MG TABLET |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
BCG VACCINE 50mg/1 1 VIAL per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
BENAZEPRIL HCL 10MG TABLET |
1 |
Preferred Generic |
$6.00 | $0.00 | None |
BENAZEPRIL HCL 20mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$6.00 | $0.00 | None |
BENAZEPRIL HCL 40MG TABLET |
1 |
Preferred Generic |
$6.00 | $0.00 | 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 |
$6.00 | $0.00 | None |
BENAZEPRIL HCL-HCTZ TABLET 10-12.5MG (100 CT) |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | None |
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT) |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | None |
BENAZEPRIL HCL-HCTZ TABLET 20-25MG (100 CT) |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | None |
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT) |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | None |
BENICAR 20MG TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days |
BENICAR 40MG TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days |
BENICAR 5MG TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days |
BENICAR HCT 20-12.5MG TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days |
BENICAR HCT 40-25MG TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days |
BENICAR HCT TABLET 12.5-40MG (30 CT) |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BENLYSTA 120mg/1.5mL 1 VIAL per CARTON / 1.5 mL in 1 VIAL |
5 |
Specialty Tier |
33% | N/A | P Q:30 /28Days |
BENZTROPINE MESYLATE 0.5 MG TABLETS |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | P |
Benztropine Mesylate 1mg 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | P |
Benztropine Mesylate 1mg/mL 5 VIAL, SINGLE-USE per CARTON / 2 mL in 1 VIAL, SINGLE-USE |
1 |
Preferred Generic |
$6.00 | $0.00 | None |
Benztropine Mesylate 2mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | P |
BEPREVE 1.5% EYE DROPS |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
BESIVANCE BESIFLOACIN OPTHALMIC SUSPENSION 0.6% 5 ML BOTDR |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
BETAGAN 0.5% EYE DROPS |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
BETAMETHASONE DIPROPIONATE 0.05% CREAM |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
Betamethasone Dipropionate 0.60mg/mL 60 mL in 1 BOTTLE |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Betamethasone Dipropionate 0.64mg/mL 60 mL in 1 BOTTLE |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
Betamethasone DP 0.05% ointment |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
BETAMETHASONE DP AUG 0.05% GEL |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
BETAMETHASONE VALERATE 0.1% lotion |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | None |
BETAMETHASONE VALERATE CREAM |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | None |
BETAMETHASONE VALERATE OINTMENT USP |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | None |
BETASERON KIT 0.3MG/VIAL 14 TRAY BOX PKGCOM |
5 |
Specialty Tier |
33% | N/A | P Q:15 /30Days |
betaxolol hcl 0.5% eye drop |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
BETHANECHOL 10 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
BETHANECHOL CHLORIDE 25MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
BETHANECHOL CHLORIDE 50MG TABLET (100 CT) |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETHANECHOL CHLORIDE 5MG TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
BETHKIS 300 MG/4 ML AMPULE |
5 |
Specialty Tier |
33% | N/A | P Q:224 /28Days |
Bicalutamide 50 mg tablet |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days |
BICILL LA PFS 600MU 1ML PED |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
BICILLIN C-R 1.2MM UNITS SYR 2ML x 10 |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
BICILLIN C-R 900/300 SYRINGE 2ML x 10 |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
BICILLIN LA PFS 1200MU 2ML |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
BICILLIN LA. 600000UNIT/ML 1ML |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
BICNU 1 KIT per CARTON |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
BIDIL TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:180 /30Days |
Biltricide 600mg/1 6 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BINOSTO 70 MG TABLET EFF |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:4 /28Days |
BISOPROLOL FUMARATE 10MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | None |
BISOPROLOL FUMARATE 5MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | None |
BISOPROLOL FUMARATE-HCTZ TABLET 10-6.25MG (500 CT) |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | None |
BISOPROLOL FUMARATE-HCTZ TABLET 2.5-6.25MG (100 CT) |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | None |
BISOPROLOL FUMARATE-HCTZ TABLET 5-6.25MG (100 CT) |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | None |
BLEOMYCIN SULFATE 30UNITS VIA |
3 |
Preferred Brand |
$45.00 | $125.00 | P |
BLEPH-10 10% EYE DROPS |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
BLEPHAMIDE 0.2% EYE DROPS |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
BLEPHAMIDE 10-0.2% EYE OINT |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | None |
BONIVA 3mg/3mL SYRINGE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P Q:3 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
$95.00 | $275.00 | 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 |
$95.00 | $275.00 | None |
BOSULIF 100 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
BOSULIF 500 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
BREO ELLIPTA 100-25 MCG INH |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:60 /30Days |
BREVICON TABLET 0.5/35 |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
BRIELLYN |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
BRILINTA 90mg/1 60 TABLET BOTTLE |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:60 /30Days |
Brimonidine Tartrate 1.5mg/mL |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
BRIMONIDINE TARTRATE OPHTHALMIC SOLUTION 0.2% 10ML BOTPL |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
BRINTELLIX 10 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BRINTELLIX 20 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | S Q:30 /30Days |
BRINTELLIX 5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | S Q:30 /30Days |
Bromocriptine mesylate 2.5mg/1 24 BOTTLE per CARTON / 100 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
BROMOCRIPTINE MESYLATE 5MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None |
BROVANA 15MCG/2ML VIAL NEBULIZER |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P Q:124 /30Days |
BUDEPRION SR 100MG TABLET SA |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:120 /30Days |
BUDEPRION SR 150MG TABLET SA |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:90 /30Days |
BUDESONIDE 0.25 MG/2 ML SUSP |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
BUDESONIDE 0.5 MG/2 ML SUSP |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
Budesonide 3mg 100 CAPSULE BOTTLE |
5 |
Specialty Tier |
33% | N/A | None |
BUMETANIDE 0.25MG/ML VIAL |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUMETANIDE 0.5 MG TABLET |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | None |
BUMETANIDE 1 MG TABLET |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | None |
BUMETANIDE 2 MG TABLET |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | None |
BUPHENYL 500MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
BUPHENYL POWDER |
5 |
Specialty Tier |
33% | N/A | None |
BUPRENEX 0.3MG/ML AMPUL |
5 |
Specialty Tier |
33% | N/A | P Q:240 /30Days |
BUPRENORPHINE 0.3MG/ML SYRN |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P Q:240 /30Days |
Buprenorphine HCl 2mg/1 30 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P Q:90 /30Days |
Buprenorphine HCl 8mg/1 30 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P Q:90 /30Days |
BUPROBAN ER 150 MG TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:90 /30Days |
BUPROPION HCL 100 MG TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUPROPION HCL 75 MG TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | None |
BUPROPION HCL SR 100 MG TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:120 /30Days |
BUPROPION HCL SR 200MG TABLET SA |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:60 /30Days |
BUPROPION HCL XL 150 MG TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:90 /30Days |
BUPROPION HCL XL 300 MG TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:90 /30Days |
Bupropion Hydrochloride 150mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:90 /30Days |
BUSPIRONE HCL 15MG TABLET (180 CT) |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | None |
BUSPIRONE HCL 30MG TABLET (60 CT) |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | None |
BUSPIRONE HCL 5 MG TABLET |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | None |
BUSPIRONE HCL 7.5MG TABLET |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | None |
BUSPIRONE HYDROCHLORIDE 10 MG TABLETS |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUSULFEX 6mg/mL |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50-325-40 |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P Q:180 /30Days |
BUTALBITAL/ACETAMINOPHEN/CAFFEINE cp |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P Q:180 /30Days |
BUTALBITAL/ASPIRIN/CAFFEINE 325; 50; 40mg/1; mg/1; mg/1 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P Q:180 /30Days |
BUTALBITAL/ASPIRIN/CAFFEINE 325; 50; 40mg/1; mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P Q:180 /30Days |
Butisol Sodium 30mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
Butisol Sodium 30mg/5mL 473 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
Butisol Sodium 50mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P |
Butorphanol 1 mg/ml vial |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:960 /30Days |
BUTORPHANOL 10MG/ML SPRAY |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:5 /28Days |
Butorphanol 2 mg/ml vial |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:480 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BYDUREON 2 MG VIAL |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | S Q:4 /28Days |
BYETTA 10ug/0.04mL |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | S Q:3 /30Days |
BYETTA 5MCG/0.02ML PEN INJ |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | S Q:3 /30Days |
Bystolic 10mg 100 TABLET in BLISTER PACK |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:120 /30Days |
Bystolic 2.5mg 100 TABLETBOTTLE |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days |
BYSTOLIC 20 MG TABLET |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:60 /30Days |
Bystolic 5mg 30 TABLET BOTTLE |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days |