2015 Medicare Part D Plan Formulary Information |
Advantra (PPO) (H7301-002-0)
Benefit Details
|
The Advantra (PPO) (H7301-002-0) Formulary Drugs Starting with the Letter B in PEORIA County, IL: CMS MA Region 14 which includes: IL Plan Monthly Premium: $29.00 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 |
4 |
Non-Preferred Brand |
50% | 50% | None |
Bacitracin 500 unit/gm Eye Ointment |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
BACITRACIN INJ 50000UNT |
4 |
Non-Preferred Brand |
50% | 50% | None |
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
BACLOFEN 10MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
BACLOFEN 20 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Balziva 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK |
4 |
Non-Preferred Brand |
50% | 50% | None |
Banzel 200mg/1 |
4 |
Non-Preferred Brand |
50% | 50% | P |
Banzel 40mg/mL |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BANZEL TABLET 400MG |
4 |
Non-Preferred Brand |
50% | 50% | P |
BARACLUDE 0.05mg/mL 1 BOTTLE per CARTON / 210 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
50% | 50% | 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 |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
BECONASE AQ 0.042% SPRAY |
4 |
Non-Preferred Brand |
50% | 50% | Q:50 /30Days |
BELEODAQ 500 MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
BENAZEPRIL HCL 10MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
BENAZEPRIL HCL 20mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
BENAZEPRIL HCL 40MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
BENAZEPRIL HCL 5MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | 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) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
BENAZEPRIL HCL-HCTZ TABLET 20-25MG (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
BENICAR 20MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
BENICAR 40MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
BENICAR 5MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
BENICAR HCT 20-12.5MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
BENICAR HCT 40-25MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
BENICAR HCT TABLET 12.5-40MG (30 CT) |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
BENLYSTA 120mg/1.5mL 1 VIAL per CARTON / 1.5 mL in 1 VIAL |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BENZTROPINE 2 MG/2 ML VIAL |
4 |
Non-Preferred Brand |
50% | 50% | P |
Benztropine mes 2 mg tablet |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
BENZTROPINE MESYLATE 0.5 MG TABLETS |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
Benztropine Mesylate 1mg 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
BESIVANCE BESIFLOACIN OPTHALMIC SUSPENSION 0.6% 5 ML BOTDR |
4 |
Non-Preferred Brand |
50% | 50% | None |
Betamethasone Dipropionate 0.5mg/g 1 TUBE in 1 CARTON / 50 g in 1 TUBE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Betamethasone Dipropionate 0.60mg/mL 60 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Betamethasone Dipropionate 0.64mg/mL 60 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Betamethasone DP 0.05% ointment |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
BETAMETHASONE DP AUG 0.05% GEL |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETAMETHASONE VALERATE 0.1% LOTION |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
BETAMETHASONE VALERATE 0.12% FOAM |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
BETAMETHASONE VALERATE CREAM |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
BETAMETHASONE VALERATE OINTMENT USP |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Betaxolol 10mg/1 |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Betaxolol 20mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Betaxolol hcl 0.5% eye drop |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
BETHANECHOL 10 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
BETHANECHOL 5 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
BETHANECHOL CHLORIDE 25MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
BETHANECHOL CHLORIDE 50MG TABLET (100 CT) |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETIMOL 0.5% EYE DROPS |
4 |
Non-Preferred Brand |
50% | 50% | None |
BETOPTIC S OPHTHALMIC SUSPENSION 0.25% 10 ML BOT |
4 |
Non-Preferred Brand |
50% | 50% | None |
BEXSERO PREFILLED SYRINGE |
4 |
Non-Preferred Brand |
50% | 50% | None |
Bicalutamide 50mL/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
BICILL LA PFS 600MU 1ML PED |
4 |
Non-Preferred Brand |
50% | 50% | None |
BICILLIN LA PFS 1200MU 2ML |
4 |
Non-Preferred Brand |
50% | 50% | None |
BICILLIN LA. 600000UNIT/ML 1ML |
4 |
Non-Preferred Brand |
50% | 50% | None |
BICNU 100 MG VIAL |
4 |
Non-Preferred Brand |
50% | 50% | None |
Biltricide 600mg/1 6 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
50% | 50% | None |
BISOPROLOL FUMARATE 10MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
BISOPROLOL FUMARATE 5MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BISOPROLOL FUMARATE-HCTZ TABLET 10-6.25MG (500 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
BISOPROLOL FUMARATE-HCTZ TABLET 2.5-6.25MG (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
BISOPROLOL FUMARATE-HCTZ TABLET 5-6.25MG (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
BLEOMYCIN SULFATE 30UNITS VIA |
4 |
Non-Preferred Brand |
50% | 50% | P |
BLEPHAMIDE 0.2% EYE DROPS |
4 |
Non-Preferred Brand |
50% | 50% | None |
BLEPHAMIDE 10-0.2% EYE OINT |
4 |
Non-Preferred Brand |
50% | 50% | None |
BOOSTRIX TDAP VACCINE SYRINGE |
4 |
Non-Preferred Brand |
50% | 50% | None |
BOOSTRIX TDAP VACCINE VIAL |
4 |
Non-Preferred Brand |
50% | 50% | None |
BOSULIF 100 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
BOSULIF 500 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
BOTOX 100UNITS VIAL |
4 |
Non-Preferred Brand |
50% | 50% | P Q:4 /84Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BOTOX 200[USP'U]/1 1 VIAL in 1 CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL |
4 |
Non-Preferred Brand |
50% | 50% | P Q:2 /84Days |
BREO ELLIPTA 100-25 MCG INH |
4 |
Non-Preferred Brand |
50% | 50% | Q:60 /30Days |
BREO ELLIPTA 200-25 MCG INH |
4 |
Non-Preferred Brand |
50% | 50% | Q:60 /30Days |
BRIELLYN TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
BRILINTA 90mg/1 60 TABLET BOTTLE |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
Brimonidine Tartrate 1.5mg/mL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
BRIMONIDINE TARTRATE OPHTHALMIC SOLUTION 0.2% 10ML BOTPL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
BRINTELLIX 10 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | S Q:30 /30Days |
BRINTELLIX 20 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | S Q:30 /30Days |
BRINTELLIX 5 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | S Q:30 /30Days |
Bromfenac 1.035mg/mL 1 BOTTLE, DROPPER per CARTON / 2.5 mL in 1 BOTTLE, DROPPER |
4 |
Non-Preferred Brand |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Bromocriptine mesylate 2.5mg/1 24 BOTTLE per CARTON / 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
BROMOCRIPTINE MESYLATE 5MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
BROVANA 15MCG/2ML VIAL NEBULIZER |
4 |
Non-Preferred Brand |
50% | 50% | P Q:120 /30Days |
BUDESONIDE 0.25 MG/2 ML SUSP |
4 |
Non-Preferred Brand |
50% | 50% | P |
BUDESONIDE 0.5 MG/2 ML SUSP |
4 |
Non-Preferred Brand |
50% | 50% | P |
Budesonide 32 mcg nasal spray |
4 |
Non-Preferred Brand |
50% | 50% | None |
Budesonide 3mg 100 CAPSULE BOTTLE |
5 |
Specialty Tier |
33% | N/A | None |
BUMETANIDE 0.25MG/ML VIAL |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Bumetanide 0.5mg/1 100 TABLET BOTTLE |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Bumetanide 1mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET in 1 BLISTER PACK |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Bumetanide 2mg/1 100 TABLET BOTTLE |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
buprenorphin-naloxon 2-0.5 mg tb |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:90 /30Days |
buprenorphin-naloxon 8-2 mg tb |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:90 /30Days |
Buprenorphine HCl 2mg/1 30 TABLET BOTTLE |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:90 /30Days |
Buprenorphine HCl 8mg/1 30 TABLET BOTTLE |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:90 /30Days |
BUPROBAN ER 150 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
BUPROPION HCL SR 100 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
BUPROPION HCL SR 200MG TABLET SA |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
BUPROPION HCL XL 150 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
BUPROPION HCL XL 300 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
Bupropion Hydrochloride 100mg/1 100 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:180 /30Days |
Bupropion Hydrochloride 150mg/1 100 TABLET, ER in 1 BOTTLE |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUPROPION HYDROCHLORIDE 75mg/1 1000 TABLET BOTTLE |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:180 /30Days |
BUSPIRONE HCL 15MG TABLET (180 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
BUSPIRONE HCL 30MG TABLET (60 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
BUSPIRONE HCL 5 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
BUSPIRONE HCL 7.5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
BUSPIRONE HYDROCHLORIDE 10 MG TABLETS |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
BUSULFEX 6mg/mL |
5 |
Specialty Tier |
33% | N/A | None |
BUTALBITAL-ASA-CAFFEINE CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | P Q:180 /30Days |
BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50-300-40 |
4 |
Non-Preferred Brand |
50% | 50% | P Q:180 /30Days |
BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50-325-40 |
4 |
Non-Preferred Brand |
50% | 50% | P Q:180 /30Days |
BUTALBITAL/ACETAMINOPHEN/CAFFEINE CP |
4 |
Non-Preferred Brand |
50% | 50% | P Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUTALBITAL/CAFFEINE/ACETAMINOPH/CODEIN |
4 |
Non-Preferred Brand |
50% | 50% | P Q:180 /30Days |