2018 Medicare Part D Plan Formulary Information |
HumanaChoice R3392-002 (Regional PPO) (R3392-002-0)
Benefit Details
|
The HumanaChoice R3392-002 (Regional PPO) (R3392-002-0) Formulary Drugs Starting with the Letter B in Statewide County, GA: CMS MA Region 8 which includes: SC GA Plan Monthly Premium: $34.80 Deductible: $340 |
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 Drug |
$97.00 | $281.00 | None |
Bacitracin 500 unit/gm Eye Ointment |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | None |
BACITRACIN INJ 50000UNT |
2* |
Generic |
$17.00 | $0.00 | None |
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT |
2* |
Generic |
$17.00 | $0.00 | None |
BACLOFEN 10 MG TABLET |
2* |
Generic |
$17.00 | $0.00 | None |
BACLOFEN 20 MG TABLET |
2* |
Generic |
$17.00 | $0.00 | None |
BACLOFEN 5 MG TABLET |
2* |
Generic |
$17.00 | $0.00 | Q:90 /30Days |
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT) |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | None |
Balziva 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | None |
Banzel 200mg/1 |
5 |
Specialty Tier |
26% | N/A | P Q:480 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Banzel 40mg/mL |
5 |
Specialty Tier |
26% | N/A | P Q:2760 /30Days |
BANZEL TABLET 400MG |
5 |
Specialty Tier |
26% | N/A | P Q:240 /30Days |
BARACLUDE 0.05mg/mL 1 BOTTLE per CARTON / 210 mL in 1 BOTTLE |
5 |
Specialty Tier |
26% | N/A | Q:630 /30Days |
BAVENCIO 200 MG/10 ML VIAL |
5 |
Specialty Tier |
26% | N/A | P |
BCG VACCINE 50mg/1 1 VIAL per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | None |
BEKYREE 28 DAY TABLET [VIORELE] |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | None |
BELBUCA 150 MCG FILM |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
BELBUCA 300 MCG FILM |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
BELBUCA 450 MCG FILM |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
BELBUCA 600 MCG FILM |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
BELBUCA 75 MCG FILM |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BELBUCA 750 MCG FILM |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
BELBUCA 900 MCG FILM |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
BELEODAQ 500 MG VIAL |
5 |
Specialty Tier |
26% | N/A | P |
BELSOMRA 10 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
BELSOMRA 15 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
BELSOMRA 20 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
BELSOMRA 5 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
BENAZEPRIL HCL 10 MG TABLET |
1* |
Preferred Generic |
$7.00 | $0.00 | None |
BENAZEPRIL HCL 20 MG TABLET |
1* |
Preferred Generic |
$7.00 | $0.00 | None |
BENAZEPRIL HCL 40 MG TABLET |
1* |
Preferred Generic |
$7.00 | $0.00 | None |
BENAZEPRIL HCL 5 MG TABLET |
1* |
Preferred Generic |
$7.00 | $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) |
2* |
Generic |
$17.00 | $0.00 | None |
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT) |
2* |
Generic |
$17.00 | $0.00 | None |
BENAZEPRIL HCL-HCTZ TABLET 20-25MG (100 CT) |
2* |
Generic |
$17.00 | $0.00 | None |
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT) |
2* |
Generic |
$17.00 | $0.00 | None |
BENICAR 20 MG TABLET |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | P Q:30 /30Days |
BENICAR 40 MG TABLET |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | P Q:30 /30Days |
BENICAR 5MG TABLET |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | P Q:30 /30Days |
BENICAR HCT 20-12.5 MG TABLET |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | P Q:30 /30Days |
BENICAR HCT 40-25 MG TABLET |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | P Q:30 /30Days |
BENICAR HCT TABLET 12.5-40MG (30 CT) |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | P Q:30 /30Days |
BENLYSTA 120mg/1.5mL 1 VIAL per CARTON / 1.5 mL in 1 VIAL |
5 |
Specialty Tier |
26% | N/A | P Q:20 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BENLYSTA 200 MG/ML AUTOINJECT |
5 |
Specialty Tier |
26% | N/A | P Q:4 /28Days |
BENLYSTA 200 MG/ML SYRINGE |
5 |
Specialty Tier |
26% | N/A | P Q:4 /28Days |
BENLYSTA 400 MG VIAL |
5 |
Specialty Tier |
26% | N/A | P Q:6 /28Days |
BENZTROPINE 2 MG/2 ML AMPULE [Cogentin] |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | None |
BENZTROPINE MES 0.5 MG Tablet [Cogentin] |
3 |
Preferred Brand |
$47.00 | $131.00 | P |
BENZTROPINE MES 1 MG TABLET [Cogentin] |
3 |
Preferred Brand |
$47.00 | $131.00 | P |
BENZTROPINE MES 2 MG TABLET [Cogentin] |
3 |
Preferred Brand |
$47.00 | $131.00 | P |
BEPREVE 1.5% EYE DROPS |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:5 /25Days |
BESIVANCE BESIFLOACIN OPTHALMIC SUSPENSION 0.6% 5 ML BOTDR |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
BETAMETHASONE DP 0.05% LOT |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Betamethasone DP 0.05% ointment |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
BETAMETHASONE DP AUG 0.05% CRM |
2* |
Generic |
$17.00 | $0.00 | None |
BETAMETHASONE DP AUG 0.05% GEL |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | None |
BETAMETHASONE DP AUG 0.05% LOT |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | None |
BETAMETHASONE DP AUG 0.05% OIN |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | None |
BETAMETHASONE VA 0.1% CREAM |
2* |
Generic |
$17.00 | $0.00 | None |
BETAMETHASONE VALERATE 0.1% LOTION |
2* |
Generic |
$17.00 | $0.00 | None |
BETAMETHASONE VALERATE OINTMENT USP |
2* |
Generic |
$17.00 | $0.00 | None |
BETASERON 0.3 MG KIT |
5 |
Specialty Tier |
26% | N/A | P Q:15 /30Days |
Betaxolol 5 MG/ML Ophthalmic Solution |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
BETHANECHOL 10 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETHANECHOL 25 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
BETHANECHOL 5 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
BETHANECHOL 50 MG TABLET |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | None |
BETHKIS 300 MG/4 ML AMPULE |
5 |
Specialty Tier |
26% | N/A | P |
BETOPTIC S OPHTHALMIC SUSPENSION 0.25% 10 ML BOT |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | S |
BEVESPI AEROSPHERE INHALER |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:11 /30Days |
BEXAROTENE 75 MG CAPSULE [Targretin] |
5 |
Specialty Tier |
26% | N/A | P Q:300 /30Days |
BEXSERO PREFILLED SYRINGE |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | None |
BICALUTAMIDE 50 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days |
BICILL LA PFS 600MU 1ML PED |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | None |
BICILLIN C-R 1.2MM UNITS SYR 2ML x 10 |
2* |
Generic |
$17.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BICILLIN C-R 900/300 SYRINGE 2ML x 10 |
2* |
Generic |
$17.00 | $0.00 | None |
BICILLIN LA PFS 1200MU 2ML |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | None |
BICILLIN LA. 600000UNIT/ML 1ML |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | None |
BICNU 100 MG VIAL |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | P |
BIDIL TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:180 /30Days |
BIKTARVY 50-200-25 MG TABLET |
5 |
Specialty Tier |
26% | N/A | Q:30 /30Days |
Biltricide 600mg/1 6 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | None |
BINOSTO 70 MG TABLET EFF |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:4 /28Days |
BISOPROLOL FUMARATE 10 MG TAB |
2* |
Generic |
$17.00 | $0.00 | None |
BISOPROLOL FUMARATE 5 MG TAB |
2* |
Generic |
$17.00 | $0.00 | None |
BISOPROLOL-HCTZ 10-6.25 MG TAB |
1* |
Preferred Generic |
$7.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BISOPROLOL-HCTZ 2.5-6.25 MG TB |
1* |
Preferred Generic |
$7.00 | $0.00 | None |
BISOPROLOL-HCTZ 5-6.25 MG TAB |
1* |
Preferred Generic |
$7.00 | $0.00 | None |
BLEOMYCIN SULFATE 30 UNIT VIAL |
3 |
Preferred Brand |
$47.00 | $131.00 | P |
BLISOVI 24 FE TABLET |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | None |
BLISOVI FE 1-20 TABLET |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | None |
BLISOVI FE 1.5-30 TABLET |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | None |
BOOSTRIX TDAP VACCINE SYRINGE |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | None |
BOOSTRIX TDAP VACCINE VIAL |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | None |
Bortezomib 3.5 Mg Intravenous Solution |
5 |
Specialty Tier |
26% | N/A | P |
BOSULIF 100 MG TABLET |
5 |
Specialty Tier |
26% | N/A | P Q:120 /30Days |
BOSULIF 400 MG TABLET |
5 |
Specialty Tier |
26% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BOSULIF 500 MG TABLET |
5 |
Specialty Tier |
26% | N/A | P Q:30 /30Days |
BREO ELLIPTA 100-25 MCG INH |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
BREO ELLIPTA 200-25 MCG INH |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
BRIELLYN TABLET |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | None |
BRILINTA 60 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
BRILINTA 90mg/1 60 TABLET BOTTLE |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
BRIMONIDINE 0.2% EYE DROP |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
BRIMONIDINE TARTRATE 0.15% DRP |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
BRIVIACT 10 MG TABLET |
5 |
Specialty Tier |
26% | N/A | P Q:60 /30Days |
BRIVIACT 10 MG/ML ORAL SOLN |
5 |
Specialty Tier |
26% | N/A | P Q:600 /30Days |
BRIVIACT 100 MG TABLET |
5 |
Specialty Tier |
26% | N/A | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BRIVIACT 25 MG TABLET |
5 |
Specialty Tier |
26% | N/A | P Q:60 /30Days |
BRIVIACT 50 MG TABLET |
5 |
Specialty Tier |
26% | N/A | P Q:60 /30Days |
BRIVIACT 50 MG/5 ML VIAL |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | P |
BRIVIACT 75 MG TABLET |
5 |
Specialty Tier |
26% | N/A | P Q:60 /30Days |
BROMOCRIPTINE 2.5 MG TABLET [Parlodel] |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | None |
BROVANA 15MCG/2ML VIAL NEBULIZER |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | P |
BUDESONIDE 0.25 MG/2 ML SUSP AMPUL-NEB [Pulmicort] |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | P |
BUDESONIDE 0.5 MG/2 ML SUSP AMPUL-NEB [Pulmicort] |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | P |
BUDESONIDE EC 3 MG CAPSULE CAPDR - ER [Entocort EC] |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | None |
BUMETANIDE 0.25MG/ML VIAL |
2* |
Generic |
$17.00 | $0.00 | None |
BUMETANIDE 0.5 MG TABLET |
2* |
Generic |
$17.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUMETANIDE 1 MG TABLET |
2* |
Generic |
$17.00 | $0.00 | None |
BUMETANIDE 2 MG TABLET |
2* |
Generic |
$17.00 | $0.00 | None |
BUPAP 50 MG-300 MG TABLET |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | P Q:180 /30Days |
BUPRENORPHINE 2 MG TABLET Subligual [Subutex] |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:90 /30Days |
BUPRENORPHINE 8 MG TABLET Subligual [Subutex] |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:90 /30Days |
BUPROPION HCL 100 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:180 /30Days |
BUPROPION HCL 75 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:180 /30Days |
BUPROPION HCL SR 100 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:120 /30Days |
BUPROPION HCL SR 150 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:90 /30Days |
BUPROPION HCL SR 150 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:90 /30Days |
BUPROPION HCL SR 200 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUPROPION HCL XL 150 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:90 /30Days |
BUPROPION HCL XL 300 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
BUSPIRONE HCL 15 MG TABLET |
2* |
Generic |
$17.00 | $0.00 | None |
BUSPIRONE HCL 30 MG TABLET |
2* |
Generic |
$17.00 | $0.00 | None |
BUSPIRONE HCL 5 MG TABLET |
2* |
Generic |
$17.00 | $0.00 | None |
BUSPIRONE HCL 7.5 MG TABLET |
2* |
Generic |
$17.00 | $0.00 | None |
BUSPIRONE HYDROCHLORIDE 10 MG TABLETS |
2* |
Generic |
$17.00 | $0.00 | None |
Busulfan 60 mg/10 ml vial [Busulfex] |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | P |
BUSULFEX 6mg/mL |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | P |
BUTALB-CAFF-ACETAMINOPH-CODEIN |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | P Q:360 /30Days |
Butisol Sodium 30mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUTORPHANOL 10MG/ML SPRAY |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:5 /28Days |
BUTORPHANOL 1MG/ML VIAL |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:960 /30Days |
BUTORPHANOL 2MG/ML VIAL |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:480 /30Days |
BYDUREON 2 MG PEN INJECT |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:4 /28Days |
BYDUREON 2 MG VIAL |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:4 /28Days |
BYDUREON BCISE 2 MG AUTOINJECT |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:3 /28Days |
BYETTA 10 MCG DOSE PEN INJ |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:2 /30Days |
BYETTA 5 MCG DOSE PEN INJ |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:2 /30Days |
Bystolic 10mg/1 30 TABLET BOTTLE |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:120 /30Days |
Bystolic 2.5mg/1 30 TABLET BOTTLE |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days |
BYSTOLIC 20 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Bystolic 5mg 30 TABLET BOTTLE |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days |