2019 Medicare Part D Plan Formulary Information |
Medicare Plus Blue PPO Essential (PPO) (H9572-004-2)
Benefit Details
|
The Medicare Plus Blue PPO Essential (PPO) (H9572-004-2) Formulary Drugs Starting with the Letter B in St. Joseph County, MI: CMS MA Region 11 which includes: MI Plan Monthly Premium: $14.00 Deductible: $405 |
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 |
Bacitracin 500 unit/gm Eye Ointment |
2 |
Generic |
$11.00 | $33.00 | None |
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT |
2 |
Generic |
$11.00 | $33.00 | None |
BACLOFEN 10 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | None |
BACLOFEN 20 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | None |
BACTROBAN NASAL 2% OINTMENT |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT) |
2 |
Generic |
$11.00 | $33.00 | None |
BALVERSA 3 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
BALVERSA 4 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
BALVERSA 5 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
Banzel 200mg/1 |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Banzel 40mg/mL |
5 |
Specialty Tier |
25% | N/A | None |
BANZEL TABLET 400MG |
5 |
Specialty Tier |
25% | N/A | None |
BAXDELA 300 MG VIAL |
5 |
Specialty Tier |
25% | N/A | None |
BAXDELA 450 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
BCG VACCINE 50mg/1 1 VIAL per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
BECONASE AQ 0.042% SPRAY |
4 |
Non-Preferred Drug |
50% | 50% | None |
BENAZEPRIL HCL 10 MG TABLET |
1* |
Preferred Generic |
$2.00 | $6.00 | None |
BENAZEPRIL HCL 20 MG TABLET |
1* |
Preferred Generic |
$2.00 | $6.00 | None |
BENAZEPRIL HCL 40 MG TABLET |
1* |
Preferred Generic |
$2.00 | $6.00 | None |
BENAZEPRIL HCL 5 MG TABLET |
1* |
Preferred Generic |
$2.00 | $6.00 | None |
BENAZEPRIL HCL-HCTZ TABLET 10-12.5MG (100 CT) |
1* |
Preferred Generic |
$2.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT) |
1* |
Preferred Generic |
$2.00 | $6.00 | None |
BENAZEPRIL HCL-HCTZ TABLET 20-25MG (100 CT) |
1* |
Preferred Generic |
$2.00 | $6.00 | None |
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT) |
1* |
Preferred Generic |
$2.00 | $6.00 | None |
BENLYSTA 200 MG/ML AUTOINJECT |
5 |
Specialty Tier |
25% | N/A | None |
BENLYSTA 200 MG/ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | None |
BENZNIDAZOLE 100 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
BENZNIDAZOLE 12.5 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | None |
BENZTROPINE MES 0.5 MG Tablet [Cogentin] |
2 |
Generic |
$11.00 | $33.00 | None |
BENZTROPINE MES 1 MG TABLET [Cogentin] |
2 |
Generic |
$11.00 | $33.00 | None |
BENZTROPINE MES 2 MG TABLET [Cogentin] |
2 |
Generic |
$11.00 | $33.00 | None |
BERINERT 500 UNIT KIT |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BESER 0.05% LOTION [Cutivate] |
2 |
Generic |
$11.00 | $33.00 | None |
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE |
2 |
Generic |
$11.00 | $33.00 | None |
BETAMETHASONE DP 0.05% LOT |
2 |
Generic |
$11.00 | $33.00 | None |
Betamethasone DP 0.05% ointment |
2 |
Generic |
$11.00 | $33.00 | None |
BETAMETHASONE DP AUG 0.05% CRM |
2 |
Generic |
$11.00 | $33.00 | None |
BETAMETHASONE DP AUG 0.05% GEL |
2 |
Generic |
$11.00 | $33.00 | None |
BETAMETHASONE DP AUG 0.05% LOT |
2 |
Generic |
$11.00 | $33.00 | None |
BETAMETHASONE DP AUG 0.05% OIN |
2 |
Generic |
$11.00 | $33.00 | None |
BETAMETHASONE VA 0.1% CREAM |
2 |
Generic |
$11.00 | $33.00 | None |
BETAMETHASONE VALERATE 0.1% LOTION |
2 |
Generic |
$11.00 | $33.00 | None |
BETAMETHASONE VALERATE OINTMENT USP |
2 |
Generic |
$11.00 | $33.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETASERON 0.3 MG KIT |
5 |
Specialty Tier |
25% | N/A | P |
BETAXOLOL 10 MG TABLET |
1* |
Preferred Generic |
$2.00 | $6.00 | None |
BETAXOLOL 20 MG TABLET |
1* |
Preferred Generic |
$2.00 | $6.00 | None |
Betaxolol 5 MG/ML Ophthalmic Solution |
1* |
Preferred Generic |
$2.00 | $6.00 | None |
BETHANECHOL 10 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | None |
BETHANECHOL 25 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | None |
BETHANECHOL 5 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | None |
BETHANECHOL 50 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | None |
BETOPTIC S OPHTHALMIC SUSPENSION 0.25% 10 ML BOT |
4 |
Non-Preferred Drug |
50% | 50% | None |
BEVYXXA 40 MG CAPSULE |
4 |
Non-Preferred Drug |
50% | 50% | None |
BEVYXXA 80 MG CAPSULE |
4 |
Non-Preferred Drug |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BEXAROTENE 75 MG CAPSULE [Targretin] |
5 |
Specialty Tier |
25% | N/A | P |
BEXSERO PREFILLED SYRINGE |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
BICALUTAMIDE 50 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | None |
BICILL LA PFS 600MU 1ML PED |
4 |
Non-Preferred Drug |
50% | 50% | None |
BICILLIN C-R 1.2MM UNITS SYR 2ML x 10 |
4 |
Non-Preferred Drug |
50% | 50% | None |
BICILLIN C-R 900/300 SYRINGE 2ML x 10 |
4 |
Non-Preferred Drug |
50% | 50% | None |
BICILLIN LA PFS 1200MU 2ML |
4 |
Non-Preferred Drug |
50% | 50% | None |
BICILLIN LA. 600000UNIT/ML 1ML |
4 |
Non-Preferred Drug |
50% | 50% | None |
BIKTARVY 50-200-25 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
Biltricide 600mg/1 6 FILM COATED TABLETS in BOTTLE |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
BIMATOPROST 0.03% EYE DROPS [Lumigan] |
4 |
Non-Preferred Drug |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BISOPROLOL FUMARATE 10 MG TAB |
1* |
Preferred Generic |
$2.00 | $6.00 | None |
BISOPROLOL FUMARATE 5 MG TAB |
1* |
Preferred Generic |
$2.00 | $6.00 | None |
BISOPROLOL-HCTZ 10-6.25 MG TAB |
1* |
Preferred Generic |
$2.00 | $6.00 | None |
BISOPROLOL-HCTZ 2.5-6.25 MG TB |
1* |
Preferred Generic |
$2.00 | $6.00 | None |
BISOPROLOL-HCTZ 5-6.25 MG TAB |
1* |
Preferred Generic |
$2.00 | $6.00 | None |
BIVIGAM LIQUID 10% VIAL |
5 |
Specialty Tier |
25% | N/A | P |
BLEPHAMIDE 10-0.2% EYE OINT |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
BLISOVI FE 1.5-30 TABLET |
2 |
Generic |
$11.00 | $33.00 | None |
BOOSTRIX TDAP VACCINE SYRINGE |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
BOOSTRIX TDAP VACCINE VIAL |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
BOSENTAN 125 MG TABLET [Tracleer] |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BOSENTAN 62.5 MG TABLET [Tracleer] |
5 |
Specialty Tier |
25% | N/A | P |
BOSULIF 100 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
BOSULIF 400 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
BOSULIF 500 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
BRAFTOVI 50 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
BRAFTOVI 75 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
BREO ELLIPTA 100-25 MCG INH |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days |
BREO ELLIPTA 200-25 MCG INH |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days |
BRILINTA 60 MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
BRILINTA 90mg/1 60 TABLET BOTTLE |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
BRIMONIDINE 0.2% EYE DROP |
2 |
Generic |
$11.00 | $33.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BRIMONIDINE TARTRATE 0.15% DRP |
2 |
Generic |
$11.00 | $33.00 | None |
BRIVIACT 10 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:180 /90Days |
BRIVIACT 10 MG/ML ORAL SOLN |
5 |
Specialty Tier |
25% | N/A | P Q:1800 /90Days |
BRIVIACT 100 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:180 /90Days |
BRIVIACT 25 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:180 /90Days |
BRIVIACT 50 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:180 /90Days |
BRIVIACT 75 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:180 /90Days |
BROMOCRIPTINE 2.5 MG TABLET [Parlodel] |
2 |
Generic |
$11.00 | $33.00 | None |
BROMOCRIPTINE MESYLATE 5MG CAPSULE [Parlodel] |
2 |
Generic |
$11.00 | $33.00 | None |
BROVANA 15MCG/2ML VIAL NEBULIZER |
4 |
Non-Preferred Drug |
50% | 50% | P Q:360 /90Days |
BUDESONIDE 0.25 MG/2 ML SUSP AMPUL-NEB [Pulmicort] |
4 |
Non-Preferred Drug |
50% | 50% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUDESONIDE 0.5 MG/2 ML SUSP AMPUL-NEB [Pulmicort] |
4 |
Non-Preferred Drug |
50% | 50% | P |
BUDESONIDE 1 MG/2 ML INH SUSP AMPUL-NEB [Pulmicort] |
4 |
Non-Preferred Drug |
50% | 50% | P |
BUDESONIDE EC 3 MG CAPSULE CAPDR - ER [Entocort EC] |
5 |
Specialty Tier |
25% | N/A | None |
BUMETANIDE 0.25MG/ML VIAL |
4 |
Non-Preferred Drug |
50% | 50% | None |
BUMETANIDE 0.5 MG TABLET |
1* |
Preferred Generic |
$2.00 | $6.00 | None |
BUMETANIDE 1 MG TABLET |
1* |
Preferred Generic |
$2.00 | $6.00 | None |
BUMETANIDE 2 MG TABLET |
1* |
Preferred Generic |
$2.00 | $6.00 | None |
BUPRENORP-NALOX 12-3 MG SL FILM [Suboxone] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
BUPRENORP-NALOX 2-0.5 MG SL FILM [Suboxone] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
BUPRENORP-NALOX 4-1 MG SL FILM [Suboxone] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
BUPRENORP-NALOX 8-2 MG SL FILM [Suboxone] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUPRENORPHIN-NALOXON 2-0.5 MG SL [Suboxone] |
2 |
Generic |
$11.00 | $33.00 | None |
BUPRENORPHIN-NALOXON 8-2 MG SL [Suboxone] |
2 |
Generic |
$11.00 | $33.00 | None |
BUPRENORPHINE 10 MCG/HR PATCH [Butrans] |
4 |
Non-Preferred Drug |
50% | 50% | Q:12 /84Days |
BUPRENORPHINE 15 MCG/HR PATCH [Butrans] |
4 |
Non-Preferred Drug |
50% | 50% | Q:12 /84Days |
BUPRENORPHINE 2 MG TABLET Subligual [Subutex] |
2 |
Generic |
$11.00 | $33.00 | None |
BUPRENORPHINE 20 MCG/HR PATCH [Butrans] |
4 |
Non-Preferred Drug |
50% | 50% | Q:12 /84Days |
BUPRENORPHINE 5 MCG/HR PATCH [Butrans] |
4 |
Non-Preferred Drug |
50% | 50% | Q:12 /84Days |
BUPRENORPHINE 7.5 MCG/HR PATCH Patch [Butrans] |
4 |
Non-Preferred Drug |
50% | 50% | Q:12 /84Days |
BUPRENORPHINE 8 MG TABLET Subligual [Subutex] |
2 |
Generic |
$11.00 | $33.00 | None |
BUPROPION HCL 100 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | None |
BUPROPION HCL 75 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUPROPION HCL SR 100 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | None |
BUPROPION HCL SR 150 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | None |
BUPROPION HCL SR 150 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | None |
BUPROPION HCL SR 200 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | None |
BUPROPION HCL XL 150 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | None |
BUPROPION HCL XL 300 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | None |
BUSPIRONE HCL 15 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | None |
BUSPIRONE HCL 30 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | None |
BUSPIRONE HCL 5 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | None |
BUSPIRONE HCL 7.5 MG TABLET |
2 |
Generic |
$11.00 | $33.00 | None |
BUSPIRONE HYDROCHLORIDE 10 MG TABLETS |
2 |
Generic |
$11.00 | $33.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUTORPHANOL 10MG/ML SPRAY |
2 |
Generic |
$11.00 | $33.00 | Q:15 /90Days |
Butrans 10ug/h |
4 |
Non-Preferred Drug |
50% | 50% | Q:12 /84Days |
BUTRANS 15 MCG/HR PATCH |
4 |
Non-Preferred Drug |
50% | 50% | Q:12 /84Days |
Butrans 20ug/h |
4 |
Non-Preferred Drug |
50% | 50% | Q:12 /84Days |
Butrans 5ug/h |
4 |
Non-Preferred Drug |
50% | 50% | Q:12 /84Days |
BUTRANS 7.5 MCG/HR PATCH |
4 |
Non-Preferred Drug |
50% | 50% | Q:12 /84Days |
BYDUREON 2 MG PEN INJECT |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:12 /84Days |
BYDUREON BCISE 2 MG AUTOINJECT |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:10 /84Days |
BYETTA 10 MCG DOSE PEN INJ |
4 |
Non-Preferred Drug |
50% | 50% | P Q:7 /84Days |
BYETTA 5 MCG DOSE PEN INJ |
4 |
Non-Preferred Drug |
50% | 50% | P Q:4 /84Days |
Bystolic 10mg/1 30 TABLET BOTTLE |
4 |
Non-Preferred Drug |
50% | 50% | S Q:360 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Bystolic 2.5mg/1 30 TABLET BOTTLE |
4 |
Non-Preferred Drug |
50% | 50% | S Q:90 /90Days |
BYSTOLIC 20 MG TABLET |
4 |
Non-Preferred Drug |
50% | 50% | S Q:180 /90Days |
Bystolic 5mg 30 TABLET BOTTLE |
4 |
Non-Preferred Drug |
50% | 50% | S Q:90 /90Days |