Q1Medicare.com 2021 Medicare Part D or Medicare Advantage Plan Formulary Browser

2021 Medicare Part D Plan Formulary Information
WPS MedicareRx Plan 1 (PDP) (S5753-006-0) Benefit Details
The WPS MedicareRx Plan 1 (PDP) (S5753-006-0) Formulary Drugs Starting with the Letter B in CMS PDP Region 16 which includes: WI Plan Monthly Premium: $79.30 Deductible: $445 Qualifies for LIS: No
Drugs Starting with Letter B Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter B Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Bacitracin 500 unit/gm Eye Ointment	2	Generic	$15.00	$37.50	None
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT	2	Generic	$15.00	$37.50	None
BACLOFEN 10 MG TABLET	2	Generic	$15.00	$37.50	None
BACLOFEN 20 MG TABLET [Lioresal]	2	Generic	$15.00	$37.50	None
BACLOFEN 5 MG TABLET	2	Generic	$15.00	$37.50	None
BALSALAZIDE DISODIUM 750 MG CAPSULE [Colazal]	2	Generic	$15.00	$37.50	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	5	Specialty Tier	25%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BANZEL 400MG TABLET	5	Specialty Tier	25%	N/A	P
Banzel 40mg/mL	5	Specialty Tier	25%	N/A	P
BARACLUDE 0.05mg/mL 1 BOTTLE per CARTON / 210 mL in 1 BOTTLE	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	$105.00	None
BENAZEPRIL HCL 10 MG TABLET	1	Preferred Generic	$3.00	$7.50	None
BENAZEPRIL HCL 20 MG TABLET	1	Preferred Generic	$3.00	$7.50	None
BENAZEPRIL HCL 40 MG TABLET	1	Preferred Generic	$3.00	$7.50	None
BENAZEPRIL HCL 5 MG TABLET	1	Preferred Generic	$3.00	$7.50	None
BENAZEPRIL-HCTZ 10-12.5 MG TABLET [Lotensin HCT]	2	Generic	$15.00	$37.50	None
BENAZEPRIL-HCTZ 20-12.5 MG TABLET [Lotensin HCT]	2	Generic	$15.00	$37.50	None
BENAZEPRIL-HCTZ 20-25 MG TABLET [Lotensin HCT]	2	Generic	$15.00	$37.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BENAZEPRIL-HCTZ 5-6.25 MG TABLET [Lotensin HCT]	2	Generic	$15.00	$37.50	None
BENLYSTA 200 MG/ML AUTOINJECT	5	Specialty Tier	25%	N/A	P
BENLYSTA 200 MG/ML SYRINGE	5	Specialty Tier	25%	N/A	P
BENZNIDAZOLE 100 MG TABLET	3	Preferred Brand	$42.00	$105.00	None
BENZNIDAZOLE 12.5 MG TABLET	3	Preferred Brand	$42.00	$105.00	None
BENZTROPINE MES 0.5 MG TABLET [Cogentin]	1	Preferred Generic	$3.00	$7.50	P
BENZTROPINE MES 1 MG TABLET [Cogentin]	1	Preferred Generic	$3.00	$7.50	P
BENZTROPINE MES 2 MG TABLET [Cogentin]	1	Preferred Generic	$3.00	$7.50	P
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE	2	Generic	$15.00	$37.50	None
BETAMETHASONE DP 0.05% LOTION	2	Generic	$15.00	$37.50	None
BETAMETHASONE DP 0.05% OINTMENT [Maxivate]	2	Generic	$15.00	$37.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BETAMETHASONE DP AUG 0.05% CREAM (g) [RRB Pak]	2	Generic	$15.00	$37.50	None
BETAMETHASONE DP AUG 0.05% GEL	2	Generic	$15.00	$37.50	None
BETAMETHASONE DP AUG 0.05% LOTION	2	Generic	$15.00	$37.50	None
BETAMETHASONE DP AUG 0.05% OINTMENT [Diprolene]	2	Generic	$15.00	$37.50	None
BETAMETHASONE VA 0.1% CREAM (G) [Valisone]	2	Generic	$15.00	$37.50	None
BETAMETHASONE VALER 0.1% LOTION [Valisone]	2	Generic	$15.00	$37.50	None
BETAMETHASONE VALER 0.1% OINTMENT [Valisone]	2	Generic	$15.00	$37.50	None
BETAMETHASONE VALER 0.12% FOAM [Luxiq Foam]	2	Generic	$15.00	$37.50	None
BETAXOLOL 10 MG TABLET	2	Generic	$15.00	$37.50	None
BETAXOLOL 20 MG TABLET	2	Generic	$15.00	$37.50	None
BETAXOLOL HCL 0.5% EYE DROPS	2	Generic	$15.00	$37.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BETHANECHOL 10 MG TABLET	2	Generic	$15.00	$37.50	None
BETHANECHOL 25 MG TABLET	2	Generic	$15.00	$37.50	None
BETHANECHOL 5 MG TABLET	2	Generic	$15.00	$37.50	None
BETHANECHOL 50 MG TABLET	2	Generic	$15.00	$37.50	None
BETHKIS 300 MG/4 ML AMPULE	5	Specialty Tier	25%	N/A	P Q:224 /28Days
BEXAROTENE 75 MG CAPSULE [Targretin]	5	Specialty Tier	25%	N/A	P
BEXSERO PREFILLED SYRINGE	3	Preferred Brand	$42.00	$105.00	None
BICALUTAMIDE 50 MG TABLET	2	Generic	$15.00	$37.50	None
BICILL LA PFS 600MU 1ML PED	4	Non-Preferred Drug	49%	49%	P
BICILLIN C-R 1.2MM UNITS SYRINGE 2ML x 10	3	Preferred Brand	$42.00	$105.00	P
BICILLIN C-R 900/300 SYRINGE 2ML x 10	3	Preferred Brand	$42.00	$105.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BICILLIN LA PFS 1200MU 2ML	4	Non-Preferred Drug	49%	49%	P
BICILLIN LA. 600000UNIT/ML 1ML	4	Non-Preferred Drug	49%	49%	P
BIKTARVY 50-200-25 MG TABLET	5	Specialty Tier	25%	N/A	None
BIMATOPROST 0.03% EYE DROPS [Lumigan]	2	Generic	$15.00	$37.50	None
BISOPROLOL FUMARATE 10 MG TABLET	2	Generic	$15.00	$37.50	None
BISOPROLOL FUMARATE 5 MG TABLET	2	Generic	$15.00	$37.50	None
BISOPROLOL-HCTZ 10-6.25 MG TABLET	1	Preferred Generic	$3.00	$7.50	None
BISOPROLOL-HCTZ 2.5-6.25 MG TABLET	1	Preferred Generic	$3.00	$7.50	None
BISOPROLOL-HCTZ 5-6.25 MG TABLET	1	Preferred Generic	$3.00	$7.50	None
BLEPHAMIDE 10-0.2% EYE OINTMENT	4	Non-Preferred Drug	49%	49%	None
BLEPHAMIDE EYE DROPS	4	Non-Preferred Drug	49%	49%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BOOSTRIX TDAP VACCINE SYRINGE	3	Preferred Brand	$42.00	$105.00	None
BOOSTRIX TDAP VACCINE VIAL	3	Preferred Brand	$42.00	$105.00	None
BOSENTAN 125 MG TABLET [Tracleer]	5	Specialty Tier	25%	N/A	P
BOSENTAN 62.5 MG TABLET [Tracleer]	5	Specialty Tier	25%	N/A	P
BOSULIF 100 MG TABLET	5	Specialty Tier	25%	N/A	P Q:90 /30Days
BOSULIF 400 MG TABLET	5	Specialty Tier	25%	N/A	P Q:30 /30Days
BOSULIF 500 MG TABLET	5	Specialty Tier	25%	N/A	P Q:30 /30Days
BRAFTOVI 75 MG CAPSULE	5	Specialty Tier	25%	N/A	P Q:180 /30Days
BREZTRI AEROSPHERE INHALER HFA AER AD	3	Preferred Brand	$42.00	$105.00	Q:11 /30Days
BRILINTA 60 MG TABLET	3	Preferred Brand	$42.00	$105.00	None
BRILINTA 90mg/1 60 TABLET BOTTLE	3	Preferred Brand	$42.00	$105.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BRIMONIDINE 0.2% EYE DROPS [Alphagan]	2	Generic	$15.00	$37.50	None
BRIMONIDINE TARTRATE 0.15% DROPS	2	Generic	$15.00	$37.50	None
BRIVIACT 10 MG TABLET	5	Specialty Tier	25%	N/A	None
BRIVIACT 10 MG/ML ORAL SOLUTION	5	Specialty Tier	25%	N/A	None
BRIVIACT 100 MG TABLET	5	Specialty Tier	25%	N/A	None
BRIVIACT 25 MG TABLET	5	Specialty Tier	25%	N/A	None
BRIVIACT 50 MG TABLET	5	Specialty Tier	25%	N/A	None
BRIVIACT 75 MG TABLET	5	Specialty Tier	25%	N/A	None
BROMFENAC SODIUM 0.09% EYE DROPS [Xibrom]	2	Generic	$15.00	$37.50	None
BROMOCRIPTINE 2.5 MG TABLET [Parlodel]	4	Non-Preferred Drug	49%	49%	None
BROMOCRIPTINE 5 MG CAPSULE [Parlodel]	4	Non-Preferred Drug	49%	49%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BRUKINSA 80 MG CAPSULE	5	Specialty Tier	25%	N/A	P
BUDESONIDE 0.25 MG/2 ML SUSP AMPUL-NEB [Pulmicort]	4	Non-Preferred Drug	49%	49%	P Q:120 /30Days
BUDESONIDE 0.5 MG/2 ML SUSP AMPUL-NEB [Pulmicort]	4	Non-Preferred Drug	49%	49%	P Q:120 /30Days
BUDESONIDE 1 MG/2 ML INH SUSP AMPUL-NEB [Pulmicort]	4	Non-Preferred Drug	49%	49%	P Q:60 /30Days
BUDESONIDE EC 3 MG CAPSULE DR - ER [Entocort EC]	4	Non-Preferred Drug	49%	49%	None
BUDESONIDE ER 9 MG TABLETDR - ER [UCERIS]	5	Specialty Tier	25%	N/A	None
BUMETANIDE 0.5 MG TABLET [Bumex]	2	Generic	$15.00	$37.50	None
BUMETANIDE 1 MG TABLET [Bumex]	2	Generic	$15.00	$37.50	None
BUMETANIDE 1 MG/4 ML VIAL	2	Generic	$15.00	$37.50	None
BUMETANIDE 2 MG TABLET [Bumex]	2	Generic	$15.00	$37.50	None
BUPRENORP-NALOX 12-3 MG SL FILM [Suboxone]	2	Generic	$15.00	$37.50	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BUPRENORP-NALOX 2-0.5 MG SL FILM [Suboxone]	2	Generic	$15.00	$37.50	Q:360 /30Days
BUPRENORP-NALOX 4-1 MG SL FILM [Suboxone]	2	Generic	$15.00	$37.50	Q:90 /30Days
BUPRENORP-NALOX 8-2 MG SL FILM [Suboxone]	2	Generic	$15.00	$37.50	Q:90 /30Days
BUPRENORPHIN-NALOXON 8-2 MG SL SUSLIGUAL TABLET [Suboxone]	2	Generic	$15.00	$37.50	Q:90 /30Days
BUPRENORPHINE 10 MCG/HR PATCH [Butrans]	4	Non-Preferred Drug	49%	49%	P Q:4 /28Days
BUPRENORPHINE 15 MCG/HR PATCH [Butrans]	4	Non-Preferred Drug	49%	49%	P Q:4 /28Days
BUPRENORPHINE 2 MG TABLET SUSLIGUAL [Subutex]	2	Generic	$15.00	$37.50	None
BUPRENORPHINE 20 MCG/HR PATCH [Butrans]	4	Non-Preferred Drug	49%	49%	P Q:4 /28Days
BUPRENORPHINE 5 MCG/HR PATCH [Butrans]	4	Non-Preferred Drug	49%	49%	P Q:4 /28Days
BUPRENORPHINE 7.5 MCG/HR PATCH [Butrans]	4	Non-Preferred Drug	49%	49%	P Q:4 /28Days
BUPRENORPHINE 8 MG TABLET SUSLIGUAL [Subutex]	2	Generic	$15.00	$37.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BUPRENORPHN-NALOXN 2-0.5 MG TABLET SUSLIGUAL [Suboxone]	2	Generic	$15.00	$37.50	Q:360 /30Days
BUPROPION HCL 100 MG TABLET	1	Preferred Generic	$3.00	$7.50	None
BUPROPION HCL 75 MG TABLET	1	Preferred Generic	$3.00	$7.50	None
BUPROPION HCL SR 100 MG TABLET SR 12H [Wellbutrin SR]	2	Generic	$15.00	$37.50	Q:60 /30Days
BUPROPION HCL SR 150 MG TABLET	2	Generic	$15.00	$37.50	None
BUPROPION HCL SR 150 MG TABLET SR 12H [Wellbutrin SR]	2	Generic	$15.00	$37.50	Q:60 /30Days
BUPROPION HCL SR 200 MG TABLET	2	Generic	$15.00	$37.50	Q:60 /30Days
BUPROPION HCL XL 150 MG TABLET	2	Generic	$15.00	$37.50	Q:90 /30Days
BUPROPION HCL XL 300 MG TABLET	2	Generic	$15.00	$37.50	Q:30 /30Days
BUSPIRONE HCL 15 MG TABLET	2	Generic	$15.00	$37.50	None
BUSPIRONE HCL 30 MG TABLET	2	Generic	$15.00	$37.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BUSPIRONE HCL 5 MG TABLET	2	Generic	$15.00	$37.50	None
BUSPIRONE HCL 7.5 MG TABLET	2	Generic	$15.00	$37.50	None
BUSPIRONE HYDROCHLORIDE 10 MG TABLET	2	Generic	$15.00	$37.50	None
BUTORPHANOL 10 MG/ML SPRAY [Stadol NS]	2	Generic	$15.00	$37.50	Q:10 /28Days
BYDUREON BCISE 2 MG AUTOINJECT	3	Preferred Brand	$42.00	$105.00	P Q:4 /28Days
BYETTA 10 MCG DOSE PEN INJ	3	Preferred Brand	$42.00	$105.00	P Q:2 /30Days
BYETTA 5 MCG DOSE PEN INJ	3	Preferred Brand	$42.00	$105.00	P Q:1 /30Days

Chart Legend:

Below are a few notes to help you understand the above 2021 Medicare Part D WPS MedicareRx Plan 1 (PDP) Plan Formulary.

Plan Name: This is the official Medicare Part D prescription drug or Medicare Advantage plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)
Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.
Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $445 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.
Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
- Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
- No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.
Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
- Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs.
- Tier Number* - Some Part D drug plans exclude one or more drug tiers from the plan’s deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
- Tier Description - This is the Medicare Part D plan’s description of this particular drug tier.
Cost Sharing - Copay / Coinsurance - This is what you will pay for formulary drugs in the Initial Coverage Phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
- Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $4,130) at a "Preferred" network pharmacy. In most cases, the "Preferred" network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
  
  * When the insulin copay is in green, example: $35.00, this Part D plan may offer particular forms of insulin as part of the Senior Savings Model. The Senior Savings Model stipulates that some insulin will cost no more than $35 in the deductible, initial coverage, and coverage gap phases of your Part D plan. Please contact the drug plan for more details.
- Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
- None - This drug does not fall under any drug utilization management controls.
- P - Prior Authorization -This drug is subject to prior authorization.
- S - Step Therapy -This drug is subject to step therapy.
- Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.

(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2021 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Medicare plan provider.