2024 Medicare Part D Plan Formulary Information |
Health Alliance Medicare POS Choice Rx (HMO-POS) (H1463-044-0)
Benefits & Contact Info
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less. Call drug plan for more details. |
The Health Alliance Medicare POS Choice Rx (HMO-POS) (H1463-044-0) Formulary Drugs Starting with the Letter B in Carroll County, IL: CMS MA Region 14 which includes: IL
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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 |
$15.00 | $30.00 | None |
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT |
2 |
Generic |
$15.00 | $30.00 | None |
BACLOFEN 10 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
BACLOFEN 20 MG TABLET [Lioresal] |
2 |
Generic |
$15.00 | $30.00 | None |
BACLOFEN 5 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
BAFIERTAM DR 95 MG CAPSULE DR |
5 |
Tier 5 |
33% | N/A | Q:120 /30Days |
BALSALAZIDE DISODIUM 750 MG CAPSULE [Colazal] |
2 |
Generic |
$15.00 | $30.00 | None |
BALVERSA 3 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
BALVERSA 4 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
BALVERSA 5 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
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 |
2 |
Generic |
$15.00 | $30.00 | None |
BARACLUDE 0.05mg/mL 1 BOTTLE per CARTON / 210 mL in 1 BOTTLE |
4 |
Non-Preferred Drug |
50% | 50% | None |
BAXDELA 300 MG VIAL |
5 |
Tier 5 |
33% | N/A | None |
BAXDELA 450 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
BCG VACCINE 50mg/1 1 VIAL per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL |
4 |
Non-Preferred Drug |
50% | 50% | None |
BELBUCA 150 MCG FILM |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
BELBUCA 300 MCG FILM |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
BELBUCA 450 MCG FILM |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
BELBUCA 600 MCG FILM |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
BELBUCA 75 MCG FILM |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
BELBUCA 750 MCG FILM |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BELBUCA 900 MCG FILM |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
BELSOMRA 10 MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
BELSOMRA 15 MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
BELSOMRA 20 MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
BELSOMRA 5 MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
BENAZEPRIL HCL 10 MG TABLET |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
BENAZEPRIL HCL 20 MG TABLET [Lotensin] |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
BENAZEPRIL HCL 40 MG TABLET [Lotensin] |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
BENAZEPRIL HCL 5 MG TABLET |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
BENAZEPRIL-HCTZ 10-12.5 MG TABLET [Lotensin HCT] |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
BENAZEPRIL-HCTZ 20-12.5 MG TABLET [Lotensin HCT] |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BENAZEPRIL-HCTZ 20-25 MG TABLET [Lotensin HCT] |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
BENAZEPRIL-HCTZ 5-6.25 MG TABLET [Lotensin HCT] |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
BENLYSTA 200 MG/ML AUTOINJECT |
5 |
Tier 5 |
33% | N/A | None |
BENLYSTA 200 MG/ML SYRINGE |
5 |
Tier 5 |
33% | N/A | None |
BENZTROPINE MES 0.5 MG TABLET [Cogentin] |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
BENZTROPINE MES 1 MG TABLET [Cogentin] |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
BENZTROPINE MES 2 MG TABLET [Cogentin] |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
BERINERT 500 UNIT KIT |
5 |
Tier 5 |
33% | N/A | P |
BESREMI 500 MCG/ML SYRINGE |
5 |
Tier 5 |
33% | N/A | P |
BETAINE 1 GRAM/SCOOP POWDER [Cystadane] |
5 |
Tier 5 |
33% | N/A | None |
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETAMETHASONE DP 0.05% LOTION |
2 |
Generic |
$15.00 | $30.00 | None |
BETAMETHASONE DP 0.05% OINTMENT [Maxivate] |
2 |
Generic |
$15.00 | $30.00 | None |
BETAMETHASONE DP AUG 0.05% CREAM (g) [RRB Pak] |
2 |
Generic |
$15.00 | $30.00 | None |
BETAMETHASONE DP AUG 0.05% GEL |
2 |
Generic |
$15.00 | $30.00 | None |
BETAMETHASONE DP AUG 0.05% LOTION [Diprolene] |
2 |
Generic |
$15.00 | $30.00 | None |
BETAMETHASONE DP AUG 0.05% OINTMENT [Diprolene] |
2 |
Generic |
$15.00 | $30.00 | None |
BETAMETHASONE VA 0.1% CREAM (G) [Valisone] |
2 |
Generic |
$15.00 | $30.00 | None |
BETAMETHASONE VALER 0.1% LOTION [Valisone] |
2 |
Generic |
$15.00 | $30.00 | None |
BETAMETHASONE VALER 0.1% OINTMENT [Valisone] |
2 |
Generic |
$15.00 | $30.00 | None |
BETASERON 0.3 MG KIT |
5 |
Tier 5 |
33% | N/A | None |
BETAXOLOL 10 MG TABLET |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BETAXOLOL 20 MG TABLET |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
BETAXOLOL HCL 0.5% EYE DROPS |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
BETHANECHOL 10 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
BETHANECHOL 25 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
BETHANECHOL 5 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
BETHANECHOL 50 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
BEVESPI AEROSPHERE INHALER |
4 |
Non-Preferred Drug |
50% | 50% | None |
BEXAROTENE 1% GEL [Targretin] |
5 |
Tier 5 |
33% | N/A | P |
BEXAROTENE 75 MG CAPSULE [Targretin] |
5 |
Tier 5 |
33% | N/A | P |
BEXSERO PREFILLED SYRINGE |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
BICALUTAMIDE 50 MG TABLET |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BICILL LA PFS 600MU 1ML PED |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
BICILLIN C-R 1.2MM UNITS SYRINGE 2ML x 10 |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
BICILLIN C-R 900/300 SYRINGE 2ML x 10 |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
BICILLIN LA PFS 1200MU 2ML |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
BICILLIN LA. 600000UNIT/ML 1ML |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
BIKTARVY 30-120-15 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
BIKTARVY 50-200-25 MG TABLET |
5 |
Tier 5 |
33% | N/A | None |
BISOPROLOL FUMARATE 10 MG TABLET [Zebeta] |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
BISOPROLOL FUMARATE 5 MG TABLET [Zebeta] |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
BISOPROLOL-HCTZ 10-6.25 MG TABLET [Ziac] |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
BISOPROLOL-HCTZ 2.5-6.25 MG TABLET [Ziac] |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BISOPROLOL-HCTZ 5-6.25 MG TABLET [Ziac] |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
BIVIGAM 10% VIAL [Panzyga] |
5 |
Tier 5 |
33% | N/A | P |
BLISOVI 24 FE TABLET [Tarina Fe 1/20] |
2 |
Generic |
$15.00 | $30.00 | None |
BLISOVI FE 1.5-30 TABLET [Microgestin Fe 1.5/30] |
2 |
Generic |
$15.00 | $30.00 | None |
BOOSTRIX TDAP VACCINE SYRINGE |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
BOOSTRIX TDAP VACCINE VIAL |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
BOSULIF 100 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P |
BOSULIF 100 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
BOSULIF 400 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
BOSULIF 50 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P |
BOSULIF 500 MG TABLET |
5 |
Tier 5 |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BRAFTOVI 75 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P |
BREO ELLIPTA 100-25 MCG INH |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
BREO ELLIPTA 200-25 MCG INH |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
BREO ELLIPTA 50-25 MCG INHALER BLST W/DEV |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
BREZTRI AEROSPHERE INHALER HFA AER AD |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
BRIELLYN TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
BRILINTA 60 MG TABLET |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
BRILINTA 90mg/1 60 TABLET BOTTLE |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
BRIMONIDINE 0.2% EYE DROPS [Alphagan] |
2 |
Generic |
$15.00 | $30.00 | None |
BRIMONIDINE TARTRATE 0.15% DROPS [Alphagan P] |
2 |
Generic |
$15.00 | $30.00 | None |
BRIMONIDINE-TIMOLOL 0.2%-0.5% DROPS [Combigan] |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BRINZOLAMIDE 1% EYE DROPS/EYE DROPPER [Azopt] |
2 |
Generic |
$15.00 | $30.00 | None |
BRIVIACT 10 MG TABLET |
5 |
Tier 5 |
33% | N/A | S |
BRIVIACT 10 MG/ML ORAL SOLUTION |
5 |
Tier 5 |
33% | N/A | S |
BRIVIACT 100 MG TABLET |
5 |
Tier 5 |
33% | N/A | S |
BRIVIACT 25 MG TABLET |
5 |
Tier 5 |
33% | N/A | S |
BRIVIACT 50 MG TABLET |
5 |
Tier 5 |
33% | N/A | S |
BRIVIACT 75 MG TABLET |
5 |
Tier 5 |
33% | N/A | S |
BROMFENAC SOD 0.075% EYE DROPS [BromSite] |
4 |
Non-Preferred Drug |
50% | 50% | None |
BROMFENAC SODIUM 0.09% EYE DROPS [Xibrom] |
2 |
Generic |
$15.00 | $30.00 | None |
BROMOCRIPTINE 2.5 MG TABLET [Parlodel] |
2 |
Generic |
$15.00 | $30.00 | None |
BROMOCRIPTINE 5 MG CAPSULE [Parlodel] |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BROMSITE 0.075% EYE DROPS |
4 |
Non-Preferred Drug |
50% | 50% | None |
BRONCHITOL 40 MG INHALE CAPSULE W/DEV |
5 |
Tier 5 |
33% | N/A | P Q:560 /28Days |
BRUKINSA 80 MG CAPSULE |
5 |
Tier 5 |
33% | N/A | P |
BUDESONIDE 0.25 MG/2 ML SUSP AMPUL-NEB [Pulmicort] |
2 |
Generic |
$15.00 | $30.00 | P |
BUDESONIDE 0.5 MG/2 ML SUSP AMPUL-NEB [Pulmicort] |
2 |
Generic |
$15.00 | $30.00 | P |
BUDESONIDE 1 MG/2 ML INH SUSP AMPUL-NEB [Pulmicort] |
2 |
Generic |
$15.00 | $30.00 | P |
BUDESONIDE 2 MG RECTAL FOAM/APPL [UCERIS Rectal] |
3 |
Preferred Brand |
$47.00 | $94.00 | None |
BUDESONIDE EC 3 MG CAPSULE DR - ER [Entocort EC] |
4 |
Non-Preferred Drug |
50% | 50% | None |
BUDESONIDE ER 9 MG TABLET ER [UCERIS] |
5 |
Tier 5 |
33% | N/A | None |
BUMETANIDE 0.5 MG TABLET [Bumex] |
2 |
Generic |
$15.00 | $30.00 | None |
BUMETANIDE 1 MG TABLET [Bumex] |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUMETANIDE 1 MG/4 ML VIAL |
2 |
Generic |
$15.00 | $30.00 | None |
BUMETANIDE 2 MG TABLET [Bumex] |
2 |
Generic |
$15.00 | $30.00 | None |
BUPRENORP-NALOX 12-3 MG SL FILM [Suboxone] |
2 |
Generic |
$15.00 | $30.00 | Q:90 /30Days |
BUPRENORPHIN-NALOXON 8-2 MG SL SUSLIGUAL TABLET [Suboxone] |
2 |
Generic |
$15.00 | $30.00 | Q:90 /30Days |
BUPRENORPHINE 10 MCG/HR PATCH [Butrans] |
2 |
Generic |
$15.00 | $30.00 | None |
BUPRENORPHINE 15 MCG/HR PATCH [Butrans] |
2 |
Generic |
$15.00 | $30.00 | None |
BUPRENORPHINE 2 MG TABLET SUBLIGUAL [Subutex] |
2 |
Generic |
$15.00 | $30.00 | Q:90 /30Days |
BUPRENORPHINE 20 MCG/HR PATCH [Butrans] |
2 |
Generic |
$15.00 | $30.00 | None |
BUPRENORPHINE 5 MCG/HR PATCH [Butrans] |
2 |
Generic |
$15.00 | $30.00 | None |
BUPRENORPHINE 7.5 MCG/HR PATCH [Butrans] |
2 |
Generic |
$15.00 | $30.00 | None |
BUPRENORPHINE 8 MG TABLET SUSLIGUAL [Subutex] |
2 |
Generic |
$15.00 | $30.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUPRENORPHINE-NALOX 2-0.5MG FILM [Suboxone] |
2 |
Generic |
$15.00 | $30.00 | Q:90 /30Days |
BUPRENORPHINE-NALOX 4-1MG FILM [Suboxone] |
2 |
Generic |
$15.00 | $30.00 | Q:90 /30Days |
BUPRENORPHINE-NALOX 8-2MG FILM [Suboxone] |
2 |
Generic |
$15.00 | $30.00 | Q:90 /30Days |
BUPRENORPHN-NALOXN 2-0.5 MG TABLET SUSLIGUAL [Suboxone] |
2 |
Generic |
$15.00 | $30.00 | Q:90 /30Days |
BUPROPION HCL 100 MG TABLET |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
BUPROPION HCL 75 MG TABLET |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
BUPROPION HCL SR 100 MG TABLET SR 12H [Wellbutrin SR] |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
BUPROPION HCL SR 150 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
BUPROPION HCL SR 150 MG TABLET SR 12H [Wellbutrin SR] |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
BUPROPION HCL SR 200 MG TABLET SR 12H [Wellbutrin SR] |
1 |
Preferred Generic |
$2.00 | $4.00 | None |
BUPROPION HCL XL 150 MG TABLET ER 24H [Wellbutrin XL] |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUPROPION HCL XL 300 MG TABLET ER 24H [Wellbutrin XL] |
2 |
Generic |
$15.00 | $30.00 | None |
BUSPIRONE HCL 15 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
BUSPIRONE HCL 30 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
BUSPIRONE HCL 5 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
BUSPIRONE HCL 7.5 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
BUSPIRONE HYDROCHLORIDE 10 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
BUTALB-ACETAMIN-CAFF 50-300-40 CAPSULE [Phrenilin Forte] |
2 |
Generic |
$15.00 | $30.00 | None |
BUTALB-ACETAMIN-CAFF 50-325-40 TABLET [Repan] |
2 |
Generic |
$15.00 | $30.00 | None |
BUTALB-CAFF-ACETAMINOPH-CODEIN |
2 |
Generic |
$15.00 | $30.00 | None |
BUTALBITAL-ASA-CAFFEINE CAPSULE [Fiorinal] |
2 |
Generic |
$15.00 | $30.00 | None |
BUTALBITAL/ACETAMINOPHEN/CAFFEINE CAPSULE |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
BUTORPHANOL 10 MG/ML SPRAY [Stadol NS] |
2 |
Generic |
$15.00 | $30.00 | Q:5 /28Days |