Q1Medicare.com 2024 Medicare Part D or Medicare Advantage Plan Formulary Browser

2024 Medicare Part D Plan Formulary Information
Medicare Plus Blue PPO Part B Credit (PPO) (H9572-006-4) 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 Medicare Plus Blue PPO Part B Credit (PPO) (H9572-006-4) Formulary Drugs Starting with the Letter B in Clinton County, MI: CMS MA Region 11 which includes: MI
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	4	Non-Preferred Drug	50%	50%	None
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT	2*	Generic	$10.00	$0.00	None
BACLOFEN 10 MG TABLET	2*	Generic	$10.00	$0.00	None
BACLOFEN 20 MG TABLET [Lioresal]	2*	Generic	$10.00	$0.00	None
BACLOFEN 5 MG TABLET	3	Preferred Brand	$45.00	$90.00	None
BALSALAZIDE DISODIUM 750 MG CAPSULE [Colazal]	4	Non-Preferred Drug	50%	50%	None
BALVERSA 3 MG TABLET	5	Tier 5	27%	N/A	P Q:90 /30Days
BALVERSA 4 MG TABLET	5	Tier 5	27%	N/A	P Q:60 /30Days
BALVERSA 5 MG TABLET	5	Tier 5	27%	N/A	P Q:30 /30Days
BAQSIMI 3 MG SPRAY ONE PACK	3	Preferred Brand	$45.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BCG VACCINE 50mg/1 1 VIAL per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL	3	Preferred Brand	$45.00	$90.00	None
BENAZEPRIL HCL 10 MG TABLET	1*	Preferred Generic	$0.00	$0.00	Q:720 /90Days
BENAZEPRIL HCL 20 MG TABLET [Lotensin]	1*	Preferred Generic	$0.00	$0.00	Q:360 /90Days
BENAZEPRIL HCL 40 MG TABLET [Lotensin]	1*	Preferred Generic	$0.00	$0.00	Q:180 /90Days
BENAZEPRIL HCL 5 MG TABLET	1*	Preferred Generic	$0.00	$0.00	Q:1440 /90Days
BENAZEPRIL-HCTZ 10-12.5 MG TABLET [Lotensin HCT]	1*	Preferred Generic	$0.00	$0.00	Q:180 /90Days
BENAZEPRIL-HCTZ 20-12.5 MG TABLET [Lotensin HCT]	1*	Preferred Generic	$0.00	$0.00	Q:90 /90Days
BENAZEPRIL-HCTZ 20-25 MG TABLET [Lotensin HCT]	1*	Preferred Generic	$0.00	$0.00	Q:90 /90Days
BENAZEPRIL-HCTZ 5-6.25 MG TABLET [Lotensin HCT]	1*	Preferred Generic	$0.00	$0.00	Q:360 /90Days
BENLYSTA 200 MG/ML AUTOINJECT	5	Tier 5	27%	N/A	P
BENLYSTA 200 MG/ML SYRINGE	5	Tier 5	27%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BENZTROPINE MES 0.5 MG TABLET [Cogentin]	2*	Generic	$10.00	$0.00	None
BENZTROPINE MES 1 MG TABLET [Cogentin]	2*	Generic	$10.00	$0.00	None
BENZTROPINE MES 2 MG TABLET [Cogentin]	2*	Generic	$10.00	$0.00	None
BESIVANCE BESIFLOACIN OPTHALMIC SUSPENSION 0.6% 5 ML BOTDR	4	Non-Preferred Drug	50%	50%	None
BESREMI 500 MCG/ML SYRINGE	5	Tier 5	27%	N/A	P Q:2 /28Days
BETAINE 1 GRAM/SCOOP POWDER [Cystadane]	5	Tier 5	27%	N/A	None
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE	3	Preferred Brand	$45.00	$90.00	None
BETAMETHASONE DP 0.05% LOTION	3	Preferred Brand	$45.00	$90.00	None
BETAMETHASONE DP 0.05% OINTMENT [Maxivate]	4	Non-Preferred Drug	50%	50%	None
BETAMETHASONE DP AUG 0.05% CREAM (g) [RRB Pak]	3	Preferred Brand	$45.00	$90.00	None
BETAMETHASONE DP AUG 0.05% GEL	4	Non-Preferred Drug	50%	50%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BETAMETHASONE DP AUG 0.05% LOTION [Diprolene]	4	Non-Preferred Drug	50%	50%	None
BETAMETHASONE DP AUG 0.05% OINTMENT [Diprolene]	4	Non-Preferred Drug	50%	50%	None
BETAMETHASONE VA 0.1% CREAM (G) [Valisone]	3	Preferred Brand	$45.00	$90.00	None
BETAMETHASONE VALER 0.1% LOTION [Valisone]	3	Preferred Brand	$45.00	$90.00	None
BETAMETHASONE VALER 0.1% OINTMENT [Valisone]	3	Preferred Brand	$45.00	$90.00	None
BETASERON 0.3 MG KIT	5	Tier 5	27%	N/A	P Q:14 /28Days
BETAXOLOL 10 MG TABLET	3	Preferred Brand	$45.00	$90.00	None
BETAXOLOL 20 MG TABLET	3	Preferred Brand	$45.00	$90.00	None
BETAXOLOL HCL 0.5% EYE DROPS	3	Preferred Brand	$45.00	$90.00	None
BETHANECHOL 10 MG TABLET	3	Preferred Brand	$45.00	$90.00	None
BETHANECHOL 25 MG TABLET	3	Preferred Brand	$45.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BETHANECHOL 5 MG TABLET	3	Preferred Brand	$45.00	$90.00	None
BETHANECHOL 50 MG TABLET	3	Preferred Brand	$45.00	$90.00	None
BETOPTIC S 0.25% EYE DROP EYE DROPPER	4	Non-Preferred Drug	50%	50%	None
BEVESPI AEROSPHERE INHALER	3	Preferred Brand	$45.00	$90.00	Q:32 /90Days
BEXAROTENE 1% GEL [Targretin]	5	Tier 5	27%	N/A	P Q:60 /30Days
BEXAROTENE 75 MG CAPSULE [Targretin]	5	Tier 5	27%	N/A	P
BEXSERO PREFILLED SYRINGE	3	Preferred Brand	$45.00	$90.00	None
BICALUTAMIDE 50 MG TABLET	3	Preferred Brand	$45.00	$90.00	None
BICILL LA PFS 600MU 1ML PED	4	Non-Preferred Drug	50%	50%	None
BICILLIN C-R 1.2MM UNITS SYRINGE 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
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	50%	50%	None
BICILLIN LA. 600000UNIT/ML 1ML	4	Non-Preferred Drug	50%	50%	None
BIKTARVY 30-120-15 MG TABLET	5	Tier 5	27%	N/A	Q:31 /31Days
BIKTARVY 50-200-25 MG TABLET	5	Tier 5	27%	N/A	Q:31 /31Days
BIMATOPROST 0.03% EYE DROPS [Lumigan]	4	Non-Preferred Drug	50%	50%	None
BISOPROLOL FUMARATE 10 MG TABLET	2*	Generic	$10.00	$0.00	None
BISOPROLOL FUMARATE 5 MG TABLET	2*	Generic	$10.00	$0.00	None
BISOPROLOL-HCTZ 10-6.25 MG TABLET [Ziac]	2*	Generic	$10.00	$0.00	None
BISOPROLOL-HCTZ 2.5-6.25 MG TABLET	2*	Generic	$10.00	$0.00	None
BISOPROLOL-HCTZ 5-6.25 MG TABLET	2*	Generic	$10.00	$0.00	None
BLISOVI FE 1.5-30 TABLET [Microgestin Fe 1.5/30]	2*	Generic	$10.00	$0.00	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	$45.00	$90.00	None
BOOSTRIX TDAP VACCINE VIAL	3	Preferred Brand	$45.00	$90.00	None
BOSENTAN 125 MG TABLET [Tracleer]	5	Tier 5	27%	N/A	P Q:60 /30Days
BOSENTAN 62.5 MG TABLET [Tracleer]	5	Tier 5	27%	N/A	P Q:120 /30Days
BOSULIF 100 MG CAPSULE	5	Tier 5	27%	N/A	P Q:150 /25Days
BOSULIF 100 MG TABLET	5	Tier 5	27%	N/A	P
BOSULIF 400 MG TABLET	5	Tier 5	27%	N/A	P
BOSULIF 50 MG CAPSULE	5	Tier 5	27%	N/A	P Q:300 /25Days
BOSULIF 500 MG TABLET	5	Tier 5	27%	N/A	P
BRAFTOVI 75 MG CAPSULE	5	Tier 5	27%	N/A	P
BREO ELLIPTA 100-25 MCG INH	3	Preferred Brand	$45.00	$90.00	Q:180 /90Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BREO ELLIPTA 200-25 MCG INH	3	Preferred Brand	$45.00	$90.00	Q:180 /90Days
BREO ELLIPTA 50-25 MCG INHALER BLST W/DEV	3	Preferred Brand	$45.00	$90.00	Q:180 /90Days
BREZTRI AEROSPHERE INHALER HFA AER AD	3	Preferred Brand	$45.00	$90.00	Q:32 /90Days
BRILINTA 60 MG TABLET	4	Non-Preferred Drug	50%	50%	Q:180 /90Days
BRILINTA 90mg/1 60 TABLET BOTTLE	4	Non-Preferred Drug	50%	50%	Q:182 /90Days
BRIMONIDINE 0.2% EYE DROPS [Alphagan]	2*	Generic	$10.00	$0.00	None
BRIMONIDINE TARTRATE 0.1% DROPS [Alphagan P]	3	Preferred Brand	$45.00	$90.00	None
BRIMONIDINE TARTRATE 0.15% DROPS [Alphagan P]	4	Non-Preferred Drug	50%	50%	None
BRINZOLAMIDE 1% EYE DROPS/EYE DROPPER [Azopt]	4	Non-Preferred Drug	50%	50%	None
BRIVIACT 10 MG TABLET	5	Tier 5	27%	N/A	P Q:62 /31Days
BRIVIACT 10 MG/ML ORAL SOLUTION	5	Tier 5	27%	N/A	P Q:620 /31Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BRIVIACT 100 MG TABLET	5	Tier 5	27%	N/A	P Q:62 /31Days
BRIVIACT 25 MG TABLET	5	Tier 5	27%	N/A	P Q:62 /31Days
BRIVIACT 50 MG TABLET	5	Tier 5	27%	N/A	P Q:62 /31Days
BRIVIACT 75 MG TABLET	5	Tier 5	27%	N/A	P Q:62 /31Days
BROMOCRIPTINE 2.5 MG TABLET [Parlodel]	4	Non-Preferred Drug	50%	50%	None
BROMOCRIPTINE 5 MG CAPSULE [Parlodel]	4	Non-Preferred Drug	50%	50%	None
BRONCHITOL 40 MG INHALE CAPSULE W/DEV	5	Tier 5	27%	N/A	P Q:560 /28Days
BRUKINSA 80 MG CAPSULE	5	Tier 5	27%	N/A	P Q:120 /30Days
BUDESONIDE 0.25 MG/2 ML SUSP AMPUL-NEB [Pulmicort]	3	Preferred Brand	$45.00	$90.00	P
BUDESONIDE 0.5 MG/2 ML SUSP AMPUL-NEB [Pulmicort]	3	Preferred Brand	$45.00	$90.00	P
BUDESONIDE 1 MG/2 ML INH SUSP AMPUL-NEB [Pulmicort]	3	Preferred Brand	$45.00	$90.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BUDESONIDE EC 3 MG CAPSULE DR - ER [Entocort EC]	4	Non-Preferred Drug	50%	50%	None
BUDESONIDE ER 9 MG TABLET ER [UCERIS]	4	Non-Preferred Drug	50%	50%	None
BUMETANIDE 0.5 MG TABLET [Bumex]	3	Preferred Brand	$45.00	$90.00	None
BUMETANIDE 1 MG TABLET [Bumex]	3	Preferred Brand	$45.00	$90.00	None
BUMETANIDE 1 MG/4 ML VIAL	4	Non-Preferred Drug	50%	50%	None
BUMETANIDE 2 MG TABLET [Bumex]	3	Preferred Brand	$45.00	$90.00	None
BUPRENORP-NALOX 12-3 MG SL FILM [Suboxone]	1*	Preferred Generic	$0.00	$0.00	Q:180 /90Days
BUPRENORPHIN-NALOXON 8-2 MG SL SUSLIGUAL TABLET [Suboxone]	1*	Preferred Generic	$0.00	$0.00	Q:270 /90Days
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 SUBLIGUAL TABLET [Subutex]	1*	Preferred Generic	$0.00	$0.00	Q:270 /90Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
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 [Butrans]	4	Non-Preferred Drug	50%	50%	Q:12 /84Days
BUPRENORPHINE 8 MG TABLET SUSLIGUAL [Subutex]	1*	Preferred Generic	$0.00	$0.00	Q:270 /90Days
BUPRENORPHINE-NALOX 2-0.5MG FILM [Suboxone]	1*	Preferred Generic	$0.00	$0.00	Q:270 /90Days
BUPRENORPHINE-NALOX 4-1MG FILM [Suboxone]	1*	Preferred Generic	$0.00	$0.00	Q:270 /90Days
BUPRENORPHINE-NALOX 8-2MG FILM [Suboxone]	1*	Preferred Generic	$0.00	$0.00	Q:270 /90Days
BUPRENORPHN-NALOXN 2-0.5 MG TABLET SUSLIGUAL [Suboxone]	1*	Preferred Generic	$0.00	$0.00	Q:270 /90Days
BUPROPION HCL 100 MG TABLET	3	Preferred Brand	$45.00	$90.00	Q:540 /90Days
BUPROPION HCL 75 MG TABLET	3	Preferred Brand	$45.00	$90.00	Q:540 /90Days
BUPROPION HCL SR 100 MG TABLET SR 12H [Wellbutrin SR]	3	Preferred Brand	$45.00	$90.00	Q:180 /90Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BUPROPION HCL SR 150 MG TABLET	3	Preferred Brand	$45.00	$90.00	Q:180 /90Days
BUPROPION HCL SR 150 MG TABLET SR 12H [Wellbutrin SR]	3	Preferred Brand	$45.00	$90.00	Q:180 /90Days
BUPROPION HCL SR 200 MG TABLET SR 12H [Wellbutrin SR]	3	Preferred Brand	$45.00	$90.00	Q:180 /90Days
BUPROPION HCL XL 150 MG TABLET ER 24H [Wellbutrin XL]	3	Preferred Brand	$45.00	$90.00	Q:270 /90Days
BUPROPION HCL XL 300 MG TABLET ER 24H [Wellbutrin XL]	3	Preferred Brand	$45.00	$90.00	Q:90 /90Days
BUSPIRONE HCL 15 MG TABLET	2*	Generic	$10.00	$0.00	None
BUSPIRONE HCL 30 MG TABLET	2*	Generic	$10.00	$0.00	None
BUSPIRONE HCL 5 MG TABLET	2*	Generic	$10.00	$0.00	None
BUSPIRONE HCL 7.5 MG TABLET	2*	Generic	$10.00	$0.00	None
BUSPIRONE HYDROCHLORIDE 10 MG TABLET	2*	Generic	$10.00	$0.00	None
BUTORPHANOL 10 MG/ML SPRAY [Stadol NS]	3	Preferred Brand	$45.00	$90.00	Q:15 /90Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
BYDUREON BCISE 2 MG AUTOINJECT	3	Preferred Brand	$45.00	$90.00	P Q:10 /84Days

Chart Legend:

Below are a few notes to help you understand the above 2024 Medicare Part D Medicare Plus Blue PPO Part B Credit (PPO) 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 $545 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 $5,030) 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.
  
  *All forms of insulin covered by any Medicare Part D plan will have a copay of $35 or less through all phases of coverage. 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 March 2024)

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.