2009 Medicare Part D Plan Formulary Information |
First Health Part D-Premier (S5768-042-0)
Benefit Details
|
The First Health Part D-Premier (S5768-042-0) Formulary Drugs Starting with the Letter F in CMS PDP Region 17 which includes: IL
|
Drugs Starting with Letter F
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
FABRAZYME 35MG VIAL |
4 |
Specialty-Generic and Brand |
33% | N/A | P |
FABRAZYME 5MG VIAL |
4 |
Specialty-Generic and Brand |
33% | N/A | P |
FACTIVE 320MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | Q:7 /7Days |
FAMCICLOVIR 125MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | None |
FAMCICLOVIR 250MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | Q:30 /10Days |
FAMCICLOVIR 500MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | Q:30 /10Days |
FAMOTIDINE 20MG TABLET (500 CT) |
1 |
Preferred Generic |
$6.00 | N/A | None |
FAMOTIDINE 40MG TABLET |
1 |
Preferred Generic |
$6.00 | N/A | None |
FAMOTIDINE INJECTION 10MG 25 X 2ML VIALSD |
1 |
Preferred Generic |
$6.00 | N/A | None |
FANSIDAR 500/25 TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FARESTON 60MG TABLET (100 CT) |
2 |
Preferred Brand |
$31.00 | N/A | Q:30 /30Days |
FASLODEX 125MG/2.5ML SYRNGE |
4 |
Specialty-Generic and Brand |
33% | N/A | P Q:5 /30Days |
FASLODEX 250MG/5ML SYRINGE |
4 |
Specialty-Generic and Brand |
33% | N/A | P Q:5 /30Days |
FAZACLO 12.5MG TABLET RAPID DISSOLVE |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | None |
FAZACLO TABLET ORALLY DISINTEGRATING 100MG (100 CT) |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | None |
FAZACLO TABLET ORALLY DISINTEGRATING 25MG (10 CT) |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | None |
FELBATOL 400MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | Q:180 /30Days |
FELBATOL 600MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | Q:180 /30Days |
FELBATOL 600MG/5ML SUSP |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | Q:900 /30Days |
FELODIPINE ER 2.5MG TABLET 90 TABLET BOT |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | None |
FELODIPINE TABLET ER 10MG (1000 CT) |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FELODIPINE TABLET ER 5MG (1000 CT) |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | None |
FEMARA 2.5MG TABLET |
2 |
Preferred Brand |
$31.00 | N/A | Q:30 /30Days |
FEMHRT 0.5MG/2.5MCG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | Q:30 /30Days |
FEMHRT 1/5 TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | Q:30 /30Days |
FEMRING 0.05MG VAGINAL RING |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | Q:1 /84Days |
FEMRING 0.10MG VAGINAL RING |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | Q:1 /84Days |
FEMTRACE 0.45MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | Q:30 /30Days |
FEMTRACE 0.9MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | Q:30 /30Days |
FEMTRACE 1.8MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | Q:30 /30Days |
FENOFIBRATE 134MG CAPSULE |
1 |
Preferred Generic |
$6.00 | N/A | None |
FENOFIBRATE 160MG TABLET |
1 |
Preferred Generic |
$6.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENOFIBRATE 200MG CAPSULE |
1 |
Preferred Generic |
$6.00 | N/A | None |
FENOFIBRATE 54MG TABLET |
1 |
Preferred Generic |
$6.00 | N/A | None |
FENOFIBRATE 67MG CAPSULE |
1 |
Preferred Generic |
$6.00 | N/A | None |
FENOGLIDE 120MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | Q:30 /30Days |
FENOGLIDE 40MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | Q:30 /30Days |
FENOPROFEN 600MG TABLET |
1 |
Preferred Generic |
$6.00 | N/A | None |
FENTANYL 100MCG/HR PATCH TRANSDERMAL 72 HOURS |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | None |
FENTANYL 12MCG/HR PATCH TRANSDERMAL 72 HOURS |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | None |
FENTANYL CITRATE INJECTION 50MCG 10 X 2ML CTG |
1 |
Preferred Generic |
$6.00 | N/A | None |
FENTANYL TRANSDERMAL SYSTEM 25MCG 5 SYSTEMS CRTN |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | None |
FENTANYL TRANSDERMAL SYSTEM 50MCG 5 SYSTEMS CRTN |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENTANYL TRANSDERMAL SYSTEM 75MCG 5 SYSTEMS CRTN |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | None |
FENTORA TABLET 100MCG |
4 |
Specialty-Generic and Brand |
33% | N/A | P Q:120 /30Days |
FENTORA TABLET 200MCG |
4 |
Specialty-Generic and Brand |
33% | N/A | P Q:120 /30Days |
FENTORA TABLET 300MCG |
4 |
Specialty-Generic and Brand |
33% | N/A | P Q:120 /30Days |
FENTORA TABLET 400MCG |
4 |
Specialty-Generic and Brand |
33% | N/A | P Q:120 /30Days |
FENTORA TABLET 600MCG |
4 |
Specialty-Generic and Brand |
33% | N/A | P Q:120 /30Days |
FENTORA TABLET 800MCG |
4 |
Specialty-Generic and Brand |
33% | N/A | P Q:120 /30Days |
FEXOFENADINE HCL 180MG TABLET |
1 |
Preferred Generic |
$6.00 | N/A | Q:30 /30Days |
FEXOFENADINE HCL 30MG TABLET |
1 |
Preferred Generic |
$6.00 | N/A | Q:60 /30Days |
FEXOFENADINE HCL 60MG TABLET (100 CT) |
1 |
Preferred Generic |
$6.00 | N/A | Q:60 /30Days |
FINASTERIDE 5MG TABLET |
1 |
Preferred Generic |
$6.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLAREX 0.1% EYE DROPS |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | None |
FLAVOXATE HCL 100MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | None |
FLEBOGAMMA INJECTION 50MG |
4 |
Specialty-Generic and Brand |
33% | N/A | P |
FLECAINIDE ACETATE 150MG TABLET (100 CT) |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLECAINIDE ACETATE 50MG TABLET (100 CT) |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLECAINIDE ACETATE TABLET 100MG (100 CT) |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLECTOR 1.3% ADHESIVE PATCH MEDICATED |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | Q:60 /30Days |
FLOMAX 0.4MG CAPSULE SA |
2 |
Preferred Brand |
$31.00 | N/A | Q:60 /30Days |
FLOVENT DISKUS /BLIST AEPB |
2 |
Preferred Brand |
$31.00 | N/A | Q:60 /30Days |
FLOVENT DISKUS /BLIST AEPB |
2 |
Preferred Brand |
$31.00 | N/A | Q:60 /30Days |
FLOVENT DISKUS POWDER 50MCG 60 CTR |
2 |
Preferred Brand |
$31.00 | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLOVENT HFA 110MCG INHALATION AEROSOL |
2 |
Preferred Brand |
$31.00 | N/A | Q:24 /30Days |
FLOVENT HFA 220MCG INHALATION AEROSOL |
2 |
Preferred Brand |
$31.00 | N/A | Q:24 /30Days |
FLOVENT HFA 44MCG INHALATION AEROSOL |
2 |
Preferred Brand |
$31.00 | N/A | Q:21 /30Days |
FLUCONAZALE INJECTION 200MG 6 X 200/250ML CTR |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUCONAZOLE 100MG TABLET |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUCONAZOLE 10MG/ML SUSPENSION RECONSTITUTED ORAL |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUCONAZOLE 150 MG TABLET |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUCONAZOLE 200MG TABLET (30 CT) |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUCONAZOLE 40MG/ML SUSPENSION RECONSTITUTED ORAL |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUCONAZOLE 50MG TABLET (30 CT) |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUCONAZOLE INJECTION 200MG 6 X 200/250ML CTR |
1 |
Preferred Generic |
$6.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUCONAZOLE INJECTION 2MG 6 X 100ML PKG |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUCONAZOLE-DEXT 200MG/100ML |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUDROCORTISONE ACETATE 0.1MG TABLET (100 CT) |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUNISOLIDE 29MCG AEROSOL SPRAY |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUOCINOLONE 0.01% CREAM |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUOCINOLONE 0.01% SOLUTION |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUOCINOLONE 0.025% CREAM |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUOCINOLONE 0.025% OINTMENT |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUOCINONIDE 0.05% CREAM |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUOCINONIDE 0.05% GEL |
1 |
Preferred Generic |
$6.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOCINONIDE 0.05% OINTMENT |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUOCINONIDE 0.05% SOLUTION |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUOCINONIDE-E 0.05% CREAM |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUOROMETHOLONE 0.1% DROPS |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUOROPLEX 1% CREAM |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | None |
FLUOROURACIL 2% SOLUTION NON-ORAL |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUOROURACIL 5% SOLUTION NON-ORAL |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUOROURACIL 50MG/ML VIAL |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUOROURACIL CREA 5% |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUOXETINE 20MG CAPSULES (100 CT) |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUOXETINE 20MG/5ML TUBEX |
1 |
Preferred Generic |
$6.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOXETINE 40MG CAPSULE (30 CT) |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUOXETINE CAPSULES 10MG (100 CT) |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUOXETINE HCL 10MG TABLET (2000 CT) |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUOXYMESTERONE 10MG TABLET |
1 |
Preferred Generic |
$6.00 | N/A | P |
FLUPHENAZINE 10MG TABLET |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUPHENAZINE 1MG TABLET |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUPHENAZINE 2.5MG TABLET |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUPHENAZINE 2.5MG/ML VIAL |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUPHENAZINE 5MG TABLET |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUPHENAZINE 5MG/ML CONC |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUPHENAZINE DECANOATE INJECTION USP 25MG 1 X 5ML VIAL |
1 |
Preferred Generic |
$6.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUPHENAZINE HCL 2.5MG/5ML ELIXIR |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLURBIPROFEN 0.03% EYE DROP |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLURBIPROFEN 100MG TABLET (500 CT) |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLURBIPROFEN 50MG TABLET |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUTAMIDE 125MG CAPSULE |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUTICASONE PROPIONATE 0.005% OINTMENT |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUTICASONE PROPIONATE 0.05% CREAM |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUTICASONE PROPIONATE 50MCG SPRAY SUSPENSION |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUVOXAMINE MALEATE 100MG TABLET |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUVOXAMINE MALEATE 25MG TABLET (100 CT) |
1 |
Preferred Generic |
$6.00 | N/A | None |
FLUVOXAMINE MALEATE 50MG TABLET |
1 |
Preferred Generic |
$6.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FML FORTE 0.25% EYE DROPS |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | None |
FML S.O.P. 0.1% OINTMENT |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | None |
FOMEPIZOLE INJECTION 1GM/ML |
4 |
Specialty-Generic and Brand |
33% | N/A | P |
FORADIL AEROLIZER 12 MCG CAP |
2 |
Preferred Brand |
$31.00 | N/A | Q:60 /30Days |
FORTEO 750MCG/3ML PEN |
4 |
Specialty-Generic and Brand |
33% | N/A | P Q:3 /28Days |
FORTEO INJECTION |
4 |
Specialty-Generic and Brand |
33% | N/A | P Q:3 /28Days |
FORTICAL 200 U/DOSE AEROSOL SPRAY W/PUMP |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | None |
FOSAMAX 70MG ORAL SOLUTION |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | Q:300 /28Days |
FOSAMAX PLUS D 70MG-5600 TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | S Q:4 /30Days |
FOSAMAX PLUS D 70MG/2800 IU 20 BLPK |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | S Q:4 /30Days |
FOSCARNET 24MG/ML INFUS BTTL |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FOSINOPRIL SODIUM 10MG TABLET (90 CT) |
1 |
Preferred Generic |
$6.00 | N/A | None |
FOSINOPRIL SODIUM 20MG TABLET |
1 |
Preferred Generic |
$6.00 | N/A | None |
FOSINOPRIL SODIUM 40MG TABLET |
1 |
Preferred Generic |
$6.00 | N/A | None |
FOSINOPRIL-HYDROCHLOROTHIAZIDE 10-12.5MG TABLET (100 CT) |
1 |
Preferred Generic |
$6.00 | N/A | None |
FOSINOPRIL-HYDROCHLOROTHIAZIDE 20-12.5MG TABLET (100 CT) |
1 |
Preferred Generic |
$6.00 | N/A | None |
FOSRENOL 1000MG TABLET CHEW |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | S Q:90 /30Days |
FOSRENOL 250MG TABLET CHEW |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | S Q:90 /30Days |
FOSRENOL 500MG TABLET CHEW |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | S Q:90 /30Days |
FOSRENOL 750MG TABLET CHEW |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | S Q:90 /30Days |
FRAGMIN 25000UNITS/ML VIAL 3.8ML x 1 |
4 |
Specialty-Generic and Brand |
33% | N/A | P |
FRAGMIN 2500UNITS SYRINGE 0.2ML x 10 |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FRAGMIN 5000UNITS SYRINGE 0.2ML x 10 |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | P |
FRAGMIN INJECTION 10000UNITS 1 X 10 SYR |
4 |
Specialty-Generic and Brand |
33% | N/A | P |
FRAGMIN INJECTION 7500UNT/ML |
4 |
Specialty-Generic and Brand |
33% | N/A | P |
FROVA 2.5MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | P Q:12 /30Days |
FURADANTIN 25MG/5ML SUSPENSION ORAL |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$61.00 | N/A | None |
FUROSEMIDE 10MG/ML SOLUTION |
1 |
Preferred Generic |
$6.00 | N/A | None |
FUROSEMIDE 20MG TABLET (1000 CT) |
1 |
Preferred Generic |
$6.00 | N/A | None |
FUROSEMIDE 40MG TABLET |
1 |
Preferred Generic |
$6.00 | N/A | None |
FUROSEMIDE 40MG/5ML TUBEX |
1 |
Preferred Generic |
$6.00 | N/A | None |
FUROSEMIDE 80MG TABLET (500 CT) |
1 |
Preferred Generic |
$6.00 | N/A | None |
FUROSEMIDE INJECTION USP 10MG 25 X 4ML VIALSD |
1 |
Preferred Generic |
$6.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FUZEON CONVENIENCE KIT |
4 |
Specialty-Generic and Brand |
33% | N/A | Q:60 /30Days |