2011 Medicare Part D Plan Formulary Information |
Blue Shield 65 Plus (HMO) (H0504-015-0)
Benefit Details
|
The Blue Shield 65 Plus (HMO) (H0504-015-0) Formulary Drugs Starting with the Letter F in Los Angeles County, CA: CMS MA Region 24 which includes: CA
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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 |
6 |
Tier 6 |
33% | 33% | P |
FACTIVE 320MG TABLET |
4 |
Tier 4 |
$80.00 | $160.00 | None |
FAMCICLOVIR 125MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
FAMCICLOVIR 250MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
FAMCICLOVIR 500MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
FAMOTIDINE 20MG PIGGYBACK |
5 |
Tier 5 |
33% | 33% | P |
FAMOTIDINE 20MG TABLET (500 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FAMOTIDINE 40MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FAMOTIDINE FOR ORAL SUSPENSION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FAMOTIDINE INJECTION 10MG 25 X 2ML VIALSD |
5 |
Tier 5 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FARESTON 60MG TABLET |
3 |
Tier 3 |
$40.00 | $80.00 | None |
FASLODEX INJECTION |
5 |
Tier 5 |
33% | 33% | P |
FAZACLO TABLETS ORALLY DISINTEGRATING |
4 |
Tier 4 |
$80.00 | $160.00 | None |
FELBATOL 400MG TABLET |
4 |
Tier 4 |
$80.00 | $160.00 | None |
FELBATOL 600MG TABLET |
4 |
Tier 4 |
$80.00 | $160.00 | None |
FELBATOL 600MG/5ML SUSP |
4 |
Tier 4 |
$80.00 | $160.00 | None |
FELODIPINE ER 2.5MG TABLET 90 TABLET BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FELODIPINE TABLET ER 10MG (1000 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FELODIPINE TABLET ER 5MG (1000 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FEMARA 2.5MG TABLET |
3 |
Tier 3 |
$40.00 | $80.00 | S |
FEMHRT 0.5MG/2.5MCG TABLET |
4 |
Tier 4 |
$80.00 | $160.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FEMHRT 1/5 TABLET |
4 |
Tier 4 |
$80.00 | $160.00 | None |
FEMRING 0.05MG VAGINAL RING |
4 |
Tier 4 |
$80.00 | $160.00 | Q:1 /84Days |
FEMRING 0.10MG VAGINAL RING |
4 |
Tier 4 |
$80.00 | $160.00 | Q:1 /84Days |
FEMTRACE 0.45MG TABLET |
4 |
Tier 4 |
$80.00 | $160.00 | None |
FEMTRACE 0.9MG TABLET |
4 |
Tier 4 |
$80.00 | $160.00 | None |
FEMTRACE 1.8MG TABLET |
4 |
Tier 4 |
$80.00 | $160.00 | None |
FENOFIBRATE 134MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FENOFIBRATE 160MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FENOFIBRATE 200MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FENOFIBRATE 54MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FENOFIBRATE 67MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENOPROFEN 600MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FENTANYL 100MCG/HR PATCH TRANSDERMAL 72 HOURS |
2 |
Tier 2 |
$10.00 | $20.00 | Q:20 /30Days |
FENTANYL 12MCG/HR PATCH TRANSDERMAL 72 HOURS |
2 |
Tier 2 |
$10.00 | $20.00 | Q:20 /30Days |
FENTANYL CITRATE INJECTION 50MCG 10 X 2ML CTG |
5 |
Tier 5 |
33% | 33% | P |
FENTANYL CITRATE LOZENGES |
2 |
Tier 2 |
$10.00 | $20.00 | P Q:120 /30Days |
FENTANYL CITRATE LOZENGES |
2 |
Tier 2 |
$10.00 | $20.00 | P Q:120 /30Days |
FENTANYL CITRATE LOZENGES |
2 |
Tier 2 |
$10.00 | $20.00 | P Q:120 /30Days |
FENTANYL CITRATE LOZENGES |
2 |
Tier 2 |
$10.00 | $20.00 | P Q:120 /30Days |
FENTANYL CITRATE LOZENGES |
2 |
Tier 2 |
$10.00 | $20.00 | P Q:120 /30Days |
FENTANYL CITRATE OTFC 200 MCG |
2 |
Tier 2 |
$10.00 | $20.00 | P Q:120 /30Days |
FENTANYL TRANSDERMAL SYSTEM 25MCG 5 SYSTEMS CRTN |
2 |
Tier 2 |
$10.00 | $20.00 | Q:20 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENTANYL TRANSDERMAL SYSTEM 50MCG 5 SYSTEMS CRTN |
2 |
Tier 2 |
$10.00 | $20.00 | Q:20 /30Days |
FENTANYL TRANSDERMAL SYSTEM 75MCG 5 SYSTEMS CRTN |
2 |
Tier 2 |
$10.00 | $20.00 | Q:20 /30Days |
FEXOFENADINE HCL 180MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | Q:30 /30Days |
FEXOFENADINE HCL 30MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | Q:30 /30Days |
FEXOFENADINE HCL 60MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | Q:30 /30Days |
FINACEA 15% GEL |
4 |
Tier 4 |
$80.00 | $160.00 | None |
FINASTERIDE 5MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLAVOXATE HCL 100MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
FLECAINIDE ACETATE 100 MG TAB #60 EA |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLECAINIDE ACETATE 150 MG TAB 360 EA |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLECAINIDE ACETATE 50MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLOVENT DISKUS /BLIST AEPB |
3 |
Tier 3 |
$40.00 | $80.00 | Q:60 /30Days |
FLOVENT DISKUS /BLIST AEPB |
3 |
Tier 3 |
$40.00 | $80.00 | Q:240 /30Days |
FLOVENT DISKUS POWDER 50MCG 60 CTR |
3 |
Tier 3 |
$40.00 | $80.00 | Q:60 /30Days |
FLOVENT HFA 110MCG INHALATION AEROSOL |
3 |
Tier 3 |
$40.00 | $80.00 | Q:24 /30Days |
FLOVENT HFA 220MCG INHALATION AEROSOL |
3 |
Tier 3 |
$40.00 | $80.00 | Q:24 /30Days |
FLOVENT HFA 44MCG INHALATION AEROSOL |
3 |
Tier 3 |
$40.00 | $80.00 | Q:22 /30Days |
FLUCONAZOLE 200MG TABLET (30 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUCONAZOLE 50MG TABLET (30 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUCONAZOLE INJECTION 200MG 6 X 200/250ML CTR |
5 |
Tier 5 |
33% | 33% | P |
FLUCONAZOLE ORAL SUSPENSION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUCONAZOLE ORAL SUSPENSION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUCONAZOLE TABLETS |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUCONAZOLE TABLETS |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUDARABINE 50MG VIAL |
5 |
Tier 5 |
33% | 33% | P |
FLUDROCORTISONE ACETATE 0.1MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL |
1 |
Tier 1 |
$5.00 | $10.00 | Q:50 /30Days |
FLUOCINOLONE 0.01% CREAM |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUOCINOLONE 0.01% SOLUTION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUOCINOLONE 0.025% CREAM |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUOCINOLONE 0.025% OINTMENT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUOCINONIDE 0.05% GEL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUOCINONIDE 0.05% OINTMENT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOCINONIDE 0.05% SOLUTION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUOCINONIDE EMOLLIENT 0.05% CREAM |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUOROMETHOLONE 0.1% DROPS |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUOROPLEX 1% CREAM |
3 |
Tier 3 |
$40.00 | $80.00 | None |
FLUOROURACIL 2% SOLUTION NON-ORAL |
2 |
Tier 2 |
$10.00 | $20.00 | None |
FLUOROURACIL 5% SOLUTION NON-ORAL |
2 |
Tier 2 |
$10.00 | $20.00 | None |
FLUOROURACIL CREA 5% |
2 |
Tier 2 |
$10.00 | $20.00 | None |
FLUOROURACIL INJECTION 50MG/ML 10 X 10 ML VIALGL |
5 |
Tier 5 |
33% | 33% | None |
FLUOXETINE 20 MG ORAL CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUOXETINE 20MG/5ML TUBEX |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUOXETINE 40MG CAPSULE (30 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOXETINE CAPSULES 10MG (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUOXETINE DR 90 MG CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | Q:4 /28Days |
FLUOXETINE HCL 20MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUOXETINE HYDROCHLORIDE TABLETS 10MG 100 BOT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUOXYMESTERONE 10MG TABLET |
2 |
Tier 2 |
$10.00 | $20.00 | None |
FLUPHENAZINE 10MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUPHENAZINE 1MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUPHENAZINE 2.5MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUPHENAZINE 2.5MG/ML VIAL |
5 |
Tier 5 |
33% | 33% | P |
FLUPHENAZINE 5MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUPHENAZINE 5MG/ML CONC |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUPHENAZINE DECANOATE INJECTION USP 25MG 1 X 5ML VIAL |
5 |
Tier 5 |
33% | 33% | P |
FLUPHENAZINE HCL 2.5MG/5ML ELIXIR |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLURBIPROFEN 0.03% EYE DROP |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLURBIPROFEN 100MG TABLET (500 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLURBIPROFEN 50MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUTAMIDE 125MG CAPSULE |
2 |
Tier 2 |
$10.00 | $20.00 | None |
FLUTICASONE PROPIONATE 0.005% OINTMENT |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUTICASONE PROPIONATE 0.05% CREAM |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUTICASONE PROPIONATE 50MCG SPRAY SUSPENSION |
1 |
Tier 1 |
$5.00 | $10.00 | Q:16 /30Days |
FLUVOXAMINE MALEATE 100MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUVOXAMINE MALEATE 25MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUVOXAMINE MALEATE 50MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FML FORTE 0.25% EYE DROPS |
3 |
Tier 3 |
$40.00 | $80.00 | None |
FML LIQUIFILM 0.1% EYE DROP |
3 |
Tier 3 |
$40.00 | $80.00 | None |
FML S.O.P. 0.1% OINTMENT |
3 |
Tier 3 |
$40.00 | $80.00 | None |
FOCALIN XR 10MG CAPSULE |
4 |
Tier 4 |
$80.00 | $160.00 | Q:30 /30Days |
FOCALIN XR 15MG CAPSULE |
4 |
Tier 4 |
$80.00 | $160.00 | Q:30 /30Days |
FOCALIN XR 20MG CAPSULE |
4 |
Tier 4 |
$80.00 | $160.00 | Q:60 /30Days |
FOCALIN XR 5MG CAPSULE |
4 |
Tier 4 |
$80.00 | $160.00 | Q:30 /30Days |
FOCALIN XR CAPSULES |
4 |
Tier 4 |
$80.00 | $160.00 | Q:30 /30Days |
FORADIL AEROLIZER 12 MCG CAP |
3 |
Tier 3 |
$40.00 | $80.00 | None |
FORTAZ/ISO-OSMOT 2GM/50ML |
5 |
Tier 5 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FORTAZ/ISO-OSMOTIC 1GM/50ML |
5 |
Tier 5 |
33% | 33% | P |
FORTEO INJECTION |
5 |
Tier 5 |
33% | 33% | P |
FORTICAL 200 U/DOSE AEROSOL SPRAY W/PUMP |
3 |
Tier 3 |
$40.00 | $80.00 | None |
FOSAMAX 70MG ORAL SOLUTION |
4 |
Tier 4 |
$80.00 | $160.00 | Q:300 /28Days |
FOSAMAX PLUS D 70MG-5600 TABLET |
4 |
Tier 4 |
$80.00 | $160.00 | Q:4 /28Days |
FOSAMAX PLUS D 70MG/2800 IU |
3 |
Tier 3 |
$40.00 | $80.00 | Q:4 /28Days |
FOSCARNET 24MG/ML INFUS BTTL |
5 |
Tier 5 |
33% | 33% | P |
FOSINOPRIL SODIUM 10MG TABLET (90 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | Q:30 /30Days |
FOSINOPRIL SODIUM 20MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | Q:30 /30Days |
FOSINOPRIL SODIUM 40MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | Q:60 /30Days |
FOSINOPRIL-HYDROCHLOROTHIAZIDE 10-12.5MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FOSINOPRIL-HYDROCHLOROTHIAZIDE 20-12.5MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | Q:120 /30Days |
FOSPHEN SDV 50MGPE/ML 2MLGEN10 50MG PE/ML VIAL |
5 |
Tier 5 |
33% | 33% | P |
FOSRENOL 1000MG TABLET CHEW |
4 |
Tier 4 |
$80.00 | $160.00 | None |
FOSRENOL 500MG TABLET CHEW |
4 |
Tier 4 |
$80.00 | $160.00 | None |
FOSRENOL 750MG TABLET CHEW |
4 |
Tier 4 |
$80.00 | $160.00 | None |
FRAGMIN 25000UNITS/ML VIAL 3.8ML x 1 |
6 |
Tier 6 |
33% | 33% | Q:8 /60Days |
FRAGMIN 2500UNITS SYRINGE 0.2ML x 10 |
5 |
Tier 5 |
33% | 33% | Q:6 /60Days |
FRAGMIN 5000UNITS SYRINGE 0.2ML x 10 |
5 |
Tier 5 |
33% | 33% | Q:6 /60Days |
FRAGMIN INJECTION 10000UNITS 1 X 10 SYR |
6 |
Tier 6 |
33% | 33% | Q:14 /60Days |
FRAGMIN INJECTION 7500UNT/ML |
6 |
Tier 6 |
33% | 33% | Q:8 /60Days |
FREAMINE III INJECTION 8.5% |
5 |
Tier 5 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FROVA 2.5MG TABLET |
4 |
Tier 4 |
$80.00 | $160.00 | Q:27 /30Days |
FURADANTIN 25 MG/5 ML SUSP 230 ML |
3 |
Tier 3 |
$40.00 | $80.00 | None |
FUROSEMIDE 10MG/ML SOLUTION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FUROSEMIDE 20MG TABLET (1000 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FUROSEMIDE 40MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FUROSEMIDE 40MG/5ML TUBEX |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FUROSEMIDE 80MG TABLET (500 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FUROSEMIDE INJECTION USP 10MG 25 X 4ML VIALSD |
5 |
Tier 5 |
33% | 33% | P |
FUZEON CONVENIENCE KIT |
6 |
Tier 6 |
33% | 33% | None |