2011 Medicare Part D Plan Formulary Information |
FHCP Medvantage Rx (HMO) (H1035-006-0)
Benefit Details
|
The FHCP Medvantage Rx (HMO) (H1035-006-0) Formulary Drugs Starting with the Letter C in Flagler County, FL: CMS MA Region 9 which includes: FL
|
Drugs Starting with Letter C
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
CABERGOLINE 0.5 MG TABLET |
2 |
Tier 2 |
20% | 20% | None |
CALCIPOTRIENE TOPICAL SOLUTION |
2 |
Tier 2 |
20% | 20% | Q:60 /3Days |
CALCITRIOL 0.25MCG CAPSULE |
2 |
Tier 2 |
20% | 20% | None |
CALCITRIOL 0.5MCG CAPSULE |
2 |
Tier 2 |
20% | 20% | None |
CALCITRIOL 1MCG/ML SOLUTION ORAL |
2 |
Tier 2 |
20% | 20% | None |
CALCIUM ACETATE CAPSULE 667 MG |
2 |
Tier 2 |
20% | 20% | None |
CALCIUM CHLORIDE 0.0014 MEQ/ML / POTASSIUM CHLORIDE 0.004 MEQ/ML / SODIUM CHLORIDE 0.103 MEQ/ML / SO |
5 |
Tier 5 |
25% | 25% | None |
CAMILA 0.35MG TABLET |
2 |
Tier 2 |
20% | 20% | None |
CAMPATH 30MG/ML VIAL |
5 |
Tier 5 |
25% | 25% | P |
CAMPRAL 333MG DOSE PAK |
4 |
Tier 4 |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX |
3 |
Tier 3 |
25% | 25% | Q:30 /3Days |
CANCIDAS IV 50MG VIAL |
5 |
Tier 5 |
25% | 25% | None |
CAPREOMYCIN 500 MG/ML INJECTABLE SOLUTION [CAPASTAT] |
5 |
Tier 5 |
25% | 25% | None |
CAPTOPRIL 100MG TABLET |
1 |
Tier 1 |
20% | 20% | None |
CAPTOPRIL 12.5MG TABLET |
1 |
Tier 1 |
20% | 20% | None |
CAPTOPRIL 25MG TABLET |
1 |
Tier 1 |
20% | 20% | None |
CAPTOPRIL 50MG TABLET |
1 |
Tier 1 |
20% | 20% | None |
CAPTOPRIL/HCTZ 25/15 TABLET |
2 |
Tier 2 |
20% | 20% | None |
CAPTOPRIL/HCTZ 50/15 TABLET |
2 |
Tier 2 |
20% | 20% | None |
CARAFATE SUS 1GM/10ML |
3 |
Tier 3 |
25% | 25% | None |
CARBAMAZEPINE ORAL SUSPENSION 200 MG |
2 |
Tier 2 |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARBAMAZEPINE TABLET CHEWABLE 100MG (100 CT) |
2 |
Tier 2 |
20% | 20% | None |
CARBAMAZEPINE TABLET USP 200MG (1000 CT) |
2 |
Tier 2 |
20% | 20% | None |
CARBIDOPA-LEVODOPA 25MG-100MG TABLET SA |
2 |
Tier 2 |
20% | 20% | None |
CARBIDOPA-LEVODOPA 50MG-200MG TABLET SA |
2 |
Tier 2 |
20% | 20% | None |
CARBIDOPA/LEVO 10/100 TABLET |
2 |
Tier 2 |
20% | 20% | None |
CARBIDOPA/LEVO 25/100 TABLET |
2 |
Tier 2 |
20% | 20% | None |
CARBIDOPA/LEVO 25/250 TABLET |
2 |
Tier 2 |
20% | 20% | None |
CARBOPLATIN INJECTION |
5 |
Tier 5 |
25% | 25% | None |
CARISOPRODOL TABLET USP 350MG (100 CT) |
2 |
Tier 2 |
20% | 20% | None |
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT |
2 |
Tier 2 |
20% | 20% | Q:10 /3Days |
CARVEDILOL 12.5MG TABLET (100 CT) |
1 |
Tier 1 |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARVEDILOL 25MG TABLET (500 CT) |
1 |
Tier 1 |
20% | 20% | None |
CARVEDILOL 3.125MG TABLET (100 CT) |
1 |
Tier 1 |
20% | 20% | None |
CARVEDILOL 6.25MG TABLET (500 CT) |
1 |
Tier 1 |
20% | 20% | None |
CEENU 10MG CAPSULE |
3 |
Tier 3 |
25% | 25% | None |
CEENU 40MG CAPSULE |
3 |
Tier 3 |
25% | 25% | None |
CEFACLOR 250MG/5ML ORAL SUSP |
2 |
Tier 2 |
20% | 20% | Q:150 /3Days |
CEFACLOR 375MG/5ML ORAL SUSP |
2 |
Tier 2 |
20% | 20% | Q:100 /3Days |
CEFACLOR CAPSULES |
2 |
Tier 2 |
20% | 20% | None |
CEFACLOR CAPSULES |
2 |
Tier 2 |
20% | 20% | None |
CEFACLOR POWDER FOR ORAL SUSPENSION USP 125MG 75ML BOT |
2 |
Tier 2 |
20% | 20% | Q:150 /3Days |
CEFADROXIL 500MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Tier 2 |
20% | 20% | Q:100 /3Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFADROXIL FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
2 |
Tier 2 |
20% | 20% | Q:100 /3Days |
CEFAZOLIN 1 GM VIAL |
5 |
Tier 5 |
25% | 25% | None |
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Tier 2 |
20% | 20% | None |
CEFDINIR CAPSULES 300MG (60 CT) |
2 |
Tier 2 |
20% | 20% | None |
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT) |
2 |
Tier 2 |
20% | 20% | Q:100 /3Days |
CEFPROZIL 250MG TABLET (100 CT) |
2 |
Tier 2 |
20% | 20% | None |
CEFPROZIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL |
2 |
Tier 2 |
20% | 20% | Q:100 /3Days |
CEFPROZIL FOR ORAL SUSPENSION 125MG/5ML 75ML BOT |
2 |
Tier 2 |
20% | 20% | Q:100 /3Days |
CEFPROZIL TABLETS 500MG 100 BOT |
2 |
Tier 2 |
20% | 20% | None |
CEFTRIAXONE FOR INJECTION 250MG BOX OF 10 VIALGL |
5 |
Tier 5 |
25% | 25% | None |
CEFTRIAXONE FOR INJECTION 500MG BOX OF 10 VIALGL |
5 |
Tier 5 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFUROXIME 250MG TABLET |
2 |
Tier 2 |
20% | 20% | None |
CEFUROXIME AXETIL 500MG TABLET (20 CT) |
2 |
Tier 2 |
20% | 20% | None |
CEFUROXIME FOR INJECTION |
5 |
Tier 5 |
25% | 25% | None |
CELLCEPT 200MG/ML ORAL SUSP |
5 |
Tier 5 |
25% | 25% | None |
CELONTIN 300MG KAPSEAL |
4 |
Tier 4 |
50% | 50% | None |
CEPHALEXIN 250MG CAPSULE |
2 |
Tier 2 |
20% | 20% | None |
CEPHALEXIN 250MG/5ML ORAL SUSP |
2 |
Tier 2 |
20% | 20% | Q:200 /3Days |
CEPHALEXIN CAPSULES 500MG (500 CT) |
2 |
Tier 2 |
20% | 20% | None |
CEPHALEXIN POWDER FOR SUSPENSION ORAL USP 125MG 200ML BOT |
2 |
Tier 2 |
20% | 20% | Q:200 /3Days |
CEREDASE 80UNITS/ML VIAL |
6 |
Tier 6 |
29% | 29% | P |
CEREZYME INJ 200UNIT |
6 |
Tier 6 |
29% | 29% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHANTIX 0.5MG TABLET |
4 |
Tier 4 |
50% | 50% | P |
CHANTIX 1MG TABLET |
4 |
Tier 4 |
50% | 50% | P |
CHEMET 100MG CAPSULE |
3 |
Tier 3 |
25% | 25% | None |
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH |
2 |
Tier 2 |
20% | 20% | Q:473 /3Days |
CHLOROQUINE PH 500MG TABLET |
2 |
Tier 2 |
20% | 20% | None |
CHLOROTHIAZIDE 250MG TABLET |
2 |
Tier 2 |
20% | 20% | None |
CHLOROTHIAZIDE 500MG TABLET |
2 |
Tier 2 |
20% | 20% | None |
CHLORPROMAZINE 100MG TABLET |
2 |
Tier 2 |
20% | 20% | None |
CHLORPROMAZINE 10MG TABLET |
2 |
Tier 2 |
20% | 20% | None |
CHLORPROMAZINE 25MG TABLET |
2 |
Tier 2 |
20% | 20% | None |
CHLORPROMAZINE 25MG/ML AMP |
5 |
Tier 5 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLORPROMAZINE 50MG TABLET |
2 |
Tier 2 |
20% | 20% | None |
CHLORPROMAZINE HCL 200MG TABLET |
2 |
Tier 2 |
20% | 20% | None |
CHLORPROPAMIDE 100MG TABLET |
2 |
Tier 2 |
20% | 20% | None |
CHLORPROPAMIDE 250MG TABLET (1000 CT) |
2 |
Tier 2 |
20% | 20% | None |
CHLORTHALIDONE 25MG TABLET (100 CT) |
1 |
Tier 1 |
20% | 20% | None |
CHLORTHALIDONE 50MG TABLET (1000 CT) |
1 |
Tier 1 |
20% | 20% | None |
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION |
2 |
Tier 2 |
20% | 20% | Q:231 /3Days |
CICLOPIROX 0.77% CREAM |
2 |
Tier 2 |
20% | 20% | Q:120 /3Days |
CICLOPIROX 0.77% TOPICAL SUSPENSION |
2 |
Tier 2 |
20% | 20% | Q:60 /3Days |
CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6ML BOT |
2 |
Tier 2 |
20% | 20% | Q:6 /3Days |
CICLOPIROX GEL |
2 |
Tier 2 |
20% | 20% | Q:120 /3Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CILOSTAZOL 50MG TABLET (60 CT) |
2 |
Tier 2 |
20% | 20% | None |
CILOSTAZOL TABLET 100MG (60 CT) |
2 |
Tier 2 |
20% | 20% | None |
CILOXAN 0.3% OINTMENT |
3 |
Tier 3 |
25% | 25% | Q:3 /3Days |
CIMETIDINE HCL 300MG/5ML SOL |
2 |
Tier 2 |
20% | 20% | None |
CIPRO IV INFUSION 200MG 100ML BAG |
5 |
Tier 5 |
25% | 25% | None |
CIPRODEX OTIC SUSPENSION |
3 |
Tier 3 |
25% | 25% | Q:7 /3Days |
CIPROFLOXACIN 250MG TABLET (100 CT) |
2 |
Tier 2 |
20% | 20% | None |
CIPROFLOXACIN 500MG TABLET |
2 |
Tier 2 |
20% | 20% | None |
CIPROFLOXACIN HCL 0.3% DROPS |
2 |
Tier 2 |
20% | 20% | Q:2 /3Days |
CIPROFLOXACIN TABLETS 750MG 100 BOT |
2 |
Tier 2 |
20% | 20% | None |
CISPLATIN 1 MG/ML INJECTABLE SOLUTION |
5 |
Tier 5 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CITALOPRAM HBR 20 MG TABLET |
1 |
Tier 1 |
20% | 20% | None |
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL |
1 |
Tier 1 |
20% | 20% | None |
CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT |
1 |
Tier 1 |
20% | 20% | None |
CITOLOPRAM HBR 10MG TABLET (100 CT) |
1 |
Tier 1 |
20% | 20% | None |
CLADRIBINE 1MG/ML VIAL |
5 |
Tier 5 |
25% | 25% | None |
CLARITHROMYCIN 250MG TABLET |
2 |
Tier 2 |
20% | 20% | None |
CLARITHROMYCIN 500MG TABLET |
2 |
Tier 2 |
20% | 20% | None |
CLARITHROMYCIN FOR ORAL SUSPENSION |
2 |
Tier 2 |
20% | 20% | Q:100 /3Days |
CLARITHROMYCIN FOR ORAL SUSPENSION |
2 |
Tier 2 |
20% | 20% | Q:100 /3Days |
CLEMASTINE FUMARATE SYRUP |
2 |
Tier 2 |
20% | 20% | Q:120 /3Days |
CLEOCIN PHOS 150MG/ML VIAL |
5 |
Tier 5 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLINDAMYCIN 150MG/ML ADDVAN |
5 |
Tier 5 |
25% | 25% | None |
CLINDAMYCIN HCL 150MG CAPSULE |
2 |
Tier 2 |
20% | 20% | None |
CLINDAMYCIN PHOSPHATE VAGINAL CREAM |
2 |
Tier 2 |
20% | 20% | None |
CLOBETASOL 0.05% OINTMENT |
2 |
Tier 2 |
20% | 20% | Q:120 /3Days |
CLOBETASOL 0.05% SOLUTION |
2 |
Tier 2 |
20% | 20% | Q:60 /3Days |
CLOBETASOL E 0.05% CREAM |
2 |
Tier 2 |
20% | 20% | Q:120 /3Days |
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE |
2 |
Tier 2 |
20% | 20% | Q:120 /3Days |
CLOMIPRAMINE HCL 25MG CAPSULE |
2 |
Tier 2 |
20% | 20% | None |
CLOMIPRAMINE HCL 50MG CAPSULE |
2 |
Tier 2 |
20% | 20% | None |
CLOMIPRAMINE HCL 75MG CAPSULE |
2 |
Tier 2 |
20% | 20% | None |
CLONIDINE HCL 0.2MG TABLET (500 CT) |
1 |
Tier 1 |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLONIDINE HCL TABLET 0.1MG (500 CT) |
1 |
Tier 1 |
20% | 20% | None |
CLONIDINE HCL TABLET 0.3MG (100 CT) |
2 |
Tier 2 |
20% | 20% | None |
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION |
2 |
Tier 2 |
20% | 20% | Q:60 /3Days |
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CREAM USP .5MG-10GM 45GM TUBE |
2 |
Tier 2 |
20% | 20% | Q:120 /3Days |
CLOZAPINE 100 MG DISINTEGRATING TABLET [FAZACLO] |
4 |
Tier 4 |
50% | 50% | None |
CLOZAPINE 100 MG ORAL TABLET |
2 |
Tier 2 |
20% | 20% | None |
CLOZAPINE 25 MG DISINTEGRATING TABLET [FAZACLO] |
4 |
Tier 4 |
50% | 50% | None |
CLOZAPINE 25MG TABLET (100 CT) |
2 |
Tier 2 |
20% | 20% | None |
CLOZAPINE 50MG TABLET (500 CT) |
2 |
Tier 2 |
20% | 20% | None |
COLCHICINE 0.6 MG ORAL TABLET [COLCRYS] |
4 |
Tier 4 |
50% | 50% | Q:60 /30Days |
COLISTIMETHATE 150MG VIAL |
5 |
Tier 5 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE |
4 |
Tier 4 |
50% | 50% | Q:30 /3Days |
COLOCORT 100MG ENEMA |
2 |
Tier 2 |
20% | 20% | None |
COMBIVIR TABLETS |
3 |
Tier 3 |
25% | 25% | None |
COMTAN 200MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
COMVAX VACCINE VIAL |
5 |
Tier 5 |
25% | 25% | None |
CONCERTA ER TABLETS 18MG 100 TABLETS BOT |
4 |
Tier 4 |
50% | 50% | S Q:31 /31Days |
CONCERTA ER TABLETS 27MG 100 TABLETS BOT |
4 |
Tier 4 |
50% | 50% | S Q:31 /31Days |
CONCERTA ER TABLETS 36MG 100 TABLETS BOT |
4 |
Tier 4 |
50% | 50% | S Q:31 /31Days |
CONCERTA ER TABLETS 54MG 100 BOT |
4 |
Tier 4 |
50% | 50% | S Q:31 /31Days |
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN |
6 |
Tier 6 |
29% | 29% | None |
CORDRAN TAPE 4MCG/SQCM 1 X 80 X 3 CTR |
3 |
Tier 3 |
25% | 25% | Q:1 /3Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
COREG CR 10MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Tier 3 |
25% | 25% | None |
COREG CR 20MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Tier 3 |
25% | 25% | None |
COREG CR 40MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Tier 3 |
25% | 25% | None |
COREG CR 80MG CAPSULE MULTIPHASIC RELEASE 24 HR |
3 |
Tier 3 |
25% | 25% | None |
CORTISONE ACETATE 25MG TABLET (100 CT) |
2 |
Tier 2 |
20% | 20% | None |
CORTISPORIN CRE 0.5% |
3 |
Tier 3 |
25% | 25% | Q:7 /3Days |
CORTISPORIN OINTMENT |
3 |
Tier 3 |
25% | 25% | Q:30 /3Days |
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT |
3 |
Tier 3 |
25% | 25% | None |
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT |
3 |
Tier 3 |
25% | 25% | None |
CRESTOR 10MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
CRESTOR 20MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CRESTOR 40MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
CRESTOR 5MG TABLET |
3 |
Tier 3 |
25% | 25% | None |
CRIXIVAN 100MG CAPSULE |
3 |
Tier 3 |
25% | 25% | None |
CRIXIVAN 200MG CAPSULE |
3 |
Tier 3 |
25% | 25% | None |
CRIXIVAN 333MG CAPSULE |
3 |
Tier 3 |
25% | 25% | None |
CRIXIVAN 400MG CAPSULE (120 CT) |
3 |
Tier 3 |
25% | 25% | None |
CROMOLYN NEBULIZER SOLUTION |
2 |
Tier 2 |
20% | 20% | P |
CROMOLYN SODIUM 4% 40MG 10ML BOT |
2 |
Tier 2 |
20% | 20% | Q:10 /3Days |
CUBICIN 500MG VIAL |
5 |
Tier 5 |
25% | 25% | None |
CUPRIMINE CAPSULES 250MG (100 CT) |
3 |
Tier 3 |
25% | 25% | None |
CUTIVATE LOTION 0.05% |
4 |
Tier 4 |
50% | 50% | Q:60 /3Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT) |
2 |
Tier 2 |
20% | 20% | None |
CYCLOPHOSPHAMIDE 50MG TABLET |
2 |
Tier 2 |
20% | 20% | None |
CYCLOSPORINE 100MG CAPSULE |
5 |
Tier 5 |
25% | 25% | None |
CYCLOSPORINE 25MG CAPSULE |
5 |
Tier 5 |
25% | 25% | None |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT |
5 |
Tier 5 |
25% | 25% | None |
CYKLOKAPRON 100MG/ML AMPUL |
5 |
Tier 5 |
25% | 25% | None |
CYMBALTA 20MG CAPSULE |
4 |
Tier 4 |
50% | 50% | None |
CYMBALTA 60MG CAPSULE |
4 |
Tier 4 |
50% | 50% | None |
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT) |
4 |
Tier 4 |
50% | 50% | None |
CYPROHEPTADINE HCL 4 MG |
2 |
Tier 2 |
20% | 20% | None |
CYSTADANE POWDER FOR ORAL SOLUTION 180GM |
4 |
Tier 4 |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYSTAGON 150MG CAPSULE |
2 |
Tier 2 |
20% | 20% | None |