2011 Medicare Part D Plan Formulary Information |
CIGNA Medicare Rx Plan One (PDP) (S5617-214-0)
Benefit Details
|
The CIGNA Medicare Rx Plan One (PDP) (S5617-214-0) Formulary Drugs Starting with the Letter F in CMS PDP Region 5 which includes: DC DE MD
|
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 Tier |
25% | 25% | P |
FACTIVE 320MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$80.00 | $200.00 | Q:30 /30Days |
FAMOTIDINE 20MG PIGGYBACK |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FAMOTIDINE 20MG TABLET (500 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FAMOTIDINE 40MG TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FAMOTIDINE INJECTION 10MG 25 X 2ML VIALSD |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FARESTON 60MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$80.00 | $200.00 | None |
FASLODEX INJECTION |
4 |
Specialty Tier |
25% | 25% | P |
FAZACLO TABLETS ORALLY DISINTEGRATING |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$80.00 | $200.00 | None |
FELBATOL 400MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$80.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FELBATOL 600MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$80.00 | $200.00 | None |
FELBATOL 600MG/5ML SUSP |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$80.00 | $200.00 | None |
FELODIPINE ER 2.5MG TABLET 90 TABLET BOT |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | S Q:30 /30Days |
FELODIPINE TABLET ER 10MG (1000 CT) |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | S Q:30 /30Days |
FELODIPINE TABLET ER 5MG (1000 CT) |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | S Q:30 /30Days |
FEMARA 2.5MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$80.00 | $200.00 | None |
FENOFIBRATE 134MG CAPSULE |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | Q:30 /30Days |
FENOFIBRATE 160MG TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | Q:30 /30Days |
FENOFIBRATE 200MG CAPSULE |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | Q:30 /30Days |
FENOFIBRATE 54MG TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | Q:60 /30Days |
FENOFIBRATE 67MG CAPSULE |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENOPROFEN 600MG TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FENTANYL 0.2 MG BUCCAL FILM [ONSOLIS] |
4 |
Specialty Tier |
25% | 25% | P Q:120 /30Days |
FENTANYL 0.4 MG BUCCAL FILM [ONSOLIS] |
4 |
Specialty Tier |
25% | 25% | P Q:120 /30Days |
FENTANYL 0.6 MG BUCCAL FILM [ONSOLIS] |
4 |
Specialty Tier |
25% | 25% | P Q:120 /30Days |
FENTANYL 0.8 MG BUCCAL FILM [ONSOLIS] |
4 |
Specialty Tier |
25% | 25% | P Q:120 /30Days |
FENTANYL 1.2 MG BUCCAL FILM [ONSOLIS] |
4 |
Specialty Tier |
25% | 25% | P Q:120 /30Days |
FENTANYL 100MCG/HR PATCH TRANSDERMAL 72 HOURS |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | Q:20 /30Days |
FENTANYL 12MCG/HR PATCH TRANSDERMAL 72 HOURS |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | Q:20 /30Days |
FENTANYL CITRATE INJECTION 50MCG 10 X 2ML CTG |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | P |
FENTANYL CITRATE LOZENGES |
4 |
Specialty Tier |
25% | 25% | P Q:120 /30Days |
FENTANYL CITRATE LOZENGES |
4 |
Specialty Tier |
25% | 25% | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENTANYL CITRATE LOZENGES |
4 |
Specialty Tier |
25% | 25% | P Q:120 /30Days |
FENTANYL CITRATE LOZENGES |
4 |
Specialty Tier |
25% | 25% | P Q:120 /30Days |
FENTANYL CITRATE LOZENGES |
4 |
Specialty Tier |
25% | 25% | P Q:120 /30Days |
FENTANYL CITRATE OTFC 200 MCG |
4 |
Specialty Tier |
25% | 25% | P Q:120 /30Days |
FENTANYL TRANSDERMAL SYSTEM 25MCG 5 SYSTEMS CRTN |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | Q:20 /30Days |
FENTANYL TRANSDERMAL SYSTEM 50MCG 5 SYSTEMS CRTN |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | Q:20 /30Days |
FENTANYL TRANSDERMAL SYSTEM 75MCG 5 SYSTEMS CRTN |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | Q:20 /30Days |
FEXOFENADINE HCL 180MG TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | Q:30 /30Days |
FEXOFENADINE HCL 30MG TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | Q:60 /30Days |
FEXOFENADINE HCL 60MG TABLET (100 CT) |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | Q:60 /30Days |
FINASTERIDE 5MG TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | Q:30 /30Days |
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 |
$80.00 | $200.00 | None |
FLAVOXATE HCL 100MG TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLECAINIDE ACETATE 100 MG TAB #60 EA |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLECAINIDE ACETATE 150 MG TAB 360 EA |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLECAINIDE ACETATE 50MG TABLET (100 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLECTOR PATCH |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$80.00 | $200.00 | None |
FLOVENT DISKUS /BLIST AEPB |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | None |
FLOVENT DISKUS /BLIST AEPB |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | None |
FLOVENT DISKUS POWDER 50MCG 60 CTR |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | None |
FLOVENT HFA 110MCG INHALATION AEROSOL |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | None |
FLOVENT HFA 220MCG INHALATION AEROSOL |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLOVENT HFA 44MCG INHALATION AEROSOL |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | None |
FLUCONAZOLE 200MG TABLET (30 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUCONAZOLE 50MG TABLET (30 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUCONAZOLE INJECTION 200MG 6 X 200/250ML CTR |
4 |
Specialty Tier |
25% | 25% | None |
FLUCONAZOLE ORAL SUSPENSION |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUCONAZOLE ORAL SUSPENSION |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUCONAZOLE TABLETS |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUCONAZOLE TABLETS |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUDARA 50MG VIAL |
4 |
Specialty Tier |
25% | 25% | P |
FLUDARABINE 50MG VIAL |
4 |
Specialty Tier |
25% | 25% | P |
FLUDROCORTISONE ACETATE 0.1MG TABLET (100 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUMADINE 100MG TABLET |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$80.00 | $200.00 | None |
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUOCINOLONE 0.01% CREAM |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUOCINOLONE 0.01% SOLUTION |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUOCINOLONE 0.025% CREAM |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUOCINOLONE 0.025% OINTMENT |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUOCINONIDE 0.05% GEL |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUOCINONIDE 0.05% OINTMENT |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUOCINONIDE 0.05% SOLUTION |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUOCINONIDE EMOLLIENT 0.05% CREAM |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUOROMETHOLONE 0.1% DROPS |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOROURACIL 2% SOLUTION NON-ORAL |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | None |
FLUOROURACIL 5% SOLUTION NON-ORAL |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | None |
FLUOROURACIL CREA 5% |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | None |
FLUOROURACIL INJECTION 50MG/ML 10 X 10 ML VIALGL |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | P |
FLUOXETINE 20 MG ORAL CAPSULE |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUOXETINE 20MG/5ML TUBEX |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUOXETINE 40MG CAPSULE (30 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUOXETINE CAPSULES 10MG (100 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUOXETINE HCL 20MG TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUOXETINE HYDROCHLORIDE TABLETS 10MG 100 BOT |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUPHENAZINE 10MG TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUPHENAZINE 1MG TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUPHENAZINE 2.5MG TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUPHENAZINE 2.5MG/ML VIAL |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUPHENAZINE 5MG TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUPHENAZINE 5MG/ML CONC |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUPHENAZINE DECANOATE INJECTION USP 25MG 1 X 5ML VIAL |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUPHENAZINE HCL 2.5MG/5ML ELIXIR |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLURBIPROFEN 0.03% EYE DROP |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLURBIPROFEN 100MG TABLET (500 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLURBIPROFEN 50MG TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUTAMIDE 125MG CAPSULE |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUTICASONE PROPIONATE 0.005% OINTMENT |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUTICASONE PROPIONATE 0.05% CREAM |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUTICASONE PROPIONATE 50MCG SPRAY SUSPENSION |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUVOXAMINE MALEATE 100MG TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUVOXAMINE MALEATE 25MG TABLET (100 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FLUVOXAMINE MALEATE 50MG TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FOMEPIZOLE INJECTION 1GM/ML |
4 |
Specialty Tier |
25% | 25% | P |
FORADIL AEROLIZER 12 MCG CAP |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | None |
FORTEO INJECTION |
4 |
Specialty Tier |
25% | 25% | P |
FORTICAL 200 U/DOSE AEROSOL SPRAY W/PUMP |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | None |
FOSAMAX 70MG ORAL SOLUTION |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$80.00 | $200.00 | Q:300 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FOSCARNET 24MG/ML INFUS BTTL |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | P |
FOSINOPRIL SODIUM 10MG TABLET (90 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FOSINOPRIL SODIUM 20MG TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FOSINOPRIL SODIUM 40MG TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FOSINOPRIL-HYDROCHLOROTHIAZIDE 10-12.5MG TABLET (100 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FOSINOPRIL-HYDROCHLOROTHIAZIDE 20-12.5MG TABLET (100 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FOSPHEN SDV 50MGPE/ML 2MLGEN10 50MG PE/ML VIAL |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FOSRENOL 1000MG TABLET CHEW |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | None |
FOSRENOL 500MG TABLET CHEW |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | None |
FOSRENOL 750MG TABLET CHEW |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | None |
FRAGMIN 25000UNITS/ML VIAL 3.8ML x 1 |
4 |
Specialty Tier |
25% | 25% | S Q:133 /365Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FRAGMIN 2500UNITS SYRINGE 0.2ML x 10 |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$80.00 | $200.00 | S Q:6 /365Days |
FRAGMIN 5000UNITS SYRINGE 0.2ML x 10 |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$80.00 | $200.00 | S Q:6 /365Days |
FRAGMIN INJECTION 10000UNITS 1 X 10 SYR |
4 |
Specialty Tier |
25% | 25% | S Q:180 /365Days |
FRAGMIN INJECTION 7500UNT/ML |
4 |
Specialty Tier |
25% | 25% | S Q:54 /365Days |
FREAMINE HBC INJECTION |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | P |
FREAMINE III INJECTION 8.5% |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | P |
FREAMINE III INJECTION WITH ELECTROLYTES 3% |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | P |
FURADANTIN 25 MG/5 ML SUSP 230 ML |
2 |
Non-Preferred Generic/Preferred Brand |
$29.00 | $72.50 | None |
FUROSEMIDE 10MG/ML SOLUTION |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FUROSEMIDE 20MG TABLET (1000 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FUROSEMIDE 40MG TABLET |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FUROSEMIDE 40MG/5ML TUBEX |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FUROSEMIDE 80MG TABLET (500 CT) |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FUROSEMIDE INJECTION USP 10MG 25 X 4ML VIALSD |
1 |
Preferred Generic/Preferred Brand |
$3.00 | $7.50 | None |
FUZEON CONVENIENCE KIT |
4 |
Specialty Tier |
25% | 25% | None |