2011 Medicare Part D Plan Formulary Information |
Health Net Orange Option 1 (PDP) (S5678-020-0)
Sanctioned Plan
|
The Health Net Orange Option 1 (PDP) (S5678-020-0) Formulary Drugs Starting with the Letter F in CMS PDP Region 7 which includes: VA
|
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 |
5 |
Tier 5 Specialty |
25% | 25% | P |
FAMOTIDINE 20MG PIGGYBACK |
4 |
Tier 4 Injectable |
25% | 25% | None |
FAMOTIDINE 20MG TABLET (500 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FAMOTIDINE 40MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FAMOTIDINE INJECTION 10MG 25 X 2ML VIALSD |
4 |
Tier 4 Injectable |
25% | 25% | None |
FARESTON 60MG TABLET |
2 |
Tier 2 Preferred Brand |
$34.00 | $68.00 | None |
FASLODEX 250MG/5ML SYRINGE |
5 |
Tier 5 Specialty |
25% | 25% | P |
FELBATOL 400MG TABLET |
2 |
Tier 2 Preferred Brand |
$34.00 | $68.00 | None |
FELBATOL 600MG TABLET |
2 |
Tier 2 Preferred Brand |
$34.00 | $68.00 | None |
FELBATOL 600MG/5ML SUSP |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$75.00 | $188.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FELODIPINE ER 2.5MG TABLET 90 TABLET BOT |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$75.00 | $188.00 | None |
FELODIPINE TABLET ER 10MG (1000 CT) |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$75.00 | $188.00 | None |
FELODIPINE TABLET ER 5MG (1000 CT) |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$75.00 | $188.00 | None |
FEMARA 2.5MG TABLET |
2 |
Tier 2 Preferred Brand |
$34.00 | $68.00 | None |
FEMHRT 0.5MG/2.5MCG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$75.00 | $188.00 | None |
FEMHRT 1/5 TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$75.00 | $188.00 | None |
FEMTRACE 0.45MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$75.00 | $188.00 | None |
FEMTRACE 0.9MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$75.00 | $188.00 | None |
FEMTRACE 1.8MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$75.00 | $188.00 | None |
FENOFIBRATE 130 MG ORAL CAPSULE [ANTARA] |
2 |
Tier 2 Preferred Brand |
$34.00 | $68.00 | None |
FENOFIBRATE 134MG CAPSULE |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENOFIBRATE 160MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FENOFIBRATE 200MG CAPSULE |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FENOFIBRATE 50 MG ORAL CAPSULE [LIPOFEN] |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$75.00 | $188.00 | None |
FENOFIBRATE 54MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FENOFIBRATE 67MG CAPSULE |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FENOGLIDE 120MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$75.00 | $188.00 | Q:1 /1Days |
FENOGLIDE 40MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$75.00 | $188.00 | Q:1 /1Days |
FENOPROFEN 600MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$75.00 | $188.00 | None |
FENTANYL 0.2 MG BUCCAL FILM [ONSOLIS] |
5 |
Tier 5 Specialty |
25% | 25% | P Q:4 /1Days |
FENTANYL 0.4 MG BUCCAL FILM [ONSOLIS] |
5 |
Tier 5 Specialty |
25% | 25% | P Q:4 /1Days |
FENTANYL 0.6 MG BUCCAL FILM [ONSOLIS] |
5 |
Tier 5 Specialty |
25% | 25% | P Q:4 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENTANYL 0.8 MG BUCCAL FILM [ONSOLIS] |
5 |
Tier 5 Specialty |
25% | 25% | P Q:4 /1Days |
FENTANYL 1.2 MG BUCCAL FILM [ONSOLIS] |
5 |
Tier 5 Specialty |
25% | 25% | P Q:4 /1Days |
FENTANYL 100MCG/HR PATCH TRANSDERMAL 72 HOURS |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$75.00 | $188.00 | Q:1 /1Days |
FENTANYL 12MCG/HR PATCH TRANSDERMAL 72 HOURS |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$75.00 | $188.00 | Q:1 /1Days |
FENTANYL CITRATE INJECTION 50MCG 10 X 2ML CTG |
4 |
Tier 4 Injectable |
25% | 25% | None |
FENTANYL TRANSDERMAL SYSTEM 25MCG 5 SYSTEMS CRTN |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$75.00 | $188.00 | Q:1 /1Days |
FENTANYL TRANSDERMAL SYSTEM 50MCG 5 SYSTEMS CRTN |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$75.00 | $188.00 | Q:1 /1Days |
FENTANYL TRANSDERMAL SYSTEM 75MCG 5 SYSTEMS CRTN |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$75.00 | $188.00 | Q:1 /1Days |
FEXOFENADINE HCL 180MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | Q:1 /1Days |
FEXOFENADINE HCL 30MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$75.00 | $188.00 | Q:2 /1Days |
FEXOFENADINE HCL 60MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FINACEA 15% GEL |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$75.00 | $188.00 | None |
FINASTERIDE 5MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$75.00 | $188.00 | None |
FLAREX 0.1% EYE DROPS |
2 |
Tier 2 Preferred Brand |
$34.00 | $68.00 | Q:1 /1Days |
FLAVOXATE HCL 100MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLEBOGAMMA 5% DIF INJECTION 50MG VIAL |
5 |
Tier 5 Specialty |
25% | 25% | P |
FLECAINIDE ACETATE 100 MG TAB #60 EA |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLECAINIDE ACETATE 150 MG TAB 360 EA |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLECAINIDE ACETATE 50MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLECTOR 1.3% ADHESIVE PATCH MEDICATED |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$75.00 | $188.00 | Q:2 /1Days |
FLOVENT DISKUS /BLIST AEPB |
2 |
Tier 2 Preferred Brand |
$34.00 | $68.00 | Q:2 /1Days |
FLOVENT DISKUS /BLIST AEPB |
2 |
Tier 2 Preferred Brand |
$34.00 | $68.00 | Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLOVENT DISKUS POWDER 50MCG 60 CTR |
2 |
Tier 2 Preferred Brand |
$34.00 | $68.00 | Q:2 /1Days |
FLOVENT HFA 110MCG INHALATION AEROSOL |
2 |
Tier 2 Preferred Brand |
$34.00 | $68.00 | Q:1 /1Days |
FLOVENT HFA 220MCG INHALATION AEROSOL |
2 |
Tier 2 Preferred Brand |
$34.00 | $68.00 | Q:1 /1Days |
FLOVENT HFA 44MCG INHALATION AEROSOL |
2 |
Tier 2 Preferred Brand |
$34.00 | $68.00 | Q:1 /1Days |
FLUCONAZOLE 100MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLUCONAZOLE 10MG/ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLUCONAZOLE 150 MG ORAL TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | Q:1 /1Days |
FLUCONAZOLE 200MG TABLET (30 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLUCONAZOLE 40MG/ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLUCONAZOLE 50MG TABLET (30 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLUCONAZOLE INJECTION 200MG 6 X 200/250ML CTR |
4 |
Tier 4 Injectable |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUDARA 50MG VIAL |
4 |
Tier 4 Injectable |
25% | 25% | None |
FLUDARABINE 50MG VIAL |
4 |
Tier 4 Injectable |
25% | 25% | None |
FLUDROCORTISONE ACETATE 0.1MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | Q:2 /1Days |
FLUOCINOLONE 0.01% CREAM |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLUOCINOLONE 0.01% SOLUTION |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLUOCINOLONE 0.025% CREAM |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLUOCINOLONE 0.025% OINTMENT |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLUOCINONIDE 0.05% GEL |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLUOCINONIDE 0.05% OINTMENT |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLUOCINONIDE 0.05% SOLUTION |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | Q:6 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOROMETHOLONE 0.1% DROPS |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLUOROPLEX 1% CREAM |
2 |
Tier 2 Preferred Brand |
$34.00 | $68.00 | None |
FLUOROURACIL 2% SOLUTION NON-ORAL |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLUOROURACIL CREA 5% |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLUOROURACIL INJECTION 50MG/ML 10 X 10 ML VIALGL |
4 |
Tier 4 Injectable |
25% | 25% | None |
FLUOXETINE 20 MG ORAL CAPSULE |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | Q:5 /1Days |
FLUOXETINE 20MG/5ML TUBEX |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | Q:25 /1Days |
FLUOXETINE CAPSULES 10MG (100 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | Q:1 /1Days |
FLUOXYMESTERONE 10MG TABLET |
2 |
Tier 2 Preferred Brand |
$34.00 | $68.00 | None |
FLUPHENAZINE 10MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLUPHENAZINE 1MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUPHENAZINE 2.5MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLUPHENAZINE 2.5MG/ML VIAL |
4 |
Tier 4 Injectable |
25% | 25% | None |
FLUPHENAZINE 5MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLUPHENAZINE 5MG/ML CONC |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLUPHENAZINE DECANOATE INJECTION USP 25MG 1 X 5ML VIAL |
4 |
Tier 4 Injectable |
25% | 25% | None |
FLUPHENAZINE HCL 2.5MG/5ML ELIXIR |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLURBIPROFEN 0.03% EYE DROP |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLURBIPROFEN 100MG TABLET (500 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLURBIPROFEN 50MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLUTAMIDE 125MG CAPSULE |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLUTICASONE PROPIONATE 0.005% OINTMENT |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUTICASONE PROPIONATE 0.05% CREAM |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLUTICASONE PROPIONATE 50MCG SPRAY SUSPENSION |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | Q:1 /1Days |
FLUVOXAMINE MALEATE 100MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLUVOXAMINE MALEATE 25MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FLUVOXAMINE MALEATE 50MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FML FORTE 0.25% EYE DROPS |
2 |
Tier 2 Preferred Brand |
$34.00 | $68.00 | None |
FML S.O.P. 0.1% OINTMENT |
2 |
Tier 2 Preferred Brand |
$34.00 | $68.00 | None |
FOMEPIZOLE INJECTION 1GM/ML |
4 |
Tier 4 Injectable |
25% | 25% | None |
FORADIL AEROLIZER 12 MCG CAP |
2 |
Tier 2 Preferred Brand |
$34.00 | $68.00 | Q:2 /1Days |
FORTAMET 1000MG TABLET SR OSMOTIC PUSH 24HR |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$75.00 | $188.00 | None |
FORTAMET 500MG TABLET SR OSMOTIC PUSH 24HR |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$75.00 | $188.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FORTAZ 1GM ADD-VANTAGE VIAL |
4 |
Tier 4 Injectable |
25% | 25% | None |
FORTAZ 2GM VIAL |
4 |
Tier 4 Injectable |
25% | 25% | None |
FORTAZ 6GM VIAL |
4 |
Tier 4 Injectable |
25% | 25% | None |
FORTAZ/ISO-OSMOT 2GM/50ML |
4 |
Tier 4 Injectable |
25% | 25% | None |
FORTAZ/ISO-OSMOTIC 1GM/50ML |
4 |
Tier 4 Injectable |
25% | 25% | None |
FORTEO INJECTION |
2 |
Tier 2 Preferred Brand |
$34.00 | $68.00 | None |
FORTICAL 200 U/DOSE AEROSOL SPRAY W/PUMP |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FOSAMAX 70MG ORAL SOLUTION |
2 |
Tier 2 Preferred Brand |
$34.00 | $68.00 | Q:11 /1Days |
FOSAMAX PLUS D 70MG-5600 TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$75.00 | $188.00 | None |
FOSAMAX PLUS D 70MG/2800 IU |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$75.00 | $188.00 | None |
FOSCARNET 24MG/ML INFUS BTTL |
4 |
Tier 4 Injectable |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FOSINOPRIL SODIUM 10MG TABLET (90 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | Q:2 /1Days |
FOSINOPRIL SODIUM 20MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | Q:2 /1Days |
FOSINOPRIL SODIUM 40MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | Q:2 /1Days |
FOSINOPRIL-HYDROCHLOROTHIAZIDE 10-12.5MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | Q:4 /1Days |
FOSINOPRIL-HYDROCHLOROTHIAZIDE 20-12.5MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | Q:4 /1Days |
FOSPHEN SDV 50MGPE/ML 2MLGEN10 50MG PE/ML VIAL |
4 |
Tier 4 Injectable |
25% | 25% | None |
FRAGMIN 25000UNITS/ML VIAL 3.8ML x 1 |
4 |
Tier 4 Injectable |
25% | 25% | Q:2 /10Days |
FRAGMIN 2500UNITS SYRINGE 0.2ML x 10 |
4 |
Tier 4 Injectable |
25% | 25% | Q:2 /10Days |
FRAGMIN 5000UNITS SYRINGE 0.2ML x 10 |
4 |
Tier 4 Injectable |
25% | 25% | Q:2 /10Days |
FRAGMIN INJECTION 10000UNITS 1 X 10 SYR |
4 |
Tier 4 Injectable |
25% | 25% | Q:3 /10Days |
FRAGMIN INJECTION 7500UNT/ML |
4 |
Tier 4 Injectable |
25% | 25% | Q:2 /10Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FREAMINE HBC INJECTION |
4 |
Tier 4 Injectable |
25% | 25% | P |
FREAMINE III INJECTION 8.5% |
4 |
Tier 4 Injectable |
25% | 25% | P |
FREAMINE III INJECTION WITH ELECTROLYTES 3% |
4 |
Tier 4 Injectable |
25% | 25% | P |
FUROSEMIDE 10MG/ML SOLUTION |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FUROSEMIDE 20MG TABLET (1000 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FUROSEMIDE 40MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FUROSEMIDE 40MG/5ML TUBEX |
2 |
Tier 2 Preferred Brand |
$34.00 | $68.00 | None |
FUROSEMIDE 80MG TABLET (500 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $8.00 | None |
FUROSEMIDE INJECTION USP 10MG 25 X 4ML VIALSD |
4 |
Tier 4 Injectable |
25% | 25% | None |
FUSILEV FOR INJECTION 50MG/VIAL 1 VIAL |
4 |
Tier 4 Injectable |
25% | 25% | None |
FUZEON CONVENIENCE KIT |
5 |
Tier 5 Specialty |
25% | 25% | None |