2011 Medicare Part D Plan Formulary Information |
Freedom Medi-Medi (HMO SNP) (H5427-078-0)
Benefit Details
|
The Freedom Medi-Medi (HMO SNP) (H5427-078-0) Formulary Drugs Starting with the Letter C in Dade County, FL: CMS MA Region 9 which includes: FL
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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 |
1 |
Tier 1 |
15% | 15% | Q:20 /30Days |
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY |
2 |
Tier 2 |
15% | 15% | Q:4 /30Days |
CALCITRIOL 0.25MCG CAPSULE |
1 |
Tier 1 |
15% | 15% | P |
CALCITRIOL 0.5MCG CAPSULE |
1 |
Tier 1 |
15% | 15% | P |
CALCIUM ACETATE CAPSULE 667 MG |
2 |
Tier 2 |
15% | 15% | None |
CALCIUM CHLORIDE 0.0014 MEQ/ML / POTASSIUM CHLORIDE 0.004 MEQ/ML / SODIUM CHLORIDE 0.103 MEQ/ML / SO |
1 |
Tier 1 |
15% | 15% | None |
CAMPATH 30MG/ML VIAL |
2 |
Tier 2 |
15% | 15% | P |
CAMPTOSAR 20MG/ML VIAL |
2 |
Tier 2 |
15% | 15% | P |
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX |
2 |
Tier 2 |
15% | 15% | Q:30 /30Days |
CAPTOPRIL 100MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CAPTOPRIL 12.5MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CAPTOPRIL 25MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CAPTOPRIL 50MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CAPTOPRIL/HCTZ 25/15 TABLET |
1 |
Tier 1 |
15% | 15% | None |
CAPTOPRIL/HCTZ 25/25 TABLET |
1 |
Tier 1 |
15% | 15% | None |
CAPTOPRIL/HCTZ 50/15 TABLET |
1 |
Tier 1 |
15% | 15% | None |
CAPTOPRIL/HCTZ 50/25 TABLET |
1 |
Tier 1 |
15% | 15% | None |
CARAC CRE 0.5% |
2 |
Tier 2 |
15% | 15% | None |
CARBAMAZEPINE EXTENDED RELEASE TABLETS 200MG |
2 |
Tier 2 |
15% | 15% | None |
CARBAMAZEPINE EXTENDED RELEASE TABLETS 400MG |
2 |
Tier 2 |
15% | 15% | None |
CARBAMAZEPINE ORAL SUSPENSION 200 MG |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARBAMAZEPINE TABLET CHEWABLE 100MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
CARBAMAZEPINE TABLET USP 200MG (1000 CT) |
1 |
Tier 1 |
15% | 15% | None |
CARBIDOPA-LEVODOPA 25MG-100MG TABLET SA |
1 |
Tier 1 |
15% | 15% | None |
CARBIDOPA-LEVODOPA 50MG-200MG TABLET SA |
1 |
Tier 1 |
15% | 15% | None |
CARBIDOPA/LEVO 10/100 TABLET |
1 |
Tier 1 |
15% | 15% | None |
CARBIDOPA/LEVO 25/100 TABLET |
1 |
Tier 1 |
15% | 15% | None |
CARBIDOPA/LEVO 25/250 TABLET |
1 |
Tier 1 |
15% | 15% | None |
CARBOPLATIN INJECTION |
1 |
Tier 1 |
15% | 15% | P |
CARISOPRODOL TABLET USP 350MG (100 CT) |
1 |
Tier 1 |
15% | 15% | Q:120 /30Days |
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT |
1 |
Tier 1 |
15% | 15% | None |
CARTIA XT 120MG CAPSULE SA |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CARTIA XT 180MG CAPSULE SA |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
CARTIA XT 240MG CAPSULE SA |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
CARTIA XT 300MG CAPSULE SR 24 HR |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
CARVEDILOL 12.5MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
CARVEDILOL 25MG TABLET (500 CT) |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
CARVEDILOL 3.125MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
CARVEDILOL 6.25MG TABLET (500 CT) |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
CASODEX 50MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
CEENU 100MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
CEENU 10MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
CEENU 40MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFACLOR 250MG/5ML ORAL SUSP |
1 |
Tier 1 |
15% | 15% | None |
CEFACLOR 375MG/5ML ORAL SUSP |
1 |
Tier 1 |
15% | 15% | None |
CEFACLOR CAPSULES |
1 |
Tier 1 |
15% | 15% | None |
CEFACLOR CAPSULES |
1 |
Tier 1 |
15% | 15% | None |
CEFACLOR ER 500MG TABLET SR 12HR |
1 |
Tier 1 |
15% | 15% | None |
CEFACLOR POWDER FOR ORAL SUSPENSION USP 125MG 75ML BOT |
1 |
Tier 1 |
15% | 15% | None |
CEFADROXIL 1G TABLET |
1 |
Tier 1 |
15% | 15% | None |
CEFADROXIL 500MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
CEFADROXIL 500MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
15% | 15% | None |
CEFADROXIL FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Tier 1 |
15% | 15% | None |
CEFEPIME HCL 2 GRAM VIAL |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL |
2 |
Tier 2 |
15% | 15% | None |
CEFOTAXIME FOR INJECTION 500MG 10 VIAL |
1 |
Tier 1 |
15% | 15% | P |
CEFOXITIN 95 MG/ML INJECTABLE SOLUTION |
1 |
Tier 1 |
15% | 15% | P |
CEFPODOXIME PROXETIL 200MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT) |
1 |
Tier 1 |
15% | 15% | None |
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN |
2 |
Tier 2 |
15% | 15% | P |
CEFTRIAXONE 10GM VIAL |
1 |
Tier 1 |
15% | 15% | None |
CEFTRIAXONE FOR INJECTION |
1 |
Tier 1 |
15% | 15% | None |
CEFTRIAXONE FOR INJECTION |
1 |
Tier 1 |
15% | 15% | None |
CEFTRIAXONE FOR INJECTION 250MG BOX OF 10 VIALGL |
1 |
Tier 1 |
15% | 15% | None |
CEFTRIAXONE FOR INJECTION 500MG BOX OF 10 VIALGL |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CEFUROXIME 250MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CEFUROXIME AXETIL 500MG TABLET (20 CT) |
1 |
Tier 1 |
15% | 15% | None |
CEFUROXIME FOR INJECTION |
1 |
Tier 1 |
15% | 15% | P |
CELONTIN 300MG KAPSEAL |
2 |
Tier 2 |
15% | 15% | None |
CEPHALEXIN 250MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
CEPHALEXIN 250MG/5ML ORAL SUSP |
1 |
Tier 1 |
15% | 15% | None |
CEPHALEXIN CAPSULES 500MG (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
CEPHALEXIN POWDER FOR SUSPENSION ORAL USP 125MG 200ML BOT |
1 |
Tier 1 |
15% | 15% | None |
CHLORAMPHEN NA SUCC 1GM VL |
1 |
Tier 1 |
15% | 15% | P |
CHLORDIAZEPOXIDE AND AMITRIPTYLINE HCL TABLET 12.5-5MG (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLOROQUINE PH 500MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CHLOROTHIAZIDE 250MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CHLOROTHIAZIDE 500MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CHLORPROMAZINE 100MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CHLORPROMAZINE 10MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CHLORPROMAZINE 25MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CHLORPROMAZINE 25MG/ML AMP |
1 |
Tier 1 |
15% | 15% | None |
CHLORPROMAZINE 50MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CHLORPROMAZINE HCL 200MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CHLORPROPAMIDE 100MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CHLORPROPAMIDE 250MG TABLET (1000 CT) |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CHLORTHALIDONE 25MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
CHLORTHALIDONE 50MG TABLET (1000 CT) |
1 |
Tier 1 |
15% | 15% | None |
CHLORZOXAZONE 500MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION |
1 |
Tier 1 |
15% | 15% | None |
CHORIONIC GONAD 10000U VIAL |
2 |
Tier 2 |
15% | 15% | P |
CICLOPIROX 0.77% CREAM |
1 |
Tier 1 |
15% | 15% | None |
CICLOPIROX 0.77% TOPICAL SUSPENSION |
1 |
Tier 1 |
15% | 15% | None |
CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6ML BOT |
1 |
Tier 1 |
15% | 15% | None |
CILOSTAZOL 50MG TABLET (60 CT) |
1 |
Tier 1 |
15% | 15% | None |
CILOSTAZOL TABLET 100MG (60 CT) |
1 |
Tier 1 |
15% | 15% | None |
CIMETIDINE 150MG/ML VIAL |
1 |
Tier 1 |
15% | 15% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CIMETIDINE HCL 300MG/5ML SOL |
1 |
Tier 1 |
15% | 15% | None |
CIMETIDINE TABLETS |
1 |
Tier 1 |
15% | 15% | None |
CIMETIDINE TABLETS |
1 |
Tier 1 |
15% | 15% | None |
CIMETIDINE TABLETS USP |
1 |
Tier 1 |
15% | 15% | None |
CIPRODEX OTIC SUSPENSION |
2 |
Tier 2 |
15% | 15% | None |
CIPROFLOXACIN 250MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
CIPROFLOXACIN 400 MG/40 ML VL |
1 |
Tier 1 |
15% | 15% | P |
CIPROFLOXACIN 500MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
CIPROFLOXACIN HCL 0.3% DROPS |
1 |
Tier 1 |
15% | 15% | None |
CIPROFLOXACIN TABLETS 750MG 100 BOT |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
CISPLATIN 1 MG/ML INJECTABLE SOLUTION |
1 |
Tier 1 |
15% | 15% | P |
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 |
15% | 15% | Q:90 /30Days |
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL |
1 |
Tier 1 |
15% | 15% | Q:600 /30Days |
CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
CITOLOPRAM HBR 10MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
CLADRIBINE 1MG/ML VIAL |
1 |
Tier 1 |
15% | 15% | P |
CLARAVIS 10MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
CLARAVIS 30MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
CLARAVIS 40MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
CLARITHROMYCIN 250MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
CLARITHROMYCIN 500MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
CLARITHROMYCIN FOR ORAL SUSPENSION |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLARITHROMYCIN FOR ORAL SUSPENSION |
1 |
Tier 1 |
15% | 15% | None |
CLEMASTINE FUM 2.68MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
CLEMASTINE FUMARATE SYRUP |
1 |
Tier 1 |
15% | 15% | None |
CLEOCIN 300MG/D5W/GALAXY |
2 |
Tier 2 |
15% | 15% | None |
CLEOCIN 600MG/D5W/GALAXY |
2 |
Tier 2 |
15% | 15% | None |
CLEOCIN 900MG/D5W/GALAXY |
2 |
Tier 2 |
15% | 15% | None |
CLINDAMYCIN HCL 150MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
CLINDAMYCIN HYDROCHLORIDE CAPSULES |
1 |
Tier 1 |
15% | 15% | None |
CLINDAMYCIN PHOSP 1% LOTION |
1 |
Tier 1 |
15% | 15% | None |
CLINDAMYCIN PHOSPHATE 1% SOLUTION NON-ORAL |
1 |
Tier 1 |
15% | 15% | None |
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOBETASOL 0.05% OINTMENT |
1 |
Tier 1 |
15% | 15% | None |
CLOBETASOL 0.05% SOLUTION |
1 |
Tier 1 |
15% | 15% | None |
CLOBETASOL E 0.05% CREAM |
1 |
Tier 1 |
15% | 15% | None |
CLOBETASOL PROPIONATE 0.05% FOAM |
2 |
Tier 2 |
15% | 15% | None |
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE |
1 |
Tier 1 |
15% | 15% | None |
CLOMIPRAMINE HCL 25MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
CLOMIPRAMINE HCL 50MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
CLOMIPRAMINE HCL 75MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
CLONIDINE HCL 0.2MG TABLET (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
CLONIDINE HCL TABLET 0.1MG (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
CLONIDINE HCL TABLET 0.3MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CLOTRIMAZOLE 1% CREAM |
1 |
Tier 1 |
15% | 15% | None |
CLOTRIMAZOLE 10MG TROCHE |
1 |
Tier 1 |
15% | 15% | None |
CLOTRIMAZOLE SOLUTION TOPICAL 1% 30ML BOTPL |
1 |
Tier 1 |
15% | 15% | None |
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION |
1 |
Tier 1 |
15% | 15% | None |
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CREAM USP .5MG-10GM 45GM TUBE |
1 |
Tier 1 |
15% | 15% | None |
CLOZAPINE 100 MG ORAL TABLET |
1 |
Tier 1 |
15% | 15% | None |
CLOZAPINE 200MG TABLET (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
CLOZAPINE 25MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
CLOZAPINE 50MG TABLET (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
CODEINE 60 MG ORAL TABLET |
2 |
Tier 2 |
15% | 15% | None |
CODEINE SULFATE 30 MG TABLET 3100 |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CODEINE SULFATE TABLETS |
2 |
Tier 2 |
15% | 15% | None |
COLISTIMETHATE 150MG VIAL |
1 |
Tier 1 |
15% | 15% | None |
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE |
2 |
Tier 2 |
15% | 15% | None |
COMTAN 200MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
COMVAX VACCINE VIAL |
2 |
Tier 2 |
15% | 15% | P |
CORTISONE ACETATE 25MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
CRIXIVAN 100MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
CRIXIVAN 200MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
CRIXIVAN 333MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
CRIXIVAN 400MG CAPSULE (120 CT) |
2 |
Tier 2 |
15% | 15% | None |
CROMOLYN NEBULIZER SOLUTION |
1 |
Tier 1 |
15% | 15% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CROMOLYN SODIUM 4% 40MG 10ML BOT |
1 |
Tier 1 |
15% | 15% | None |
CUPRIMINE CAPSULES 250MG (100 CT) |
2 |
Tier 2 |
15% | 15% | None |
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT) |
1 |
Tier 1 |
15% | 15% | Q:90 /30Days |
CYCLOBENZAPRINE HCL 5MG TABLET (500 CT) |
1 |
Tier 1 |
15% | 15% | Q:90 /30Days |
CYCLOPHOSPHAMIDE 25MG TABLET |
1 |
Tier 1 |
15% | 15% | P |
CYCLOPHOSPHAMIDE 50MG TABLET |
1 |
Tier 1 |
15% | 15% | P |
CYCLOSPORINE 100MG CAPSULE |
2 |
Tier 2 |
15% | 15% | P |
CYCLOSPORINE 100MG CAPSULE |
1 |
Tier 1 |
15% | 15% | P |
CYCLOSPORINE 25MG CAPSULE |
1 |
Tier 1 |
15% | 15% | P |
CYCLOSPORINE 50MG CAPSULE |
2 |
Tier 2 |
15% | 15% | P |
CYCLOSPORINE 50MG/ML AMP |
1 |
Tier 1 |
15% | 15% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT |
1 |
Tier 1 |
15% | 15% | P |
CYKLOKAPRON 100MG/ML AMPUL |
2 |
Tier 2 |
15% | 15% | None |
CYPROHEPTADINE HCL 4 MG |
1 |
Tier 1 |
15% | 15% | None |
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL |
2 |
Tier 2 |
15% | 15% | None |
CYSTADANE POWDER FOR ORAL SOLUTION 180GM |
2 |
Tier 2 |
15% | 15% | None |
CYTARABINE 20MG/ML VIAL |
1 |
Tier 1 |
15% | 15% | P |
CYTARABINE SOLUTION INJECTION 100MG 20ML VIALSD |
1 |
Tier 1 |
15% | 15% | P |
CYTOMEL 25MCG TABLET |
2 |
Tier 2 |
15% | 15% | None |
CYTOMEL 50MCG TABLET |
2 |
Tier 2 |
15% | 15% | None |
CYTOMEL 5MCG TABLET |
2 |
Tier 2 |
15% | 15% | None |