2012 Medicare Part D Plan Formulary Information |
PacificSource Medicare Explorer Rx 2 (PPO) (H4754-002-0)
Benefit Details
|
The PacificSource Medicare Explorer Rx 2 (PPO) (H4754-002-0) Formulary Drugs Starting with the Letter F in LINCOLN County, ID: CMS MA Region 23 which includes: ID
|
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 |
Tier 4 |
33% | N/A | None |
FACTIVE 320mg/1 7 TABLET in 1 BLISTER PACK |
3 |
Tier 3 |
$80.00 | $240.00 | Q:7 /7Days |
FAMCICLOVIR 125MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | Q:21 /10Days |
FAMCICLOVIR 250MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | Q:68 /34Days |
FAMCICLOVIR 500MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | Q:21 /7Days |
FAMOTIDINE 20MG PIGGYBACK |
1 |
Tier 1 |
$5.00 | $10.00 | None |
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 |
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 |
FAMVIR 125MG TABLET |
3 |
Tier 3 |
$80.00 | $240.00 | Q:21 /10Days |
FAMVIR 250MG TABLET |
3 |
Tier 3 |
$80.00 | $240.00 | Q:68 /34Days |
FAMVIR 500MG TABLET |
3 |
Tier 3 |
$80.00 | $240.00 | Q:21 /7Days |
FANAPT 1 KIT in 1 DOSE PACK |
2 |
Tier 2 |
$40.00 | $100.00 | Q:1 /34Days |
FANAPT 10mg/1 60 TABLET in 1 BOTTLE |
2 |
Tier 2 |
$40.00 | $100.00 | Q:68 /34Days |
FANAPT 12mg/1 60 TABLET in 1 BOTTLE |
2 |
Tier 2 |
$40.00 | $100.00 | Q:68 /34Days |
FANAPT 1mg/1 60 TABLET in 1 BOTTLE |
2 |
Tier 2 |
$40.00 | $100.00 | Q:68 /34Days |
FANAPT 2mg/1 60 TABLET in 1 BOTTLE |
2 |
Tier 2 |
$40.00 | $100.00 | Q:68 /34Days |
FANAPT 4mg/1 60 TABLET in 1 BOTTLE |
2 |
Tier 2 |
$40.00 | $100.00 | Q:68 /34Days |
FANAPT 6mg/1 60 TABLET in 1 BOTTLE |
2 |
Tier 2 |
$40.00 | $100.00 | Q:68 /34Days |
FANAPT 8mg/1 60 TABLET in 1 BOTTLE |
2 |
Tier 2 |
$40.00 | $100.00 | Q:68 /34Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FARESTON 60MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | None |
FASLODEX INJECTION |
4 |
Tier 4 |
33% | N/A | None |
FazaClo 100mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
2 |
Tier 2 |
$40.00 | $100.00 | None |
FazaClo 12.5mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
2 |
Tier 2 |
$40.00 | $100.00 | None |
FazaClo 150mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
2 |
Tier 2 |
$40.00 | $100.00 | None |
FazaClo 25mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
2 |
Tier 2 |
$40.00 | $100.00 | None |
FAZACLO TABLETS ORALLY DISINTEGRATING |
2 |
Tier 2 |
$40.00 | $100.00 | None |
FELBAMATE 400 MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FELBAMATE 600 MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FELBAMATE 600 MG/5 ML SUSP |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FELBATOL 400MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FELBATOL 600MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | None |
FELBATOL 600MG/5ML SUSP |
2 |
Tier 2 |
$40.00 | $100.00 | None |
FELDENE 10MG CAPSULE |
3 |
Tier 3 |
$80.00 | $240.00 | S |
FELDENE 20MG CAPSULE |
3 |
Tier 3 |
$80.00 | $240.00 | S |
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 |
$80.00 | $240.00 | None |
FEMCON Fe 72 CARTON in 1 CASE / 5 CELLO PACK in 1 CARTON / 1 BLISTER PACK in 1 CELLO PACK / 1 KIT |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FEMHRT 0.5MG/2.5MCG TABLET |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FEMHRT 1/5 TABLET |
3 |
Tier 3 |
$80.00 | $240.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FEMRING 0.05MG VAGINAL RING |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FEMRING 0.10MG VAGINAL RING |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FEMTRACE 0.45MG TABLET |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FEMTRACE 0.9MG TABLET |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FEMTRACE 1.8MG TABLET |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FENOFIBRATE 134MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FENOFIBRATE 160mg/1 90 TABLET in 1 BOTTLE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FENOFIBRATE 200MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FENOFIBRATE 50 MG ORAL CAPSULE [LIPOFEN] |
3 |
Tier 3 |
$80.00 | $240.00 | S |
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 |
Fenoglide 120mg/1 90 TABLET in 1 BOTTLE, PLASTIC |
3 |
Tier 3 |
$80.00 | $240.00 | None |
Fenoglide 40mg/1 90 TABLET in 1 BOTTLE, PLASTIC |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FENOPROFEN 600MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FENTANYL 100MCG/HR PATCH TRANSDERMAL 72 HOURS |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FENTANYL 12MCG/HR PATCH TRANSDERMAL 72 HOURS |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FENTANYL 75 MCG/HR PATCH |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FENTANYL CITRATE 1600ug/1 30 BLISTER PACK in 1 CARTON / 1 LOZENGE in 1 BLISTER PACK |
4 |
Tier 4 |
33% | N/A | P Q:120 /30Days |
FENTANYL CITRATE INJECTION 50MCG 10 X 2ML CTG |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FENTANYL CITRATE LOZENGES |
4 |
Tier 4 |
33% | N/A | P Q:120 /30Days |
FENTANYL CITRATE LOZENGES |
4 |
Tier 4 |
33% | N/A | P Q:120 /30Days |
FENTANYL CITRATE LOZENGES |
4 |
Tier 4 |
33% | N/A | 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 |
Tier 4 |
33% | N/A | P Q:120 /30Days |
FENTANYL CITRATE OTFC 200 MCG |
4 |
Tier 4 |
33% | N/A | P Q:120 /30Days |
FENTANYL TRANSDERMAL SYSTEM 25MCG 5 SYSTEMS CRTN |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FENTANYL TRANSDERMAL SYSTEM 50MCG 5 SYSTEMS CRTN |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FENTORA TABLET 100MCG |
4 |
Tier 4 |
33% | N/A | P Q:112 /28Days |
FENTORA TABLET 200MCG |
4 |
Tier 4 |
33% | N/A | P Q:112 /28Days |
FENTORA TABLET 400MCG |
4 |
Tier 4 |
33% | N/A | P Q:112 /28Days |
FENTORA TABLET 600MCG |
4 |
Tier 4 |
33% | N/A | P Q:112 /28Days |
FENTORA TABLET 800MCG |
4 |
Tier 4 |
33% | N/A | P Q:112 /28Days |
FERRIPROX 500 MG TABLET |
4 |
Tier 4 |
33% | N/A | None |
FIBRICOR 105mg/1 30 TABLET in 1 BOTTLE, PLASTIC |
3 |
Tier 3 |
$80.00 | $240.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FIBRICOR 35mg/1 30 TABLET in 1 BOTTLE, PLASTIC |
3 |
Tier 3 |
$80.00 | $240.00 | S |
FINACEA 15% GEL |
2 |
Tier 2 |
$40.00 | $100.00 | None |
FINASTERIDE 5MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Fioricet with Codeine 325; 50; 40; 30mg/1; mg/1; mg/1; mg/1 100 CAPSULE in 1 BOTTLE |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FIORINAL W/CODEINE #3 CAPSULE |
3 |
Tier 3 |
$80.00 | $240.00 | None |
Firazyr 30.0mg/3mL 1 SYRINGE, GLASS in 1 CARTON / 3 mL in 1 SYRINGE, GLASS |
4 |
Tier 4 |
33% | N/A | P |
FLAGYL 250MG TABLET (100 CT) |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FLAGYL 375 CAPSULE |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FLAGYL 500MG TABLET |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FLAGYL ER 750MG TABLET SA |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FLAREX 0.1% EYE DROPS |
3 |
Tier 3 |
$80.00 | $240.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLAVOXATE HCL 100MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | 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 |
FLECTOR PATCH |
3 |
Tier 3 |
$80.00 | $240.00 | S Q:60 /30Days |
Flo-Pred 15mg/5mL 1 BOTTLE in 1 CARTON / 52 mL in 1 BOTTLE |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FLOMAX 0.4MG CAPSULE SA |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FLONASE 0.05% NASAL SPRAY |
3 |
Tier 3 |
$80.00 | $240.00 | S Q:32 /34Days |
FLOVENT DISKUS 100ug/1 60 POWDER, METERED in 1 INHALER |
3 |
Tier 3 |
$80.00 | $240.00 | Q:120 /30Days |
FLOVENT DISKUS 250ug/1 60 POWDER, METERED in 1 INHALER |
3 |
Tier 3 |
$80.00 | $240.00 | Q:300 /30Days |
FLOVENT DISKUS POWDER 50MCG 60 CTR |
3 |
Tier 3 |
$80.00 | $240.00 | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLOVENT HFA 110ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Tier 3 |
$80.00 | $240.00 | Q:12 /34Days |
FLOVENT HFA 220ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Tier 3 |
$80.00 | $240.00 | Q:36 /34Days |
FLOVENT HFA 44ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Tier 3 |
$80.00 | $240.00 | Q:21 /34Days |
Fluconazole 200mg/1 30 TABLET in 1 BOTTLE |
1 |
Tier 1 |
$5.00 | $10.00 | P |
Fluconazole 50mg/1 30 TABLET in 1 BOTTLE |
1 |
Tier 1 |
$5.00 | $10.00 | P |
FLUCONAZOLE INJECTION 200MG 6 X 200/250ML CTR |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUCONAZOLE ORAL SUSPENSION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUCONAZOLE ORAL SUSPENSION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUCONAZOLE TABLETS |
1 |
Tier 1 |
$5.00 | $10.00 | P |
FLUCONAZOLE TABLETS |
1 |
Tier 1 |
$5.00 | $10.00 | Q:2 /7Days |
Flucytosine 250mg/1 |
4 |
Tier 4 |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Flucytosine 500mg/1 |
4 |
Tier 4 |
33% | N/A | None |
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:75 /34Days |
FLUOCINOLONE 0.01% BODY OIL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
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 |
FLUOCINOLONE OIL 0.01% EAR DRP |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUOCINONIDE 0.05% SOLUTION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Fluocinonide 0.5mg/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE |
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 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Fluocinonide 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUOROMETHOLONE 0.1% DROPS |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUOROPLEX 1% CREAM |
2 |
Tier 2 |
$40.00 | $100.00 | None |
FLUOROURACIL 2% SOLUTION NON-ORAL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUOROURACIL 5% SOLUTION NON-ORAL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUOROURACIL CREA 5% |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Fluoxetine 20mg/5mL 120 mL in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUOXETINE 40MG CAPSULE (30 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | Q:68 /34Days |
FLUOXETINE CAPSULES 10MG (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | Q:34 /34Days |
FLUOXETINE DR 90 MG CAPSULE |
1 |
Tier 1 |
$5.00 | $10.00 | Q:5 /34Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOXETINE HCL 20MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Fluoxetine Hydrochloride 20mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUOXETINE HYDROCHLORIDE TABLETS 10MG 100 BOT |
1 |
Tier 1 |
$5.00 | $10.00 | Q:34 /34Days |
FLUOXYMESTERONE 10MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | 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 |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUPHENAZINE 5MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUPHENAZINE 5MG/ML CONC |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Fluphenazine Decanoate 25mg/mL |
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 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/1 500 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLURBIPROFEN 50MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Flutamide 125mg/1 500 CAPSULE in 1 BOTTLE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUTICASONE PROP 0.05% LOTION |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Fluticasone Propionate 0.05mg/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Fluticasone Propionate 0.5mg/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FLUTICASONE PROPIONATE 50MCG SPRAY SUSPENSION |
1 |
Tier 1 |
$5.00 | $10.00 | Q:32 /34Days |
FLUVASTATIN SODIUM 20 MG CAP |
1 |
Tier 1 |
$5.00 | $10.00 | Q:34 /34Days |
FLUVASTATIN SODIUM 40 MG CAP |
1 |
Tier 1 |
$5.00 | $10.00 | Q:68 /34Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUVOXAMINE MALEATE 100MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | Q:102 /34Days |
FLUVOXAMINE MALEATE 25MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | Q:34 /34Days |
Fluvoxamine maleate 50mg/1 100 TABLET, FILM COATED in 1 BOTTLE |
1 |
Tier 1 |
$5.00 | $10.00 | Q:68 /34Days |
FML FORTE 0.25% EYE DROPS |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FML LIQUIFILM 0.1% EYE DROP |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FML S.O.P. 0.1% OINTMENT |
2 |
Tier 2 |
$40.00 | $100.00 | None |
FOCALIN 10MG TABLET |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FOCALIN 2.5MG TABLET |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FOCALIN 5MG TABLET |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FOCALIN XR 10MG CAPSULE |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FOCALIN XR 15MG CAPSULE |
3 |
Tier 3 |
$80.00 | $240.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FOCALIN XR 20MG CAPSULE |
3 |
Tier 3 |
$80.00 | $240.00 | None |
Focalin XR 25mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
3 |
Tier 3 |
$80.00 | $240.00 | None |
Focalin XR 35mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
3 |
Tier 3 |
$80.00 | $240.00 | None |
Focalin XR 40mg/1 100 CAPSULE, EXTENDED RELEASE in 1 BOTTLE |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FOCALIN XR 5MG CAPSULE |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FOCALIN XR CAPSULES |
3 |
Tier 3 |
$80.00 | $240.00 | None |
Fomepizole 1g/mL 1 VIAL in 1 CARTON / 1.5 mL in 1 VIAL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Fondaparinux Sodium 10mg/0.8mL 2 SYRINGE in 1 CARTON / 0.8 mL in 1 SYRINGE |
4 |
Tier 4 |
33% | N/A | None |
Fondaparinux Sodium 2.5mg/0.5mL 2 SYRINGE in 1 CARTON / 0.5 mL in 1 SYRINGE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Fondaparinux Sodium 5mg/4mL 2 SYRINGE in 1 CARTON / 0.4 mL in 1 SYRINGE |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Fondaparinux Sodium 7.5mg/0.6mL 2 SYRINGE in 1 CARTON / 0.6 mL in 1 SYRINGE |
4 |
Tier 4 |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FORADIL AEROLIZER 12 MCG CAP |
2 |
Tier 2 |
$40.00 | $100.00 | Q:120 /34Days |
FORTAMET 1000MG TABLET SR OSMOTIC PUSH 24HR |
3 |
Tier 3 |
$80.00 | $240.00 | S |
FORTAMET 500MG TABLET SR OSMOTIC PUSH 24HR |
3 |
Tier 3 |
$80.00 | $240.00 | S |
FORTAZ 2GM VIAL |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FORTAZ 6GM VIAL |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FORTAZ/ISO-OSMOT 2GM/50ML |
2 |
Tier 2 |
$40.00 | $100.00 | None |
FORTAZ/ISO-OSMOTIC 1GM/50ML |
2 |
Tier 2 |
$40.00 | $100.00 | None |
Forteo 250ug/mL 1 SYRINGE in 1 CARTON / 2.4 mL in 1 SYRINGE |
4 |
Tier 4 |
33% | N/A | P Q:1 /28Days |
FORTESTA 10mg/0.5g |
3 |
Tier 3 |
$80.00 | $240.00 | P |
FORTICAL 200 U/DOSE AEROSOL SPRAY W/PUMP |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FOSAMAX 10MG TABLET (30 CT) |
3 |
Tier 3 |
$80.00 | $240.00 | S Q:34 /34Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FOSAMAX 40MG TABLET |
3 |
Tier 3 |
$80.00 | $240.00 | S Q:34 /34Days |
FOSAMAX 5MG TABLET (30 CT) |
3 |
Tier 3 |
$80.00 | $240.00 | S Q:34 /34Days |
FOSAMAX 70MG ORAL SOLUTION |
3 |
Tier 3 |
$80.00 | $240.00 | S Q:375 /35Days |
FOSAMAX 70MG TABLET |
3 |
Tier 3 |
$80.00 | $240.00 | S Q:5 /35Days |
FOSAMAX PLUS D 70; 5600mg/1; [iU]/1 4 TABLET in 1 BLISTER PACK |
3 |
Tier 3 |
$80.00 | $240.00 | S Q:5 /35Days |
FOSAMAX PLUS D 70MG/2800 IU |
3 |
Tier 3 |
$80.00 | $240.00 | S Q:5 /35Days |
FOSAMAX TABLET 35MG 20 BLPK |
3 |
Tier 3 |
$80.00 | $240.00 | S Q:5 /35Days |
FOSCARNET 24MG/ML INFUS BTTL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FOSINOPRIL SODIUM 10MG TABLET (90 CT) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FOSINOPRIL SODIUM 20MG TABLET |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FOSINOPRIL SODIUM 40MG TABLET |
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 |
FOSINOPRIL SODIUM AND HYDROCHLOROTHIAZIDE TABLETS 10;12.5 MG;MG |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FOSINOPRIL SODIUM AND HYDROCHLOROTHIAZIDE TABLETS 20;12.5 MG;MG |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Fosphenytoin 50mg/mL |
1 |
Tier 1 |
$5.00 | $10.00 | None |
FOSRENOL 1000MG TABLET CHEW |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FOSRENOL 500MG TABLET CHEW |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FOSRENOL 750MG TABLET CHEW |
3 |
Tier 3 |
$80.00 | $240.00 | None |
Fragmin 12500[iU]/0.5mL |
4 |
Tier 4 |
33% | N/A | None |
Fragmin 15000[iU]/0.6mL |
4 |
Tier 4 |
33% | N/A | None |
Fragmin 18000[iU]/0.72mL |
4 |
Tier 4 |
33% | N/A | None |
FRAGMIN 25000UNITS/ML VIAL 3.8ML x 1 |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FRAGMIN 2500UNITS SYRINGE 0.2ML x 10 |
3 |
Tier 3 |
$80.00 | $240.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FRAGMIN 5000UNITS SYRINGE 0.2ML x 10 |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FRAGMIN INJECTION 10000UNITS 1 X 10 SYR |
4 |
Tier 4 |
33% | N/A | None |
FRAGMIN INJECTION 7500UNT/ML |
4 |
Tier 4 |
33% | N/A | None |
FREAMINE III INJECTION 8.5% |
2 |
Tier 2 |
$40.00 | $100.00 | None |
FREAMINE III INJECTION WITH ELECTROLYTES 3% |
3 |
Tier 3 |
$80.00 | $240.00 | None |
FROVA 2.5MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | Q:27 /28Days |
FURADANTIN 25 MG/5 ML SUSP 230 ML |
3 |
Tier 3 |
$80.00 | $240.00 | None |
Furosemide 10mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 4 mL in 1 VIAL, SINGLE-DOSE |
1 |
Tier 1 |
$5.00 | $10.00 | 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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
FUZEON CONVENIENCE KIT |
4 |
Tier 4 |
33% | N/A | None |