2012 Medicare Part D Plan Formulary Information |
MedicareBlue PPO (Regional PPO) (R5566-005-0)
Benefit Details
|
The MedicareBlue PPO (Regional PPO) (R5566-005-0) Formulary Drugs Starting with the Letter F in Statewide County, IA: CMS MA Region 19 which includes: IA MN MT NE ND SD WY
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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 |
45% | 45% | None |
FAMCICLOVIR 125MG TABLET |
2 |
Tier 2 |
$11.00 | $22.00 | None |
FAMCICLOVIR 250MG TABLET |
2 |
Tier 2 |
$11.00 | $22.00 | None |
FAMCICLOVIR 500MG TABLET |
2 |
Tier 2 |
$11.00 | $22.00 | None |
FAMOTIDINE 20MG TABLET (500 CT) |
2 |
Tier 2 |
$11.00 | $22.00 | None |
FAMOTIDINE 40MG TABLET |
2 |
Tier 2 |
$11.00 | $22.00 | None |
FAMOTIDINE FOR ORAL SUSPENSION |
2 |
Tier 2 |
$11.00 | $22.00 | None |
FAMOTIDINE INJECTION 10MG 25 X 2ML VIALSD |
2 |
Tier 2 |
$11.00 | $22.00 | None |
FANAPT 1 KIT in 1 DOSE PACK |
4 |
Tier 4 |
45% | 45% | S Q:56 /28Days |
FANAPT 10mg/1 60 TABLET in 1 BOTTLE |
4 |
Tier 4 |
45% | 45% | S Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FANAPT 12mg/1 60 TABLET in 1 BOTTLE |
4 |
Tier 4 |
45% | 45% | S Q:60 /30Days |
FANAPT 1mg/1 60 TABLET in 1 BOTTLE |
4 |
Tier 4 |
45% | 45% | S Q:60 /30Days |
FANAPT 2mg/1 60 TABLET in 1 BOTTLE |
4 |
Tier 4 |
45% | 45% | S Q:60 /30Days |
FANAPT 4mg/1 60 TABLET in 1 BOTTLE |
4 |
Tier 4 |
45% | 45% | S Q:60 /30Days |
FANAPT 6mg/1 60 TABLET in 1 BOTTLE |
4 |
Tier 4 |
45% | 45% | S Q:60 /30Days |
FANAPT 8mg/1 60 TABLET in 1 BOTTLE |
4 |
Tier 4 |
45% | 45% | S Q:60 /30Days |
FARESTON 60MG TABLET |
4 |
Tier 4 |
45% | 45% | None |
FASLODEX INJECTION |
4 |
Tier 4 |
45% | 45% | None |
FazaClo 100mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
4 |
Tier 4 |
45% | 45% | S Q:90 /30Days |
FazaClo 12.5mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
4 |
Tier 4 |
45% | 45% | S Q:90 /30Days |
FazaClo 150mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
4 |
Tier 4 |
45% | 45% | S Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FazaClo 25mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
4 |
Tier 4 |
45% | 45% | S Q:270 /30Days |
FAZACLO TABLETS ORALLY DISINTEGRATING |
4 |
Tier 4 |
45% | 45% | S Q:120 /30Days |
FELBAMATE 400 MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
FELBAMATE 600 MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
FELBAMATE 600 MG/5 ML SUSP |
1 |
Tier 1 |
$6.00 | $12.00 | None |
FELBATOL 400MG TABLET |
4 |
Tier 4 |
45% | 45% | None |
FELBATOL 600MG TABLET |
4 |
Tier 4 |
45% | 45% | None |
FELBATOL 600MG/5ML SUSP |
4 |
Tier 4 |
45% | 45% | None |
FELODIPINE ER 2.5MG TABLET 90 TABLET BOT |
1 |
Tier 1 |
$6.00 | $12.00 | None |
FELODIPINE TABLET ER 10MG (1000 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
FELODIPINE TABLET ER 5MG (1000 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FEMARA 2.5MG TABLET |
4 |
Tier 4 |
45% | 45% | None |
FENOFIBRATE 134MG CAPSULE |
1 |
Tier 1 |
$6.00 | $12.00 | Q:30 /30Days |
FENOFIBRATE 160mg/1 90 TABLET in 1 BOTTLE |
1 |
Tier 1 |
$6.00 | $12.00 | Q:30 /30Days |
FENOFIBRATE 200MG CAPSULE |
1 |
Tier 1 |
$6.00 | $12.00 | Q:30 /30Days |
FENOFIBRATE 50 MG ORAL CAPSULE [LIPOFEN] |
4 |
Tier 4 |
45% | 45% | Q:60 /30Days |
FENOFIBRATE 54MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | Q:60 /30Days |
FENOFIBRATE 67MG CAPSULE |
1 |
Tier 1 |
$6.00 | $12.00 | Q:30 /30Days |
FENTANYL 100MCG/HR PATCH TRANSDERMAL 72 HOURS |
2 |
Tier 2 |
$11.00 | $22.00 | Q:15 /30Days |
FENTANYL 12MCG/HR PATCH TRANSDERMAL 72 HOURS |
2 |
Tier 2 |
$11.00 | $22.00 | Q:15 /30Days |
FENTANYL 75 MCG/HR PATCH |
2 |
Tier 2 |
$11.00 | $22.00 | Q:15 /30Days |
FENTANYL CITRATE 1600ug/1 30 BLISTER PACK in 1 CARTON / 1 LOZENGE in 1 BLISTER PACK |
2 |
Tier 2 |
$11.00 | $22.00 | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENTANYL CITRATE LOZENGES |
2 |
Tier 2 |
$11.00 | $22.00 | P Q:120 /30Days |
FENTANYL CITRATE LOZENGES |
2 |
Tier 2 |
$11.00 | $22.00 | P Q:120 /30Days |
FENTANYL CITRATE LOZENGES |
2 |
Tier 2 |
$11.00 | $22.00 | P Q:120 /30Days |
FENTANYL CITRATE LOZENGES |
2 |
Tier 2 |
$11.00 | $22.00 | P Q:120 /30Days |
FENTANYL CITRATE OTFC 200 MCG |
2 |
Tier 2 |
$11.00 | $22.00 | P Q:120 /30Days |
FENTANYL TRANSDERMAL SYSTEM 25MCG 5 SYSTEMS CRTN |
2 |
Tier 2 |
$11.00 | $22.00 | Q:15 /30Days |
FENTANYL TRANSDERMAL SYSTEM 50MCG 5 SYSTEMS CRTN |
2 |
Tier 2 |
$11.00 | $22.00 | Q:15 /30Days |
FINACEA 15% GEL |
4 |
Tier 4 |
45% | 45% | None |
FINASTERIDE 5MG TABLET |
2 |
Tier 2 |
$11.00 | $22.00 | Q:30 /30Days |
Firazyr 30.0mg/3mL 1 SYRINGE, GLASS in 1 CARTON / 3 mL in 1 SYRINGE, GLASS |
4 |
Tier 4 |
45% | 45% | Q:9 /30Days |
FIRMAGON 20mg/mL 1 VIAL, GLASS in 1 CARTON / 4 mL in 1 VIAL, GLASS |
4 |
Tier 4 |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLECAINIDE ACETATE 100 MG TAB #60 EA |
2 |
Tier 2 |
$11.00 | $22.00 | None |
FLECAINIDE ACETATE 150 MG TAB 360 EA |
2 |
Tier 2 |
$11.00 | $22.00 | None |
FLECAINIDE ACETATE 50MG TABLET (100 CT) |
2 |
Tier 2 |
$11.00 | $22.00 | None |
FLOVENT DISKUS 100ug/1 60 POWDER, METERED in 1 INHALER |
3 |
Tier 3 |
$33.00 | $66.00 | Q:60 /30Days |
FLOVENT DISKUS 250ug/1 60 POWDER, METERED in 1 INHALER |
3 |
Tier 3 |
$33.00 | $66.00 | Q:240 /30Days |
FLOVENT DISKUS POWDER 50MCG 60 CTR |
3 |
Tier 3 |
$33.00 | $66.00 | Q:60 /30Days |
FLOVENT HFA 110ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Tier 3 |
$33.00 | $66.00 | Q:12 /30Days |
FLOVENT HFA 220ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Tier 3 |
$33.00 | $66.00 | Q:24 /30Days |
FLOVENT HFA 44ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Tier 3 |
$33.00 | $66.00 | Q:11 /30Days |
Fluconazole 200mg/1 30 TABLET in 1 BOTTLE |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Fluconazole 50mg/1 30 TABLET in 1 BOTTLE |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUCONAZOLE INJECTION 200MG 6 X 200/250ML CTR |
2 |
Tier 2 |
$11.00 | $22.00 | None |
FLUCONAZOLE ORAL SUSPENSION |
2 |
Tier 2 |
$11.00 | $22.00 | None |
FLUCONAZOLE ORAL SUSPENSION |
2 |
Tier 2 |
$11.00 | $22.00 | None |
FLUCONAZOLE TABLETS |
2 |
Tier 2 |
$11.00 | $22.00 | None |
FLUCONAZOLE TABLETS |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Flucytosine 250mg/1 |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Flucytosine 500mg/1 |
2 |
Tier 2 |
$11.00 | $22.00 | None |
FLUDARABINE 50MG VIAL |
1 |
Tier 1 |
$6.00 | $12.00 | None |
FLUDROCORTISONE ACETATE 0.1MG TABLET (100 CT) |
2 |
Tier 2 |
$11.00 | $22.00 | None |
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL |
2 |
Tier 2 |
$11.00 | $22.00 | Q:75 /30Days |
FLUOCINOLONE 0.01% CREAM |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOCINOLONE OIL 0.01% EAR DRP |
2 |
Tier 2 |
$11.00 | $22.00 | None |
FLUOCINONIDE 0.05% SOLUTION |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Fluocinonide 0.5mg/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Fluocinonide 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Fluocinonide 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
2 |
Tier 2 |
$11.00 | $22.00 | None |
FLUOROMETHOLONE 0.1% DROPS |
2 |
Tier 2 |
$11.00 | $22.00 | None |
FLUOROPLEX 1% CREAM |
4 |
Tier 4 |
45% | 45% | None |
FLUOROURACIL 2% SOLUTION NON-ORAL |
2 |
Tier 2 |
$11.00 | $22.00 | None |
FLUOROURACIL 5% SOLUTION NON-ORAL |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Fluorouracil 50mg/mL |
1 |
Tier 1 |
$6.00 | $12.00 | P |
FLUOROURACIL CREA 5% |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Fluoxetine 20mg/5mL 120 mL in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
$6.00 | $12.00 | Q:600 /30Days |
FLUOXETINE 40MG CAPSULE (30 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | Q:60 /30Days |
FLUOXETINE CAPSULES 10MG (100 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | Q:30 /30Days |
FLUOXETINE DR 90 MG CAPSULE |
1 |
Tier 1 |
$6.00 | $12.00 | Q:4 /28Days |
FLUOXETINE HCL 20MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | Q:120 /30Days |
Fluoxetine Hydrochloride 20mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Tier 1 |
$6.00 | $12.00 | Q:120 /30Days |
FLUOXETINE HYDROCHLORIDE TABLETS 10MG 100 BOT |
1 |
Tier 1 |
$6.00 | $12.00 | Q:30 /30Days |
FLUOXYMESTERONE 10MG TABLET |
4 |
Tier 4 |
45% | 45% | None |
FLUPHENAZINE 10MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
FLUPHENAZINE 1MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
FLUPHENAZINE 2.5MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUPHENAZINE 2.5MG/ML VIAL |
4 |
Tier 4 |
45% | 45% | None |
FLUPHENAZINE 5MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
FLUPHENAZINE 5MG/ML CONC |
4 |
Tier 4 |
45% | 45% | None |
Fluphenazine Decanoate 25mg/mL |
1 |
Tier 1 |
$6.00 | $12.00 | None |
FLUPHENAZINE HCL 2.5MG/5ML ELIXIR |
4 |
Tier 4 |
45% | 45% | None |
FLURBIPROFEN 0.03% EYE DROP |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Flurbiprofen 100mg/1 500 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
2 |
Tier 2 |
$11.00 | $22.00 | None |
FLURBIPROFEN 50MG TABLET |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Flutamide 125mg/1 500 CAPSULE in 1 BOTTLE |
1 |
Tier 1 |
$6.00 | $12.00 | None |
FLUTICASONE PROP 0.05% LOTION |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Fluticasone Propionate 0.05mg/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Fluticasone Propionate 0.5mg/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE |
2 |
Tier 2 |
$11.00 | $22.00 | None |
FLUTICASONE PROPIONATE 50MCG SPRAY SUSPENSION |
2 |
Tier 2 |
$11.00 | $22.00 | Q:16 /30Days |
FLUVOXAMINE MALEATE 100MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | Q:90 /30Days |
FLUVOXAMINE MALEATE 25MG TABLET (100 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | Q:30 /30Days |
Fluvoxamine maleate 50mg/1 100 TABLET, FILM COATED in 1 BOTTLE |
1 |
Tier 1 |
$6.00 | $12.00 | Q:30 /30Days |
Fomepizole 1g/mL 1 VIAL in 1 CARTON / 1.5 mL in 1 VIAL |
2 |
Tier 2 |
$11.00 | $22.00 | None |
Fondaparinux Sodium 10mg/0.8mL 2 SYRINGE in 1 CARTON / 0.8 mL in 1 SYRINGE |
2 |
Tier 2 |
$11.00 | $22.00 | Q:24 /90Days |
Fondaparinux Sodium 2.5mg/0.5mL 2 SYRINGE in 1 CARTON / 0.5 mL in 1 SYRINGE |
2 |
Tier 2 |
$11.00 | $22.00 | Q:15 /90Days |
Fondaparinux Sodium 5mg/4mL 2 SYRINGE in 1 CARTON / 0.4 mL in 1 SYRINGE |
2 |
Tier 2 |
$11.00 | $22.00 | Q:12 /90Days |
Fondaparinux Sodium 7.5mg/0.6mL 2 SYRINGE in 1 CARTON / 0.6 mL in 1 SYRINGE |
2 |
Tier 2 |
$11.00 | $22.00 | Q:18 /90Days |
FORADIL AEROLIZER 12 MCG CAP |
3 |
Tier 3 |
$33.00 | $66.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FORTAZ/ISO-OSMOT 2GM/50ML |
4 |
Tier 4 |
45% | 45% | None |
FORTAZ/ISO-OSMOTIC 1GM/50ML |
4 |
Tier 4 |
45% | 45% | None |
Forteo 250ug/mL 1 SYRINGE in 1 CARTON / 2.4 mL in 1 SYRINGE |
4 |
Tier 4 |
45% | 45% | P |
FORTICAL 200 U/DOSE AEROSOL SPRAY W/PUMP |
2 |
Tier 2 |
$11.00 | $22.00 | None |
FOSCARNET 24MG/ML INFUS BTTL |
4 |
Tier 4 |
45% | 45% | P |
FOSINOPRIL SODIUM 10MG TABLET (90 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
FOSINOPRIL SODIUM 20MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
FOSINOPRIL SODIUM 40MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
FOSINOPRIL SODIUM AND HYDROCHLOROTHIAZIDE TABLETS 10;12.5 MG;MG |
1 |
Tier 1 |
$6.00 | $12.00 | None |
FOSINOPRIL SODIUM AND HYDROCHLOROTHIAZIDE TABLETS 20;12.5 MG;MG |
1 |
Tier 1 |
$6.00 | $12.00 | None |
Fosphenytoin 50mg/mL |
1 |
Tier 1 |
$6.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FOSRENOL 1000MG TABLET CHEW |
3 |
Tier 3 |
$33.00 | $66.00 | None |
FOSRENOL 500MG TABLET CHEW |
3 |
Tier 3 |
$33.00 | $66.00 | None |
FOSRENOL 750MG TABLET CHEW |
3 |
Tier 3 |
$33.00 | $66.00 | None |
FREAMINE III INJECTION 8.5% |
2 |
Tier 2 |
$11.00 | $22.00 | P |
Furosemide 10mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 4 mL in 1 VIAL, SINGLE-DOSE |
1 |
Tier 1 |
$6.00 | $12.00 | None |
FUROSEMIDE 10MG/ML SOLUTION |
1 |
Tier 1 |
$6.00 | $12.00 | None |
FUROSEMIDE 20MG TABLET (1000 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
FUROSEMIDE 40MG TABLET |
1 |
Tier 1 |
$6.00 | $12.00 | None |
FUROSEMIDE 80MG TABLET (500 CT) |
1 |
Tier 1 |
$6.00 | $12.00 | None |
FUZEON CONVENIENCE KIT |
4 |
Tier 4 |
45% | 45% | None |