2012 Medicare Part D Plan Formulary Information |
Humana Walmart-Preferred Rx Plan (PDP) (S5884-138-0)
Benefit Details
|
The Humana Walmart-Preferred Rx Plan (PDP) (S5884-138-0) Formulary Drugs Starting with the Letter F in CMS PDP Region 15 which includes: IN KY
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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 |
Non-Preferred Brand Drugs |
35% | 35% | P |
FACTIVE 320mg/1 7 TABLET in 1 BLISTER PACK |
4 |
Non-Preferred Brand Drugs |
35% | 35% | None |
FAMCICLOVIR 125MG TABLET |
3 |
Preferred Brand Drugs |
20% | 20% | Q:60 /30Days |
FAMCICLOVIR 250MG TABLET |
3 |
Preferred Brand Drugs |
20% | 20% | Q:60 /30Days |
FAMCICLOVIR 500MG TABLET |
3 |
Preferred Brand Drugs |
20% | 20% | Q:60 /30Days |
FAMOTIDINE 20MG PIGGYBACK |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
FAMOTIDINE 20MG TABLET (500 CT) |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | None |
FAMOTIDINE 40MG TABLET |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
FAMOTIDINE FOR ORAL SUSPENSION |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
FAMOTIDINE INJECTION 10MG 25 X 2ML VIALSD |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FANAPT 1 KIT in 1 DOSE PACK |
4 |
Non-Preferred Brand Drugs |
35% | 35% | P Q:60 /30Days |
FANAPT 10mg/1 60 TABLET in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
35% | 35% | P Q:60 /30Days |
FANAPT 12mg/1 60 TABLET in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
35% | 35% | P Q:60 /30Days |
FANAPT 1mg/1 60 TABLET in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
35% | 35% | P Q:60 /30Days |
FANAPT 2mg/1 60 TABLET in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
35% | 35% | P Q:60 /30Days |
FANAPT 4mg/1 60 TABLET in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
35% | 35% | P Q:60 /30Days |
FANAPT 6mg/1 60 TABLET in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
35% | 35% | P Q:60 /30Days |
FANAPT 8mg/1 60 TABLET in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
35% | 35% | P Q:60 /30Days |
FARESTON 60MG TABLET |
4 |
Non-Preferred Brand Drugs |
35% | 35% | Q:30 /30Days |
FASLODEX INJECTION |
4 |
Non-Preferred Brand Drugs |
35% | 35% | P Q:30 /30Days |
FazaClo 100mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
35% | 35% | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FazaClo 12.5mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
35% | 35% | S |
FazaClo 150mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
35% | 35% | S |
FazaClo 25mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
35% | 35% | S |
FAZACLO TABLETS ORALLY DISINTEGRATING |
4 |
Non-Preferred Brand Drugs |
35% | 35% | S |
FELBAMATE 400 MG TABLET |
4 |
Non-Preferred Brand Drugs |
35% | 35% | None |
FELBAMATE 600 MG TABLET |
4 |
Non-Preferred Brand Drugs |
35% | 35% | None |
FELBAMATE 600 MG/5 ML SUSP |
4 |
Non-Preferred Brand Drugs |
35% | 35% | None |
FELBATOL 400MG TABLET |
4 |
Non-Preferred Brand Drugs |
35% | 35% | None |
FELBATOL 600MG TABLET |
4 |
Non-Preferred Brand Drugs |
35% | 35% | None |
FELBATOL 600MG/5ML SUSP |
4 |
Non-Preferred Brand Drugs |
35% | 35% | None |
FELODIPINE ER 2.5MG TABLET 90 TABLET BOT |
3 |
Preferred Brand Drugs |
20% | 20% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FELODIPINE TABLET ER 10MG (1000 CT) |
3 |
Preferred Brand Drugs |
20% | 20% | Q:30 /30Days |
FELODIPINE TABLET ER 5MG (1000 CT) |
3 |
Preferred Brand Drugs |
20% | 20% | Q:30 /30Days |
FEMARA 2.5MG TABLET |
4 |
Non-Preferred Brand Drugs |
35% | 35% | P Q:30 /30Days |
FEMCON Fe 72 CARTON in 1 CASE / 5 CELLO PACK in 1 CARTON / 1 BLISTER PACK in 1 CELLO PACK / 1 KIT |
4 |
Non-Preferred Brand Drugs |
35% | 35% | None |
FENOFIBRATE 134MG CAPSULE |
3 |
Preferred Brand Drugs |
20% | 20% | Q:30 /30Days |
FENOFIBRATE 160mg/1 90 TABLET in 1 BOTTLE |
3 |
Preferred Brand Drugs |
20% | 20% | Q:30 /30Days |
FENOFIBRATE 200MG CAPSULE |
3 |
Preferred Brand Drugs |
20% | 20% | Q:30 /30Days |
FENOFIBRATE 54MG TABLET |
3 |
Preferred Brand Drugs |
20% | 20% | Q:60 /30Days |
FENOFIBRATE 67MG CAPSULE |
3 |
Preferred Brand Drugs |
20% | 20% | Q:60 /30Days |
FENOPROFEN 600MG TABLET |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
FENTANYL 100MCG/HR PATCH TRANSDERMAL 72 HOURS |
3 |
Preferred Brand Drugs |
20% | 20% | Q:20 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENTANYL 12MCG/HR PATCH TRANSDERMAL 72 HOURS |
3 |
Preferred Brand Drugs |
20% | 20% | Q:20 /30Days |
FENTANYL 75 MCG/HR PATCH |
3 |
Preferred Brand Drugs |
20% | 20% | Q:20 /30Days |
FENTANYL CITRATE 1600ug/1 30 BLISTER PACK in 1 CARTON / 1 LOZENGE in 1 BLISTER PACK |
4 |
Non-Preferred Brand Drugs |
35% | 35% | P Q:120 /30Days |
FENTANYL CITRATE INJECTION 50MCG 10 X 2ML CTG |
3 |
Preferred Brand Drugs |
20% | 20% | None |
FENTANYL CITRATE LOZENGES |
4 |
Non-Preferred Brand Drugs |
35% | 35% | P Q:120 /30Days |
FENTANYL CITRATE LOZENGES |
4 |
Non-Preferred Brand Drugs |
35% | 35% | P Q:120 /30Days |
FENTANYL CITRATE LOZENGES |
4 |
Non-Preferred Brand Drugs |
35% | 35% | P Q:120 /30Days |
FENTANYL CITRATE LOZENGES |
4 |
Non-Preferred Brand Drugs |
35% | 35% | P Q:120 /30Days |
FENTANYL CITRATE OTFC 200 MCG |
4 |
Non-Preferred Brand Drugs |
35% | 35% | P Q:120 /30Days |
FENTANYL TRANSDERMAL SYSTEM 25MCG 5 SYSTEMS CRTN |
3 |
Preferred Brand Drugs |
20% | 20% | Q:20 /30Days |
FENTANYL TRANSDERMAL SYSTEM 50MCG 5 SYSTEMS CRTN |
3 |
Preferred Brand Drugs |
20% | 20% | Q:20 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FINASTERIDE 5MG TABLET |
3 |
Preferred Brand Drugs |
20% | 20% | Q:30 /30Days |
Firazyr 30.0mg/3mL 1 SYRINGE, GLASS in 1 CARTON / 3 mL in 1 SYRINGE, GLASS |
4 |
Non-Preferred Brand Drugs |
35% | 35% | P Q:9 /30Days |
FIRMAGON 20mg/mL 1 VIAL, GLASS in 1 CARTON / 4 mL in 1 VIAL, GLASS |
4 |
Non-Preferred Brand Drugs |
35% | 35% | P Q:4 /28Days |
FLAVOXATE HCL 100MG TABLET |
3 |
Preferred Brand Drugs |
20% | 20% | None |
FLECAINIDE ACETATE 100 MG TAB #60 EA |
3 |
Preferred Brand Drugs |
20% | 20% | None |
FLECAINIDE ACETATE 150 MG TAB 360 EA |
3 |
Preferred Brand Drugs |
20% | 20% | None |
FLECAINIDE ACETATE 50MG TABLET (100 CT) |
3 |
Preferred Brand Drugs |
20% | 20% | None |
FLOVENT DISKUS 100ug/1 60 POWDER, METERED in 1 INHALER |
3 |
Preferred Brand Drugs |
20% | 20% | Q:60 /30Days |
FLOVENT DISKUS 250ug/1 60 POWDER, METERED in 1 INHALER |
3 |
Preferred Brand Drugs |
20% | 20% | Q:60 /30Days |
FLOVENT DISKUS POWDER 50MCG 60 CTR |
3 |
Preferred Brand Drugs |
20% | 20% | Q:60 /30Days |
FLOVENT HFA 110ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand Drugs |
20% | 20% | Q:24 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLOVENT HFA 220ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand Drugs |
20% | 20% | Q:24 /30Days |
FLOVENT HFA 44ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand Drugs |
20% | 20% | Q:11 /30Days |
Fluconazole 200mg/1 30 TABLET in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
Fluconazole 50mg/1 30 TABLET in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
FLUCONAZOLE INJECTION 200MG 6 X 200/250ML CTR |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
FLUCONAZOLE ORAL SUSPENSION |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
FLUCONAZOLE ORAL SUSPENSION |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
FLUCONAZOLE TABLETS |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
FLUCONAZOLE TABLETS |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | Q:4 /28Days |
Flucytosine 250mg/1 |
3 |
Preferred Brand Drugs |
20% | 20% | None |
Flucytosine 500mg/1 |
3 |
Preferred Brand Drugs |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUDARABINE 50MG VIAL |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | P |
FLUDROCORTISONE ACETATE 0.1MG TABLET (100 CT) |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL |
3 |
Preferred Brand Drugs |
20% | 20% | Q:50 /30Days |
FLUOCINOLONE 0.01% CREAM |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
FLUOCINOLONE 0.01% SOLUTION |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
FLUOCINOLONE 0.025% CREAM |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
FLUOCINOLONE 0.025% OINTMENT |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
FLUOCINONIDE 0.05% SOLUTION |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
Fluocinonide 0.5mg/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
Fluocinonide 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
Fluocinonide 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOROMETHOLONE 0.1% DROPS |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
FLUOROPLEX 1% CREAM |
4 |
Non-Preferred Brand Drugs |
35% | 35% | None |
FLUOROURACIL 2% SOLUTION NON-ORAL |
3 |
Preferred Brand Drugs |
20% | 20% | None |
FLUOROURACIL 5% SOLUTION NON-ORAL |
3 |
Preferred Brand Drugs |
20% | 20% | None |
Fluorouracil 50mg/mL |
3 |
Preferred Brand Drugs |
20% | 20% | P |
FLUOROURACIL CREA 5% |
3 |
Preferred Brand Drugs |
20% | 20% | None |
Fluoxetine 20mg/5mL 120 mL in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
FLUOXETINE 40MG CAPSULE (30 CT) |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | Q:60 /30Days |
FLUOXETINE CAPSULES 10MG (100 CT) |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | Q:60 /30Days |
FLUOXETINE DR 90 MG CAPSULE |
3 |
Preferred Brand Drugs |
20% | 20% | Q:4 /28Days |
FLUOXETINE HCL 20MG TABLET |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Fluoxetine Hydrochloride 20mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | Q:120 /30Days |
FLUOXETINE HYDROCHLORIDE TABLETS 10MG 100 BOT |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | None |
FLUOXYMESTERONE 10MG TABLET |
4 |
Non-Preferred Brand Drugs |
35% | 35% | None |
FLUPHENAZINE 10MG TABLET |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
FLUPHENAZINE 1MG TABLET |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | None |
FLUPHENAZINE 2.5MG TABLET |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
FLUPHENAZINE 2.5MG/ML VIAL |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
FLUPHENAZINE 5MG TABLET |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
FLUPHENAZINE 5MG/ML CONC |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
Fluphenazine Decanoate 25mg/mL |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
FLUPHENAZINE HCL 2.5MG/5ML ELIXIR |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLURBIPROFEN 0.03% EYE DROP |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
Flurbiprofen 100mg/1 500 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
FLURBIPROFEN 50MG TABLET |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
Flutamide 125mg/1 500 CAPSULE in 1 BOTTLE |
3 |
Preferred Brand Drugs |
20% | 20% | None |
Fluticasone Propionate 0.05mg/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
Fluticasone Propionate 0.5mg/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
FLUTICASONE PROPIONATE 50MCG SPRAY SUSPENSION |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | Q:16 /30Days |
FLUVOXAMINE MALEATE 100MG TABLET |
3 |
Preferred Brand Drugs |
20% | 20% | Q:90 /30Days |
FLUVOXAMINE MALEATE 25MG TABLET (100 CT) |
3 |
Preferred Brand Drugs |
20% | 20% | Q:90 /30Days |
Fluvoxamine maleate 50mg/1 100 TABLET, FILM COATED in 1 BOTTLE |
3 |
Preferred Brand Drugs |
20% | 20% | Q:90 /30Days |
FML FORTE 0.25% EYE DROPS |
4 |
Non-Preferred Brand Drugs |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FML S.O.P. 0.1% OINTMENT |
4 |
Non-Preferred Brand Drugs |
35% | 35% | None |
FOLOTYN 20mg/mL 1 VIAL, SINGLE-USE in 1 CARTON / 2 mL in 1 VIAL, SINGLE-USE |
4 |
Non-Preferred Brand Drugs |
35% | 35% | None |
Fomepizole 1g/mL 1 VIAL in 1 CARTON / 1.5 mL in 1 VIAL |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
Fondaparinux Sodium 10mg/0.8mL 2 SYRINGE in 1 CARTON / 0.8 mL in 1 SYRINGE |
4 |
Non-Preferred Brand Drugs |
35% | 35% | Q:14 /30Days |
Fondaparinux Sodium 2.5mg/0.5mL 2 SYRINGE in 1 CARTON / 0.5 mL in 1 SYRINGE |
4 |
Non-Preferred Brand Drugs |
35% | 35% | Q:14 /30Days |
Fondaparinux Sodium 5mg/4mL 2 SYRINGE in 1 CARTON / 0.4 mL in 1 SYRINGE |
4 |
Non-Preferred Brand Drugs |
35% | 35% | Q:14 /30Days |
Fondaparinux Sodium 7.5mg/0.6mL 2 SYRINGE in 1 CARTON / 0.6 mL in 1 SYRINGE |
4 |
Non-Preferred Brand Drugs |
35% | 35% | Q:14 /30Days |
FORADIL AEROLIZER 12 MCG CAP |
4 |
Non-Preferred Brand Drugs |
35% | 35% | Q:60 /30Days |
Forteo 250ug/mL 1 SYRINGE in 1 CARTON / 2.4 mL in 1 SYRINGE |
4 |
Non-Preferred Brand Drugs |
35% | 35% | S Q:2 /28Days |
FORTICAL 200 U/DOSE AEROSOL SPRAY W/PUMP |
4 |
Non-Preferred Brand Drugs |
35% | 35% | P Q:4 /28Days |
FOSINOPRIL SODIUM 10MG TABLET (90 CT) |
3 |
Preferred Brand Drugs |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FOSINOPRIL SODIUM 20MG TABLET |
3 |
Preferred Brand Drugs |
20% | 20% | None |
FOSINOPRIL SODIUM 40MG TABLET |
3 |
Preferred Brand Drugs |
20% | 20% | None |
FOSINOPRIL SODIUM AND HYDROCHLOROTHIAZIDE TABLETS 10;12.5 MG;MG |
3 |
Preferred Brand Drugs |
20% | 20% | None |
FOSINOPRIL SODIUM AND HYDROCHLOROTHIAZIDE TABLETS 20;12.5 MG;MG |
3 |
Preferred Brand Drugs |
20% | 20% | None |
Fosphenytoin 50mg/mL |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
Fragmin 12500[iU]/0.5mL |
4 |
Non-Preferred Brand Drugs |
35% | 35% | Q:14 /30Days |
Fragmin 15000[iU]/0.6mL |
4 |
Non-Preferred Brand Drugs |
35% | 35% | Q:14 /30Days |
Fragmin 18000[iU]/0.72mL |
4 |
Non-Preferred Brand Drugs |
35% | 35% | Q:14 /30Days |
FRAGMIN 25000UNITS/ML VIAL 3.8ML x 1 |
4 |
Non-Preferred Brand Drugs |
35% | 35% | Q:2 /30Days |
FRAGMIN 2500UNITS SYRINGE 0.2ML x 10 |
4 |
Non-Preferred Brand Drugs |
35% | 35% | Q:14 /30Days |
FRAGMIN 5000UNITS SYRINGE 0.2ML x 10 |
4 |
Non-Preferred Brand Drugs |
35% | 35% | Q:14 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FRAGMIN INJECTION 10000UNITS 1 X 10 SYR |
4 |
Non-Preferred Brand Drugs |
35% | 35% | Q:14 /30Days |
FRAGMIN INJECTION 7500UNT/ML |
4 |
Non-Preferred Brand Drugs |
35% | 35% | Q:14 /30Days |
FREAMINE III INJECTION 8.5% |
4 |
Non-Preferred Brand Drugs |
35% | 35% | P |
FREAMINE III INJECTION WITH ELECTROLYTES 3% |
4 |
Non-Preferred Brand Drugs |
35% | 35% | P |
Furosemide 10mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 4 mL in 1 VIAL, SINGLE-DOSE |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
FUROSEMIDE 10MG/ML SOLUTION |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
FUROSEMIDE 20MG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | None |
FUROSEMIDE 40MG TABLET |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | None |
FUROSEMIDE 40MG/5ML TUBEX |
2 |
Non-Preferred Generic Drugs |
$5.00 | $0.00 | None |
FUROSEMIDE 80MG TABLET (500 CT) |
1 |
Preferred Generic Drugs |
$1.00 | $0.00 | None |
FUSILEV I.V. 50 MG VIAL |
4 |
Non-Preferred Brand Drugs |
35% | 35% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FUZEON CONVENIENCE KIT |
3 |
Preferred Brand Drugs |
20% | 20% | Q:60 /30Days |