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2012 Medicare Part D and Medicare Advantage Plan Formulary Browser

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Blue Cross MedicareRx Plus (PDP) (S5596-034-0)
Tier 1 (407)
Tier 2 (1277)
Tier 3 (451)
Tier 4 (270)
Tier 5 (604)
Tier 6 (434)
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Cick on the first letter of your drug name to browse the formulary:

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M N O P Q R S T U V W X Y Z 0-9 
2012 Medicare Part D Plan Formulary Information
Blue Cross MedicareRx Plus (PDP) (S5596-034-0)
Benefit Details           
The Blue Cross MedicareRx Plus (PDP) (S5596-034-0)
Formulary Drugs Starting with the Letter F

in CMS PDP Region 32 which includes: CA
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   6 Specialty Tier Drugs 33%N/AP
FAMCICLOVIR 125MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
FAMCICLOVIR 250MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
FAMCICLOVIR 500MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
FAMOTIDINE 20MG PIGGYBACK   5 Injectable Drug 33%33%None
FAMOTIDINE 20MG TABLET (500 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
FAMOTIDINE 40MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
FAMOTIDINE FOR ORAL SUSPENSION   2 Non-Preferred Generic Drugs $7.00$10.50None
FAMOTIDINE INJECTION 10MG 25 X 2ML VIALSD   5 Injectable Drug 33%33%None
FANAPT 1 KIT in 1 DOSE PACK   4 Non-Preferred Brand Drugs $90.00$225.00Q:8
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FANAPT 10mg/1 60 TABLET in 1 BOTTLE   4 Non-Preferred Brand Drugs $90.00$225.00Q:60
/30Days
FANAPT 12mg/1 60 TABLET in 1 BOTTLE   4 Non-Preferred Brand Drugs $90.00$225.00Q:60
/30Days
FANAPT 1mg/1 60 TABLET in 1 BOTTLE   4 Non-Preferred Brand Drugs $90.00$225.00Q:60
/30Days
FANAPT 2mg/1 60 TABLET in 1 BOTTLE   4 Non-Preferred Brand Drugs $90.00$225.00Q:60
/30Days
FANAPT 4mg/1 60 TABLET in 1 BOTTLE   4 Non-Preferred Brand Drugs $90.00$225.00Q:60
/30Days
FANAPT 6mg/1 60 TABLET in 1 BOTTLE   4 Non-Preferred Brand Drugs $90.00$225.00Q:60
/30Days
FANAPT 8mg/1 60 TABLET in 1 BOTTLE   4 Non-Preferred Brand Drugs $90.00$225.00Q:60
/30Days
FARESTON 60MG TABLET   3 Preferred Brand Drugs $45.00$112.50None
FASLODEX INJECTION   6 Specialty Tier Drugs 33%N/ANone
FazaClo 100mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE   4 Non-Preferred Brand Drugs $90.00$225.00Q:270
/30Days
FazaClo 12.5mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE   4 Non-Preferred Brand Drugs $90.00$225.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FazaClo 150mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE   4 Non-Preferred Brand Drugs $90.00$225.00Q:180
/30Days
FazaClo 25mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE   4 Non-Preferred Brand Drugs $90.00$225.00Q:90
/30Days
FAZACLO TABLETS ORALLY DISINTEGRATING   4 Non-Preferred Brand Drugs $90.00$225.00Q:120
/30Days
FELBAMATE 400 MG TABLET   3 Preferred Brand Drugs $45.00$112.50None
FELBAMATE 600 MG TABLET   3 Preferred Brand Drugs $45.00$112.50None
FELBAMATE 600 MG/5 ML SUSP   3 Preferred Brand Drugs $45.00$112.50None
FELBATOL 400MG TABLET   3 Preferred Brand Drugs $45.00$112.50None
FELBATOL 600MG TABLET   3 Preferred Brand Drugs $45.00$112.50None
FELBATOL 600MG/5ML SUSP   3 Preferred Brand Drugs $45.00$112.50None
FELODIPINE ER 2.5MG TABLET 90 TABLET BOT   2 Non-Preferred Generic Drugs $7.00$10.50None
FELODIPINE TABLET ER 10MG (1000 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FELODIPINE TABLET ER 5MG (1000 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
FEMTRACE 0.45MG TABLET   3 Preferred Brand Drugs $45.00$112.50S
FEMTRACE 0.9MG TABLET   3 Preferred Brand Drugs $45.00$112.50S
FEMTRACE 1.8MG TABLET   3 Preferred Brand Drugs $45.00$112.50S
FENOFIBRATE 134MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
FENOFIBRATE 160mg/1 90 TABLET in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
FENOFIBRATE 200MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
FENOFIBRATE 50 MG ORAL CAPSULE [LIPOFEN]   3 Preferred Brand Drugs $45.00$112.50None
FENOFIBRATE 54MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
FENOFIBRATE 67MG CAPSULE   2 Non-Preferred Generic Drugs $7.00$10.50None
FENOPROFEN 600MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FENTANYL 100MCG/HR PATCH TRANSDERMAL 72 HOURS   3 Preferred Brand Drugs $45.00$112.50Q:15
/30Days
FENTANYL 12MCG/HR PATCH TRANSDERMAL 72 HOURS   3 Preferred Brand Drugs $45.00$112.50Q:15
/30Days
FENTANYL 75 MCG/HR PATCH   3 Preferred Brand Drugs $45.00$112.50Q:15
/30Days
FENTANYL CITRATE 1600ug/1 30 BLISTER PACK in 1 CARTON / 1 LOZENGE in 1 BLISTER PACK   6 Specialty Tier Drugs 33%N/AP Q:120
/30Days
FENTANYL CITRATE INJECTION 50MCG 10 X 2ML CTG   5 Injectable Drug 33%33%None
FENTANYL CITRATE LOZENGES   6 Specialty Tier Drugs 33%N/AP Q:120
/30Days
FENTANYL CITRATE LOZENGES   6 Specialty Tier Drugs 33%N/AP Q:120
/30Days
FENTANYL CITRATE LOZENGES   6 Specialty Tier Drugs 33%N/AP Q:120
/30Days
FENTANYL CITRATE LOZENGES   6 Specialty Tier Drugs 33%N/AP Q:120
/30Days
FENTANYL CITRATE OTFC 200 MCG   6 Specialty Tier Drugs 33%N/AP Q:120
/30Days
FENTANYL TRANSDERMAL SYSTEM 25MCG 5 SYSTEMS CRTN   3 Preferred Brand Drugs $45.00$112.50Q:15
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FENTANYL TRANSDERMAL SYSTEM 50MCG 5 SYSTEMS CRTN   3 Preferred Brand Drugs $45.00$112.50Q:15
/30Days
FENTORA TABLET 100MCG   6 Specialty Tier Drugs 33%N/AP Q:120
/30Days
FENTORA TABLET 200MCG   6 Specialty Tier Drugs 33%N/AP Q:120
/30Days
FENTORA TABLET 400MCG   6 Specialty Tier Drugs 33%N/AP Q:120
/30Days
FENTORA TABLET 600MCG   6 Specialty Tier Drugs 33%N/AP Q:120
/30Days
FENTORA TABLET 800MCG   6 Specialty Tier Drugs 33%N/AP Q:120
/30Days
FERRIPROX 500 MG TABLET   6 Specialty Tier Drugs 33%N/AP
FINASTERIDE 5MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
Firazyr 30.0mg/3mL 1 SYRINGE, GLASS in 1 CARTON / 3 mL in 1 SYRINGE, GLASS   6 Specialty Tier Drugs 33%N/AP
FIRMAGON 20mg/mL 1 VIAL, GLASS in 1 CARTON / 4 mL in 1 VIAL, GLASS   5 Injectable Drug 33%33%P
FLAVOXATE HCL 100MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
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 Non-Preferred Generic Drugs $7.00$10.50None
FLECAINIDE ACETATE 150 MG TAB 360 EA   2 Non-Preferred Generic Drugs $7.00$10.50None
FLECAINIDE ACETATE 50MG TABLET (100 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
FLONASE 0.05% NASAL SPRAY   4 Non-Preferred Brand Drugs $90.00$225.00S Q:16
/30Days
FLOVENT DISKUS 100ug/1 60 POWDER, METERED in 1 INHALER   3 Preferred Brand Drugs $45.00$112.50Q:60
/30Days
FLOVENT DISKUS 250ug/1 60 POWDER, METERED in 1 INHALER   3 Preferred Brand Drugs $45.00$112.50Q:240
/30Days
FLOVENT DISKUS POWDER 50MCG 60 CTR   3 Preferred Brand Drugs $45.00$112.50Q:240
/30Days
FLOVENT HFA 110ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand Drugs $45.00$112.50Q:12
/30Days
FLOVENT HFA 220ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand Drugs $45.00$112.50Q:24
/30Days
FLOVENT HFA 44ug/1 120 AEROSOL, METERED in 1 INHALER   3 Preferred Brand Drugs $45.00$112.50Q:11
/30Days
Fluconazole 200mg/1 30 TABLET in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Fluconazole 50mg/1 30 TABLET in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
FLUCONAZOLE INJECTION 200MG 6 X 200/250ML CTR   5 Injectable Drug 33%33%None
FLUCONAZOLE ORAL SUSPENSION   2 Non-Preferred Generic Drugs $7.00$10.50None
FLUCONAZOLE ORAL SUSPENSION   2 Non-Preferred Generic Drugs $7.00$10.50None
FLUCONAZOLE TABLETS   2 Non-Preferred Generic Drugs $7.00$10.50None
FLUCONAZOLE TABLETS   2 Non-Preferred Generic Drugs $7.00$10.50None
Flucytosine 250mg/1   6 Specialty Tier Drugs 33%N/ANone
Flucytosine 500mg/1   6 Specialty Tier Drugs 33%N/ANone
FLUDARA FOR INJECTION 50 MG/VIAL   6 Specialty Tier Drugs 33%N/AP
FLUDARABINE 50MG VIAL   6 Specialty Tier Drugs 33%N/AP
FLUDROCORTISONE ACETATE 0.1MG TABLET (100 CT)   1 Preferred Generic Drugs $2.00$3.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL   2 Non-Preferred Generic Drugs $7.00$10.50Q:50
/30Days
FLUOCINOLONE 0.01% CREAM   1 Preferred Generic Drugs $2.00$3.00None
FLUOCINOLONE 0.01% SOLUTION   1 Preferred Generic Drugs $2.00$3.00None
FLUOCINOLONE 0.025% CREAM   1 Preferred Generic Drugs $2.00$3.00None
FLUOCINOLONE 0.025% OINTMENT   1 Preferred Generic Drugs $2.00$3.00None
FLUOCINOLONE OIL 0.01% EAR DRP   3 Preferred Brand Drugs $45.00$112.50None
FLUOCINONIDE 0.05% SOLUTION   1 Preferred Generic Drugs $2.00$3.00None
Fluocinonide 0.5mg/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE   1 Preferred Generic Drugs $2.00$3.00None
Fluocinonide 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE   2 Non-Preferred Generic Drugs $7.00$10.50None
Fluocinonide 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE   1 Preferred Generic Drugs $2.00$3.00None
FLUOROMETHOLONE 0.1% DROPS   1 Preferred Generic Drugs $2.00$3.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLUOROURACIL 2% SOLUTION NON-ORAL   2 Non-Preferred Generic Drugs $7.00$10.50None
FLUOROURACIL 5% SOLUTION NON-ORAL   2 Non-Preferred Generic Drugs $7.00$10.50None
Fluorouracil 50mg/mL   5 Injectable Drug 33%33%P
FLUOROURACIL CREA 5%   2 Non-Preferred Generic Drugs $7.00$10.50None
Fluoxetine 20mg/5mL 120 mL in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $7.00$10.50Q:600
/30Days
FLUOXETINE 40MG CAPSULE (30 CT)   2 Non-Preferred Generic Drugs $7.00$10.50Q:60
/30Days
FLUOXETINE CAPSULES 10MG (100 CT)   2 Non-Preferred Generic Drugs $7.00$10.50Q:45
/30Days
FLUOXETINE HCL 20MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50Q:120
/30Days
Fluoxetine Hydrochloride 20mg/1 100 CAPSULE in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50Q:120
/30Days
FLUOXETINE HYDROCHLORIDE TABLETS 10MG 100 BOT   2 Non-Preferred Generic Drugs $7.00$10.50Q:240
/30Days
FLUOXYMESTERONE 10MG TABLET   3 Preferred Brand Drugs $45.00$112.50P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLUPHENAZINE 10MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
FLUPHENAZINE 1MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
FLUPHENAZINE 2.5MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
FLUPHENAZINE 2.5MG/ML VIAL   5 Injectable Drug 33%33%None
FLUPHENAZINE 5MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
FLUPHENAZINE 5MG/ML CONC   2 Non-Preferred Generic Drugs $7.00$10.50None
Fluphenazine Decanoate 25mg/mL   5 Injectable Drug 33%33%None
FLUPHENAZINE HCL 2.5MG/5ML ELIXIR   2 Non-Preferred Generic Drugs $7.00$10.50None
FLURBIPROFEN 0.03% EYE DROP   1 Preferred Generic Drugs $2.00$3.00None
Flurbiprofen 100mg/1 500 TABLET, FILM COATED in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $7.00$10.50None
FLURBIPROFEN 50MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Flutamide 125mg/1 500 CAPSULE in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50None
Fluticasone Propionate 0.05mg/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE   2 Non-Preferred Generic Drugs $7.00$10.50None
Fluticasone Propionate 0.5mg/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE   2 Non-Preferred Generic Drugs $7.00$10.50None
FLUTICASONE PROPIONATE 50MCG SPRAY SUSPENSION   2 Non-Preferred Generic Drugs $7.00$10.50Q:16
/30Days
FLUVOXAMINE MALEATE 100MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50Q:90
/30Days
FLUVOXAMINE MALEATE 25MG TABLET (100 CT)   2 Non-Preferred Generic Drugs $7.00$10.50Q:30
/30Days
Fluvoxamine maleate 50mg/1 100 TABLET, FILM COATED in 1 BOTTLE   2 Non-Preferred Generic Drugs $7.00$10.50Q:30
/30Days
Fomepizole 1g/mL 1 VIAL in 1 CARTON / 1.5 mL in 1 VIAL   6 Specialty Tier Drugs 33%N/ANone
Fondaparinux Sodium 10mg/0.8mL 2 SYRINGE in 1 CARTON / 0.8 mL in 1 SYRINGE   6 Specialty Tier Drugs 33%N/ANone
Fondaparinux Sodium 2.5mg/0.5mL 2 SYRINGE in 1 CARTON / 0.5 mL in 1 SYRINGE   5 Injectable Drug 33%33%None
Fondaparinux Sodium 5mg/4mL 2 SYRINGE in 1 CARTON / 0.4 mL in 1 SYRINGE   6 Specialty Tier Drugs 33%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Fondaparinux Sodium 7.5mg/0.6mL 2 SYRINGE in 1 CARTON / 0.6 mL in 1 SYRINGE   6 Specialty Tier Drugs 33%N/ANone
FORADIL AEROLIZER 12 MCG CAP   3 Preferred Brand Drugs $45.00$112.50Q:60
/30Days
FORTAZ 2GM VIAL   5 Injectable Drug 33%33%None
FORTAZ 6GM VIAL   5 Injectable Drug 33%33%None
FORTAZ/ISO-OSMOT 2GM/50ML   5 Injectable Drug 33%33%None
FORTAZ/ISO-OSMOTIC 1GM/50ML   5 Injectable Drug 33%33%None
Forteo 250ug/mL 1 SYRINGE in 1 CARTON / 2.4 mL in 1 SYRINGE   5 Injectable Drug 33%33%P Q:3
/28Days
FORTICAL 200 U/DOSE AEROSOL SPRAY W/PUMP   2 Non-Preferred Generic Drugs $7.00$10.50Q:4
/30Days
FOSAMAX 10MG TABLET (30 CT)   4 Non-Preferred Brand Drugs $90.00$225.00S Q:30
/30Days
FOSAMAX 40MG TABLET   4 Non-Preferred Brand Drugs $90.00$225.00S Q:30
/30Days
FOSAMAX 5MG TABLET (30 CT)   4 Non-Preferred Brand Drugs $90.00$225.00S Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FOSAMAX 70MG ORAL SOLUTION   4 Non-Preferred Brand Drugs $90.00$225.00S Q:300
/28Days
FOSAMAX 70MG TABLET   4 Non-Preferred Brand Drugs $90.00$225.00S Q:4
/28Days
FOSAMAX PLUS D 70; 5600mg/1; [iU]/1 4 TABLET in 1 BLISTER PACK   4 Non-Preferred Brand Drugs $90.00$225.00S Q:4
/28Days
FOSAMAX PLUS D 70MG/2800 IU   4 Non-Preferred Brand Drugs $90.00$225.00S Q:4
/28Days
FOSAMAX TABLET 35MG 20 BLPK   4 Non-Preferred Brand Drugs $90.00$225.00S Q:4
/28Days
FOSCARNET 24MG/ML INFUS BTTL   5 Injectable Drug 33%33%None
FOSINOPRIL SODIUM 10MG TABLET (90 CT)   2 Non-Preferred Generic Drugs $7.00$10.50None
FOSINOPRIL SODIUM 20MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
FOSINOPRIL SODIUM 40MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
FOSINOPRIL SODIUM AND HYDROCHLOROTHIAZIDE TABLETS 10;12.5 MG;MG   2 Non-Preferred Generic Drugs $7.00$10.50None
FOSINOPRIL SODIUM AND HYDROCHLOROTHIAZIDE TABLETS 20;12.5 MG;MG   2 Non-Preferred Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Fosphenytoin 50mg/mL   5 Injectable Drug 33%33%None
Fragmin 12500[iU]/0.5mL   6 Specialty Tier Drugs 33%N/AS
Fragmin 15000[iU]/0.6mL   6 Specialty Tier Drugs 33%N/AS
Fragmin 18000[iU]/0.72mL   6 Specialty Tier Drugs 33%N/AS
FRAGMIN 25000UNITS/ML VIAL 3.8ML x 1   6 Specialty Tier Drugs 33%N/AS
FRAGMIN 2500UNITS SYRINGE 0.2ML x 10   5 Injectable Drug 33%33%S
FRAGMIN 5000UNITS SYRINGE 0.2ML x 10   5 Injectable Drug 33%33%S
FRAGMIN INJECTION 10000UNITS 1 X 10 SYR   6 Specialty Tier Drugs 33%N/AS
FRAGMIN INJECTION 7500UNT/ML   6 Specialty Tier Drugs 33%N/AS
FREAMINE III INJECTION 8.5%   5 Injectable Drug 33%33%None
FREAMINE III INJECTION WITH ELECTROLYTES 3%   5 Injectable Drug 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Furosemide 10mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 4 mL in 1 VIAL, SINGLE-DOSE   5 Injectable Drug 33%33%None
FUROSEMIDE 10MG/ML SOLUTION   1 Preferred Generic Drugs $2.00$3.00None
FUROSEMIDE 20MG TABLET (1000 CT)   1 Preferred Generic Drugs $2.00$3.00None
FUROSEMIDE 40MG TABLET   1 Preferred Generic Drugs $2.00$3.00None
FUROSEMIDE 40MG/5ML TUBEX   1 Preferred Generic Drugs $2.00$3.00None
FUROSEMIDE 80MG TABLET (500 CT)   1 Preferred Generic Drugs $2.00$3.00None
FUSILEV I.V. 50 MG VIAL   5 Injectable Drug 33%33%P
FUZEON CONVENIENCE KIT   6 Specialty Tier Drugs 33%N/AQ:1
/1Days

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D Blue Cross MedicareRx Plus (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $320 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.

  • Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
    • Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.

    • No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.

  • Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
  • Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
    • Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
    • Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
  • Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
    • Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2930) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2012 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
    • Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
  • Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
    • None - This drug does not fall under any drug utilization management controls.
    • P - Prior Authorization -This drug is subject to prior authorization.
    • S - Step Therapy -This drug is subject to step therapy.
    • Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.




(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2012 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.







Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.