2012 Medicare Part D Plan Formulary Information |
Freedom Medi-Medi Partial (HMO SNP) (H5427-078-0)
Benefit Details
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The Freedom Medi-Medi Partial (HMO SNP) (H5427-078-0) Formulary Drugs Starting with the Letter A in Dade County, FL: CMS MA Region 9 which includes: FL
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Drugs Starting with Letter A
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
ACCOLATE 10MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:60 /30Days |
ACCOLATE 20MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:60 /30Days |
ACEBUTOLOL 200MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
ACEBUTOLOL 400MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE |
2 |
Tier 2 |
15% | 15% | None |
Acetaminophen and Codeine Phosphate 300; 60mg/1; mg/1 500 TABLET in 1 BOTTLE |
1 |
Tier 1 |
15% | 15% | Q:360 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD |
1 |
Tier 1 |
15% | 15% | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) |
1 |
Tier 1 |
15% | 15% | Q:360 /30Days |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
1 |
Tier 1 |
15% | 15% | Q:360 /30Days |
ACETAZOLAMIDE 125MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
ACETYLCYSTEINE 10% VIAL |
1 |
Tier 1 |
15% | 15% | P |
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN |
1 |
Tier 1 |
15% | 15% | P |
ACTHIB VACCINE VIAL 10-24UNT/5ML |
2 |
Tier 2 |
15% | 15% | None |
Acyclovir 200mg/1 |
1 |
Tier 1 |
15% | 15% | None |
Acyclovir 200mg/5mL 473 mL in 1 BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
Acyclovir 400mg/1 100 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK |
1 |
Tier 1 |
15% | 15% | None |
Acyclovir 800mg/1 100 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK |
1 |
Tier 1 |
15% | 15% | None |
ADACEL VIAL 2UNT/5UNT |
2 |
Tier 2 |
15% | 15% | None |
AFEDITAB CR 30MG TABLET SA |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
AFEDITAB CR 60MG TABLET 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 |
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER |
1 |
Tier 1 |
15% | 15% | P |
ALBUTEROL SULFATE 4MG TABLET SR 12HR |
1 |
Tier 1 |
15% | 15% | None |
ALBUTEROL SULFATE 8MG TABLET SR 12HR |
1 |
Tier 1 |
15% | 15% | None |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
1 |
Tier 1 |
15% | 15% | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
ALBUTEROL TABLET 4MG (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
ALCLOMETASONE DIPROPIONATE 0.05% CREAM |
1 |
Tier 1 |
15% | 15% | None |
Alclometasone Dipropionate 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
1 |
Tier 1 |
15% | 15% | None |
ALENDRONATE SODIUM 10MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
ALENDRONATE SODIUM 40MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
ALENDRONATE SODIUM 5MG TABLET |
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 |
ALENDRONATE SODIUM 70mg/1 |
1 |
Tier 1 |
15% | 15% | Q:4 /28Days |
ALENDRONATE SODIUM TABLET 35MG 20 CRTN |
1 |
Tier 1 |
15% | 15% | Q:4 /28Days |
ALINIA 100MG/5ML SUSPENSION |
2 |
Tier 2 |
15% | 15% | Q:60 /3Days |
ALINIA 500MG TABLET |
2 |
Tier 2 |
15% | 15% | Q:6 /3Days |
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET in 1 BLISTER PACK |
1 |
Tier 1 |
15% | 15% | None |
ALLOPURINOL SODIUM 500MG VIAL |
1 |
Tier 1 |
15% | 15% | P |
ALLOPURINOL TABLETS |
1 |
Tier 1 |
15% | 15% | None |
AMANTADINE 100MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
AMANTADINE 100MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMCINONIDE 0.1% CREAM |
1 |
Tier 1 |
15% | 15% | None |
AMCINONIDE 0.1% LOTION |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMCINONIDE 0.1% OINTMENT 60GM TUBE |
1 |
Tier 1 |
15% | 15% | None |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
AMINOPHYLLINE 100MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMINOPHYLLINE 200MG TABLET (1000 CT) |
1 |
Tier 1 |
15% | 15% | None |
Aminophylline 25mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIA |
1 |
Tier 1 |
15% | 15% | None |
AMIODARONE HCL 400MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMIODARONE HCL INJECTION |
1 |
Tier 1 |
15% | 15% | None |
Amiodarone hydrochloride 200mg/1 |
1 |
Tier 1 |
15% | 15% | None |
AMITRIP/CDP 25-10 TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMITRIP/PERPHEN 10-2 TABLET |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIP/PERPHEN 10-4 TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMITRIP/PERPHEN 25-2 TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMITRIP/PERPHEN 25-4 TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMITRIP/PERPHEN 50-4 TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMITRIPTYLINE HCL 100MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMITRIPTYLINE HCL 10MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMITRIPTYLINE HCL 150 MG TAB |
1 |
Tier 1 |
15% | 15% | None |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
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 |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES |
2 |
Tier 2 |
15% | 15% | Q:30 /30Days |
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES |
2 |
Tier 2 |
15% | 15% | Q:30 /30Days |
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE |
2 |
Tier 2 |
15% | 15% | Q:30 /30Days |
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE |
2 |
Tier 2 |
15% | 15% | Q:30 /30Days |
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE |
2 |
Tier 2 |
15% | 15% | Q:30 /30Days |
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE |
2 |
Tier 2 |
15% | 15% | Q:30 /30Days |
AMMONIUM CHLORIDE 5 MEQ/ML |
1 |
Tier 1 |
15% | 15% | None |
AMOX TR-K CLV 500-125 MG TAB |
1 |
Tier 1 |
15% | 15% | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE |
1 |
Tier 1 |
15% | 15% | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE |
1 |
Tier 1 |
15% | 15% | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
15% | 15% | None |
AMOXAPINE 100MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMOXAPINE 150MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMOXAPINE 25MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMOXAPINE 50MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN 125MG TABLET CHEW |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN 200MG TABLET CHEW |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN 250MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Amoxicillin 250mg/1 500 TABLET, CHEWABLE in 1 BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN 500MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN 875MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN CAP 500MG |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
1 |
Tier 1 |
15% | 15% | None |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPHETAMINE SALT COMBO 15MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:120 /30Days |
AMPHETAMINE SALT COMBO 30MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:90 /30Days |
AMPHETAMINE SALTS 20MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
Ampicillin 125mg/1 10 VIAL in 1 BOX / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL |
1 |
Tier 1 |
15% | 15% | P |
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL |
1 |
Tier 1 |
15% | 15% | P |
AMPICILLIN CAPSULES 250MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
1 |
Tier 1 |
15% | 15% | None |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
1 |
Tier 1 |
15% | 15% | None |
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Anagrelide Hydrochloride 1mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
ANASTROZOLE TABLETS |
2 |
Tier 2 |
15% | 15% | Q:30 /30Days |
ANCOBON 250MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
ANCOBON 500MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
ANTABUSE 250MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
APRI 0.15-0.03 TABLET |
1 |
Tier 1 |
15% | 15% | None |
ARANELLE 7-9-5 TABLET |
1 |
Tier 1 |
15% | 15% | None |
AROMASIN 25MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
ASACOL 400mg/1 12 BOTTLE in 1 CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE |
2 |
Tier 2 |
15% | 15% | None |
ATENOLOL 100mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
15% | 15% | None |
Atenolol 25mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATENOLOL TABLET USP 50MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
ATORVASTATIN 10 MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
ATORVASTATIN 20 MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
ATORVASTATIN 40 MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
ATORVASTATIN 80 MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
ATROPINE 0.1MG/ML SYRINGE |
1 |
Tier 1 |
15% | 15% | None |
ATROVENT HFA AER 17MCG |
2 |
Tier 2 |
15% | 15% | Q:26 /30Days |
AUGMENTED BETAMETHASONE DIPROPIONATE OINTMENT |
1 |
Tier 1 |
15% | 15% | None |
AVANDAMET 1000; 2mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
15% | 15% | S Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVANDAMET 1000; 4mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
15% | 15% | S Q:60 /30Days |
AVANDAMET 500; 2mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
15% | 15% | S Q:60 /30Days |
AVANDAMET 500; 4mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
15% | 15% | S Q:60 /30Days |
AVANDARYL 1; 4mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
15% | 15% | S Q:60 /30Days |
AVANDARYL 2; 4mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
15% | 15% | S Q:60 /30Days |
AVANDARYL 4; 4mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
15% | 15% | S Q:60 /30Days |
AVANDIA 2mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
15% | 15% | S Q:30 /30Days |
AVANDIA 4mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
15% | 15% | S Q:60 /30Days |
AVANDIA 8mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
15% | 15% | S Q:30 /30Days |
AVODART 0.5MG SOFTGEL |
2 |
Tier 2 |
15% | 15% | Q:30 /30Days |
AZACTAM INJECTION 1GM/50ML |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZACTAM INJECTION 2GM/50ML |
2 |
Tier 2 |
15% | 15% | None |
AZASAN 100MG TABLET |
2 |
Tier 2 |
15% | 15% | P |
AZASAN 75MG TABLET |
2 |
Tier 2 |
15% | 15% | P |
AZATHIOPRINE 50MG TABLET |
1 |
Tier 1 |
15% | 15% | P |
AZITHROMYCIN 250 MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:6 /10Days |
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION |
1 |
Tier 1 |
15% | 15% | None |
Azithromycin 500mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
1 |
Tier 1 |
15% | 15% | Q:5 /10Days |
Azithromycin 600mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
1 |
Tier 1 |
15% | 15% | Q:10 /10Days |