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CVS Caremark Value (PDP) (S5601-064-0)
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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
CVS Caremark Value (PDP) (S5601-064-0)
Benefit Details           
The CVS Caremark Value (PDP) (S5601-064-0)
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   4 Specialty Tier Drugs 25%N/AP
FAMCICLOVIR 125MG TABLET   1 Generic Drugs $7.00$10.50None
FAMCICLOVIR 250MG TABLET   1 Generic Drugs $7.00$10.50None
FAMCICLOVIR 500MG TABLET   1 Generic Drugs $7.00$10.50None
FAMOTIDINE 20MG PIGGYBACK   1 Generic Drugs $7.00$10.50None
FAMOTIDINE 20MG TABLET (500 CT)   1 Generic Drugs $7.00$10.50None
FAMOTIDINE 40MG TABLET   1 Generic Drugs $7.00$10.50None
FAMOTIDINE FOR ORAL SUSPENSION   1 Generic Drugs $7.00$10.50None
FAMOTIDINE INJECTION 10MG 25 X 2ML VIALSD   1 Generic Drugs $7.00$10.50None
FANAPT 1 KIT in 1 DOSE PACK   3 Non-Preferred Brand Drugs $95.00$261.25S
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   3 Non-Preferred Brand Drugs $95.00$261.25S
FANAPT 12mg/1 60 TABLET in 1 BOTTLE   3 Non-Preferred Brand Drugs $95.00$261.25S
FANAPT 1mg/1 60 TABLET in 1 BOTTLE   3 Non-Preferred Brand Drugs $95.00$261.25S
FANAPT 2mg/1 60 TABLET in 1 BOTTLE   3 Non-Preferred Brand Drugs $95.00$261.25S
FANAPT 4mg/1 60 TABLET in 1 BOTTLE   3 Non-Preferred Brand Drugs $95.00$261.25S
FANAPT 6mg/1 60 TABLET in 1 BOTTLE   3 Non-Preferred Brand Drugs $95.00$261.25S
FANAPT 8mg/1 60 TABLET in 1 BOTTLE   3 Non-Preferred Brand Drugs $95.00$261.25S
FARESTON 60MG TABLET   2 Preferred Brand Drugs $45.00$101.25None
FASLODEX INJECTION   4 Specialty Tier Drugs 25%N/AP
FazaClo 100mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE   3 Non-Preferred Brand Drugs $95.00$261.25P
FazaClo 12.5mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE   3 Non-Preferred Brand Drugs $95.00$261.25P
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   3 Non-Preferred Brand Drugs $95.00$261.25P
FazaClo 25mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE   3 Non-Preferred Brand Drugs $95.00$261.25P
FAZACLO TABLETS ORALLY DISINTEGRATING   3 Non-Preferred Brand Drugs $95.00$261.25P
FELBAMATE 400 MG TABLET   1 Generic Drugs $7.00$10.50None
FELBAMATE 600 MG TABLET   1 Generic Drugs $7.00$10.50None
FELBAMATE 600 MG/5 ML SUSP   1 Generic Drugs $7.00$10.50None
FELODIPINE ER 2.5MG TABLET 90 TABLET BOT   1 Generic Drugs $7.00$10.50None
FELODIPINE TABLET ER 10MG (1000 CT)   1 Generic Drugs $7.00$10.50None
FELODIPINE TABLET ER 5MG (1000 CT)   1 Generic Drugs $7.00$10.50None
FENOFIBRATE 134MG CAPSULE   1 Generic Drugs $7.00$10.50None
FENOFIBRATE 160mg/1 90 TABLET in 1 BOTTLE   1 Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FENOFIBRATE 200MG CAPSULE   1 Generic Drugs $7.00$10.50None
FENOFIBRATE 50 MG ORAL CAPSULE [LIPOFEN]   2 Preferred Brand Drugs $45.00$101.25None
FENOFIBRATE 54MG TABLET   1 Generic Drugs $7.00$10.50None
FENOFIBRATE 67MG CAPSULE   1 Generic Drugs $7.00$10.50None
FENTANYL 100MCG/HR PATCH TRANSDERMAL 72 HOURS   1 Generic Drugs $7.00$10.50P Q:10
/30Days
FENTANYL 12MCG/HR PATCH TRANSDERMAL 72 HOURS   1 Generic Drugs $7.00$10.50Q:10
/30Days
FENTANYL 75 MCG/HR PATCH   1 Generic Drugs $7.00$10.50P Q:10
/30Days
FENTANYL CITRATE 1600ug/1 30 BLISTER PACK in 1 CARTON / 1 LOZENGE in 1 BLISTER PACK   4 Specialty Tier Drugs 25%N/AP Q:120
/30Days
FENTANYL CITRATE INJECTION 50MCG 10 X 2ML CTG   1 Generic Drugs $7.00$10.50P
FENTANYL CITRATE LOZENGES   4 Specialty Tier Drugs 25%N/AP Q:120
/30Days
FENTANYL CITRATE LOZENGES   4 Specialty Tier Drugs 25%N/AP Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FENTANYL CITRATE LOZENGES   4 Specialty Tier Drugs 25%N/AP Q:120
/30Days
FENTANYL CITRATE LOZENGES   4 Specialty Tier Drugs 25%N/AP Q:120
/30Days
FENTANYL CITRATE OTFC 200 MCG   2 Preferred Brand Drugs $45.00$101.25P Q:120
/30Days
FENTANYL TRANSDERMAL SYSTEM 25MCG 5 SYSTEMS CRTN   1 Generic Drugs $7.00$10.50Q:10
/30Days
FENTANYL TRANSDERMAL SYSTEM 50MCG 5 SYSTEMS CRTN   1 Generic Drugs $7.00$10.50P Q:10
/30Days
FINASTERIDE 5MG TABLET   1 Generic Drugs $7.00$10.50None
FLECAINIDE ACETATE 100 MG TAB #60 EA   1 Generic Drugs $7.00$10.50None
FLECAINIDE ACETATE 150 MG TAB 360 EA   1 Generic Drugs $7.00$10.50None
FLECAINIDE ACETATE 50MG TABLET (100 CT)   1 Generic Drugs $7.00$10.50None
FLOVENT DISKUS 100ug/1 60 POWDER, METERED in 1 INHALER   2 Preferred Brand Drugs $45.00$101.25Q:120
/30Days
FLOVENT DISKUS 250ug/1 60 POWDER, METERED in 1 INHALER   2 Preferred Brand Drugs $45.00$101.25Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLOVENT DISKUS POWDER 50MCG 60 CTR   2 Preferred Brand Drugs $45.00$101.25Q:120
/30Days
FLOVENT HFA 110ug/1 120 AEROSOL, METERED in 1 INHALER   2 Preferred Brand Drugs $45.00$101.25Q:24
/30Days
FLOVENT HFA 220ug/1 120 AEROSOL, METERED in 1 INHALER   2 Preferred Brand Drugs $45.00$101.25Q:24
/30Days
FLOVENT HFA 44ug/1 120 AEROSOL, METERED in 1 INHALER   2 Preferred Brand Drugs $45.00$101.25Q:24
/30Days
Fluconazole 200mg/1 30 TABLET in 1 BOTTLE   1 Generic Drugs $7.00$10.50None
Fluconazole 50mg/1 30 TABLET in 1 BOTTLE   1 Generic Drugs $7.00$10.50None
FLUCONAZOLE INJECTION 200MG 6 X 200/250ML CTR   1 Generic Drugs $7.00$10.50None
FLUCONAZOLE ORAL SUSPENSION   1 Generic Drugs $7.00$10.50None
FLUCONAZOLE ORAL SUSPENSION   1 Generic Drugs $7.00$10.50None
FLUCONAZOLE TABLETS   1 Generic Drugs $7.00$10.50None
FLUCONAZOLE TABLETS   1 Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Flucytosine 250mg/1   1 Generic Drugs $7.00$10.50None
Flucytosine 500mg/1   1 Generic Drugs $7.00$10.50None
FLUDARABINE 50MG VIAL   4 Specialty Tier Drugs 25%N/AP
FLUDROCORTISONE ACETATE 0.1MG TABLET (100 CT)   1 Generic Drugs $7.00$10.50None
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL   1 Generic Drugs $7.00$10.50Q:50
/30Days
FLUOCINOLONE 0.01% BODY OIL   1 Generic Drugs $7.00$10.50None
FLUOCINOLONE 0.01% CREAM   1 Generic Drugs $7.00$10.50None
FLUOCINOLONE 0.01% SOLUTION   1 Generic Drugs $7.00$10.50None
FLUOCINOLONE 0.025% CREAM   1 Generic Drugs $7.00$10.50None
FLUOCINOLONE 0.025% OINTMENT   1 Generic Drugs $7.00$10.50None
FLUOCINOLONE OIL 0.01% EAR DRP   1 Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLUOCINONIDE 0.05% SOLUTION   1 Generic Drugs $7.00$10.50None
Fluocinonide 0.5mg/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE   1 Generic Drugs $7.00$10.50None
Fluocinonide 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE   1 Generic Drugs $7.00$10.50None
Fluocinonide 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE   1 Generic Drugs $7.00$10.50None
FLUOROMETHOLONE 0.1% DROPS   1 Generic Drugs $7.00$10.50None
FLUOROURACIL 2% SOLUTION NON-ORAL   1 Generic Drugs $7.00$10.50None
FLUOROURACIL 5% SOLUTION NON-ORAL   1 Generic Drugs $7.00$10.50None
Fluorouracil 50mg/mL   1 Generic Drugs $7.00$10.50P
FLUOROURACIL CREA 5%   1 Generic Drugs $7.00$10.50None
Fluoxetine 20mg/5mL 120 mL in 1 BOTTLE, PLASTIC   1 Generic Drugs $7.00$10.50None
FLUOXETINE 40MG CAPSULE (30 CT)   1 Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLUOXETINE CAPSULES 10MG (100 CT)   1 Generic Drugs $7.00$10.50Q:30
/30Days
FLUOXETINE HCL 20MG TABLET   1 Generic Drugs $7.00$10.50None
Fluoxetine Hydrochloride 20mg/1 100 CAPSULE in 1 BOTTLE   1 Generic Drugs $7.00$10.50Q:30
/30Days
FLUOXETINE HYDROCHLORIDE TABLETS 10MG 100 BOT   1 Generic Drugs $7.00$10.50Q:45
/30Days
FLUOXYMESTERONE 10MG TABLET   2 Preferred Brand Drugs $45.00$101.25P
FLUPHENAZINE 10MG TABLET   1 Generic Drugs $7.00$10.50None
FLUPHENAZINE 1MG TABLET   1 Generic Drugs $7.00$10.50None
FLUPHENAZINE 2.5MG TABLET   1 Generic Drugs $7.00$10.50None
FLUPHENAZINE 2.5MG/ML VIAL   1 Generic Drugs $7.00$10.50None
FLUPHENAZINE 5MG TABLET   1 Generic Drugs $7.00$10.50None
FLUPHENAZINE 5MG/ML CONC   1 Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Fluphenazine Decanoate 25mg/mL   1 Generic Drugs $7.00$10.50None
FLUPHENAZINE HCL 2.5MG/5ML ELIXIR   1 Generic Drugs $7.00$10.50None
FLURBIPROFEN 0.03% EYE DROP   1 Generic Drugs $7.00$10.50None
Flurbiprofen 100mg/1 500 TABLET, FILM COATED in 1 BOTTLE, PLASTIC   1 Generic Drugs $7.00$10.50None
FLURBIPROFEN 50MG TABLET   1 Generic Drugs $7.00$10.50None
Flutamide 125mg/1 500 CAPSULE in 1 BOTTLE   1 Generic Drugs $7.00$10.50None
Fluticasone Propionate 0.05mg/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE   1 Generic Drugs $7.00$10.50None
Fluticasone Propionate 0.5mg/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE   1 Generic Drugs $7.00$10.50None
FLUTICASONE PROPIONATE 50MCG SPRAY SUSPENSION   1 Generic Drugs $7.00$10.50Q:16
/30Days
FLUVOXAMINE MALEATE 100MG TABLET   1 Generic Drugs $7.00$10.50None
FLUVOXAMINE MALEATE 25MG TABLET (100 CT)   1 Generic Drugs $7.00$10.50Q:45
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Fluvoxamine maleate 50mg/1 100 TABLET, FILM COATED in 1 BOTTLE   1 Generic Drugs $7.00$10.50Q:45
/30Days
FML S.O.P. 0.1% OINTMENT   2 Preferred Brand Drugs $45.00$101.25None
Fondaparinux Sodium 10mg/0.8mL 2 SYRINGE in 1 CARTON / 0.8 mL in 1 SYRINGE   4 Specialty Tier Drugs 25%N/AQ:30
/180Days
Fondaparinux Sodium 2.5mg/0.5mL 2 SYRINGE in 1 CARTON / 0.5 mL in 1 SYRINGE   1 Generic Drugs $7.00$10.50Q:30
/180Days
Fondaparinux Sodium 5mg/4mL 2 SYRINGE in 1 CARTON / 0.4 mL in 1 SYRINGE   4 Specialty Tier Drugs 25%N/AQ:30
/180Days
Fondaparinux Sodium 7.5mg/0.6mL 2 SYRINGE in 1 CARTON / 0.6 mL in 1 SYRINGE   4 Specialty Tier Drugs 25%N/AQ:30
/180Days
FORADIL AEROLIZER 12 MCG CAP   2 Preferred Brand Drugs $45.00$101.25Q:60
/30Days
Forteo 250ug/mL 1 SYRINGE in 1 CARTON / 2.4 mL in 1 SYRINGE   4 Specialty Tier Drugs 25%N/AP
FORTICAL 200 U/DOSE AEROSOL SPRAY W/PUMP   1 Generic Drugs $7.00$10.50None
FOSINOPRIL SODIUM 10MG TABLET (90 CT)   1 Generic Drugs $7.00$10.50None
FOSINOPRIL SODIUM 20MG TABLET   1 Generic Drugs $7.00$10.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FOSINOPRIL SODIUM 40MG TABLET   1 Generic Drugs $7.00$10.50None
FOSINOPRIL SODIUM AND HYDROCHLOROTHIAZIDE TABLETS 10;12.5 MG;MG   1 Generic Drugs $7.00$10.50None
FOSINOPRIL SODIUM AND HYDROCHLOROTHIAZIDE TABLETS 20;12.5 MG;MG   1 Generic Drugs $7.00$10.50None
FOSRENOL 1000MG TABLET CHEW   2 Preferred Brand Drugs $45.00$101.25None
FOSRENOL 500MG TABLET CHEW   2 Preferred Brand Drugs $45.00$101.25None
FOSRENOL 750MG TABLET CHEW   2 Preferred Brand Drugs $45.00$101.25None
Fragmin 12500[iU]/0.5mL   4 Specialty Tier Drugs 25%N/AQ:30
/180Days
Fragmin 15000[iU]/0.6mL   4 Specialty Tier Drugs 25%N/AQ:30
/180Days
Fragmin 18000[iU]/0.72mL   4 Specialty Tier Drugs 25%N/AQ:30
/180Days
FRAGMIN 25000UNITS/ML VIAL 3.8ML x 1   2 Preferred Brand Drugs $45.00$101.25Q:30
/180Days
FRAGMIN 2500UNITS SYRINGE 0.2ML x 10   2 Preferred Brand Drugs $45.00$101.25Q:30
/180Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FRAGMIN 5000UNITS SYRINGE 0.2ML x 10   2 Preferred Brand Drugs $45.00$101.25Q:30
/180Days
FRAGMIN INJECTION 10000UNITS 1 X 10 SYR   4 Specialty Tier Drugs 25%N/AQ:30
/180Days
FRAGMIN INJECTION 7500UNT/ML   4 Specialty Tier Drugs 25%N/AQ:30
/180Days
FREAMINE III INJECTION 8.5%   1 Generic Drugs $7.00$10.50P
FREAMINE III INJECTION WITH ELECTROLYTES 3%   2 Preferred Brand Drugs $45.00$101.25P
Furosemide 10mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 4 mL in 1 VIAL, SINGLE-DOSE   1 Generic Drugs $7.00$10.50None
FUROSEMIDE 10MG/ML SOLUTION   1 Generic Drugs $7.00$10.50None
FUROSEMIDE 20MG TABLET (1000 CT)   1 Generic Drugs $7.00$10.50None
FUROSEMIDE 40MG TABLET   1 Generic Drugs $7.00$10.50None
FUROSEMIDE 80MG TABLET (500 CT)   1 Generic Drugs $7.00$10.50None
FUZEON CONVENIENCE KIT   4 Specialty Tier Drugs 25%N/ANone

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D CVS Caremark Value (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.