2013 Medicare Part D Plan Formulary Information |
NetworkCares (PPO SNP) (H5215-007-0)
Benefit Details
|
The NetworkCares (PPO SNP) (H5215-007-0) Formulary Drugs Starting with the Letter F in FOND DU LAC County, WI: CMS MA Region 14 which includes: WI
|
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 |
5 |
Specialty Tier |
33% | N/A | None |
FACTIVE 320mg/1 7 TABLET in 1 BLISTER PACK |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FAMCICLOVIR 125MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:21 /1Days |
FAMCICLOVIR 250MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:68 /1Days |
FAMCICLOVIR 500MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:21 /1Days |
FAMOTIDINE 20MG PIGGYBACK |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FAMOTIDINE 20MG TABLET (500 CT) |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FAMOTIDINE 40MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FAMOTIDINE FOR ORAL SUSPENSION |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FAMOTIDINE INJECTION 10MG 25 X 2ML VIALSD |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FAMVIR 125MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | Q:21 /1Days |
FAMVIR 250MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | Q:68 /1Days |
FAMVIR 500MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | Q:21 /1Days |
FANAPT 1 KIT in 1 DOSE PACK |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S |
FANAPT 10mg/1 60 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S |
FANAPT 12mg/1 60 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S |
FANAPT 1mg/1 60 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S |
FANAPT 2mg/1 60 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S |
FANAPT 4mg/1 60 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S |
FANAPT 6mg/1 60 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S |
FANAPT 8mg/1 60 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FARESTON 60 MG TABLET |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
FASLODEX INJECTION |
5 |
Specialty Tier |
33% | N/A | None |
FazaClo 100mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S |
FazaClo 12.5mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S |
FazaClo 150mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S |
FazaClo 25mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S |
FAZACLO TABLETS ORALLY DISINTEGRATING |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S |
FELBAMATE 400 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FELBAMATE 600 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FELBAMATE 600 MG/5 ML SUSP |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FELBATOL 400MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FELBATOL 600MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S |
FELBATOL 600MG/5ML SUSP |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S |
FELDENE 10MG CAPSULE |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S |
FELDENE 20MG CAPSULE |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S |
FELODIPINE ER 2.5MG TABLET 90 TABLET BOT |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FELODIPINE TABLET ER 10MG (1000 CT) |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FELODIPINE TABLET ER 5MG (1000 CT) |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FEMARA 2.5MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
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 |
$93.00 | $265.00 | None |
FEMHRT 0.5MG/2.5MCG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FEMHRT 1/5 TABLET |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FEMRING 0.05MG VAGINAL RING |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FEMRING 0.10MG VAGINAL RING |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FEMTRACE 0.45MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FEMTRACE 0.9MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
fenofibrate 130 mg capsule |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FENOFIBRATE 134MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
fenofibrate 145 mg tablet |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FENOFIBRATE 160mg/1 90 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FENOFIBRATE 200MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
fenofibrate 43 mg capsule |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
fenofibrate 48 mg tablet |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENOFIBRATE 50 MG ORAL CAPSULE [LIPOFEN] |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S |
Fenofibrate 54mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FENOFIBRATE 67MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FENOPROFEN 600MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FENTANYL 100MCG/HR PATCH TRANSDERMAL 72 HOURS |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FENTANYL 12MCG/HR PATCH TRANSDERMAL 72 HOURS |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FENTANYL 75 MCG/HR PATCH |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FENTANYL CITRATE 1600ug/1 30 BLISTER PACK in 1 CARTON / 1 LOZENGE in 1 BLISTER PACK |
5 |
Specialty Tier |
33% | N/A | Q:124 /31Days |
FENTANYL CITRATE 200ug/1 30 BLISTER PACK in 1 CARTON / 1 LOZENGE in 1 BLISTER PACK |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:124 /31Days |
FENTANYL CITRATE LOZENGES |
5 |
Specialty Tier |
33% | N/A | Q:124 /31Days |
FENTANYL CITRATE LOZENGES |
5 |
Specialty Tier |
33% | N/A | Q:124 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENTANYL CITRATE LOZENGES |
5 |
Specialty Tier |
33% | N/A | Q:124 /31Days |
FENTANYL CITRATE LOZENGES |
5 |
Specialty Tier |
33% | N/A | Q:124 /31Days |
FENTANYL TRANSDERMAL SYSTEM 25MCG 5 SYSTEMS CRTN |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FENTANYL TRANSDERMAL SYSTEM 50MCG 5 SYSTEMS CRTN |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FENTORA TABLET 100MCG |
5 |
Specialty Tier |
33% | N/A | Q:112 /28Days |
FENTORA TABLET 200MCG |
5 |
Specialty Tier |
33% | N/A | Q:112 /28Days |
FENTORA TABLET 400MCG |
5 |
Specialty Tier |
33% | N/A | Q:112 /28Days |
FENTORA TABLET 600MCG |
5 |
Specialty Tier |
33% | N/A | Q:112 /28Days |
FENTORA TABLET 800MCG |
5 |
Specialty Tier |
33% | N/A | Q:112 /28Days |
FERRIPROX 500 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
FEXMID 7.5 MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FIBRICOR 105mg/1 30 TABLET BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S |
FIBRICOR 35mg/1 30 TABLET BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S |
FINACEA 15% GEL |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
FINASTERIDE 5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Fioricet with Codeine 325; 50; 40; 30mg 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FIORINAL W/CODEINE #3 CAPSULE |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
Firazyr 30.0mg/3mL 1 SYRINGE, GLASS in 1 CARTON / 3 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
33% | N/A | None |
FIRMAGON 20mg/mL 1 VIAL, GLASS in 1 CARTON / 4 mL in 1 VIAL, GLASS |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FLAGYL 250MG TABLET (100 CT) |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FLAGYL 375 CAPSULE |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FLAGYL 500MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLAGYL ER 750MG TABLET SA |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FLAREX 0.1% EYE DROPS |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FLAVOXATE HCL 100MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLECAINIDE ACETATE 100 MG TAB #60 EA |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLECAINIDE ACETATE 150 MG TAB 360 EA |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLECAINIDE ACETATE 50MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLECTOR PATCH |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
Flo-Pred 15mg/5mL 1 BOTTLE in 1 CARTON / 52 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FLOMAX 0.4MG CAPSULE SA |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S |
FLONASE 0.05% NASAL SPRAY |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S Q:32 /1Days |
FLOVENT DISKUS 100ug/1 60 POWDER, METERED in 1 INHALER |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:120 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLOVENT DISKUS 250ug/1 60 POWDER, METERED in 1 INHALER |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:120 /1Days |
FLOVENT DISKUS POWDER 50MCG 60 CTR |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:120 /1Days |
FLOVENT HFA 110ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:24 /1Days |
FLOVENT HFA 220ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:24 /1Days |
FLOVENT HFA 44ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:21 /1Days |
Fluconazole 200mg/1 30 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Fluconazole 50mg/1 30 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUCONAZOLE INJECTION 200MG 6 X 200/250ML CTR |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUCONAZOLE ORAL SUSPENSION |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUCONAZOLE ORAL SUSPENSION |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUCONAZOLE TABLETS |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUCONAZOLE TABLETS |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Flucytosine 250mg/1 |
5 |
Specialty Tier |
33% | N/A | None |
Flucytosine 500mg/1 |
5 |
Specialty Tier |
33% | N/A | None |
FLUDARABINE 50MG VIAL |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
FLUDROCORTISONE ACETATE 0.1MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:50 /1Days |
FLUOCINOLONE 0.01% BODY OIL |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUOCINOLONE 0.01% CREAM |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUOCINOLONE 0.01% SOLUTION |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUOCINOLONE 0.025% CREAM |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUOCINOLONE 0.025% OINTMENT |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | 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 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUOCINONIDE 0.05% SOLUTION |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Fluocinonide 0.5mg/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Fluocinonide 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Fluocinonide 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUOROPLEX 1% CREAM |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
FLUOROURACIL 2% TOPICAL SOLN |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUOROURACIL 5% TOP SOLUTION |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
fluorouracil 500 mg/10 ml vial |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUOROURACIL CREA 5% |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Fluoxetine 20mg/5mL 120 mL in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOXETINE 40MG CAPSULE (30 CT) |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUOXETINE CAPSULES 10MG (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUOXETINE DR 90 MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUOXETINE HCL 20MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUOXETINE HCL 60 MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
Fluoxetine Hydrochloride 20mg/1 100 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUOXETINE HYDROCHLORIDE TABLETS 10MG 100 BOT |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUOXYMESTERONE 10MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUPHENAZINE 10MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUPHENAZINE 1MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUPHENAZINE 2.5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUPHENAZINE 2.5MG/ML VIAL |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUPHENAZINE 5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUPHENAZINE 5MG/ML CONC |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Fluphenazine Decanoate 25mg/mL |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUPHENAZINE HCL 2.5MG/5ML ELIXIR |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Flurazepam 30mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC |
3 |
Preferred Brand |
$42.00 | $105.00 | P |
FLURAZEPAM HCL 15mg/1 500 CAPSULE in 1 BOTTLE, PLASTIC |
3 |
Preferred Brand |
$42.00 | $105.00 | P |
FLURBIPROFEN 0.03% EYE DROP |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Flurbiprofen 100mg/1 100 BOTTLE in 1 BOTTLE / 100 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLURBIPROFEN 50MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Flutamide 125mg/1 500 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUTICASONE PROP 0.05% LOTION |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Fluticasone Propionate 0.05mg/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Fluticasone Propionate 0.5mg/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUTICASONE PROPIONATE 50MCG SPRAY SUSPENSION |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:32 /1Days |
FLUVASTATIN SODIUM 20 MG CAP |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUVASTATIN SODIUM 40 MG CAP |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUVOXAMINE MALEATE 100MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FLUVOXAMINE MALEATE 25MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Fluvoxamine maleate 50mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FML FORTE 0.25% EYE DROPS |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FML LIQUIFILM 0.1% EYE DROP |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | 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 |
$93.00 | $265.00 | None |
FOCALIN 10MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FOCALIN 2.5MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FOCALIN 5MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FOCALIN XR 10MG CAPSULE |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FOCALIN XR 15MG CAPSULE |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FOCALIN XR 20MG CAPSULE |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
Focalin XR 25mg EXTENDED RELEASE 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
Focalin XR 35mg EXTENDED RELEASE 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
Focalin XR 40mg EXTENDED RELEASE 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FOCALIN XR 5MG CAPSULE |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FOCALIN XR CAPSULES |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FOLOTYN 20mg/mL 1 VIAL, SINGLE-USE in 1 CARTON / 2 mL in 1 VIAL, SINGLE-USE |
5 |
Specialty Tier |
33% | N/A | None |
Fomepizole 1g/mL 1 VIAL in 1 CARTON / 1.5 mL in 1 VIAL |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Fondaparinux Sodium 10mg/0.8mL 2 SYRINGE in 1 CARTON / 0.8 mL in 1 SYRINGE |
5 |
Specialty Tier |
33% | N/A | None |
Fondaparinux Sodium 2.5mg/0.5mL 2 SYRINGE in 1 CARTON / 0.5 mL in 1 SYRINGE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Fondaparinux Sodium 5mg/4mL 2 SYRINGE in 1 CARTON / 0.4 mL in 1 SYRINGE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Fondaparinux Sodium 7.5mg/0.6mL 2 SYRINGE in 1 CARTON / 0.6 mL in 1 SYRINGE |
5 |
Specialty Tier |
33% | N/A | None |
FORADIL AEROLIZER 12 MCG CAP |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | Q:120 /1Days |
FORFIVO XL 450 MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FORTAMET 1000MG TABLET SR OSMOTIC PUSH 24HR |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S Q:78 /31Days |
FORTAMET 500MG TABLET SR OSMOTIC PUSH 24HR |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S Q:155 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FORTAZ 2GM VIAL |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FORTAZ 6GM VIAL |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FORTAZ/ISO-OSMOT 2GM/50ML |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FORTAZ/ISO-OSMOTIC 1GM/50ML |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
Forteo 250ug/mL 1 SYRINGE in 1 CARTON / 2.4 mL in 1 SYRINGE |
5 |
Specialty Tier |
33% | N/A | None |
FORTESTA 10mg/0.5g |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | P |
FORTICAL 200 U/DOSE AEROSOL SPRAY W/PUMP |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FOSAMAX 70MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S Q:5 /1Days |
FOSAMAX PLUS D 70; 5600mg/1; [iU]/1 4 TABLET in 1 BLISTER PACK |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S Q:5 /1Days |
FOSAMAX PLUS D 70MG/2800 IU |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S Q:5 /1Days |
FOSCARNET 24MG/ML INFUS BTTL |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FOSINOPRIL SODIUM 10MG TABLET (90 CT) |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
FOSINOPRIL SODIUM 20MG TABLET |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
FOSINOPRIL SODIUM 40MG TABLET |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
FOSINOPRIL SODIUM AND HYDROCHLOROTHIAZIDE TABLETS 10;12.5 MG;MG |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FOSINOPRIL SODIUM AND HYDROCHLOROTHIAZIDE TABLETS 20;12.5 MG;MG |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Fosphenytoin Sodium 50mg/mL 2 mL in 1 VIAL |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FOSRENOL 1000MG TABLET CHEW |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FOSRENOL 500MG TABLET CHEW |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FOSRENOL 750MG TABLET CHEW |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
Fragmin 12500[iU]/0.5mL |
5 |
Specialty Tier |
33% | N/A | None |
Fragmin 15000[iU]/0.6mL |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Fragmin 18000[iU]/0.72mL |
5 |
Specialty Tier |
33% | N/A | None |
FRAGMIN 25000UNITS/ML VIAL 3.8ML x 1 |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
FRAGMIN 2500UNITS SYRINGE 0.2ML x 10 |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | Q:10 /10Days |
FRAGMIN 5000UNITS SYRINGE 0.2ML x 10 |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | Q:14 /14Days |
FRAGMIN INJECTION 10000UNITS 1 X 10 SYR |
5 |
Specialty Tier |
33% | N/A | None |
FRAGMIN INJECTION 7500UNT/ML |
5 |
Specialty Tier |
33% | N/A | None |
FREAMINE III INJECTION 8.5% |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
FREAMINE III INJECTION WITH ELECTROLYTES 3% |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
FROVA 2.5MG TABLET |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | S Q:9 /1Days |
FULYZAQ 125 MG DR TABLET |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FURADANTIN 25 MG/5 ML SUSP 230 ML |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | 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 |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FUROSEMIDE 10MG/ML SOLUTION |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Furosemide 20mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
Furosemide 40 mg tablet |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FUROSEMIDE 40MG/5ML TUBEX |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FUROSEMIDE 80MG TABLET (500 CT) |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None |
FUSILEV I.V. 50 MG VIAL |
4 |
Non-Preferred Brand |
$93.00 | $265.00 | None |
FUZEON CONVENIENCE KIT |
5 |
Specialty Tier |
33% | N/A | None |