2013 Medicare Part D Plan Formulary Information |
Optimum Platinum Plan (HMO-POS) (H5594-002-0)
Benefit Details
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The Optimum Platinum Plan (HMO-POS) (H5594-002-0) Formulary Drugs Starting with the Letter F in MIAMI-DADE County, FL: CMS MA Region 9 which includes: FL
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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 |
Specialty Tier |
33% | 33% | P |
FAMCICLOVIR 125MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FAMCICLOVIR 250MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FAMOTIDINE 20MG TABLET (500 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FAMOTIDINE 40MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FAMOTIDINE INJECTION 10MG 25 X 2ML VIALSD |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
FANAPT 1 KIT in 1 DOSE PACK |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | S |
FANAPT 10mg/1 60 TABLET BOTTLE |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | S Q:60 /30Days |
FANAPT 12mg/1 60 TABLET BOTTLE |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | S Q:60 /30Days |
FANAPT 1mg/1 60 TABLET BOTTLE |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | S Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FANAPT 2mg/1 60 TABLET BOTTLE |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | S Q:60 /30Days |
FANAPT 4mg/1 60 TABLET BOTTLE |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | S Q:60 /30Days |
FANAPT 6mg/1 60 TABLET BOTTLE |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | S Q:60 /30Days |
FANAPT 8mg/1 60 TABLET BOTTLE |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | S Q:60 /30Days |
FARESTON 60 MG TABLET |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
FASLODEX INJECTION |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | P |
FazaClo 100mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | S |
FazaClo 12.5mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | S |
FazaClo 150mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | S |
FazaClo 25mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | S |
FAZACLO TABLETS ORALLY DISINTEGRATING |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FELBATOL 400MG TABLET |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
FELBATOL 600MG TABLET |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
FELBATOL 600MG/5ML SUSP |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
FELODIPINE ER 2.5MG TABLET 90 TABLET BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
FELODIPINE TABLET ER 10MG (1000 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
FELODIPINE TABLET ER 5MG (1000 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
fenofibrate 130 mg capsule |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
FENOFIBRATE 134MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FENOFIBRATE 160mg/1 90 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FENOFIBRATE 200MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
fenofibrate 43 mg capsule |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Fenofibrate 54mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FENOFIBRATE 67MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FENOPROFEN 600MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FENTANYL 100MCG/HR PATCH TRANSDERMAL 72 HOURS |
2 |
Preferred Brand |
$5.00 | $10.00 | Q:15 /30Days |
FENTANYL 12MCG/HR PATCH TRANSDERMAL 72 HOURS |
2 |
Preferred Brand |
$5.00 | $10.00 | Q:15 /30Days |
FENTANYL 75 MCG/HR PATCH |
2 |
Preferred Brand |
$5.00 | $10.00 | Q:15 /30Days |
FENTANYL TRANSDERMAL SYSTEM 25MCG 5 SYSTEMS CRTN |
2 |
Preferred Brand |
$5.00 | $10.00 | Q:15 /30Days |
FENTANYL TRANSDERMAL SYSTEM 50MCG 5 SYSTEMS CRTN |
2 |
Preferred Brand |
$5.00 | $10.00 | Q:15 /30Days |
FENTORA TABLET 100MCG |
4 |
Specialty Tier |
33% | 33% | P Q:112 /28Days |
FENTORA TABLET 200MCG |
4 |
Specialty Tier |
33% | 33% | P Q:112 /28Days |
FENTORA TABLET 400MCG |
4 |
Specialty Tier |
33% | 33% | P Q:112 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENTORA TABLET 600MCG |
4 |
Specialty Tier |
33% | 33% | P Q:112 /28Days |
FENTORA TABLET 800MCG |
4 |
Specialty Tier |
33% | 33% | P Q:112 /28Days |
FINASTERIDE 5MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
FIRMAGON 20mg/mL 1 VIAL, GLASS in 1 CARTON / 4 mL in 1 VIAL, GLASS |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | P |
FLAREX 0.1% EYE DROPS |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
FLAVOXATE HCL 100MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FLECAINIDE ACETATE 100 MG TAB #60 EA |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FLECAINIDE ACETATE 150 MG TAB 360 EA |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FLECAINIDE ACETATE 50MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FLOVENT HFA 110ug/1 120 AEROSOL, METERED in 1 INHALER |
2 |
Preferred Brand |
$5.00 | $10.00 | Q:12 /30Days |
FLOVENT HFA 220ug/1 120 AEROSOL, METERED in 1 INHALER |
2 |
Preferred Brand |
$5.00 | $10.00 | Q:24 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLOVENT HFA 44ug/1 120 AEROSOL, METERED in 1 INHALER |
2 |
Preferred Brand |
$5.00 | $10.00 | Q:11 /30Days |
Fluconazole 200mg/1 30 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Fluconazole 50mg/1 30 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FLUCONAZOLE INJECTION 200MG 6 X 200/250ML CTR |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
FLUCONAZOLE ORAL SUSPENSION |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FLUCONAZOLE ORAL SUSPENSION |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FLUCONAZOLE TABLETS |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FLUCONAZOLE TABLETS |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:2 /30Days |
FLUDARABINE 50MG VIAL |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
FLUDROCORTISONE ACETATE 0.1MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOCINOLONE 0.01% CREAM |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FLUOCINOLONE 0.01% SOLUTION |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FLUOCINOLONE 0.025% CREAM |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FLUOCINOLONE 0.025% OINTMENT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FLUOCINONIDE 0.05% SOLUTION |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Fluocinonide 0.5mg/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Fluocinonide 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Fluocinonide 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FLUOROPLEX 1% CREAM |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
FLUOROURACIL 2% TOPICAL SOLN |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FLUOROURACIL 5% TOP SOLUTION |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
fluorouracil 500 mg/10 ml vial |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
FLUOROURACIL CREA 5% |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
Fluoxetine 20mg/5mL 120 mL in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:600 /30Days |
FLUOXETINE 40MG CAPSULE (30 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days |
FLUOXETINE CAPSULES 10MG (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
FLUOXETINE DR 90 MG CAPSULE |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | Q:4 /28Days |
Fluoxetine Hydrochloride 20mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:120 /30Days |
FLUOXYMESTERONE 10MG TABLET |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
FLUPHENAZINE 10MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FLUPHENAZINE 1MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FLUPHENAZINE 2.5MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUPHENAZINE 2.5MG/ML VIAL |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
FLUPHENAZINE 5MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FLUPHENAZINE 5MG/ML CONC |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Fluphenazine Decanoate 25mg/mL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FLUPHENAZINE HCL 2.5MG/5ML ELIXIR |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Flurbiprofen 100mg/1 100 BOTTLE in 1 BOTTLE / 100 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FLURBIPROFEN 50MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Flutamide 125mg/1 500 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FLUTICASONE PROP 0.05% LOTION |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Fluticasone Propionate 0.05mg/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Fluticasone Propionate 0.5mg/g 1 TUBE in 1 CARTON / 30 g in 1 TUBE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUTICASONE PROPIONATE 50MCG SPRAY SUSPENSION |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:16 /30Days |
FLUVOXAMINE MALEATE 100MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:90 /30Days |
FLUVOXAMINE MALEATE 25MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days |
Fluvoxamine maleate 50mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days |
FML FORTE 0.25% EYE DROPS |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
FML S.O.P. 0.1% OINTMENT |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
FOLOTYN 20mg/mL 1 VIAL, SINGLE-USE in 1 CARTON / 2 mL in 1 VIAL, SINGLE-USE |
4 |
Specialty Tier |
33% | 33% | P |
Fomepizole 1g/mL 1 VIAL in 1 CARTON / 1.5 mL in 1 VIAL |
4 |
Specialty Tier |
33% | 33% | None |
FORTAMET 1000MG TABLET SR OSMOTIC PUSH 24HR |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Forteo 250ug/mL 1 SYRINGE in 1 CARTON / 2.4 mL in 1 SYRINGE |
4 |
Specialty Tier |
33% | 33% | P |
FORTICAL 200 U/DOSE AEROSOL SPRAY W/PUMP |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FOSAMAX PLUS D 70; 5600mg/1; [iU]/1 4 TABLET in 1 BLISTER PACK |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
FOSAMAX PLUS D 70MG/2800 IU |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
FOSCARNET 24MG/ML INFUS BTTL |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | None |
FOSINOPRIL SODIUM 10MG TABLET (90 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FOSINOPRIL SODIUM 20MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FOSINOPRIL SODIUM 40MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FOSINOPRIL SODIUM AND HYDROCHLOROTHIAZIDE TABLETS 10;12.5 MG;MG |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days |
FOSINOPRIL SODIUM AND HYDROCHLOROTHIAZIDE TABLETS 20;12.5 MG;MG |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:120 /30Days |
Fosphenytoin Sodium 50mg/mL 2 mL in 1 VIAL |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
FREAMINE III INJECTION 8.5% |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
FREAMINE III INJECTION WITH ELECTROLYTES 3% |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FROVA 2.5MG TABLET |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | Q:12 /30Days |
FULYZAQ 125 MG DR TABLET |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | Q:60 /30Days |
Furosemide 10mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 4 mL in 1 VIAL, SINGLE-DOSE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FUROSEMIDE 10MG/ML SOLUTION |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Furosemide 20mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Furosemide 40 mg tablet |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FUROSEMIDE 80MG TABLET (500 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FUZEON CONVENIENCE KIT |
4 |
Specialty Tier |
33% | 33% | Q:60 /30Days |