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Educators Rx Advantage (PDP) (S5877-007-0)
Tier 1 (2248)
Tier 2 (730)
Tier 3 (1793)
Tier 4 (569)

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2014 Medicare Part D Plan Formulary Information
Educators Rx Advantage (PDP) (S5877-007-0)
Benefit Details           
The Educators Rx Advantage (PDP) (S5877-007-0)
Formulary Drugs Starting with the Letter F

in CMS PDP Region 31 which includes: ID UT
Plan Monthly Premium: $121.10 Deductible: $0 Qualifies for LIS: No
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
FABIOR 0.1% FOAM   3 Non-Preferred Brand 40%40%None
FABRAZYME 35MG VIAL   4 Specialty Tier 33%33%None
FACTIVE 320 MG TABLET   3 Non-Preferred Brand 40%40%None
FAMCICLOVIR 125MG TABLET   1 Generic 10%10%None
FAMCICLOVIR 250MG TABLET   1 Generic 10%10%None
FAMCICLOVIR 500MG TABLET   1 Generic 10%10%None
FAMOTIDINE 20MG PIGGYBACK   1 Generic 10%10%None
FAMOTIDINE 20MG TABLET (500 CT)   1 Generic 10%10%None
FAMOTIDINE 40MG TABLET   1 Generic 10%10%None
FAMOTIDINE 50 MG/5MLFOR ORAL SUSPENSION   1 Generic 10%10%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FAMOTIDINE INJECTION 10MG 25 X 2ML VIALSD   1 Generic 10%10%None
FAMVIR 125MG TABLET   3 Non-Preferred Brand 40%40%None
FAMVIR 250MG TABLET   3 Non-Preferred Brand 40%40%None
FAMVIR 500MG TABLET   3 Non-Preferred Brand 40%40%None
FANAPT 1 KIT in 1 DOSE PACK   2 Preferred Brand 20%20%Q:1
/90Days
FANAPT 10mg/1 60 TABLET BOTTLE   2 Preferred Brand 20%20%Q:270
/90Days
FANAPT 12mg/1 60 TABLET BOTTLE   2 Preferred Brand 20%20%Q:180
/90Days
FANAPT 1mg/1 60 TABLET BOTTLE   2 Preferred Brand 20%20%Q:2160
/90Days
FANAPT 2mg/1 60 TABLET BOTTLE   2 Preferred Brand 20%20%Q:1080
/90Days
FANAPT 4mg/1 60 TABLET BOTTLE   2 Preferred Brand 20%20%Q:540
/90Days
FANAPT 6mg/1 60 TABLET BOTTLE   2 Preferred Brand 20%20%Q:360
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FANAPT 8mg/1 60 TABLET BOTTLE   2 Preferred Brand 20%20%Q:270
/90Days
FARESTON 60 MG TABLET   2 Preferred Brand 20%20%None
FARXIGA 10 MG TABLET   3 Non-Preferred Brand 40%40%None
FARXIGA 5 MG TABLET   3 Non-Preferred Brand 40%40%None
FASLODEX 50MG/ML INJECTION   4 Specialty Tier 33%33%None
FazaClo 100mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE   3 Non-Preferred Brand 40%40%None
FazaClo 12.5mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE   3 Non-Preferred Brand 40%40%None
FazaClo 150mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE   2 Preferred Brand 20%20%None
FAZACLO 200 MG TABLETS ORALLY DISINTEGRATING   2 Preferred Brand 20%20%None
FazaClo 25mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE   3 Non-Preferred Brand 40%40%None
FELBAMATE 400 MG TABLET   1 Generic 10%10%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FELBAMATE 600 MG TABLET   1 Generic 10%10%None
FELBAMATE 600 MG/5 ML SUSP   1 Generic 10%10%None
FELBATOL 400MG TABLET   3 Non-Preferred Brand 40%40%None
FELBATOL 600MG TABLET   3 Non-Preferred Brand 40%40%None
FELBATOL 600MG/5ML SUSP   3 Non-Preferred Brand 40%40%None
FELDENE 10MG CAPSULE   3 Non-Preferred Brand 40%40%S
FELDENE 20MG CAPSULE   3 Non-Preferred Brand 40%40%S
FELODIPINE ER 10 MG TABLET   1 Generic 10%10%None
FELODIPINE ER 2.5 MG TABLET   1 Generic 10%10%None
FELODIPINE ER 5 MG TABLET   1 Generic 10%10%None
FEMARA 2.5MG TABLET   3 Non-Preferred Brand 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FEMCON Fe 72 CARTON in 1 CASE / 5 CELLO PACK per CARTON / 1 BLISTER PACK in 1 CELLO PACK / 1 KIT   3 Non-Preferred Brand 40%40%None
FEMRING 0.05MG VAGINAL RING   3 Non-Preferred Brand 40%40%None
FEMRING 0.10MG VAGINAL RING   3 Non-Preferred Brand 40%40%None
FENOFIBRATE 130 MG CAPSULE   1 Generic 10%10%None
FENOFIBRATE 134MG CAPSULE   1 Generic 10%10%None
fenofibrate 145 mg tablet   1 Generic 10%10%None
FENOFIBRATE 150 MG CAPSULE   3 Non-Preferred Brand 40%40%S
FENOFIBRATE 160mg/1 90 TABLET BOTTLE   1 Generic 10%10%None
FENOFIBRATE 200MG CAPSULE   1 Generic 10%10%None
FENOFIBRATE 43 MG CAPSULE   1 Generic 10%10%None
fenofibrate 48 mg tablet   1 Generic 10%10%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FENOFIBRATE 50 MG CAPSULE   3 Non-Preferred Brand 40%40%S
FENOFIBRATE 50 MG ORAL CAPSULE [LIPOFEN]   3 Non-Preferred Brand 40%40%S
Fenofibrate 54mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC   1 Generic 10%10%None
FENOFIBRATE 67MG CAPSULE   1 Generic 10%10%None
Fenofibric acid dr 135 mg capsule [TRILIPIX]   1 Generic 10%10%None
Fenofibric acid dr 45 mg capsule [TRILIPIX]   1 Generic 10%10%None
FENOGLIDE 120 MG TABLET   3 Non-Preferred Brand 40%40%S
FENOGLIDE 40 MG TABLET   3 Non-Preferred Brand 40%40%S
FENOPROFEN 600MG TABLET   1 Generic 10%10%None
FENTANYL 100MCG/HR PATCH TRANSDERMAL 72 HOURS   1 Generic 10%10%Q:30
/90Days
FENTANYL 12MCG/HR PATCH TRANSDERMAL 72 HOURS   1 Generic 10%10%Q:30
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FENTANYL 75 MCG/HR PATCH   1 Generic 10%10%Q:30
/90Days
FENTANYL CITRATE 1600ug/1 30 BLISTER PACK per CARTON / 1 LOZENGE per BLISTER PACK   4 Specialty Tier 33%33%P Q:90
/90Days
FENTANYL CITRATE 200ug/1 30 BLISTER PACK per CARTON / 1 LOZENGE per BLISTER PACK   4 Specialty Tier 33%33%P Q:360
/90Days
FENTANYL CITRATE LOZENGES   4 Specialty Tier 33%33%P Q:120
/90Days
FENTANYL CITRATE LOZENGES   4 Specialty Tier 33%33%P Q:360
/90Days
FENTANYL CITRATE LOZENGES   4 Specialty Tier 33%33%P Q:240
/90Days
FENTANYL CITRATE LOZENGES   4 Specialty Tier 33%33%P Q:180
/90Days
FENTANYL TRANSDERMAL SYSTEM 25MCG 5 SYSTEMS CRTN   1 Generic 10%10%Q:30
/90Days
FENTANYL TRANSDERMAL SYSTEM 50MCG 5 SYSTEMS CRTN   1 Generic 10%10%Q:30
/90Days
FENTORA TABLET 100MCG   4 Specialty Tier 33%33%P Q:336
/84Days
FENTORA TABLET 200MCG   4 Specialty Tier 33%33%P Q:336
/84Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FENTORA TABLET 400MCG   4 Specialty Tier 33%33%P Q:336
/84Days
FENTORA TABLET 600MCG   4 Specialty Tier 33%33%P Q:240
/84Days
FENTORA TABLET 800MCG   4 Specialty Tier 33%33%P Q:180
/84Days
FERRIPROX 500 MG TABLET   4 Specialty Tier 33%33%None
FETZIMA 20-40 MG TITRATION PAK   2 Preferred Brand 20%20%P
FETZIMA ER 120 MG CAPSULE   2 Preferred Brand 20%20%P
FETZIMA ER 20 MG CAPSULE   2 Preferred Brand 20%20%P
FETZIMA ER 40 MG CAPSULE   2 Preferred Brand 20%20%P
FETZIMA ER 80 MG CAPSULE   2 Preferred Brand 20%20%P
FIBRICOR 105mg/1 30 TABLET BOTTLE, PLASTIC   3 Non-Preferred Brand 40%40%S
FIBRICOR 35mg/1 30 TABLET BOTTLE, PLASTIC   3 Non-Preferred Brand 40%40%S
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FINACEA 15% GEL   2 Preferred Brand 20%20%None
FINASTERIDE 5MG TABLET   1 Generic 10%10%None
Firazyr 30.0mg/3mL 1 SYRINGE, GLASS per CARTON / 3 mL in 1 SYRINGE, GLASS   4 Specialty Tier 33%33%P
FIRMAGON 20mg/mL 1 VIAL, GLASS per CARTON / 4 mL in 1 VIAL, GLASS   2 Preferred Brand 20%20%None
FLAGYL 250MG TABLET (100 CT)   3 Non-Preferred Brand 40%40%None
FLAGYL 375MG CAPSULE   3 Non-Preferred Brand 40%40%None
FLAGYL 500MG TABLET   3 Non-Preferred Brand 40%40%None
FLAGYL ER 750MG TABLET SA   3 Non-Preferred Brand 40%40%None
FLAREX 0.1% EYE DROPS   3 Non-Preferred Brand 40%40%None
FLAVOXATE HCL 100MG TABLET   1 Generic 10%10%None
FLECAINIDE ACETATE 100 MG TAB #60 EA   1 Generic 10%10%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLECAINIDE ACETATE 150 MG TAB 360 EA   1 Generic 10%10%None
FLECAINIDE ACETATE 50 MG TAB   1 Generic 10%10%None
FLECTOR PATCH   3 Non-Preferred Brand 40%40%S Q:180
/90Days
Flo-Pred 15mg/5mL 1 BOTTLE per CARTON / 52 mL in 1 BOTTLE   3 Non-Preferred Brand 40%40%None
FLOMAX 0.4MG CAPSULE SA   3 Non-Preferred Brand 40%40%S
FLONASE 0.05% NASAL SPRAY   3 Non-Preferred Brand 40%40%Q:48
/90Days
FLOVENT DISKUS 100ug/1 60 POWDER, METERED in 1 INHALER   2 Preferred Brand 20%20%Q:360
/90Days
FLOVENT DISKUS 250ug/1 60 POWDER, METERED in 1 INHALER   2 Preferred Brand 20%20%Q:900
/90Days
FLOVENT DISKUS POWDER 50MCG 60 CTR   2 Preferred Brand 20%20%Q:360
/90Days
FLOVENT HFA 110ug/1 120 AEROSOL, METERED in 1 INHALER   2 Preferred Brand 20%20%Q:36
/90Days
FLOVENT HFA 220ug/1 120 AEROSOL, METERED in 1 INHALER   2 Preferred Brand 20%20%Q:72
/90Days
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 20%20%Q:32
/90Days
FLUCONAZOLE 100 MG TABLET   1 Generic 10%10%None
FLUCONAZOLE 10MG/ML ORAL SUSPENSION   1 Generic 10%10%None
FLUCONAZOLE 150MG TABLETS   1 Generic 10%10%None
Fluconazole 200mg/1 30 TABLET BOTTLE   1 Generic 10%10%None
FLUCONAZOLE 40MG/ML ORAL SUSPENSION   1 Generic 10%10%None
Fluconazole 50mg/1 30 TABLET BOTTLE   1 Generic 10%10%None
FLUCONAZOLE INJECTION 200MG 6 X 200/250ML CTR   1 Generic 10%10%None
Flucytosine 250mg/1   4 Specialty Tier 33%33%None
Flucytosine 500mg/1   4 Specialty Tier 33%33%None
FLUDARABINE 50MG VIAL   1 Generic 10%10%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLUDROCORTISONE ACETATE 0.1MG TABLET (100 CT)   1 Generic 10%10%None
FLUNISOLIDE 29 MCG-0.025% SPR   1 Generic 10%10%Q:150
/90Days
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL   1 Generic 10%10%Q:150
/90Days
FLUOCINOLONE 0.01% BODY OIL   1 Generic 10%10%None
FLUOCINOLONE 0.01% CREAM   1 Generic 10%10%None
FLUOCINOLONE 0.01% SOLUTION   1 Generic 10%10%None
FLUOCINOLONE 0.025% CREAM   1 Generic 10%10%None
FLUOCINOLONE 0.025% OINTMENT   1 Generic 10%10%None
FLUOCINOLONE OIL 0.01% EAR DRP   1 Generic 10%10%None
FLUOCINONIDE 0.05% SOLUTION   1 Generic 10%10%None
fluocinonide 0.1% cream   1 Generic 10%10%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Fluocinonide 0.5mg/g 1 TUBE per CARTON / 30 g in 1 TUBE   1 Generic 10%10%None
Fluocinonide 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   1 Generic 10%10%None
Fluocinonide 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   1 Generic 10%10%None
FLUOROURACIL 2% TOPICAL SOLN   1 Generic 10%10%None
FLUOROURACIL 5% TOP SOLUTION   1 Generic 10%10%None
fluorouracil 500 mg/10 ml vial   1 Generic 10%10%None
FLUOROURACIL CREA 5%   1 Generic 10%10%None
Fluoxetine 20mg/5mL 120 mL in 1 BOTTLE, PLASTIC   1 Generic 10%10%None
FLUOXETINE 40MG CAPSULE (30 CT)   1 Generic 10%10%Q:180
/90Days
FLUOXETINE CAPSULES 10MG (100 CT)   1 Generic 10%10%Q:720
/90Days
FLUOXETINE DR 90 MG CAPSULE   1 Generic 10%10%Q:12
/84Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLUOXETINE HCL 20MG TABLET   1 Generic 10%10%None
FLUOXETINE HCL 60 MG TABLET   3 Non-Preferred Brand 40%40%S
Fluoxetine Hydrochloride 20mg/1 100 CAPSULE BOTTLE   1 Generic 10%10%None
FLUOXETINE HYDROCHLORIDE TABLETS 10MG 100 BOT   1 Generic 10%10%Q:720
/90Days
FLUOXYMESTERONE 10MG TABLET   1 Generic 10%10%None
FLUPHENAZINE 10MG TABLET   1 Generic 10%10%None
FLUPHENAZINE 1MG TABLET   1 Generic 10%10%None
FLUPHENAZINE 2.5MG TABLET   1 Generic 10%10%None
FLUPHENAZINE 2.5MG/ML VIAL   1 Generic 10%10%None
FLUPHENAZINE 5MG TABLET   1 Generic 10%10%None
FLUPHENAZINE 5MG/ML CONC   1 Generic 10%10%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Fluphenazine Decanoate 25mg/mL   1 Generic 10%10%None
FLUPHENAZINE HCL 2.5MG/5ML ELIXIR   1 Generic 10%10%None
FLURBIPROFEN 0.03% EYE DROP   1 Generic 10%10%None
Flurbiprofen 100mg/1 100 BOTTLE in 1 BOTTLE / 100 FILM COATED TABLETS in BOTTLE   1 Generic 10%10%None
FLURBIPROFEN 50MG TABLET   1 Generic 10%10%None
Flutamide 125mg/1 500 CAPSULE BOTTLE   1 Generic 10%10%None
FLUTICASONE PROP 0.05% LOTION   1 Generic 10%10%None
Fluticasone Propionate 0.05mg/g 1 TUBE per CARTON / 30 g in 1 TUBE   1 Generic 10%10%None
Fluticasone Propionate 0.5mg/g 1 TUBE per CARTON / 30 g in 1 TUBE   1 Generic 10%10%None
FLUTICASONE PROPIONATE 50MCG SPRAY SUSPENSION   1 Generic 10%10%Q:48
/90Days
FLUVASTATIN SODIUM 20 MG CAPSULE [Lescol]   1 Generic 10%10%Q:90
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FLUVASTATIN SODIUM 40 MG CAPSULE [Lescol]   1 Generic 10%10%Q:180
/90Days
fluvoxamine er 100 mg capsule   1 Generic 10%10%Q:270
/90Days
fluvoxamine er 150 mg capsule   1 Generic 10%10%Q:180
/90Days
FLUVOXAMINE MALEATE 100MG TABLET   1 Generic 10%10%Q:270
/90Days
Fluvoxamine Maleate 25 mg tab   1 Generic 10%10%Q:1080
/90Days
Fluvoxamine maleate 50mg/1 100 FILM COATED TABLETS in BOTTLE   1 Generic 10%10%Q:540
/90Days
FML FORTE 0.25% EYE DROPS   3 Non-Preferred Brand 40%40%None
FML LIQUIFILM 0.1% EYE DROP   3 Non-Preferred Brand 40%40%None
FML S.O.P. 0.1% OINTMENT   2 Preferred Brand 20%20%None
FOCALIN 10MG TABLET   3 Non-Preferred Brand 40%40%None
FOCALIN 2.5MG TABLET   3 Non-Preferred Brand 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FOCALIN 5MG TABLET   3 Non-Preferred Brand 40%40%None
FOCALIN XR 10MG CAPSULE   3 Non-Preferred Brand 40%40%None
FOCALIN XR 15MG CAPSULE   3 Non-Preferred Brand 40%40%None
FOCALIN XR 20MG CAPSULE   3 Non-Preferred Brand 40%40%None
Focalin XR 25mg EXTENDED RELEASE 100 CAPSULE BOTTLE   3 Non-Preferred Brand 40%40%None
FOCALIN XR 30MG CAPSULES   3 Non-Preferred Brand 40%40%None
Focalin XR 35mg EXTENDED RELEASE 100 CAPSULE BOTTLE   3 Non-Preferred Brand 40%40%None
Focalin XR 40mg EXTENDED RELEASE 100 CAPSULE BOTTLE   3 Non-Preferred Brand 40%40%None
FOCALIN XR 5MG CAPSULE   3 Non-Preferred Brand 40%40%None
FOLOTYN 20mg/mL 1 VIAL, SINGLE-USE per CARTON / 2 mL in 1 VIAL, SINGLE-USE   4 Specialty Tier 33%33%None
Fomepizole 1g/mL 1 VIAL per CARTON / 1.5 mL in 1 VIAL   1 Generic 10%10%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Fondaparinux Sodium 10mg/0.8mL 2 SYRINGES per CARTON / 0.8 mL in 1 SYRINGE [Arixtra]   4 Specialty Tier 33%33%None
Fondaparinux Sodium 2.5mg/0.5mL 2 SYRINGES per CARTON / 0.5 mL in 1 SYRINGE [Arixtra]   1 Generic 10%10%None
Fondaparinux Sodium 5mg/4mL 2 SYRINGES per CARTON / 0.4 mL in 1 SYRINGE [Arixtra]   4 Specialty Tier 33%33%None
Fondaparinux Sodium 7.5mg/0.6mL 2 SYRINGES per CARTON / 0.6 mL in 1 SYRINGE [Arixtra]   4 Specialty Tier 33%33%None
FORADIL AEROLIZER 12 MCG CAP   2 Preferred Brand 20%20%Q:180
/90Days
FORFIVO XL 450 MG TABLET   3 Non-Preferred Brand 40%40%Q:90
/90Days
FORTAMET 1000MG TABLET SR OSMOTIC PUSH 24HR   3 Non-Preferred Brand 40%40%S Q:225
/90Days
FORTAMET 500MG TABLET SR OSMOTIC PUSH 24HR   3 Non-Preferred Brand 40%40%S Q:450
/90Days
FORTAZ 2 GM VIAL   3 Non-Preferred Brand 40%40%None
FORTAZ 6 GM VIAL   3 Non-Preferred Brand 40%40%None
FORTAZ-ISO-OSMOT 2 GM/50 ML   2 Preferred Brand 20%20%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FORTAZ-ISO-OSMOTIC 1 GM/50 ML   2 Preferred Brand 20%20%None
Forteo 250ug/mL 1 SYRINGE per CARTON / 2.4 mL in 1 SYRINGE   4 Specialty Tier 33%33%P Q:9
/84Days
FORTESTA 10mg/0.5g   3 Non-Preferred Brand 40%40%P
FORTICAL 200 U/DOSE AEROSOL SPRAY W/PUMP   1 Generic 10%10%None
FOSAMAX 70MG TABLET   3 Non-Preferred Brand 40%40%S Q:13
/90Days
FOSAMAX PLUS D 70; 5600mg/1; [iU]/1 4 TABLET per BLISTER PACK   3 Non-Preferred Brand 40%40%S Q:13
/90Days
FOSAMAX PLUS D 70MG/2800 IU   3 Non-Preferred Brand 40%40%S Q:13
/90Days
FOSCARNET 24MG/ML INFUS BTTL   1 Generic 10%10%P
FOSINOPRIL SODIUM 10MG TABLET (90 CT)   1 Generic 10%10%None
FOSINOPRIL SODIUM 20MG TABLET   1 Generic 10%10%None
FOSINOPRIL SODIUM 40MG TABLET   1 Generic 10%10%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FOSINOPRIL-HCTZ 10-12.5 MG TAB   1 Generic 10%10%None
FOSINOPRIL-HCTZ 20-12.5 MG TAB   1 Generic 10%10%None
Fosphenytoin Sodium 50mg/mL 2 mL in 1 VIAL   1 Generic 10%10%None
FOSRENOL 1000MG TABLET CHEW   3 Non-Preferred Brand 40%40%None
FOSRENOL 500MG TABLET CHEW   3 Non-Preferred Brand 40%40%None
FOSRENOL 750MG TABLET CHEW   3 Non-Preferred Brand 40%40%None
Fragmin 12500[iU]/0.5mL   4 Specialty Tier 33%33%None
Fragmin 15000[iU]/0.6mL   4 Specialty Tier 33%33%None
Fragmin 18000[iU]/0.72mL   4 Specialty Tier 33%33%None
FRAGMIN 25000UNITS/ML VIAL 3.8ML x 1   3 Non-Preferred Brand 40%40%None
FRAGMIN 2500UNITS SYRINGE 0.2ML x 10   3 Non-Preferred Brand 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FRAGMIN 5000UNITS SYRINGE 0.2ML x 10   3 Non-Preferred Brand 40%40%None
FRAGMIN INJECTION 10000UNITS 1 X 10 SYR   4 Specialty Tier 33%33%None
FRAGMIN INJECTION 7500UNT/ML   4 Specialty Tier 33%33%None
FROVA 2.5MG TABLET   3 Non-Preferred Brand 40%40%Q:81
/84Days
FULYZAQ 125 MG DR TABLET   3 Non-Preferred Brand 40%40%None
FURADANTIN 25 MG/5 ML SUSP 230 ML   3 Non-Preferred Brand 40%40%None
Furosemide 10mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 4 mL in 1 VIAL, SINGLE-DOSE   1 Generic 10%10%None
FUROSEMIDE 10MG/ML SOLUTION   1 Generic 10%10%None
Furosemide 20mg/1 100 TABLET BOTTLE   1 Generic 10%10%None
FUROSEMIDE 40 MG TABLET   1 Generic 10%10%None
FUROSEMIDE 40MG/5ML TUBEX   1 Generic 10%10%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
FUROSEMIDE 80MG TABLET (500 CT)   1 Generic 10%10%None
FUSILEV I.V. 50 MG VIAL   4 Specialty Tier 33%33%None
FUZEON 90 MG VIAL   4 Specialty Tier 33%33%None
FYCOMPA 10 MG TABLET   2 Preferred Brand 20%20%None
FYCOMPA 12 MG TABLET   2 Preferred Brand 20%20%None
FYCOMPA 2 MG TABLET   2 Preferred Brand 20%20%None
FYCOMPA 4 MG TABLET   2 Preferred Brand 20%20%None
FYCOMPA 6 MG TABLET   2 Preferred Brand 20%20%None
FYCOMPA 8 MG TABLET   2 Preferred Brand 20%20%None

Chart Legend:

Below are a few notes to help you understand the above 2014 Medicare Part D Educators Rx Advantage (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 $310 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 $2850) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2014 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 2014 )

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.