2014 Medicare Part D Plan Formulary Information |
First+Plus Platino (HMO SNP) (H5887-010-0)
Benefit Details
|
The First+Plus Platino (HMO SNP) (H5887-010-0) Formulary Drugs Starting with the Letter F in GUAYANILLA County, PR: CMS MA Region 30 which includes: PR Plan Monthly Premium: $0.00 Deductible: $310 |
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 |
Tier 5 |
15% | 15% | P |
FAMCICLOVIR 125MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
FAMCICLOVIR 250MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
FAMCICLOVIR 500MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
FAMOTIDINE 20MG PIGGYBACK |
1 |
Tier 1 |
15% | 15% | None |
FAMOTIDINE 20MG TABLET (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
FAMOTIDINE 40MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
FAMOTIDINE 50 MG/5MLFOR ORAL SUSPENSION |
1 |
Tier 1 |
15% | 15% | None |
FAMOTIDINE INJECTION 10MG 25 X 2ML VIALSD |
1 |
Tier 1 |
15% | 15% | None |
FANAPT 1 KIT in 1 DOSE PACK |
4 |
Tier 4 |
15% | 15% | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FANAPT 10mg/1 60 TABLET BOTTLE |
4 |
Tier 4 |
15% | 15% | S |
FANAPT 12mg/1 60 TABLET BOTTLE |
4 |
Tier 4 |
15% | 15% | S |
FANAPT 1mg/1 60 TABLET BOTTLE |
4 |
Tier 4 |
15% | 15% | S |
FANAPT 2mg/1 60 TABLET BOTTLE |
4 |
Tier 4 |
15% | 15% | S |
FANAPT 4mg/1 60 TABLET BOTTLE |
4 |
Tier 4 |
15% | 15% | S |
FANAPT 6mg/1 60 TABLET BOTTLE |
4 |
Tier 4 |
15% | 15% | S |
FANAPT 8mg/1 60 TABLET BOTTLE |
4 |
Tier 4 |
15% | 15% | S |
FARESTON 60 MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
FARXIGA 10 MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
FARXIGA 5 MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
FASLODEX 50MG/ML INJECTION |
5 |
Tier 5 |
15% | 15% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FazaClo 100mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
4 |
Tier 4 |
15% | 15% | None |
FazaClo 150mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
4 |
Tier 4 |
15% | 15% | None |
FAZACLO 200 MG TABLETS ORALLY DISINTEGRATING |
4 |
Tier 4 |
15% | 15% | None |
FazaClo 25mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
4 |
Tier 4 |
15% | 15% | None |
FELBAMATE 400 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
FELBAMATE 600 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
FELBAMATE 600 MG/5 ML SUSP |
2 |
Tier 2 |
15% | 15% | None |
FELODIPINE ER 10 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
FELODIPINE ER 2.5 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
FELODIPINE ER 5 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
FEMRING 0.05MG VAGINAL RING |
4 |
Tier 4 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FEMRING 0.10MG VAGINAL RING |
4 |
Tier 4 |
15% | 15% | None |
FENOFIBRATE 130 MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
FENOFIBRATE 134MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
fenofibrate 145 mg tablet |
2 |
Tier 2 |
15% | 15% | None |
FENOFIBRATE 160mg/1 90 TABLET BOTTLE |
2 |
Tier 2 |
15% | 15% | None |
FENOFIBRATE 200MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
FENOFIBRATE 43 MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
fenofibrate 48 mg tablet |
2 |
Tier 2 |
15% | 15% | None |
Fenofibrate 54mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Tier 2 |
15% | 15% | None |
FENOFIBRATE 67MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
Fenofibric acid dr 135 mg capsule [TRILIPIX] |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Fenofibric acid dr 45 mg capsule [TRILIPIX] |
2 |
Tier 2 |
15% | 15% | None |
FENTANYL 100MCG/HR PATCH TRANSDERMAL 72 HOURS |
2 |
Tier 2 |
15% | 15% | P Q:10 /30Days |
FENTANYL 12MCG/HR PATCH TRANSDERMAL 72 HOURS |
2 |
Tier 2 |
15% | 15% | P Q:10 /30Days |
FENTANYL 75 MCG/HR PATCH |
2 |
Tier 2 |
15% | 15% | P Q:10 /30Days |
FENTANYL TRANSDERMAL SYSTEM 25MCG 5 SYSTEMS CRTN |
2 |
Tier 2 |
15% | 15% | P Q:10 /30Days |
FENTANYL TRANSDERMAL SYSTEM 50MCG 5 SYSTEMS CRTN |
2 |
Tier 2 |
15% | 15% | P Q:10 /30Days |
FENTORA TABLET 100MCG |
4 |
Tier 4 |
15% | 15% | Q:240 /30Days |
FENTORA TABLET 200MCG |
4 |
Tier 4 |
15% | 15% | Q:240 /30Days |
FENTORA TABLET 400MCG |
4 |
Tier 4 |
15% | 15% | Q:240 /30Days |
FENTORA TABLET 600MCG |
4 |
Tier 4 |
15% | 15% | Q:240 /30Days |
FENTORA TABLET 800MCG |
4 |
Tier 4 |
15% | 15% | Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FERRIPROX 500 MG TABLET |
4 |
Tier 4 |
15% | 15% | P |
FETZIMA 20-40 MG TITRATION PAK |
4 |
Tier 4 |
15% | 15% | None |
FETZIMA ER 120 MG CAPSULE |
4 |
Tier 4 |
15% | 15% | None |
FETZIMA ER 20 MG CAPSULE |
4 |
Tier 4 |
15% | 15% | None |
FETZIMA ER 40 MG CAPSULE |
4 |
Tier 4 |
15% | 15% | None |
FETZIMA ER 80 MG CAPSULE |
4 |
Tier 4 |
15% | 15% | None |
FINASTERIDE 5MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
FLAREX 0.1% EYE DROPS |
4 |
Tier 4 |
15% | 15% | None |
FLECAINIDE ACETATE 100 MG TAB #60 EA |
1 |
Tier 1 |
15% | 15% | None |
FLECAINIDE ACETATE 150 MG TAB 360 EA |
2 |
Tier 2 |
15% | 15% | None |
FLECAINIDE ACETATE 50 MG TAB |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLOVENT DISKUS 100ug/1 60 POWDER, METERED in 1 INHALER |
4 |
Tier 4 |
15% | 15% | None |
FLOVENT DISKUS 250ug/1 60 POWDER, METERED in 1 INHALER |
4 |
Tier 4 |
15% | 15% | None |
FLOVENT DISKUS POWDER 50MCG 60 CTR |
4 |
Tier 4 |
15% | 15% | None |
FLOVENT HFA 110ug/1 120 AEROSOL, METERED in 1 INHALER |
4 |
Tier 4 |
15% | 15% | None |
FLOVENT HFA 220ug/1 120 AEROSOL, METERED in 1 INHALER |
4 |
Tier 4 |
15% | 15% | None |
FLOVENT HFA 44ug/1 120 AEROSOL, METERED in 1 INHALER |
4 |
Tier 4 |
15% | 15% | None |
FLUCONAZOLE 100 MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
FLUCONAZOLE 10MG/ML ORAL SUSPENSION |
1 |
Tier 1 |
15% | 15% | None |
FLUCONAZOLE 150MG TABLETS |
1 |
Tier 1 |
15% | 15% | None |
Fluconazole 200mg/1 30 TABLET BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
FLUCONAZOLE 40MG/ML ORAL SUSPENSION |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Fluconazole 50mg/1 30 TABLET BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
FLUCONAZOLE INJECTION 200MG 6 X 200/250ML CTR |
2 |
Tier 2 |
15% | 15% | None |
Flucytosine 250mg/1 |
5 |
Tier 5 |
15% | 15% | None |
Flucytosine 500mg/1 |
5 |
Tier 5 |
15% | 15% | None |
FLUDARABINE 50MG VIAL |
1 |
Tier 1 |
15% | 15% | P |
FLUDROCORTISONE ACETATE 0.1MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
FLUNISOLIDE 29 MCG-0.025% SPR |
2 |
Tier 2 |
15% | 15% | None |
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL |
2 |
Tier 2 |
15% | 15% | None |
FLUOCINOLONE 0.01% BODY OIL |
2 |
Tier 2 |
15% | 15% | None |
FLUOCINOLONE 0.01% CREAM |
2 |
Tier 2 |
15% | 15% | None |
FLUOCINOLONE 0.01% SOLUTION |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOCINOLONE 0.025% CREAM |
1 |
Tier 1 |
15% | 15% | None |
FLUOCINOLONE 0.025% OINTMENT |
1 |
Tier 1 |
15% | 15% | None |
FLUOCINOLONE OIL 0.01% EAR DRP |
2 |
Tier 2 |
15% | 15% | None |
FLUOCINONIDE 0.05% SOLUTION |
2 |
Tier 2 |
15% | 15% | None |
fluocinonide 0.1% cream |
2 |
Tier 2 |
15% | 15% | None |
Fluocinonide 0.5mg/g 1 TUBE per CARTON / 30 g in 1 TUBE |
2 |
Tier 2 |
15% | 15% | None |
Fluocinonide 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2 |
Tier 2 |
15% | 15% | None |
Fluocinonide 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2 |
Tier 2 |
15% | 15% | None |
FLUOROURACIL 2% TOPICAL SOLN |
1 |
Tier 1 |
15% | 15% | None |
FLUOROURACIL 5% TOP SOLUTION |
1 |
Tier 1 |
15% | 15% | None |
fluorouracil 500 mg/10 ml vial |
1 |
Tier 1 |
15% | 15% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Fluoxetine 20mg/5mL 120 mL in 1 BOTTLE, PLASTIC |
2 |
Tier 2 |
15% | 15% | None |
FLUOXETINE 40MG CAPSULE (30 CT) |
1 |
Tier 1 |
15% | 15% | None |
FLUOXETINE CAPSULES 10MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
FLUOXETINE HCL 20MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
FLUOXETINE HCL 60 MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Fluoxetine Hydrochloride 20mg/1 100 CAPSULE BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
FLUOXETINE HYDROCHLORIDE TABLETS 10MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
FLUOXYMESTERONE 10MG TABLET |
4 |
Tier 4 |
15% | 15% | P |
FLUPHENAZINE 10MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
FLUPHENAZINE 1MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
FLUPHENAZINE 2.5MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUPHENAZINE 2.5MG/ML VIAL |
1 |
Tier 1 |
15% | 15% | None |
FLUPHENAZINE 5MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
FLUPHENAZINE 5MG/ML CONC |
1 |
Tier 1 |
15% | 15% | None |
Fluphenazine Decanoate 25mg/mL |
2 |
Tier 2 |
15% | 15% | None |
FLUPHENAZINE HCL 2.5MG/5ML ELIXIR |
1 |
Tier 1 |
15% | 15% | None |
FLURBIPROFEN 0.03% EYE DROP |
1 |
Tier 1 |
15% | 15% | None |
Flurbiprofen 100mg/1 100 BOTTLE in 1 BOTTLE / 100 FILM COATED TABLETS in BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
FLURBIPROFEN 50MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Flutamide 125mg/1 500 CAPSULE BOTTLE |
2 |
Tier 2 |
15% | 15% | None |
FLUTICASONE PROP 0.05% LOTION |
2 |
Tier 2 |
15% | 15% | None |
Fluticasone Propionate 0.05mg/g 1 TUBE per CARTON / 30 g in 1 TUBE |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Fluticasone Propionate 0.5mg/g 1 TUBE per CARTON / 30 g in 1 TUBE |
2 |
Tier 2 |
15% | 15% | None |
FLUTICASONE PROPIONATE 50MCG SPRAY SUSPENSION |
2 |
Tier 2 |
15% | 15% | None |
fluvoxamine er 100 mg capsule |
2 |
Tier 2 |
15% | 15% | None |
fluvoxamine er 150 mg capsule |
2 |
Tier 2 |
15% | 15% | None |
FLUVOXAMINE MALEATE 100MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
Fluvoxamine Maleate 25 mg tab |
1 |
Tier 1 |
15% | 15% | None |
Fluvoxamine maleate 50mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
Fondaparinux Sodium 10mg/0.8mL 2 SYRINGES per CARTON / 0.8 mL in 1 SYRINGE [Arixtra] |
1 |
Tier 1 |
15% | 15% | P Q:30 /180Days |
Fondaparinux Sodium 2.5mg/0.5mL 2 SYRINGES per CARTON / 0.5 mL in 1 SYRINGE [Arixtra] |
1 |
Tier 1 |
15% | 15% | P Q:30 /180Days |
Fondaparinux Sodium 5mg/4mL 2 SYRINGES per CARTON / 0.4 mL in 1 SYRINGE [Arixtra] |
1 |
Tier 1 |
15% | 15% | P Q:30 /180Days |
Fondaparinux Sodium 7.5mg/0.6mL 2 SYRINGES per CARTON / 0.6 mL in 1 SYRINGE [Arixtra] |
1 |
Tier 1 |
15% | 15% | P Q:30 /180Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FORADIL AEROLIZER 12 MCG CAP |
3 |
Tier 3 |
15% | 15% | None |
Forteo 250ug/mL 1 SYRINGE per CARTON / 2.4 mL in 1 SYRINGE |
5 |
Tier 5 |
15% | 15% | P Q:2 /28Days |
FORTICAL 200 U/DOSE AEROSOL SPRAY W/PUMP |
4 |
Tier 4 |
15% | 15% | None |
FOSCARNET 24MG/ML INFUS BTTL |
4 |
Tier 4 |
15% | 15% | P |
FOSINOPRIL SODIUM 10MG TABLET (90 CT) |
2 |
Tier 2 |
15% | 15% | None |
FOSINOPRIL SODIUM 20MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
FOSINOPRIL SODIUM 40MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
FOSINOPRIL-HCTZ 10-12.5 MG TAB |
2 |
Tier 2 |
15% | 15% | None |
FOSINOPRIL-HCTZ 20-12.5 MG TAB |
2 |
Tier 2 |
15% | 15% | None |
Fosphenytoin Sodium 50mg/mL 2 mL in 1 VIAL |
1 |
Tier 1 |
15% | 15% | None |
FRAGMIN 25000UNITS/ML VIAL 3.8ML x 1 |
4 |
Tier 4 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FRAGMIN 2500UNITS SYRINGE 0.2ML x 10 |
4 |
Tier 4 |
15% | 15% | None |
FRAGMIN 5000UNITS SYRINGE 0.2ML x 10 |
4 |
Tier 4 |
15% | 15% | None |
FRAGMIN INJECTION 10000UNITS 1 X 10 SYR |
5 |
Tier 5 |
15% | 15% | None |
FRAGMIN INJECTION 7500UNT/ML |
5 |
Tier 5 |
15% | 15% | None |
FROVA 2.5MG TABLET |
4 |
Tier 4 |
15% | 15% | S |
FULYZAQ 125 MG DR TABLET |
4 |
Tier 4 |
15% | 15% | P |
FURADANTIN 25 MG/5 ML SUSP 230 ML |
4 |
Tier 4 |
15% | 15% | None |
Furosemide 10mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 4 mL in 1 VIAL, SINGLE-DOSE |
1 |
Tier 1 |
15% | 15% | None |
FUROSEMIDE 10MG/ML SOLUTION |
1 |
Tier 1 |
15% | 15% | None |
Furosemide 20mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
FUROSEMIDE 40 MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FUROSEMIDE 40MG/5ML TUBEX |
1 |
Tier 1 |
15% | 15% | None |
FUROSEMIDE 80MG TABLET (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
FUZEON 90 MG VIAL |
5 |
Tier 5 |
15% | 15% | None |
FYCOMPA 10 MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
FYCOMPA 12 MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
FYCOMPA 2 MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
FYCOMPA 4 MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
FYCOMPA 6 MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
FYCOMPA 8 MG TABLET |
4 |
Tier 4 |
15% | 15% | None |