2015 Medicare Part D Plan Formulary Information |
SeniorCare Sr VIP - Basic Rx (Cost) (H4564-017-0)
Benefit Details
|
The SeniorCare Sr VIP - Basic Rx (Cost) (H4564-017-0) Formulary Drugs Starting with the Letter F in WASHINGTON County, TX: CMS MA Region 17 which includes: TX Plan Monthly Premium: $205.50 Deductible: $0 |
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% | 33% | None |
FALMINA-28 TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FAMCICLOVIR 125MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FAMCICLOVIR 250MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FAMCICLOVIR 500MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FAMOTIDINE 20MG TABLET (500 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
FAMOTIDINE 40MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
FANAPT 1 KIT in 1 DOSE PACK |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
FANAPT 1 MG 60 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
FANAPT 10 MG 60 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FANAPT 12 MG 60 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
FANAPT 2 MG 60 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
FANAPT 4 MG 60 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
FANAPT 6 MG 60 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
FANAPT 8 MG 60 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
FARESTON 60 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
FARYDAK 10 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
FARYDAK 15 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
FARYDAK 20 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
FASLODEX 50MG/ML INJECTION |
5 |
Specialty Tier |
33% | 33% | P |
FazaClo 100mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FazaClo 12.5mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
FazaClo 150mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
FAZACLO 200 MG TABLETS ORALLY DISINTEGRATING |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
FazaClo 25mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
FELBAMATE 400 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
FELBAMATE 600 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
FELBAMATE 600 MG/5 ML SUSP |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
FELODIPINE ER 10 MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FELODIPINE ER 2.5 MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FELODIPINE ER 5 MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FENOFIBRATE 134MG CAPSULE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
fenofibrate 145 mg tablet |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FENOFIBRATE 160mg/1 90 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FENOFIBRATE 200MG CAPSULE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FENOFIBRATE 48 MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FENOFIBRATE 54mg/1 90 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FENOFIBRATE 67MG CAPSULE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Fenofibric acid dr 135 mg capsule [TRILIPIX] |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Fenofibric acid dr 45 mg capsule [TRILIPIX] |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FENOPROFEN 600MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FENTANYL 100MCG/HR PATCH TRANSDERMAL 72 HOURS |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:20 /30Days |
FENTANYL 12MCG/HR PATCH TRANSDERMAL 72 HOURS |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:20 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENTANYL 75 MCG/HR PATCH |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:20 /30Days |
FENTANYL CITRATE 1600ug/1 30 BLISTER PACK per CARTON / 1 LOZENGE per BLISTER PACK |
5 |
Specialty Tier |
33% | 33% | P Q:120 /30Days |
FENTANYL CITRATE 200ug/1 30 BLISTER PACK per CARTON / 1 LOZENGE per BLISTER PACK |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | P Q:120 /30Days |
FENTANYL CITRATE LOZENGES |
5 |
Specialty Tier |
33% | 33% | P Q:120 /30Days |
FENTANYL CITRATE LOZENGES |
5 |
Specialty Tier |
33% | 33% | P Q:120 /30Days |
FENTANYL CITRATE LOZENGES |
5 |
Specialty Tier |
33% | 33% | P Q:120 /30Days |
FENTANYL CITRATE LOZENGES |
5 |
Specialty Tier |
33% | 33% | P Q:120 /30Days |
FENTANYL TRANSDERMAL SYSTEM 25MCG 5 SYSTEMS CRTN |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:20 /30Days |
FENTANYL TRANSDERMAL SYSTEM 50MCG 5 SYSTEMS CRTN |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:20 /30Days |
FETZIMA 20-40 MG TITRATION PAK |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
FETZIMA ER 120 MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FETZIMA ER 20 MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
FETZIMA ER 40 MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
FETZIMA ER 80 MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
FINASTERIDE 5MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Firazyr 30.0mg/3mL 1 SYRINGE, GLASS per CARTON / 3 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
33% | 33% | P |
FLAVOXATE HCL 100MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FLECAINIDE ACETATE 100 MG TAB #60 EA |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FLECAINIDE ACETATE 150 MG TAB 360 EA |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FLECAINIDE ACETATE 50 MG TAB |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FLOVENT DISKUS 100ug/1 60 POWDER, METERED in 1 INHALER |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
FLOVENT DISKUS 250ug/1 60 POWDER, METERED in 1 INHALER |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLOVENT DISKUS POWDER 50MCG 60 CTR |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
FLOVENT HFA 110ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
FLOVENT HFA 220ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
FLOVENT HFA 44ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
FLUCONAZOLE 100 MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FLUCONAZOLE 10MG/ML ORAL SUSPENSION |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FLUCONAZOLE 150MG TABLETS |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Fluconazole 200mg/1 30 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FLUCONAZOLE 40MG/ML ORAL SUSPENSION |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Fluconazole 50mg/1 30 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FLUCONAZOLE INJECTION 200MG 6 X 200/250ML CTR |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Flucytosine 250mg/1 |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
Flucytosine 500mg/1 |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
FLUDROCORTISONE ACETATE 0.1MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FLUOCINOLONE 0.01% BODY OIL |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FLUOCINOLONE 0.01% CREAM |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FLUOCINOLONE 0.01% SOLUTION |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FLUOCINOLONE 0.025% CREAM |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FLUOCINOLONE 0.025% OINTMENT |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FLUOCINOLONE OIL 0.01% EAR DRP |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FLUOCINONIDE 0.05% SOLUTION |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | 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 |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Fluocinonide 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Fluocinonide 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Fluorometholone 0.1% drops |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FLUOROURACIL 0.5% CREAM |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FLUOROURACIL 2% TOPICAL SOLN |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FLUOROURACIL 5% TOP SOLUTION |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FLUOROURACIL CREA 5% |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Fluoxetine 10mg/1 30 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Fluoxetine 20mg/5mL 120 mL in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
FLUOXETINE 40MG CAPSULE (30 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOXETINE CAPSULES 10MG (100 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
FLUOXETINE HCL 20 MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
FLUOXETINE HCL 60 MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Fluoxetine Hydrochloride 20mg/1 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
FLUPHENAZINE 10MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FLUPHENAZINE 1MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FLUPHENAZINE 2.5MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FLUPHENAZINE 2.5MG/ML VIAL |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FLUPHENAZINE 5MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FLUPHENAZINE 5MG/ML CONC |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Fluphenazine Decanoate 25mg/mL |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUPHENAZINE HCL 2.5MG/5ML ELIXIR |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Flurazepam Hydrochloride 15mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Flurazepam Hydrochloride 30mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
FLURBIPROFEN 0.03% EYE DROP |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Flurbiprofen 100mg/1 100 BOTTLE in 1 BOTTLE / 100 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FLURBIPROFEN 50MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Flutamide 125mg/1 500 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
FLUTICASONE PROP 0.05% LOTION |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Fluticasone Propionate 0.05mg/g 1 TUBE per CARTON / 30 g in 1 TUBE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Fluticasone Propionate 0.5mg/g 1 TUBE per CARTON / 30 g in 1 TUBE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FLUTICASONE PROPIONATE 50MCG SPRAY SUSPENSION |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUVOXAMINE MALEATE 100MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Fluvoxamine Maleate 25mg/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 FILM COATED TABLETS in |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Fluvoxamine maleate 50mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FML FORTE 0.25% EYE DROPS |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
FML LIQUIFILM 0.1% EYE DROP |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
FML S.O.P. 0.1% OINTMENT |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Fondaparinux Sodium 10mg/0.8mL 2 SYRINGES per CARTON / 0.8 mL in 1 SYRINGE [Arixtra] |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:24 /30Days |
Fondaparinux Sodium 2.5mg/0.5mL 2 SYRINGES per CARTON / 0.5 mL in 1 SYRINGE [Arixtra] |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:15 /30Days |
Fondaparinux Sodium 5mg/4mL 2 SYRINGES per CARTON / 0.4 mL in 1 SYRINGE [Arixtra] |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:12 /30Days |
Fondaparinux Sodium 7.5mg/0.6mL 2 SYRINGES per CARTON / 0.6 mL in 1 SYRINGE [Arixtra] |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:18 /30Days |
FORADIL AEROLIZER 12 MCG CAP |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Forteo 250ug/mL 1 SYRINGE per CARTON / 2.4 mL in 1 SYRINGE |
5 |
Specialty Tier |
33% | 33% | P |
FORTICAL 200 U/DOSE AEROSOL SPRAY W/PUMP |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
FOSCARNET 24MG/ML INFUS BTTL |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | P |
FOSINOPRIL SODIUM 10MG TABLET (90 CT) |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FOSINOPRIL SODIUM 20MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Fosinopril Sodium 40mg/1 90 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FOSINOPRIL-HCTZ 10-12.5 MG TAB |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
FOSINOPRIL-HCTZ 20-12.5 MG TAB |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Fosphenytoin Sodium 50mg/mL 2 mL in 1 VIAL |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
FRAGMIN 10,000 UNITS SYRINGE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:30 /30Days |
FRAGMIN 12,500 UNITS SYRINGE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:15 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FRAGMIN 15,000 UNITS SYRINGE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:18 /30Days |
FRAGMIN 18,000 UNITS SYRINGE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:22 /30Days |
FRAGMIN 2,500 UNITS SYRINGE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:6 /30Days |
FRAGMIN 5,000 UNITS SYRINGE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:6 /30Days |
FRAGMIN 7,500 UNITS/0.3 ML SYR |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:9 /30Days |
FREAMINE HBC INJECTION |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | P |
Furosemide 10mg/mL 10 CARTON in 1 CONTAINER / 1 SYRINGE, PLASTIC in 1 CARTON / 4 mL in 1 SYRINGE, P |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
FUROSEMIDE 10MG/ML SOLUTION |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Furosemide 20mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Furosemide 40 mg/4 ml vial |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Furosemide 40mg/1 5000 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FUROSEMIDE 40MG/5ML TUBEX |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
FUROSEMIDE 80MG TABLET (500 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
FUZEON 90 MG VIAL |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
FYCOMPA 10 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
FYCOMPA 12 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
FYCOMPA 2 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
FYCOMPA 4 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
FYCOMPA 6 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
FYCOMPA 8 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |