2016 Medicare Part D Plan Formulary Information |
Blue Medicare HMO Enhanced (HMO) (H3449-005-0)
Benefit Details
|
The Blue Medicare HMO Enhanced (HMO) (H3449-005-0) Formulary Drugs Starting with the Letter F in Hertford County, NC: CMS MA Region 7 which includes: NC Plan Monthly Premium: $64.70 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 |
Generic |
$6.00 | $18.00 | None |
FAMOTIDINE 20MG TABLET (500 CT) |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
FAMOTIDINE 40MG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
FAMOTIDINE INJECTION 10MG 25 X 2ML VIALSD |
2 |
Generic |
$6.00 | $18.00 | None |
FANAPT 1 MG 60 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | P Q:60 /30Days |
FANAPT 10 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | P Q:60 /30Days |
FANAPT 12 MG 60 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | P Q:60 /30Days |
FANAPT 2 MG 60 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | P Q:60 /30Days |
FANAPT 4 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FANAPT 6 MG 60 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | P Q:60 /30Days |
FANAPT 8 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | P Q:60 /30Days |
FANAPT TITR TABLETS |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | P Q:56 /28Days |
FARESTON 60 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
FARYDAK 10 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P Q:6 /21Days |
FARYDAK 15 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P Q:6 /21Days |
FARYDAK 20 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P Q:6 /21Days |
FASLODEX 50MG/ML INJECTION |
5 |
Specialty Tier |
33% | 33% | None |
FazaClo 100mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | P Q:90 /30Days |
FazaClo 12.5mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | P Q:90 /30Days |
FazaClo 150mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | P Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FAZACLO 200 MG TABLETS ORALLY DISINTEGRATING |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | P Q:120 /30Days |
FazaClo 25mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | P Q:270 /30Days |
FELBAMATE 400 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
FELBAMATE 600 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
FELBAMATE 600 MG/5 ML SUSP |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
FENOFIBRATE 134MG CAPSULE [LIPOFEN] |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days |
FENOFIBRATE 145 MG TABLET [LIPOFEN] |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days |
FENOFIBRATE 160 MG 90 TABLET BOTTLE [LIPOFEN] |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days |
FENOFIBRATE 200 MG CAPSULE [LIPOFEN] |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days |
FENOFIBRATE 48 MG TABLET [LIPOFEN] |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days |
FENOFIBRATE 54 MG 90 TABLET BOTTLE [LIPOFEN] |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENOFIBRATE 67MG CAPSULE [LIPOFEN] |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days |
FENTANYL 100MCG/HR PATCH TRANSDERMAL 72 HOURS |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:15 /30Days |
FENTANYL 12MCG/HR PATCH TRANSDERMAL 72 HOURS |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:15 /30Days |
FENTANYL 75 MCG/HR PATCH |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:15 /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 |
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 CITRATE LOZENGES |
5 |
Specialty Tier |
33% | 33% | P Q:120 /30Days |
FENTANYL TRANSDERMAL SYSTEM 25MCG 5 SYSTEMS CRTN |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:15 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENTANYL TRANSDERMAL SYSTEM 50MCG 5 SYSTEMS CRTN |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:15 /30Days |
FETZIMA 20-40 MG TITRATION PAK |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | Q:28 /28Days |
FETZIMA ER 120 MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | Q:30 /30Days |
FETZIMA ER 20 MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | Q:30 /30Days |
FETZIMA ER 40 MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | Q:30 /30Days |
FETZIMA ER 80 MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | Q:30 /30Days |
FINACEA 15% FOAM |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
FINACEA 15% GEL |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
FINASTERIDE 5 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | Q:30 /30Days |
Firazyr 30.0mg/3mL 1 SYRINGE, GLASS per CARTON / 3 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
33% | 33% | P Q:18 /30Days |
FIRMAGON 2 X 120 MG KIT |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FIRMAGON 80 MG KIT |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
FLECAINIDE ACETATE 100 MG TAB #60 EA |
2 |
Generic |
$6.00 | $18.00 | None |
FLECAINIDE ACETATE 150 MG TAB 360 EA |
2 |
Generic |
$6.00 | $18.00 | None |
FLECAINIDE ACETATE 50 MG TAB |
2 |
Generic |
$6.00 | $18.00 | None |
FLOVENT DISKUS 100ug/1 60 POWDER, METERED in 1 INHALER |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days |
FLOVENT DISKUS 250ug/1 60 POWDER, METERED in 1 INHALER |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:240 /30Days |
FLOVENT DISKUS POWDER 50MCG 60 CTR |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days |
FLOVENT HFA 110ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:12 /30Days |
FLOVENT HFA 220ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:24 /30Days |
FLOVENT HFA 44ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:11 /30Days |
FLUCONAZOLE 100 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUCONAZOLE 10MG/ML ORAL SUSPENSION |
2 |
Generic |
$6.00 | $18.00 | None |
FLUCONAZOLE 150MG TABLETS |
2 |
Generic |
$6.00 | $18.00 | None |
Fluconazole 200mg/1 30 TABLET BOTTLE |
2 |
Generic |
$6.00 | $18.00 | None |
Fluconazole 400 MG/ 200 ML Injectable Solution |
2 |
Generic |
$6.00 | $18.00 | None |
FLUCONAZOLE 40MG/ML ORAL SUSPENSION |
2 |
Generic |
$6.00 | $18.00 | None |
Fluconazole 50mg/1 30 TABLET BOTTLE |
2 |
Generic |
$6.00 | $18.00 | None |
FLUCONAZOLE-NACL 200 MG/100 ML |
2 |
Generic |
$6.00 | $18.00 | None |
Flucytosine 250mg/1 |
5 |
Specialty Tier |
33% | 33% | None |
Flucytosine 500mg/1 |
5 |
Specialty Tier |
33% | 33% | None |
FLUDARABINE 50MG VIAL |
2 |
Generic |
$6.00 | $18.00 | None |
FLUDROCORTISONE ACETATE 0.1MG TABLET (100 CT) |
2 |
Generic |
$6.00 | $18.00 | 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 |
Generic |
$6.00 | $18.00 | None |
Fluocinonide 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2 |
Generic |
$6.00 | $18.00 | None |
Fluocinonide 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2 |
Generic |
$6.00 | $18.00 | None |
Fluorometholone 0.1% drops |
2 |
Generic |
$6.00 | $18.00 | None |
fluorouracil 500 mg/10 ml vial |
2 |
Generic |
$6.00 | $18.00 | P |
FLUOROURACIL CREA 5% |
2 |
Generic |
$6.00 | $18.00 | None |
Fluoxetine 10mg/1 30 FILM COATED TABLETS in BOTTLE |
2 |
Generic |
$6.00 | $18.00 | Q:30 /30Days |
Fluoxetine 20mg/5mL 120 mL in 1 BOTTLE, PLASTIC |
2 |
Generic |
$6.00 | $18.00 | Q:600 /30Days |
FLUOXETINE 40MG CAPSULE (30 CT) |
2 |
Generic |
$6.00 | $18.00 | Q:60 /30Days |
FLUOXETINE CAPSULES 10MG (100 CT) |
1 |
Preferred Generic |
$3.00 | $9.00 | Q:30 /30Days |
FLUOXETINE HCL 20 MG TABLET |
2 |
Generic |
$6.00 | $18.00 | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Fluoxetine Hydrochloride 20mg/1 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
$3.00 | $9.00 | Q:120 /30Days |
FLUPHENAZINE 10MG TABLET |
2 |
Generic |
$6.00 | $18.00 | P |
FLUPHENAZINE 1MG TABLET |
2 |
Generic |
$6.00 | $18.00 | P |
FLUPHENAZINE 2.5MG TABLET |
2 |
Generic |
$6.00 | $18.00 | P |
FLUPHENAZINE 2.5MG/ML VIAL |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | P |
FLUPHENAZINE 5MG TABLET |
2 |
Generic |
$6.00 | $18.00 | P |
FLUPHENAZINE 5MG/ML CONC |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | P |
Fluphenazine Decanoate 25mg/mL |
2 |
Generic |
$6.00 | $18.00 | P |
FLUPHENAZINE HCL 2.5MG/5ML ELIXIR |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | P |
FLURBIPROFEN 0.03% EYE DROP |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
Flutamide 125mg/1 500 CAPSULE BOTTLE |
2 |
Generic |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUTICASONE PROPIONATE 50MCG SPRAY SUSPENSION |
2 |
Generic |
$6.00 | $18.00 | Q:16 /30Days |
FLUVOXAMINE MALEATE 100MG TABLET |
2 |
Generic |
$6.00 | $18.00 | Q:90 /30Days |
Fluvoxamine Maleate 25mg/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 FILM COATED TABLETS in |
2 |
Generic |
$6.00 | $18.00 | Q:30 /30Days |
Fluvoxamine maleate 50mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Generic |
$6.00 | $18.00 | Q:30 /30Days |
FOLOTYN 20mg/mL 1 VIAL, SINGLE-USE per CARTON / 2 mL in 1 VIAL, SINGLE-USE |
5 |
Specialty Tier |
33% | 33% | None |
Fondaparinux Sodium 10mg/0.8mL 2 SYRINGES per CARTON / 0.8 mL in 1 SYRINGE [Arixtra] |
5 |
Specialty Tier |
33% | 33% | Q:24 /90Days |
Fondaparinux Sodium 2.5mg/0.5mL 2 SYRINGES per CARTON / 0.5 mL in 1 SYRINGE [Arixtra] |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | Q:15 /90Days |
Fondaparinux Sodium 5mg/4mL 2 SYRINGES per CARTON / 0.4 mL in 1 SYRINGE [Arixtra] |
5 |
Specialty Tier |
33% | 33% | Q:12 /90Days |
Fondaparinux Sodium 7.5mg/0.6mL 2 SYRINGES per CARTON / 0.6 mL in 1 SYRINGE [Arixtra] |
5 |
Specialty Tier |
33% | 33% | Q:18 /90Days |
Forteo 250ug/mL 1 SYRINGE per CARTON / 2.4 mL in 1 SYRINGE |
5 |
Specialty Tier |
33% | 33% | P |
FOSINOPRIL SODIUM 10MG TABLET (90 CT) |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FOSINOPRIL SODIUM 20 MG TAB |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
Fosinopril Sodium 40mg/1 90 TABLET BOTTLE |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
Fosphenytoin Sodium 50mg/mL 2 mL in 1 VIAL |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
FOSRENOL 1,000 MG POWDER PACK |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
FOSRENOL 1000MG TABLET CHEW |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
FOSRENOL 500MG TABLET CHEW |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
FOSRENOL 750 MG POWDER PACKET |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
FOSRENOL 750MG TABLET CHEW |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
Furosemide 10mg/mL 10 CARTON in 1 CONTAINER / 1 SYRINGE, PLASTIC in 1 CARTON / 4 mL in 1 SYRINGE, P |
2 |
Generic |
$6.00 | $18.00 | None |
FUROSEMIDE 10MG/ML SOLUTION |
2 |
Generic |
$6.00 | $18.00 | None |
Furosemide 20mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Furosemide 40 mg/4 ml vial |
2 |
Generic |
$6.00 | $18.00 | None |
Furosemide 40mg/1 5000 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
FUROSEMIDE 80MG TABLET (500 CT) |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
FUZEON 90 MG VIAL |
5 |
Specialty Tier |
33% | 33% | Q:60 /30Days |
FYCOMPA 0.5 MG/ML ORAL SUSP |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
FYCOMPA 10 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
FYCOMPA 12 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
FYCOMPA 2 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
FYCOMPA 4 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
FYCOMPA 6 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |
FYCOMPA 8 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None |