2016 Medicare Part D Plan Formulary Information |
Freedom Medi-Medi Full (HMO SNP) (H5427-087-0)
Benefit Details
|
The Freedom Medi-Medi Full (HMO SNP) (H5427-087-0) Formulary Drugs Starting with the Letter F in Marion County, FL: CMS MA Region 9 which includes: FL Plan Monthly Premium: $28.00 Deductible: $360 |
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 |
1 |
Tier 1 |
$0.00 | $0.00 | P |
FAMCICLOVIR 125MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FAMCICLOVIR 250MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FAMCICLOVIR 500MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FAMOTIDINE 20MG TABLET (500 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FAMOTIDINE 40MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FAMOTIDINE INJECTION 10MG 25 X 2ML VIALSD |
1 |
Tier 1 |
$0.00 | $0.00 | P |
FANAPT 1 MG 60 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | S Q:60 /30Days |
FANAPT 10 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | S Q:60 /30Days |
FANAPT 12 MG 60 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | S Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FANAPT 2 MG 60 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | S Q:60 /30Days |
FANAPT 4 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | S Q:60 /30Days |
FANAPT 6 MG 60 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | S Q:60 /30Days |
FANAPT 8 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | S Q:60 /30Days |
FANAPT TITR TABLETS |
1 |
Tier 1 |
$0.00 | $0.00 | S |
FARESTON 60 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FARXIGA 10 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:30 /30Days |
FARXIGA 5 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:30 /30Days |
FARYDAK 10 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FARYDAK 15 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FARYDAK 20 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FASLODEX 50MG/ML INJECTION |
1 |
Tier 1 |
$0.00 | $0.00 | P |
FazaClo 100mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | S |
FazaClo 12.5mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | S |
FazaClo 150mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | S |
FAZACLO 200 MG TABLETS ORALLY DISINTEGRATING |
1 |
Tier 1 |
$0.00 | $0.00 | S |
FazaClo 25mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | S |
FELBATOL 400MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FELBATOL 600MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FELBATOL 600MG/5ML SUSP |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FELODIPINE ER 10 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
FELODIPINE ER 2.5 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FELODIPINE ER 5 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
FENOFIBRATE 130 MG CAPSULE [LIPOFEN] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FENOFIBRATE 134MG CAPSULE [LIPOFEN] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FENOFIBRATE 160 MG 90 TABLET BOTTLE [LIPOFEN] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FENOFIBRATE 200 MG CAPSULE [LIPOFEN] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FENOFIBRATE 43 MG CAPSULE [LIPOFEN] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FENOFIBRATE 54 MG 90 TABLET BOTTLE [LIPOFEN] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FENOFIBRATE 67MG CAPSULE [LIPOFEN] |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FENOPROFEN 600MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FENTANYL 100MCG/HR PATCH TRANSDERMAL 72 HOURS |
1 |
Tier 1 |
$0.00 | $0.00 | Q:15 /30Days |
FENTANYL 12MCG/HR PATCH TRANSDERMAL 72 HOURS |
1 |
Tier 1 |
$0.00 | $0.00 | Q:15 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENTANYL 37.5 MCG/HR PATCH [DURAGESIC] |
1 |
Tier 1 |
$0.00 | $0.00 | Q:15 /30Days |
FENTANYL 62.5 MCG/HR PATCH [DURAGESIC] |
1 |
Tier 1 |
$0.00 | $0.00 | Q:15 /30Days |
FENTANYL 75 MCG/HR PATCH |
1 |
Tier 1 |
$0.00 | $0.00 | Q:15 /30Days |
FENTANYL 87.5 MCG/HR PATCH [DURAGESIC] |
1 |
Tier 1 |
$0.00 | $0.00 | Q:15 /30Days |
FENTANYL TRANSDERMAL SYSTEM 25MCG 5 SYSTEMS CRTN |
1 |
Tier 1 |
$0.00 | $0.00 | Q:15 /30Days |
FENTANYL TRANSDERMAL SYSTEM 50MCG 5 SYSTEMS CRTN |
1 |
Tier 1 |
$0.00 | $0.00 | Q:15 /30Days |
FENTORA TABLET 100MCG |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:112 /28Days |
FENTORA TABLET 200MCG |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:112 /28Days |
FENTORA TABLET 400MCG |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:112 /28Days |
FENTORA TABLET 600MCG |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:112 /28Days |
FENTORA TABLET 800MCG |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:112 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FERRIPROX 500 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P |
FETZIMA 20-40 MG TITRATION PAK |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FETZIMA ER 120 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
FETZIMA ER 20 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
FETZIMA ER 40 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
FETZIMA ER 80 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
FINASTERIDE 5 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
Firazyr 30.0mg/3mL 1 SYRINGE, GLASS per CARTON / 3 mL in 1 SYRINGE, GLASS |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:9 /30Days |
FIRMAGON 2 X 120 MG KIT |
1 |
Tier 1 |
$0.00 | $0.00 | P |
FIRMAGON 80 MG KIT |
1 |
Tier 1 |
$0.00 | $0.00 | P |
FLAREX 0.1% EYE DROPS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLAVOXATE HCL 100MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FLECAINIDE ACETATE 100 MG TAB #60 EA |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FLECAINIDE ACETATE 150 MG TAB 360 EA |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FLECAINIDE ACETATE 50 MG TAB |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FLOVENT DISKUS 100ug/1 60 POWDER, METERED in 1 INHALER |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
FLOVENT DISKUS 250ug/1 60 POWDER, METERED in 1 INHALER |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
FLOVENT DISKUS POWDER 50MCG 60 CTR |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
FLOVENT HFA 110ug/1 120 AEROSOL, METERED in 1 INHALER |
1 |
Tier 1 |
$0.00 | $0.00 | Q:12 /30Days |
FLOVENT HFA 220ug/1 120 AEROSOL, METERED in 1 INHALER |
1 |
Tier 1 |
$0.00 | $0.00 | Q:24 /30Days |
FLOVENT HFA 44ug/1 120 AEROSOL, METERED in 1 INHALER |
1 |
Tier 1 |
$0.00 | $0.00 | Q:11 /30Days |
FLUCONAZOLE 100 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUCONAZOLE 10MG/ML ORAL SUSPENSION |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FLUCONAZOLE 150MG TABLETS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Fluconazole 200mg/1 30 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Fluconazole 400 MG/ 200 ML Injectable Solution |
1 |
Tier 1 |
$0.00 | $0.00 | P |
FLUCONAZOLE 40MG/ML ORAL SUSPENSION |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Fluconazole 50mg/1 30 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FLUCONAZOLE-NACL 200 MG/100 ML |
1 |
Tier 1 |
$0.00 | $0.00 | P |
FLUDARABINE 50MG VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | P |
FLUDROCORTISONE ACETATE 0.1MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL |
1 |
Tier 1 |
$0.00 | $0.00 | Q:50 /30Days |
FLUOCINOLONE 0.01% CREAM |
1 |
Tier 1 |
$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% SOLUTION |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FLUOCINOLONE 0.025% CREAM |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FLUOCINOLONE 0.025% OINTMENT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FLUOCINOLONE OIL 0.01% EAR DRP |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FLUOCINONIDE 0.05% SOLUTION |
1 |
Tier 1 |
$0.00 | $0.00 | None |
fluocinonide 0.1% cream |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Fluocinonide 0.5mg/g 1 TUBE per CARTON / 30 g in 1 TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Fluocinonide 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Fluocinonide 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Fluorometholone 0.1% drops |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FLUOROURACIL 0.5% CREAM |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOROURACIL 2% TOPICAL SOLN |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FLUOROURACIL 5% TOP SOLUTION |
1 |
Tier 1 |
$0.00 | $0.00 | None |
fluorouracil 500 mg/10 ml vial |
1 |
Tier 1 |
$0.00 | $0.00 | P |
FLUOROURACIL CREA 5% |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Fluoxetine 20mg/5mL 120 mL in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
$0.00 | $0.00 | Q:600 /30Days |
FLUOXETINE 40MG CAPSULE (30 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:90 /30Days |
FLUOXETINE CAPSULES 10MG (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
FLUOXETINE DR 90 MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:4 /28Days |
Fluoxetine Hydrochloride 20mg/1 100 CAPSULE BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:120 /30Days |
FLUPHENAZINE 10MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FLUPHENAZINE 1MG TABLET |
1 |
Tier 1 |
$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 TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FLUPHENAZINE 2.5MG/ML VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FLUPHENAZINE 5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FLUPHENAZINE 5MG/ML CONC |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Fluphenazine Decanoate 25mg/mL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FLUPHENAZINE HCL 2.5MG/5ML ELIXIR |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Flurazepam Hydrochloride 15mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Flurazepam Hydrochloride 30mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Flurbiprofen 100mg/1 100 BOTTLE in 1 BOTTLE / 100 FILM COATED TABLETS in BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FLURBIPROFEN 50MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Flutamide 125mg/1 500 CAPSULE BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUTICASONE PROP 0.05% LOTION |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Fluticasone Propionate 0.05mg/g 1 TUBE per CARTON / 30 g in 1 TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Fluticasone Propionate 0.5mg/g 1 TUBE per CARTON / 30 g in 1 TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FLUTICASONE PROPIONATE 50MCG SPRAY SUSPENSION |
1 |
Tier 1 |
$0.00 | $0.00 | Q:16 /30Days |
FLUVOXAMINE MALEATE 100MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:90 /30Days |
Fluvoxamine Maleate 25mg/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 FILM COATED TABLETS in |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
Fluvoxamine maleate 50mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
FML FORTE 0.25% EYE DROPS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FML S.O.P. 0.1% OINTMENT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FOLOTYN 20mg/mL 1 VIAL, SINGLE-USE per CARTON / 2 mL in 1 VIAL, SINGLE-USE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
Fomepizole 1g/mL 1 VIAL per CARTON / 1.5 mL in 1 VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FORFIVO XL 450 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
Forteo 250ug/mL 1 SYRINGE per CARTON / 2.4 mL in 1 SYRINGE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
FORTICAL 200 U/DOSE AEROSOL SPRAY W/PUMP |
1 |
Tier 1 |
$0.00 | $0.00 | Q:4 /30Days |
FOSAMAX PLUS D 70; 5600mg/1; [iU]/1 4 TABLET per BLISTER PACK |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FOSAMAX PLUS D 70MG/2800 IU |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FOSINOPRIL SODIUM 10MG TABLET (90 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FOSINOPRIL SODIUM 20 MG TAB |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Fosinopril Sodium 40mg/1 90 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FOSINOPRIL-HCTZ 10-12.5 MG TAB |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
FOSINOPRIL-HCTZ 20-12.5 MG TAB |
1 |
Tier 1 |
$0.00 | $0.00 | Q:120 /30Days |
Fosphenytoin Sodium 50mg/mL 2 mL in 1 VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FROVA 2.5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:12 /30Days |
Furosemide 10mg/mL 10 CARTON in 1 CONTAINER / 1 SYRINGE, PLASTIC in 1 CARTON / 4 mL in 1 SYRINGE, P |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FUROSEMIDE 10MG/ML SOLUTION |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Furosemide 20mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Furosemide 40 mg/4 ml vial |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Furosemide 40mg/1 5000 TABLET BOTTLE, PLASTIC |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FUROSEMIDE 80MG TABLET (500 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FUZEON 90 MG VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
FYCOMPA 0.5 MG/ML ORAL SUSP |
1 |
Tier 1 |
$0.00 | $0.00 | None |
FYCOMPA 10 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
FYCOMPA 12 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FYCOMPA 2 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
FYCOMPA 4 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
FYCOMPA 6 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
FYCOMPA 8 MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |