2016 Medicare Part D Plan Formulary Information |
PriorityMedicare Merit (PPO) (H4875-016-3)
Benefit Details
|
The PriorityMedicare Merit (PPO) (H4875-016-3) Formulary Drugs Starting with the Letter F in Wayne County, MI: CMS MA Region 11 which includes: MI Plan Monthly Premium: $95.00 Deductible: $75 |
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 |
4 |
Tier 4 |
$95.00 | $237.50 | Q:100 /30Days |
FABRAZYME 35MG VIAL |
5 |
Tier 5 |
31% | N/A | None |
FALMINA-28 TABLET |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FAMCICLOVIR 125MG TABLET |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FAMCICLOVIR 250MG TABLET |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FAMCICLOVIR 500MG TABLET |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FAMOTIDINE 20MG TABLET (500 CT) |
1* |
Tier 1 |
$4.00 | $0.00 | None |
FAMOTIDINE 40MG TABLET |
1* |
Tier 1 |
$4.00 | $0.00 | None |
FAMOTIDINE INJECTION 10MG 25 X 2ML VIALSD |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FANAPT 1 MG 60 TABLET BOTTLE |
4 |
Tier 4 |
$95.00 | $237.50 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FANAPT 10 MG TABLET |
4 |
Tier 4 |
$95.00 | $237.50 | Q:60 /30Days |
FANAPT 12 MG 60 TABLET BOTTLE |
4 |
Tier 4 |
$95.00 | $237.50 | Q:60 /30Days |
FANAPT 2 MG 60 TABLET BOTTLE |
4 |
Tier 4 |
$95.00 | $237.50 | Q:60 /30Days |
FANAPT 4 MG TABLET |
4 |
Tier 4 |
$95.00 | $237.50 | Q:60 /30Days |
FANAPT 6 MG 60 TABLET BOTTLE |
4 |
Tier 4 |
$95.00 | $237.50 | Q:60 /30Days |
FANAPT 8 MG TABLET |
4 |
Tier 4 |
$95.00 | $237.50 | Q:60 /30Days |
FANAPT TITR TABLETS |
4 |
Tier 4 |
$95.00 | $237.50 | None |
FARESTON 60 MG TABLET |
5 |
Tier 5 |
31% | N/A | None |
FARXIGA 10 MG TABLET |
3 |
Tier 3 |
$45.00 | $112.50 | Q:30 /30Days |
FARXIGA 5 MG TABLET |
3 |
Tier 3 |
$45.00 | $112.50 | Q:30 /30Days |
FARYDAK 10 MG CAPSULE |
5 |
Tier 5 |
31% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FARYDAK 15 MG CAPSULE |
5 |
Tier 5 |
31% | N/A | P |
FARYDAK 20 MG CAPSULE |
5 |
Tier 5 |
31% | N/A | P |
FASLODEX 50MG/ML INJECTION |
5 |
Tier 5 |
31% | N/A | None |
FazaClo 100mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
4 |
Tier 4 |
$95.00 | $237.50 | None |
FazaClo 12.5mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
4 |
Tier 4 |
$95.00 | $237.50 | None |
FazaClo 25mg/1 100 TABLET, ORALLY DISINTEGRATING in 1 BOTTLE |
4 |
Tier 4 |
$95.00 | $237.50 | None |
FELBAMATE 400 MG TABLET |
4 |
Tier 4 |
$95.00 | $237.50 | None |
FELBAMATE 600 MG TABLET |
4 |
Tier 4 |
$95.00 | $237.50 | None |
FELBAMATE 600 MG/5 ML SUSP |
4 |
Tier 4 |
$95.00 | $237.50 | None |
FELODIPINE ER 10 MG TABLET |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FELODIPINE ER 2.5 MG TABLET |
2* |
Tier 2 |
$12.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FELODIPINE ER 5 MG TABLET |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FEMCON FE CHEWABLE TABLET |
4 |
Tier 4 |
$95.00 | $237.50 | None |
FEMRING 0.05MG VAGINAL RING |
3 |
Tier 3 |
$45.00 | $112.50 | None |
FEMRING 0.10MG VAGINAL RING |
3 |
Tier 3 |
$45.00 | $112.50 | None |
FENOFIBRATE 130 MG CAPSULE [LIPOFEN] |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FENOFIBRATE 134MG CAPSULE [LIPOFEN] |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FENOFIBRATE 145 MG TABLET [LIPOFEN] |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FENOFIBRATE 150 MG CAPSULE [LIPOFEN] |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FENOFIBRATE 160 MG 90 TABLET BOTTLE [LIPOFEN] |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FENOFIBRATE 200 MG CAPSULE [LIPOFEN] |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FENOFIBRATE 43 MG CAPSULE [LIPOFEN] |
2* |
Tier 2 |
$12.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENOFIBRATE 48 MG TABLET [LIPOFEN] |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FENOFIBRATE 50 MG CAPSULE [LIPOFEN] |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FENOFIBRATE 54 MG 90 TABLET BOTTLE [LIPOFEN] |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FENOFIBRATE 67MG CAPSULE [LIPOFEN] |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FENOFIBRIC ACID 105 MG TABLET [TRILIPIX] |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FENOFIBRIC ACID 35 MG TABLET [TRILIPIX] |
2* |
Tier 2 |
$12.00 | $0.00 | None |
Fenofibric acid dr 135 mg capsule [TRILIPIX] |
2* |
Tier 2 |
$12.00 | $0.00 | None |
Fenofibric acid dr 45 mg capsule [TRILIPIX] |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FENOPROFEN 600MG TABLET |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FENTANYL 100MCG/HR PATCH TRANSDERMAL 72 HOURS |
2* |
Tier 2 |
$12.00 | $0.00 | Q:15 /30Days |
FENTANYL 12MCG/HR PATCH TRANSDERMAL 72 HOURS |
2* |
Tier 2 |
$12.00 | $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] |
4 |
Tier 4 |
$95.00 | $237.50 | Q:15 /30Days |
FENTANYL 62.5 MCG/HR PATCH [DURAGESIC] |
4 |
Tier 4 |
$95.00 | $237.50 | Q:15 /30Days |
FENTANYL 75 MCG/HR PATCH |
2* |
Tier 2 |
$12.00 | $0.00 | Q:15 /30Days |
FENTANYL 87.5 MCG/HR PATCH [DURAGESIC] |
5 |
Tier 5 |
31% | N/A | Q:15 /30Days |
FENTANYL CITRATE 1600ug/1 30 BLISTER PACK per CARTON / 1 LOZENGE per BLISTER PACK |
5 |
Tier 5 |
31% | N/A | P Q:29 /30Days |
FENTANYL CITRATE 200ug/1 30 BLISTER PACK per CARTON / 1 LOZENGE per BLISTER PACK |
5 |
Tier 5 |
31% | N/A | P Q:120 /30Days |
FENTANYL CITRATE LOZENGES |
5 |
Tier 5 |
31% | N/A | P Q:39 /30Days |
FENTANYL CITRATE LOZENGES |
5 |
Tier 5 |
31% | N/A | P Q:116 /30Days |
FENTANYL CITRATE LOZENGES |
5 |
Tier 5 |
31% | N/A | P Q:77 /30Days |
FENTANYL CITRATE LOZENGES |
5 |
Tier 5 |
31% | N/A | P Q:58 /30Days |
FENTANYL TRANSDERMAL SYSTEM 25MCG 5 SYSTEMS CRTN |
2* |
Tier 2 |
$12.00 | $0.00 | 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 |
2* |
Tier 2 |
$12.00 | $0.00 | Q:15 /30Days |
FENTORA TABLET 100MCG |
5 |
Tier 5 |
31% | N/A | P Q:120 /30Days |
FENTORA TABLET 200MCG |
5 |
Tier 5 |
31% | N/A | P Q:120 /30Days |
FENTORA TABLET 400MCG |
5 |
Tier 5 |
31% | N/A | P Q:116 /30Days |
FENTORA TABLET 600MCG |
5 |
Tier 5 |
31% | N/A | P Q:77 /30Days |
FENTORA TABLET 800MCG |
5 |
Tier 5 |
31% | N/A | P Q:58 /30Days |
FERRIPROX 500 MG TABLET |
5 |
Tier 5 |
31% | N/A | None |
FETZIMA 20-40 MG TITRATION PAK |
4 |
Tier 4 |
$95.00 | $237.50 | Q:30 /30Days |
FETZIMA ER 120 MG CAPSULE |
4 |
Tier 4 |
$95.00 | $237.50 | Q:30 /30Days |
FETZIMA ER 20 MG CAPSULE |
4 |
Tier 4 |
$95.00 | $237.50 | Q:30 /30Days |
FETZIMA ER 40 MG CAPSULE |
4 |
Tier 4 |
$95.00 | $237.50 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FETZIMA ER 80 MG CAPSULE |
4 |
Tier 4 |
$95.00 | $237.50 | Q:30 /30Days |
FINACEA 15% GEL |
4 |
Tier 4 |
$95.00 | $237.50 | None |
FINASTERIDE 5 MG TABLET |
2* |
Tier 2 |
$12.00 | $0.00 | None |
Firazyr 30.0mg/3mL 1 SYRINGE, GLASS per CARTON / 3 mL in 1 SYRINGE, GLASS |
5 |
Tier 5 |
31% | N/A | None |
FIRMAGON 2 X 120 MG KIT |
5 |
Tier 5 |
31% | N/A | None |
FIRMAGON 80 MG KIT |
4 |
Tier 4 |
$95.00 | $237.50 | None |
FLAREX 0.1% EYE DROPS |
3 |
Tier 3 |
$45.00 | $112.50 | None |
FLAVOXATE HCL 100MG TABLET |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLECAINIDE ACETATE 100 MG TAB #60 EA |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLECAINIDE ACETATE 150 MG TAB 360 EA |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLECAINIDE ACETATE 50 MG TAB |
2* |
Tier 2 |
$12.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLECTOR PATCH |
4 |
Tier 4 |
$95.00 | $237.50 | P |
FLUCONAZOLE 100 MG TABLET |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLUCONAZOLE 10MG/ML ORAL SUSPENSION |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLUCONAZOLE 150MG TABLETS |
2* |
Tier 2 |
$12.00 | $0.00 | None |
Fluconazole 200mg/1 30 TABLET BOTTLE |
2* |
Tier 2 |
$12.00 | $0.00 | None |
Fluconazole 400 MG/ 200 ML Injectable Solution |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLUCONAZOLE 40MG/ML ORAL SUSPENSION |
2* |
Tier 2 |
$12.00 | $0.00 | None |
Fluconazole 50mg/1 30 TABLET BOTTLE |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLUDARABINE 50MG VIAL |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLUDROCORTISONE ACETATE 0.1MG TABLET (100 CT) |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL |
2* |
Tier 2 |
$12.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOCINOLONE 0.01% BODY OIL |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLUOCINOLONE 0.01% CREAM |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLUOCINOLONE 0.01% SOLUTION |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLUOCINOLONE 0.025% CREAM |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLUOCINOLONE 0.025% OINTMENT |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLUOCINOLONE OIL 0.01% EAR DRP |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLUOCINONIDE 0.05% SOLUTION |
2* |
Tier 2 |
$12.00 | $0.00 | None |
fluocinonide 0.1% cream |
2* |
Tier 2 |
$12.00 | $0.00 | None |
Fluocinonide 0.5mg/g 1 TUBE per CARTON / 30 g in 1 TUBE |
2* |
Tier 2 |
$12.00 | $0.00 | None |
Fluocinonide 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2* |
Tier 2 |
$12.00 | $0.00 | None |
Fluocinonide 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
2* |
Tier 2 |
$12.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Fluorometholone 0.1% drops |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLUOROURACIL 0.5% CREAM |
5 |
Tier 5 |
31% | N/A | None |
FLUOROURACIL 2% TOPICAL SOLN |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLUOROURACIL 5% TOP SOLUTION |
2* |
Tier 2 |
$12.00 | $0.00 | None |
fluorouracil 500 mg/10 ml vial |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLUOROURACIL CREA 5% |
2* |
Tier 2 |
$12.00 | $0.00 | None |
Fluoxetine 10mg/1 30 FILM COATED TABLETS in BOTTLE |
1* |
Tier 1 |
$4.00 | $0.00 | None |
Fluoxetine 20mg/5mL 120 mL in 1 BOTTLE, PLASTIC |
1* |
Tier 1 |
$4.00 | $0.00 | None |
FLUOXETINE 40MG CAPSULE (30 CT) |
1* |
Tier 1 |
$4.00 | $0.00 | None |
FLUOXETINE CAPSULES 10MG (100 CT) |
1* |
Tier 1 |
$4.00 | $0.00 | None |
FLUOXETINE DR 90 MG CAPSULE |
2* |
Tier 2 |
$12.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOXETINE HCL 20 MG TABLET |
1* |
Tier 1 |
$4.00 | $0.00 | None |
FLUOXETINE HCL 60 MG TABLET |
1* |
Tier 1 |
$4.00 | $0.00 | None |
Fluoxetine Hydrochloride 20mg/1 100 CAPSULE BOTTLE |
1* |
Tier 1 |
$4.00 | $0.00 | None |
FLUPHENAZINE 10MG TABLET |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLUPHENAZINE 1MG TABLET |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLUPHENAZINE 2.5MG TABLET |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLUPHENAZINE 2.5MG/ML VIAL |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLUPHENAZINE 5MG TABLET |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLUPHENAZINE 5MG/ML CONC |
2* |
Tier 2 |
$12.00 | $0.00 | None |
Fluphenazine Decanoate 25mg/mL |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLUPHENAZINE HCL 2.5MG/5ML ELIXIR |
2* |
Tier 2 |
$12.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Flurazepam Hydrochloride 15mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC |
1* |
Tier 1 |
$4.00 | $0.00 | None |
Flurazepam Hydrochloride 30mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC |
1* |
Tier 1 |
$4.00 | $0.00 | None |
FLURBIPROFEN 0.03% EYE DROP |
2* |
Tier 2 |
$12.00 | $0.00 | None |
Flurbiprofen 100mg/1 100 BOTTLE in 1 BOTTLE / 100 FILM COATED TABLETS in BOTTLE |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLURBIPROFEN 50MG TABLET |
2* |
Tier 2 |
$12.00 | $0.00 | None |
Flutamide 125mg/1 500 CAPSULE BOTTLE |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLUTICASONE PROP 0.05% LOTION |
2* |
Tier 2 |
$12.00 | $0.00 | None |
Fluticasone Propionate 0.05mg/g 1 TUBE per CARTON / 30 g in 1 TUBE |
2* |
Tier 2 |
$12.00 | $0.00 | None |
Fluticasone Propionate 0.5mg/g 1 TUBE per CARTON / 30 g in 1 TUBE |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLUTICASONE PROPIONATE 50MCG SPRAY SUSPENSION |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLUVASTATIN ER 80 MG TABLET [Lescol] |
2* |
Tier 2 |
$12.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUVASTATIN SODIUM 20 MG CAPSULE [Lescol] |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLUVASTATIN SODIUM 40 MG CAPSULE [Lescol] |
2* |
Tier 2 |
$12.00 | $0.00 | None |
fluvoxamine er 100 mg capsule |
2* |
Tier 2 |
$12.00 | $0.00 | None |
fluvoxamine er 150 mg capsule |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FLUVOXAMINE MALEATE 100MG TABLET |
2* |
Tier 2 |
$12.00 | $0.00 | None |
Fluvoxamine Maleate 25mg/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 FILM COATED TABLETS in |
2* |
Tier 2 |
$12.00 | $0.00 | None |
Fluvoxamine maleate 50mg/1 100 FILM COATED TABLETS in BOTTLE |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FML FORTE 0.25% EYE DROPS |
3 |
Tier 3 |
$45.00 | $112.50 | None |
FML S.O.P. 0.1% OINTMENT |
3 |
Tier 3 |
$45.00 | $112.50 | None |
Focalin XR 25mg EXTENDED RELEASE 100 CAPSULE BOTTLE |
4 |
Tier 4 |
$95.00 | $237.50 | Q:30 /30Days |
Focalin XR 35mg EXTENDED RELEASE 100 CAPSULE BOTTLE |
4 |
Tier 4 |
$95.00 | $237.50 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FOLOTYN 20mg/mL 1 VIAL, SINGLE-USE per CARTON / 2 mL in 1 VIAL, SINGLE-USE |
5 |
Tier 5 |
31% | N/A | None |
Fondaparinux Sodium 10mg/0.8mL 2 SYRINGES per CARTON / 0.8 mL in 1 SYRINGE [Arixtra] |
5 |
Tier 5 |
31% | N/A | Q:24 /30Days |
Fondaparinux Sodium 2.5mg/0.5mL 2 SYRINGES per CARTON / 0.5 mL in 1 SYRINGE [Arixtra] |
4 |
Tier 4 |
$95.00 | $237.50 | Q:15 /30Days |
Fondaparinux Sodium 5mg/4mL 2 SYRINGES per CARTON / 0.4 mL in 1 SYRINGE [Arixtra] |
5 |
Tier 5 |
31% | N/A | Q:12 /30Days |
Fondaparinux Sodium 7.5mg/0.6mL 2 SYRINGES per CARTON / 0.6 mL in 1 SYRINGE [Arixtra] |
5 |
Tier 5 |
31% | N/A | Q:18 /30Days |
FORADIL AEROLIZER 12 MCG CAP |
4 |
Tier 4 |
$95.00 | $237.50 | None |
FORFIVO XL 450 MG TABLET |
4 |
Tier 4 |
$95.00 | $237.50 | Q:30 /30Days |
Forteo 250ug/mL 1 SYRINGE per CARTON / 2.4 mL in 1 SYRINGE |
5 |
Tier 5 |
31% | N/A | P |
FORTICAL 200 U/DOSE AEROSOL SPRAY W/PUMP |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FOSAMAX PLUS D 70; 5600mg/1; [iU]/1 4 TABLET per BLISTER PACK |
3 |
Tier 3 |
$45.00 | $112.50 | Q:4 /28Days |
FOSAMAX PLUS D 70MG/2800 IU |
3 |
Tier 3 |
$45.00 | $112.50 | Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FOSINOPRIL SODIUM 10MG TABLET (90 CT) |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FOSINOPRIL SODIUM 20 MG TAB |
2* |
Tier 2 |
$12.00 | $0.00 | None |
Fosinopril Sodium 40mg/1 90 TABLET BOTTLE |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FOSINOPRIL-HCTZ 10-12.5 MG TAB |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FOSINOPRIL-HCTZ 20-12.5 MG TAB |
2* |
Tier 2 |
$12.00 | $0.00 | None |
Fosphenytoin Sodium 50mg/mL 2 mL in 1 VIAL |
2* |
Tier 2 |
$12.00 | $0.00 | None |
FOSRENOL 1000MG TABLET CHEW |
5 |
Tier 5 |
31% | N/A | None |
FOSRENOL 500MG TABLET CHEW |
5 |
Tier 5 |
31% | N/A | None |
FOSRENOL 750MG TABLET CHEW |
5 |
Tier 5 |
31% | N/A | None |
FRAGMIN 10,000 UNITS SYRINGE |
5 |
Tier 5 |
31% | N/A | None |
FRAGMIN 2,500 UNITS SYRINGE |
4 |
Tier 4 |
$95.00 | $237.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FRAGMIN 5,000 UNITS SYRINGE |
4 |
Tier 4 |
$95.00 | $237.50 | None |
FRAGMIN 7,500 UNITS/0.3 ML SYR |
5 |
Tier 5 |
31% | N/A | None |
FROVA 2.5MG TABLET |
4 |
Tier 4 |
$95.00 | $237.50 | S Q:18 /30Days |
FROVATRIPTAN SUCC 2.5 MG TABLET [Frova] |
4 |
Tier 4 |
$95.00 | $237.50 | Q:18 /30Days |
FUROSEMIDE 10MG/ML SOLUTION |
1* |
Tier 1 |
$4.00 | $0.00 | None |
Furosemide 20mg/1 100 TABLET BOTTLE |
1* |
Tier 1 |
$4.00 | $0.00 | None |
Furosemide 40 mg/4 ml vial |
1* |
Tier 1 |
$4.00 | $0.00 | None |
Furosemide 40mg/1 5000 TABLET BOTTLE, PLASTIC |
1* |
Tier 1 |
$4.00 | $0.00 | None |
FUROSEMIDE 80MG TABLET (500 CT) |
1* |
Tier 1 |
$4.00 | $0.00 | None |
FUSILEV I.V. 50 MG VIAL |
5 |
Tier 5 |
31% | N/A | None |
FUZEON 90 MG VIAL |
5 |
Tier 5 |
31% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FYCOMPA 0.5 MG/ML ORAL SUSP |
4 |
Tier 4 |
$95.00 | $237.50 | Q:180 /30Days |
FYCOMPA 10 MG TABLET |
4 |
Tier 4 |
$95.00 | $237.50 | Q:30 /30Days |
FYCOMPA 12 MG TABLET |
4 |
Tier 4 |
$95.00 | $237.50 | Q:30 /30Days |
FYCOMPA 2 MG TABLET |
4 |
Tier 4 |
$95.00 | $237.50 | Q:30 /30Days |
FYCOMPA 4 MG TABLET |
4 |
Tier 4 |
$95.00 | $237.50 | Q:30 /30Days |
FYCOMPA 6 MG TABLET |
4 |
Tier 4 |
$95.00 | $237.50 | Q:30 /30Days |
FYCOMPA 8 MG TABLET |
4 |
Tier 4 |
$95.00 | $237.50 | Q:30 /30Days |