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2016 Medicare Part D Plan Formulary Information
Health Alliance Medicare HMO Basic Rx (HMO) (H1463-009-0) Benefit Details
The Health Alliance Medicare HMO Basic Rx (HMO) (H1463-009-0) Formulary Drugs Starting with the Letter F in McLean County, IL: CMS MA Region 14 which includes: IL Plan Monthly Premium: $35.00 Deductible: $360
Drugs Starting with Letter F Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter F Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
FABRAZYME 35MG VIAL	5	Specialty Tier	25%	25%	P
FALMINA-28 TABLET	2	Generic	$20.00	$60.00	None
FAMCICLOVIR 125MG TABLET	2	Generic	$20.00	$60.00	None
FAMCICLOVIR 250MG TABLET	2	Generic	$20.00	$60.00	None
FAMCICLOVIR 500MG TABLET	2	Generic	$20.00	$60.00	None
FAMOTIDINE 20MG PIGGYBACK	1*	Preferred Generic	$0.00	$46.50	None
FAMOTIDINE 20MG TABLET (500 CT)	1*	Preferred Generic	$0.00	$46.50	None
FAMOTIDINE 40MG TABLET	1*	Preferred Generic	$0.00	$46.50	None
FAMOTIDINE 50 MG/5MLFOR ORAL SUSPENSION	1*	Preferred Generic	$0.00	$46.50	None
FAMOTIDINE INJECTION 10MG 25 X 2ML VIALSD	1*	Preferred Generic	$0.00	$46.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
FANAPT 1 MG 60 TABLET BOTTLE	4	Non-Preferred Brand	$100.00	$300.00	S
FANAPT 10 MG TABLET	4	Non-Preferred Brand	$100.00	$300.00	S
FANAPT 12 MG 60 TABLET BOTTLE	4	Non-Preferred Brand	$100.00	$300.00	S
FANAPT 2 MG 60 TABLET BOTTLE	4	Non-Preferred Brand	$100.00	$300.00	S
FANAPT 4 MG TABLET	4	Non-Preferred Brand	$100.00	$300.00	S
FANAPT 6 MG 60 TABLET BOTTLE	4	Non-Preferred Brand	$100.00	$300.00	S
FANAPT 8 MG TABLET	4	Non-Preferred Brand	$100.00	$300.00	S
FANAPT TITR TABLETS	4	Non-Preferred Brand	$100.00	$300.00	S
FARESTON 60 MG TABLET	5	Specialty Tier	25%	25%	P
FARYDAK 10 MG CAPSULE	5	Specialty Tier	25%	25%	P
FARYDAK 15 MG CAPSULE	5	Specialty Tier	25%	25%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
FARYDAK 20 MG CAPSULE	5	Specialty Tier	25%	25%	P
FASLODEX 50MG/ML INJECTION	3	Preferred Brand	$47.00	$141.00	None
FELBAMATE 400 MG TABLET	2	Generic	$20.00	$60.00	None
FELBAMATE 600 MG TABLET	2	Generic	$20.00	$60.00	None
FELBAMATE 600 MG/5 ML SUSP	2	Generic	$20.00	$60.00	None
FEMRING 0.05MG VAGINAL RING	4	Non-Preferred Brand	$100.00	$300.00	None
FEMRING 0.10MG VAGINAL RING	4	Non-Preferred Brand	$100.00	$300.00	None
FENOFIBRATE 120 MG TABLET [LIPOFEN]	2	Generic	$20.00	$60.00	None
FENOFIBRATE 130 MG CAPSULE [LIPOFEN]	2	Generic	$20.00	$60.00	None
FENOFIBRATE 134MG CAPSULE [LIPOFEN]	1*	Preferred Generic	$0.00	$46.50	None
FENOFIBRATE 145 MG TABLET [LIPOFEN]	2	Generic	$20.00	$60.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
FENOFIBRATE 150 MG CAPSULE [LIPOFEN]	2	Generic	$20.00	$60.00	None
FENOFIBRATE 160 MG 90 TABLET BOTTLE [LIPOFEN]	2	Generic	$20.00	$60.00	None
FENOFIBRATE 200 MG CAPSULE [LIPOFEN]	1*	Preferred Generic	$0.00	$46.50	None
FENOFIBRATE 40 MG TABLET [LIPOFEN]	2	Generic	$20.00	$60.00	None
FENOFIBRATE 43 MG CAPSULE [LIPOFEN]	2	Generic	$20.00	$60.00	None
FENOFIBRATE 48 MG TABLET [LIPOFEN]	2	Generic	$20.00	$60.00	None
FENOFIBRATE 50 MG CAPSULE [LIPOFEN]	2	Generic	$20.00	$60.00	None
FENOFIBRATE 54 MG 90 TABLET BOTTLE [LIPOFEN]	2	Generic	$20.00	$60.00	None
FENOFIBRATE 67MG CAPSULE [LIPOFEN]	1*	Preferred Generic	$0.00	$46.50	None
FENOFIBRIC ACID 105 MG TABLET [TRILIPIX]	1*	Preferred Generic	$0.00	$46.50	None
FENOFIBRIC ACID 35 MG TABLET [TRILIPIX]	1*	Preferred Generic	$0.00	$46.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Fenofibric acid dr 135 mg capsule [TRILIPIX]	2	Generic	$20.00	$60.00	None
Fenofibric acid dr 45 mg capsule [TRILIPIX]	1*	Preferred Generic	$0.00	$46.50	None
FENOPROFEN 600MG TABLET	1*	Preferred Generic	$0.00	$46.50	None
FENOPROFEN CALCIUM 400 MG CAP	1*	Preferred Generic	$0.00	$46.50	None
FENTANYL 100MCG/HR PATCH TRANSDERMAL 72 HOURS	2	Generic	$20.00	$60.00	Q:20 /30Days
FENTANYL 12MCG/HR PATCH TRANSDERMAL 72 HOURS	2	Generic	$20.00	$60.00	Q:10 /30Days
FENTANYL 37.5 MCG/HR PATCH [DURAGESIC]	2	Generic	$20.00	$60.00	Q:10 /30Days
FENTANYL 62.5 MCG/HR PATCH [DURAGESIC]	2	Generic	$20.00	$60.00	Q:10 /30Days
FENTANYL 75 MCG/HR PATCH	2	Generic	$20.00	$60.00	Q:10 /30Days
FENTANYL 87.5 MCG/HR PATCH [DURAGESIC]	2	Generic	$20.00	$60.00	Q:10 /30Days
FENTANYL CITRATE 1600ug/1 30 BLISTER PACK per CARTON / 1 LOZENGE per BLISTER PACK	5	Specialty Tier	25%	25%	P Q:120 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
FENTANYL CITRATE 200ug/1 30 BLISTER PACK per CARTON / 1 LOZENGE per BLISTER PACK	5	Specialty Tier	25%	25%	P Q:120 /30Days
FENTANYL CITRATE LOZENGES	5	Specialty Tier	25%	25%	P Q:120 /30Days
FENTANYL CITRATE LOZENGES	5	Specialty Tier	25%	25%	P Q:120 /30Days
FENTANYL CITRATE LOZENGES	5	Specialty Tier	25%	25%	P Q:120 /30Days
FENTANYL CITRATE LOZENGES	5	Specialty Tier	25%	25%	P Q:120 /30Days
FENTANYL TRANSDERMAL SYSTEM 25MCG 5 SYSTEMS CRTN	2	Generic	$20.00	$60.00	Q:10 /30Days
FENTANYL TRANSDERMAL SYSTEM 50MCG 5 SYSTEMS CRTN	2	Generic	$20.00	$60.00	Q:10 /30Days
FERRIPROX 100 MG/ML SOLUTION	5	Specialty Tier	25%	25%	None
FERRIPROX 500 MG TABLET	4	Non-Preferred Brand	$100.00	$300.00	None
FETZIMA 20-40 MG TITRATION PAK	4	Non-Preferred Brand	$100.00	$300.00	S
FETZIMA ER 120 MG CAPSULE	4	Non-Preferred Brand	$100.00	$300.00	S
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	$100.00	$300.00	S
FETZIMA ER 40 MG CAPSULE	4	Non-Preferred Brand	$100.00	$300.00	S
FETZIMA ER 80 MG CAPSULE	4	Non-Preferred Brand	$100.00	$300.00	S
FINACEA 15% FOAM	4	Non-Preferred Brand	$100.00	$300.00	P
FINACEA 15% GEL	4	Non-Preferred Brand	$100.00	$300.00	P
FINASTERIDE 5 MG TABLET	1*	Preferred Generic	$0.00	$46.50	None
Firazyr 30.0mg/3mL 1 SYRINGE, GLASS per CARTON / 3 mL in 1 SYRINGE, GLASS	5	Specialty Tier	25%	25%	P
FIRMAGON 2 X 120 MG KIT	4	Non-Preferred Brand	$100.00	$300.00	None
FIRMAGON 80 MG KIT	4	Non-Preferred Brand	$100.00	$300.00	None
FLAVOXATE HCL 100MG TABLET	1*	Preferred Generic	$0.00	$46.50	None
FLEBOGAMMA DIF INJECTION	5	Specialty Tier	25%	25%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
FLECAINIDE ACETATE 100 MG TAB #60 EA	1*	Preferred Generic	$0.00	$46.50	None
FLECAINIDE ACETATE 150 MG TAB 360 EA	1*	Preferred Generic	$0.00	$46.50	None
FLECAINIDE ACETATE 50 MG TAB	1*	Preferred Generic	$0.00	$46.50	None
FLUCONAZOLE 100 MG TABLET	2	Generic	$20.00	$60.00	None
FLUCONAZOLE 10MG/ML ORAL SUSPENSION	2	Generic	$20.00	$60.00	None
FLUCONAZOLE 150MG TABLETS	2	Generic	$20.00	$60.00	None
Fluconazole 200mg/1 30 TABLET BOTTLE	2	Generic	$20.00	$60.00	None
Fluconazole 400 MG/ 200 ML Injectable Solution	1*	Preferred Generic	$0.00	$46.50	None
FLUCONAZOLE 40MG/ML ORAL SUSPENSION	2	Generic	$20.00	$60.00	None
Fluconazole 50mg/1 30 TABLET BOTTLE	2	Generic	$20.00	$60.00	None
FLUCONAZOLE-NACL 200 MG/100 ML	1*	Preferred Generic	$0.00	$46.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Flucytosine 250mg/1	1*	Preferred Generic	$0.00	$46.50	None
Flucytosine 500mg/1	1*	Preferred Generic	$0.00	$46.50	None
FLUDARABINE 50MG VIAL	1*	Preferred Generic	$0.00	$46.50	None
FLUDROCORTISONE ACETATE 0.1MG TABLET (100 CT)	1*	Preferred Generic	$0.00	$46.50	None
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL	1*	Preferred Generic	$0.00	$46.50	None
FLUOCINOLONE 0.01% BODY OIL	2	Generic	$20.00	$60.00	None
FLUOCINOLONE 0.01% CREAM	2	Generic	$20.00	$60.00	None
FLUOCINOLONE 0.01% SOLUTION	2	Generic	$20.00	$60.00	None
FLUOCINOLONE 0.025% CREAM	2	Generic	$20.00	$60.00	None
FLUOCINOLONE 0.025% OINTMENT	2	Generic	$20.00	$60.00	None
FLUOCINOLONE OIL 0.01% EAR DRP	2	Generic	$20.00	$60.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
FLUOCINONIDE 0.05% SOLUTION	2	Generic	$20.00	$60.00	None
fluocinonide 0.1% cream	2	Generic	$20.00	$60.00	None
Fluocinonide 0.5mg/g 1 TUBE per CARTON / 30 g in 1 TUBE	2	Generic	$20.00	$60.00	None
Fluocinonide 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE	2	Generic	$20.00	$60.00	None
Fluorometholone 0.1% drops	2	Generic	$20.00	$60.00	None
FLUOROURACIL 0.5% CREAM	2	Generic	$20.00	$60.00	None
FLUOROURACIL 2% TOPICAL SOLN	2	Generic	$20.00	$60.00	None
FLUOROURACIL 5% TOP SOLUTION	2	Generic	$20.00	$60.00	None
fluorouracil 500 mg/10 ml vial	2	Generic	$20.00	$60.00	P
FLUOROURACIL CREA 5%	2	Generic	$20.00	$60.00	None
Fluoxetine 10mg/1 30 FILM COATED TABLETS in BOTTLE	1*	Preferred Generic	$0.00	$46.50	None
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	1*	Preferred Generic	$0.00	$46.50	None
FLUOXETINE 40MG CAPSULE (30 CT)	1*	Preferred Generic	$0.00	$46.50	None
FLUOXETINE CAPSULES 10MG (100 CT)	1*	Preferred Generic	$0.00	$46.50	None
FLUOXETINE DR 90 MG CAPSULE	1*	Preferred Generic	$0.00	$46.50	None
FLUOXETINE HCL 20 MG TABLET	1*	Preferred Generic	$0.00	$46.50	None
FLUOXETINE HCL 60 MG TABLET	1*	Preferred Generic	$0.00	$46.50	None
Fluoxetine Hydrochloride 20mg/1 100 CAPSULE BOTTLE	1*	Preferred Generic	$0.00	$46.50	None
FLUPHENAZINE 10MG TABLET	1*	Preferred Generic	$0.00	$46.50	None
FLUPHENAZINE 1MG TABLET	1*	Preferred Generic	$0.00	$46.50	None
FLUPHENAZINE 2.5MG TABLET	1*	Preferred Generic	$0.00	$46.50	None
FLUPHENAZINE 2.5MG/ML VIAL	1*	Preferred Generic	$0.00	$46.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
FLUPHENAZINE 5MG TABLET	1*	Preferred Generic	$0.00	$46.50	None
FLUPHENAZINE 5MG/ML CONC	1*	Preferred Generic	$0.00	$46.50	None
Fluphenazine Decanoate 25mg/mL	1*	Preferred Generic	$0.00	$46.50	None
FLUPHENAZINE HCL 2.5MG/5ML ELIXIR	1*	Preferred Generic	$0.00	$46.50	None
Flurandrenolide 0.05% Cream [Cordran]	2	Generic	$20.00	$60.00	None
Flurazepam Hydrochloride 15mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC	2	Generic	$20.00	$60.00	Q:30 /30Days
Flurazepam Hydrochloride 30mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC	2	Generic	$20.00	$60.00	Q:30 /30Days
FLURBIPROFEN 0.03% EYE DROP	1*	Preferred Generic	$0.00	$46.50	None
Flurbiprofen 100mg/1 100 BOTTLE in 1 BOTTLE / 100 FILM COATED TABLETS in BOTTLE	1*	Preferred Generic	$0.00	$46.50	None
FLURBIPROFEN 50MG TABLET	1*	Preferred Generic	$0.00	$46.50	None
Flutamide 125mg/1 500 CAPSULE BOTTLE	2	Generic	$20.00	$60.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Fluticasone Propionate 0.05mg/g 1 TUBE per CARTON / 30 g in 1 TUBE	1*	Preferred Generic	$0.00	$46.50	None
Fluticasone Propionate 0.5mg/g 1 TUBE per CARTON / 30 g in 1 TUBE	1*	Preferred Generic	$0.00	$46.50	None
FLUTICASONE PROPIONATE 50MCG SPRAY SUSPENSION	1*	Preferred Generic	$0.00	$46.50	None
FLUVASTATIN ER 80 MG TABLET [Lescol]	2	Generic	$20.00	$60.00	None
fluvoxamine er 100 mg capsule	4	Non-Preferred Brand	$100.00	$300.00	S
fluvoxamine er 150 mg capsule	4	Non-Preferred Brand	$100.00	$300.00	S
FLUVOXAMINE MALEATE 100MG TABLET	1*	Preferred Generic	$0.00	$46.50	None
Fluvoxamine Maleate 25mg/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 FILM COATED TABLETS in	1*	Preferred Generic	$0.00	$46.50	None
Fluvoxamine maleate 50mg/1 100 FILM COATED TABLETS in BOTTLE	1*	Preferred Generic	$0.00	$46.50	None
FOLOTYN 20mg/mL 1 VIAL, SINGLE-USE per CARTON / 2 mL in 1 VIAL, SINGLE-USE	3	Preferred Brand	$47.00	$141.00	None
Fomepizole 1g/mL 1 VIAL per CARTON / 1.5 mL in 1 VIAL	1*	Preferred Generic	$0.00	$46.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Fondaparinux Sodium 10mg/0.8mL 2 SYRINGES per CARTON / 0.8 mL in 1 SYRINGE [Arixtra]	5	Specialty Tier	25%	25%	None
Fondaparinux Sodium 2.5mg/0.5mL 2 SYRINGES per CARTON / 0.5 mL in 1 SYRINGE [Arixtra]	4	Non-Preferred Brand	$100.00	$300.00	None
Fondaparinux Sodium 5mg/4mL 2 SYRINGES per CARTON / 0.4 mL in 1 SYRINGE [Arixtra]	5	Specialty Tier	25%	25%	None
Fondaparinux Sodium 7.5mg/0.6mL 2 SYRINGES per CARTON / 0.6 mL in 1 SYRINGE [Arixtra]	5	Specialty Tier	25%	25%	None
FORADIL AEROLIZER 12 MCG CAP	3	Preferred Brand	$47.00	$141.00	None
FORFIVO XL 450 MG TABLET	4	Non-Preferred Brand	$100.00	$300.00	None
Forteo 250ug/mL 1 SYRINGE per CARTON / 2.4 mL in 1 SYRINGE	5	Specialty Tier	25%	25%	P
FORTICAL 200 U/DOSE AEROSOL SPRAY W/PUMP	4	Non-Preferred Brand	$100.00	$300.00	None
FOSINOPRIL SODIUM 10MG TABLET (90 CT)	1*	Preferred Generic	$0.00	$46.50	None
FOSINOPRIL SODIUM 20 MG TAB	1*	Preferred Generic	$0.00	$46.50	None
Fosinopril Sodium 40mg/1 90 TABLET BOTTLE	1*	Preferred Generic	$0.00	$46.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
FOSINOPRIL-HCTZ 10-12.5 MG TAB	2	Generic	$20.00	$60.00	None
FOSINOPRIL-HCTZ 20-12.5 MG TAB	2	Generic	$20.00	$60.00	None
Fosphenytoin Sodium 50mg/mL 2 mL in 1 VIAL	1*	Preferred Generic	$0.00	$46.50	None
FOSRENOL 1,000 MG POWDER PACK	4	Non-Preferred Brand	$100.00	$300.00	None
FOSRENOL 1000MG TABLET CHEW	4	Non-Preferred Brand	$100.00	$300.00	None
FOSRENOL 500MG TABLET CHEW	4	Non-Preferred Brand	$100.00	$300.00	None
FOSRENOL 750 MG POWDER PACKET	4	Non-Preferred Brand	$100.00	$300.00	None
FOSRENOL 750MG TABLET CHEW	4	Non-Preferred Brand	$100.00	$300.00	None
FRAGMIN 10,000 UNITS SYRINGE	4	Non-Preferred Brand	$100.00	$300.00	None
FRAGMIN 12,500 UNITS SYRINGE	4	Non-Preferred Brand	$100.00	$300.00	None
FRAGMIN 15,000 UNITS SYRINGE	4	Non-Preferred Brand	$100.00	$300.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
FRAGMIN 18,000 UNITS SYRINGE	4	Non-Preferred Brand	$100.00	$300.00	None
FRAGMIN 2,500 UNITS SYRINGE	4	Non-Preferred Brand	$100.00	$300.00	None
FRAGMIN 5,000 UNITS SYRINGE	4	Non-Preferred Brand	$100.00	$300.00	None
FRAGMIN 7,500 UNITS/0.3 ML SYR	4	Non-Preferred Brand	$100.00	$300.00	None
FRAGMIN 95,000 UNITS/3.8 ML VL	4	Non-Preferred Brand	$100.00	$300.00	None
FREAMINE HBC INJECTION	3	Preferred Brand	$47.00	$141.00	P
Furosemide 10mg/mL 10 CARTON in 1 CONTAINER / 1 SYRINGE, PLASTIC in 1 CARTON / 4 mL in 1 SYRINGE, P	1*	Preferred Generic	$0.00	$46.50	None
FUROSEMIDE 10MG/ML SOLUTION	1*	Preferred Generic	$0.00	$46.50	None
Furosemide 20mg/1 100 TABLET BOTTLE	1*	Preferred Generic	$0.00	$46.50	None
Furosemide 40 mg/4 ml vial	1*	Preferred Generic	$0.00	$46.50	None
Furosemide 40mg/1 5000 TABLET BOTTLE, PLASTIC	1*	Preferred Generic	$0.00	$46.50	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	$0.00	$46.50	None
FUROSEMIDE 80MG TABLET (500 CT)	1*	Preferred Generic	$0.00	$46.50	None
FUSILEV I.V. 50 MG VIAL	3	Preferred Brand	$47.00	$141.00	None
FUZEON 90 MG VIAL	5	Specialty Tier	25%	25%	None
FYAVOLV 0.5 MG-2.5 MCG TABLET	2	Generic	$20.00	$60.00	None
FYAVOLV 1 MG-5 MCG TABLET	2	Generic	$20.00	$60.00	None
FYCOMPA 0.5 MG/ML ORAL SUSP	4	Non-Preferred Brand	$100.00	$300.00	None
FYCOMPA 10 MG TABLET	4	Non-Preferred Brand	$100.00	$300.00	None
FYCOMPA 12 MG TABLET	4	Non-Preferred Brand	$100.00	$300.00	None
FYCOMPA 2 MG TABLET	4	Non-Preferred Brand	$100.00	$300.00	None
FYCOMPA 4 MG TABLET	4	Non-Preferred Brand	$100.00	$300.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
FYCOMPA 6 MG TABLET	4	Non-Preferred Brand	$100.00	$300.00	None
FYCOMPA 8 MG TABLET	4	Non-Preferred Brand	$100.00	$300.00	None

Chart Legend:

Below are a few notes to help you understand the above 2016 Medicare Part D Health Alliance Medicare HMO Basic Rx (HMO) Plan Formulary.

Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).
Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.
Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $360 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.
Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
- Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
- No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.
Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
- Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
- Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
- Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $3310) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2016 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
- Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
- None - This drug does not fall under any drug utilization management controls.
- P - Prior Authorization -This drug is subject to prior authorization.
- S - Step Therapy -This drug is subject to step therapy.
- Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.

(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2016 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.