2017 Medicare Part D Plan Formulary Information |
Platino Plus (HMO SNP) (H5774-024-0)
Benefit Details
|
The Platino Plus (HMO SNP) (H5774-024-0) Formulary Drugs Starting with the Letter F in Arecibo County, PR: CMS MA Region 30 which includes: PR Plan Monthly Premium: $0.00 Deductible: $400 |
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 |
25% | N/A | P |
FAMCICLOVIR 125MG TABLET |
2 |
Generic |
$10.00 | N/A | None |
FAMCICLOVIR 250MG TABLET |
2 |
Generic |
$10.00 | N/A | None |
FAMCICLOVIR 500MG TABLET |
2 |
Generic |
$10.00 | N/A | None |
FAMOTIDINE 20MG PIGGYBACK |
2 |
Generic |
$10.00 | N/A | None |
FAMOTIDINE 20MG TABLET (500 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
FAMOTIDINE 40MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
FAMOTIDINE 50 MG/5MLFOR ORAL SUSPENSION |
2 |
Generic |
$10.00 | N/A | None |
FAMOTIDINE INJECTION 10MG 25 X 2ML VIALSD |
2 |
Generic |
$10.00 | N/A | None |
FANAPT 1 MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | N/A | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FANAPT 10 MG TABLET |
5 |
Specialty Tier |
25% | N/A | S |
FANAPT 12 MG TABLET |
5 |
Specialty Tier |
25% | N/A | S |
FANAPT 2 MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | N/A | S |
FANAPT 4 MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | N/A | S |
FANAPT 6 MG TABLET |
5 |
Specialty Tier |
25% | N/A | S |
FANAPT 8 MG TABLET |
5 |
Specialty Tier |
25% | N/A | S |
FANAPT TITR TABLETS |
4 |
Non-Preferred Brand |
$50.00 | N/A | S Q:8 /30Days |
FARESTON 60 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
FARYDAK 10 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
FARYDAK 15 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
FARYDAK 20 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FASLODEX 50MG/ML INJECTION |
5 |
Specialty Tier |
25% | N/A | P |
FELBAMATE 400 MG TABLET |
2 |
Generic |
$10.00 | N/A | None |
FELBAMATE 600 MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | N/A | None |
FELBAMATE 600 MG/5 ML SUSP |
5 |
Specialty Tier |
25% | N/A | None |
FELODIPINE ER 10 MG TABLET |
2 |
Generic |
$10.00 | N/A | None |
FELODIPINE ER 2.5 MG TABLET |
2 |
Generic |
$10.00 | N/A | None |
FELODIPINE ER 5 MG TABLET |
2 |
Generic |
$10.00 | N/A | None |
FENOFIBRATE 130 MG CAPSULE [LIPOFEN] |
3 |
Preferred Brand |
$35.00 | N/A | None |
FENOFIBRATE 134MG CAPSULE [LIPOFEN] |
2 |
Generic |
$10.00 | N/A | None |
FENOFIBRATE 145 MG TABLET [LIPOFEN] |
2 |
Generic |
$10.00 | N/A | None |
FENOFIBRATE 160 MG 90 TABLET BOTTLE [LIPOFEN] |
2 |
Generic |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENOFIBRATE 200 MG CAPSULE [LIPOFEN] |
2 |
Generic |
$10.00 | N/A | None |
FENOFIBRATE 43 MG CAPSULE [LIPOFEN] |
2 |
Generic |
$10.00 | N/A | None |
FENOFIBRATE 48 MG TABLET [LIPOFEN] |
2 |
Generic |
$10.00 | N/A | None |
FENOFIBRATE 54 MG 90 TABLET BOTTLE [LIPOFEN] |
2 |
Generic |
$10.00 | N/A | None |
FENOFIBRATE 67MG CAPSULE [LIPOFEN] |
2 |
Generic |
$10.00 | N/A | None |
Fenofibric acid dr 135 mg capsule [TRILIPIX] |
2 |
Generic |
$10.00 | N/A | None |
Fenofibric acid dr 45 mg capsule [TRILIPIX] |
2 |
Generic |
$10.00 | N/A | None |
FENTANYL 100MCG/HR PATCH TRANSDERMAL 72 HOURS |
3 |
Preferred Brand |
$35.00 | N/A | P |
FENTANYL 12MCG/HR PATCH TRANSDERMAL 72 HOURS |
3 |
Preferred Brand |
$35.00 | N/A | P Q:15 /30Days |
FENTANYL 37.5 MCG/HR PATCH [DURAGESIC] |
4 |
Non-Preferred Brand |
$50.00 | N/A | P Q:15 /30Days |
FENTANYL 62.5 MCG/HR PATCH [DURAGESIC] |
5 |
Specialty Tier |
25% | N/A | P Q:15 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENTANYL 75 MCG/HR PATCH |
3 |
Preferred Brand |
$35.00 | N/A | P |
FENTANYL 87.5 MCG/HR PATCH [DURAGESIC] |
5 |
Specialty Tier |
25% | N/A | P Q:15 /30Days |
FENTANYL TRANSDERMAL SYSTEM 25MCG 5 SYSTEMS CRTN |
2 |
Generic |
$10.00 | N/A | P Q:15 /30Days |
FENTANYL TRANSDERMAL SYSTEM 50MCG 5 SYSTEMS CRTN |
2 |
Generic |
$10.00 | N/A | P |
FENTORA TABLET 100MCG |
5 |
Specialty Tier |
25% | N/A | P Q:180 /30Days |
FENTORA TABLET 200MCG |
5 |
Specialty Tier |
25% | N/A | P |
FENTORA TABLET 400MCG |
5 |
Specialty Tier |
25% | N/A | P Q:56 /30Days |
FENTORA TABLET 600MCG |
5 |
Specialty Tier |
25% | N/A | P Q:28 /30Days |
FENTORA TABLET 800MCG |
5 |
Specialty Tier |
25% | N/A | P Q:28 /30Days |
FERRIPROX 500 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
FETZIMA 20-40 MG TITRATION PAK |
4 |
Non-Preferred Brand |
$50.00 | N/A | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FETZIMA ER 120 MG CAPSULE |
4 |
Non-Preferred Brand |
$50.00 | N/A | S |
FETZIMA ER 20 MG CAPSULE |
4 |
Non-Preferred Brand |
$50.00 | N/A | S |
FETZIMA ER 40 MG CAPSULE |
4 |
Non-Preferred Brand |
$50.00 | N/A | S |
FETZIMA ER 80 MG CAPSULE |
4 |
Non-Preferred Brand |
$50.00 | N/A | S |
Finasteride 5 mg tablet |
1 |
Preferred Generic |
$4.00 | N/A | None |
Firazyr 30.0mg/3mL 1 SYRINGE, GLASS per CARTON / 3 mL in 1 SYRINGE, GLASS |
5 |
Specialty Tier |
25% | N/A | P |
FLECAINIDE ACETATE 100 MG TAB #60 EA |
2 |
Generic |
$10.00 | N/A | None |
FLECAINIDE ACETATE 150 MG TAB 360 EA |
2 |
Generic |
$10.00 | N/A | None |
FLECAINIDE ACETATE 50 MG TAB |
2 |
Generic |
$10.00 | N/A | None |
FLOVENT DISKUS 100ug/1 60 POWDER, METERED in 1 INHALER |
3 |
Preferred Brand |
$35.00 | N/A | Q:120 /30Days |
FLOVENT DISKUS 250ug/1 60 POWDER, METERED in 1 INHALER |
3 |
Preferred Brand |
$35.00 | N/A | Q:120 /30Days |
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 |
$35.00 | N/A | Q:240 /30Days |
FLOVENT HFA 110ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$35.00 | N/A | Q:24 /30Days |
FLOVENT HFA 220ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$35.00 | N/A | Q:24 /30Days |
FLOVENT HFA 44ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$35.00 | N/A | Q:21 /30Days |
FLUCONAZOLE 100 MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
FLUCONAZOLE 10MG/ML ORAL SUSPENSION |
2 |
Generic |
$10.00 | N/A | None |
FLUCONAZOLE 150MG TABLETS |
1 |
Preferred Generic |
$4.00 | N/A | None |
Fluconazole 200mg/1 30 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | N/A | None |
FLUCONAZOLE 40MG/ML ORAL SUSPENSION |
2 |
Generic |
$10.00 | N/A | None |
Fluconazole 50mg/1 30 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | N/A | None |
Fluconazole-dext 400 mg/200 ml |
2 |
Generic |
$10.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUCONAZOLE-NACL 200 MG/100 ML |
2 |
Generic |
$10.00 | N/A | P |
Flucytosine 250mg/1 |
5 |
Specialty Tier |
25% | N/A | P |
Flucytosine 500mg/1 |
5 |
Specialty Tier |
25% | N/A | P |
FLUDARABINE 50MG VIAL |
2 |
Generic |
$10.00 | N/A | P |
FLUDROCORTISONE ACETATE 0.1MG TABLET (100 CT) |
2 |
Generic |
$10.00 | N/A | None |
FLUOCINOLONE 0.01% BODY OIL |
3 |
Preferred Brand |
$35.00 | N/A | None |
Fluocinolone 0.01% cream |
3 |
Preferred Brand |
$35.00 | N/A | None |
FLUOCINOLONE 0.01% SOLUTION |
3 |
Preferred Brand |
$35.00 | N/A | None |
Fluocinolone 0.025% cream |
2 |
Generic |
$10.00 | N/A | None |
FLUOCINOLONE 0.025% OINTMENT |
2 |
Generic |
$10.00 | N/A | None |
FLUOCINOLONE OIL 0.01% EAR DRP |
3 |
Preferred Brand |
$35.00 | N/A | Q:20 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOCINONIDE 0.05% SOLUTION |
2 |
Generic |
$10.00 | N/A | None |
Fluocinonide 0.5mg/g 1 TUBE per CARTON / 30 g in 1 TUBE |
3 |
Preferred Brand |
$35.00 | N/A | None |
Fluocinonide 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
3 |
Preferred Brand |
$35.00 | N/A | None |
Fluocinonide 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
3 |
Preferred Brand |
$35.00 | N/A | None |
FLUOCINONIDE-E 0.05% CREAM |
3 |
Preferred Brand |
$35.00 | N/A | None |
Fluorometholone 0.1% drops |
2 |
Generic |
$10.00 | N/A | None |
FLUOROURACIL 2% TOPICAL SOLN |
2 |
Generic |
$10.00 | N/A | None |
FLUOROURACIL 5% TOP SOLUTION |
2 |
Generic |
$10.00 | N/A | None |
fluorouracil 500 mg/10 ml vial |
2 |
Generic |
$10.00 | N/A | P |
FLUOROURACIL CREA 5% |
3 |
Preferred Brand |
$35.00 | N/A | None |
Fluoxetine 10mg/1 30 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$4.00 | N/A | 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 |
$4.00 | N/A | None |
FLUOXETINE 40MG CAPSULE (30 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
FLUOXETINE CAPSULES 10MG (100 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
FLUOXETINE HCL 20 MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
FLUOXETINE HCL 60 MG TABLET |
2 |
Generic |
$10.00 | N/A | None |
Fluoxetine Hydrochloride 20mg/1 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
$4.00 | N/A | None |
FLUPHENAZINE 10MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
FLUPHENAZINE 1MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
FLUPHENAZINE 2.5 MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
FLUPHENAZINE 2.5MG/ML VIAL |
2 |
Generic |
$10.00 | N/A | P |
FLUPHENAZINE 5MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUPHENAZINE 5MG/ML CONC |
2 |
Generic |
$10.00 | N/A | None |
Fluphenazine Decanoate 25mg/mL |
3 |
Preferred Brand |
$35.00 | N/A | P |
FLUPHENAZINE HCL 2.5MG/5ML ELIXIR |
2 |
Generic |
$10.00 | N/A | None |
Flurazepam Hydrochloride 15mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
$4.00 | N/A | None |
Flurazepam Hydrochloride 30mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
$4.00 | N/A | None |
FLURBIPROFEN 0.03% EYE DROP |
1 |
Preferred Generic |
$4.00 | N/A | Q:5 /90Days |
FLUTAMIDE 125 MG CAPSULE |
2 |
Generic |
$10.00 | N/A | None |
Fluticasone Propionate 0.05mg/g 1 TUBE per CARTON / 30 g in 1 TUBE |
2 |
Generic |
$10.00 | N/A | None |
Fluticasone Propionate 0.5mg/g 1 TUBE per CARTON / 30 g in 1 TUBE |
2 |
Generic |
$10.00 | N/A | None |
FLUTICASONE PROPIONATE 50MCG SPRAY SUSPENSION |
1 |
Preferred Generic |
$4.00 | N/A | Q:16 /30Days |
FLUTICASONE-SALMETEROL 113-14 [Advair Diskus, Advair HFA, AIRDUO RESPICLICK] |
3 |
Preferred Brand |
$35.00 | N/A | P Q:1 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUTICASONE-SALMETEROL 232-14 [Advair Diskus, Advair HFA, AIRDUO RESPICLICK] |
3 |
Preferred Brand |
$35.00 | N/A | P Q:1 /30Days |
FLUTICASONE-SALMETEROL 55-14 [Advair Diskus, Advair HFA, AIRDUO RESPICLICK] |
3 |
Preferred Brand |
$35.00 | N/A | P Q:1 /30Days |
FLUVOXAMINE MALEATE 100MG TABLET |
2 |
Generic |
$10.00 | N/A | None |
Fluvoxamine Maleate 25mg/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 FILM COATED TABLETS in |
2 |
Generic |
$10.00 | N/A | None |
Fluvoxamine maleate 50mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Generic |
$10.00 | N/A | None |
Fondaparinux Sodium 10mg/0.8mL 2 SYRINGES per CARTON / 0.8 mL in 1 SYRINGE [Arixtra] |
5 |
Specialty Tier |
25% | N/A | Q:24 /30Days |
Fondaparinux Sodium 2.5mg/0.5mL 2 SYRINGES per CARTON / 0.5 mL in 1 SYRINGE [Arixtra] |
4 |
Non-Preferred Brand |
$50.00 | N/A | Q:15 /30Days |
Fondaparinux Sodium 5mg/4mL 2 SYRINGES per CARTON / 0.4 mL in 1 SYRINGE [Arixtra] |
5 |
Specialty Tier |
25% | N/A | Q:12 /30Days |
Fondaparinux Sodium 7.5mg/0.6mL 2 SYRINGES per CARTON / 0.6 mL in 1 SYRINGE [Arixtra] |
5 |
Specialty Tier |
25% | N/A | Q:18 /30Days |
Forteo 250ug/mL 1 SYRINGE per CARTON / 2.4 mL in 1 SYRINGE |
5 |
Specialty Tier |
25% | N/A | P Q:2 /28Days |
FOSINOPRIL SODIUM 10MG TABLET (90 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FOSINOPRIL SODIUM 20 MG TAB |
1 |
Preferred Generic |
$4.00 | N/A | None |
Fosinopril Sodium 40mg/1 90 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | N/A | None |
FOSINOPRIL-HCTZ 10-12.5 MG TAB |
2 |
Generic |
$10.00 | N/A | None |
FOSINOPRIL-HCTZ 20-12.5 MG TAB |
2 |
Generic |
$10.00 | N/A | None |
Furosemide 10 ML 10 MG/ML Injection |
2 |
Generic |
$10.00 | N/A | P |
Furosemide 10mg/mL 10 CARTON in 1 CONTAINER / 1 SYRINGE, PLASTIC in 1 CARTON / 4 mL in 1 SYRINGE, P |
2 |
Generic |
$10.00 | N/A | P |
FUROSEMIDE 10MG/ML SOLUTION |
1 |
Preferred Generic |
$4.00 | N/A | None |
FUROSEMIDE 20 MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
FUROSEMIDE 40 MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
FUROSEMIDE 80 MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
FUZEON 90 MG VIAL |
5 |
Specialty Tier |
25% | 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 |
Non-Preferred Brand |
$50.00 | N/A | None |
FYCOMPA 10 MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | N/A | None |
FYCOMPA 12 MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | N/A | None |
FYCOMPA 2 MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | N/A | None |
FYCOMPA 4 MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | N/A | None |
FYCOMPA 6 MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | N/A | None |
FYCOMPA 8 MG TABLET |
4 |
Non-Preferred Brand |
$50.00 | N/A | None |