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2018 Medicare Part D Plan Formulary Information
Allwell Medicare (HMO) (H1436-001-0) Benefit Details
The Allwell Medicare (HMO) (H1436-001-0) Formulary Drugs Starting with the Letter F in Clarendon County, SC: CMS MA Region 8 which includes: SC Plan Monthly Premium: $0.00 Deductible: $0
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
FABIOR 0.1% FOAM	4	Non-Preferred Brand	$100.00	N/A	Q:3 /1Days
FABRAZYME 35MG VIAL	5	Specialty Tier	33%	N/A	None
FALMINA-28 TABLET	2	Generic	$12.00	N/A	None
FAMCICLOVIR 125 MG TABLET	3	Preferred Brand	$47.00	N/A	None
FAMCICLOVIR 250 MG TABLET	3	Preferred Brand	$47.00	N/A	None
FAMCICLOVIR 500 MG TABLET	3	Preferred Brand	$47.00	N/A	None
Famotidine 20 MG in 2 ML Injection	1	Preferred Generic	$0.00	N/A	None
FAMOTIDINE 20 MG TABLET	1	Preferred Generic	$0.00	N/A	None
FAMOTIDINE 40 MG TABLET	1	Preferred Generic	$0.00	N/A	None
FAMOTIDINE 50 MG/5MLFOR ORAL SUSPENSION	4	Non-Preferred Brand	$100.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
FANAPT 1 MG TABLET	4	Non-Preferred Brand	$100.00	N/A	None
FANAPT 10 MG TABLET	4	Non-Preferred Brand	$100.00	N/A	None
FANAPT 12 MG TABLET	5	Specialty Tier	33%	N/A	None
FANAPT 2 MG TABLET	4	Non-Preferred Brand	$100.00	N/A	None
FANAPT 4 MG TABLET	4	Non-Preferred Brand	$100.00	N/A	None
FANAPT 6 MG TABLET	5	Specialty Tier	33%	N/A	None
FANAPT 8 MG TABLET	5	Specialty Tier	33%	N/A	None
FANAPT TITR TABLETS	4	Non-Preferred Brand	$100.00	N/A	None
FARESTON 60 MG TABLET	5	Specialty Tier	33%	N/A	None
FARXIGA 10 MG TABLET	4	Non-Preferred Brand	$100.00	N/A	None
FARXIGA 5 MG TABLET	4	Non-Preferred Brand	$100.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
FARYDAK 10 MG CAPSULE	5	Specialty Tier	33%	N/A	P
FARYDAK 15 MG CAPSULE	5	Specialty Tier	33%	N/A	P
FARYDAK 20 MG CAPSULE	5	Specialty Tier	33%	N/A	P
FASENRA 30 MG/ML SYRINGE	5	Specialty Tier	33%	N/A	P
FASLODEX 50MG/ML INJECTION	5	Specialty Tier	33%	N/A	None
FAYOSIM TABLET TBDSPK 3MO [Quartette]	2	Generic	$12.00	N/A	None
FAZACLO 12.5 MG ODT TAB RAPDIS	4	Non-Preferred Brand	$100.00	N/A	None
FAZACLO 150 MG ODT TAB RAPDIS	4	Non-Preferred Brand	$100.00	N/A	None
FAZACLO 200 MG ODT TAB RAPDIS	5	Specialty Tier	33%	N/A	None
FELBAMATE 400 MG TABLET	2	Generic	$12.00	N/A	None
FELBAMATE 600 MG TABLET	4	Non-Preferred Brand	$100.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
FELBAMATE 600 MG/5 ML SUSP	2	Generic	$12.00	N/A	None
FELODIPINE ER 10 MG TABLET	3	Preferred Brand	$47.00	N/A	None
FELODIPINE ER 2.5 MG TABLET	3	Preferred Brand	$47.00	N/A	None
FELODIPINE ER 5 MG TABLET	3	Preferred Brand	$47.00	N/A	None
FEMRING 0.05MG VAGINAL RING	4	Non-Preferred Brand	$100.00	N/A	None
FEMRING 0.10MG VAGINAL RING	4	Non-Preferred Brand	$100.00	N/A	None
Femynor 28 tablet	2	Generic	$12.00	N/A	None
FENOFIBRATE 120 MG TABLET [LIPOFEN]	2	Generic	$12.00	N/A	None
FENOFIBRATE 130 MG CAPSULE [LIPOFEN]	3	Preferred Brand	$47.00	N/A	None
FENOFIBRATE 134MG CAPSULE [LIPOFEN]	2	Generic	$12.00	N/A	None
FENOFIBRATE 145 MG TABLET [LIPOFEN]	2	Generic	$12.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
FENOFIBRATE 150 MG CAPSULE [LIPOFEN]	4	Non-Preferred Brand	$100.00	N/A	None
FENOFIBRATE 160 MG TABLET [LIPOFEN]	2	Generic	$12.00	N/A	None
FENOFIBRATE 200 MG CAPSULE [LIPOFEN]	2	Generic	$12.00	N/A	None
FENOFIBRATE 40 MG TABLET [LIPOFEN]	2	Generic	$12.00	N/A	None
FENOFIBRATE 43 MG CAPSULE [LIPOFEN]	3	Preferred Brand	$47.00	N/A	None
FENOFIBRATE 48 MG TABLET [Tricor]	2	Generic	$12.00	N/A	None
FENOFIBRATE 50 MG CAPSULE [LIPOFEN]	4	Non-Preferred Brand	$100.00	N/A	None
FENOFIBRATE 50 MG ORAL CAPSULE [LIPOFEN]	4	Non-Preferred Brand	$100.00	N/A	None
FENOFIBRATE 54 MG 90 TABLET BOTTLE [LIPOFEN]	2	Generic	$12.00	N/A	None
FENOFIBRATE 67MG CAPSULE [LIPOFEN]	2	Generic	$12.00	N/A	None
FENOFIBRIC ACID DR 135 MG CAP [TRILIPIX]	4	Non-Preferred Brand	$100.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Fenofibric acid dr 45 mg capsule [TRILIPIX]	4	Non-Preferred Brand	$100.00	N/A	None
FENTANYL 100 MCG/HR PATCH TD72 [Duragesic]	4	Non-Preferred Brand	$100.00	N/A	Q:1 /1Days
FENTANYL 12 MCG/HR PATCH TD72 [Duragesic]	4	Non-Preferred Brand	$100.00	N/A	Q:1 /1Days
FENTANYL 25 MCG/HR PATCH TD72 [Duragesic]	4	Non-Preferred Brand	$100.00	N/A	Q:1 /1Days
FENTANYL 50 MCG/HR PATCH TD72 [Duragesic]	4	Non-Preferred Brand	$100.00	N/A	Q:1 /1Days
FENTANYL 75 MCG/HR PATCH TD72 [Duragesic]	4	Non-Preferred Brand	$100.00	N/A	Q:1 /1Days
FENTANYL CITRATE OTFC 1,200 MCG [Actiq]	5	Specialty Tier	33%	N/A	P Q:4 /1Days
FENTANYL CITRATE OTFC 1,600 MCG [Actiq]	5	Specialty Tier	33%	N/A	P Q:4 /1Days
FENTANYL CITRATE OTFC 200 MCG [Actiq]	5	Specialty Tier	33%	N/A	P Q:8 /1Days
FENTANYL CITRATE OTFC 400 MCG [Actiq]	5	Specialty Tier	33%	N/A	P Q:4 /1Days
FENTANYL CITRATE OTFC 600 MCG [Actiq]	5	Specialty Tier	33%	N/A	P Q:4 /1Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
FENTANYL CITRATE OTFC 800 MCG [Actiq]	5	Specialty Tier	33%	N/A	P Q:4 /1Days
FENTORA TABLET 100MCG	5	Specialty Tier	33%	N/A	P Q:16 /1Days
FENTORA TABLET 200MCG	5	Specialty Tier	33%	N/A	P Q:8 /1Days
FENTORA TABLET 400MCG	5	Specialty Tier	33%	N/A	P Q:4 /1Days
FENTORA TABLET 600MCG	5	Specialty Tier	33%	N/A	P Q:4 /1Days
FENTORA TABLET 800MCG	5	Specialty Tier	33%	N/A	P Q:4 /1Days
FERRIPROX 500 MG TABLET	5	Specialty Tier	33%	N/A	P
FETZIMA 20-40 MG TITRATION PAK	4	Non-Preferred Brand	$100.00	N/A	S
FETZIMA ER 120 MG CAPSULE	4	Non-Preferred Brand	$100.00	N/A	S Q:1 /1Days
FETZIMA ER 20 MG CAPSULE	4	Non-Preferred Brand	$100.00	N/A	S Q:2 /1Days
FETZIMA ER 40 MG CAPSULE	4	Non-Preferred Brand	$100.00	N/A	S Q:1 /1Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
FETZIMA ER 80 MG CAPSULE	4	Non-Preferred Brand	$100.00	N/A	S Q:1 /1Days
FIASP 100 UNIT/ML FLEXTOUCH INSULN PEN	4	Non-Preferred Brand	$100.00	N/A	Q:2 /1Days
FIASP 100 UNIT/ML VIAL	4	Non-Preferred Brand	$100.00	N/A	Q:2 /1Days
FINACEA 15% FOAM	4	Non-Preferred Brand	$100.00	N/A	None
FINACEA 15% GEL	4	Non-Preferred Brand	$100.00	N/A	None
FINASTERIDE 5 MG TABLET	2	Generic	$12.00	N/A	None
FIRAZYR 30 MG/3 ML SYRINGE	5	Specialty Tier	33%	N/A	P
FIRMAGON 2 X 120 MG KIT	5	Specialty Tier	33%	N/A	None
FIRMAGON 80 MG KIT	4	Non-Preferred Brand	$100.00	N/A	None
FLAREX 0.1% EYE DROPS	3	Preferred Brand	$47.00	N/A	None
FLAVOXATE 100 MG TAB 100	3	Preferred Brand	$47.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
FLEBOGAMMA DIF INJECTION	5	Specialty Tier	33%	N/A	P
FLECAINIDE ACETATE 100 MG TAB	3	Preferred Brand	$47.00	N/A	None
FLECAINIDE ACETATE 150 MG TAB	3	Preferred Brand	$47.00	N/A	None
FLECAINIDE ACETATE 50 MG TAB	3	Preferred Brand	$47.00	N/A	None
FLECTOR PATCH	4	Non-Preferred Brand	$100.00	N/A	P
FLOVENT DISKUS 100ug/1 60 POWDER, METERED in 1 INHALER	3	Preferred Brand	$47.00	N/A	None
FLOVENT DISKUS 250ug/1 60 POWDER, METERED in 1 INHALER	3	Preferred Brand	$47.00	N/A	None
FLOVENT DISKUS POWDER 50MCG 60 CTR	3	Preferred Brand	$47.00	N/A	None
FLOVENT HFA 110ug/1 120 AEROSOL, METERED in 1 INHALER	3	Preferred Brand	$47.00	N/A	Q:1 /1Days
FLOVENT HFA 220ug/1 120 AEROSOL, METERED in 1 INHALER	3	Preferred Brand	$47.00	N/A	Q:1 /1Days
FLOVENT HFA 44ug/1 120 AEROSOL, METERED in 1 INHALER	3	Preferred Brand	$47.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
FLUCONAZOLE 10 MG/ML SUSP	3	Preferred Brand	$47.00	N/A	None
FLUCONAZOLE 100 MG TABLET	2	Generic	$12.00	N/A	None
FLUCONAZOLE 150 MG TABLET	2	Generic	$12.00	N/A	None
FLUCONAZOLE 200 MG TABLET	2	Generic	$12.00	N/A	None
FLUCONAZOLE 40 MG/ML SUSP	3	Preferred Brand	$47.00	N/A	None
Fluconazole 50mg/1 30 TABLET BOTTLE	2	Generic	$12.00	N/A	None
FLUCONAZOLE-NACL 200 MG/100 ML	3	Preferred Brand	$47.00	N/A	None
FLUCONAZOLE-NACL 400 MG/200 ML	3	Preferred Brand	$47.00	N/A	None
Flucytosine 500mg/1	2	Generic	$12.00	N/A	None
Fludarabine phosphate 50 MG Injection	2	Generic	$12.00	N/A	None
FLUDROCORTISONE 0.1 MG TABLET	3	Preferred Brand	$47.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL	2	Generic	$12.00	N/A	None
Fluocinolone 0.01% cream	4	Non-Preferred Brand	$100.00	N/A	None
FLUOCINOLONE 0.01% SCALP OIL	4	Non-Preferred Brand	$100.00	N/A	None
FLUOCINOLONE 0.01% SOLUTION	4	Non-Preferred Brand	$100.00	N/A	None
FLUOCINOLONE 0.025% CREAM	4	Non-Preferred Brand	$100.00	N/A	None
FLUOCINOLONE 0.025% OINTMENT	4	Non-Preferred Brand	$100.00	N/A	None
FLUOCINOLONE OIL 0.01% EAR DRP	4	Non-Preferred Brand	$100.00	N/A	None
FLUOCINONIDE 0.05% GEL	4	Non-Preferred Brand	$100.00	N/A	None
FLUOCINONIDE 0.05% OINTMENT	4	Non-Preferred Brand	$100.00	N/A	None
FLUOCINONIDE 0.05% SOLUTION	4	Non-Preferred Brand	$100.00	N/A	None
FLUOCINONIDE 0.1% CREAM	2	Generic	$12.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
FLUOCINONIDE-E 0.05% CREAM	4	Non-Preferred Brand	$100.00	N/A	None
Fluorometholone 0.1% drops	3	Preferred Brand	$47.00	N/A	None
FLUOROURACIL 0.5% CREAM	5	Specialty Tier	33%	N/A	None
FLUOROURACIL 2% TOPICAL SOLN	3	Preferred Brand	$47.00	N/A	None
FLUOROURACIL 5,000 MG/100 ML	4	Non-Preferred Brand	$100.00	N/A	P
FLUOROURACIL 5% TOP SOLUTION	3	Preferred Brand	$47.00	N/A	None
FLUOROURACIL CREA 5%	4	Non-Preferred Brand	$100.00	N/A	None
Fluoxetine 10mg/1 30 FILM COATED TABLETS in BOTTLE	3	Preferred Brand	$47.00	N/A	None
Fluoxetine 20mg/5mL 120 mL in 1 BOTTLE, PLASTIC	2	Generic	$12.00	N/A	None
FLUOXETINE CAPSULES 10MG (100 CT)	1	Preferred Generic	$0.00	N/A	None
FLUOXETINE DR 90 MG CAPSULE	2	Generic	$12.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
FLUOXETINE HCL 20 MG CAPSULE	1	Preferred Generic	$0.00	N/A	None
FLUOXETINE HCL 20 MG TABLET	3	Preferred Brand	$47.00	N/A	None
FLUOXETINE HCL 40 MG CAPSULE	1	Preferred Generic	$0.00	N/A	None
FLUOXETINE HCL 60 MG TABLET	2	Generic	$12.00	N/A	None
FLUPHENAZINE 1 MG TABLET	2	Generic	$12.00	N/A	None
FLUPHENAZINE 10 MG TABLET	2	Generic	$12.00	N/A	None
FLUPHENAZINE 2.5 MG TABLET	2	Generic	$12.00	N/A	None
FLUPHENAZINE 2.5MG/ML VIAL	2	Generic	$12.00	N/A	None
FLUPHENAZINE 5 MG TABLET	2	Generic	$12.00	N/A	None
FLUPHENAZINE 5MG/ML CONC	2	Generic	$12.00	N/A	None
FLUPHENAZINE DEC 125 MG/5 ML	3	Preferred Brand	$47.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Flurandrenolide 0.5 MG/ML Topical Lotion [Cordran]	4	Non-Preferred Brand	$100.00	N/A	None
Flurazepam Hydrochloride 15mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC	1	Preferred Generic	$0.00	N/A	None
Flurazepam Hydrochloride 30mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC	1	Preferred Generic	$0.00	N/A	None
FLURBIPROFEN 0.03% EYE DROP	2	Generic	$12.00	N/A	None
Flurbiprofen 100mg/1 100 BOTTLE in 1 BOTTLE / 100 FILM COATED TABLETS in BOTTLE	3	Preferred Brand	$47.00	N/A	None
FLURBIPROFEN 50MG TABLET	3	Preferred Brand	$47.00	N/A	None
FLUTAMIDE 125 MG CAPSULE	4	Non-Preferred Brand	$100.00	N/A	None
FLUTICASONE PROP 0.05% LOTION	4	Non-Preferred Brand	$100.00	N/A	None
Fluticasone Propionate 0.05mg/g 1 TUBE per CARTON / 30 g in 1 TUBE	2	Generic	$12.00	N/A	None
Fluticasone Propionate 0.5mg/g 1 TUBE per CARTON / 30 g in 1 TUBE	3	Preferred Brand	$47.00	N/A	None
FLUTICASONE PROPIONATE 50MCG SPRAY SUSPENSION	2	Generic	$12.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
FLUVASTATIN ER 80 MG TABLET [Lescol]	4	Non-Preferred Brand	$100.00	N/A	None
FLUVASTATIN SODIUM 20 MG CAP [Lescol]	6	Select Care Drugs	$0.00	N/A	Q:3 /1Days
FLUVASTATIN SODIUM 40 MG CAPSULE [Lescol]	6	Select Care Drugs	$0.00	N/A	Q:2 /1Days
FLUVOXAMINE ER 100 MG CAPSULE	4	Non-Preferred Brand	$100.00	N/A	None
FLUVOXAMINE ER 150 MG CAPSULE	4	Non-Preferred Brand	$100.00	N/A	None
FLUVOXAMINE MALEATE 100MG TABLET	2	Generic	$12.00	N/A	None
Fluvoxamine Maleate 25mg/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 FILM COATED TABLETS in	2	Generic	$12.00	N/A	None
Fluvoxamine maleate 50mg/1 100 FILM COATED TABLETS in BOTTLE	2	Generic	$12.00	N/A	None
FML FORTE 0.25% EYE DROPS	3	Preferred Brand	$47.00	N/A	None
FML S.O.P. 0.1% OINTMENT	3	Preferred Brand	$47.00	N/A	None
FOLOTYN 20mg/mL 1 VIAL, SINGLE-USE per CARTON / 2 mL in 1 VIAL, SINGLE-USE	5	Specialty Tier	33%	N/A	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	33%	N/A	None
Fondaparinux Sodium 2.5mg/0.5mL 2 SYRINGES per CARTON / 0.5 mL in 1 SYRINGE [Arixtra]	4	Non-Preferred Brand	$100.00	N/A	None
Fondaparinux Sodium 5mg/4mL 2 SYRINGES per CARTON / 0.4 mL in 1 SYRINGE [Arixtra]	5	Specialty Tier	33%	N/A	None
Fondaparinux Sodium 7.5mg/0.6mL 2 SYRINGES per CARTON / 0.6 mL in 1 SYRINGE [Arixtra]	5	Specialty Tier	33%	N/A	None
FORFIVO XL 450 MG TABLET	4	Non-Preferred Brand	$100.00	N/A	S
Forteo 250ug/mL 1 SYRINGE per CARTON / 2.4 mL in 1 SYRINGE	5	Specialty Tier	33%	N/A	P
FORTESTA 10mg/0.5g	4	Non-Preferred Brand	$100.00	N/A	None
FOSAMAX PLUS D 70; 5600mg/1; [iU]/1 4 TABLET per BLISTER PACK	4	Non-Preferred Brand	$100.00	N/A	None
FOSAMAX PLUS D 70MG/2800 IU	4	Non-Preferred Brand	$100.00	N/A	None
FOSAMPRENAVIR 700 MG TABLET [Lexiva]	5	Specialty Tier	33%	N/A	None
FOSINOPRIL SODIUM 10 MG TAB	6	Select Care Drugs	$0.00	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	6	Select Care Drugs	$0.00	N/A	None
FOSINOPRIL SODIUM 40 MG TAB	6	Select Care Drugs	$0.00	N/A	None
FOSINOPRIL-HCTZ 10-12.5 MG TAB	6	Select Care Drugs	$0.00	N/A	None
FOSINOPRIL-HCTZ 20-12.5 MG TAB	6	Select Care Drugs	$0.00	N/A	None
FOSPHENYTOIN 100 MG PE/2 ML VL	2	Generic	$12.00	N/A	None
FOSRENOL 1000MG TABLET CHEW	3	Preferred Brand	$47.00	N/A	None
FOSRENOL 500MG TABLET CHEW	3	Preferred Brand	$47.00	N/A	None
FOSRENOL 750MG TABLET CHEW	3	Preferred Brand	$47.00	N/A	None
FRAGMIN 10,000 UNITS SYRINGE	4	Non-Preferred Brand	$100.00	N/A	None
FRAGMIN 12,500 UNITS SYRINGE	5	Specialty Tier	33%	N/A	None
FRAGMIN 15,000 UNITS SYRINGE	5	Specialty Tier	33%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
FRAGMIN 18,000 UNITS SYRINGE	5	Specialty Tier	33%	N/A	None
FRAGMIN 2,500 UNITS SYRINGE	4	Non-Preferred Brand	$100.00	N/A	None
FRAGMIN 5,000 UNITS SYRINGE	4	Non-Preferred Brand	$100.00	N/A	None
FRAGMIN 7,500 UNITS/0.3 ML SYR	5	Specialty Tier	33%	N/A	None
FRAGMIN 95,000 UNITS/3.8 ML VL	5	Specialty Tier	33%	N/A	None
FROVATRIPTAN SUCC 2.5 MG TABLET [Frova]	4	Non-Preferred Brand	$100.00	N/A	Q:1 /1Days
FUROSEMIDE 10 MG/ML SOLUTION	3	Preferred Brand	$47.00	N/A	None
Furosemide 10 ML 10 MG/ML Injection	3	Preferred Brand	$47.00	N/A	None
Furosemide 10mg/mL 10 CARTON in 1 CONTAINER / 1 SYRINGE, PLASTIC in 1 CARTON / 4 mL in 1 SYRINGE, P	3	Preferred Brand	$47.00	N/A	None
FUROSEMIDE 20 MG TABLET	1	Preferred Generic	$0.00	N/A	None
FUROSEMIDE 40 MG TABLET	1	Preferred Generic	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
FUROSEMIDE 80 MG TABLET	1	Preferred Generic	$0.00	N/A	None
FUZEON 90 MG VIAL	5	Specialty Tier	33%	N/A	None
FYCOMPA 0.5 MG/ML ORAL SUSP	4	Non-Preferred Brand	$100.00	N/A	None
FYCOMPA 10 MG TABLET	4	Non-Preferred Brand	$100.00	N/A	None
FYCOMPA 12 MG TABLET	4	Non-Preferred Brand	$100.00	N/A	None
FYCOMPA 2 MG TABLET	4	Non-Preferred Brand	$100.00	N/A	None
FYCOMPA 4 MG TABLET	4	Non-Preferred Brand	$100.00	N/A	None
FYCOMPA 6 MG TABLET	4	Non-Preferred Brand	$100.00	N/A	None
FYCOMPA 8 MG TABLET	4	Non-Preferred Brand	$100.00	N/A	None

Chart Legend:

Below are a few notes to help you understand the above 2018 Medicare Part D Allwell Medicare (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). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)
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 $405 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 five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs. *Some Part D plans exclude one or more drug tiers from the deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
- Tier 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 $3750) at a "Preferred" network pharmacy. In most cases, the "Preferred" network network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
- 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 2018 )

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.