2018 Medicare Part D Plan Formulary Information |
Health Alliance Medicare POS 30 Rx (HMO-POS) (H1463-017-0)
Benefit Details
|
The Health Alliance Medicare POS 30 Rx (HMO-POS) (H1463-017-0) Formulary Drugs Starting with the Letter F in Effingham County, IL: CMS MA Region 14 which includes: IL Plan Monthly Premium: $96.00 Deductible: $0 |
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 |
33% | N/A | P |
FABRAZYME 5 MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
FALMINA-28 TABLET |
2 |
Generic |
$20.00 | N/A | None |
FAMCICLOVIR 125 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
FAMCICLOVIR 250 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
FAMCICLOVIR 500 MG TABLET |
2 |
Generic |
$20.00 | 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 20MG PIGGYBACK |
1 |
Preferred Generic |
$0.00 | N/A | None |
FAMOTIDINE 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 |
FAMOTIDINE 50 MG/5MLFOR ORAL SUSPENSION |
1 |
Preferred Generic |
$0.00 | N/A | None |
FANAPT 1 MG TABLET |
4 |
Non-Preferred Drug |
50% | N/A | S |
FANAPT 10 MG TABLET |
5 |
Specialty Tier |
33% | N/A | S |
FANAPT 12 MG TABLET |
5 |
Specialty Tier |
33% | N/A | S |
FANAPT 2 MG TABLET |
4 |
Non-Preferred Drug |
50% | N/A | S |
FANAPT 4 MG TABLET |
4 |
Non-Preferred Drug |
50% | N/A | S |
FANAPT 6 MG TABLET |
5 |
Specialty Tier |
33% | N/A | S |
FANAPT 8 MG TABLET |
5 |
Specialty Tier |
33% | N/A | S |
FANAPT TITR TABLETS |
4 |
Non-Preferred Drug |
50% | N/A | S |
FARESTON 60 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
FARYDAK 10 MG CAPSULE |
5 |
Specialty Tier |
33% | 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 |
Specialty Tier |
33% | N/A | P |
FARYDAK 20 MG CAPSULE |
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 |
$20.00 | N/A | None |
FELBAMATE 400 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
FELBAMATE 600 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
FELBAMATE 600 MG/5 ML SUSP |
4 |
Non-Preferred Drug |
50% | N/A | None |
FELODIPINE ER 10 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
FELODIPINE ER 2.5 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
FELODIPINE ER 5 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
FEMRING 0.05MG VAGINAL RING |
4 |
Non-Preferred Drug |
50% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FEMRING 0.10MG VAGINAL RING |
4 |
Non-Preferred Drug |
50% | N/A | None |
Femynor 28 tablet |
2 |
Generic |
$20.00 | N/A | None |
FENOFIBRATE 120 MG TABLET [LIPOFEN] |
2 |
Generic |
$20.00 | N/A | None |
FENOFIBRATE 130 MG CAPSULE [LIPOFEN] |
2 |
Generic |
$20.00 | N/A | None |
FENOFIBRATE 134MG CAPSULE [LIPOFEN] |
1 |
Preferred Generic |
$0.00 | N/A | None |
FENOFIBRATE 145 MG TABLET [LIPOFEN] |
2 |
Generic |
$20.00 | N/A | None |
FENOFIBRATE 150 MG CAPSULE [LIPOFEN] |
2 |
Generic |
$20.00 | N/A | None |
FENOFIBRATE 160 MG TABLET [LIPOFEN] |
2 |
Generic |
$20.00 | N/A | None |
FENOFIBRATE 200 MG CAPSULE [LIPOFEN] |
1 |
Preferred Generic |
$0.00 | N/A | None |
FENOFIBRATE 40 MG TABLET [LIPOFEN] |
2 |
Generic |
$20.00 | N/A | None |
FENOFIBRATE 43 MG CAPSULE [LIPOFEN] |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENOFIBRATE 48 MG TABLET [Tricor] |
2 |
Generic |
$20.00 | N/A | None |
FENOFIBRATE 50 MG CAPSULE [LIPOFEN] |
2 |
Generic |
$20.00 | N/A | None |
FENOFIBRATE 54 MG 90 TABLET BOTTLE [LIPOFEN] |
2 |
Generic |
$20.00 | N/A | None |
FENOFIBRATE 67MG CAPSULE [LIPOFEN] |
1 |
Preferred Generic |
$0.00 | N/A | None |
FENOFIBRIC ACID 105 MG TABLET [TRILIPIX] |
1 |
Preferred Generic |
$0.00 | N/A | None |
FENOFIBRIC ACID 35 MG TABLET [TRILIPIX] |
1 |
Preferred Generic |
$0.00 | N/A | None |
FENOFIBRIC ACID DR 135 MG CAP [TRILIPIX] |
2 |
Generic |
$20.00 | N/A | None |
Fenofibric acid dr 45 mg capsule [TRILIPIX] |
1 |
Preferred Generic |
$0.00 | N/A | None |
FENOPROFEN 600MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
FENOPROFEN CALCIUM 400 MG CAP |
1 |
Preferred Generic |
$0.00 | N/A | None |
FENTANYL 100 MCG/HR PATCH TD72 [Duragesic] |
2 |
Generic |
$20.00 | N/A | Q:20 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENTANYL 12 MCG/HR PATCH TD72 [Duragesic] |
2 |
Generic |
$20.00 | N/A | Q:10 /30Days |
FENTANYL 25 MCG/HR PATCH TD72 [Duragesic] |
2 |
Generic |
$20.00 | N/A | Q:10 /30Days |
FENTANYL 37.5 MCG/HR PATCH TD72 |
2 |
Generic |
$20.00 | N/A | Q:10 /30Days |
FENTANYL 50 MCG/HR PATCH TD72 [Duragesic] |
2 |
Generic |
$20.00 | N/A | Q:10 /30Days |
FENTANYL 62.5 MCG/HR PATCH TD72 |
2 |
Generic |
$20.00 | N/A | Q:10 /30Days |
FENTANYL 75 MCG/HR PATCH TD72 [Duragesic] |
2 |
Generic |
$20.00 | N/A | Q:10 /30Days |
FENTANYL 87.5 MCG/HR PATCH TD72 |
2 |
Generic |
$20.00 | N/A | Q:10 /30Days |
FENTANYL CITRATE OTFC 1,200 MCG [Actiq] |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
FENTANYL CITRATE OTFC 1,600 MCG [Actiq] |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
FENTANYL CITRATE OTFC 200 MCG [Actiq] |
4 |
Non-Preferred Drug |
50% | N/A | P Q:120 /30Days |
FENTANYL CITRATE OTFC 400 MCG [Actiq] |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENTANYL CITRATE OTFC 600 MCG [Actiq] |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
FENTANYL CITRATE OTFC 800 MCG [Actiq] |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
FERRIPROX 100 MG/ML SOLUTION |
5 |
Specialty Tier |
33% | N/A | None |
FERRIPROX 500 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
FETZIMA 20-40 MG TITRATION PAK |
4 |
Non-Preferred Drug |
50% | N/A | S |
FETZIMA ER 120 MG CAPSULE |
4 |
Non-Preferred Drug |
50% | N/A | S |
FETZIMA ER 20 MG CAPSULE |
4 |
Non-Preferred Drug |
50% | N/A | S |
FETZIMA ER 40 MG CAPSULE |
4 |
Non-Preferred Drug |
50% | N/A | S |
FETZIMA ER 80 MG CAPSULE |
4 |
Non-Preferred Drug |
50% | N/A | S |
FINACEA 15% FOAM |
4 |
Non-Preferred Drug |
50% | N/A | None |
FINACEA 15% GEL |
4 |
Non-Preferred Drug |
50% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FINASTERIDE 5 MG TABLET |
1 |
Preferred Generic |
$0.00 | 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 Drug |
50% | N/A | None |
FLAVOXATE 100 MG TAB 100 |
1 |
Preferred Generic |
$0.00 | N/A | None |
FLEBOGAMMA DIF INJECTION |
5 |
Specialty Tier |
33% | N/A | P |
FLECAINIDE ACETATE 100 MG TAB |
1 |
Preferred Generic |
$0.00 | N/A | None |
FLECAINIDE ACETATE 150 MG TAB |
1 |
Preferred Generic |
$0.00 | N/A | None |
FLECAINIDE ACETATE 50 MG TAB |
1 |
Preferred Generic |
$0.00 | N/A | None |
FLUCONAZOLE 10 MG/ML SUSP |
2 |
Generic |
$20.00 | N/A | None |
FLUCONAZOLE 100 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUCONAZOLE 150 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
FLUCONAZOLE 200 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
FLUCONAZOLE 40 MG/ML SUSP |
2 |
Generic |
$20.00 | N/A | None |
Fluconazole 50mg/1 30 TABLET BOTTLE |
2 |
Generic |
$20.00 | N/A | None |
FLUCONAZOLE-NACL 200 MG/100 ML |
2 |
Generic |
$20.00 | N/A | None |
FLUCONAZOLE-NACL 400 MG/200 ML |
1 |
Preferred Generic |
$0.00 | N/A | None |
FLUCYTOSINE 250 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | None |
Flucytosine 500mg/1 |
5 |
Specialty Tier |
33% | N/A | None |
Fludarabine phosphate 50 MG Injection |
1 |
Preferred Generic |
$0.00 | N/A | None |
FLUDROCORTISONE 0.1 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL |
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 |
Fluocinolone 0.01% cream |
2 |
Generic |
$20.00 | N/A | None |
FLUOCINOLONE 0.01% SCALP OIL |
2 |
Generic |
$20.00 | N/A | None |
FLUOCINOLONE 0.01% SOLUTION |
2 |
Generic |
$20.00 | N/A | None |
FLUOCINOLONE 0.025% CREAM |
2 |
Generic |
$20.00 | N/A | None |
FLUOCINOLONE 0.025% OINTMENT |
2 |
Generic |
$20.00 | N/A | None |
FLUOCINOLONE OIL 0.01% EAR DRP |
2 |
Generic |
$20.00 | N/A | None |
FLUOCINONIDE 0.05% GEL |
2 |
Generic |
$20.00 | N/A | None |
FLUOCINONIDE 0.05% OINTMENT |
2 |
Generic |
$20.00 | N/A | None |
FLUOCINONIDE 0.05% SOLUTION |
2 |
Generic |
$20.00 | N/A | None |
FLUOCINONIDE 0.1% CREAM |
2 |
Generic |
$20.00 | N/A | None |
Fluorometholone 0.1% drops |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOROURACIL 0.5% CREAM |
5 |
Specialty Tier |
33% | N/A | None |
FLUOROURACIL 2% TOPICAL SOLN |
2 |
Generic |
$20.00 | N/A | None |
FLUOROURACIL 5,000 MG/100 ML |
2 |
Generic |
$20.00 | N/A | P |
FLUOROURACIL 5% TOP SOLUTION |
2 |
Generic |
$20.00 | N/A | None |
FLUOROURACIL CREA 5% |
2 |
Generic |
$20.00 | N/A | None |
Fluoxetine 10mg/1 30 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$0.00 | N/A | None |
Fluoxetine 20mg/5mL 120 mL in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | N/A | None |
FLUOXETINE CAPSULES 10MG (100 CT) |
1 |
Preferred Generic |
$0.00 | N/A | None |
FLUOXETINE DR 90 MG CAPSULE |
1 |
Preferred Generic |
$0.00 | N/A | None |
FLUOXETINE HCL 20 MG CAPSULE |
1 |
Preferred Generic |
$0.00 | N/A | None |
FLUOXETINE HCL 20 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 |
FLUOXETINE HCL 40 MG CAPSULE |
1 |
Preferred Generic |
$0.00 | N/A | None |
FLUOXETINE HCL 60 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
FLUPHENAZINE 1 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
FLUPHENAZINE 10 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
FLUPHENAZINE 2.5 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
FLUPHENAZINE 2.5 MG/5 ML ELIX |
1 |
Preferred Generic |
$0.00 | N/A | None |
FLUPHENAZINE 2.5MG/ML VIAL |
1 |
Preferred Generic |
$0.00 | N/A | None |
FLUPHENAZINE 5 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
FLUPHENAZINE 5MG/ML CONC |
1 |
Preferred Generic |
$0.00 | N/A | None |
FLUPHENAZINE DEC 125 MG/5 ML |
1 |
Preferred Generic |
$0.00 | N/A | None |
Flurandrenolide 0.05% Cream [Cordran] |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Flurandrenolide 0.05% ointment [Cordran] |
2 |
Generic |
$20.00 | N/A | None |
Flurandrenolide 0.5 MG/ML Topical Lotion [Cordran] |
4 |
Non-Preferred Drug |
50% | N/A | None |
Flurazepam Hydrochloride 15mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC |
2 |
Generic |
$20.00 | N/A | Q:30 /30Days |
Flurazepam Hydrochloride 30mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC |
2 |
Generic |
$20.00 | N/A | Q:30 /30Days |
FLURBIPROFEN 0.03% EYE DROP |
1 |
Preferred Generic |
$0.00 | N/A | None |
Flurbiprofen 100mg/1 100 BOTTLE in 1 BOTTLE / 100 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$0.00 | N/A | None |
FLURBIPROFEN 50MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
FLUTAMIDE 125 MG CAPSULE |
2 |
Generic |
$20.00 | N/A | None |
Fluticasone Propionate 0.05mg/g 1 TUBE per CARTON / 30 g in 1 TUBE |
1 |
Preferred Generic |
$0.00 | N/A | None |
Fluticasone Propionate 0.5mg/g 1 TUBE per CARTON / 30 g in 1 TUBE |
1 |
Preferred Generic |
$0.00 | N/A | None |
FLUTICASONE PROPIONATE 50MCG SPRAY SUSPENSION |
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 |
FLUTICASONE-SALMETEROL 113-14 [Advair Diskus, Advair HFA, AIRDUO RESPICLICK] |
2 |
Generic |
$20.00 | N/A | None |
FLUTICASONE-SALMETEROL 232-14 [Advair Diskus, Advair HFA, AIRDUO RESPICLICK] |
2 |
Generic |
$20.00 | N/A | None |
FLUTICASONE-SALMETEROL 55-14 [Advair Diskus, Advair HFA, AIRDUO RESPICLICK] |
2 |
Generic |
$20.00 | N/A | None |
FLUVASTATIN ER 80 MG TABLET [Lescol] |
2 |
Generic |
$20.00 | N/A | None |
FLUVOXAMINE ER 100 MG CAPSULE |
4 |
Non-Preferred Drug |
50% | N/A | S |
FLUVOXAMINE ER 150 MG CAPSULE |
4 |
Non-Preferred Drug |
50% | N/A | S |
FLUVOXAMINE MALEATE 100MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
Fluvoxamine Maleate 25mg/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 FILM COATED TABLETS in |
1 |
Preferred Generic |
$0.00 | N/A | None |
Fluvoxamine maleate 50mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$0.00 | 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 |
FOMEPIZOLE 1.5 GM/1.5 ML VIAL [Antizol] |
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 Drug |
50% | 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 Drug |
50% | N/A | None |
Forteo 250ug/mL 1 SYRINGE per CARTON / 2.4 mL in 1 SYRINGE |
5 |
Specialty Tier |
33% | N/A | P |
FOSAMPRENAVIR 700 MG TABLET [Lexiva] |
5 |
Specialty Tier |
33% | N/A | None |
FOSINOPRIL SODIUM 10 MG TAB |
1 |
Preferred Generic |
$0.00 | N/A | None |
FOSINOPRIL SODIUM 20 MG TAB |
1 |
Preferred Generic |
$0.00 | N/A | None |
FOSINOPRIL SODIUM 40 MG TAB |
1 |
Preferred Generic |
$0.00 | N/A | None |
FOSINOPRIL-HCTZ 10-12.5 MG TAB |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FOSINOPRIL-HCTZ 20-12.5 MG TAB |
2 |
Generic |
$20.00 | N/A | None |
FOSPHENYTOIN 100 MG PE/2 ML VL |
1 |
Preferred Generic |
$0.00 | N/A | None |
FOSRENOL 1,000 MG POWDER PACK |
5 |
Specialty Tier |
33% | N/A | None |
FOSRENOL 1000MG TABLET CHEW |
5 |
Specialty Tier |
33% | N/A | None |
FOSRENOL 500MG TABLET CHEW |
5 |
Specialty Tier |
33% | N/A | None |
FOSRENOL 750 MG POWDER PACKET |
5 |
Specialty Tier |
33% | N/A | None |
FOSRENOL 750MG TABLET CHEW |
5 |
Specialty Tier |
33% | N/A | None |
FRAGMIN 10,000 UNITS SYRINGE |
5 |
Specialty Tier |
33% | 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 |
FRAGMIN 18,000 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 2,500 UNITS SYRINGE |
4 |
Non-Preferred Drug |
50% | N/A | None |
FRAGMIN 5,000 UNITS SYRINGE |
4 |
Non-Preferred Drug |
50% | 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 |
FREAMINE HBC INJECTION |
3 |
Preferred Brand |
$47.00 | N/A | P |
FUROSEMIDE 10 MG/ML SOLUTION |
1 |
Preferred Generic |
$0.00 | N/A | None |
Furosemide 10 ML 10 MG/ML Injection |
1 |
Preferred Generic |
$0.00 | N/A | None |
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 | 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 |
FUROSEMIDE 40MG/5ML TUBEX |
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 |
FUSILEV I.V. 50 MG VIAL |
5 |
Specialty Tier |
33% | N/A | None |
FUZEON 90 MG VIAL |
5 |
Specialty Tier |
33% | N/A | None |
FYAVOLV 1 MG-5 MCG TABLET |
2 |
Generic |
$20.00 | N/A | None |
FYCOMPA 0.5 MG/ML ORAL SUSP |
4 |
Non-Preferred Drug |
50% | N/A | None |
FYCOMPA 10 MG TABLET |
4 |
Non-Preferred Drug |
50% | N/A | None |
FYCOMPA 12 MG TABLET |
4 |
Non-Preferred Drug |
50% | N/A | None |
FYCOMPA 2 MG TABLET |
4 |
Non-Preferred Drug |
50% | N/A | None |
FYCOMPA 4 MG TABLET |
4 |
Non-Preferred Drug |
50% | N/A | None |
FYCOMPA 6 MG TABLET |
4 |
Non-Preferred Drug |
50% | N/A | None |
FYCOMPA 8 MG TABLET |
4 |
Non-Preferred Drug |
50% | N/A | None |