2019 Medicare Part D Plan Formulary Information |
Preferred Gold with Part D (HMO-POS) (H3305-021-0)
Benefit Details
|
The Preferred Gold with Part D (HMO-POS) (H3305-021-0) Formulary Drugs Starting with the Letter F in Greene County, NY: CMS MA Region 3 which includes: NY Plan Monthly Premium: $120.00 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 |
FALMINA-28 TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
FAMCICLOVIR 125 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
FAMCICLOVIR 250 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
FAMCICLOVIR 500 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
FAMOTIDINE 20 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
FAMOTIDINE 40 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
FAMOTIDINE 50 MG/5MLFOR ORAL SUSPENSION |
2 |
Generic |
$10.00 | $20.00 | None |
FANAPT 1 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
FANAPT 10 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
FANAPT 12 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FANAPT 2 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
FANAPT 4 MG TABLET |
5 |
Specialty Tier |
33% | 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 |
FARESTON 60 MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
FARXIGA 10 MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:30 /30Days |
FARXIGA 5 MG TABLET |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:30 /30Days |
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 |
FELBAMATE 400 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FELBAMATE 600 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
FELBAMATE 600 MG/5 ML SUSP |
2 |
Generic |
$10.00 | $20.00 | None |
FELODIPINE ER 10 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
FELODIPINE ER 2.5 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
FELODIPINE ER 5 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
Femynor 28 tablet |
2 |
Generic |
$10.00 | $20.00 | None |
FENOFIBRATE 134MG CAPSULE [LIPOFEN] |
2 |
Generic |
$10.00 | $20.00 | None |
FENOFIBRATE 145 MG TABLET [LIPOFEN] |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
FENOFIBRATE 160 MG TABLET [LIPOFEN] |
2 |
Generic |
$10.00 | $20.00 | None |
FENOFIBRATE 200 MG CAPSULE [LIPOFEN] |
2 |
Generic |
$10.00 | $20.00 | None |
FENOFIBRATE 43 MG CAPSULE [LIPOFEN] |
2 |
Generic |
$10.00 | $20.00 | 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 |
$10.00 | $20.00 | None |
FENOFIBRATE 54 MG 90 TABLET BOTTLE [LIPOFEN] |
2 |
Generic |
$10.00 | $20.00 | None |
FENOFIBRATE 67MG CAPSULE [LIPOFEN] |
2 |
Generic |
$10.00 | $20.00 | None |
FENTANYL 100 MCG/HR PATCH TD72 [Duragesic] |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:20 /30Days |
FENTANYL 12 MCG/HR PATCH TD72 [Duragesic] |
2 |
Generic |
$10.00 | $20.00 | Q:20 /30Days |
FENTANYL 25 MCG/HR PATCH TD72 [Duragesic] |
2 |
Generic |
$10.00 | $20.00 | Q:20 /30Days |
FENTANYL 50 MCG/HR PATCH TD72 [Duragesic] |
2 |
Generic |
$10.00 | $20.00 | Q:20 /30Days |
FENTANYL 75 MCG/HR PATCH TD72 [Duragesic] |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:20 /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 |
27% | 27% | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENTANYL CITRATE OTFC 400 MCG [Actiq] |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
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 |
FENTORA TABLET 100MCG |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
FENTORA TABLET 200MCG |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
FENTORA TABLET 400MCG |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
FENTORA TABLET 600MCG |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
FENTORA TABLET 800MCG |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
FERRIPROX 500 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
FETZIMA 20-40 MG TITRATION PAK |
4 |
Non-Preferred Drug |
27% | 27% | P |
FETZIMA ER 120 MG CAPSULE |
4 |
Non-Preferred Drug |
27% | 27% | P |
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 Drug |
27% | 27% | P |
FETZIMA ER 40 MG CAPSULE |
4 |
Non-Preferred Drug |
27% | 27% | P |
FETZIMA ER 80 MG CAPSULE |
4 |
Non-Preferred Drug |
27% | 27% | P |
FINASTERIDE 5 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
FIRAZYR 30 MG/3 ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | P |
FIRDAPSE 10 MG TABLET |
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 |
27% | 27% | Q:4 /28Days |
FIRVANQ 25 MG/ML SOLUTION SOLN RECON |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
FIRVANQ 50 MG/ML SOLUTION SOLN RECON |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
FLAVOXATE 100 MG TAB 100 |
2 |
Generic |
$10.00 | $20.00 | 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 |
2 |
Generic |
$10.00 | $20.00 | None |
FLECAINIDE ACETATE 150 MG TAB |
2 |
Generic |
$10.00 | $20.00 | None |
FLECAINIDE ACETATE 50 MG TAB |
2 |
Generic |
$10.00 | $20.00 | None |
FLOVENT DISKUS 100ug/1 60 POWDER, METERED in 1 INHALER |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
FLOVENT DISKUS 250ug/1 60 POWDER, METERED in 1 INHALER |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
FLOVENT DISKUS POWDER 50MCG 60 CTR |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
FLOVENT HFA 110ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
FLOVENT HFA 220ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
FLOVENT HFA 44ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
FLUCONAZOLE 10 MG/ML SUSP |
2 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUCONAZOLE 100 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
FLUCONAZOLE 150 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
FLUCONAZOLE 200 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
FLUCONAZOLE 40 MG/ML SUSP |
2 |
Generic |
$10.00 | $20.00 | None |
Fluconazole 50mg/1 30 TABLET BOTTLE |
2 |
Generic |
$10.00 | $20.00 | None |
FLUCONAZOLE-NACL 200 MG/100 ML |
2 |
Generic |
$10.00 | $20.00 | None |
FLUCONAZOLE-NACL 400 MG/200 ML |
2 |
Generic |
$10.00 | $20.00 | None |
FLUCYTOSINE 250 MG CAPSULE [Ancobon] |
2 |
Generic |
$10.00 | $20.00 | None |
FLUCYTOSINE 500 MG CAPSULE [Ancobon] |
2 |
Generic |
$10.00 | $20.00 | None |
FLUDROCORTISONE 0.1 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL |
2 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Fluocinolone 0.01% cream |
2 |
Generic |
$10.00 | $20.00 | None |
FLUOCINOLONE 0.01% SCALP OIL |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:120 /30Days |
FLUOCINOLONE 0.01% SOLUTION |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:120 /30Days |
FLUOCINOLONE 0.025% CREAM (g) [Synalar] |
2 |
Generic |
$10.00 | $20.00 | None |
FLUOCINOLONE 0.025% OINTMENT |
2 |
Generic |
$10.00 | $20.00 | None |
FLUOCINOLONE OIL 0.01% EAR DRP |
2 |
Generic |
$10.00 | $20.00 | None |
FLUOCINONIDE 0.05% GEL |
2 |
Generic |
$10.00 | $20.00 | None |
FLUOCINONIDE 0.05% OINTMENT |
2 |
Generic |
$10.00 | $20.00 | None |
FLUOCINONIDE 0.05% SOLUTION |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:120 /30Days |
FLUOCINONIDE-E 0.05% CREAM |
2 |
Generic |
$10.00 | $20.00 | None |
Fluorometholone 0.1% drops |
3 |
Preferred Brand |
$35.00 | $70.00 | 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 |
$10.00 | $20.00 | None |
FLUOROURACIL 5% TOP SOLUTION |
2 |
Generic |
$10.00 | $20.00 | None |
FLUOROURACIL CREA 5% |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
Fluoxetine 20mg/5mL 120 mL in 1 BOTTLE, PLASTIC |
2 |
Generic |
$10.00 | $20.00 | None |
FLUOXETINE CAPSULES 10MG (100 CT) |
2 |
Generic |
$10.00 | $20.00 | None |
FLUOXETINE HCL 20 MG CAPSULE |
2 |
Generic |
$10.00 | $20.00 | None |
FLUOXETINE HCL 40 MG CAPSULE |
2 |
Generic |
$10.00 | $20.00 | None |
FLUPHENAZINE 1 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
FLUPHENAZINE 10 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
FLUPHENAZINE 2.5 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUPHENAZINE 2.5 MG/5 ML ELIX |
2 |
Generic |
$10.00 | $20.00 | None |
FLUPHENAZINE 2.5MG/ML VIAL |
2 |
Generic |
$10.00 | $20.00 | None |
FLUPHENAZINE 5 MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
FLUPHENAZINE 5MG/ML CONC |
2 |
Generic |
$10.00 | $20.00 | None |
FLUPHENAZINE DEC 125 MG/5 ML |
2 |
Generic |
$10.00 | $20.00 | None |
FLURBIPROFEN 0.03% EYE DROPS [Ocufen] |
2 |
Generic |
$10.00 | $20.00 | None |
FLUTAMIDE 125 MG CAPSULE |
2 |
Generic |
$10.00 | $20.00 | None |
FLUTICASONE PROP 0.05% LOTION |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:120 /30Days |
Fluticasone Propionate 0.05mg/g 1 TUBE per CARTON / 30 g in 1 TUBE |
2 |
Generic |
$10.00 | $20.00 | None |
Fluticasone Propionate 0.5mg/g 1 TUBE per CARTON / 30 g in 1 TUBE |
2 |
Generic |
$10.00 | $20.00 | None |
FLUTICASONE PROPIONATE 50MCG SPRAY SUSPENSION |
2 |
Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUTICASONE-SALMETEROL 100-50 BLST W/DEV [Advair] |
2 |
Generic |
$10.00 | $20.00 | None |
FLUTICASONE-SALMETEROL 250-50 BLST W/DEV [Advair] |
2 |
Generic |
$10.00 | $20.00 | None |
FLUTICASONE-SALMETEROL 500-50 BLST W/DEV [Advair] |
2 |
Generic |
$10.00 | $20.00 | None |
FLUVASTATIN SODIUM 20 MG CAP [Lescol] |
2 |
Generic |
$10.00 | $20.00 | None |
FLUVASTATIN SODIUM 40 MG CAPSULE [Lescol] |
2 |
Generic |
$10.00 | $20.00 | None |
FLUVOXAMINE MALEATE 100MG TABLET |
2 |
Generic |
$10.00 | $20.00 | None |
Fluvoxamine Maleate 25mg/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 FILM COATED TABLETS in |
2 |
Generic |
$10.00 | $20.00 | None |
Fluvoxamine maleate 50mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Generic |
$10.00 | $20.00 | None |
FML FORTE 0.25% EYE DROPS |
4 |
Non-Preferred Drug |
27% | 27% | None |
FML S.O.P. 0.1% OINTMENT |
4 |
Non-Preferred Drug |
27% | 27% | None |
Fondaparinux Sodium 10mg/0.8mL 2 SYRINGES per CARTON / 0.8 mL in 1 SYRINGE [Arixtra] |
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 2.5mg/0.5mL 2 SYRINGES per CARTON / 0.5 mL in 1 SYRINGE [Arixtra] |
4 |
Non-Preferred Drug |
27% | 27% | 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 |
Forteo 250ug/mL 1 SYRINGE per CARTON / 2.4 mL in 1 SYRINGE |
5 |
Specialty Tier |
33% | N/A | P Q:2 /28Days |
FOSAMPRENAVIR 700 MG TABLET [Lexiva] |
5 |
Specialty Tier |
33% | N/A | None |
FOSINOPRIL SODIUM 10 MG TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FOSINOPRIL SODIUM 20 MG TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FOSINOPRIL SODIUM 40 MG TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FOSINOPRIL-HCTZ 10-12.5 MG TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FOSINOPRIL-HCTZ 20-12.5 MG TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FRAGMIN 10,000 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 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 |
FRAGMIN 2,500 UNITS SYRINGE |
4 |
Non-Preferred Drug |
27% | 27% | None |
FRAGMIN 5,000 UNITS SYRINGE |
4 |
Non-Preferred Drug |
27% | 27% | 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 |
FUROSEMIDE 10 MG/ML SOLUTION |
2 |
Generic |
$10.00 | $20.00 | None |
Furosemide 10 ML 10 MG/ML Injection |
2 |
Generic |
$10.00 | $20.00 | None |
Furosemide 10mg/mL 10 CARTON in 1 CONTAINER / 1 SYRINGE, PLASTIC in 1 CARTON / 4 mL in 1 SYRINGE, P |
2 |
Generic |
$10.00 | $20.00 | None |
FUROSEMIDE 20 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FUROSEMIDE 40 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FUROSEMIDE 80 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
FUZEON 90 MG VIAL |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
FYCOMPA 0.5 MG/ML ORAL SUSP |
5 |
Specialty Tier |
33% | N/A | None |
FYCOMPA 10 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
FYCOMPA 12 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
FYCOMPA 2 MG TABLET |
4 |
Non-Preferred Drug |
27% | 27% | Q:30 /30Days |
FYCOMPA 4 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
FYCOMPA 6 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
FYCOMPA 8 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |