2019 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 Yabucoa County, PR: CMS MA Region 30 which includes: PR Plan Monthly Premium: $0.00 Deductible: $415 |
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 |
FAMCICLOVIR 125 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
FAMCICLOVIR 250 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
FAMCICLOVIR 500 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
FAMOTIDINE 20 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
FAMOTIDINE 40 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
FANAPT 1 MG TABLET |
4 |
Non-Preferred Drug |
$60.00 | $120.00 | S |
FANAPT 10 MG TABLET |
5 |
Specialty Tier |
25% | 25% | S |
FANAPT 12 MG TABLET |
5 |
Specialty Tier |
25% | 25% | S |
FANAPT 2 MG TABLET |
4 |
Non-Preferred Drug |
$60.00 | $120.00 | S |
FANAPT 4 MG TABLET |
4 |
Non-Preferred Drug |
$60.00 | $120.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FANAPT 6 MG TABLET |
5 |
Specialty Tier |
25% | 25% | S |
FANAPT 8 MG TABLET |
5 |
Specialty Tier |
25% | 25% | S |
FANAPT TITR TABLETS |
4 |
Non-Preferred Drug |
$60.00 | $120.00 | S Q:8 /30Days |
FARESTON 60 MG TABLET |
5 |
Specialty Tier |
25% | 25% | None |
FARYDAK 10 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
FARYDAK 15 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
FARYDAK 20 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
FELBAMATE 400 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
FELBAMATE 600 MG TABLET |
4 |
Non-Preferred Drug |
$60.00 | $120.00 | None |
FELBAMATE 600 MG/5 ML SUSP |
5 |
Specialty Tier |
25% | 25% | None |
FELODIPINE ER 10 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FELODIPINE ER 2.5 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
FELODIPINE ER 5 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
FENOFIBRATE 130 MG CAPSULE [LIPOFEN] |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
FENOFIBRATE 134MG CAPSULE [LIPOFEN] |
2 |
Generic |
$15.00 | $30.00 | None |
FENOFIBRATE 145 MG TABLET [LIPOFEN] |
2 |
Generic |
$15.00 | $30.00 | None |
FENOFIBRATE 160 MG TABLET [LIPOFEN] |
2 |
Generic |
$15.00 | $30.00 | None |
FENOFIBRATE 200 MG CAPSULE [LIPOFEN] |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
FENOFIBRATE 43 MG CAPSULE [LIPOFEN] |
2 |
Generic |
$15.00 | $30.00 | None |
FENOFIBRATE 48 MG TABLET [Tricor] |
2 |
Generic |
$15.00 | $30.00 | None |
FENOFIBRATE 54 MG 90 TABLET BOTTLE [LIPOFEN] |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
FENOFIBRATE 67MG CAPSULE [LIPOFEN] |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENOFIBRIC ACID DR 135 MG CAP [TRILIPIX] |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
FENOFIBRIC ACID DR 45 MG CAPSULE DR [Trilipix] |
2 |
Generic |
$15.00 | $30.00 | None |
FENTANYL 100 MCG/HR PATCH TD72 [Duragesic] |
3 |
Preferred Brand |
$35.00 | $70.00 | P Q:10 /30Days |
FENTANYL 12 MCG/HR PATCH TD72 [Duragesic] |
3 |
Preferred Brand |
$35.00 | $70.00 | P Q:10 /30Days |
FENTANYL 25 MCG/HR PATCH TD72 [Duragesic] |
2 |
Generic |
$15.00 | $30.00 | P Q:10 /30Days |
FENTANYL 37.5 MCG/HR PATCH TD72 |
4 |
Non-Preferred Drug |
$60.00 | $120.00 | P Q:10 /30Days |
FENTANYL 50 MCG/HR PATCH TD72 [Duragesic] |
2 |
Generic |
$15.00 | $30.00 | P Q:10 /30Days |
FENTANYL 62.5 MCG/HR PATCH TD72 |
5 |
Specialty Tier |
25% | 25% | P Q:10 /30Days |
FENTANYL 75 MCG/HR PATCH TD72 [Duragesic] |
3 |
Preferred Brand |
$35.00 | $70.00 | P Q:10 /30Days |
FENTANYL 87.5 MCG/HR PATCH TD72 |
5 |
Specialty Tier |
25% | 25% | P Q:10 /30Days |
FENTORA TABLET 100MCG |
5 |
Specialty Tier |
25% | 25% | P Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENTORA TABLET 200MCG |
5 |
Specialty Tier |
25% | 25% | P Q:140 /30Days |
FENTORA TABLET 400MCG |
5 |
Specialty Tier |
25% | 25% | P Q:56 /30Days |
FENTORA TABLET 600MCG |
5 |
Specialty Tier |
25% | 25% | P Q:28 /30Days |
FENTORA TABLET 800MCG |
5 |
Specialty Tier |
25% | 25% | P Q:28 /30Days |
FERRIPROX 500 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
FETZIMA 20-40 MG TITRATION PAK |
4 |
Non-Preferred Drug |
$60.00 | $120.00 | S |
FETZIMA ER 120 MG CAPSULE |
4 |
Non-Preferred Drug |
$60.00 | $120.00 | S |
FETZIMA ER 20 MG CAPSULE |
4 |
Non-Preferred Drug |
$60.00 | $120.00 | S |
FETZIMA ER 40 MG CAPSULE |
4 |
Non-Preferred Drug |
$60.00 | $120.00 | S |
FETZIMA ER 80 MG CAPSULE |
4 |
Non-Preferred Drug |
$60.00 | $120.00 | S |
FINASTERIDE 5 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FIRAZYR 30 MG/3 ML SYRINGE |
5 |
Specialty Tier |
25% | 25% | P |
FIRVANQ 25 MG/ML SOLUTION SOLN RECON |
3 |
Preferred Brand |
$35.00 | $70.00 | P |
FIRVANQ 50 MG/ML SOLUTION SOLN RECON |
4 |
Non-Preferred Drug |
$60.00 | $120.00 | P |
FLECAINIDE ACETATE 100 MG TAB |
2 |
Generic |
$15.00 | $30.00 | None |
FLECAINIDE ACETATE 150 MG TAB |
2 |
Generic |
$15.00 | $30.00 | None |
FLECAINIDE ACETATE 50 MG TAB |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
FLUCONAZOLE 10 MG/ML SUSP |
2 |
Generic |
$15.00 | $30.00 | None |
FLUCONAZOLE 100 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
FLUCONAZOLE 150 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
FLUCONAZOLE 200 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
FLUCONAZOLE 40 MG/ML SUSP |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Fluconazole 50mg/1 30 TABLET BOTTLE |
2 |
Generic |
$15.00 | $30.00 | None |
FLUCONAZOLE-NACL 200 MG/100 ML |
2 |
Generic |
$15.00 | $30.00 | P |
FLUCONAZOLE-NACL 400 MG/200 ML |
2 |
Generic |
$15.00 | $30.00 | P |
FLUCYTOSINE 250 MG CAPSULE [Ancobon] |
5 |
Specialty Tier |
25% | 25% | None |
FLUCYTOSINE 500 MG CAPSULE [Ancobon] |
5 |
Specialty Tier |
25% | 25% | None |
FLUDROCORTISONE 0.1 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
Fluocinolone 0.01% cream |
2 |
Generic |
$15.00 | $30.00 | None |
FLUOCINOLONE 0.01% SCALP OIL |
4 |
Non-Preferred Drug |
$60.00 | $120.00 | None |
FLUOCINOLONE 0.01% SOLUTION |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
FLUOCINOLONE 0.025% CREAM (g) [Synalar] |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
FLUOCINOLONE 0.025% OINTMENT |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOCINOLONE OIL 0.01% EAR DRP |
4 |
Non-Preferred Drug |
$60.00 | $120.00 | Q:20 /30Days |
FLUOCINONIDE 0.05% OINTMENT |
2 |
Generic |
$15.00 | $30.00 | None |
FLUOCINONIDE 0.05% SOLUTION |
2 |
Generic |
$15.00 | $30.00 | None |
Fluorometholone 0.1% drops |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
FLUOROURACIL 2% TOPICAL SOLN |
2 |
Generic |
$15.00 | $30.00 | None |
FLUOROURACIL 5% TOP SOLUTION |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
FLUOROURACIL CREA 5% |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
Fluoxetine 20mg/5mL 120 mL in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
FLUOXETINE CAPSULES 10MG (100 CT) |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
FLUOXETINE HCL 20 MG CAPSULE |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
FLUOXETINE HCL 40 MG CAPSULE |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOXETINE HCL 60 MG TABLET |
4 |
Non-Preferred Drug |
$60.00 | $120.00 | None |
FLUPHENAZINE 1 MG TABLET |
4 |
Non-Preferred Drug |
$60.00 | $120.00 | None |
FLUPHENAZINE 10 MG TABLET |
4 |
Non-Preferred Drug |
$60.00 | $120.00 | None |
FLUPHENAZINE 2.5 MG TABLET |
4 |
Non-Preferred Drug |
$60.00 | $120.00 | None |
FLUPHENAZINE 2.5 MG/5 ML ELIX |
2 |
Generic |
$15.00 | $30.00 | None |
FLUPHENAZINE 2.5MG/ML VIAL |
4 |
Non-Preferred Drug |
$60.00 | $120.00 | P |
FLUPHENAZINE 5 MG TABLET |
4 |
Non-Preferred Drug |
$60.00 | $120.00 | None |
FLUPHENAZINE 5MG/ML CONC |
2 |
Generic |
$15.00 | $30.00 | None |
FLUPHENAZINE DEC 125 MG/5 ML |
3 |
Preferred Brand |
$35.00 | $70.00 | P |
Flurazepam Hydrochloride 15mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC |
2 |
Generic |
$15.00 | $30.00 | None |
Flurazepam Hydrochloride 30mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLURBIPROFEN 0.03% EYE DROPS [Ocufen] |
1 |
Preferred Generic |
$5.00 | $10.00 | Q:5 /90Days |
FLUTAMIDE 125 MG CAPSULE |
3 |
Preferred Brand |
$35.00 | $70.00 | None |
Fluticasone Propionate 0.5mg/g 1 TUBE per CARTON / 30 g in 1 TUBE |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
FLUTICASONE PROPIONATE 50MCG SPRAY SUSPENSION |
1 |
Preferred Generic |
$5.00 | $10.00 | Q:16 /30Days |
FLUTICASONE-SALMETEROL 113-14 [Advair Diskus, Advair HFA, AIRDUO RESPICLICK] |
2 |
Generic |
$15.00 | $30.00 | Q:1 /30Days |
FLUTICASONE-SALMETEROL 232-14 [Advair Diskus, Advair HFA, AIRDUO RESPICLICK] |
2 |
Generic |
$15.00 | $30.00 | Q:1 /30Days |
FLUTICASONE-SALMETEROL 55-14 [Advair Diskus, Advair HFA, AIRDUO RESPICLICK] |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:1 /30Days |
FLUVOXAMINE MALEATE 100MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
Fluvoxamine Maleate 25mg/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 FILM COATED TABLETS in |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
Fluvoxamine maleate 50mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
Fondaparinux Sodium 10mg/0.8mL 2 SYRINGES per CARTON / 0.8 mL in 1 SYRINGE [Arixtra] |
5 |
Specialty Tier |
25% | 25% | Q:24 /30Days |
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 |
$60.00 | $120.00 | Q:15 /30Days |
Fondaparinux Sodium 5mg/4mL 2 SYRINGES per CARTON / 0.4 mL in 1 SYRINGE [Arixtra] |
5 |
Specialty Tier |
25% | 25% | Q:12 /30Days |
Fondaparinux Sodium 7.5mg/0.6mL 2 SYRINGES per CARTON / 0.6 mL in 1 SYRINGE [Arixtra] |
5 |
Specialty Tier |
25% | 25% | Q:18 /30Days |
Forteo 250ug/mL 1 SYRINGE per CARTON / 2.4 mL in 1 SYRINGE |
5 |
Specialty Tier |
25% | 25% | P |
FOSAMPRENAVIR 700 MG TABLET [Lexiva] |
5 |
Specialty Tier |
25% | 25% | None |
FOSINOPRIL SODIUM 10 MG TAB |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
FOSINOPRIL SODIUM 20 MG TAB |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
FOSINOPRIL SODIUM 40 MG TAB |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
FOSINOPRIL-HCTZ 10-12.5 MG TAB |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
FOSINOPRIL-HCTZ 20-12.5 MG TAB |
6 |
Select Care Drugs |
$0.00 | $0.00 | None |
FUROSEMIDE 10 MG/ML SOLUTION |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Furosemide 10 ML 10 MG/ML Injection |
1 |
Preferred Generic |
$5.00 | $10.00 | P |
Furosemide 10mg/mL 10 CARTON in 1 CONTAINER / 1 SYRINGE, PLASTIC in 1 CARTON / 4 mL in 1 SYRINGE, P |
1 |
Preferred Generic |
$5.00 | $10.00 | P |
FUROSEMIDE 20 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
FUROSEMIDE 40 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
FUROSEMIDE 80 MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
FUZEON 90 MG VIAL |
5 |
Specialty Tier |
25% | 25% | None |
FYCOMPA 0.5 MG/ML ORAL SUSP |
4 |
Non-Preferred Drug |
$60.00 | $120.00 | None |
FYCOMPA 10 MG TABLET |
4 |
Non-Preferred Drug |
$60.00 | $120.00 | None |
FYCOMPA 12 MG TABLET |
4 |
Non-Preferred Drug |
$60.00 | $120.00 | None |
FYCOMPA 2 MG TABLET |
4 |
Non-Preferred Drug |
$60.00 | $120.00 | None |
FYCOMPA 4 MG TABLET |
4 |
Non-Preferred Drug |
$60.00 | $120.00 | 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 Drug |
$60.00 | $120.00 | None |
FYCOMPA 8 MG TABLET |
4 |
Non-Preferred Drug |
$60.00 | $120.00 | None |