2019 Medicare Part D Plan Formulary Information |
Mutual of Omaha Rx Value (PDP) (S7126-044-0)
Benefit Details
|
The Mutual of Omaha Rx Value (PDP) (S7126-044-0) Formulary Drugs Starting with the Letter F in CMS PDP Region 12 which includes: AL TN Plan Monthly Premium: $28.80 Deductible: $415 Qualifies for LIS: No |
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 |
4 |
Non-Preferred Drug |
35% | N/A | Q:60 /30Days |
FAMCICLOVIR 250 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | Q:60 /30Days |
FAMCICLOVIR 500 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | Q:21 /30Days |
FAMOTIDINE 20 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
FAMOTIDINE 40 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
FAMOTIDINE 50 MG/5MLFOR ORAL SUSPENSION |
4 |
Non-Preferred Drug |
35% | N/A | None |
FANAPT 1 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | P Q:60 /30Days |
FANAPT 10 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | P Q:60 /30Days |
FANAPT 12 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | P Q:60 /30Days |
FANAPT 2 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FANAPT 4 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | P Q:60 /30Days |
FANAPT 6 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | P Q:60 /30Days |
FANAPT 8 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | P Q:60 /30Days |
FANAPT TITR TABLETS |
4 |
Non-Preferred Drug |
35% | N/A | P Q:8 /28Days |
FARESTON 60 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
FARYDAK 10 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:12 /21Days |
FARYDAK 15 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:6 /21Days |
FARYDAK 20 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:6 /21Days |
FASENRA 30 MG/ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P |
FAYOSIM TABLET TBDSPK 3MO [Quartette] |
4 |
Non-Preferred Drug |
35% | N/A | None |
FAZACLO 150 MG ODT TAB RAPDIS |
4 |
Non-Preferred Drug |
35% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FAZACLO 200 MG ODT TAB RAPDIS |
4 |
Non-Preferred Drug |
35% | N/A | None |
FELBAMATE 400 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | None |
FELBAMATE 600 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | None |
FELBAMATE 600 MG/5 ML SUSP |
4 |
Non-Preferred Drug |
35% | N/A | None |
FELODIPINE ER 10 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | None |
FELODIPINE ER 2.5 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | None |
FELODIPINE ER 5 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | None |
Femynor 28 tablet |
4 |
Non-Preferred Drug |
35% | N/A | None |
FENOFIBRATE 134MG CAPSULE [LIPOFEN] |
3 |
Preferred Brand |
15% | 18% | Q:30 /30Days |
FENOFIBRATE 145 MG TABLET [LIPOFEN] |
3 |
Preferred Brand |
15% | 18% | Q:30 /30Days |
FENOFIBRATE 160 MG TABLET [LIPOFEN] |
2* |
Generic |
$4.00 | $8.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENOFIBRATE 200 MG CAPSULE [LIPOFEN] |
3 |
Preferred Brand |
15% | 18% | Q:30 /30Days |
FENOFIBRATE 48 MG TABLET [Tricor] |
3 |
Preferred Brand |
15% | 18% | Q:60 /30Days |
FENOFIBRATE 54 MG 90 TABLET BOTTLE [LIPOFEN] |
2* |
Generic |
$4.00 | $8.00 | Q:60 /30Days |
FENOFIBRATE 67MG CAPSULE [LIPOFEN] |
3 |
Preferred Brand |
15% | 18% | Q:60 /30Days |
FENTANYL 100 MCG/HR PATCH TD72 [Duragesic] |
3 |
Preferred Brand |
15% | 18% | P Q:10 /30Days |
FENTANYL 12 MCG/HR PATCH TD72 [Duragesic] |
3 |
Preferred Brand |
15% | 18% | P Q:10 /30Days |
FENTANYL 25 MCG/HR PATCH TD72 [Duragesic] |
3 |
Preferred Brand |
15% | 18% | P Q:10 /30Days |
FENTANYL 50 MCG/HR PATCH TD72 [Duragesic] |
3 |
Preferred Brand |
15% | 18% | P Q:10 /30Days |
FENTANYL 75 MCG/HR PATCH TD72 [Duragesic] |
3 |
Preferred Brand |
15% | 18% | P Q:10 /30Days |
FENTANYL CITRATE OTFC 1,200 MCG [Actiq] |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
FENTANYL CITRATE OTFC 1,600 MCG [Actiq] |
5 |
Specialty Tier |
25% | 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 200 MCG [Actiq] |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
FENTANYL CITRATE OTFC 400 MCG [Actiq] |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
FENTANYL CITRATE OTFC 600 MCG [Actiq] |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
FENTANYL CITRATE OTFC 800 MCG [Actiq] |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
FERRIPROX 500 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
FETZIMA 20-40 MG TITRATION PAK |
4 |
Non-Preferred Drug |
35% | N/A | S Q:28 /28Days |
FETZIMA ER 120 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | N/A | S Q:30 /30Days |
FETZIMA ER 20 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | N/A | S Q:30 /30Days |
FETZIMA ER 40 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | N/A | S Q:30 /30Days |
FETZIMA ER 80 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | N/A | S Q:30 /30Days |
FINASTERIDE 5 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | Q:30 /30Days |
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% | N/A | P Q:270 /30Days |
FIRDAPSE 10 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
FIRMAGON 2 X 120 MG KIT |
4 |
Non-Preferred Drug |
35% | N/A | P |
FIRMAGON 80 MG KIT |
4 |
Non-Preferred Drug |
35% | N/A | P |
FLAC OTIC OIL 0.01% EAR DROPS [Flac] |
4 |
Non-Preferred Drug |
35% | N/A | None |
FLECAINIDE ACETATE 100 MG TAB |
2* |
Generic |
$4.00 | $8.00 | None |
FLECAINIDE ACETATE 150 MG TAB |
2* |
Generic |
$4.00 | $8.00 | None |
FLECAINIDE ACETATE 50 MG TAB |
2* |
Generic |
$4.00 | $8.00 | None |
FLOVENT DISKUS 100ug/1 60 POWDER, METERED in 1 INHALER |
3 |
Preferred Brand |
15% | 18% | Q:60 /30Days |
FLOVENT DISKUS 250ug/1 60 POWDER, METERED in 1 INHALER |
3 |
Preferred Brand |
15% | 18% | Q:240 /30Days |
FLOVENT DISKUS POWDER 50MCG 60 CTR |
3 |
Preferred Brand |
15% | 18% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLOVENT HFA 110ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
15% | 18% | Q:12 /30Days |
FLOVENT HFA 220ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
15% | 18% | Q:24 /30Days |
FLOVENT HFA 44ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
15% | 18% | Q:11 /30Days |
FLUCONAZOLE 10 MG/ML SUSP |
3 |
Preferred Brand |
15% | 18% | None |
FLUCONAZOLE 100 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
FLUCONAZOLE 150 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
FLUCONAZOLE 200 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
FLUCONAZOLE 40 MG/ML SUSP |
3 |
Preferred Brand |
15% | 18% | None |
Fluconazole 50mg/1 30 TABLET BOTTLE |
2* |
Generic |
$4.00 | $8.00 | None |
FLUCONAZOLE-NACL 200 MG/100 ML |
4 |
Non-Preferred Drug |
35% | N/A | None |
FLUCONAZOLE-NACL 400 MG/200 ML |
4 |
Non-Preferred Drug |
35% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUCYTOSINE 250 MG CAPSULE [Ancobon] |
5 |
Specialty Tier |
25% | N/A | None |
FLUCYTOSINE 500 MG CAPSULE [Ancobon] |
5 |
Specialty Tier |
25% | N/A | None |
FLUDROCORTISONE 0.1 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL |
2* |
Generic |
$4.00 | $8.00 | Q:50 /30Days |
Fluocinolone 0.01% cream |
4 |
Non-Preferred Drug |
35% | N/A | None |
FLUOCINOLONE 0.01% SCALP OIL |
4 |
Non-Preferred Drug |
35% | N/A | None |
FLUOCINOLONE 0.01% SOLUTION |
4 |
Non-Preferred Drug |
35% | N/A | None |
FLUOCINOLONE 0.025% CREAM (g) [Synalar] |
4 |
Non-Preferred Drug |
35% | N/A | None |
FLUOCINOLONE 0.025% OINTMENT |
4 |
Non-Preferred Drug |
35% | N/A | None |
FLUOCINOLONE OIL 0.01% EAR DRP |
4 |
Non-Preferred Drug |
35% | N/A | None |
FLUOCINONIDE 0.05% GEL |
2* |
Generic |
$4.00 | $8.00 | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOCINONIDE 0.05% OINTMENT |
2* |
Generic |
$4.00 | $8.00 | Q:120 /30Days |
FLUOCINONIDE 0.05% SOLUTION |
4 |
Non-Preferred Drug |
35% | N/A | Q:120 /30Days |
FLUOCINONIDE-E 0.05% CREAM |
2* |
Generic |
$4.00 | $8.00 | Q:120 /30Days |
Fluorometholone 0.1% drops |
4 |
Non-Preferred Drug |
35% | N/A | None |
FLUOROURACIL 2% TOPICAL SOLN |
4 |
Non-Preferred Drug |
35% | N/A | None |
FLUOROURACIL 5% TOP SOLUTION |
4 |
Non-Preferred Drug |
35% | N/A | None |
FLUOROURACIL CREA 5% |
4 |
Non-Preferred Drug |
35% | N/A | None |
Fluoxetine 10mg/1 30 FILM COATED TABLETS in BOTTLE |
2* |
Generic |
$4.00 | $8.00 | Q:30 /30Days |
Fluoxetine 20mg/5mL 120 mL in 1 BOTTLE, PLASTIC |
2* |
Generic |
$4.00 | $8.00 | None |
FLUOXETINE CAPSULES 10MG (100 CT) |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:30 /30Days |
FLUOXETINE HCL 20 MG CAPSULE |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOXETINE HCL 20 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
FLUOXETINE HCL 40 MG CAPSULE |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:60 /30Days |
FLUOXETINE HCL 60 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
FLUPHENAZINE 1 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
FLUPHENAZINE 10 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
FLUPHENAZINE 2.5 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
FLUPHENAZINE 2.5 MG/5 ML ELIX |
4 |
Non-Preferred Drug |
35% | N/A | None |
FLUPHENAZINE 2.5MG/ML VIAL |
4 |
Non-Preferred Drug |
35% | N/A | None |
FLUPHENAZINE 5 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
FLUPHENAZINE 5MG/ML CONC |
2* |
Generic |
$4.00 | $8.00 | None |
FLUPHENAZINE DEC 125 MG/5 ML |
4 |
Non-Preferred Drug |
35% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUTAMIDE 125 MG CAPSULE |
4 |
Non-Preferred Drug |
35% | N/A | None |
Fluticasone Propionate 0.05mg/g 1 TUBE per CARTON / 30 g in 1 TUBE |
2* |
Generic |
$4.00 | $8.00 | None |
Fluticasone Propionate 0.5mg/g 1 TUBE per CARTON / 30 g in 1 TUBE |
2* |
Generic |
$4.00 | $8.00 | None |
FLUTICASONE PROPIONATE 50MCG SPRAY SUSPENSION |
2* |
Generic |
$4.00 | $8.00 | Q:16 /30Days |
FLUVASTATIN SODIUM 20 MG CAP [Lescol] |
4 |
Non-Preferred Drug |
35% | N/A | Q:30 /30Days |
FLUVASTATIN SODIUM 40 MG CAPSULE [Lescol] |
4 |
Non-Preferred Drug |
35% | N/A | Q:60 /30Days |
FLUVOXAMINE MALEATE 100MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | Q:90 /30Days |
Fluvoxamine Maleate 25mg/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 FILM COATED TABLETS in |
4 |
Non-Preferred Drug |
35% | N/A | Q:30 /30Days |
Fluvoxamine maleate 50mg/1 100 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Drug |
35% | N/A | Q:60 /30Days |
Fondaparinux Sodium 10mg/0.8mL 2 SYRINGES per CARTON / 0.8 mL in 1 SYRINGE [Arixtra] |
5 |
Specialty Tier |
25% | N/A | None |
Fondaparinux Sodium 2.5mg/0.5mL 2 SYRINGES per CARTON / 0.5 mL in 1 SYRINGE [Arixtra] |
3 |
Preferred Brand |
15% | 18% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Fondaparinux Sodium 5mg/4mL 2 SYRINGES per CARTON / 0.4 mL in 1 SYRINGE [Arixtra] |
5 |
Specialty Tier |
25% | N/A | None |
Fondaparinux Sodium 7.5mg/0.6mL 2 SYRINGES per CARTON / 0.6 mL in 1 SYRINGE [Arixtra] |
5 |
Specialty Tier |
25% | N/A | None |
FOSAMPRENAVIR 700 MG TABLET [Lexiva] |
5 |
Specialty Tier |
25% | N/A | Q:120 /30Days |
FREAMINE HBC INJECTION |
3 |
Preferred Brand |
15% | 18% | P |
FUROSEMIDE 10 MG/ML SOLUTION |
2* |
Generic |
$4.00 | $8.00 | None |
Furosemide 10 ML 10 MG/ML Injection |
4 |
Non-Preferred Drug |
35% | N/A | None |
Furosemide 10mg/mL 10 CARTON in 1 CONTAINER / 1 SYRINGE, PLASTIC in 1 CARTON / 4 mL in 1 SYRINGE, P |
4 |
Non-Preferred Drug |
35% | N/A | None |
FUROSEMIDE 20 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
FUROSEMIDE 40 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
FUROSEMIDE 40MG/5ML TUBEX |
2* |
Generic |
$4.00 | $8.00 | None |
FUROSEMIDE 80 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FUZEON 90 MG VIAL |
4 |
Non-Preferred Drug |
35% | N/A | Q:60 /30Days |
FYCOMPA 0.5 MG/ML ORAL SUSP |
4 |
Non-Preferred Drug |
35% | N/A | P Q:720 /30Days |
FYCOMPA 10 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | P Q:30 /30Days |
FYCOMPA 12 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | P Q:30 /30Days |
FYCOMPA 2 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | P Q:180 /30Days |
FYCOMPA 4 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | P Q:90 /30Days |
FYCOMPA 6 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | P Q:60 /30Days |
FYCOMPA 8 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | P Q:30 /30Days |