2019 Medicare Part D Plan Formulary Information |
WellCare Classic (PDP) (S4802-071-0)
Benefit Details
 |
The WellCare Classic (PDP) (S4802-071-0) Formulary Drugs Starting with the Letter F in CMS PDP Region 12 which includes: AL TN Plan Monthly Premium: $29.90 Deductible: $415 Qualifies for LIS: Yes |
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  |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
FAMCICLOVIR 125 MG TABLET  |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
FAMCICLOVIR 250 MG TABLET  |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
FAMCICLOVIR 500 MG TABLET  |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
FAMOTIDINE 20 MG TABLET  |
2 |
Generic |
$1.00 | $2.50 | None |
FAMOTIDINE 40 MG TABLET  |
2 |
Generic |
$1.00 | $2.50 | None |
FANAPT 1 MG TABLET  |
4 |
Non-Preferred Drug |
42% | 42% | Q:60 /30Days |
FANAPT 10 MG TABLET  |
4 |
Non-Preferred Drug |
42% | 42% | Q:60 /30Days |
FANAPT 12 MG TABLET  |
4 |
Non-Preferred Drug |
42% | 42% | Q:60 /30Days |
FANAPT 2 MG TABLET  |
4 |
Non-Preferred Drug |
42% | 42% | 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 |
42% | 42% | Q:60 /30Days |
FANAPT 6 MG TABLET  |
4 |
Non-Preferred Drug |
42% | 42% | Q:60 /30Days |
FANAPT 8 MG TABLET  |
4 |
Non-Preferred Drug |
42% | 42% | Q:60 /30Days |
FANAPT TITR TABLETS  |
4 |
Non-Preferred Drug |
42% | 42% | None |
FARXIGA 10 MG TABLET  |
3 |
Preferred Brand |
$37.00 | $92.50 | Q:30 /30Days |
FARXIGA 5 MG TABLET  |
3 |
Preferred Brand |
$37.00 | $92.50 | Q:60 /30Days |
FARYDAK 10 MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P |
FARYDAK 15 MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P |
FARYDAK 20 MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P |
FELBAMATE 400 MG TABLET  |
4 |
Non-Preferred Drug |
42% | 42% | None |
FELBAMATE 600 MG TABLET  |
4 |
Non-Preferred Drug |
42% | 42% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FELBAMATE 600 MG/5 ML SUSP  |
5 |
Specialty Tier |
25% | N/A | None |
FELODIPINE ER 10 MG TABLET  |
2 |
Generic |
$1.00 | $2.50 | None |
FELODIPINE ER 2.5 MG TABLET  |
2 |
Generic |
$1.00 | $2.50 | None |
FELODIPINE ER 5 MG TABLET  |
2 |
Generic |
$1.00 | $2.50 | None |
Femynor 28 tablet  |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
FENOFIBRATE 134MG CAPSULE [LIPOFEN] ![Compare how all Medicare Part D PDP plans in AL cover FENOFIBRATE 134MG CAPSULE [LIPOFEN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
FENOFIBRATE 145 MG TABLET [LIPOFEN] ![Compare how all Medicare Part D PDP plans in AL cover FENOFIBRATE 145 MG TABLET [LIPOFEN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
FENOFIBRATE 160 MG TABLET [LIPOFEN] ![Compare how all Medicare Part D PDP plans in AL cover FENOFIBRATE 160 MG TABLET [LIPOFEN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
FENOFIBRATE 200 MG CAPSULE [LIPOFEN] ![Compare how all Medicare Part D PDP plans in AL cover FENOFIBRATE 200 MG CAPSULE [LIPOFEN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
FENOFIBRATE 48 MG TABLET [Tricor] ![Compare how all Medicare Part D PDP plans in AL cover FENOFIBRATE 48 MG TABLET [Tricor].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
FENOFIBRATE 54 MG 90 TABLET BOTTLE [LIPOFEN] ![Compare how all Medicare Part D PDP plans in AL cover FENOFIBRATE 54 MG 90 TABLET BOTTLE [LIPOFEN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENOFIBRATE 67MG CAPSULE [LIPOFEN] ![Compare how all Medicare Part D PDP plans in AL cover FENOFIBRATE 67MG CAPSULE [LIPOFEN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
FENTANYL 100 MCG/HR PATCH TD72 [Duragesic] ![Compare how all Medicare Part D PDP plans in AL cover FENTANYL 100 MCG/HR PATCH TD72 [Duragesic].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
42% | 42% | P Q:10 /30Days |
FENTANYL 12 MCG/HR PATCH TD72 [Duragesic] ![Compare how all Medicare Part D PDP plans in AL cover FENTANYL 12 MCG/HR PATCH TD72 [Duragesic].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
42% | 42% | P Q:10 /30Days |
FENTANYL 25 MCG/HR PATCH TD72 [Duragesic] ![Compare how all Medicare Part D PDP plans in AL cover FENTANYL 25 MCG/HR PATCH TD72 [Duragesic].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
42% | 42% | P Q:10 /30Days |
FENTANYL 50 MCG/HR PATCH TD72 [Duragesic] ![Compare how all Medicare Part D PDP plans in AL cover FENTANYL 50 MCG/HR PATCH TD72 [Duragesic].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
42% | 42% | P Q:10 /30Days |
FENTANYL 75 MCG/HR PATCH TD72 [Duragesic] ![Compare how all Medicare Part D PDP plans in AL cover FENTANYL 75 MCG/HR PATCH TD72 [Duragesic].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
42% | 42% | P Q:10 /30Days |
FENTANYL CITRATE OTFC 1,200 MCG [Actiq] ![Compare how all Medicare Part D PDP plans in AL cover FENTANYL CITRATE OTFC 1,200 MCG [Actiq].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
FENTANYL CITRATE OTFC 1,600 MCG [Actiq] ![Compare how all Medicare Part D PDP plans in AL cover FENTANYL CITRATE OTFC 1,600 MCG [Actiq].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
FENTANYL CITRATE OTFC 200 MCG [Actiq] ![Compare how all Medicare Part D PDP plans in AL cover FENTANYL CITRATE OTFC 200 MCG [Actiq].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
FENTANYL CITRATE OTFC 400 MCG [Actiq] ![Compare how all Medicare Part D PDP plans in AL cover FENTANYL CITRATE OTFC 400 MCG [Actiq].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
FENTANYL CITRATE OTFC 600 MCG [Actiq] ![Compare how all Medicare Part D PDP plans in AL cover FENTANYL CITRATE OTFC 600 MCG [Actiq].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
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 800 MCG [Actiq] ![Compare how all Medicare Part D PDP plans in AL cover FENTANYL CITRATE OTFC 800 MCG [Actiq].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
FENTORA TABLET 100MCG  |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
FENTORA TABLET 200MCG  |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
FENTORA TABLET 400MCG  |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
FENTORA TABLET 600MCG  |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
FENTORA TABLET 800MCG  |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
FETZIMA 20-40 MG TITRATION PAK  |
4 |
Non-Preferred Drug |
42% | 42% | P |
FETZIMA ER 120 MG CAPSULE  |
4 |
Non-Preferred Drug |
42% | 42% | P Q:30 /30Days |
FETZIMA ER 20 MG CAPSULE  |
4 |
Non-Preferred Drug |
42% | 42% | P Q:180 /30Days |
FETZIMA ER 40 MG CAPSULE  |
4 |
Non-Preferred Drug |
42% | 42% | P Q:90 /30Days |
FETZIMA ER 80 MG CAPSULE  |
4 |
Non-Preferred Drug |
42% | 42% | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FIASP 100 UNIT/ML FLEXTOUCH INSULN PEN  |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
FIASP 100 UNIT/ML VIAL  |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
FINASTERIDE 5 MG TABLET  |
2 |
Generic |
$1.00 | $2.50 | None |
FIRAZYR 30 MG/3 ML SYRINGE  |
5 |
Specialty Tier |
25% | N/A | P Q:27 /30Days |
FLAC OTIC OIL 0.01% EAR DROPS [Flac] ![Compare how all Medicare Part D PDP plans in AL cover FLAC OTIC OIL 0.01% EAR DROPS [Flac].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$1.00 | $2.50 | None |
FLEBOGAMMA DIF INJECTION  |
5 |
Specialty Tier |
25% | N/A | P |
FLECAINIDE ACETATE 100 MG TAB  |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
FLECAINIDE ACETATE 150 MG TAB  |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
FLECAINIDE ACETATE 50 MG TAB  |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
FLOVENT DISKUS 100ug/1 60 POWDER, METERED in 1 INHALER  |
3 |
Preferred Brand |
$37.00 | $92.50 | Q:120 /30Days |
FLOVENT DISKUS 250ug/1 60 POWDER, METERED in 1 INHALER  |
3 |
Preferred Brand |
$37.00 | $92.50 | Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLOVENT DISKUS POWDER 50MCG 60 CTR  |
3 |
Preferred Brand |
$37.00 | $92.50 | Q:120 /30Days |
FLOVENT HFA 110ug/1 120 AEROSOL, METERED in 1 INHALER  |
3 |
Preferred Brand |
$37.00 | $92.50 | Q:24 /30Days |
FLOVENT HFA 220ug/1 120 AEROSOL, METERED in 1 INHALER  |
3 |
Preferred Brand |
$37.00 | $92.50 | Q:24 /30Days |
FLOVENT HFA 44ug/1 120 AEROSOL, METERED in 1 INHALER  |
3 |
Preferred Brand |
$37.00 | $92.50 | Q:21 /30Days |
FLUCONAZOLE 10 MG/ML SUSP  |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
FLUCONAZOLE 100 MG TABLET  |
2 |
Generic |
$1.00 | $2.50 | None |
FLUCONAZOLE 150 MG TABLET  |
2 |
Generic |
$1.00 | $2.50 | None |
FLUCONAZOLE 200 MG TABLET  |
2 |
Generic |
$1.00 | $2.50 | None |
FLUCONAZOLE 40 MG/ML SUSP  |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
Fluconazole 50mg/1 30 TABLET BOTTLE  |
2 |
Generic |
$1.00 | $2.50 | None |
FLUCONAZOLE-NACL 200 MG/100 ML  |
4 |
Non-Preferred Drug |
42% | 42% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUCONAZOLE-NACL 400 MG/200 ML  |
4 |
Non-Preferred Drug |
42% | 42% | None |
FLUCYTOSINE 250 MG CAPSULE [Ancobon] ![Compare how all Medicare Part D PDP plans in AL cover FLUCYTOSINE 250 MG CAPSULE [Ancobon].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | None |
FLUCYTOSINE 500 MG CAPSULE [Ancobon] ![Compare how all Medicare Part D PDP plans in AL cover FLUCYTOSINE 500 MG CAPSULE [Ancobon].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | None |
FLUDROCORTISONE 0.1 MG TABLET  |
2 |
Generic |
$1.00 | $2.50 | None |
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL  |
3 |
Preferred Brand |
$37.00 | $92.50 | Q:75 /30Days |
FLUOCINOLONE 0.01% SOLUTION  |
4 |
Non-Preferred Drug |
42% | 42% | None |
FLUOCINOLONE OIL 0.01% EAR DRP  |
2 |
Generic |
$1.00 | $2.50 | None |
FLUOCINONIDE 0.05% GEL  |
4 |
Non-Preferred Drug |
42% | 42% | None |
FLUOCINONIDE 0.05% SOLUTION  |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
FLUOCINONIDE-E 0.05% CREAM  |
4 |
Non-Preferred Drug |
42% | 42% | None |
Fluorometholone 0.1% drops  |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOROURACIL 2% TOPICAL SOLN  |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
FLUOROURACIL 5% TOP SOLUTION  |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
FLUOROURACIL CREA 5%  |
4 |
Non-Preferred Drug |
42% | 42% | None |
Fluoxetine 20mg/5mL 120 mL in 1 BOTTLE, PLASTIC  |
2 |
Generic |
$1.00 | $2.50 | None |
FLUOXETINE CAPSULES 10MG (100 CT)  |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
FLUOXETINE HCL 20 MG CAPSULE  |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
FLUOXETINE HCL 40 MG CAPSULE  |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
FLUPHENAZINE 1 MG TABLET  |
4 |
Non-Preferred Drug |
42% | 42% | None |
FLUPHENAZINE 10 MG TABLET  |
4 |
Non-Preferred Drug |
42% | 42% | None |
FLUPHENAZINE 2.5 MG TABLET  |
4 |
Non-Preferred Drug |
42% | 42% | None |
FLUPHENAZINE 2.5 MG/5 ML ELIX  |
4 |
Non-Preferred Drug |
42% | 42% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUPHENAZINE 2.5MG/ML VIAL  |
4 |
Non-Preferred Drug |
42% | 42% | None |
FLUPHENAZINE 5 MG TABLET  |
4 |
Non-Preferred Drug |
42% | 42% | None |
FLUPHENAZINE 5MG/ML CONC  |
4 |
Non-Preferred Drug |
42% | 42% | None |
FLUPHENAZINE DEC 125 MG/5 ML  |
4 |
Non-Preferred Drug |
42% | 42% | None |
FLURBIPROFEN 0.03% EYE DROPS [Ocufen] ![Compare how all Medicare Part D PDP plans in AL cover FLURBIPROFEN 0.03% EYE DROPS [Ocufen].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$1.00 | $2.50 | None |
Flurbiprofen 100mg/1 100 BOTTLE in 1 BOTTLE / 100 FILM COATED TABLETS in BOTTLE  |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
FLURBIPROFEN 50MG TABLET  |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
FLUTAMIDE 125 MG CAPSULE  |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
Fluticasone Propionate 0.05mg/g 1 TUBE per CARTON / 30 g in 1 TUBE  |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
Fluticasone Propionate 0.5mg/g 1 TUBE per CARTON / 30 g in 1 TUBE  |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
FLUTICASONE PROPIONATE 50MCG SPRAY SUSPENSION  |
2 |
Generic |
$1.00 | $2.50 | Q:16 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUVOXAMINE MALEATE 100MG TABLET  |
2 |
Generic |
$1.00 | $2.50 | None |
Fluvoxamine Maleate 25mg/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 FILM COATED TABLETS in  |
2 |
Generic |
$1.00 | $2.50 | None |
Fluvoxamine maleate 50mg/1 100 FILM COATED TABLETS in BOTTLE  |
2 |
Generic |
$1.00 | $2.50 | None |
Fondaparinux Sodium 10mg/0.8mL 2 SYRINGES per CARTON / 0.8 mL in 1 SYRINGE [Arixtra] ![Compare how all Medicare Part D PDP plans in AL cover Fondaparinux Sodium 10mg/0.8mL 2 SYRINGES per CARTON / 0.8 mL in 1 SYRINGE [Arixtra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | None |
Fondaparinux Sodium 2.5mg/0.5mL 2 SYRINGES per CARTON / 0.5 mL in 1 SYRINGE [Arixtra] ![Compare how all Medicare Part D PDP plans in AL cover Fondaparinux Sodium 2.5mg/0.5mL 2 SYRINGES per CARTON / 0.5 mL in 1 SYRINGE [Arixtra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
42% | 42% | None |
Fondaparinux Sodium 5mg/4mL 2 SYRINGES per CARTON / 0.4 mL in 1 SYRINGE [Arixtra] ![Compare how all Medicare Part D PDP plans in AL cover Fondaparinux Sodium 5mg/4mL 2 SYRINGES per CARTON / 0.4 mL in 1 SYRINGE [Arixtra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | None |
Fondaparinux Sodium 7.5mg/0.6mL 2 SYRINGES per CARTON / 0.6 mL in 1 SYRINGE [Arixtra] ![Compare how all Medicare Part D PDP plans in AL cover Fondaparinux Sodium 7.5mg/0.6mL 2 SYRINGES per CARTON / 0.6 mL in 1 SYRINGE [Arixtra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | None |
Forteo 250ug/mL 1 SYRINGE per CARTON / 2.4 mL in 1 SYRINGE  |
5 |
Specialty Tier |
25% | N/A | P |
FOSAMPRENAVIR 700 MG TABLET [Lexiva] ![Compare how all Medicare Part D PDP plans in AL cover FOSAMPRENAVIR 700 MG TABLET [Lexiva].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | 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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FOSINOPRIL SODIUM 40 MG TAB  |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
FOSINOPRIL-HCTZ 10-12.5 MG TAB  |
2 |
Generic |
$1.00 | $2.50 | None |
FOSINOPRIL-HCTZ 20-12.5 MG TAB  |
2 |
Generic |
$1.00 | $2.50 | None |
FREAMINE HBC INJECTION  |
4 |
Non-Preferred Drug |
42% | 42% | P |
FUROSEMIDE 10 MG/ML SOLUTION  |
2 |
Generic |
$1.00 | $2.50 | None |
Furosemide 10 ML 10 MG/ML Injection  |
4 |
Non-Preferred Drug |
42% | 42% | 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 |
42% | 42% | None |
FUROSEMIDE 20 MG TABLET  |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
FUROSEMIDE 40 MG TABLET  |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
FUROSEMIDE 40MG/5ML TUBEX  |
2 |
Generic |
$1.00 | $2.50 | None |
FUROSEMIDE 80 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 |
FUZEON 90 MG VIAL  |
5 |
Specialty Tier |
25% | N/A | None |
FYAVOLV 1 MG-5 MCG TABLET  |
3 |
Preferred Brand |
$37.00 | $92.50 | None |
FYCOMPA 0.5 MG/ML ORAL SUSP  |
4 |
Non-Preferred Drug |
42% | 42% | P Q:720 /30Days |
FYCOMPA 10 MG TABLET  |
4 |
Non-Preferred Drug |
42% | 42% | P Q:30 /30Days |
FYCOMPA 12 MG TABLET  |
4 |
Non-Preferred Drug |
42% | 42% | P Q:30 /30Days |
FYCOMPA 2 MG TABLET  |
4 |
Non-Preferred Drug |
42% | 42% | P Q:60 /30Days |
FYCOMPA 4 MG TABLET  |
4 |
Non-Preferred Drug |
42% | 42% | P Q:60 /30Days |
FYCOMPA 6 MG TABLET  |
4 |
Non-Preferred Drug |
42% | 42% | P Q:60 /30Days |
FYCOMPA 8 MG TABLET  |
4 |
Non-Preferred Drug |
42% | 42% | P Q:30 /30Days |