2020 Medicare Part D Plan Formulary Information |
Express Scripts Medicare - Choice (PDP) (S5660-181-0)
Benefit Details
|
The Express Scripts Medicare - Choice (PDP) (S5660-181-0) Formulary Drugs Starting with the Letter F in CMS PDP Region 11 which includes: FL Plan Monthly Premium: $87.60 Deductible: $250 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 |
FALMINA-28 TABLET |
2* |
Generic |
$7.00 | $4.00 | None |
FAMCICLOVIR 125 MG TABLET |
2* |
Generic |
$7.00 | $4.00 | Q:60 /30Days |
FAMCICLOVIR 250 MG TABLET |
2* |
Generic |
$7.00 | $4.00 | Q:60 /30Days |
FAMCICLOVIR 500 MG TABLET |
2* |
Generic |
$7.00 | $4.00 | Q:21 /30Days |
FAMOTIDINE 20 MG TABLET |
2* |
Generic |
$7.00 | $4.00 | None |
FAMOTIDINE 40 MG TABLET |
2* |
Generic |
$7.00 | $4.00 | None |
FAMOTIDINE 50 MG/5MLFOR ORAL SUSPENSION |
2* |
Generic |
$7.00 | $4.00 | None |
FANAPT 1 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | Q:60 /30Days |
FANAPT 10 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | Q:60 /30Days |
FANAPT 12 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FANAPT 2 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | Q:60 /30Days |
FANAPT 4 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | Q:60 /30Days |
FANAPT 6 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | Q:60 /30Days |
FANAPT 8 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | Q:60 /30Days |
FANAPT TITR TABLETS |
4 |
Non-Preferred Drug |
46% | N/A | Q:8 /28Days |
FARXIGA 10 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | Q:30 /30Days |
FARXIGA 5 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | Q:60 /30Days |
FARYDAK 10 MG CAPSULE |
5 |
Specialty Tier |
28% | N/A | P Q:6 /21Days |
FARYDAK 20 MG CAPSULE |
5 |
Specialty Tier |
28% | N/A | P Q:6 /21Days |
FASENRA 30 MG/ML SYRINGE |
5 |
Specialty Tier |
28% | N/A | P |
FAYOSIM TABLET TBDSPK 3MO [Quartette] |
2* |
Generic |
$7.00 | $4.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FEBUXOSTAT 40 MG TABLET [Uloric] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
FEBUXOSTAT 80 MG TABLET [Uloric] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
FELBAMATE 400 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | None |
FELBAMATE 600 MG TABLET [Felbatol] |
4 |
Non-Preferred Drug |
46% | N/A | None |
FELBAMATE 600 MG/5 ML ORAL SUSPENSION [Felbatol] |
4 |
Non-Preferred Drug |
46% | N/A | None |
FELODIPINE ER 10 MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
FELODIPINE ER 2.5 MG TABLET ER 24H [Plendil] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
FELODIPINE ER 5 MG TABLET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
FEMYNOR 28 TABLET [VyLibra] |
2* |
Generic |
$7.00 | $4.00 | None |
FENOFIBRATE 134MG CAPSULE [LIPOFEN] |
2* |
Generic |
$7.00 | $4.00 | Q:30 /30Days |
FENOFIBRATE 145 MG TABLET [Tricor] |
2* |
Generic |
$7.00 | $4.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENOFIBRATE 160 MG TABLET [LIPOFEN] |
2* |
Generic |
$7.00 | $4.00 | Q:30 /30Days |
FENOFIBRATE 200 MG CAPSULE [LIPOFEN] |
2* |
Generic |
$7.00 | $4.00 | Q:30 /30Days |
FENOFIBRATE 48 MG TABLET [Tricor] |
2* |
Generic |
$7.00 | $4.00 | Q:60 /30Days |
FENOFIBRATE 50 MG ORAL CAPSULE [LIPOFEN] |
4 |
Non-Preferred Drug |
46% | N/A | None |
FENOFIBRATE 54 MG 90 TABLET BOTTLE [LIPOFEN] |
2* |
Generic |
$7.00 | $4.00 | Q:60 /30Days |
FENOFIBRATE 67MG CAPSULE [LIPOFEN] |
2* |
Generic |
$7.00 | $4.00 | Q:60 /30Days |
FENOFIBRIC ACID DR 135 MG CAPSULE [TRILIPIX] |
2* |
Generic |
$7.00 | $4.00 | None |
FENOFIBRIC ACID DR 45 MG CAPSULE DR [Trilipix] |
2* |
Generic |
$7.00 | $4.00 | None |
FENTANYL 100 MCG/HR PATCH TD72 [Duragesic] |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:10 /30Days |
FENTANYL 12 MCG/HR PATCH TD72 [Duragesic] |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:10 /30Days |
FENTANYL 25 MCG/HR PATCH TD72 [Duragesic] |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:10 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENTANYL 50 MCG/HR PATCH TD72 [Duragesic] |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:10 /30Days |
FENTANYL 75 MCG/HR PATCH TD72 [Duragesic] |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:10 /30Days |
FENTANYL CIT OTFC 1,200 MCG LOZENGE HD [Actiq] |
5 |
Specialty Tier |
28% | N/A | P Q:120 /30Days |
FENTANYL CIT OTFC 1,600 MCG LOZENGE HD [Actiq] |
5 |
Specialty Tier |
28% | N/A | P Q:120 /30Days |
FENTANYL CITRATE OTFC 200 MCG LOZENGE HD [Actiq] |
5 |
Specialty Tier |
28% | N/A | P Q:120 /30Days |
FENTANYL CITRATE OTFC 400 MCG LOZENGE HD [Actiq] |
5 |
Specialty Tier |
28% | N/A | P Q:120 /30Days |
FENTANYL CITRATE OTFC 600 MCG LOZENGE HD [Actiq] |
5 |
Specialty Tier |
28% | N/A | P Q:120 /30Days |
FENTANYL CITRATE OTFC 800 MCG LOZENGE HD [Actiq] |
5 |
Specialty Tier |
28% | N/A | P Q:120 /30Days |
FERRIPROX 1,000 MG TABLET |
5 |
Specialty Tier |
28% | N/A | P |
FERRIPROX 500 MG TABLET |
5 |
Specialty Tier |
28% | N/A | P |
FETZIMA 20-40 MG TITRATION PAK |
4 |
Non-Preferred Drug |
46% | N/A | S Q:28 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FETZIMA ER 120 MG CAPSULE |
4 |
Non-Preferred Drug |
46% | N/A | S Q:30 /30Days |
FETZIMA ER 20 MG CAPSULE |
4 |
Non-Preferred Drug |
46% | N/A | S Q:30 /30Days |
FETZIMA ER 40 MG CAPSULE |
4 |
Non-Preferred Drug |
46% | N/A | S Q:30 /30Days |
FETZIMA ER 80 MG CAPSULE |
4 |
Non-Preferred Drug |
46% | N/A | S Q:30 /30Days |
FINASTERIDE 5 MG TABLET [Proscar] |
2* |
Generic |
$7.00 | $4.00 | Q:30 /30Days |
FIRAZYR 30 MG/3 ML SYRINGE |
5 |
Specialty Tier |
28% | N/A | P Q:270 /30Days |
FIRDAPSE 10 MG TABLET |
5 |
Specialty Tier |
28% | N/A | P |
FIRMAGON 2 X 120 MG KIT |
4 |
Non-Preferred Drug |
46% | N/A | P |
FIRMAGON 80 MG KIT |
4 |
Non-Preferred Drug |
46% | N/A | P |
FLAC OTIC OIL 0.01% EAR DROPS [Flac] |
4 |
Non-Preferred Drug |
46% | N/A | None |
FLECAINIDE ACETATE 100 MG TABLET [Tambocor] |
2* |
Generic |
$7.00 | $4.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLECAINIDE ACETATE 150 MG TABLET [Tambocor] |
2* |
Generic |
$7.00 | $4.00 | None |
FLECAINIDE ACETATE 50 MG TABLET [Tambocor] |
2* |
Generic |
$7.00 | $4.00 | None |
FLOVENT DISKUS 100ug/1 60 POWDER, METERED in 1 INHALER |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:60 /30Days |
FLOVENT DISKUS 250ug/1 60 POWDER, METERED in 1 INHALER |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:240 /30Days |
FLOVENT DISKUS POWDER 50MCG 60 CTR |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:60 /30Days |
FLOVENT HFA 110ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:12 /30Days |
FLOVENT HFA 220ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:24 /30Days |
FLOVENT HFA 44ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:11 /30Days |
FLUCONAZOLE 10 MG/ML ORAL SUSPENSION [Diflucan] |
2* |
Generic |
$7.00 | $4.00 | None |
FLUCONAZOLE 100 MG TABLET [Diflucan] |
2* |
Generic |
$7.00 | $4.00 | None |
FLUCONAZOLE 150 MG TABLET [Diflucan] |
2* |
Generic |
$7.00 | $4.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUCONAZOLE 200 MG TABLET [Diflucan] |
2* |
Generic |
$7.00 | $4.00 | None |
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION [Diflucan] |
2* |
Generic |
$7.00 | $4.00 | None |
FLUCONAZOLE 50 MG TABLET [Diflucan] |
2* |
Generic |
$7.00 | $4.00 | None |
FLUCONAZOLE-NACL 200 MG/100 ML PIGGYBACK [Diflucan] |
2* |
Generic |
$7.00 | $4.00 | P |
FLUCONAZOLE-NACL 400 MG/200 ML PIGGYBACK [Diflucan] |
2* |
Generic |
$7.00 | $4.00 | P |
FLUCYTOSINE 250 MG CAPSULE [Ancobon] |
5 |
Specialty Tier |
28% | N/A | None |
FLUCYTOSINE 500 MG CAPSULE [Ancobon] |
5 |
Specialty Tier |
28% | N/A | None |
FLUDROCORTISONE 0.1 MG TABLET |
2* |
Generic |
$7.00 | $4.00 | None |
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:50 /30Days |
FLUOCINOLONE 0.01% CREAM (g) |
4 |
Non-Preferred Drug |
46% | N/A | None |
FLUOCINOLONE 0.01% SCALP OIL [Derma-Smoothe/FS] |
4 |
Non-Preferred Drug |
46% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOCINOLONE 0.01% SOLUTION [Synalar] |
4 |
Non-Preferred Drug |
46% | N/A | None |
FLUOCINOLONE 0.025% CREAM (g) [Synalar] |
4 |
Non-Preferred Drug |
46% | N/A | None |
FLUOCINOLONE 0.025% OINTMENT |
4 |
Non-Preferred Drug |
46% | N/A | None |
FLUOCINOLONE OIL 0.01% EAR DROPS [Flac] |
4 |
Non-Preferred Drug |
46% | N/A | None |
FLUOCINONIDE 0.05% GEL |
2* |
Generic |
$7.00 | $4.00 | Q:120 /30Days |
FLUOCINONIDE 0.05% OINTMENT [Lidex] |
2* |
Generic |
$7.00 | $4.00 | Q:120 /30Days |
FLUOCINONIDE 0.05% SOLUTION |
2* |
Generic |
$7.00 | $4.00 | Q:120 /30Days |
FLUOCINONIDE 0.1% CREAM (g) [Vanos] |
4 |
Non-Preferred Drug |
46% | N/A | Q:120 /30Days |
FLUOCINONIDE-E 0.05% CREAM |
2* |
Generic |
$7.00 | $4.00 | Q:120 /30Days |
Fluorometholone 0.1% drops |
2* |
Generic |
$7.00 | $4.00 | None |
FLUOROURACIL 2% TOPICAL SOLUTION |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOROURACIL 5% CREAM (g) [Efudex] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
FLUOROURACIL 5% TOPICAL SOLUTION |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
Fluoxetine 20mg/5mL 120 mL in 1 BOTTLE, PLASTIC |
2* |
Generic |
$7.00 | $4.00 | None |
FLUOXETINE HCL 10 MG CAPSULE [Selfemra] |
1* |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days |
FLUOXETINE HCL 10 MG TABLET [Sarafem] |
2* |
Generic |
$7.00 | $4.00 | Q:30 /30Days |
FLUOXETINE HCL 20 MG CAPSULE |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
FLUOXETINE HCL 20 MG TABLET [Sarafem] |
2* |
Generic |
$7.00 | $4.00 | None |
FLUOXETINE HCL 40 MG CAPSULE [Prozac] |
1* |
Preferred Generic |
$2.00 | $0.00 | Q:60 /30Days |
FLUOXETINE HCL 60 MG TABLET |
2* |
Generic |
$7.00 | $4.00 | None |
FLUPHENAZINE 1 MG TABLET |
2* |
Generic |
$7.00 | $4.00 | None |
FLUPHENAZINE 10 MG TABLET [Prolixin] |
2* |
Generic |
$7.00 | $4.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUPHENAZINE 2.5 MG TABLET |
2* |
Generic |
$7.00 | $4.00 | None |
FLUPHENAZINE 2.5 MG/5 ML ELIX |
2* |
Generic |
$7.00 | $4.00 | None |
FLUPHENAZINE 2.5MG/ML VIAL |
2* |
Generic |
$7.00 | $4.00 | None |
FLUPHENAZINE 5 MG TABLET |
2* |
Generic |
$7.00 | $4.00 | None |
FLUPHENAZINE 5MG/ML CONC |
2* |
Generic |
$7.00 | $4.00 | None |
FLUPHENAZINE DEC 125 MG/5 ML VIAL [Prolixin Decanoate] |
2* |
Generic |
$7.00 | $4.00 | None |
FLURBIPROFEN 0.03% EYE DROPS [Ocufen] |
2* |
Generic |
$7.00 | $4.00 | None |
Flurbiprofen 100mg/1 100 BOTTLE in 1 BOTTLE / 100 FILM COATED TABLETS in BOTTLE |
2* |
Generic |
$7.00 | $4.00 | None |
FLUTAMIDE 125 MG CAPSULE |
2* |
Generic |
$7.00 | $4.00 | None |
FLUTICASONE PROP 0.005% OINTMENT [Cutivate] |
2* |
Generic |
$7.00 | $4.00 | None |
Fluticasone Propionate 0.5mg/g 1 TUBE per CARTON / 30 g in 1 TUBE |
2* |
Generic |
$7.00 | $4.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUTICASONE PROPIONATE 50 MCG SPRAY SUSPENSION |
2* |
Generic |
$7.00 | $4.00 | Q:16 /30Days |
FLUVASTATIN SODIUM 20 MG CAPSULE [Lescol] |
2* |
Generic |
$7.00 | $4.00 | Q:30 /30Days |
FLUVASTATIN SODIUM 40 MG CAPSULE [Lescol] |
2* |
Generic |
$7.00 | $4.00 | Q:60 /30Days |
FLUVOXAMINE MALEATE 100 MG TABLET [Luvox] |
4 |
Non-Preferred Drug |
46% | N/A | Q:90 /30Days |
FLUVOXAMINE MALEATE 25 MG TABLET [Luvox] |
4 |
Non-Preferred Drug |
46% | N/A | Q:30 /30Days |
FLUVOXAMINE MALEATE 50 MG TABLET [Luvox] |
4 |
Non-Preferred Drug |
46% | N/A | Q:60 /30Days |
FONDAPARINUX 10 MG/0.8 ML SYRINGE [Arixtra] |
5 |
Specialty Tier |
28% | N/A | None |
FONDAPARINUX 2.5 MG/0.5 ML SYRINGE [Arixtra] |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
FONDAPARINUX 5 MG/0.4 ML SYRINGE [Arixtra] |
5 |
Specialty Tier |
28% | N/A | None |
FONDAPARINUX 7.5 MG/0.6 ML SYRINGE [Arixtra] |
5 |
Specialty Tier |
28% | N/A | None |
FORFIVO XL 450 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FOSAMPRENAVIR 700 MG TABLET [Lexiva] |
5 |
Specialty Tier |
28% | N/A | Q:120 /30Days |
FOSINOPRIL SODIUM 10 MG TABLET |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
FOSINOPRIL SODIUM 20 MG TABLET |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
FOSINOPRIL SODIUM 40 MG TABLET |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
FOSINOPRIL-HCTZ 10-12.5 MG TABLET [Monopril-HCT] |
2* |
Generic |
$7.00 | $4.00 | None |
FOSINOPRIL-HCTZ 20-12.5 MG TABLET [Monopril-HCT] |
2* |
Generic |
$7.00 | $4.00 | None |
FRAGMIN 2,500 UNITS SYRINGE |
4 |
Non-Preferred Drug |
46% | N/A | None |
FRAGMIN 5,000 UNITS SYRINGE |
4 |
Non-Preferred Drug |
46% | N/A | None |
FRAGMIN 95,000 UNITS/3.8 ML VIAL |
4 |
Non-Preferred Drug |
46% | N/A | None |
FREAMINE HBC INJECTION |
3 |
Preferred Brand |
$42.00 | $126.00 | P |
FUROSEMIDE 10 MG/ML SOLUTION |
2* |
Generic |
$7.00 | $4.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FUROSEMIDE 100 MG/10 ML VIAL |
2* |
Generic |
$7.00 | $4.00 | None |
Furosemide 10mg/mL 10 CARTON in 1 CONTAINER / 1 SYRINGE, PLASTIC in 1 CARTON / 4 mL in 1 SYRINGE, P |
2* |
Generic |
$7.00 | $4.00 | None |
FUROSEMIDE 20 MG TABLET |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
FUROSEMIDE 40 MG TABLET [Lasix] |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
FUROSEMIDE 40MG/5ML TUBEX |
2* |
Generic |
$7.00 | $4.00 | None |
FUROSEMIDE 80 MG TABLET |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
FUZEON 90 MG VIAL |
5 |
Specialty Tier |
28% | N/A | Q:60 /30Days |
FYCOMPA 0.5 MG/ML ORAL SUSP |
4 |
Non-Preferred Drug |
46% | N/A | P Q:720 /30Days |
FYCOMPA 10 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | P Q:30 /30Days |
FYCOMPA 12 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | P Q:30 /30Days |
FYCOMPA 2 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FYCOMPA 4 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | P Q:60 /30Days |
FYCOMPA 6 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | P Q:60 /30Days |
FYCOMPA 8 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | P Q:30 /30Days |