2022 Medicare Part D Plan Formulary Information |
Mutual of Omaha Rx Plus (PDP) (S7126-010-0)
Benefit Details
|
The Mutual of Omaha Rx Plus (PDP) (S7126-010-0) Formulary Drugs Starting with the Letter F in CMS PDP Region 11 which includes: FL
|
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 |
41% | N/A | Q:60 /30Days |
FAMCICLOVIR 250 MG TABLET [Famvir] |
4 |
Non-Preferred Drug |
41% | N/A | Q:60 /30Days |
FAMCICLOVIR 500 MG TABLET [Famvir] |
4 |
Non-Preferred Drug |
41% | N/A | Q:21 /30Days |
FAMOTIDINE 20 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | None |
FAMOTIDINE 40 MG TABLET |
2 |
Generic |
$3.00 | $9.00 | None |
FAMOTIDINE 50 MG/5MLFOR ORAL SUSPENSION |
4 |
Non-Preferred Drug |
41% | N/A | None |
FANAPT 1 MG TABLET |
4 |
Non-Preferred Drug |
41% | N/A | Q:60 /30Days |
FANAPT 10 MG TABLET |
4 |
Non-Preferred Drug |
41% | N/A | Q:60 /30Days |
FANAPT 12 MG TABLET |
4 |
Non-Preferred Drug |
41% | N/A | Q:60 /30Days |
FANAPT 2 MG TABLET |
4 |
Non-Preferred Drug |
41% | N/A | 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 |
41% | N/A | Q:60 /30Days |
FANAPT 6 MG TABLET |
4 |
Non-Preferred Drug |
41% | N/A | Q:60 /30Days |
FANAPT 8 MG TABLET |
4 |
Non-Preferred Drug |
41% | N/A | Q:60 /30Days |
FANAPT TITR TABLETS |
4 |
Non-Preferred Drug |
41% | N/A | Q:8 /28Days |
FARXIGA 10 MG TABLET |
3 |
Preferred Brand |
18% | 18% | Q:30 /30Days |
FARXIGA 5 MG TABLET |
3 |
Preferred Brand |
18% | 18% | Q:60 /30Days |
FASENRA 30 MG/ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P Q:1 /28Days |
FASENRA PEN 30 MG/ML AUTO INJCT |
5 |
Specialty Tier |
25% | N/A | P Q:1 /28Days |
FEBUXOSTAT 40 MG TABLET [Uloric] |
3 |
Preferred Brand |
18% | 18% | None |
FEBUXOSTAT 80 MG TABLET [Uloric] |
3 |
Preferred Brand |
18% | 18% | None |
FELBAMATE 400 MG TABLET |
4 |
Non-Preferred Drug |
41% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FELBAMATE 600 MG TABLET [Felbatol] |
4 |
Non-Preferred Drug |
41% | N/A | None |
FELBAMATE 600 MG/5 ML ORAL SUSPENSION [Felbatol] |
4 |
Non-Preferred Drug |
41% | N/A | None |
FELODIPINE ER 10 MG TABLET |
3 |
Preferred Brand |
18% | 18% | None |
FELODIPINE ER 2.5 MG TABLET ER 24H [Plendil] |
3 |
Preferred Brand |
18% | 18% | None |
FELODIPINE ER 5 MG TABLET |
3 |
Preferred Brand |
18% | 18% | None |
FEMYNOR 28 TABLET [VyLibra] |
4 |
Non-Preferred Drug |
41% | N/A | None |
FENOFIBRATE 134 MG CAPSULE [Tricor] |
3 |
Preferred Brand |
18% | 18% | Q:30 /30Days |
FENOFIBRATE 145 MG TABLET [Tricor] |
3 |
Preferred Brand |
18% | 18% | Q:30 /30Days |
FENOFIBRATE 160 MG TABLET [Triglide] |
3 |
Preferred Brand |
18% | 18% | Q:30 /30Days |
FENOFIBRATE 200 MG CAPSULE [Tricor] |
3 |
Preferred Brand |
18% | 18% | Q:30 /30Days |
FENOFIBRATE 48 MG TABLET [Tricor] |
3 |
Preferred Brand |
18% | 18% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENOFIBRATE 54 MG 90 TABLET BOTTLE [LIPOFEN] |
3 |
Preferred Brand |
18% | 18% | Q:60 /30Days |
FENOFIBRATE 67 MG CAPSULE [Tricor] |
3 |
Preferred Brand |
18% | 18% | Q:60 /30Days |
FENTANYL 100 MCG/HR PATCH TD72 [Duragesic] |
4 |
Non-Preferred Drug |
41% | N/A | P Q:10 /30Days |
FENTANYL 12 MCG/HR PATCH TD72 [Duragesic] |
4 |
Non-Preferred Drug |
41% | N/A | P Q:10 /30Days |
FENTANYL 25 MCG/HR PATCH TD72 [Duragesic] |
4 |
Non-Preferred Drug |
41% | N/A | P Q:10 /30Days |
FENTANYL 50 MCG/HR PATCH TD72 [Duragesic] |
4 |
Non-Preferred Drug |
41% | N/A | P Q:10 /30Days |
FENTANYL 75 MCG/HR PATCH TD72 [Duragesic] |
4 |
Non-Preferred Drug |
41% | N/A | P Q:10 /30Days |
FENTANYL CIT OTFC 1,200 MCG LOZENGE HD [Actiq] |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
FENTANYL CIT OTFC 1,600 MCG LOZENGE HD [Actiq] |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
FENTANYL CITRATE OTFC 200 MCG LOZENGE HD [Actiq] |
4 |
Non-Preferred Drug |
41% | N/A | P Q:120 /30Days |
FENTANYL CITRATE OTFC 400 MCG LOZENGE HD [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 600 MCG LOZENGE HD [Actiq] |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
FENTANYL CITRATE OTFC 800 MCG LOZENGE HD [Actiq] |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
FESOTERODINE ER 4 MG TABLET 24H [Toviaz] |
3 |
Preferred Brand |
18% | 18% | None |
FESOTERODINE ER 8 MG TABLET 24H [Toviaz] |
3 |
Preferred Brand |
18% | 18% | None |
FETZIMA 20-40 MG TITRATION PAK |
3 |
Preferred Brand |
18% | 18% | Q:28 /28Days |
FETZIMA ER 120 MG CAPSULE |
3 |
Preferred Brand |
18% | 18% | Q:30 /30Days |
FETZIMA ER 20 MG CAPSULE |
3 |
Preferred Brand |
18% | 18% | Q:30 /30Days |
FETZIMA ER 40 MG CAPSULE |
3 |
Preferred Brand |
18% | 18% | Q:30 /30Days |
FETZIMA ER 80 MG CAPSULE |
3 |
Preferred Brand |
18% | 18% | Q:30 /30Days |
FINASTERIDE 5 MG TABLET [Proscar] |
2 |
Generic |
$3.00 | $9.00 | Q:30 /30Days |
FINTEPLA 2.2 MG/ML SOLUTION |
4 |
Non-Preferred Drug |
41% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FIRMAGON 2 X 120 MG KIT |
4 |
Non-Preferred Drug |
41% | N/A | P |
FIRMAGON 80 MG KIT |
4 |
Non-Preferred Drug |
41% | N/A | P |
FLAC OTIC OIL 0.01% EAR DROPS [Flac] |
4 |
Non-Preferred Drug |
41% | N/A | None |
FLECAINIDE ACETATE 100 MG TABLET [Tambocor] |
2 |
Generic |
$3.00 | $9.00 | None |
FLECAINIDE ACETATE 150 MG TABLET [Tambocor] |
2 |
Generic |
$3.00 | $9.00 | None |
FLECAINIDE ACETATE 50 MG TABLET [Tambocor] |
2 |
Generic |
$3.00 | $9.00 | None |
FLOVENT DISKUS 100ug/1 60 POWDER, METERED in 1 INHALER |
3 |
Preferred Brand |
18% | 18% | Q:60 /30Days |
FLOVENT DISKUS 250ug/1 60 POWDER, METERED in 1 INHALER |
3 |
Preferred Brand |
18% | 18% | Q:240 /30Days |
FLOVENT DISKUS POWDER 50MCG 60 CTR |
3 |
Preferred Brand |
18% | 18% | Q:60 /30Days |
FLOVENT HFA 110ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
18% | 18% | Q:12 /30Days |
FLOVENT HFA 220ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
18% | 18% | Q:24 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLOVENT HFA 44ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
18% | 18% | Q:11 /30Days |
FLUCONAZOLE 10 MG/ML ORAL SUSPENSION [Diflucan] |
3 |
Preferred Brand |
18% | 18% | None |
FLUCONAZOLE 100 MG TABLET [Diflucan] |
2 |
Generic |
$3.00 | $9.00 | None |
FLUCONAZOLE 150 MG TABLET [Diflucan] |
2 |
Generic |
$3.00 | $9.00 | None |
FLUCONAZOLE 200 MG TABLET [Diflucan] |
2 |
Generic |
$3.00 | $9.00 | None |
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION [Diflucan] |
3 |
Preferred Brand |
18% | 18% | None |
FLUCONAZOLE 50 MG TABLET [Diflucan] |
2 |
Generic |
$3.00 | $9.00 | None |
FLUCONAZOLE-NACL 200 MG/100 ML PIGGYBACK [Diflucan] |
4 |
Non-Preferred Drug |
41% | N/A | P |
FLUCONAZOLE-NACL 400 MG/200 ML PIGGYBACK [Diflucan] |
4 |
Non-Preferred Drug |
41% | N/A | P |
FLUCYTOSINE 250 MG CAPSULE [Ancobon] |
5 |
Specialty Tier |
25% | N/A | None |
FLUCYTOSINE 500 MG CAPSULE [Ancobon] |
5 |
Specialty Tier |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUDROCORTISONE 0.1 MG TABLET [Florinef] |
2 |
Generic |
$3.00 | $9.00 | None |
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL |
3 |
Preferred Brand |
18% | 18% | Q:50 /30Days |
FLUOCINOLONE 0.01% CREAM (G) |
4 |
Non-Preferred Drug |
41% | N/A | None |
FLUOCINOLONE 0.01% SCALP OIL [Derma-Smoothe/FS] |
4 |
Non-Preferred Drug |
41% | N/A | None |
FLUOCINOLONE 0.01% SOLUTION [Synalar] |
4 |
Non-Preferred Drug |
41% | N/A | None |
FLUOCINOLONE 0.025% CREAM (G) [Synalar] |
4 |
Non-Preferred Drug |
41% | N/A | None |
FLUOCINOLONE 0.025% OINTMENT [Synalar] |
4 |
Non-Preferred Drug |
41% | N/A | None |
FLUOCINOLONE OIL 0.01% EAR DROPS [Flac] |
4 |
Non-Preferred Drug |
41% | N/A | None |
FLUOCINONIDE 0.05% CREAM (G) [Lidex] |
3 |
Preferred Brand |
18% | 18% | Q:120 /30Days |
FLUOCINONIDE 0.05% GEL [Lidex] |
3 |
Preferred Brand |
18% | 18% | Q:120 /30Days |
FLUOCINONIDE 0.05% OINTMENT [Lidex] |
3 |
Preferred Brand |
18% | 18% | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOCINONIDE 0.05% SOLUTION |
3 |
Preferred Brand |
18% | 18% | Q:120 /30Days |
FLUOCINONIDE-E 0.05% CREAM |
3 |
Preferred Brand |
18% | 18% | Q:120 /30Days |
Fluorometholone 0.1% drops |
4 |
Non-Preferred Drug |
41% | N/A | None |
FLUOROURACIL 2% TOPICAL SOLUTION |
4 |
Non-Preferred Drug |
41% | N/A | None |
FLUOROURACIL 5% CREAM (g) [Efudex] |
4 |
Non-Preferred Drug |
41% | N/A | None |
FLUOROURACIL 5% TOPICAL SOLUTION |
4 |
Non-Preferred Drug |
41% | N/A | None |
FLUOXETINE 20 MG/5 ML SOLUTION [Prozac] |
2 |
Generic |
$3.00 | $9.00 | None |
FLUOXETINE HCL 10 MG CAPSULE [Prozac] |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
FLUOXETINE HCL 10 MG TABLET [Sarafem] |
2 |
Generic |
$3.00 | $9.00 | Q:240 /30Days |
FLUOXETINE HCL 10 MG TABLET [Sarafem] |
2 |
Generic |
$3.00 | $9.00 | Q:240 /30Days |
FLUOXETINE HCL 20 MG CAPSULE |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOXETINE HCL 20 MG TABLET [Sarafem] |
2 |
Generic |
$3.00 | $9.00 | Q:120 /30Days |
FLUOXETINE HCL 20 MG TABLET [Sarafem] |
2 |
Generic |
$3.00 | $9.00 | Q:120 /30Days |
FLUOXETINE HCL 40 MG CAPSULE [Prozac] |
2 |
Generic |
$3.00 | $9.00 | Q:60 /30Days |
FLUOXETINE HCL 60 MG TABLET |
3 |
Preferred Brand |
18% | 18% | Q:30 /30Days |
FLUPHENAZINE 1 MG TABLET |
4 |
Non-Preferred Drug |
41% | N/A | None |
FLUPHENAZINE 10 MG TABLET [Prolixin] |
4 |
Non-Preferred Drug |
41% | N/A | None |
FLUPHENAZINE 2.5 MG TABLET |
4 |
Non-Preferred Drug |
41% | N/A | None |
FLUPHENAZINE 2.5 MG/5 ML ELIXIR [Prolixin] |
4 |
Non-Preferred Drug |
41% | N/A | None |
FLUPHENAZINE 2.5MG/ML VIAL |
4 |
Non-Preferred Drug |
41% | N/A | None |
FLUPHENAZINE 5 MG TABLET |
4 |
Non-Preferred Drug |
41% | N/A | None |
FLUPHENAZINE 5MG/ML CONC |
4 |
Non-Preferred Drug |
41% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUPHENAZINE DEC 125 MG/5 ML VIAL [Prolixin Decanoate] |
4 |
Non-Preferred Drug |
41% | N/A | None |
FLUTICASONE PROP 0.005% OINTMENT [Cutivate] |
3 |
Preferred Brand |
18% | 18% | None |
Fluticasone Propionate 0.5mg/g 1 TUBE per CARTON / 30 g in 1 TUBE |
3 |
Preferred Brand |
18% | 18% | None |
FLUTICASONE PROPIONATE 50 MCG SPRAY SUSPENSION |
2 |
Generic |
$3.00 | $9.00 | Q:16 /30Days |
FLUVASTATIN SODIUM 20 MG CAPSULE [Lescol] |
4 |
Non-Preferred Drug |
41% | N/A | Q:30 /30Days |
FLUVASTATIN SODIUM 40 MG CAPSULE [Lescol] |
4 |
Non-Preferred Drug |
41% | N/A | Q:60 /30Days |
FLUVOXAMINE MALEATE 100 MG TABLET [Luvox] |
4 |
Non-Preferred Drug |
41% | N/A | Q:90 /30Days |
FLUVOXAMINE MALEATE 25 MG TABLET [Luvox] |
4 |
Non-Preferred Drug |
41% | N/A | Q:30 /30Days |
FLUVOXAMINE MALEATE 50 MG TABLET [Luvox] |
4 |
Non-Preferred Drug |
41% | N/A | Q:60 /30Days |
FONDAPARINUX 10 MG/0.8 ML SYRINGE [Arixtra] |
5 |
Specialty Tier |
25% | N/A | None |
FONDAPARINUX 2.5 MG/0.5 ML SYR SYRINGE [Arixtra] |
4 |
Non-Preferred Drug |
41% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FONDAPARINUX 5 MG/0.4 ML SYRINGE [Arixtra] |
5 |
Specialty Tier |
25% | N/A | None |
FONDAPARINUX 7.5 MG/0.6 ML SYRINGE [Arixtra] |
5 |
Specialty Tier |
25% | N/A | None |
FORMOTEROL 20 MCG/2 ML VIAL-NEB [Perforomist] |
3 |
Preferred Brand |
18% | 18% | P Q:120 /30Days |
FOSAMPRENAVIR 700 MG TABLET [Lexiva] |
5 |
Specialty Tier |
25% | N/A | Q:120 /30Days |
FOSINOPRIL SODIUM 10 MG TABLET [Monopril] |
2 |
Generic |
$3.00 | $9.00 | None |
FOSINOPRIL SODIUM 20 MG TABLET [Monopril] |
2 |
Generic |
$3.00 | $9.00 | None |
FOSINOPRIL SODIUM 40 MG TABLET [Monopril] |
2 |
Generic |
$3.00 | $9.00 | None |
FOSINOPRIL-HCTZ 10-12.5 MG TABLET [Monopril-HCT] |
2 |
Generic |
$3.00 | $9.00 | None |
FOSINOPRIL-HCTZ 20-12.5 MG TABLET [Monopril-HCT] |
2 |
Generic |
$3.00 | $9.00 | None |
FOTIVDA 0.89 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:21 /28Days |
FOTIVDA 1.34 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:21 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FUROSEMIDE 10 MG/ML SOLUTION |
2 |
Generic |
$3.00 | $9.00 | None |
FUROSEMIDE 100 MG/10 ML VIAL |
4 |
Non-Preferred Drug |
41% | 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 |
41% | N/A | None |
FUROSEMIDE 20 MG TABLET [Lasix] |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
FUROSEMIDE 40 MG TABLET [Lasix] |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
FUROSEMIDE 40MG/5ML TUBEX |
2 |
Generic |
$3.00 | $9.00 | None |
FUROSEMIDE 80 MG TABLET [Lasix] |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
FUZEON 90 MG VIAL |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
FYCOMPA 0.5 MG/ML ORAL SUSP |
4 |
Non-Preferred Drug |
41% | N/A | P Q:720 /30Days |
FYCOMPA 10 MG TABLET |
4 |
Non-Preferred Drug |
41% | N/A | P Q:30 /30Days |
FYCOMPA 12 MG TABLET |
4 |
Non-Preferred Drug |
41% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FYCOMPA 2 MG TABLET |
4 |
Non-Preferred Drug |
41% | N/A | P Q:60 /30Days |
FYCOMPA 4 MG TABLET |
4 |
Non-Preferred Drug |
41% | N/A | P Q:60 /30Days |
FYCOMPA 6 MG TABLET |
4 |
Non-Preferred Drug |
41% | N/A | P Q:60 /30Days |
FYCOMPA 8 MG TABLET |
4 |
Non-Preferred Drug |
41% | N/A | P Q:30 /30Days |