2023 Medicare Part D Plan Formulary Information |
Summit Health Value + Rx (HMO) (H2765-002-0)
Benefit Details
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less. Call drug plan for more details. |
The Summit Health Value + Rx (HMO) (H2765-002-0) Formulary Drugs Starting with the Letter F in Wallowa County, OR: CMS MA Region 23 which includes: OR
|
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 [Vienva] |
2* |
Generic |
$10.00 | $25.00 | None |
FAMCICLOVIR 125 MG TABLET |
2* |
Generic |
$10.00 | $25.00 | None |
FAMCICLOVIR 250 MG TABLET [Famvir] |
2* |
Generic |
$10.00 | $25.00 | None |
FAMCICLOVIR 500 MG TABLET [Famvir] |
2* |
Generic |
$10.00 | $25.00 | None |
FAMOTIDINE 20 MG TABLET [Zantac 360] |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
FAMOTIDINE 40 MG TABLET [Pepcid] |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
FANAPT 1 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P Q:60 /30Days |
FANAPT 10 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P Q:60 /30Days |
FANAPT 12 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P Q:60 /30Days |
FANAPT 2 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | 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 Brand |
$100.00 | $250.00 | P Q:60 /30Days |
FANAPT 6 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P Q:60 /30Days |
FANAPT 8 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P Q:60 /30Days |
FANAPT TITR TABLETS |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P Q:60 /30Days |
FARXIGA 10 MG TABLET |
3 |
Preferred Brand |
$45.00 | $113.00 | Q:30 /30Days |
FARXIGA 5 MG TABLET |
3 |
Preferred Brand |
$45.00 | $113.00 | Q:30 /30Days |
FASENRA 30 MG/ML SYRINGE |
5 |
Preferred Specialty Tier |
24% | N/A | P |
FASENRA PEN 30 MG/ML AUTO INJCT |
5 |
Preferred Specialty Tier |
24% | N/A | P |
FEBUXOSTAT 40 MG TABLET [Uloric] |
2* |
Generic |
$10.00 | $25.00 | S |
FEBUXOSTAT 80 MG TABLET [Uloric] |
2* |
Generic |
$10.00 | $25.00 | S |
FELBAMATE 400 MG TABLET [Felbatol] |
2* |
Generic |
$10.00 | $25.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FELBAMATE 600 MG TABLET [Felbatol] |
2* |
Generic |
$10.00 | $25.00 | None |
FELBAMATE 600 MG/5 ML ORAL SUSPENSION [Felbatol] |
2* |
Generic |
$10.00 | $25.00 | None |
FELODIPINE ER 10 MG TABLET |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
FELODIPINE ER 2.5 MG TABLET ER 24H [Plendil] |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
FELODIPINE ER 5 MG TABLET |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
FEMRING 0.05 MG/DAY VAGINAL RING |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | S |
FEMRING 0.10 MG/DAY VAGINAL RING |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | S |
FENOFIBRATE 134 MG CAPSULE [Tricor] |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
FENOFIBRATE 145 MG TABLET [Tricor] |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
FENOFIBRATE 160 MG TABLET [Triglide] |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
FENOFIBRATE 200 MG CAPSULE [Tricor] |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENOFIBRATE 48 MG TABLET [Tricor] |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
FENOFIBRATE 54 MG TABLET [Lofibra] |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
FENOFIBRATE 67 MG CAPSULE [Tricor] |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
FENOFIBRATE 90 MG CAPSULE [Antara] |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
FENOFIBRIC ACID DR 135 MG CAPSULE DR [Trilipix] |
2* |
Generic |
$10.00 | $25.00 | None |
FENOFIBRIC ACID DR 45 MG CAPSULE DR [Trilipix] |
2* |
Generic |
$10.00 | $25.00 | None |
FENTANYL 100 MCG/HR PATCH TD72 [Duragesic] |
2* |
Generic |
$10.00 | $25.00 | Q:10 /30Days |
FENTANYL 12 MCG/HR PATCH TD72 [Duragesic] |
2* |
Generic |
$10.00 | $25.00 | Q:10 /30Days |
FENTANYL 25 MCG/HR PATCH TD72 [Duragesic] |
2* |
Generic |
$10.00 | $25.00 | Q:10 /30Days |
FENTANYL 50 MCG/HR PATCH TD72 [Duragesic] |
2* |
Generic |
$10.00 | $25.00 | Q:10 /30Days |
FENTANYL 75 MCG/HR PATCH TD72 [Duragesic] |
2* |
Generic |
$10.00 | $25.00 | Q:10 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENTANYL CIT 100 MCG BUCCAL TABLET EFF [Fentora] |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P Q:120 /30Days |
FENTANYL CIT 200 MCG BUCCAL TABLET EFF [Fentora] |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P Q:120 /30Days |
FENTANYL CIT 400 MCG BUCCAL TABLET EFF [Fentora] |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P Q:120 /30Days |
FENTANYL CIT 600 MCG BUCCAL TABLET EFF [Fentora] |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P Q:120 /30Days |
FENTANYL CIT 800 MCG BUCCAL TABLET EFF [Fentora] |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P Q:120 /30Days |
FENTANYL CIT OTFC 1,200 MCG LOZENGE HD [Actiq] |
2* |
Generic |
$10.00 | $25.00 | P Q:120 /30Days |
FENTANYL CIT OTFC 1,600 MCG LOZENGE HD [Actiq] |
2* |
Generic |
$10.00 | $25.00 | P Q:120 /30Days |
FENTANYL CITRATE OTFC 200 MCG LOZENGE HD [Actiq] |
2* |
Generic |
$10.00 | $25.00 | P Q:120 /30Days |
FENTANYL CITRATE OTFC 400 MCG LOZENGE HD [Actiq] |
2* |
Generic |
$10.00 | $25.00 | P Q:120 /30Days |
FENTANYL CITRATE OTFC 600 MCG LOZENGE HD [Actiq] |
2* |
Generic |
$10.00 | $25.00 | P Q:120 /30Days |
FENTANYL CITRATE OTFC 800 MCG LOZENGE HD [Actiq] |
2* |
Generic |
$10.00 | $25.00 | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FERRIPROX 1,000 MG TABLET (2X/DAY) |
6 |
Specialty Tier |
29% | N/A | P |
FERRIPROX 100 MG/ML SOLUTION |
6 |
Specialty Tier |
29% | N/A | P |
FESOTERODINE ER 4 MG TABLET 24H [Toviaz] |
2* |
Generic |
$10.00 | $25.00 | None |
FESOTERODINE ER 8 MG TABLET 24H [Toviaz] |
2* |
Generic |
$10.00 | $25.00 | None |
FETZIMA 20-40 MG TITRATION PAK |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | S Q:30 /30Days |
FETZIMA ER 120 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | S Q:30 /30Days |
FETZIMA ER 20 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | S Q:30 /30Days |
FETZIMA ER 40 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | S Q:30 /30Days |
FETZIMA ER 80 MG CAPSULE |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | S Q:30 /30Days |
FIASP 100 UNIT/ML FLEXTOUCH INSULIN PEN |
3 |
Preferred Brand |
$35 max* | $113.00 | None |
FIASP 100 UNIT/ML VIAL |
3 |
Preferred Brand |
$35 max* | $113.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FIASP PENFILL 100 UNIT/ML CART CARTRIDGE |
3 |
Preferred Brand |
$35 max* | $113.00 | None |
FINACEA 15% FOAM |
3 |
Preferred Brand |
$45.00 | $113.00 | Q:50 /30Days |
FINASTERIDE 5 MG TABLET [Proscar] |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
FINGOLIMOD 0.5 MG CAPSULE [Gilenya] |
5 |
Preferred Specialty Tier |
24% | N/A | None |
FINTEPLA 2.2 MG/ML SOLUTION |
6 |
Specialty Tier |
29% | N/A | P Q:360 /30Days |
FINZALA 1-0.02(24)-75 CHEWABLE TABLET [Minastrin] |
2* |
Generic |
$10.00 | $25.00 | None |
FIRDAPSE 10 MG TABLET |
5 |
Preferred Specialty Tier |
24% | N/A | P |
FIRMAGON 2 X 120 MG KIT |
3 |
Preferred Brand |
$45.00 | $113.00 | P |
FIRMAGON 80 MG KIT |
3 |
Preferred Brand |
$45.00 | $113.00 | P |
FIRVANQ 25 MG/ML SOLUTION SOLUTION RECON |
3 |
Preferred Brand |
$45.00 | $113.00 | None |
FIRVANQ 50 MG/ML SOLUTION RECON |
3 |
Preferred Brand |
$45.00 | $113.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLAC OTIC OIL 0.01% EAR DROPS [Flac] |
2* |
Generic |
$10.00 | $25.00 | None |
FLAREX 0.1% EYE DROPS EYE DROPPER |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
FLAVOXATE HCL 100 MG TABLET [Urispas] |
2* |
Generic |
$10.00 | $25.00 | None |
FLEBOGAMMA DIF 10% VIAL |
5 |
Preferred Specialty Tier |
24% | N/A | P |
FLECAINIDE ACETATE 100 MG TABLET [Tambocor] |
2* |
Generic |
$10.00 | $25.00 | None |
FLECAINIDE ACETATE 150 MG TABLET [Tambocor] |
2* |
Generic |
$10.00 | $25.00 | None |
FLECAINIDE ACETATE 50 MG TABLET [Tambocor] |
2* |
Generic |
$10.00 | $25.00 | None |
FLECTOR 1.3% PATCH TD12 |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P Q:60 /30Days |
FLOVENT DISKUS 100ug/1 60 POWDER, METERED in 1 INHALER |
3 |
Preferred Brand |
$45.00 | $113.00 | Q:60 /30Days |
FLOVENT DISKUS 250ug/1 60 POWDER, METERED in 1 INHALER |
3 |
Preferred Brand |
$45.00 | $113.00 | Q:60 /30Days |
FLOVENT DISKUS POWDER 50MCG 60 CTR |
3 |
Preferred Brand |
$45.00 | $113.00 | 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 |
$45.00 | $113.00 | Q:24 /30Days |
FLOVENT HFA 220ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$45.00 | $113.00 | Q:24 /30Days |
FLOVENT HFA 44ug/1 120 AEROSOL, METERED in 1 INHALER |
3 |
Preferred Brand |
$45.00 | $113.00 | Q:21 /30Days |
FLUCONAZOLE 10 MG/ML ORAL SUSPENSION [Diflucan] |
2* |
Generic |
$10.00 | $25.00 | None |
FLUCONAZOLE 100 MG TABLET [Diflucan] |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
FLUCONAZOLE 150 MG TABLET [Diflucan] |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
FLUCONAZOLE 200 MG TABLET [Diflucan] |
2* |
Generic |
$10.00 | $25.00 | None |
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION [Diflucan] |
2* |
Generic |
$10.00 | $25.00 | None |
FLUCONAZOLE 50 MG TABLET [Diflucan] |
2* |
Generic |
$10.00 | $25.00 | None |
FLUCONAZOLE-NACL 200 MG/100 ML PIGGYBACK [Diflucan] |
2* |
Generic |
$10.00 | $25.00 | None |
FLUCONAZOLE-NACL 400 MG/200 ML PIGGYBACK [Diflucan] |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUCYTOSINE 250 MG CAPSULE [Ancobon] |
2* |
Generic |
$10.00 | $25.00 | None |
FLUCYTOSINE 500 MG CAPSULE [Ancobon] |
2* |
Generic |
$10.00 | $25.00 | None |
FLUDROCORTISONE 0.1 MG TABLET [Florinef] |
2* |
Generic |
$10.00 | $25.00 | None |
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:50 /30Days |
FLUOCINOLONE 0.01% CREAM (G) |
2* |
Generic |
$10.00 | $25.00 | Q:120 /30Days |
FLUOCINOLONE 0.01% SCALP OIL [Derma-Smoothe/FS] |
2* |
Generic |
$10.00 | $25.00 | Q:120 /30Days |
FLUOCINOLONE 0.01% SOLUTION [Synalar] |
2* |
Generic |
$10.00 | $25.00 | Q:90 /30Days |
FLUOCINOLONE 0.025% CREAM (G) [Synalar] |
2* |
Generic |
$10.00 | $25.00 | Q:120 /30Days |
FLUOCINOLONE 0.025% OINTMENT [Synalar] |
2* |
Generic |
$10.00 | $25.00 | Q:120 /30Days |
FLUOCINOLONE OIL 0.01% EAR DROPS [Flac] |
2* |
Generic |
$10.00 | $25.00 | None |
FLUOCINONIDE 0.05% CREAM (G) [Lidex] |
2* |
Generic |
$10.00 | $25.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOCINONIDE 0.05% GEL [Lidex] |
2* |
Generic |
$10.00 | $25.00 | Q:60 /30Days |
FLUOCINONIDE 0.05% OINTMENT [Lidex] |
2* |
Generic |
$10.00 | $25.00 | Q:60 /30Days |
FLUOCINONIDE 0.05% SOLUTION |
2* |
Generic |
$10.00 | $25.00 | Q:60 /30Days |
FLUOCINONIDE 0.1% CREAM (g) [Vanos] |
2* |
Generic |
$10.00 | $25.00 | Q:60 /30Days |
FLUOCINONIDE-E 0.05% CREAM (G) [Lidex -E] |
2* |
Generic |
$10.00 | $25.00 | Q:120 /30Days |
Fluorometholone 0.1% drops |
2* |
Generic |
$10.00 | $25.00 | None |
FLUOROURACIL 2% TOPICAL SOLUTION |
3 |
Preferred Brand |
$45.00 | $113.00 | Q:10 /30Days |
FLUOROURACIL 5% CREAM (g) [Efudex] |
2* |
Generic |
$10.00 | $25.00 | Q:40 /30Days |
FLUOROURACIL 5% TOPICAL SOLUTION |
3 |
Preferred Brand |
$45.00 | $113.00 | Q:10 /30Days |
FLUOXETINE 20 MG/5 ML SOLUTION [Prozac] |
2* |
Generic |
$10.00 | $25.00 | None |
FLUOXETINE HCL 10 MG CAPSULE [Prozac] |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOXETINE HCL 20 MG CAPSULE |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
FLUOXETINE HCL 40 MG CAPSULE [Prozac] |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
FLUOXETINE HCL 60 MG TABLET |
2* |
Generic |
$10.00 | $25.00 | None |
FLUPHENAZINE 1 MG TABLET |
2* |
Generic |
$10.00 | $25.00 | None |
FLUPHENAZINE 10 MG TABLET [Prolixin] |
2* |
Generic |
$10.00 | $25.00 | None |
FLUPHENAZINE 2.5 MG TABLET |
2* |
Generic |
$10.00 | $25.00 | None |
FLUPHENAZINE 2.5 MG/5 ML ELIXIR [Prolixin] |
3 |
Preferred Brand |
$45.00 | $113.00 | None |
FLUPHENAZINE 2.5MG/ML VIAL |
3 |
Preferred Brand |
$45.00 | $113.00 | None |
FLUPHENAZINE 5 MG TABLET |
2* |
Generic |
$10.00 | $25.00 | None |
FLUPHENAZINE 5MG/ML CONC |
3 |
Preferred Brand |
$45.00 | $113.00 | None |
FLUPHENAZINE DEC 125 MG/5 ML VIAL [Prolixin Decanoate] |
2* |
Generic |
$10.00 | $25.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLURBIPROFEN 0.03% EYE DROPS [Ocufen] |
3 |
Preferred Brand |
$45.00 | $113.00 | None |
Flurbiprofen 100mg/1 100 BOTTLE in 1 BOTTLE / 100 FILM COATED TABLETS in BOTTLE |
2* |
Generic |
$10.00 | $25.00 | None |
FLUTICASONE PROP 0.005% OINTMENT [Cutivate] |
1* |
Preferred Generic |
$4.00 | $10.00 | Q:240 /30Days |
FLUTICASONE PROP HFA 110 MCG AER W/ADAP [Flovent HFA] |
3 |
Preferred Brand |
$45.00 | $113.00 | Q:24 /30Days |
FLUTICASONE PROP HFA 220 MCG AER W/ADAP [Flovent HFA] |
3 |
Preferred Brand |
$45.00 | $113.00 | Q:24 /30Days |
FLUTICASONE PROP HFA 44 MCG AER W/ADAP [Flovent HFA] |
3 |
Preferred Brand |
$45.00 | $113.00 | Q:21 /30Days |
Fluticasone Propionate 0.5mg/g 1 TUBE per CARTON / 30 g in 1 TUBE |
1* |
Preferred Generic |
$4.00 | $10.00 | Q:240 /30Days |
FLUTICASONE PROPIONATE 50 MCG SPRAY SUSPENSION |
1* |
Preferred Generic |
$4.00 | $10.00 | Q:32 /30Days |
FLUTICASONE-SALMETEROL 100-50 INHALER [Advair] |
2* |
Generic |
$10.00 | $25.00 | Q:60 /30Days |
FLUTICASONE-SALMETEROL 113-14 [Advair Diskus, Advair HFA, AIRDUO RESPICLICK] |
2* |
Generic |
$10.00 | $25.00 | Q:1 /30Days |
FLUTICASONE-SALMETEROL 232-14 [Advair Diskus, Advair HFA, AIRDUO RESPICLICK] |
2* |
Generic |
$10.00 | $25.00 | Q:1 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUTICASONE-SALMETEROL 250-50 INHALER [Advair] |
2* |
Generic |
$10.00 | $25.00 | Q:60 /30Days |
FLUTICASONE-SALMETEROL 500-50 INHALER [Advair] |
2* |
Generic |
$10.00 | $25.00 | Q:60 /30Days |
FLUTICASONE-SALMETEROL 55-14 [Advair Diskus, Advair HFA, AIRDUO RESPICLICK] |
2* |
Generic |
$10.00 | $25.00 | Q:1 /30Days |
FLUTICASONE-VILANTEROL 100-25 BLST W/DEV [BREO ELLIPTA] |
3 |
Preferred Brand |
$45.00 | $113.00 | Q:60 /30Days |
FLUTICASONE-VILANTEROL 200-25 BLST W/DEV [BREO ELLIPTA] |
3 |
Preferred Brand |
$45.00 | $113.00 | Q:60 /30Days |
FLUVASTATIN ER 80 MG TABLET ER 24H [Lescol XL] |
2* |
Generic |
$10.00 | $25.00 | None |
FLUVASTATIN SODIUM 20 MG CAPSULE [Lescol] |
2* |
Generic |
$10.00 | $25.00 | None |
FLUVASTATIN SODIUM 40 MG CAPSULE [Lescol] |
2* |
Generic |
$10.00 | $25.00 | None |
FLUVOXAMINE MALEATE 100 MG TABLET [Luvox] |
2* |
Generic |
$10.00 | $25.00 | None |
FLUVOXAMINE MALEATE 25 MG TABLET [Luvox] |
2* |
Generic |
$10.00 | $25.00 | None |
FLUVOXAMINE MALEATE 50 MG TABLET [Luvox] |
2* |
Generic |
$10.00 | $25.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FML FORTE 0.25% EYE DROPS |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
FONDAPARINUX 10 MG/0.8 ML SYRINGE [Arixtra] |
2* |
Generic |
$10.00 | $25.00 | None |
FONDAPARINUX 2.5 MG/0.5 ML SYRINGE [Arixtra] |
2* |
Generic |
$10.00 | $25.00 | None |
FONDAPARINUX 5 MG/0.4 ML SYRINGE [Arixtra] |
2* |
Generic |
$10.00 | $25.00 | None |
FONDAPARINUX 7.5 MG/0.6 ML SYRINGE [Arixtra] |
2* |
Generic |
$10.00 | $25.00 | None |
FORMOTEROL 20 MCG/2 ML VIAL-NEB [Perforomist] |
2* |
Generic |
$10.00 | $25.00 | P Q:120 /30Days |
Forteo 250ug/mL 1 SYRINGE per CARTON / 2.4 mL in 1 SYRINGE |
5 |
Preferred Specialty Tier |
24% | N/A | Q:2 /28Days |
FOSAMPRENAVIR 700 MG TABLET [Lexiva] |
5 |
Preferred Specialty Tier |
24% | N/A | None |
FOSFOMYCIN 3 GM SACHET PACKET [Monurol] |
2* |
Generic |
$10.00 | $25.00 | None |
FOSINOPRIL SODIUM 10 MG TABLET [Monopril] |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
FOSINOPRIL SODIUM 20 MG TABLET [Monopril] |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FOSINOPRIL SODIUM 40 MG TABLET [Monopril] |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
FOSINOPRIL-HCTZ 10-12.5 MG TABLET [Monopril-HCT] |
2* |
Generic |
$10.00 | $25.00 | None |
FOSINOPRIL-HCTZ 20-12.5 MG TABLET [Monopril-HCT] |
2* |
Generic |
$10.00 | $25.00 | None |
FOTIVDA 0.89 MG CAPSULE |
6 |
Specialty Tier |
29% | N/A | P Q:21 /28Days |
FOTIVDA 1.34 MG CAPSULE |
6 |
Specialty Tier |
29% | N/A | P Q:21 /28Days |
FUROSCIX 80 MG/10ML ON-BODY KIT |
5 |
Preferred Specialty Tier |
24% | N/A | Q:8 /7Days |
FUROSEMIDE 10 MG/ML SOLUTION |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
FUROSEMIDE 100 MG/10 ML VIAL |
2* |
Generic |
$10.00 | $25.00 | None |
FUROSEMIDE 20 MG TABLET [Lasix] |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
FUROSEMIDE 40 MG TABLET [Lasix] |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
FUROSEMIDE 40MG/5ML TUBEX |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FUROSEMIDE 80 MG TABLET [Lasix] |
1* |
Preferred Generic |
$4.00 | $10.00 | None |
FUZEON 90 MG VIAL |
5 |
Preferred Specialty Tier |
24% | N/A | None |
FYAVOLV 0.5 MG-2.5 MCG TABLET [Jevantique] |
2* |
Generic |
$10.00 | $25.00 | None |
FYAVOLV 1 MG-5 MCG TABLET [Jinteli 1/5] |
2* |
Generic |
$10.00 | $25.00 | None |
FYCOMPA 0.5 MG/ML ORAL SUSP |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P Q:720 /30Days |
FYCOMPA 10 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P Q:30 /30Days |
FYCOMPA 12 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P Q:30 /30Days |
FYCOMPA 2 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P Q:30 /30Days |
FYCOMPA 4 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P Q:60 /30Days |
FYCOMPA 6 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P Q:60 /30Days |
FYCOMPA 8 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P |