2024 Medicare Part D Plan Formulary Information |
Signature Advantage Community (HMO I-SNP) (H2400-002-0)
Benefits & Contact Info
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 Signature Advantage Community (HMO I-SNP) (H2400-002-0) Formulary Drugs Starting with the Letter F in Rockcastle County, KY: CMS MA Region 13 which includes: KY
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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] |
1 |
Tier 1 |
25% | N/A | None |
FAMCICLOVIR 125 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
FAMCICLOVIR 250 MG TABLET [Famvir] |
1 |
Tier 1 |
25% | N/A | None |
FAMCICLOVIR 500 MG TABLET [Famvir] |
1 |
Tier 1 |
25% | N/A | None |
FAMOTIDINE 20 MG TABLET [Zantac 360] |
1 |
Tier 1 |
25% | N/A | None |
FAMOTIDINE 40 MG TABLET [Pepcid] |
1 |
Tier 1 |
25% | N/A | None |
FAMOTIDINE 40 MG/5 ML ORAL SUSPENSION [Pepcid] |
1 |
Tier 1 |
25% | N/A | None |
FANAPT 1 MG TABLET |
1 |
Tier 1 |
25% | N/A | Q:60 /30Days |
FANAPT 10 MG TABLET |
1 |
Tier 1 |
25% | N/A | Q:60 /30Days |
FANAPT 12 MG TABLET |
1 |
Tier 1 |
25% | 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 |
1 |
Tier 1 |
25% | N/A | Q:60 /30Days |
FANAPT 4 MG TABLET |
1 |
Tier 1 |
25% | N/A | Q:60 /30Days |
FANAPT 6 MG TABLET |
1 |
Tier 1 |
25% | N/A | Q:60 /30Days |
FANAPT 8 MG TABLET |
1 |
Tier 1 |
25% | N/A | Q:60 /30Days |
FANAPT TITR TABLETS |
1 |
Tier 1 |
25% | N/A | Q:8 /28Days |
FEBUXOSTAT 40 MG TABLET [Uloric] |
1 |
Tier 1 |
25% | N/A | None |
FEBUXOSTAT 80 MG TABLET [Uloric] |
1 |
Tier 1 |
25% | N/A | None |
FELBAMATE 400 MG TABLET [Felbatol] |
1 |
Tier 1 |
25% | N/A | None |
FELBAMATE 600 MG TABLET [Felbatol] |
1 |
Tier 1 |
25% | N/A | None |
FELBAMATE 600 MG/5 ML ORAL SUSPENSION [Felbatol] |
1 |
Tier 1 |
25% | N/A | None |
FELODIPINE ER 10 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FELODIPINE ER 2.5 MG TABLET ER 24H [Plendil] |
1 |
Tier 1 |
25% | N/A | None |
FELODIPINE ER 5 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
FENOFIBRATE 130 MG CAPSULE [Antara] |
1 |
Tier 1 |
25% | N/A | None |
FENOFIBRATE 134 MG CAPSULE [Tricor] |
1 |
Tier 1 |
25% | N/A | None |
FENOFIBRATE 145 MG TABLET [Tricor] |
1 |
Tier 1 |
25% | N/A | None |
FENOFIBRATE 150 MG CAPSULE [LIPOFEN] |
1 |
Tier 1 |
25% | N/A | None |
FENOFIBRATE 160 MG TABLET [Triglide] |
1 |
Tier 1 |
25% | N/A | None |
FENOFIBRATE 200 MG CAPSULE [Tricor] |
1 |
Tier 1 |
25% | N/A | None |
FENOFIBRATE 43 MG CAPSULE [Antara] |
1 |
Tier 1 |
25% | N/A | None |
FENOFIBRATE 48 MG TABLET [Tricor] |
1 |
Tier 1 |
25% | N/A | None |
FENOFIBRATE 50 MG CAPSULE [LIPOFEN] |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENOFIBRATE 54 MG TABLET [Lofibra] |
1 |
Tier 1 |
25% | N/A | None |
FENOFIBRATE 67 MG CAPSULE [Tricor] |
1 |
Tier 1 |
25% | N/A | None |
FENOFIBRIC ACID DR 135 MG CAPSULE [Trilipix] |
1 |
Tier 1 |
25% | N/A | None |
FENOFIBRIC ACID DR 45 MG CAPSULE DR [Trilipix] |
1 |
Tier 1 |
25% | N/A | None |
FENTANYL 100 MCG/HR PATCH TD72 [Duragesic] |
1 |
Tier 1 |
25% | N/A | P Q:10 /30Days |
FENTANYL 12 MCG/HR PATCH TD72 [Duragesic] |
1 |
Tier 1 |
25% | N/A | P Q:10 /30Days |
FENTANYL 25 MCG/HR PATCH TD72 [Duragesic] |
1 |
Tier 1 |
25% | N/A | P Q:10 /30Days |
FENTANYL 37.5 MCG/HR PATCH TD72 |
1 |
Tier 1 |
25% | N/A | P Q:10 /30Days |
FENTANYL 50 MCG/HR PATCH TD72 [Duragesic] |
1 |
Tier 1 |
25% | N/A | P Q:10 /30Days |
FENTANYL 62.5 MCG/HR PATCH TD72 |
1 |
Tier 1 |
25% | N/A | P Q:10 /30Days |
FENTANYL 75 MCG/HR PATCH TD72 [Duragesic] |
1 |
Tier 1 |
25% | N/A | P Q:10 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FENTANYL 87.5 MCG/HR PATCH TD72 |
1 |
Tier 1 |
25% | N/A | P Q:10 /30Days |
FENTANYL CIT OTFC 1,200 MCG LOZENGE HD [Actiq] |
1 |
Tier 1 |
25% | N/A | P Q:120 /30Days |
FENTANYL CIT OTFC 1,600 MCG LOZENGE HD [Actiq] |
1 |
Tier 1 |
25% | N/A | P Q:120 /30Days |
FENTANYL CITRATE OTFC 200 MCG LOZENGE HD [Actiq] |
1 |
Tier 1 |
25% | N/A | P Q:120 /30Days |
FENTANYL CITRATE OTFC 400 MCG LOZENGE HD [Actiq] |
1 |
Tier 1 |
25% | N/A | P Q:120 /30Days |
FENTANYL CITRATE OTFC 600 MCG LOZENGE HD [Actiq] |
1 |
Tier 1 |
25% | N/A | P Q:120 /30Days |
FENTANYL CITRATE OTFC 800 MCG LOZENGE HD [Actiq] |
1 |
Tier 1 |
25% | N/A | P Q:120 /30Days |
FERRIPROX 1,000 MG TABLET (2X/DAY) |
1 |
Tier 1 |
25% | N/A | P |
FERRIPROX 100 MG/ML SOLUTION |
1 |
Tier 1 |
25% | N/A | P |
FESOTERODINE ER 4 MG TABLET 24H [Toviaz] |
1 |
Tier 1 |
25% | N/A | None |
FESOTERODINE ER 8 MG TABLET 24H [Toviaz] |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FETZIMA 20-40 MG TITRATION PAK |
1 |
Tier 1 |
25% | N/A | Q:28 /28Days |
FETZIMA ER 120 MG CAPSULE |
1 |
Tier 1 |
25% | N/A | Q:30 /30Days |
FETZIMA ER 20 MG CAPSULE |
1 |
Tier 1 |
25% | N/A | Q:30 /30Days |
FETZIMA ER 40 MG CAPSULE |
1 |
Tier 1 |
25% | N/A | Q:30 /30Days |
FETZIMA ER 80 MG CAPSULE |
1 |
Tier 1 |
25% | N/A | Q:30 /30Days |
FIASP 100 UNIT/ML FLEXTOUCH INSULIN PEN |
1 |
Tier 1 |
25% | N/A | None |
FIASP 100 UNIT/ML VIAL |
1 |
Tier 1 |
25% | N/A | None |
FIASP PENFILL 100 UNIT/ML CART CARTRIDGE |
1 |
Tier 1 |
25% | N/A | None |
FILSPARI 200 MG TABLET |
1 |
Tier 1 |
25% | N/A | P Q:30 /30Days |
FILSPARI 400 MG TABLET |
1 |
Tier 1 |
25% | N/A | P Q:30 /30Days |
FINASTERIDE 5 MG TABLET [Proscar] |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FINGOLIMOD 0.5 MG CAPSULE [Gilenya] |
1 |
Tier 1 |
25% | N/A | P |
FINTEPLA 2.2 MG/ML SOLUTION |
1 |
Tier 1 |
25% | N/A | P |
FIRMAGON 2 X 120 MG KIT |
1 |
Tier 1 |
25% | N/A | P |
FIRMAGON 80 MG KIT |
1 |
Tier 1 |
25% | N/A | P |
FIRVANQ 25 MG/ML SOLUTION SOLUTION RECON |
1 |
Tier 1 |
25% | N/A | None |
FIRVANQ 50 MG/ML SOLUTION RECON |
1 |
Tier 1 |
25% | N/A | None |
FLAVOXATE HCL 100 MG TABLET [Urispas] |
1 |
Tier 1 |
25% | N/A | None |
FLECAINIDE ACETATE 100 MG TABLET [Tambocor] |
1 |
Tier 1 |
25% | N/A | None |
FLECAINIDE ACETATE 150 MG TABLET [Tambocor] |
1 |
Tier 1 |
25% | N/A | None |
FLECAINIDE ACETATE 50 MG TABLET [Tambocor] |
1 |
Tier 1 |
25% | N/A | None |
FLUCONAZOLE 10 MG/ML ORAL SUSPENSION [Diflucan] |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUCONAZOLE 100 MG TABLET [Diflucan] |
1 |
Tier 1 |
25% | N/A | None |
FLUCONAZOLE 150 MG TABLET [Diflucan] |
1 |
Tier 1 |
25% | N/A | None |
FLUCONAZOLE 200 MG TABLET [Diflucan] |
1 |
Tier 1 |
25% | N/A | None |
FLUCONAZOLE 40 MG/ML ORAL SUSPENSION [Diflucan] |
1 |
Tier 1 |
25% | N/A | None |
FLUCONAZOLE 50 MG TABLET [Diflucan] |
1 |
Tier 1 |
25% | N/A | None |
FLUCONAZOLE-NACL 200 MG/100 ML PIGGYBACK [Diflucan] |
1 |
Tier 1 |
25% | N/A | None |
FLUCONAZOLE-NACL 400 MG/200 ML PIGGYBACK [Diflucan] |
1 |
Tier 1 |
25% | N/A | None |
FLUCYTOSINE 250 MG CAPSULE [Ancobon] |
1 |
Tier 1 |
25% | N/A | None |
FLUCYTOSINE 500 MG CAPSULE [Ancobon] |
1 |
Tier 1 |
25% | N/A | None |
FLUDROCORTISONE 0.1 MG TABLET [Florinef] |
1 |
Tier 1 |
25% | N/A | None |
FLUNISOLIDE NASAL SOLUTION 0.025% 25ML INHL |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOCINOLONE 0.01% CREAM (G) |
1 |
Tier 1 |
25% | N/A | None |
FLUOCINOLONE 0.01% SCALP OIL [Derma-Smoothe/FS] |
1 |
Tier 1 |
25% | N/A | None |
FLUOCINOLONE 0.01% SOLUTION [Synalar] |
1 |
Tier 1 |
25% | N/A | None |
FLUOCINOLONE 0.025% CREAM (G) [Synalar] |
1 |
Tier 1 |
25% | N/A | None |
FLUOCINOLONE 0.025% OINTMENT [Synalar] |
1 |
Tier 1 |
25% | N/A | None |
FLUOCINOLONE OIL 0.01% EAR DROPS [Flac] |
1 |
Tier 1 |
25% | N/A | None |
FLUOCINONIDE 0.05% CREAM (G) [Lidex] |
1 |
Tier 1 |
25% | N/A | None |
FLUOCINONIDE 0.05% GEL [Lidex] |
1 |
Tier 1 |
25% | N/A | None |
FLUOCINONIDE 0.05% OINTMENT [Lidex] |
1 |
Tier 1 |
25% | N/A | None |
FLUOCINONIDE 0.05% SOLUTION |
1 |
Tier 1 |
25% | N/A | None |
FLUOCINONIDE-E 0.05% CREAM (G) [Lidex -E] |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUOROMETHOLONE 0.1% EYE DROPS with DROPPER [FML] |
1 |
Tier 1 |
25% | N/A | None |
FLUOROURACIL 2% TOPICAL SOLUTION |
1 |
Tier 1 |
25% | N/A | None |
FLUOROURACIL 5% CREAM (g) [Efudex] |
1 |
Tier 1 |
25% | N/A | None |
FLUOROURACIL 5% TOPICAL SOLUTION |
1 |
Tier 1 |
25% | N/A | None |
FLUOXETINE 20 MG/5 ML SOLUTION [Prozac] |
1 |
Tier 1 |
25% | N/A | None |
FLUOXETINE HCL 10 MG CAPSULE [Prozac] |
1 |
Tier 1 |
25% | N/A | None |
FLUOXETINE HCL 10 MG TABLET [Sarafem] |
1 |
Tier 1 |
25% | N/A | None |
FLUOXETINE HCL 20 MG CAPSULE |
1 |
Tier 1 |
25% | N/A | None |
FLUOXETINE HCL 20 MG TABLET [Sarafem] |
1 |
Tier 1 |
25% | N/A | None |
FLUOXETINE HCL 40 MG CAPSULE [Prozac] |
1 |
Tier 1 |
25% | N/A | None |
FLUOXETINE HCL 60 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUPHENAZINE 1 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
FLUPHENAZINE 10 MG TABLET [Prolixin] |
1 |
Tier 1 |
25% | N/A | None |
FLUPHENAZINE 2.5 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
FLUPHENAZINE 2.5 MG/5 ML ELIXIR [Prolixin] |
1 |
Tier 1 |
25% | N/A | None |
FLUPHENAZINE 2.5MG/ML VIAL |
1 |
Tier 1 |
25% | N/A | None |
FLUPHENAZINE 5 MG TABLET |
1 |
Tier 1 |
25% | N/A | None |
FLUPHENAZINE 5MG/ML CONC |
1 |
Tier 1 |
25% | N/A | None |
FLUPHENAZINE DEC 125 MG/5 ML VIAL [Prolixin Decanoate] |
1 |
Tier 1 |
25% | N/A | None |
FLURBIPROFEN 0.03% EYE DROPS [Ocufen] |
1 |
Tier 1 |
25% | N/A | None |
Flurbiprofen 100mg/1 100 BOTTLE in 1 BOTTLE / 100 FILM COATED TABLETS in BOTTLE |
1 |
Tier 1 |
25% | N/A | None |
FLUTICASONE PROP 0.005% OINTMENT [Cutivate] |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUTICASONE PROP HFA 110 MCG AER W/ADAP [Flovent HFA] |
1 |
Tier 1 |
25% | N/A | None |
FLUTICASONE PROP HFA 220 MCG AER W/ADAP [Flovent HFA] |
1 |
Tier 1 |
25% | N/A | None |
FLUTICASONE PROP HFA 44 MCG AER W/ADAP [Flovent HFA] |
1 |
Tier 1 |
25% | N/A | None |
Fluticasone Propionate 0.5mg/g 1 TUBE per CARTON / 30 g in 1 TUBE |
1 |
Tier 1 |
25% | N/A | None |
FLUTICASONE PROPIONATE 50 MCG SPRAY SUSPENSION |
1 |
Tier 1 |
25% | N/A | None |
FLUTICASONE-SALMETEROL 100-50 INHALER [Advair] |
1 |
Tier 1 |
25% | N/A | None |
FLUTICASONE-SALMETEROL 113-14 [Advair Diskus, Advair HFA, AIRDUO RESPICLICK] |
1 |
Tier 1 |
25% | N/A | None |
FLUTICASONE-SALMETEROL 115-21 HFA AER AD [Advair HFA] |
1 |
Tier 1 |
25% | N/A | None |
FLUTICASONE-SALMETEROL 230-21 HFA AER AD [Advair HFA] |
1 |
Tier 1 |
25% | N/A | None |
FLUTICASONE-SALMETEROL 232-14 [Advair Diskus, Advair HFA, AIRDUO RESPICLICK] |
1 |
Tier 1 |
25% | N/A | None |
FLUTICASONE-SALMETEROL 250-50 INHALER [Advair] |
1 |
Tier 1 |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FLUTICASONE-SALMETEROL 45-21 HFA AER AD [Advair HFA] |
1 |
Tier 1 |
25% | N/A | None |
FLUTICASONE-SALMETEROL 500-50 INHALER [Advair] |
1 |
Tier 1 |
25% | N/A | None |
FLUTICASONE-SALMETEROL 55-14 [Advair Diskus, Advair HFA, AIRDUO RESPICLICK] |
1 |
Tier 1 |
25% | N/A | None |
FLUVASTATIN ER 80 MG TABLET ER 24H [Lescol XL] |
1 |
Tier 1 |
25% | N/A | None |
FLUVOXAMINE ER 100 MG CAPSULE |
1 |
Tier 1 |
25% | N/A | None |
FLUVOXAMINE ER 150 MG CAPSULE |
1 |
Tier 1 |
25% | N/A | None |
FLUVOXAMINE MALEATE 100 MG TABLET [Luvox] |
1 |
Tier 1 |
25% | N/A | None |
FLUVOXAMINE MALEATE 25 MG TABLET [Luvox] |
1 |
Tier 1 |
25% | N/A | None |
FLUVOXAMINE MALEATE 50 MG TABLET [Luvox] |
1 |
Tier 1 |
25% | N/A | None |
FONDAPARINUX 10 MG/0.8 ML SYRINGE [Arixtra] |
1 |
Tier 1 |
25% | N/A | None |
FONDAPARINUX 2.5 MG/0.5 ML SYRINGE [Arixtra] |
1 |
Tier 1 |
25% | 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] |
1 |
Tier 1 |
25% | N/A | None |
FONDAPARINUX 7.5 MG/0.6 ML SYRINGE [Arixtra] |
1 |
Tier 1 |
25% | N/A | None |
FOSAMPRENAVIR 700 MG TABLET [Lexiva] |
1 |
Tier 1 |
25% | N/A | None |
FOSFOMYCIN 3 GM SACHET PACKET [Monurol] |
1 |
Tier 1 |
25% | N/A | None |
FOSINOPRIL SODIUM 10 MG TABLET [Monopril] |
1 |
Tier 1 |
25% | N/A | None |
FOSINOPRIL SODIUM 20 MG TABLET [Monopril] |
1 |
Tier 1 |
25% | N/A | None |
FOSINOPRIL SODIUM 40 MG TABLET [Monopril] |
1 |
Tier 1 |
25% | N/A | None |
FOSINOPRIL-HCTZ 10-12.5 MG TABLET [Monopril-HCT] |
1 |
Tier 1 |
25% | N/A | None |
FOSINOPRIL-HCTZ 20-12.5 MG TABLET [Monopril-HCT] |
1 |
Tier 1 |
25% | N/A | None |
FOTIVDA 0.89 MG CAPSULE |
1 |
Tier 1 |
25% | N/A | P Q:21 /28Days |
FOTIVDA 1.34 MG CAPSULE |
1 |
Tier 1 |
25% | N/A | P Q:21 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FRUZAQLA 1 MG CAPSULE |
1 |
Tier 1 |
25% | N/A | P Q:84 /21Days |
FRUZAQLA 5 MG CAPSULE |
1 |
Tier 1 |
25% | N/A | P Q:21 /21Days |
FUROSEMIDE 10 MG/ML SOLUTION |
1 |
Tier 1 |
25% | N/A | None |
FUROSEMIDE 100 MG/10 ML VIAL |
1 |
Tier 1 |
25% | N/A | None |
FUROSEMIDE 20 MG TABLET [Lasix] |
1 |
Tier 1 |
25% | N/A | None |
FUROSEMIDE 40 MG TABLET [Lasix] |
1 |
Tier 1 |
25% | N/A | None |
FUROSEMIDE 40MG/5ML TUBEX |
1 |
Tier 1 |
25% | N/A | None |
FUROSEMIDE 80 MG TABLET [Lasix] |
1 |
Tier 1 |
25% | N/A | None |
FUZEON 90 MG VIAL |
1 |
Tier 1 |
25% | N/A | None |
FYCOMPA 0.5 MG/ML ORAL SUSPENSION |
1 |
Tier 1 |
25% | N/A | Q:720 /30Days |
FYCOMPA 10 MG TABLET |
1 |
Tier 1 |
25% | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
FYCOMPA 12 MG TABLET |
1 |
Tier 1 |
25% | N/A | Q:30 /30Days |
FYCOMPA 2 MG TABLET |
1 |
Tier 1 |
25% | N/A | Q:30 /30Days |
FYCOMPA 4 MG TABLET |
1 |
Tier 1 |
25% | N/A | Q:30 /30Days |
FYCOMPA 6 MG TABLET |
1 |
Tier 1 |
25% | N/A | Q:30 /30Days |
FYCOMPA 8 MG TABLET |
1 |
Tier 1 |
25% | N/A | Q:30 /30Days |