2009 Medicare Part D Plan Formulary Information |
Citrus Part D Plus FL. (S8465-002-0)
Benefit Details
|
The Citrus Part D Plus FL. (S8465-002-0) Formulary Drugs Starting with the Letter L in CMS PDP Region 11 which includes: FL
|
Drugs Starting with Letter L
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
LABETALOL HCL 100MG TABLET |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
LABETALOL HCL 200MG TABLET |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
LABETALOL HCL 300MG TABLET |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
LACLOTION 12% LOTION |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
LACRISERT OPTHALMIC INSERT 5MG 60 BLPK |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | None |
LACTATED RINGERS INJECTION |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | P |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
LAMICTAL 100MG TABLET |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | Q:90 /30Days |
LAMICTAL 150MG TABLET |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | Q:90 /30Days |
LAMICTAL 200MG TABLET |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMICTAL 25MG TABLET |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | Q:90 /30Days |
LAMICTAL 25MG TABLET STARTER KIT |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | Q:90 /30Days |
LAMICTAL TABLET STARTER KIT |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | Q:90 /30Days |
LAMICTAL TABLET STARTER KIT |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | Q:90 /30Days |
LAMISIL 1% SOLUTION |
3 |
Tier 3 - Preferred Brands |
$30.00 | $90.00 | Q:30 /30Days |
LAMOTRIGINE 25MG TABLET DISPERSIBLE |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | Q:600 /30Days |
LAMOTRIGINE 5MG TABLET DISPERSIBLE |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | Q:600 /30Days |
LANOXIN 0.125MG TABLET |
3 |
Tier 3 - Preferred Brands |
$30.00 | $90.00 | Q:120 /30Days |
LANOXIN 0.25MG TABLET |
3 |
Tier 3 - Preferred Brands |
$30.00 | $90.00 | Q:60 /30Days |
LANOXIN 0.25MG/ML AMPUL |
3 |
Tier 3 - Preferred Brands |
$30.00 | $90.00 | P |
LANOXIN PED 0.1MG/ML AMPUL |
3 |
Tier 3 - Preferred Brands |
$30.00 | $90.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LANTUS 100U/ML VIAL |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | Q:30 /30Days |
LANTUS INJECTION |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | Q:30 /30Days |
LEENA 7-9-5 TABLET |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
LEFLUNOMIDE 10MG TABLET (500 CT) |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
LEFLUNOMIDE 20MG TABLET (500 CT) |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
LESSINA 0.1-0.02 TABLET |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
LEUCOVORIN CALCIUM 100MG VL |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | P |
LEUCOVORIN CALCIUM 10MG TABLET |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | P |
LEUCOVORIN CALCIUM 15MG TABLET |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | None |
LEUCOVORIN CALCIUM 200MG VL |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | P |
LEUCOVORIN CALCIUM 25MG TABLET |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUCOVORIN CALCIUM 350MG VL |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | P |
LEUCOVORIN CALCIUM 50MG VL |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | P |
LEUCOVORIN CALCIUM 5MG TABLET |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | None |
LEUCOVORIN CALCIUM INJECTION 10MG/ML 1X50ML VIL CRTN |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | P |
LEUKERAN 2MG TABLET |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | P |
LEUPROLIDE 1MG/0.2ML VIAL |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | P |
LEVATOL 20MG TABLET |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
LEVEMIR 100UNITS/ML VIAL |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | Q:30 /30Days |
LEVEMIR FLEXPEN 100UNITS/ML |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | Q:30 /30Days |
LEVOBUNOLOL 0.5% EYE DROPS |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
LEVOBUNOLOL HCL OPHTHALMIC SOLUTION 0.25% 10ML BOT |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOCARNITINE 100MG/ML SOLUTION ORAL |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
LEVOCARNITINE TABLET 330MG 90 BLPK |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
LEVORA-28 TABLET 0.15/30 |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
LEVORPHANOL 2MG TABLET |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
LEVOTHROID 100MCG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LEVOTHROID 112MCG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LEVOTHROID 125MCG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LEVOTHROID 137MCG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LEVOTHROID 150MCG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LEVOTHROID 175MCG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LEVOTHROID 200MCG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHROID 25MCG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LEVOTHROID 300MCG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LEVOTHROID 50MCG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LEVOTHROID 75MCG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LEVOTHROID 88MCG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT) |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM .150MG TABLET (100 CT) |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 100MCG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 112MCG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 125MCG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE SODIUM 175MCG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 200MCG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 25MCG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 300MCG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 50MCG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 88MCG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LEXAPRO 10MG TABLET |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | Q:30 /30Days |
LEXAPRO 20MG TABLET |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | Q:30 /30Days |
LEXAPRO 5MG TABLET |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | Q:30 /30Days |
LEXAPRO 5MG/5ML SOLUTION |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | Q:620 /30Days |
LEXIVA 50MG/ML SUSPENSION ORAL |
3 |
Tier 3 - Preferred Brands |
$30.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEXIVA 700MG TABLET |
3 |
Tier 3 - Preferred Brands |
$30.00 | $90.00 | None |
LIDOCAINE 5% OINTMENT |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
LIDOCAINE HCL 2% JELLY |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
LIDOCAINE HCL 2% JELLY 30ML TUBE |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | Q:30 /1Days |
LIDODERM 5% PATCH |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | Q:90 /30Days |
LIDOMAR VISCOUS 20MG/ML SOLUTION NON-ORAL |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LINDANE 1% LOTION |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
LINDANE 1% SHAMPOO |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
LIPITOR 10MG TABLET |
3 |
Tier 3 - Preferred Brands |
$30.00 | $90.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIPITOR 20MG TABLET (5000 CT) |
3 |
Tier 3 - Preferred Brands |
$30.00 | $90.00 | Q:30 /30Days |
LIPITOR 40MG TABLET (500 CT) |
3 |
Tier 3 - Preferred Brands |
$30.00 | $90.00 | Q:30 /30Days |
LIPITOR 80MG TABLET |
3 |
Tier 3 - Preferred Brands |
$30.00 | $90.00 | Q:30 /30Days |
LISINOPRIL 10MG TABLET (100 CT) |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LISINOPRIL 2.5MG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LISINOPRIL 20MG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LISINOPRIL 30MG TABLET (100 CT) |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LISINOPRIL 40MG TABLET (500 CT) |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LISINOPRIL 5MG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LISINOPRIL-HCTZ 10/12.5 TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT) |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL-HCTZ 20/12.5 TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LITHIUM CARBONATE 150MG CAPSULE |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LITHIUM CARBONATE 300MG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LITHIUM CARBONATE 450MG TABLET SA |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LITHIUM CARBONATE 600MG CAP |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LODOSYN 25MG TABLET |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | None |
LOFENE 2.5MG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LOFIBRA 67MG CAPSULE |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOKARA 0.05% LOTION |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
LONOX 2.5MG TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LOPROX 0.77% CREAM |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | None |
LOPROX 1% SHAMPOO |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | None |
LOPROX GEL TOPICAL |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | None |
LOTEMAX 0.5% EYE DROPS |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | None |
LOTRONEX 0.5MG TABLET |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | Q:60 /30Days |
LOTRONEX 1MG TABLET |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | Q:60 /30Days |
LOVASTATIN 10MG TABLET (100 CT) |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | Q:30 /30Days |
LOVASTATIN 20MG TABLET (1000 CT) |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | Q:30 /30Days |
LOVASTATIN 40MG TABLET (100 CT) |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOVAZA 1G CAPSULE |
3 |
Tier 3 - Preferred Brands |
$30.00 | $90.00 | Q:120 /30Days |
LOVENOX 100MG PREFILLED SYR |
5 |
Tier 5 - Specialty |
33% | N/A | P Q:28 /30Days |
LOVENOX 120MG PREFILLED SYR |
5 |
Tier 5 - Specialty |
33% | N/A | P Q:22 /30Days |
LOVENOX 150MG PREFILLED SYR |
5 |
Tier 5 - Specialty |
33% | N/A | P Q:28 /30Days |
LOVENOX 300MG VIAL |
5 |
Tier 5 - Specialty |
33% | N/A | P Q:84 /30Days |
LOVENOX 30MG PREFILLED SYRN |
5 |
Tier 5 - Specialty |
33% | N/A | P Q:8 /30Days |
LOVENOX 40MG PREFILLED SYRN |
5 |
Tier 5 - Specialty |
33% | N/A | P Q:11 /30Days |
LOVENOX 60MG PREFILLED SYRN |
5 |
Tier 5 - Specialty |
33% | N/A | P Q:16 /30Days |
LOVENOX 80MG PREFILLED SYRN |
5 |
Tier 5 - Specialty |
33% | N/A | P Q:22 /30Days |
LOW-OGESTREL-28 TABLET |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
LOXAPINE 10MG CAPSULE (1000 CT) |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOXAPINE 25MG CAPSULE (100 CT) |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
LOXAPINE 50MG CAPSULE (1000 CT) |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
LOXAPINE 5MG CAPSULE (100 CT) |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |
LUMIGAN 0.03% EYE DROPS |
4 |
Tier 4 - Brands |
$65.00 | $195.00 | Q:7 /30Days |
LUTERA 0.1-0.02 TABLET |
1 |
Tier 1 - Preferred Generics |
$0.00 | $0.00 | None |
LYRICA 100MG CAPSULE |
3 |
Tier 3 - Preferred Brands |
$30.00 | $90.00 | Q:120 /30Days |
LYRICA 150MG CAPSULE |
3 |
Tier 3 - Preferred Brands |
$30.00 | $90.00 | Q:120 /30Days |
LYRICA 200MG CAPSULE |
3 |
Tier 3 - Preferred Brands |
$30.00 | $90.00 | Q:120 /30Days |
LYRICA 225MG CAPSULE |
3 |
Tier 3 - Preferred Brands |
$30.00 | $90.00 | Q:120 /30Days |
LYRICA 25MG CAPSULE |
3 |
Tier 3 - Preferred Brands |
$30.00 | $90.00 | Q:120 /30Days |
LYRICA 300MG CAPSULE |
3 |
Tier 3 - Preferred Brands |
$30.00 | $90.00 | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYRICA 50MG CAPSULE |
3 |
Tier 3 - Preferred Brands |
$30.00 | $90.00 | Q:120 /30Days |
LYRICA 75MG CAPSULE |
3 |
Tier 3 - Preferred Brands |
$30.00 | $90.00 | Q:120 /30Days |
LYSODREN 500MG TABLET |
2 |
Tier 2 - Generics |
$5.00 | $15.00 | None |