2013 Medicare Part D Plan Formulary Information |
FHCP Medvantage Rx (HMO) (H1035-006-0)
Benefit Details
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The FHCP Medvantage Rx (HMO) (H1035-006-0) Formulary Drugs Starting with the Letter L in VOLUSIA County, FL: CMS MA Region 9 which includes: FL
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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 |
L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE 16 VACCINE 0.04 MG/ML / L1 PROTEIN, HUMAN PAPILLOMAVIRU |
6 |
Injectable Drugs |
25% | 25% | None |
LABETALOL HCL 100MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LABETALOL HCL 200MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LABETALOL HCL 300MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LACTATED RINGERS INJECTION |
6 |
Injectable Drugs |
25% | 25% | None |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | Q:480 /3Days |
LAMIVUDINE 150 MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LAMIVUDINE 300 MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LAMIVUDINE-ZIDOVUDINE TABLET |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LAMOTRIGINE 150MG TABLET (60 CT) |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE 200MG TABLET (60 CT) |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LAMOTRIGINE 25MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LAMOTRIGINE TABLET 100MG (100 CT) |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
Lansoprazole 15mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
Lansoprazole 30mg/1 30 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LANTUS 100U/ML VIAL |
4 |
Non-Preferred Brand |
$70.00 | $207.00 | Q:10 /3Days |
LATANOPROST OPHTHALMIC SOLUTION .005% |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | Q:3 /3Days |
LATUDA 120 MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $207.00 | P |
LATUDA 20 MG TABLET |
4 |
Non-Preferred Brand |
$70.00 | $207.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Latuda 40mg/1 |
4 |
Non-Preferred Brand |
$70.00 | $207.00 | P |
Latuda 80mg/1 |
4 |
Non-Preferred Brand |
$70.00 | $207.00 | P |
LEFLUNOMIDE 10MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LEFLUNOMIDE TABLETS |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
Letrozole 2.5mg/1 500 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LEUCOVORIN CALCIUM 100MG VL |
6 |
Injectable Drugs |
25% | 25% | None |
LEUCOVORIN CALCIUM 5MG TABLET |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LEUKERAN 2MG TABLET |
3 |
Preferred Brand |
$40.00 | $117.00 | None |
LEUKINE INJECTION 250 MCG/ML |
5 |
Specialty Tier |
29% | N/A | P |
LEUPROLIDE ACETATE INJECTION |
6 |
Injectable Drugs |
25% | 25% | None |
LEVEMIR 100UNITS/ML VIAL |
3 |
Preferred Brand |
$40.00 | $117.00 | Q:10 /3Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LEVETIRACETAM 100MG/ML INJECTION |
6 |
Injectable Drugs |
25% | 25% | None |
LEVETIRACETAM 500 MG TABLET 120 BOT |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
Levetiracetam 750mg/1 60 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
Levetiracetam er 500 mg tablet |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LEVETIRACETAM TABLETS 1000MG 60 BOT |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LEVETIRACETAM TABLETS 250MG 500 BOT |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LEVETIRACETAM TABLETS 750MG 500 BOT |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION |
1 |
Preferred Generic |
$2.00 | $3.00 | Q:10 /3Days |
Levocetirizine dihydrochloride 5mg/1 30 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
Levofloxacin 250mg/1 |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levofloxacin 25mg/mL 1 BOTTLE in 1 CARTON / 100 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | Q:100 /3Days |
Levofloxacin 500mg/1 |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
Levofloxacin 5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | Q:5 /3Days |
Levofloxacin 5mg/mL 24 POUCH in 1 CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG |
6 |
Injectable Drugs |
25% | 25% | None |
Levofloxacin 750mg/1 |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LEVORA-28 TABLET 0.15/30 |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
Levothyroxine Sodium 100ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$2.00 | $3.00 | None |
Levothyroxine Sodium 112ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$2.00 | $3.00 | None |
Levothyroxine Sodium 125ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$2.00 | $3.00 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET |
1 |
Preferred Generic |
$2.00 | $3.00 | None |
Levothyroxine Sodium 150ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$2.00 | $3.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levothyroxine Sodium 175ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$2.00 | $3.00 | None |
Levothyroxine Sodium 200ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$2.00 | $3.00 | None |
Levothyroxine Sodium 25ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1 |
Preferred Generic |
$2.00 | $3.00 | None |
Levothyroxine Sodium 300ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$2.00 | $3.00 | None |
Levothyroxine Sodium 50ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1 |
Preferred Generic |
$2.00 | $3.00 | None |
Levothyroxine Sodium 75ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1 |
Preferred Generic |
$2.00 | $3.00 | None |
Levothyroxine Sodium 88ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1 |
Preferred Generic |
$2.00 | $3.00 | None |
LEXIVA 50mg/mL 225 mL in 1 BOTTLE |
3 |
Preferred Brand |
$40.00 | $117.00 | None |
LEXIVA TABLETS |
3 |
Preferred Brand |
$40.00 | $117.00 | None |
LIDOCAINE 5% OINTMENT |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | Q:35 /3Days |
LIDOCAINE HCL 1% VIAL |
6 |
Injectable Drugs |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | Q:100 /3Days |
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | Q:30 /3Days |
LIDODERM 5% PATCH |
4 |
Non-Preferred Brand |
$70.00 | $207.00 | P |
LINZESS 145 MCG CAPSULE |
4 |
Non-Preferred Brand |
$70.00 | $207.00 | P |
LINZESS 290 MCG CAPSULE |
4 |
Non-Preferred Brand |
$70.00 | $207.00 | P |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LISINOPRIL 10MG TABLET (100 CT) |
1 |
Preferred Generic |
$2.00 | $3.00 | None |
LISINOPRIL 2.5 MG TABLET |
1 |
Preferred Generic |
$2.00 | $3.00 | None |
LISINOPRIL 20MG TABLET |
1 |
Preferred Generic |
$2.00 | $3.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL 30MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LISINOPRIL 40MG TABLET (500 CT) |
1 |
Preferred Generic |
$2.00 | $3.00 | None |
Lisinopril 5mg/1 1000 TABLET BOTTLE |
1 |
Preferred Generic |
$2.00 | $3.00 | None |
Lithium Carbonate 150mg/1 100 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) |
1 |
Preferred Generic |
$2.00 | $3.00 | None |
Lithium Carbonate 450mg/1 |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LOPERAMIDE HCL 2MG CAPSULE |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
Lorazepam 0.5mg/1 500 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
Lorazepam 1mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
Lorazepam 2mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOSARTAN POTASSIUM 100 MG TAB |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LOSARTAN POTASSIUM 25 MG TAB |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LOSARTAN POTASSIUM 50 MG TAB |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LOTEMAX 0.5% EYE DROPS |
4 |
Non-Preferred Brand |
$70.00 | $207.00 | Q:5 /3Days |
LOTRONEX TABLETS .5MG 30 BOTPL |
3 |
Preferred Brand |
$40.00 | $117.00 | P |
LOTRONEX TABLETS 1MG 30 BOTPL |
5 |
Specialty Tier |
29% | N/A | P |
Lovastatin 10mg 60 TABLET BOTTLE |
1 |
Preferred Generic |
$2.00 | $3.00 | None |
Lovastatin 20mg 500 TABLET BOTTLE |
1 |
Preferred Generic |
$2.00 | $3.00 | None |
LOVASTATIN 40 MG ORAL TABLET |
1 |
Preferred Generic |
$2.00 | $3.00 | None |
LOVAZA 1g/ 120 LIQUID FILLED CAPSULES in BOTTLE |
3 |
Preferred Brand |
$40.00 | $117.00 | None |
LOW-OGESTREL-28 TABLET |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOXAPINE 25MG CAPSULE (100 CT) |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LOXAPINE CAPSULES 10MG 100 BOT |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LOXAPINE CAPSULES 50MG 100 BOT |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LOXAPINE CAPSULES 5MG 100 BOT |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LUPRON DEPOT 3.75 MG KIT |
6 |
Injectable Drugs |
25% | 25% | None |
LUPRON DEPOT 7.5 MG KIT |
6 |
Injectable Drugs |
25% | 25% | None |
Lupron Depot-PED 1 KIT in 1 CARTON |
6 |
Injectable Drugs |
25% | 25% | None |
LUPRON DEPOT-PED 11.25 MG KIT |
6 |
Injectable Drugs |
25% | 25% | None |
LUPRON DEPOT-PED 15 MG KIT |
6 |
Injectable Drugs |
25% | 25% | None |
LUTERA 0.1-0.02 TABLET |
2 |
Non-Preferred Generic |
$7.00 | $18.00 | None |
LYRICA 100MG CAPSULE |
4 |
Non-Preferred Brand |
$70.00 | $207.00 | P Q:93 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYRICA 150MG CAPSULE |
4 |
Non-Preferred Brand |
$70.00 | $207.00 | P Q:93 /31Days |
LYRICA 20 MG/ML ORAL SOLUTION |
4 |
Non-Preferred Brand |
$70.00 | $207.00 | P |
LYRICA 200MG CAPSULE |
4 |
Non-Preferred Brand |
$70.00 | $207.00 | P Q:93 /31Days |
LYRICA 225MG CAPSULE |
4 |
Non-Preferred Brand |
$70.00 | $207.00 | P Q:93 /31Days |
LYRICA 25MG CAPSULE |
4 |
Non-Preferred Brand |
$70.00 | $207.00 | P Q:93 /31Days |
LYRICA 300MG CAPSULE |
4 |
Non-Preferred Brand |
$70.00 | $207.00 | P Q:93 /31Days |
LYRICA 50MG CAPSULE |
4 |
Non-Preferred Brand |
$70.00 | $207.00 | P Q:93 /31Days |
LYRICA 75MG CAPSULE |
4 |
Non-Preferred Brand |
$70.00 | $207.00 | P Q:93 /31Days |
LYSODREN 500MG TABLET |
3 |
Preferred Brand |
$40.00 | $117.00 | None |