2018 Medicare Part D Plan Formulary Information |
FHCP's Premier Plus Plan (HMO) (H1035-011-0)
Benefit Details
|
The FHCP's Premier Plus Plan (HMO) (H1035-011-0) Formulary Drugs Starting with the Letter L in Seminole County, FL: CMS MA Region 9 which includes: FL Plan Monthly Premium: $24.00 Deductible: $0 |
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 100 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
LABETALOL HCL 200 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
LABETALOL HCL 300 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
LACTATED RINGERS INJECTION |
5 |
Injectable Drugs |
25% | N/A | P |
LACTULOSE 10 GM/15 ML SOLUTION [Constulose] |
2 |
Generic |
$7.00 | N/A | None |
Lamivudine 10 mg/ml oral soln |
2 |
Generic |
$7.00 | N/A | None |
LAMIVUDINE 150 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
LAMIVUDINE 300 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
Lamivudine hbv 100 mg tablet |
2 |
Generic |
$7.00 | N/A | None |
LAMIVUDINE-ZIDOVUDINE TABLET |
2 |
Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE 150MG TABLET (60 CT) |
2 |
Generic |
$7.00 | N/A | None |
LAMOTRIGINE 200MG TABLET (60 CT) |
2 |
Generic |
$7.00 | N/A | None |
LAMOTRIGINE 25 MG DISPER TAB CHW DSP [Lamictal CD] |
2 |
Generic |
$7.00 | N/A | None |
LAMOTRIGINE 25MG TABLET (100 CT) |
2 |
Generic |
$7.00 | N/A | None |
LAMOTRIGINE 5 MG DISPER TABLET CHW DSP [Lamictal CD] |
2 |
Generic |
$7.00 | N/A | None |
LAMOTRIGINE TABLET 100MG (100 CT) |
2 |
Generic |
$7.00 | N/A | None |
LANSOPRAZOLE DR 15 MG CAPSULE DR [Prevacid]
|
2 |
Generic |
$7.00 | N/A | None |
LANSOPRAZOLE DR 30 MG CAPSULE [Prevacid] |
2 |
Generic |
$7.00 | N/A | None |
LANTHANUM CARB 1,000 MG TAB CHEW [Fosrenol] |
6 |
Specialty Tier |
33% | N/A | P |
LANTHANUM CARB 500 MG TAB CHEW [Fosrenol] |
6 |
Specialty Tier |
33% | N/A | P |
LANTHANUM CARB 750 MG TAB CHEW [Fosrenol] |
6 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LANTUS 100U/ML VIAL |
4 |
Non-Preferred Brand |
$90.00 | N/A | None |
Lartruvo 19 mL in 1 VIAL, SINGLE-USE |
6 |
Specialty Tier |
33% | N/A | P |
LARTRUVO 500 MG/50 ML VIAL |
6 |
Specialty Tier |
33% | N/A | P |
LATANOPROST 0.005% EYE DROPS |
2 |
Generic |
$7.00 | N/A | None |
LATUDA 120 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P |
LATUDA 20 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P |
LATUDA 40 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P |
LATUDA 60 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P |
LATUDA 80 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P |
LEFLUNOMIDE 10 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
LEFLUNOMIDE 20 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LENVIMA 10 MG DAILY DOSE |
6 |
Specialty Tier |
33% | N/A | P |
LENVIMA 14 MG DAILY DOSE |
6 |
Specialty Tier |
33% | N/A | P |
LENVIMA 20 MG DAILY DOSE |
6 |
Specialty Tier |
33% | N/A | P |
LENVIMA 24 MG DAILY DOSE |
6 |
Specialty Tier |
33% | N/A | P |
LETROZOLE 2.5 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
LEUCOVORIN CALCIUM 100MG VL |
5 |
Injectable Drugs |
25% | N/A | P |
LEUCOVORIN CALCIUM 350MG VL |
5 |
Injectable Drugs |
25% | N/A | P |
LEUCOVORIN CALCIUM 5 MG TAB |
2 |
Generic |
$7.00 | N/A | None |
LEUKERAN 2 MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | None |
LEUKINE 250 MCG VIAL |
6 |
Specialty Tier |
33% | N/A | P |
LEUPROLIDE 2WK 14 MG/2.8 ML KT |
5 |
Injectable Drugs |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVEMIR 100UNITS/ML VIAL |
3 |
Preferred Brand |
$42.00 | N/A | None |
LEVEMIR FLEXTOUCH 100 UNITS/ML |
3 |
Preferred Brand |
$42.00 | N/A | None |
LEVETIRACETAM 1,000 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
LEVETIRACETAM 100 MG/ML SOLN |
2 |
Generic |
$7.00 | N/A | None |
Levetiracetam 100 ML 10 MG/ML Injection |
5 |
Injectable Drugs |
25% | N/A | None |
Levetiracetam 100 ML 15 MG/ML Injection |
5 |
Injectable Drugs |
25% | N/A | None |
Levetiracetam 100 ML 5 MG/ML Injection |
5 |
Injectable Drugs |
25% | N/A | None |
LEVETIRACETAM 250 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
LEVETIRACETAM 500 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
LEVETIRACETAM 750 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
LEVETIRACETAM ER 500 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM ER 750 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION |
1 |
Preferred Generic |
$0.00 | N/A | None |
LEVOCETIRIZINE 5 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
LEVOFLOXACIN 0.5% EYE DROPS [LEVAQUIN] |
2 |
Generic |
$7.00 | N/A | None |
LEVOFLOXACIN 25 MG/ML SOLUTION [LEVAQUIN] |
2 |
Generic |
$7.00 | N/A | None |
LEVOFLOXACIN 250 MG TABLET [LEVAQUIN] |
2 |
Generic |
$7.00 | N/A | None |
Levofloxacin 500 MG per 20 ML Injection [LEVAQUIN] |
5 |
Injectable Drugs |
25% | N/A | P |
LEVOFLOXACIN 500 MG TABLET [LEVAQUIN] |
2 |
Generic |
$7.00 | N/A | None |
Levofloxacin 5mg/mL 24 POUCH per CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG [LEVAQUIN] |
5 |
Injectable Drugs |
25% | N/A | P |
LEVOFLOXACIN 750 MG TABLET [LEVAQUIN] |
2 |
Generic |
$7.00 | N/A | None |
LEVONOR-ETH ESTRAD 0.1-0.02 MG |
2 |
Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVONOR-ETH ESTRAD TRIPHASIC |
2 |
Generic |
$7.00 | N/A | None |
Levora-28 tablet |
2 |
Generic |
$7.00 | N/A | None |
LEVOTHYROXINE 100 MCG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
LEVOTHYROXINE 112 MCG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
LEVOTHYROXINE 125 MCG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
LEVOTHYROXINE 137 MCG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
LEVOTHYROXINE 150 MCG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
LEVOTHYROXINE 175 MCG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
LEVOTHYROXINE 200 MCG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
LEVOTHYROXINE 25 MCG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
LEVOTHYROXINE 300 MCG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE 50 MCG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
LEVOTHYROXINE 75 MCG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
LEVOTHYROXINE 88 MCG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
LEXIVA 50mg/mL 225 mL in 1 BOTTLE |
3 |
Preferred Brand |
$42.00 | N/A | None |
LEXIVA 700MG TABLETS |
3 |
Preferred Brand |
$42.00 | N/A | None |
LIDOCAINE 2% VISCOUS SOLN |
2 |
Generic |
$7.00 | N/A | Q:360 /3Days |
LIDOCAINE 5% OINTMENT |
2 |
Generic |
$7.00 | N/A | Q:35 /2Days |
Lidocaine 5% patch |
2 |
Generic |
$7.00 | N/A | P |
LIDOCAINE-PRILOCAINE CREAM |
2 |
Generic |
$7.00 | N/A | Q:30 /30Days |
Lincomycin 300 MG/ML Injectable Solution [Lincocin] |
5 |
Injectable Drugs |
25% | N/A | None |
Linezolid 20 MG/ML Oral Suspension [Zyvox] |
2 |
Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LINEZOLID 600 MG TABLET [Zyvox] |
2 |
Generic |
$7.00 | N/A | None |
LINEZOLID 600 MG/300 ML IV SOL [Zyvox] |
5 |
Injectable Drugs |
25% | N/A | None |
LINZESS 145 MCG CAPSULE |
3 |
Preferred Brand |
$42.00 | N/A | None |
LINZESS 290 MCG CAPSULE |
3 |
Preferred Brand |
$42.00 | N/A | None |
LINZESS 72 MCG CAPSULE |
3 |
Preferred Brand |
$42.00 | N/A | None |
LIOTHYRONINE SOD 25 MCG TAB |
2 |
Generic |
$7.00 | N/A | None |
LIOTHYRONINE SOD 5 MCG TAB |
2 |
Generic |
$7.00 | N/A | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT |
2 |
Generic |
$7.00 | N/A | None |
LISINOPRIL 10 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
LISINOPRIL 2.5 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
LISINOPRIL 20 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL 30 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
LISINOPRIL 40 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
LISINOPRIL 5 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
LISINOPRIL-HCTZ 10-12.5 MG TAB |
1 |
Preferred Generic |
$0.00 | N/A | None |
LISINOPRIL-HCTZ 20-12.5 MG TAB |
1 |
Preferred Generic |
$0.00 | N/A | None |
LISINOPRIL-HCTZ 20-25 MG TAB |
1 |
Preferred Generic |
$0.00 | N/A | None |
LITHIUM CARBONATE 150 MG CAP |
2 |
Generic |
$7.00 | N/A | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) |
1 |
Preferred Generic |
$0.00 | N/A | None |
Lithium Carbonate 450mg/1 |
2 |
Generic |
$7.00 | N/A | None |
LITHIUM CARBONATE ER 300 MG TB |
2 |
Generic |
$7.00 | N/A | None |
LITHIUM CIT 8MEQ/5ML SYRUP |
2 |
Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LONSURF 15 MG-6.14 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P |
LONSURF 20 MG-8.19 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P |
LOPERAMIDE HCL 2MG CAPSULE |
2 |
Generic |
$7.00 | N/A | None |
LOPINAVIR-RITONAVIR 80-20MG/ML Solution [Kaletra] |
2 |
Generic |
$7.00 | N/A | None |
LORAZEPAM 0.5 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
LORAZEPAM 1 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
LORAZEPAM 2 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
LOSARTAN POTASSIUM 100 MG TAB |
1 |
Preferred Generic |
$0.00 | N/A | None |
LOSARTAN POTASSIUM 25 MG TAB |
1 |
Preferred Generic |
$0.00 | N/A | None |
LOSARTAN POTASSIUM 50 MG TAB |
1 |
Preferred Generic |
$0.00 | N/A | None |
LOSARTAN-HCTZ 100-12.5 MG TAB |
1 |
Preferred Generic |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOSARTAN-HCTZ 100-25 MG TAB |
1 |
Preferred Generic |
$0.00 | N/A | None |
LOSARTAN-HCTZ 50-12.5 MG TAB |
1 |
Preferred Generic |
$0.00 | N/A | None |
LOTEMAX 0.5% EYE DROPS |
4 |
Non-Preferred Brand |
$90.00 | N/A | None |
LOVASTATIN 10 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
LOVASTATIN 20 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
LOVASTATIN 40 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
LOXAPINE 10 MG CAPSULE |
2 |
Generic |
$7.00 | N/A | None |
LOXAPINE 25MG CAPSULE (100 CT) |
2 |
Generic |
$7.00 | N/A | None |
LOXAPINE CAPSULES 50MG 100 BOT |
2 |
Generic |
$7.00 | N/A | None |
LOXAPINE CAPSULES 5MG 100 BOT |
2 |
Generic |
$7.00 | N/A | None |
Lumizyme 5mg/mL |
5 |
Injectable Drugs |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUPRON DEPOT 11.25 MG 3MO KIT |
5 |
Injectable Drugs |
25% | N/A | P |
LUPRON DEPOT 22.5 MG 3MO KIT SYRINGEKIT |
5 |
Injectable Drugs |
25% | N/A | P |
LUPRON DEPOT 3.75 MG KIT |
5 |
Injectable Drugs |
25% | N/A | P |
LUPRON DEPOT 7.5 MG KIT |
5 |
Injectable Drugs |
25% | N/A | P |
LUPRON DEPOT-PED 11.25 MG KIT |
5 |
Injectable Drugs |
25% | N/A | P |
LUPRON DEPOT-PED 15 MG KIT |
5 |
Injectable Drugs |
25% | N/A | P |
LYNPARZA 100 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P |
LYNPARZA 150 MG TABLET |
6 |
Specialty Tier |
33% | N/A | P |
LYNPARZA 50 MG CAPSULE |
6 |
Specialty Tier |
33% | N/A | P |
LYRICA 100MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | N/A | Q:93 /31Days |
LYRICA 150MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | N/A | Q:93 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYRICA 20 MG/ML ORAL SOLUTION |
4 |
Non-Preferred Brand |
$90.00 | N/A | None |
LYRICA 200MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | N/A | Q:93 /31Days |
LYRICA 225MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | N/A | Q:93 /31Days |
LYRICA 25MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | N/A | Q:93 /31Days |
LYRICA 300MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | N/A | Q:93 /31Days |
LYRICA 50MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | N/A | Q:93 /31Days |
LYRICA 75MG CAPSULE |
4 |
Non-Preferred Brand |
$90.00 | N/A | Q:93 /31Days |
LYSODREN 500MG TABLET |
3 |
Preferred Brand |
$42.00 | N/A | None |