Liberty Medicare Advantage (HMO C-SNP) Formulary



Below is the 2023 Formulary, or prescription drug list, from Liberty Medicare Advantage (HMO C-SNP) by Liberty Advantage, Llc. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a North Carolina Medicare Part-C plan that covers your prescriptions. It also helps you compare costs among Medicare Part D and Medicare Advantage plans available to you. You’ll want to make sure the medicines you are currently taking are covered under any plans you are considering enrolling in.

This Liberty Medicare Advantage (HMO C-SNP)(H6351-004) plan has a $0 drug deductible. The Initial Coverage Limit (ICL) for this plan is $4660. The Initial Coverage Period is the period after the Deductible has been met but before the Coverage Gap phase. Once you and your plan provider have spent $4660 on covered drugs. (Combined amount plus your deductible) You will enter the coverage gap. (AKA "donut hole") Once you reach the coverage gap you will be required to pay 25% of the plan's cost for covered brand-name prescription drugs unless your plan offers additional coverage. You can see if this plan offers coverage in the "donut hole" by clicking the "Coverage Gap" link above the chart.

In 2023 if you have spent $7400 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. Liberty Advantage, Llc will begin paying approximately 95% of your covered medication expenses. You can see if this plan covers your drugs in the Catastrophic Phase by clicking the "Catastrophic" link above the chart.



Plan Overview

Plan Name:Liberty Medicare Advantage (HMO C-SNP)
Plan ID: H6351-004
Provider: Liberty Advantage, Llc
Plan Year:2023
Premium:$0.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:North Carolina
Similar Plan:H6351-005


Change Table Options:

Drugs Starting Letter:
Coverage Phase:

*Tip Click the Drug name to Compare Coverage and Retail Cost for Every Plan In Your Area
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Drug
Name⇅
Tier
Level
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Labetalol Hcl
1NA$0NANN
Lamivudine
2NANNANN
Lamotrigine
1NA$0NANN
Lampit
3NA$35NAYN
Lansoprazole
2NANNANN
Lansoprazole, Amoxicillin And Clarithromycin
2NANNANN
Lanthanum Carbonate
2NANNANN
Lantus
6NA$0NANN
Lapatinib
5NA33%NAYN
Larissia
2NANNANN
Latanoprost
1NA$0NA5/30NN
Layolis Fe
2NANNANN
Leena
2NANNANN
Leflunomide
1NA$0NANN
Lenvima
5NA33%NA90/30YN
Lessina
2NANNANN
Leucovorin Calcium
1NA$0NANN
Leukeran
3NA$35NANN
Leuprolide Acetate
2NANNANN
Levalbuterol
2NANNAYN
Levalbuterol Hydrochloride
2NANNAYN
Levalbuterol Tartrate Hfa Inhalation
4NA$95NA30/30NY
Levemir
6NA$0NANN
Levetiracetam
1NA$0NANN
Levo-t
1NA$0NANN
Levobunolol Hydrochloride
1NA$0NANN
Levocarnitine
1NA$0NANN
Levocetirizine Dihydrochloride
2NANNANN
Levofloxacin
2NANNANN
Levonorgestrel And Ethinyl Estradiol
2NANNANN
Levonorgestrel And Ethinyl Estradiol And Ethinyl E
2NANNANN
Levora
2NANNANN
Levothyroxine Sodium
1NA$0NANN
Levoxyl
1NA$0NANN
Lexiva
3NA$35NANN
Lidocaine
1NA$0NA107/30YN
Lidocaine Hydrochloride
1NA$0NANN
Lindane
2NANNANN
Linezolid
2NANNANN
Lisinopril
1NA$0NANN
Lithium Carbonate
1NA$0NANN
Lithostat
4NA$95NANN
Livalo
4NA$95NANY
Livmarli
5NA33%NA90/30YN
Lo Loestrin Fe
4NA$95NANN
Loestrin
2NANNANN
Lokelma
3NA$35NAYN
Lonhala Magnair
3NA$35NA60/30NY
Lonsurf
5NA33%NAYN
Loperamide Hydrochloride
1NA$0NANN
Lopinavir And Ritonavir
2NANNANN
Lopinavir-ritonavir
2NANNANN
Lorazepam
1NA$0NA150/30NN
Lorbrena
5NA33%NA30/30YN
Loryna
2NANNANN
Loteprednol Etabonate
2NANNANN
Low-ogestrel
2NANNANN
Loxapine
1NA$0NANN
Lupkynis
5NA33%NA180/30YN
Lupron Depot
5NA33%NA1/112NN
Lutera
2NANNANN
Lyleq
2NANNANN
Lyllana
1NA$0NANN
Lynparza
5NA33%NA120/30YN
Lysodren
3NA$35NANN
Lyza
2NANNANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H6351-004

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $0. Some plans offer select Pre-deductible drug Coverage
2. Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit of $4660
3. Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $7400 in 2023.
4. Catastrophic: Anything over $7400 you will receive a significant increase in coverage.

Definitions:

Premium: A monthly flat fee that varies by plan.
Deductible: The amount you must pay each year for your prescriptions before your plan begins to pay its share of your covered drugs. The max in 2023 is $505. Some plans have a $0 Deductible.
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Does the Deduct Apply: Some drugs do not require that the deductible is met before you receive coverage.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Cost Preferred: Your Cost for the Drug at the Providers In-Network Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non-Preferred: Your Cost for the Prescription Drug at a Non-Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.


What if a drug I need is not listed?

Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plan's formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.

Last updated on

Source:CMS Formulary Data Q4 2022
Source:NDC Directory by FDA.gov

**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.

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