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AARP MedicareRx Preferred (PDP) (S5820-035-0)
Tier 1 (1691)
Tier 2 (794)
Tier 3 (2052)
Tier 4 (379)

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A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2010 Medicare Part D Plan Formulary Information
AARP MedicareRx Preferred (PDP) (S5820-035-0)
Benefit Details  
The AARP MedicareRx Preferred (PDP) (S5820-035-0)
Formulary Drugs Starting with the Letter L
in CMS PDP Region 36 which includes: GU
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   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LABETALOL HCL 200MG TABLET   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LABETALOL HCL 300MG TABLET   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LABETALOL HCL 5MG/20ML VIAL   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LAC HYDRIN LOTION 12% 225 G BOTPL   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LAC-HYDRIN 12% CREAM   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LACLOTION 12% LOTION   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LACRISERT OPTHALMIC INSERT 5MG 60 BLPK   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LACTATED RINGERS INJECTION   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LACTATED RINGERS IRRIGATION 20-30-600MG 3000ML BAG   1 Tier 1 Preferred Generic Brand $10.00$14.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LAMICTAL 100MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LAMICTAL 150MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LAMICTAL 200MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LAMICTAL 25MG DISPER TABLET CHEW   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LAMICTAL 25MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LAMICTAL 25MG TABLET STARTER KIT   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LAMICTAL 5MG DISPER TABLET CHEW   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LAMICTAL ODT 100MG TABLET 30 EA   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:93
/31Days
LAMICTAL ODT 200MG TABLET 30 EA   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:93
/31Days
LAMICTAL ODT 25MG TABLET 30 EA   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:31
/31Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LAMICTAL ODT 50MG TABLET 30 EA   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:31
/31Days
LAMICTAL TABLET STARTER KIT   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LAMICTAL TABLET STARTER KIT   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LAMISIL 1% SOLUTION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LAMISIL 125MG GRANULES IN PACKET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LAMISIL 187.5MG GRANULES IN PACKET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LAMISIL 250MG TABLET (30 CT)   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LAMOTRIGINE 150MG TABLET (60 CT)   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LAMOTRIGINE 200MG TABLET (60 CT)   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LAMOTRIGINE 25MG TABLET (100 CT)   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LAMOTRIGINE 25MG TABLET DISPERSIBLE   2 Tier 2 Generic Preferred Brand $40.00$105.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LAMOTRIGINE 5MG TABLET DISPERSIBLE   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LAMOTRIGINE TABLET 100MG (100 CT)   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LANOXIN 0.125MG TABLET   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LANOXIN 0.25MG TABLET   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LANOXIN 0.25MG/ML AMPUL   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LANOXIN PED 0.1MG/ML AMPUL   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LANREOTIDE INJECTION 30MG   4 Tier 4 Specialty 33%33%P
LANTUS 100U/ML VIAL   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LANTUS INJECTION   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LARIAM 250MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LASIX 20MG TABLET (1000 CT)   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LASIX 40MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LASIX 80MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LEENA 7-9-5 TABLET   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEFLUNOMIDE 10MG TABLET (500 CT)   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEFLUNOMIDE 20MG TABLET (500 CT)   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LESCOL 20MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00S Q:31
/31Days
LESCOL 40MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00S Q:62
/31Days
LESCOL XL 80MG TABLET SA   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00S Q:31
/31Days
LESSINA 0.1-0.02 TABLET   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LETAIRIS 10MG TABLET   4 Tier 4 Specialty 33%33%P
LETAIRIS 5MG TABLET   4 Tier 4 Specialty 33%33%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LEUCOVORIN CALCIUM 100MG VL   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEUCOVORIN CALCIUM 10MG TABLET   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEUCOVORIN CALCIUM 15MG TABLET   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEUCOVORIN CALCIUM 25MG TABLET   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEUCOVORIN CALCIUM 350MG VL   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEUCOVORIN CALCIUM 5MG TABLET   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEUKERAN 2MG TABLET   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LEUKINE 250MCG VIAL   4 Tier 4 Specialty 33%33%P
LEUKINE LIQUID INJECTION 500MCG/VIAL 500 MCG X 5 VILMD CRTN   4 Tier 4 Specialty 33%33%P
LEUPROLIDE ACETATE INJECTION 14 DAY PATIENT ADMINISTRATION KIT 1-.7 1 X 2.8ML PKGCOM   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LEUSTATIN 1MG/ML VIAL   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LEVAQUIN 250MG TABLET   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LEVAQUIN 25MG/ML SOLUTION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LEVAQUIN 500MG TABLET   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LEVAQUIN 750MG TABLET   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LEVAQUIN IV 25MG/ML VIAL   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LEVAQUIN/D5W INJ 250/50ML   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LEVATOL 20MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LEVEMIR 100UNITS/ML VIAL   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LEVEMIR FLEXPEN 100UNITS/ML   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LEVETIRACETAM 500 MG TABLET 120 BOT   2 Tier 2 Generic Preferred Brand $40.00$105.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LEVETIRACETAM TABLETS 1000MG 60 BOT   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LEVETIRACETAM TABLETS 250MG 500 BOT   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LEVETIRACETAM TABLETS 750MG 500 BOT   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LEVO-DROMORAN 2MG/ML AMPUL   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LEVOBUNOLOL 0.5% EYE DROPS   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEVOBUNOLOL HCL OPHTHALMIC SOLUTION 0.25% 10ML BOT   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEVOCARNITINE 100MG/ML SOLUTION ORAL   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEVOCARNITINE 200MG/ML VIAL   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEVOCARNITINE TABLET 330MG 90 BLPK   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEVORA-28 TABLET 0.15/30   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEVORPHANOL 2MG TABLET   2 Tier 2 Generic Preferred Brand $40.00$105.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LEVOTHROID 100MCG TABLET   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LEVOTHROID 112MCG TABLET   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LEVOTHROID 125MCG TABLET   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LEVOTHROID 137MCG TABLET   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LEVOTHROID 150MCG TABLET   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LEVOTHROID 175MCG TABLET   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LEVOTHROID 200MCG TABLET   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LEVOTHROID 25MCG TABLET   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LEVOTHROID 300MCG TABLET   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LEVOTHROID 50MCG TABLET   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LEVOTHROID 75MCG TABLET   2 Tier 2 Generic Preferred Brand $40.00$105.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LEVOTHROID 88MCG TABLET   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT)   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEVOTHYROXINE SODIUM .150MG TABLET (100 CT)   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEVOTHYROXINE SODIUM 100MCG TABLET   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEVOTHYROXINE SODIUM 112MCG TABLET   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEVOTHYROXINE SODIUM 125MCG TABLET   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEVOTHYROXINE SODIUM 137MCG TABLET   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEVOTHYROXINE SODIUM 175MCG TABLET   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEVOTHYROXINE SODIUM 200MCG TABLET   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEVOTHYROXINE SODIUM 25MCG TABLET   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEVOTHYROXINE SODIUM 300MCG TABLET   1 Tier 1 Preferred Generic Brand $10.00$14.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LEVOTHYROXINE SODIUM 50MCG TABLET   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEVOTHYROXINE SODIUM 88MCG TABLET   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEVOXYL 100MCG TABLET (1000 CT)   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEVOXYL 112MCG TABLET (1000 CT)   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEVOXYL 125MCG TABLET (1000 CT)   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEVOXYL 137MCG TABLET (1000 CT)   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEVOXYL 150MCG TABLET (1000 CT)   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEVOXYL 175MCG TABLET (1000 CT)   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEVOXYL 200MCG TABLET (1000 CT)   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEVOXYL 25MCG TABLET (1000 CT)   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEVOXYL 50MCG TABLET (1000 CT)   1 Tier 1 Preferred Generic Brand $10.00$14.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LEVOXYL 75MCG TABLET (1000 CT)   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEVOXYL 88MCG TABLET (1000 CT)   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LEXAPRO 10MG TABLET   2 Tier 2 Generic Preferred Brand $40.00$105.00Q:31
/31Days
LEXAPRO 20MG TABLET   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LEXAPRO 5MG TABLET   2 Tier 2 Generic Preferred Brand $40.00$105.00Q:31
/31Days
LEXAPRO 5MG/5ML SOLUTION   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LEXIVA 50MG/ML SUSPENSION ORAL   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LEXIVA 700MG TABLET   4 Tier 4 Specialty 33%33%None
LIALDA 1.2G TABLET DELAYED RELEASE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LIDOCAINE 5% OINTMENT   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LIDOCAINE HCL 0.5% VIAL   1 Tier 1 Preferred Generic Brand $10.00$14.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LIDOCAINE HCL 1% VIAL   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LIDOCAINE HCL 2% JELLY   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LIDOCAINE HCL 2% JELLY 30ML TUBE   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LIDODERM 5% PATCH   2 Tier 2 Generic Preferred Brand $40.00$105.00Q:93
/31Days
LIMBITROL TABLET 5-12.5MG   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LINCOCIN 300MG/ML VIAL   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LINDANE 1% LOTION   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LINDANE SHAMPOO 1MG 2 FLO BOT   2 Tier 2 Generic Preferred Brand $40.00$105.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LIOTHYRONINE SODIUM INJECTION 10MCG   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LIPITOR 10MG TABLET   2 Tier 2 Generic Preferred Brand $40.00$105.00Q:31
/31Days
LIPITOR 20MG TABLET (5000 CT)   2 Tier 2 Generic Preferred Brand $40.00$105.00Q:31
/31Days
LIPITOR 40MG TABLET (500 CT)   2 Tier 2 Generic Preferred Brand $40.00$105.00Q:31
/31Days
LIPITOR 80MG TABLET   2 Tier 2 Generic Preferred Brand $40.00$105.00Q:31
/31Days
LIPOFEN 150MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LIPOFEN 50MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LIPRAM 4500 CAPSULE EC   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LIPRAM-PN10 CAPSULE EC   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LIPRAM-PN16 CAPSULE EC   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LIPRAM-PN20 CAPSULE EC   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LIPRAM-UL12 CAPSULE EC   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LIPRAM-UL18 CAPSULE EC   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LIPRAM-UL20 CAPSULE EC   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LIQUADD 5MG/5ML SOLUTION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:1860
/31Days
LISINOPRIL 10MG TABLET (100 CT)   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LISINOPRIL 2.5MG TABLET   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LISINOPRIL 20MG TABLET   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LISINOPRIL 30MG TABLET (100 CT)   1 Tier 1 Preferred Generic Brand $10.00$14.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LISINOPRIL 40MG TABLET (500 CT)   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LISINOPRIL 5MG TABLET   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LISINOPRIL-HCTZ 10/12.5 TABLET   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT)   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LISINOPRIL-HCTZ 20/12.5 TABLET   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LITHIUM CARBONATE 150MG CAPSULE   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LITHIUM CARBONATE 300MG CAPSULE (100 CT)   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LITHIUM CARBONATE 300MG TABLET   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LITHIUM CARBONATE 450MG TABLET SA   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LITHIUM CARBONATE 600MG CAP   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LITHIUM CARBONATE ER TABLET 300MG (100 CT)   1 Tier 1 Preferred Generic Brand $10.00$14.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LITHIUM CIT 8MEQ/5ML SYRUP   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LITHOBID 300MG TABLET SA   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LITHOSTAT 250MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LO/OVRAL-28 TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOCOID 0.1% OINTMENT 15GM TUBE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOCOID 0.1% SOLUTION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOCOID LIPOCREAM CREAM 0.1% 15 GM TUBE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOCOID LOTN 0.1 %   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LODOSYN 25MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOESTRIN 21 1.5/30 TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOESTRIN 21 1/20 TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LOESTRIN 24 FE TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOESTRIN FE 1-0.02MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOESTRIN FE 1.5/30 28 DAY REGIMEN TABLETS 30;1.5;75MCG;MG;MG 5 DISPENSERS CTR   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOFIBRA 134MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOFIBRA 160MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOFIBRA 200MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOFIBRA 54MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOFIBRA 67MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOKARA 0.05% LOTION   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LOMOTIL LIQ 2.5/5   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOMOTIL TABLET 0.025-2.5MG (500 CT)   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LONOX 2.5MG TABLET   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LOPERAMIDE HCL 2MG CAPSULE   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LOPID 600MG TABLET (500 CT)   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOPRESSOR 100MG TABLET (100 CT)   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOPRESSOR 1MG/ML AMPUL   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOPRESSOR 50MG TABLET (100 CT)   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOPRESSOR HCT 100/25 TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOPRESSOR HCT 50/25 TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOPROX 1% SHAMPOO   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOPROX GEL TOPICAL   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LORCET 10/650 TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LORCET PLUS TABLET 7.5-650   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LORTAB 10/500MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LORTAB 5/500 TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LORTAB 7.5/500 TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LORTAB ELIXIR 500-7.5MG/15ML   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOTEMAX 0.5% EYE DROPS   2 Tier 2 Generic Preferred Brand $40.00$105.00None
LOTENSIN 10MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOTENSIN 20MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOTENSIN 40MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOTENSIN 5MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOTENSIN HCT 10/12.5 TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LOTENSIN HCT 20/12.5 TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOTENSIN HCT 20/25 TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOTENSIN HCT 5/6.25 TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOTREL 10/20MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:31
/31Days
LOTREL 10/40MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:31
/31Days
LOTREL 2.5/10MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:31
/31Days
LOTREL 5/10MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:31
/31Days
LOTREL 5/20MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:31
/31Days
LOTREL 5/40MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:31
/31Days
LOTRISONE CREAM   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOTRISONE LOTION   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LOTRONEX TABLETS .5MG 30 BOTPL   2 Tier 2 Generic Preferred Brand $40.00$105.00P Q:62
/31Days
LOTRONEX TABLETS 1MG 30 BOTPL   2 Tier 2 Generic Preferred Brand $40.00$105.00P Q:62
/31Days
LOVASTATIN 10MG TABLET (100 CT)   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LOVASTATIN 20MG TABLET (1000 CT)   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LOVASTATIN 40MG TABLET (100 CT)   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LOVAZA CAPSULES 1GM 120 BOT   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOVENOX 100MG PREFILLED SYR   4 Tier 4 Specialty 33%33%None
LOVENOX 120MG PREFILLED SYR   4 Tier 4 Specialty 33%33%None
LOVENOX 150MG PREFILLED SYR   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOVENOX 300MG VIAL   4 Tier 4 Specialty 33%33%None
LOVENOX 30MG PREFILLED SYRN   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LOVENOX 40MG PREFILLED SYRN   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:800
/1Days
LOVENOX 60MG PREFILLED SYRN   4 Tier 4 Specialty 33%33%None
LOVENOX 80MG PREFILLED SYRN   4 Tier 4 Specialty 33%33%None
LOW-OGESTREL-28 TABLET   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LOXAPINE 25MG CAPSULE (100 CT)   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LOXAPINE CAPSULES 10MG 100 BOT   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LOXAPINE CAPSULES 50MG 100 BOT   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LOXAPINE CAPSULES 5MG 100 BOT   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LOXITANE 10MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOXITANE 25MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LOXITANE 50MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LOXITANE 5MG CAPSULE   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LUFYLLIN 200MG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LUFYLLIN-400 TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LUMIGAN 0.03% EYE DROPS   2 Tier 2 Generic Preferred Brand $40.00$105.00Q:5
/31Days
LUNESTA 2MG TABLET   2 Tier 2 Generic Preferred Brand $40.00$105.00S Q:31
/31Days
LUNESTA 3MG TABLET   2 Tier 2 Generic Preferred Brand $40.00$105.00S Q:31
/31Days
LUNESTA TABLETS 1MG 30 BOT   2 Tier 2 Generic Preferred Brand $40.00$105.00S Q:31
/31Days
LUPRON 2-WK 1MG/0.2ML KIT   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LUPRON DEPOT 3.75MG KIT   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LUPRON DEPOT 7.5MG KIT   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LUPRON DEPOT-3 MONTH KIT   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LUPRON DEPOT-3 MONTH KIT   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LUPRON DEPOT-4 MONTH KIT   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LUPRON DEPOT-PED 11.25MG KT   4 Tier 4 Specialty 33%33%None
LUPRON DEPOT-PED 15MG KIT   4 Tier 4 Specialty 33%33%None
LUTERA 0.1-0.02 TABLET   1 Tier 1 Preferred Generic Brand $10.00$14.00None
LUVOX CR 100MG CAPSULE SR 24 HR   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:62
/31Days
LUVOX CR 150MG CAPSULE SR 24 HR   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00Q:62
/31Days
LUXIQ 0.12% FOAM   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LYBREL 90-20MCG TABLET   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $90.00$255.00None
LYRICA 100MG CAPSULE   2 Tier 2 Generic Preferred Brand $40.00$105.00Q:93
/31Days
LYRICA 150MG CAPSULE   2 Tier 2 Generic Preferred Brand $40.00$105.00Q:93
/31Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LYRICA 200MG CAPSULE   2 Tier 2 Generic Preferred Brand $40.00$105.00Q:93
/31Days
LYRICA 225MG CAPSULE   2 Tier 2 Generic Preferred Brand $40.00$105.00Q:93
/31Days
LYRICA 25MG CAPSULE   2 Tier 2 Generic Preferred Brand $40.00$105.00Q:93
/31Days
LYRICA 300MG CAPSULE   2 Tier 2 Generic Preferred Brand $40.00$105.00Q:62
/31Days
LYRICA 50MG CAPSULE   2 Tier 2 Generic Preferred Brand $40.00$105.00Q:93
/31Days
LYRICA 75MG CAPSULE   2 Tier 2 Generic Preferred Brand $40.00$105.00Q:93
/31Days
LYSODREN 500MG TABLET   2 Tier 2 Generic Preferred Brand $40.00$105.00None

Chart Legend:

Below are a few notes to help you understand the above 2010 Medicare Part D AARP MedicareRx Preferred (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $310 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.

  • Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
    • Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.

    • No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.

  • Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
  • Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
    • Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
    • Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
  • Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
    • Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2830) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
    • Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
  • Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
    • None - This drug does not fall under any drug utilization management controls.
    • P - Prior Authorization -This drug is subject to prior authorization.
    • S - Step Therapy -This drug is subject to step therapy.
    • Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.




(Chart Source: Centers for Medicare and Medicaid files: CMS Data October 2010 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.