2011 Medicare Part D Plan Formulary Information |
WellCare Signature (PDP) (S5967-035-0)
Benefit Details
|
The WellCare Signature (PDP) (S5967-035-0) Formulary Drugs Starting with the Letter L in CMS PDP Region 01 which includes: ME NH
|
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 |
2 |
Preferred Brand |
$40.00 | $100.00 | P |
L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE 16 VACCINE 0.04 MG/ML / L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE |
2 |
Preferred Brand |
$40.00 | $100.00 | P |
LABETALOL HCL 100MG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LABETALOL HCL 200MG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LABETALOL HCL 300MG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LABETALOL HCL 5MG/20ML VIAL |
1 |
Generic |
$0.00 | $0.00 | None |
LACLOTION 12% LOTION |
1 |
Generic |
$0.00 | $0.00 | None |
LACRISERT OPTHALMIC INSERT 5MG 60 BLPK |
3 |
Non-Preferred Brand |
$88.00 | $220.00 | None |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT |
1 |
Generic |
$0.00 | $0.00 | None |
LAMOTRIGINE 150MG TABLET (60 CT) |
1 |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE 200MG TABLET (60 CT) |
1 |
Generic |
$0.00 | $0.00 | None |
LAMOTRIGINE 25MG TABLET (100 CT) |
1 |
Generic |
$0.00 | $0.00 | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE |
1 |
Generic |
$0.00 | $0.00 | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE |
1 |
Generic |
$0.00 | $0.00 | None |
LAMOTRIGINE TABLET 100MG (100 CT) |
1 |
Generic |
$0.00 | $0.00 | None |
LANOXIN 0.125MG TABLET |
2 |
Preferred Brand |
$40.00 | $100.00 | None |
LANOXIN 0.25MG TABLET |
2 |
Preferred Brand |
$40.00 | $100.00 | None |
LANOXIN 0.25MG/ML AMPUL |
2 |
Preferred Brand |
$40.00 | $100.00 | None |
LANOXIN PED 0.1MG/ML AMPUL |
2 |
Preferred Brand |
$40.00 | $100.00 | None |
LANREOTIDE 240 MG/ML PREFILLED SYRINGE [SOMATULINE] |
4 |
Specialty Tier |
33% | N/A | P |
LANREOTIDE INJECTION 30MG |
4 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LANSOPRAZOLE 15 MG ENTERIC COATED CAPSULE |
1 |
Generic |
$0.00 | $0.00 | S |
LANSOPRAZOLE 30 MG ENTERIC COATED CAPSULE |
1 |
Generic |
$0.00 | $0.00 | S |
LANTUS 100U/ML VIAL |
2 |
Preferred Brand |
$40.00 | $100.00 | Q:60 /31Days |
LANTUS SOLOSTAR INJECTION |
2 |
Preferred Brand |
$40.00 | $100.00 | Q:60 /31Days |
LEENA 7-9-5 TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LEFLUNOMIDE 10MG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LEFLUNOMIDE TABLETS |
1 |
Generic |
$0.00 | $0.00 | None |
LESSINA 0.1-0.02 TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LETAIRIS 10MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
LETAIRIS 5MG TABLET |
4 |
Specialty Tier |
33% | N/A | P |
LEUCOVORIN CALCIUM 100MG VL |
1 |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUCOVORIN CALCIUM 10MG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LEUCOVORIN CALCIUM 15MG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LEUCOVORIN CALCIUM 25MG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LEUCOVORIN CALCIUM 350MG VL |
1 |
Generic |
$0.00 | $0.00 | None |
LEUCOVORIN CALCIUM 5MG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LEUKERAN 2MG TABLET |
2 |
Preferred Brand |
$40.00 | $100.00 | None |
LEUKINE 250MCG VIAL |
3 |
Non-Preferred Brand |
$88.00 | $220.00 | P |
LEUKINE LIQUID INJECTION 500MCG/VIAL 500 MCG X 5 VILMD CRTN |
3 |
Non-Preferred Brand |
$88.00 | $220.00 | P |
LEUPROLIDE 11.25 MG/ML PREFILLED SYRINGE [LUPRON] |
4 |
Specialty Tier |
33% | N/A | P |
LEUPROLIDE 15 MG/ML PREFILLED SYRINGE [LUPRON] |
4 |
Specialty Tier |
33% | N/A | P |
LEUPROLIDE 15 MG/ML PREFILLED SYRINGE [LUPRON] |
4 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUPROLIDE 20 MG/ML PREFILLED SYRINGE [LUPRON] |
4 |
Specialty Tier |
33% | N/A | P |
LEUPROLIDE 3.75 MG/ML PREFILLED SYRINGE [LUPRON] |
4 |
Specialty Tier |
33% | N/A | P |
LEUPROLIDE 7.5 MG/ML PREFILLED SYRINGE [LUPRON] |
4 |
Specialty Tier |
33% | N/A | P |
LEUPROLIDE7.5 MG/ML PREFILLED SYRINGE [LUPRON] |
4 |
Specialty Tier |
33% | N/A | P |
LEVAQUIN 750 MG TABLET |
2 |
Preferred Brand |
$40.00 | $100.00 | None |
LEVAQUIN INJECTION 25 MG/ML |
2 |
Preferred Brand |
$40.00 | $100.00 | None |
LEVAQUIN INJECTION 5 MG/ML |
2 |
Preferred Brand |
$40.00 | $100.00 | None |
LEVEMIR 100UNITS/ML VIAL |
3 |
Non-Preferred Brand |
$88.00 | $220.00 | Q:60 /31Days |
LEVEMIR FLEXPEN 100UNITS/ML |
3 |
Non-Preferred Brand |
$88.00 | $220.00 | Q:60 /31Days |
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT |
1 |
Generic |
$0.00 | $0.00 | None |
LEVETIRACETAM 500 MG TABLET 120 BOT |
1 |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM INJECTION |
1 |
Generic |
$0.00 | $0.00 | None |
LEVETIRACETAM TABLETS 1000MG 60 BOT |
1 |
Generic |
$0.00 | $0.00 | None |
LEVETIRACETAM TABLETS 250MG 500 BOT |
1 |
Generic |
$0.00 | $0.00 | None |
LEVETIRACETAM TABLETS 750MG 500 BOT |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOBUNOLOL 0.25% EYE DROPS |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOFLOXACIN 250 MG ORAL TABLET [LEVAQUIN] |
2 |
Preferred Brand |
$40.00 | $100.00 | None |
LEVOFLOXACIN 500 MG ORAL TABLET [LEVAQUIN] |
2 |
Preferred Brand |
$40.00 | $100.00 | None |
LEVORA-28 TABLET 0.15/30 |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOTHROID 100MCG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOTHROID 112MCG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHROID 125MCG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOTHROID 137MCG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOTHROID 150MCG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOTHROID 175MCG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOTHROID 200MCG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOTHROID 25MCG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOTHROID 300MCG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOTHROID 50MCG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOTHROID 75MCG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOTHROID 88MCG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT) |
1 |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE SODIUM .150MG TABLET (100 CT) |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 100MCG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 112MCG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 125MCG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 175MCG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 200MCG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 25MCG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 300MCG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 50MCG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 88MCG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 100MCG TABLET (1000 CT) |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOXYL 112MCG TABLET (1000 CT) |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOXYL 125MCG TABLET (1000 CT) |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOXYL 137MCG TABLET (1000 CT) |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOXYL 150MCG TABLET (1000 CT) |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOXYL 175MCG TABLET (1000 CT) |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOXYL 200MCG TABLET (1000 CT) |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOXYL 25MCG TABLET (1000 CT) |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOXYL 50MCG TABLET (1000 CT) |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOXYL 75MCG TABLET (1000 CT) |
1 |
Generic |
$0.00 | $0.00 | None |
LEVOXYL 88MCG TABLET (1000 CT) |
1 |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEXAPRO 10MG TABLET |
3 |
Non-Preferred Brand |
$88.00 | $220.00 | S Q:31 /31Days |
LEXAPRO 20MG TABLET |
3 |
Non-Preferred Brand |
$88.00 | $220.00 | S Q:31 /31Days |
LEXAPRO 5MG TABLET |
3 |
Non-Preferred Brand |
$88.00 | $220.00 | S Q:31 /31Days |
LEXAPRO 5MG/5ML SOLUTION |
3 |
Non-Preferred Brand |
$88.00 | $220.00 | S |
LEXIVA 50MG/ML SUSPENSION ORAL |
3 |
Non-Preferred Brand |
$88.00 | $220.00 | None |
LEXIVA TABLETS |
3 |
Non-Preferred Brand |
$88.00 | $220.00 | None |
LIDOCAINE 5% OINTMENT |
1 |
Generic |
$0.00 | $0.00 | None |
LIDOCAINE HCL 2% JELLY 30ML TUBE |
1 |
Generic |
$0.00 | $0.00 | None |
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM |
1 |
Generic |
$0.00 | $0.00 | None |
LIDODERM 5% PATCH |
3 |
Non-Preferred Brand |
$88.00 | $220.00 | P Q:93 /31Days |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT |
1 |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT |
1 |
Generic |
$0.00 | $0.00 | None |
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT |
1 |
Generic |
$0.00 | $0.00 | None |
LIPITOR 10MG TABLET |
2 |
Preferred Brand |
$40.00 | $100.00 | None |
LIPITOR 20MG TABLET (5000 CT) |
2 |
Preferred Brand |
$40.00 | $100.00 | None |
LIPITOR 40MG TABLET (500 CT) |
2 |
Preferred Brand |
$40.00 | $100.00 | None |
LIPITOR 80MG TABLET |
2 |
Preferred Brand |
$40.00 | $100.00 | None |
LIPOSYN II 10% IV FAT EMUL |
2 |
Preferred Brand |
$40.00 | $100.00 | None |
LIPOSYN III 30% IV FAT EMUL |
2 |
Preferred Brand |
$40.00 | $100.00 | None |
LISINOPRIL 10MG TABLET (100 CT) |
1 |
Generic |
$0.00 | $0.00 | None |
LISINOPRIL 2.5MG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LISINOPRIL 20MG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL 30MG TABLET (100 CT) |
1 |
Generic |
$0.00 | $0.00 | None |
LISINOPRIL 40MG TABLET (500 CT) |
1 |
Generic |
$0.00 | $0.00 | None |
LISINOPRIL TABLETS 5 MG |
1 |
Generic |
$0.00 | $0.00 | None |
LISINOPRIL-HCTZ 10/12.5 TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT) |
1 |
Generic |
$0.00 | $0.00 | None |
LISINOPRIL-HCTZ 20/12.5 TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LITHIUM CARBONATE 150MG CAPSULE |
1 |
Generic |
$0.00 | $0.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) |
1 |
Generic |
$0.00 | $0.00 | None |
LITHIUM CARBONATE 300MG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LITHIUM CARBONATE CAPSULES |
1 |
Generic |
$0.00 | $0.00 | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) |
1 |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LITHIUM CIT 8MEQ/5ML SYRUP |
1 |
Generic |
$0.00 | $0.00 | None |
LITHIUM ER 450 MG TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LOPERAMIDE HCL 2MG CAPSULE |
1 |
Generic |
$0.00 | $0.00 | None |
LOSARTAN POTASSIUM 100 MG TAB |
1 |
Generic |
$0.00 | $0.00 | None |
LOSARTAN POTASSIUM 25 MG TAB |
1 |
Generic |
$0.00 | $0.00 | None |
LOSARTAN POTASSIUM 50 MG TAB |
1 |
Generic |
$0.00 | $0.00 | None |
LOSARTAN-HCTZ 100-12.5 MG TAB |
1 |
Generic |
$0.00 | $0.00 | None |
LOSARTAN-HCTZ 100-25 MG TAB |
1 |
Generic |
$0.00 | $0.00 | None |
LOSARTAN-HCTZ 50-12.5 MG TAB |
1 |
Generic |
$0.00 | $0.00 | None |
LOTRONEX TABLETS .5MG 30 BOTPL |
2 |
Preferred Brand |
$40.00 | $100.00 | Q:62 /31Days |
LOTRONEX TABLETS 1MG 30 BOTPL |
4 |
Specialty Tier |
33% | N/A | Q:62 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOVASTATIN 10MG TABLET (100 CT) |
1 |
Generic |
$0.00 | $0.00 | None |
LOVASTATIN 20 MG ORAL TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LOVASTATIN 40 MG ORAL TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LOVAZA CAPSULES 1GM 120 BOT |
3 |
Non-Preferred Brand |
$88.00 | $220.00 | None |
LOVENOX 100MG PREFILLED SYR |
4 |
Specialty Tier |
33% | N/A | Q:28 /31Days |
LOVENOX 120MG PREFILLED SYR |
4 |
Specialty Tier |
33% | N/A | Q:22 /31Days |
LOVENOX 150MG PREFILLED SYR |
4 |
Specialty Tier |
33% | N/A | Q:28 /31Days |
LOVENOX 300MG VIAL |
4 |
Specialty Tier |
33% | N/A | Q:24 /31Days |
LOVENOX 30MG PREFILLED SYRN |
2 |
Preferred Brand |
$40.00 | $100.00 | Q:8 /31Days |
LOVENOX 40MG PREFILLED SYRN |
2 |
Preferred Brand |
$40.00 | $100.00 | Q:8 /31Days |
LOVENOX 60MG PREFILLED SYRN |
4 |
Specialty Tier |
33% | N/A | Q:17 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOVENOX 80MG PREFILLED SYRN |
4 |
Specialty Tier |
33% | N/A | Q:22 /31Days |
LOW-OGESTREL-28 TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LOXAPINE 25MG CAPSULE (100 CT) |
1 |
Generic |
$0.00 | $0.00 | None |
LOXAPINE CAPSULES 10MG 100 BOT |
1 |
Generic |
$0.00 | $0.00 | None |
LOXAPINE CAPSULES 50MG 100 BOT |
1 |
Generic |
$0.00 | $0.00 | None |
LOXAPINE CAPSULES 5MG 100 BOT |
1 |
Generic |
$0.00 | $0.00 | None |
LUMIGAN 0.03% EYE DROPS |
2 |
Preferred Brand |
$40.00 | $100.00 | Q:5 /31Days |
LUTERA 0.1-0.02 TABLET |
1 |
Generic |
$0.00 | $0.00 | None |
LYRICA 100MG CAPSULE |
3 |
Non-Preferred Brand |
$88.00 | $220.00 | P |
LYRICA 150MG CAPSULE |
3 |
Non-Preferred Brand |
$88.00 | $220.00 | P |
LYRICA 200MG CAPSULE |
3 |
Non-Preferred Brand |
$88.00 | $220.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYRICA 225MG CAPSULE |
3 |
Non-Preferred Brand |
$88.00 | $220.00 | P |
LYRICA 25MG CAPSULE |
3 |
Non-Preferred Brand |
$88.00 | $220.00 | P |
LYRICA 300MG CAPSULE |
3 |
Non-Preferred Brand |
$88.00 | $220.00 | P |
LYRICA 50MG CAPSULE |
3 |
Non-Preferred Brand |
$88.00 | $220.00 | P |
LYRICA 75MG CAPSULE |
3 |
Non-Preferred Brand |
$88.00 | $220.00 | P |
LYSODREN 500MG TABLET |
2 |
Preferred Brand |
$40.00 | $100.00 | None |