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Aetna Medicare Rx Premier (PDP) (S5810-202-0)
Tier 1 (1451)
Tier 2 (735)
Tier 3 (314)
Tier 4 (729)
Tier 5 (319)
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2012 Medicare Part D Plan Formulary Information
Aetna Medicare Rx Premier (PDP) (S5810-202-0)
Benefit Details           
The Aetna Medicare Rx Premier (PDP) (S5810-202-0)
Formulary Drugs Starting with the Letter L

in CMS PDP Region 32 which includes: CA
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   4 Non-Preferred Brand Drugs $80.00$225.00P
L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE 16 VACCINE 0.04 MG/ML / L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE   4 Non-Preferred Brand Drugs $80.00$225.00P
LABETALOL HCL 100MG TABLET   1 Preferred Generic Drugs $4.00$12.00None
LABETALOL HCL 200MG TABLET   1 Preferred Generic Drugs $4.00$12.00None
LABETALOL HCL 300MG TABLET   1 Preferred Generic Drugs $4.00$12.00None
LABETALOL HCL 5MG/20ML VIAL   1 Preferred Generic Drugs $4.00$12.00None
LACLOTION 12% LOTION   1 Preferred Generic Drugs $4.00$12.00None
LACRISERT OPTHALMIC INSERT 5MG 60 BLPK   4 Non-Preferred Brand Drugs $80.00$225.00None
LACTATED RINGERS INJECTION   2 Non-Preferred Generic Drugs $25.00$60.00None
LACTATED RINGERS IRRIGATION 20-30-600MG 3000ML BAG   2 Non-Preferred Generic Drugs $25.00$60.00None
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 Preferred Generic Drugs $4.00$12.00None
LAMICTAL ODT 100mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK   4 Non-Preferred Brand Drugs $80.00$225.00S
LAMICTAL ODT 200mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK   4 Non-Preferred Brand Drugs $80.00$225.00S
LAMICTAL ODT 25mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK   4 Non-Preferred Brand Drugs $80.00$225.00S
LAMICTAL ODT 50mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK   4 Non-Preferred Brand Drugs $80.00$225.00S
LAMISIL 125MG GRANULES IN PACKET   4 Non-Preferred Brand Drugs $80.00$225.00P
LAMISIL 187.5MG GRANULES IN PACKET   4 Non-Preferred Brand Drugs $80.00$225.00P
LAMIVUDINE 150 MG TABLET   2 Non-Preferred Generic Drugs $25.00$60.00None
LAMIVUDINE 300 MG TABLET   2 Non-Preferred Generic Drugs $25.00$60.00None
LAMIVUDINE-ZIDOVUDINE TABLET   2 Non-Preferred Generic Drugs $25.00$60.00None
LAMOTRIGINE 150MG TABLET (60 CT)   2 Non-Preferred Generic Drugs $25.00$60.00None
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 Drugs $25.00$60.00None
LAMOTRIGINE 25MG TABLET (100 CT)   2 Non-Preferred Generic Drugs $25.00$60.00None
LAMOTRIGINE 25MG TABLET DISPERSIBLE   2 Non-Preferred Generic Drugs $25.00$60.00None
LAMOTRIGINE 5MG TABLET DISPERSIBLE   2 Non-Preferred Generic Drugs $25.00$60.00None
LAMOTRIGINE TABLET 100MG (100 CT)   2 Non-Preferred Generic Drugs $25.00$60.00None
LANREOTIDE 240 MG/ML PREFILLED SYRINGE [SOMATULINE]   5 Specialty Tier Drugs 33%33%P S
lansoprazole 15mg/1 10 BLISTER PACK in 1 CARTON / 10 TABLET, ORALLY DISINTEGRATING, DELAYED RELEASE   2 Non-Preferred Generic Drugs $25.00$60.00Q:1
/1Days
Lansoprazole 15mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $25.00$60.00Q:1
/1Days
lansoprazole 30mg/1 10 BLISTER PACK in 1 CARTON / 10 TABLET, ORALLY DISINTEGRATING, DELAYED RELEASE   2 Non-Preferred Generic Drugs $25.00$60.00Q:2
/1Days
Lansoprazole 30mg/1 30 CAPSULE, DELAYED RELEASE in 1 BOTTLE   2 Non-Preferred Generic Drugs $25.00$60.00Q:2
/1Days
LANTUS 100U/ML VIAL   4 Non-Preferred Brand Drugs $80.00$225.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LANTUS SOLOSTAR INJECTION   4 Non-Preferred Brand Drugs $80.00$225.00None
LATANOPROST OPHTHALMIC SOLUTION .005%   2 Non-Preferred Generic Drugs $25.00$60.00None
LATUDA 20 MG TABLET   4 Non-Preferred Brand Drugs $80.00$225.00P Q:1
/1Days
Latuda 40mg/1   4 Non-Preferred Brand Drugs $80.00$225.00P Q:1
/1Days
Latuda 80mg/1   4 Non-Preferred Brand Drugs $80.00$225.00P Q:2
/1Days
LEENA 7-9-5 TABLET   1 Preferred Generic Drugs $4.00$12.00None
LEFLUNOMIDE 10MG TABLET   1 Preferred Generic Drugs $4.00$12.00None
LEFLUNOMIDE TABLETS   1 Preferred Generic Drugs $4.00$12.00None
Lessina 3 POUCH in 1 CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER PACK   1 Preferred Generic Drugs $4.00$12.00None
LETAIRIS 10MG TABLET   5 Specialty Tier Drugs 33%33%P Q:1
/1Days
LETAIRIS 5MG TABLET   5 Specialty Tier Drugs 33%33%P Q:1
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Letrozole 2.5mg/1 500 TABLET, FILM COATED in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $25.00$60.00Q:1
/1Days
LEUCOVORIN CALCIUM 100MG VL   2 Non-Preferred Generic Drugs $25.00$60.00P
LEUCOVORIN CALCIUM 10MG TABLET   1 Preferred Generic Drugs $4.00$12.00None
Leucovorin Calcium 15mg/1 24 TABLET in 1 BOTTLE   1 Preferred Generic Drugs $4.00$12.00None
LEUCOVORIN CALCIUM 25MG TABLET   1 Preferred Generic Drugs $4.00$12.00None
LEUCOVORIN CALCIUM 350MG VL   1 Preferred Generic Drugs $4.00$12.00P
LEUCOVORIN CALCIUM 5MG TABLET   1 Preferred Generic Drugs $4.00$12.00None
LEUKERAN 2MG TABLET   4 Non-Preferred Brand Drugs $80.00$225.00None
LEUKINE 500 MCG/ML   5 Specialty Tier Drugs 33%33%P
LEUKINE INJECTION 250 MCG/ML   5 Specialty Tier Drugs 33%33%P
LEUPROLIDE ACETATE INJECTION   1 Preferred Generic Drugs $4.00$12.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVALBUTEROL 1.25 MG/0.5 ML   2 Non-Preferred Generic Drugs $25.00$60.00P
LEVAQUIN 250mg/1 10 BLISTER PACK in 1 CARTON / 10 TABLET, FILM COATED in 1 BLISTER PACK   4 Non-Preferred Brand Drugs $80.00$225.00None
LEVAQUIN 25mg/mL 480 mL in 1 BOTTLE   4 Non-Preferred Brand Drugs $80.00$225.00None
LEVAQUIN 500mg/1 50 TABLET, FILM COATED in 1 BOTTLE   4 Non-Preferred Brand Drugs $80.00$225.00None
LEVAQUIN 750 MG TABLET   4 Non-Preferred Brand Drugs $80.00$225.00None
LEVAQUIN INJECTION 25 MG/ML   4 Non-Preferred Brand Drugs $80.00$225.00None
LEVAQUIN INJECTION 5 MG/ML   4 Non-Preferred Brand Drugs $80.00$225.00None
LEVEMIR 100UNITS/ML VIAL   3 Preferred Brand Drugs $35.00$90.00None
Levemir 14.2mg/mL 5 SYRINGE, PLASTIC in 1 CARTON / 3 mL in 1 SYRINGE, PLASTIC   3 Preferred Brand Drugs $35.00$90.00None
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT   2 Non-Preferred Generic Drugs $25.00$60.00None
LEVETIRACETAM 500 MG TABLET 120 BOT   1 Preferred Generic Drugs $4.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVETIRACETAM INJECTION   2 Non-Preferred Generic Drugs $25.00$60.00None
LEVETIRACETAM TABLETS 1000MG 60 BOT   1 Preferred Generic Drugs $4.00$12.00None
LEVETIRACETAM TABLETS 250MG 500 BOT   1 Preferred Generic Drugs $4.00$12.00None
LEVETIRACETAM TABLETS 750MG 500 BOT   1 Preferred Generic Drugs $4.00$12.00None
LEVOBUNOLOL 0.25% EYE DROPS   1 Preferred Generic Drugs $4.00$12.00None
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION   1 Preferred Generic Drugs $4.00$12.00None
LEVOCARNITINE 100MG/ML SOLUTION ORAL   2 Non-Preferred Generic Drugs $25.00$60.00P
LEVOCARNITINE 200MG/ML VIAL   2 Non-Preferred Generic Drugs $25.00$60.00P
LEVOCARNITINE TABLET 330MG 90 BLPK   2 Non-Preferred Generic Drugs $25.00$60.00P
LEVOCETIRIZINE 2.5 MG/5 ML SOL   1 Preferred Generic Drugs $4.00$12.00Q:10
/1Days
Levocetirizine dihydrochloride 5mg/1 30 TABLET in 1 BOTTLE   1 Preferred Generic Drugs $4.00$12.00Q:1
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Levofloxacin 250mg/1   2 Non-Preferred Generic Drugs $25.00$60.00None
Levofloxacin 25mg/mL 1 BOTTLE in 1 CARTON / 100 mL in 1 BOTTLE   2 Non-Preferred Generic Drugs $25.00$60.00None
Levofloxacin 25mg/mL 1 VIAL in 1 CARTON / 30 mL in 1 VIAL   2 Non-Preferred Generic Drugs $25.00$60.00None
Levofloxacin 500mg/1   2 Non-Preferred Generic Drugs $25.00$60.00None
Levofloxacin 5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER   2 Non-Preferred Generic Drugs $25.00$60.00None
Levofloxacin 5mg/mL 24 POUCH in 1 CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG   2 Non-Preferred Generic Drugs $25.00$60.00None
Levofloxacin 750mg/1   2 Non-Preferred Generic Drugs $25.00$60.00None
LEVORA-28 TABLET 0.15/30   1 Preferred Generic Drugs $4.00$12.00None
LEVORPHANOL TARTRATE 2mg/1 100 TABLET in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $25.00$60.00None
Levothroid 100ug/1 100 TABLET BOTTLE   1 Preferred Generic Drugs $4.00$12.00None
Levothroid 112ug/1 100 TABLET BOTTLE   1 Preferred Generic Drugs $4.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Levothroid 125ug/1 100 TABLET BOTTLE   1 Preferred Generic Drugs $4.00$12.00None
Levothroid 137ug/1 100 TABLET BOTTLE   1 Preferred Generic Drugs $4.00$12.00None
Levothroid 150ug/1 100 TABLET BOTTLE   1 Preferred Generic Drugs $4.00$12.00None
Levothroid 175ug/1 100 TABLET BOTTLE   1 Preferred Generic Drugs $4.00$12.00None
Levothroid 200ug/1 100 TABLET BOTTLE   1 Preferred Generic Drugs $4.00$12.00None
Levothroid 25ug/1 100 TABLET BOTTLE   1 Preferred Generic Drugs $4.00$12.00None
Levothroid 300ug/1 100 TABLET BOTTLE   1 Preferred Generic Drugs $4.00$12.00None
Levothroid 50ug/1 100 TABLET BOTTLE   1 Preferred Generic Drugs $4.00$12.00None
Levothroid 75ug/1 100 TABLET BOTTLE   1 Preferred Generic Drugs $4.00$12.00None
Levothroid 88ug/1 100 TABLET BOTTLE   1 Preferred Generic Drugs $4.00$12.00None
LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT)   1 Preferred Generic Drugs $4.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVOTHYROXINE SODIUM .150MG TABLET (100 CT)   1 Preferred Generic Drugs $4.00$12.00None
LEVOTHYROXINE SODIUM 100MCG TABLET   1 Preferred Generic Drugs $4.00$12.00None
LEVOTHYROXINE SODIUM 112MCG TABLET   1 Preferred Generic Drugs $4.00$12.00None
LEVOTHYROXINE SODIUM 125MCG TABLET   1 Preferred Generic Drugs $4.00$12.00None
LEVOTHYROXINE SODIUM 137MCG TABLET   1 Preferred Generic Drugs $4.00$12.00None
LEVOTHYROXINE SODIUM 175MCG TABLET   1 Preferred Generic Drugs $4.00$12.00None
LEVOTHYROXINE SODIUM 200MCG TABLET   1 Preferred Generic Drugs $4.00$12.00None
LEVOTHYROXINE SODIUM 25MCG TABLET   1 Preferred Generic Drugs $4.00$12.00None
LEVOTHYROXINE SODIUM 300MCG TABLET   1 Preferred Generic Drugs $4.00$12.00None
LEVOTHYROXINE SODIUM 50MCG TABLET   1 Preferred Generic Drugs $4.00$12.00None
LEVOTHYROXINE SODIUM 88MCG TABLET   1 Preferred Generic Drugs $4.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVOXYL 100MCG TABLET (1000 CT)   1 Preferred Generic Drugs $4.00$12.00None
LEVOXYL 112MCG TABLET (1000 CT)   1 Preferred Generic Drugs $4.00$12.00None
LEVOXYL 125MCG TABLET (1000 CT)   1 Preferred Generic Drugs $4.00$12.00None
LEVOXYL 137MCG TABLET (1000 CT)   1 Preferred Generic Drugs $4.00$12.00None
LEVOXYL 150MCG TABLET (1000 CT)   1 Preferred Generic Drugs $4.00$12.00None
LEVOXYL 175MCG TABLET (1000 CT)   1 Preferred Generic Drugs $4.00$12.00None
LEVOXYL 200MCG TABLET (1000 CT)   1 Preferred Generic Drugs $4.00$12.00None
LEVOXYL 25MCG TABLET (1000 CT)   1 Preferred Generic Drugs $4.00$12.00None
LEVOXYL 50MCG TABLET (1000 CT)   1 Preferred Generic Drugs $4.00$12.00None
LEVOXYL 75MCG TABLET (1000 CT)   1 Preferred Generic Drugs $4.00$12.00None
LEVOXYL 88MCG TABLET (1000 CT)   1 Preferred Generic Drugs $4.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEXAPRO 10MG TABLET   4 Non-Preferred Brand Drugs $80.00$225.00S Q:1
/1Days
LEXAPRO 20MG TABLET   4 Non-Preferred Brand Drugs $80.00$225.00S Q:1
/1Days
LEXAPRO 5MG TABLET   4 Non-Preferred Brand Drugs $80.00$225.00S Q:1
/1Days
LEXAPRO 5MG/5ML SOLUTION   4 Non-Preferred Brand Drugs $80.00$225.00S Q:20
/1Days
LEXIVA 50mg/mL 225 mL in 1 BOTTLE   4 Non-Preferred Brand Drugs $80.00$225.00None
LEXIVA TABLETS   5 Specialty Tier Drugs 33%33%None
LIALDA 1.2G TABLET DELAYED RELEASE   4 Non-Preferred Brand Drugs $80.00$225.00Q:4
/1Days
LIDOCAINE 5% OINTMENT   1 Preferred Generic Drugs $4.00$12.00None
LIDOCAINE HCL 0.5% VIAL   1 Preferred Generic Drugs $4.00$12.00P
LIDOCAINE HCL 1% VIAL   1 Preferred Generic Drugs $4.00$12.00P
lidocaine hcl 2% jelly   1 Preferred Generic Drugs $4.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LIDOCAINE HCL 2% JELLY 30ML TUBE   1 Preferred Generic Drugs $4.00$12.00None
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT   1 Preferred Generic Drugs $4.00$12.00None
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT   1 Preferred Generic Drugs $4.00$12.00None
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM   1 Preferred Generic Drugs $4.00$12.00None
LIDODERM 5% PATCH   3 Preferred Brand Drugs $35.00$90.00P S Q:3
/1Days
Lindane 10mg/mL   2 Non-Preferred Generic Drugs $25.00$60.00Q:2
/1Days
LINDANE SHAMPOO 1MG 2 FLO BOT   2 Non-Preferred Generic Drugs $25.00$60.00Q:2
/1Days
Lioresal 0.05mg/mL   4 Non-Preferred Brand Drugs $80.00$225.00P
Lioresal 0.5mg/mL   4 Non-Preferred Brand Drugs $80.00$225.00P
Lioresal 2mg/mL   5 Specialty Tier Drugs 33%33%P
liothyronine sodium 10ug/mL 1 VIAL in 1 CARTON / 1 mL in 1 VIAL   2 Non-Preferred Generic Drugs $25.00$60.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT   1 Preferred Generic Drugs $4.00$12.00None
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT   1 Preferred Generic Drugs $4.00$12.00None
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT   1 Preferred Generic Drugs $4.00$12.00None
LIPITOR 10MG TABLET   3 Preferred Brand Drugs $35.00$90.00Q:1
/1Days
LIPITOR 20MG TABLET (5000 CT)   3 Preferred Brand Drugs $35.00$90.00Q:1
/1Days
LIPITOR 40MG TABLET (500 CT)   3 Preferred Brand Drugs $35.00$90.00Q:1
/1Days
LIPITOR 80MG TABLET   3 Preferred Brand Drugs $35.00$90.00Q:1
/1Days
LIPOSYN II 10% IV FAT EMUL   4 Non-Preferred Brand Drugs $80.00$225.00None
Liposyn III 1.2; 2.5; 10g/100mL; g/100mL; g/100mL 12 BOTTLE, GLASS in 1 CASE / 250 mL in 1 BOTTLE,   4 Non-Preferred Brand Drugs $80.00$225.00None
Liposyn III 1.2; 2.5; 20g/100mL; g/100mL; g/100mL 12 BOTTLE, GLASS in 1 CASE / 250 mL in 1 BOTTLE,   4 Non-Preferred Brand Drugs $80.00$225.00None
LIPOSYN III 30% IV FAT EMUL   2 Non-Preferred Generic Drugs $25.00$60.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LISINOPRIL 10MG TABLET (100 CT)   1 Preferred Generic Drugs $4.00$12.00None
Lisinopril 2.5mg 100 TABLET BOTTLE   1 Preferred Generic Drugs $4.00$12.00None
LISINOPRIL 20MG TABLET   1 Preferred Generic Drugs $4.00$12.00None
LISINOPRIL 30MG TABLET (100 CT)   1 Preferred Generic Drugs $4.00$12.00None
LISINOPRIL 40MG TABLET (500 CT)   1 Preferred Generic Drugs $4.00$12.00None
Lisinopril 5mg/1 1000 TABLET in 1 BOTTLE   1 Preferred Generic Drugs $4.00$12.00None
LISINOPRIL-HCTZ 10/12.5 TABLET   1 Preferred Generic Drugs $4.00$12.00None
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT)   1 Preferred Generic Drugs $4.00$12.00None
LISINOPRIL-HCTZ 20/12.5 TABLET   1 Preferred Generic Drugs $4.00$12.00None
LITHIUM CARBONATE 150MG CAPSULE   1 Preferred Generic Drugs $4.00$12.00None
LITHIUM CARBONATE 300MG CAPSULE (100 CT)   1 Preferred Generic Drugs $4.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LITHIUM CARBONATE 300MG TABLET   1 Preferred Generic Drugs $4.00$12.00None
Lithium Carbonate 450mg/1   1 Preferred Generic Drugs $4.00$12.00None
LITHIUM CARBONATE CAPSULES   1 Preferred Generic Drugs $4.00$12.00None
LITHIUM CARBONATE ER TABLET 300MG (100 CT)   1 Preferred Generic Drugs $4.00$12.00None
LITHIUM CIT 8MEQ/5ML SYRUP   1 Preferred Generic Drugs $4.00$12.00None
LODOSYN TAB 25MG   4 Non-Preferred Brand Drugs $80.00$225.00None
LOFIBRA 134MG CAPSULE   4 Non-Preferred Brand Drugs $80.00$225.00None
LOFIBRA 160MG TABLET   4 Non-Preferred Brand Drugs $80.00$225.00None
LOFIBRA 200MG CAPSULE   4 Non-Preferred Brand Drugs $80.00$225.00None
LOFIBRA 54MG TABLET   4 Non-Preferred Brand Drugs $80.00$225.00None
LOFIBRA 67MG CAPSULE   4 Non-Preferred Brand Drugs $80.00$225.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LOKARA 0.05% LOTION   1 Preferred Generic Drugs $4.00$12.00None
LOPERAMIDE HCL 2MG CAPSULE   1 Preferred Generic Drugs $4.00$12.00None
LORCET 10/650 TABLET   4 Non-Preferred Brand Drugs $80.00$225.00Q:6
/1Days
LORCET PLUS TABLET 7.5-650   4 Non-Preferred Brand Drugs $80.00$225.00Q:6
/1Days
LORTAB 10/500MG TABLET   4 Non-Preferred Brand Drugs $80.00$225.00Q:8
/1Days
LORTAB 5/500 TABLET   4 Non-Preferred Brand Drugs $80.00$225.00Q:8
/1Days
LORTAB 7.5/500 TABLET   4 Non-Preferred Brand Drugs $80.00$225.00Q:8
/1Days
LORTAB ELIXIR 500-7.5MG/15ML   4 Non-Preferred Brand Drugs $80.00$225.00Q:90
/1Days
LOSARTAN POTASSIUM 100 MG TAB   1 Preferred Generic Drugs $4.00$12.00None
LOSARTAN POTASSIUM 25 MG TAB   1 Preferred Generic Drugs $4.00$12.00Q:2
/1Days
LOSARTAN POTASSIUM 50 MG TAB   1 Preferred Generic Drugs $4.00$12.00Q:2
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LOSARTAN-HCTZ 100-12.5 MG TAB   1 Preferred Generic Drugs $4.00$12.00None
LOSARTAN-HCTZ 100-25 MG TAB   1 Preferred Generic Drugs $4.00$12.00None
LOSARTAN-HCTZ 50-12.5 MG TAB   1 Preferred Generic Drugs $4.00$12.00Q:1
/1Days
LOSEASONIQUE TABLET   4 Non-Preferred Brand Drugs $80.00$225.00None
LOTEMAX 0.5% EYE DROPS   3 Preferred Brand Drugs $35.00$90.00None
Lotemax 5mg/g 1 TUBE in 1 CARTON / 3.5 g in 1 TUBE   3 Preferred Brand Drugs $35.00$90.00None
LOTRONEX TABLETS .5MG 30 BOTPL   5 Specialty Tier Drugs 33%33%P Q:2
/1Days
LOTRONEX TABLETS 1MG 30 BOTPL   5 Specialty Tier Drugs 33%33%P Q:2
/1Days
Lovastatin 10mg 60 TABLET BOTTLE   1 Preferred Generic Drugs $4.00$12.00Q:2
/1Days
Lovastatin 20mg 500 TABLET BOTTLE   1 Preferred Generic Drugs $4.00$12.00Q:2
/1Days
LOVASTATIN 40 MG ORAL TABLET   1 Preferred Generic Drugs $4.00$12.00Q:2
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LOVAZA 1g/ 120 LIQUID FILLED CAPSULES in BOTTLE   3 Preferred Brand Drugs $35.00$90.00Q:4
/1Days
LOVENOX 100MG PREFILLED SYR   5 Specialty Tier Drugs 33%33%None
LOVENOX 120MG PREFILLED SYR   5 Specialty Tier Drugs 33%33%None
LOVENOX 150MG PREFILLED SYR   5 Specialty Tier Drugs 33%33%None
LOVENOX 30MG PREFILLED SYRN   4 Non-Preferred Brand Drugs $80.00$225.00None
LOVENOX 40MG PREFILLED SYRN   4 Non-Preferred Brand Drugs $80.00$225.00None
LOVENOX 60MG PREFILLED SYRN   4 Non-Preferred Brand Drugs $80.00$225.00None
LOVENOX 80MG PREFILLED SYRN   5 Specialty Tier Drugs 33%33%None
LOW-OGESTREL-28 TABLET   1 Preferred Generic Drugs $4.00$12.00None
LOXAPINE 25MG CAPSULE (100 CT)   2 Non-Preferred Generic Drugs $25.00$60.00None
LOXAPINE CAPSULES 10MG 100 BOT   2 Non-Preferred Generic Drugs $25.00$60.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LOXAPINE CAPSULES 50MG 100 BOT   2 Non-Preferred Generic Drugs $25.00$60.00None
LOXAPINE CAPSULES 5MG 100 BOT   2 Non-Preferred Generic Drugs $25.00$60.00None
LOXITANE 10MG CAPSULE   4 Non-Preferred Brand Drugs $80.00$225.00None
LOXITANE 25MG CAPSULE   4 Non-Preferred Brand Drugs $80.00$225.00None
LOXITANE 50MG CAPSULE   4 Non-Preferred Brand Drugs $80.00$225.00None
LOXITANE 5MG CAPSULE   4 Non-Preferred Brand Drugs $80.00$225.00None
LUFYLLIN 200MG TABLET   4 Non-Preferred Brand Drugs $80.00$225.00None
LUFYLLIN-400 TABLET   4 Non-Preferred Brand Drugs $80.00$225.00None
LUMIGAN 0.03% EYE DROPS   3 Preferred Brand Drugs $35.00$90.00None
LUMIGAN 0.1mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER   3 Preferred Brand Drugs $35.00$90.00None
Lumizyme 5mg/mL   5 Specialty Tier Drugs 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Lupron Depot 1 KIT in 1 CARTON   5 Specialty Tier Drugs 33%33%P
LUPRON DEPOT 3.75 MG KIT   4 Non-Preferred Brand Drugs $80.00$225.00P
LUPRON DEPOT 7.5 MG KIT   5 Specialty Tier Drugs 33%33%P
LUPRON DEPOT-PED 11.25 MG KIT   5 Specialty Tier Drugs 33%33%P
LUPRON DEPOT-PED 15 MG KIT   5 Specialty Tier Drugs 33%33%P
LUTERA 0.1-0.02 TABLET   1 Preferred Generic Drugs $4.00$12.00None
LYRICA 100MG CAPSULE   4 Non-Preferred Brand Drugs $80.00$225.00Q:3
/1Days
LYRICA 150MG CAPSULE   4 Non-Preferred Brand Drugs $80.00$225.00Q:3
/1Days
LYRICA 200MG CAPSULE   4 Non-Preferred Brand Drugs $80.00$225.00Q:3
/1Days
LYRICA 225MG CAPSULE   4 Non-Preferred Brand Drugs $80.00$225.00Q:2
/1Days
LYRICA 25MG CAPSULE   4 Non-Preferred Brand Drugs $80.00$225.00Q:3
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LYRICA 300MG CAPSULE   4 Non-Preferred Brand Drugs $80.00$225.00Q:2
/1Days
LYRICA 50MG CAPSULE   4 Non-Preferred Brand Drugs $80.00$225.00Q:3
/1Days
LYRICA 75MG CAPSULE   4 Non-Preferred Brand Drugs $80.00$225.00Q:3
/1Days
LYSODREN 500MG TABLET   3 Preferred Brand Drugs $35.00$90.00None
LYSTEDA TABLETS   3 Preferred Brand Drugs $35.00$90.00P Q:30
/5Days

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D Aetna Medicare Rx Premier (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 the standard $320 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 wit 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 which tier the drug is in. 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 intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2930) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2012 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 September 2012 )

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.







Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.