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Humana Walmart-Preferred Rx Plan (PDP) (S5552-004-0)
Tier 1 (261)
Tier 2 (938)
Tier 3 (799)
Tier 4 (931)
Tier 5 (343)
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Cick on the first letter of your drug name to browse the formulary:

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 
2013 Medicare Part D Plan Formulary Information
Humana Walmart-Preferred Rx Plan (PDP) (S5552-004-0)
Benefit Details           
The Humana Walmart-Preferred Rx Plan (PDP) (S5552-004-0)
Formulary Drugs Starting with the Letter L
in CMS PDP Region 3 which includes: NY
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   3 Preferred Brand 20%20%None
LABETALOL HCL 100MG TABLET   2 Non-Preferred Generics $4.00$0.00None
LABETALOL HCL 200MG TABLET   2 Non-Preferred Generics $4.00$0.00None
LABETALOL HCL 300MG TABLET   2 Non-Preferred Generics $4.00$0.00None
LABETALOL HCL 5MG/20ML VIAL   2 Non-Preferred Generics $4.00$0.00None
LACLOTION 12% LOTION   4 Non-Preferred Brand 33%33%None
LACRISERT 5 MG EYE INSERT   4 Non-Preferred Brand 33%33%None
Lactated Ringers 200; 300; 6; 3.1mg/1000mL; mg/1000mL; g/1000mL; g/1000mL 5000 mL in 1 BAG   2 Non-Preferred Generics $4.00$0.00None
LACTATED RINGERS INJECTION   2 Non-Preferred Generics $4.00$0.00None
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT   1 Preferred Generics $1.00$0.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LAMICTAL 100MG TABLET   4 Non-Preferred Brand 33%33%None
LAMICTAL 150MG TABLET   4 Non-Preferred Brand 33%33%None
LAMICTAL 200MG TABLET   4 Non-Preferred Brand 33%33%None
LAMICTAL 25MG DISPER TABLET CHEW   4 Non-Preferred Brand 33%33%None
LAMICTAL 25MG TABLET   4 Non-Preferred Brand 33%33%None
LAMICTAL 25MG TABLET STARTER KIT   4 Non-Preferred Brand 33%33%None
LAMICTAL 5MG DISPER TABLET CHEW   4 Non-Preferred Brand 33%33%None
LAMICTAL KIT 100;25MG;MG   4 Non-Preferred Brand 33%33%None
LAMICTAL ODT 100mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK   4 Non-Preferred Brand 33%33%None
LAMICTAL ODT 200mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK   4 Non-Preferred Brand 33%33%None
LAMICTAL ODT 25mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK   4 Non-Preferred Brand 33%33%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LAMICTAL ODT 50mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK   4 Non-Preferred Brand 33%33%None
LAMICTAL TABLET STARTER KIT   4 Non-Preferred Brand 33%33%None
LAMICTAL XR 100 MG TABLET   4 Non-Preferred Brand 33%33%None
LAMICTAL XR 200 MG TABLET   4 Non-Preferred Brand 33%33%None
LAMICTAL XR 25 MG TABLET   4 Non-Preferred Brand 33%33%None
LAMICTAL XR 250mg/1 30 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE   4 Non-Preferred Brand 33%33%None
LAMICTAL XR 300mg/1 30 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE   4 Non-Preferred Brand 33%33%None
LAMICTAL XR 50 MG TABLET   4 Non-Preferred Brand 33%33%None
LAMICTAL XR START KIT (BLUE)   4 Non-Preferred Brand 33%33%None
LAMICTAL XR START KIT (GREEN)   4 Non-Preferred Brand 33%33%None
LAMICTAL XR START KIT (ORANGE)   4 Non-Preferred Brand 33%33%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LAMIVUDINE 150 MG TABLET   4 Non-Preferred Brand 33%33%Q:60
/30Days
LAMIVUDINE 300 MG TABLET   4 Non-Preferred Brand 33%33%Q:30
/30Days
LAMIVUDINE-ZIDOVUDINE TABLET   4 Non-Preferred Brand 33%33%Q:60
/30Days
LAMOTRIGINE 150MG TABLET (60 CT)   2 Non-Preferred Generics $4.00$0.00None
LAMOTRIGINE 200MG TABLET (60 CT)   2 Non-Preferred Generics $4.00$0.00None
LAMOTRIGINE 25MG TABLET (100 CT)   2 Non-Preferred Generics $4.00$0.00None
LAMOTRIGINE 25MG TABLET DISPERSIBLE   2 Non-Preferred Generics $4.00$0.00None
LAMOTRIGINE 5MG TABLET DISPERSIBLE   2 Non-Preferred Generics $4.00$0.00None
LAMOTRIGINE ER 100 MG TABLET   4 Non-Preferred Brand 33%33%None
lamotrigine er 200 mg tablet   4 Non-Preferred Brand 33%33%None
lamotrigine er 25 mg tablet   4 Non-Preferred Brand 33%33%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
lamotrigine er 250 mg tablet   4 Non-Preferred Brand 33%33%None
lamotrigine er 300 mg tablet   4 Non-Preferred Brand 33%33%None
lamotrigine er 50 mg tablet   4 Non-Preferred Brand 33%33%None
LAMOTRIGINE TABLET 100MG (100 CT)   2 Non-Preferred Generics $4.00$0.00None
LANOXIN 0.125MG TABLET   4 Non-Preferred Brand 33%33%Q:30
/30Days
LANOXIN 0.25MG TABLET   4 Non-Preferred Brand 33%33%P
LANOXIN 250ug/mL 10 AMPULE in 1 BOX / 2 mL in 1 AMPULE   4 Non-Preferred Brand 33%33%P
LANOXIN PED 0.1MG/ML AMPUL   4 Non-Preferred Brand 33%33%P
LANREOTIDE 240 MG/ML PREFILLED SYRINGE [SOMATULINE]   5 Specialty 25%N/AP Q:1
/28Days
Lansoprazole 15mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE, PLASTIC   3 Preferred Brand 20%20%Q:60
/30Days
Lansoprazole 30mg/1 30 CAPSULE, DELAYED RELEASE in 1 BOTTLE   3 Preferred Brand 20%20%Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LANTUS 100U/ML VIAL   3 Preferred Brand 20%20%None
LANTUS SOLOSTAR INJECTION   3 Preferred Brand 20%20%None
LATANOPROST OPHTHALMIC SOLUTION .005%   2 Non-Preferred Generics $4.00$0.00Q:3
/25Days
LATUDA 120 MG TABLET   4 Non-Preferred Brand 33%33%P Q:30
/30Days
LATUDA 20 MG TABLET   4 Non-Preferred Brand 33%33%P Q:30
/30Days
Latuda 40mg/1   4 Non-Preferred Brand 33%33%P Q:30
/30Days
Latuda 80mg/1   4 Non-Preferred Brand 33%33%P Q:60
/30Days
LEFLUNOMIDE 10MG TABLET   2 Non-Preferred Generics $4.00$0.00Q:30
/30Days
LEFLUNOMIDE TABLETS   2 Non-Preferred Generics $4.00$0.00Q:30
/30Days
Lessina 3 POUCH in 1 CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER PACK   4 Non-Preferred Brand 33%33%None
LETAIRIS 10MG TABLET   5 Specialty 25%N/AP Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LETAIRIS 5MG TABLET   5 Specialty 25%N/AP Q:30
/30Days
Letrozole 2.5mg/1 500 FILM COATED TABLETS in BOTTLE, PLASTIC   2 Non-Preferred Generics $4.00$0.00Q:30
/30Days
LEUCOVORIN CALCIUM 100MG VL   2 Non-Preferred Generics $4.00$0.00P
LEUCOVORIN CALCIUM 10MG TABLET   2 Non-Preferred Generics $4.00$0.00None
Leucovorin Calcium 15mg/1 24 TABLET BOTTLE   2 Non-Preferred Generics $4.00$0.00None
LEUCOVORIN CALCIUM 25MG TABLET   2 Non-Preferred Generics $4.00$0.00None
LEUCOVORIN CALCIUM 350MG VL   2 Non-Preferred Generics $4.00$0.00P
LEUCOVORIN CALCIUM 5MG TABLET   2 Non-Preferred Generics $4.00$0.00None
LEUKERAN 2MG TABLET   4 Non-Preferred Brand 33%33%None
LEUKINE 500 MCG/ML   5 Specialty 25%N/AP
LEUKINE INJECTION 250 MCG/ML   5 Specialty 25%N/AP
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LEUPROLIDE ACETATE INJECTION   3 Preferred Brand 20%20%P Q:3
/14Days
LEVALBUTEROL 1.25 MG/0.5 ML   2 Non-Preferred Generics $4.00$0.00P
LEVAQUIN 25mg/mL 480 mL in 1 BOTTLE   4 Non-Preferred Brand 33%33%None
LEVAQUIN INJECTION 5 MG/ML   4 Non-Preferred Brand 33%33%None
LEVEMIR 100UNITS/ML VIAL   3 Preferred Brand 20%20%None
Levemir 14.2mg/mL 5 SYRINGE, PLASTIC in 1 CARTON / 3 mL in 1 SYRINGE, PLASTIC   3 Preferred Brand 20%20%None
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT   2 Non-Preferred Generics $4.00$0.00None
LEVETIRACETAM 100MG/ML INJECTION   2 Non-Preferred Generics $4.00$0.00None
LEVETIRACETAM 500 MG TABLET 120 BOT   2 Non-Preferred Generics $4.00$0.00None
Levetiracetam 750mg/1 60 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE   2 Non-Preferred Generics $4.00$0.00None
Levetiracetam er 500 mg tablet   2 Non-Preferred Generics $4.00$0.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LEVETIRACETAM TABLETS 1000MG 60 BOT   2 Non-Preferred Generics $4.00$0.00None
LEVETIRACETAM TABLETS 250MG 500 BOT   2 Non-Preferred Generics $4.00$0.00None
LEVETIRACETAM TABLETS 750MG 500 BOT   2 Non-Preferred Generics $4.00$0.00None
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION   1 Preferred Generics $1.00$0.00None
LEVOCARNITINE 100MG/ML SOLUTION ORAL   3 Preferred Brand 20%20%P
LEVOCARNITINE 200MG/ML VIAL   3 Preferred Brand 20%20%P
LEVOCARNITINE TABLET 330MG 90 BLPK   3 Preferred Brand 20%20%P
Levocetirizine dihydrochloride 5mg/1 30 TABLET BOTTLE   2 Non-Preferred Generics $4.00$0.00Q:30
/30Days
Levofloxacin 250mg/1   2 Non-Preferred Generics $4.00$0.00None
Levofloxacin 25mg/mL 1 BOTTLE in 1 CARTON / 100 mL in 1 BOTTLE   2 Non-Preferred Generics $4.00$0.00None
Levofloxacin 25mg/mL 1 VIAL in 1 CARTON / 30 mL in 1 VIAL   4 Non-Preferred Brand 33%33%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Levofloxacin 500mg/1   2 Non-Preferred Generics $4.00$0.00None
Levofloxacin 5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER   2 Non-Preferred Generics $4.00$0.00None
Levofloxacin 5mg/mL 24 POUCH in 1 CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG   4 Non-Preferred Brand 33%33%None
Levofloxacin 750mg/1   2 Non-Preferred Generics $4.00$0.00None
LEVONEST-28 TABLET   4 Non-Preferred Brand 33%33%None
levonor-eth estrad 0.15-0.03   4 Non-Preferred Brand 33%33%Q:91
/90Days
LEVORA-28 TABLET 0.15/30   4 Non-Preferred Brand 33%33%None
LEVORPHANOL TARTRATE 2mg 100 TABLET BOTTLE   3 Preferred Brand 20%20%Q:240
/30Days
Levothroid 100ug/1 100 TABLET BOTTLE   2 Non-Preferred Generics $4.00$0.00None
Levothroid 112ug/1 100 TABLET BOTTLE   2 Non-Preferred Generics $4.00$0.00None
Levothroid 125ug/1 100 TABLET BOTTLE   2 Non-Preferred Generics $4.00$0.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Levothroid 137ug/1 100 TABLET BOTTLE   2 Non-Preferred Generics $4.00$0.00None
Levothroid 150ug/1 100 TABLET BOTTLE   2 Non-Preferred Generics $4.00$0.00None
Levothroid 175ug/1 100 TABLET BOTTLE   2 Non-Preferred Generics $4.00$0.00None
Levothroid 200ug/1 100 TABLET BOTTLE   2 Non-Preferred Generics $4.00$0.00None
Levothroid 25ug/1 100 TABLET BOTTLE   2 Non-Preferred Generics $4.00$0.00None
Levothroid 300ug/1 100 TABLET BOTTLE   2 Non-Preferred Generics $4.00$0.00None
Levothroid 50ug/1 100 TABLET BOTTLE   2 Non-Preferred Generics $4.00$0.00None
Levothroid 75ug/1 100 TABLET BOTTLE   2 Non-Preferred Generics $4.00$0.00None
Levothroid 88ug/1 100 TABLET BOTTLE   2 Non-Preferred Generics $4.00$0.00None
Levothyroxine Sodium 100ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA   1 Preferred Generics $1.00$0.00None
Levothyroxine Sodium 112ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA   1 Preferred Generics $1.00$0.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Levothyroxine Sodium 125ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA   1 Preferred Generics $1.00$0.00None
LEVOTHYROXINE SODIUM 137MCG TABLET   2 Non-Preferred Generics $4.00$0.00None
Levothyroxine Sodium 150ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA   1 Preferred Generics $1.00$0.00None
Levothyroxine Sodium 175ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA   1 Preferred Generics $1.00$0.00None
Levothyroxine Sodium 200ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA   1 Preferred Generics $1.00$0.00None
Levothyroxine Sodium 25ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS   1 Preferred Generics $1.00$0.00None
Levothyroxine Sodium 300ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA   2 Non-Preferred Generics $4.00$0.00None
Levothyroxine Sodium 50ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS   1 Preferred Generics $1.00$0.00None
Levothyroxine Sodium 75ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS   1 Preferred Generics $1.00$0.00None
Levothyroxine Sodium 88ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS   1 Preferred Generics $1.00$0.00None
LEVOXYL 100MCG TABLET (1000 CT)   3 Preferred Brand 20%20%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LEVOXYL 112MCG TABLET (1000 CT)   3 Preferred Brand 20%20%None
LEVOXYL 125MCG TABLET (1000 CT)   3 Preferred Brand 20%20%None
LEVOXYL 137MCG TABLET (1000 CT)   3 Preferred Brand 20%20%None
LEVOXYL 150MCG TABLET (1000 CT)   3 Preferred Brand 20%20%None
LEVOXYL 175MCG TABLET (1000 CT)   3 Preferred Brand 20%20%None
LEVOXYL 200MCG TABLET (1000 CT)   3 Preferred Brand 20%20%None
LEVOXYL 25MCG TABLET (1000 CT)   3 Preferred Brand 20%20%None
LEVOXYL 50MCG TABLET (1000 CT)   3 Preferred Brand 20%20%None
LEVOXYL 75MCG TABLET (1000 CT)   3 Preferred Brand 20%20%None
LEVOXYL 88MCG TABLET (1000 CT)   3 Preferred Brand 20%20%None
LEXIVA 50mg/mL 225 mL in 1 BOTTLE   3 Preferred Brand 20%20%Q:1575
/28Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LEXIVA TABLETS   5 Specialty 25%N/AQ:120
/30Days
LIALDA 1.2G TABLET DELAYED RELEASE   4 Non-Preferred Brand 33%33%Q:120
/30Days
LIDOCAINE 5% OINTMENT   2 Non-Preferred Generics $4.00$0.00P
LIDOCAINE HCL 1% VIAL   2 Non-Preferred Generics $4.00$0.00None
lidocaine hcl 2% jelly   2 Non-Preferred Generics $4.00$0.00None
LIDOCAINE HCL 2% JELLY 30ML TUBE   2 Non-Preferred Generics $4.00$0.00None
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT   2 Non-Preferred Generics $4.00$0.00None
Lidocaine Hydrochloride 5mg/mL 25 VIAL, SINGLE-DOSE in 1 CONTAINER / 50 mL in 1 VIAL, SINGLE-DOSE   2 Non-Preferred Generics $4.00$0.00None
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT   2 Non-Preferred Generics $4.00$0.00None
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM   2 Non-Preferred Generics $4.00$0.00P
LIDODERM 5% PATCH   4 Non-Preferred Brand 33%33%P Q:90
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Lindane 10mg/mL   4 Non-Preferred Brand 33%33%None
LINDANE SHAMPOO 1MG 2 FLO BOT   4 Non-Preferred Brand 33%33%None
LINZESS 145 MCG CAPSULE   4 Non-Preferred Brand 33%33%Q:30
/30Days
LINZESS 290 MCG CAPSULE   4 Non-Preferred Brand 33%33%Q:30
/30Days
Lioresal 0.05mg/mL   4 Non-Preferred Brand 33%33%None
Lioresal 0.5mg/mL   4 Non-Preferred Brand 33%33%None
Lioresal 2mg/mL   5 Specialty 25%N/ANone
liothyronine sodium 10ug/mL 1 VIAL in 1 CARTON / 1 mL in 1 VIAL   3 Preferred Brand 20%20%None
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT   2 Non-Preferred Generics $4.00$0.00None
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT   2 Non-Preferred Generics $4.00$0.00None
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT   2 Non-Preferred Generics $4.00$0.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
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 33%33%P
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 33%33%P
LISINOPRIL 10MG TABLET (100 CT)   1 Preferred Generics $1.00$0.00None
LISINOPRIL 2.5 MG TABLET   1 Preferred Generics $1.00$0.00None
LISINOPRIL 20MG TABLET   1 Preferred Generics $1.00$0.00None
LISINOPRIL 30MG TABLET (100 CT)   2 Non-Preferred Generics $4.00$0.00None
LISINOPRIL 40MG TABLET (500 CT)   2 Non-Preferred Generics $4.00$0.00None
Lisinopril 5mg/1 1000 TABLET BOTTLE   1 Preferred Generics $1.00$0.00None
LISINOPRIL-HCTZ 10/12.5 TABLET   1 Preferred Generics $1.00$0.00None
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT)   1 Preferred Generics $1.00$0.00None
LISINOPRIL-HCTZ 20/12.5 TABLET   1 Preferred Generics $1.00$0.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Lithium Carbonate 150mg/1 100 CAPSULE in 1 BOTTLE   2 Non-Preferred Generics $4.00$0.00None
Lithium Carbonate 300 mg tab   2 Non-Preferred Generics $4.00$0.00None
LITHIUM CARBONATE 300MG CAPSULE (100 CT)   1 Preferred Generics $1.00$0.00None
Lithium Carbonate 450mg/1   2 Non-Preferred Generics $4.00$0.00None
LITHIUM CARBONATE CAPSULES   2 Non-Preferred Generics $4.00$0.00None
LITHIUM CARBONATE ER TABLET 300MG (100 CT)   2 Non-Preferred Generics $4.00$0.00None
LITHIUM CIT 8MEQ/5ML SYRUP   2 Non-Preferred Generics $4.00$0.00None
LOKARA 0.05% LOTION   2 Non-Preferred Generics $4.00$0.00None
LOPERAMIDE HCL 2MG CAPSULE   2 Non-Preferred Generics $4.00$0.00None
Lorazepam 0.5mg/1 500 TABLET BOTTLE   2 Non-Preferred Generics $4.00$0.00Q:90
/30Days
Lorazepam 1mg/1 100 TABLET BOTTLE   2 Non-Preferred Generics $4.00$0.00Q:90
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Lorazepam 2mg/1 100 TABLET BOTTLE   2 Non-Preferred Generics $4.00$0.00Q:150
/30Days
Lorazepam 2mg/mL 30 mL in 1 BOTTLE, DROPPER   3 Preferred Brand 20%20%Q:150
/30Days
Loryna (drospirenone and ethinyl estradiol) 3 CARTON in 1 BOX / 1 KIT in 1 CARTON   4 Non-Preferred Brand 33%33%None
LOSARTAN POTASSIUM 100 MG TAB   2 Non-Preferred Generics $4.00$0.00Q:60
/30Days
LOSARTAN POTASSIUM 25 MG TAB   2 Non-Preferred Generics $4.00$0.00Q:60
/30Days
LOSARTAN POTASSIUM 50 MG TAB   2 Non-Preferred Generics $4.00$0.00Q:60
/30Days
LOSARTAN-HCTZ 100-12.5 MG TAB   2 Non-Preferred Generics $4.00$0.00Q:60
/30Days
LOSARTAN-HCTZ 100-25 MG TAB   2 Non-Preferred Generics $4.00$0.00Q:60
/30Days
LOSARTAN-HCTZ 50-12.5 MG TAB   2 Non-Preferred Generics $4.00$0.00Q:60
/30Days
LOSEASONIQUE TABLET   4 Non-Preferred Brand 33%33%Q:91
/90Days
LOTRONEX TABLETS .5MG 30 BOTPL   5 Specialty 25%N/AQ:60
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LOTRONEX TABLETS 1MG 30 BOTPL   5 Specialty 25%N/AQ:60
/30Days
Lovastatin 10mg 60 TABLET BOTTLE   1 Preferred Generics $1.00$0.00Q:60
/30Days
Lovastatin 20mg 500 TABLET BOTTLE   1 Preferred Generics $1.00$0.00Q:60
/30Days
LOVASTATIN 40 MG ORAL TABLET   2 Non-Preferred Generics $4.00$0.00Q:60
/30Days
LOVAZA 1g/ 120 LIQUID FILLED CAPSULES in BOTTLE   3 Preferred Brand 20%20%Q:120
/30Days
LOW-OGESTREL-28 TABLET   4 Non-Preferred Brand 33%33%None
LOXAPINE 25MG CAPSULE (100 CT)   3 Preferred Brand 20%20%None
LOXAPINE CAPSULES 10MG 100 BOT   3 Preferred Brand 20%20%None
LOXAPINE CAPSULES 50MG 100 BOT   3 Preferred Brand 20%20%None
LOXAPINE CAPSULES 5MG 100 BOT   3 Preferred Brand 20%20%None
LUMIGAN 0.03% EYE DROPS   3 Preferred Brand 20%20%Q:3
/25Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LUMIGAN 0.1mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER   3 Preferred Brand 20%20%Q:3
/25Days
Lumizyme 5mg/mL   5 Specialty 25%N/AP
Lupron Depot 1 KIT in 1 CARTON   5 Specialty 25%N/AP Q:1
/168Days
LUPRON DEPOT 22.5 MG 3MO KIT [LUPRON]   4 Non-Preferred Brand 33%33%P Q:1
/90Days
LUPRON DEPOT 3.75 MG KIT   4 Non-Preferred Brand 33%33%P Q:1
/30Days
LUPRON DEPOT 7.5 MG KIT   5 Specialty 25%N/AP Q:1
/30Days
LUPRON DEPOT-4 MONTH KIT   4 Non-Preferred Brand 33%33%P Q:1
/112Days
Lupron Depot-PED 1 KIT in 1 CARTON   4 Non-Preferred Brand 33%33%P Q:1
/90Days
LUPRON DEPOT-PED 11.25 MG KIT   5 Specialty 25%N/AP Q:1
/28Days
LUPRON DEPOT-PED 15 MG KIT   5 Specialty 25%N/AP Q:1
/28Days
LUTERA 0.1-0.02 TABLET   4 Non-Preferred Brand 33%33%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LUVOX CR 100MG CAPSULE SR 24 HR   3 Preferred Brand 20%20%Q:60
/30Days
LUVOX CR 150MG CAPSULE SR 24 HR   3 Preferred Brand 20%20%Q:60
/30Days
LYRICA 100MG CAPSULE   4 Non-Preferred Brand 33%33%Q:90
/30Days
LYRICA 150MG CAPSULE   4 Non-Preferred Brand 33%33%Q:90
/30Days
LYRICA 20 MG/ML ORAL SOLUTION   4 Non-Preferred Brand 33%33%Q:900
/30Days
LYRICA 200MG CAPSULE   4 Non-Preferred Brand 33%33%Q:90
/30Days
LYRICA 225MG CAPSULE   4 Non-Preferred Brand 33%33%Q:60
/30Days
LYRICA 25MG CAPSULE   4 Non-Preferred Brand 33%33%Q:90
/30Days
LYRICA 300MG CAPSULE   4 Non-Preferred Brand 33%33%Q:60
/30Days
LYRICA 50MG CAPSULE   4 Non-Preferred Brand 33%33%Q:90
/30Days
LYRICA 75MG CAPSULE   4 Non-Preferred Brand 33%33%Q:90
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LYSODREN 500MG TABLET   3 Preferred Brand 20%20%None

Chart Legend:

Below are a few notes to help you understand the above 2013 Medicare Part D Humana Walmart-Preferred Rx Plan (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 $325 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 intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2970) 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 2013 )

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.