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Kaiser Permanente Senior Advantage Silver Plan (HMO) (H0630-021-0)
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2014 Medicare Part D Plan Formulary Information
Kaiser Permanente Senior Advantage Silver Plan (HMO) (H0630-021-0)
Benefit Details           
The Kaiser Permanente Senior Advantage Silver Plan (HMO) (H0630-021-0)
Formulary Drugs Starting with the Letter L
in WELD County, CO: CMS MA Region 20 which includes: CO
Plan Monthly Premium: $41.00 Deductible: $0
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   2 Non-Preferred Generic $10.00$20.00None
LABETALOL HCL 200MG TABLET   2 Non-Preferred Generic $10.00$20.00None
LABETALOL HCL 300MG TABLET   2 Non-Preferred Generic $10.00$20.00None
LABETALOL HCL 5MG/20ML VIAL   2 Non-Preferred Generic $10.00$20.00None
Lac Hydrin Cream 120mg/g 140 g in 1 TUBE   4 Non-Preferred Brand $95.00$190.00None
Lac-Hydrin 120mg/g 400 g in 1 BOTTLE, PLASTIC   4 Non-Preferred Brand $95.00$190.00None
LACRISERT 5 MG EYE INSERT   3 Preferred Brand $45.00$90.00None
LACTATED RINGERS INJECTION   2 Non-Preferred Generic $10.00$20.00None
LACTATED RINGERS IRRIGATION   2 Non-Preferred Generic $10.00$20.00None
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT   2 Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LAMICTAL 100MG TABLET   4 Non-Preferred Brand $95.00$190.00None
LAMICTAL 150MG TABLET   4 Non-Preferred Brand $95.00$190.00None
LAMICTAL 200MG TABLET   4 Non-Preferred Brand $95.00$190.00None
LAMICTAL 25MG DISPER TABLET CHEW   4 Non-Preferred Brand $95.00$190.00None
LAMICTAL 25MG TABLET   4 Non-Preferred Brand $95.00$190.00None
LAMICTAL 25MG TABLET STARTER KIT   3 Preferred Brand $45.00$90.00None
LAMICTAL 25MG/100MG TABLET STARTER KIT   3 Preferred Brand $45.00$90.00None
LAMICTAL 5MG DISPER TABLET CHEW   4 Non-Preferred Brand $95.00$190.00None
LAMICTAL KIT 100;25MG;MG   3 Preferred Brand $45.00$90.00None
LAMICTAL ODT 100mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK   4 Non-Preferred Brand $95.00$190.00None
LAMICTAL ODT 200mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LAMICTAL ODT 25mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK   4 Non-Preferred Brand $95.00$190.00None
LAMICTAL ODT 50mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK   4 Non-Preferred Brand $95.00$190.00None
LAMICTAL XR 100 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
LAMICTAL XR 200 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
LAMICTAL XR 25 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
LAMICTAL XR 250mg/1 30 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE   4 Non-Preferred Brand $95.00$190.00None
LAMICTAL XR 300mg/1 30 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE   4 Non-Preferred Brand $95.00$190.00None
LAMICTAL XR 50 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
LAMICTAL XR START KIT (BLUE)   4 Non-Preferred Brand $95.00$190.00None
LAMICTAL XR START KIT (GREEN)   4 Non-Preferred Brand $95.00$190.00None
LAMICTAL XR START KIT (ORANGE)   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LAMISIL 125MG GRANULES IN PACKET   4 Non-Preferred Brand $95.00$190.00None
LAMISIL 187.5MG GRANULES IN PACKET   4 Non-Preferred Brand $95.00$190.00None
LAMISIL 250MG TABLET (30 CT)   4 Non-Preferred Brand $95.00$190.00None
LAMIVUDINE 150 MG TABLET   2 Non-Preferred Generic $10.00$20.00None
LAMIVUDINE 300 MG TABLET   2 Non-Preferred Generic $10.00$20.00None
Lamivudine hbv 100 mg tablet   2 Non-Preferred Generic $10.00$20.00None
LAMIVUDINE-ZIDOVUDINE TABLET   2 Non-Preferred Generic $10.00$20.00None
LAMOTRIGINE 150MG TABLET (60 CT)   2 Non-Preferred Generic $10.00$20.00None
LAMOTRIGINE 200MG TABLET (60 CT)   2 Non-Preferred Generic $10.00$20.00None
LAMOTRIGINE 25MG TABLET (100 CT)   2 Non-Preferred Generic $10.00$20.00None
LAMOTRIGINE 25MG TABLET DISPERSIBLE   2 Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LAMOTRIGINE 5MG TABLET DISPERSIBLE   2 Non-Preferred Generic $10.00$20.00None
LAMOTRIGINE ER 100 MG TABLET   2 Non-Preferred Generic $10.00$20.00None
lamotrigine er 200 mg tablet   2 Non-Preferred Generic $10.00$20.00None
lamotrigine er 25 mg tablet   2 Non-Preferred Generic $10.00$20.00None
lamotrigine er 250 mg tablet   2 Non-Preferred Generic $10.00$20.00None
lamotrigine er 300 mg tablet   2 Non-Preferred Generic $10.00$20.00None
lamotrigine er 50 mg tablet   2 Non-Preferred Generic $10.00$20.00None
LAMOTRIGINE TABLET 100MG (100 CT)   2 Non-Preferred Generic $10.00$20.00None
LANOXIN 0.25 MG/ML AMPUL   4 Non-Preferred Brand $95.00$190.00None
LANOXIN 0.25MG TABLET   4 Non-Preferred Brand $95.00$190.00None
LANOXIN 125 MCG TABLET   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LANOXIN 187.5 MCG TABLET   4 Non-Preferred Brand $95.00$190.00None
LANOXIN 62.5 MCG TABLET   4 Non-Preferred Brand $95.00$190.00None
LANREOTIDE 240 MG/ML PREFILLED SYRINGE [SOMATULINE]   4 Non-Preferred Brand $95.00$190.00None
LANSOPRAZOL-AMOXICIL-CLARITHRO   2 Non-Preferred Generic $10.00$20.00None
Lansoprazole 15mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic $10.00$20.00None
Lansoprazole 30mg/1 30 CAPSULE, DELAYED RELEASE in 1 BOTTLE   2 Non-Preferred Generic $10.00$20.00None
LANTUS 100U/ML VIAL   3 Preferred Brand $45.00$90.00None
LANTUS SOLOSTAR INJECTION   4 Non-Preferred Brand $95.00$190.00None
LARIN 21 1-20 tablet   2 Non-Preferred Generic $10.00$20.00None
LARIN FE 1-20 TABLET   2 Non-Preferred Generic $10.00$20.00None
LARIN FE 1.5-30 TABLET   2 Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LASIX 20MG TABLETS   4 Non-Preferred Brand $95.00$190.00None
LASIX 40MG TABLET   4 Non-Preferred Brand $95.00$190.00None
LASIX 80MG TABLETS   4 Non-Preferred Brand $95.00$190.00None
LASTACAFT 2.5mg/mL 1 BOTTLE, PLASTIC per CARTON / 3 mL in 1 BOTTLE, PLASTIC   4 Non-Preferred Brand $95.00$190.00None
LATANOPROST 0.005% EYE DROPS   2 Non-Preferred Generic $10.00$20.00None
LATUDA 120 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
LATUDA 20 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
Latuda 40mg/1   4 Non-Preferred Brand $95.00$190.00None
LATUDA 60 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
Latuda 80mg/1   4 Non-Preferred Brand $95.00$190.00None
LAZANDA 100 MCG NASAL SPRAY   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LAZANDA 400 MCG NASAL SPRAY   4 Non-Preferred Brand $95.00$190.00None
LEENA 7-9-5 TABLET   2 Non-Preferred Generic $10.00$20.00None
LEFLUNOMIDE 10MG TABLET   2 Non-Preferred Generic $10.00$20.00None
LEFLUNOMIDE 20 MG TABLET   2 Non-Preferred Generic $10.00$20.00None
LESCOL 20MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
LESCOL 40MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
LESCOL XL 80MG TABLET SA   4 Non-Preferred Brand $95.00$190.00None
Lessina 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK   2 Non-Preferred Generic $10.00$20.00None
LETAIRIS 10MG TABLET   5 Specialty Tier 25%25%None
LETAIRIS 5MG TABLET   5 Specialty Tier 25%25%None
Letrozole 2.5mg/1 500 FILM COATED TABLETS in BOTTLE, PLASTIC   2 Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LEUCOVORIN CALCIUM 100MG VL   2 Non-Preferred Generic $10.00$20.00None
LEUCOVORIN CALCIUM 10MG TABLET   2 Non-Preferred Generic $10.00$20.00None
Leucovorin Calcium 15mg/1 24 TABLET BOTTLE   2 Non-Preferred Generic $10.00$20.00None
LEUCOVORIN CALCIUM 25MG TABLET   2 Non-Preferred Generic $10.00$20.00None
LEUCOVORIN CALCIUM 350MG VL   2 Non-Preferred Generic $10.00$20.00None
LEUCOVORIN CALCIUM 5MG TABLET   2 Non-Preferred Generic $10.00$20.00None
LEUKERAN 2 MG TABLET   3 Preferred Brand $45.00$90.00None
LEUKINE 250 MCG VIAL   3 Preferred Brand $45.00$90.00None
LEUPROLIDE ACETATE 1MG/0.2ML INJECTION   2 Non-Preferred Generic $10.00$20.00None
Levalbuterol 0.31 mg/3 ml sol   2 Non-Preferred Generic $10.00$20.00None
Levalbuterol 0.63 mg/3 ml sol   2 Non-Preferred Generic $10.00$20.00None
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 $10.00$20.00None
LEVAQUIN 250mg/1 10 BLISTER PACK per CARTON / 10 FILM COATED TABLETS in BLISTER PACK   4 Non-Preferred Brand $95.00$190.00None
LEVAQUIN 25mg/mL 480 mL in 1 BOTTLE   4 Non-Preferred Brand $95.00$190.00None
LEVAQUIN 500mg/1 50 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Brand $95.00$190.00None
LEVAQUIN 750 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
LEVAQUIN INJECTION 5 MG/ML   4 Non-Preferred Brand $95.00$190.00None
LEVATOL 20 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
LEVEMIR 100UNITS/ML VIAL   4 Non-Preferred Brand $95.00$190.00None
Levemir 14.2mg/mL 5 SYRINGE, PLASTIC per CARTON / 3 mL in 1 SYRINGE, PLASTIC   4 Non-Preferred Brand $95.00$190.00None
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT   2 Non-Preferred Generic $10.00$20.00None
LEVETIRACETAM 100MG/ML INJECTION   2 Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LEVETIRACETAM 500 MG TABLET 120 BOT   2 Non-Preferred Generic $10.00$20.00None
LEVETIRACETAM ER 500 MG TABLET   2 Non-Preferred Generic $10.00$20.00None
LEVETIRACETAM ER 750 MG TABLET   2 Non-Preferred Generic $10.00$20.00None
LEVETIRACETAM TABLETS 1000MG 60 BOT   2 Non-Preferred Generic $10.00$20.00None
LEVETIRACETAM TABLETS 250MG 500 BOT   2 Non-Preferred Generic $10.00$20.00None
LEVETIRACETAM TABLETS 750MG 500 BOT   2 Non-Preferred Generic $10.00$20.00None
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION   2 Non-Preferred Generic $10.00$20.00None
LEVOCARNITINE 100MG/ML SOLUTION ORAL   2 Non-Preferred Generic $10.00$20.00P
LEVOCARNITINE 200MG/ML VIAL   2 Non-Preferred Generic $10.00$20.00None
LEVOCARNITINE TABLET 330MG 90 BLPK   2 Non-Preferred Generic $10.00$20.00P
LEVOCETIRIZINE 2.5 MG/5 ML SOL   2 Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Levocetirizine dihydrochloride 5mg/1 30 TABLET BOTTLE   2 Non-Preferred Generic $10.00$20.00None
Levofloxacin 250mg/1 [LEVAQUIN]   2 Non-Preferred Generic $10.00$20.00None
Levofloxacin 25mg/mL 1 BOTTLE per CARTON / 100 mL in 1 BOTTLE [LEVAQUIN]   2 Non-Preferred Generic $10.00$20.00None
Levofloxacin 25mg/mL 1 VIAL per CARTON / 30 mL in 1 VIAL   2 Non-Preferred Generic $10.00$20.00None
Levofloxacin 500mg/1 [LEVAQUIN]   2 Non-Preferred Generic $10.00$20.00None
Levofloxacin 5mg/mL 1 BOTTLE, DROPPER per CARTON / 5 mL in 1 BOTTLE, DROPPER [LEVAQUIN]   2 Non-Preferred Generic $10.00$20.00None
Levofloxacin 5mg/mL 24 POUCH per CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG [LEVAQUIN]   2 Non-Preferred Generic $10.00$20.00None
Levofloxacin 750mg/1 [LEVAQUIN]   2 Non-Preferred Generic $10.00$20.00None
LEVONEST-28 TABLET   2 Non-Preferred Generic $10.00$20.00None
levonor-eth estrad 0.15-0.03   2 Non-Preferred Generic $10.00$20.00None
LEVORA-28 TABLET 0.15/30   2 Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LEVORPHANOL TARTRATE 2mg 100 TABLET BOTTLE   2 Non-Preferred Generic $10.00$20.00None
LEVOTHYROXINE 100 MCG VIAL   4 Non-Preferred Brand $95.00$190.00None
Levothyroxine Sodium 100ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA   2 Non-Preferred Generic $10.00$20.00None
Levothyroxine Sodium 112ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA   2 Non-Preferred Generic $10.00$20.00None
Levothyroxine Sodium 125ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA   2 Non-Preferred Generic $10.00$20.00None
LEVOTHYROXINE SODIUM 137MCG TABLET   2 Non-Preferred Generic $10.00$20.00None
Levothyroxine Sodium 150ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA   2 Non-Preferred Generic $10.00$20.00None
Levothyroxine Sodium 175ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA   2 Non-Preferred Generic $10.00$20.00None
Levothyroxine Sodium 200ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA   2 Non-Preferred Generic $10.00$20.00None
Levothyroxine Sodium 25ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS   2 Non-Preferred Generic $10.00$20.00None
Levothyroxine Sodium 300ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA   2 Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Levothyroxine Sodium 50ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS   2 Non-Preferred Generic $10.00$20.00None
Levothyroxine Sodium 75ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS   2 Non-Preferred Generic $10.00$20.00None
Levothyroxine Sodium 88ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS   2 Non-Preferred Generic $10.00$20.00None
LEVOXYL 100MCG TABLET (1000 CT)   2 Non-Preferred Generic $10.00$20.00None
LEVOXYL 112MCG TABLET (1000 CT)   2 Non-Preferred Generic $10.00$20.00None
LEVOXYL 125MCG TABLET (1000 CT)   2 Non-Preferred Generic $10.00$20.00None
LEVOXYL 137MCG TABLET (1000 CT)   2 Non-Preferred Generic $10.00$20.00None
LEVOXYL 150MCG TABLET (1000 CT)   2 Non-Preferred Generic $10.00$20.00None
LEVOXYL 175MCG TABLET (1000 CT)   2 Non-Preferred Generic $10.00$20.00None
LEVOXYL 200MCG TABLET (1000 CT)   2 Non-Preferred Generic $10.00$20.00None
LEVOXYL 25MCG TABLET (1000 CT)   2 Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LEVOXYL 50MCG TABLET (1000 CT)   2 Non-Preferred Generic $10.00$20.00None
LEVOXYL 75MCG TABLET (1000 CT)   2 Non-Preferred Generic $10.00$20.00None
LEVOXYL 88MCG TABLET (1000 CT)   2 Non-Preferred Generic $10.00$20.00None
LEXAPRO 10MG TABLET   4 Non-Preferred Brand $95.00$190.00None
LEXAPRO 20MG TABLET   4 Non-Preferred Brand $95.00$190.00None
LEXAPRO 5MG TABLET   4 Non-Preferred Brand $95.00$190.00None
LEXAPRO 5MG/5ML SOLUTION   4 Non-Preferred Brand $95.00$190.00None
LEXIVA 50mg/mL 225 mL in 1 BOTTLE   4 Non-Preferred Brand $95.00$190.00None
LEXIVA 700MG TABLETS   5 Specialty Tier 25%25%None
LIALDA 1.2G TABLET DELAYED RELEASE   3 Preferred Brand $45.00$90.00None
LIDOCAINE 5% OINTMENT   2 Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Lidocaine 5% patch   2 Non-Preferred Generic $10.00$20.00None
LIDOCAINE HCL 1% VIAL   2 Non-Preferred Generic $10.00$20.00None
lidocaine hcl 2% jelly   2 Non-Preferred Generic $10.00$20.00None
lidocaine hcl 2% jelly   2 Non-Preferred Generic $10.00$20.00None
LIDOCAINE HCL 2% JELLY 30ML TUBE   2 Non-Preferred Generic $10.00$20.00None
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT   2 Non-Preferred Generic $10.00$20.00None
Lidocaine Hydrochloride 5mg/mL 25 VIAL, SINGLE-DOSE in 1 CONTAINER / 50 mL in 1 VIAL, SINGLE-DOSE   2 Non-Preferred Generic $10.00$20.00None
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT   2 Non-Preferred Generic $10.00$20.00None
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM   2 Non-Preferred Generic $10.00$20.00P
LIDODERM 5% PATCH   4 Non-Preferred Brand $95.00$190.00None
LINCOCIN 300MG/ML VIAL   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Lindane 10mg/mL   2 Non-Preferred Generic $10.00$20.00None
LINDANE SHAMPOO 1MG 2 FLO BOT   2 Non-Preferred Generic $10.00$20.00None
LINZESS 145 MCG CAPSULE   3 Preferred Brand $45.00$90.00None
LINZESS 290 MCG CAPSULE   3 Preferred Brand $45.00$90.00None
Lioresal 0.05mg/mL   4 Non-Preferred Brand $95.00$190.00None
Lioresal 0.5mg/mL   4 Non-Preferred Brand $95.00$190.00None
Lioresal 2mg/mL   4 Non-Preferred Brand $95.00$190.00None
liothyronine sodium 10ug/mL 1 VIAL per CARTON / 1 mL in 1 VIAL   2 Non-Preferred Generic $10.00$20.00None
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT   2 Non-Preferred Generic $10.00$20.00None
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT   2 Non-Preferred Generic $10.00$20.00None
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT   2 Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LIPITOR 10MG TABLET   4 Non-Preferred Brand $95.00$190.00None
LIPITOR 20MG TABLET (5000 CT)   4 Non-Preferred Brand $95.00$190.00None
LIPITOR 40MG TABLET (500 CT)   4 Non-Preferred Brand $95.00$190.00None
LIPITOR 80MG TABLET   4 Non-Preferred Brand $95.00$190.00None
LIPOFEN 150MG CAPSULES   4 Non-Preferred Brand $95.00$190.00None
Liposyn III 1.2; 2.5; 10g/100mL; g/100mL; g/100mL 12 BOTTLE, GLASS in 1 CASE / 250 mL in 1 BOTTLE,   3 Preferred Brand $45.00$90.00None
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 $95.00$190.00None
LIPTRUZET 10-10 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
LIPTRUZET 10-20 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
LIPTRUZET 10-40 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
LIPTRUZET 10-80 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
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 $6.00$12.00None
LISINOPRIL 2.5 MG TABLET   1 Preferred Generic $6.00$12.00None
Lisinopril 20 mg tablet   1 Preferred Generic $6.00$12.00None
LISINOPRIL 30MG TABLET (100 CT)   2 Non-Preferred Generic $10.00$20.00None
LISINOPRIL 40MG TABLET (500 CT)   1 Preferred Generic $6.00$12.00None
Lisinopril 5mg/1 1000 TABLET BOTTLE   1 Preferred Generic $6.00$12.00None
Lisinopril with Hydrochlorothiazide 12.5; 10mg/1; mg/1 100 TABLET BOTTLE, PLASTIC   1 Preferred Generic $6.00$12.00None
Lisinopril with Hydrochlorothiazide 12.5; 20mg/1; mg/1 100 TABLET BOTTLE, PLASTIC   1 Preferred Generic $6.00$12.00None
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT)   1 Preferred Generic $6.00$12.00None
Lithium Carbonate 150mg/1 100 CAPSULE BOTTLE, PLASTIC   2 Non-Preferred Generic $10.00$20.00None
LITHIUM CARBONATE 300MG CAPSULE (100 CT)   2 Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Lithium Carbonate 300mg/1 1000 TABLET BOTTLE   2 Non-Preferred Generic $10.00$20.00None
Lithium Carbonate 450mg/1   2 Non-Preferred Generic $10.00$20.00None
LITHIUM CARBONATE 600 MG CAP   2 Non-Preferred Generic $10.00$20.00None
LITHIUM CARBONATE ER TABLET 300MG (100 CT)   2 Non-Preferred Generic $10.00$20.00None
LITHIUM CIT 8MEQ/5ML SYRUP   3 Preferred Brand $45.00$90.00None
LITHOBID 300MG TABLET SA   4 Non-Preferred Brand $95.00$190.00None
LIVALO 1 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
LIVALO 2 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
LIVALO 4 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
Lo Loestrin Fe 5 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK   4 Non-Preferred Brand $95.00$190.00None
LO MINASTRIN FE TABLET CHEW   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Locoid Lipocream 1.0mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   4 Non-Preferred Brand $95.00$190.00None
LOCOID LOTN 0.1 %   4 Non-Preferred Brand $95.00$190.00None
LODOSYN TAB 25MG   3 Preferred Brand $45.00$90.00None
LOESTRIN 24 FE TABLET   4 Non-Preferred Brand $95.00$190.00None
LOFIBRA 134MG CAPSULE   2 Non-Preferred Generic $10.00$20.00None
LOFIBRA 160MG TABLET   2 Non-Preferred Generic $10.00$20.00None
LOFIBRA 200MG CAPSULE   2 Non-Preferred Generic $10.00$20.00None
LOFIBRA 54MG TABLET   2 Non-Preferred Generic $10.00$20.00None
LOFIBRA 67MG CAPSULE   2 Non-Preferred Generic $10.00$20.00None
LOKARA 0.05% LOTION   2 Non-Preferred Generic $10.00$20.00None
LOMEDIA 24 FE 24MG TABLET   2 Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Lomotil 0.025; 2.5mg/1; mg/1 100 TABLET BOTTLE   4 Non-Preferred Brand $95.00$190.00None
LOMUSTINE 10 MG CAPSULE [Ceenu]   3 Preferred Brand $45.00$90.00None
LOMUSTINE 100 MG CAPSULE [Ceenu]   3 Preferred Brand $45.00$90.00None
LOMUSTINE 40 MG CAPSULE [Ceenu]   3 Preferred Brand $45.00$90.00None
LOPERAMIDE HCL 2MG CAPSULE   2 Non-Preferred Generic $10.00$20.00None
LOPID 600MG TABLET (500 CT)   4 Non-Preferred Brand $95.00$190.00None
LOPRESSOR 100MG TABLET (100 CT)   4 Non-Preferred Brand $95.00$190.00None
LOPRESSOR 1MG/ML AMPUL   4 Non-Preferred Brand $95.00$190.00None
LOPRESSOR 50MG TABLET (100 CT)   4 Non-Preferred Brand $95.00$190.00None
LOPRESSOR HCT 50-25 TABLET   4 Non-Preferred Brand $95.00$190.00None
LOPROX 1% SHAMPOO   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LORAZEPAM 0.5 MG TABLET   2 Non-Preferred Generic $10.00$20.00None
Lorazepam 1mg/1 100 TABLET BOTTLE   2 Non-Preferred Generic $10.00$20.00None
Lorazepam 2mg/1 100 TABLET BOTTLE   2 Non-Preferred Generic $10.00$20.00None
Lorazepam 2mg/mL 30 mL in 1 BOTTLE, DROPPER   2 Non-Preferred Generic $10.00$20.00None
lorcet 5-325 mg tablet   2 Non-Preferred Generic $10.00$20.00None
lorcet hd 10-325 mg tablet   2 Non-Preferred Generic $10.00$20.00None
Lorcet plus 7.5-325 mg tablet   2 Non-Preferred Generic $10.00$20.00None
lortab 10-325 mg tablet   2 Non-Preferred Generic $10.00$20.00None
lortab 5-325 mg tablet   2 Non-Preferred Generic $10.00$20.00None
lortab 7.5-325 mg tablet   2 Non-Preferred Generic $10.00$20.00None
Loryna (drospirenone and ethinyl estradiol) 3 CARTON in 1 BOX / 1 KIT per CARTON   2 Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LORZONE 375 MG TABLET   2 Non-Preferred Generic $10.00$20.00None
LORZONE 750 MG TABLET   2 Non-Preferred Generic $10.00$20.00None
LOSARTAN POTASSIUM 100 MG TAB   2 Non-Preferred Generic $10.00$20.00None
LOSARTAN POTASSIUM 25 MG TAB   2 Non-Preferred Generic $10.00$20.00None
LOSARTAN POTASSIUM 50 MG TAB   2 Non-Preferred Generic $10.00$20.00None
LOSARTAN-HCTZ 100-12.5 MG TAB   2 Non-Preferred Generic $10.00$20.00None
LOSARTAN-HCTZ 100-25 MG TAB   2 Non-Preferred Generic $10.00$20.00None
LOSARTAN-HCTZ 50-12.5 MG TAB   2 Non-Preferred Generic $10.00$20.00None
LOSEASONIQUE TABLET   4 Non-Preferred Brand $95.00$190.00None
LOTEMAX 0.5% EYE DROPS   4 Non-Preferred Brand $95.00$190.00None
LOTEMAX 0.5% OPHTHALMIC GEL   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Lotemax 5mg/g 1 TUBE per CARTON / 3.5 g in 1 TUBE   4 Non-Preferred Brand $95.00$190.00None
LOTENSIN 20 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
LOTENSIN 40 MG TABLET   4 Non-Preferred Brand $95.00$190.00None
LOTENSIN HCT 10-12.5 TABLET   4 Non-Preferred Brand $95.00$190.00None
LOTENSIN HCT 20-12.5 TABLET   4 Non-Preferred Brand $95.00$190.00None
LOTENSIN HCT 20-25 TABLET   4 Non-Preferred Brand $95.00$190.00None
LOTREL 10/20MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
LOTREL 10/40MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
LOTREL 2.5/10MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
Lotrel 5; 40mg/1; mg/1 100 CAPSULE BOTTLE   4 Non-Preferred Brand $95.00$190.00None
LOTREL 5/10MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LOTREL 5/20MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
LOTRISONE CREAM   4 Non-Preferred Brand $95.00$190.00None
LOTRONEX TABLETS .5MG 30 BOTPL   4 Non-Preferred Brand $95.00$190.00None
LOTRONEX TABLETS 1MG 30 BOTPL   4 Non-Preferred Brand $95.00$190.00None
Lovastatin 10mg 60 TABLET BOTTLE   1 Preferred Generic $6.00$12.00None
Lovastatin 20mg 500 TABLET BOTTLE   1 Preferred Generic $6.00$12.00None
LOVASTATIN 40 MG ORAL TABLET   1 Preferred Generic $6.00$12.00None
LOVAZA 1g/ 120 LIQUID FILLED CAPSULES in BOTTLE   4 Non-Preferred Brand $95.00$190.00None
LOVENOX 100MG PREFILLED SYR   3 Preferred Brand $45.00$90.00None
LOVENOX 120MG PREFILLED SYR   3 Preferred Brand $45.00$90.00None
LOVENOX 150MG PREFILLED SYR   3 Preferred Brand $45.00$90.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LOVENOX 300MG VIAL   3 Preferred Brand $45.00$90.00None
LOVENOX 30MG PREFILLED SYRN   3 Preferred Brand $45.00$90.00None
LOVENOX 40MG PREFILLED SYRN   3 Preferred Brand $45.00$90.00None
LOVENOX 60MG PREFILLED SYRN   3 Preferred Brand $45.00$90.00None
LOVENOX 80MG PREFILLED SYRN   3 Preferred Brand $45.00$90.00None
LOW-OGESTREL-28 TABLET   2 Non-Preferred Generic $10.00$20.00None
LOXAPINE 25MG CAPSULE (100 CT)   2 Non-Preferred Generic $10.00$20.00None
LOXAPINE CAPSULES 10MG 100 BOT   2 Non-Preferred Generic $10.00$20.00None
LOXAPINE CAPSULES 50MG 100 BOT   2 Non-Preferred Generic $10.00$20.00None
LOXAPINE CAPSULES 5MG 100 BOT   2 Non-Preferred Generic $10.00$20.00None
LOXITANE 10MG CAPSULE   2 Non-Preferred Generic $10.00$20.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LOXITANE 25MG CAPSULE   2 Non-Preferred Generic $10.00$20.00None
LOXITANE 5MG CAPSULE   2 Non-Preferred Generic $10.00$20.00None
LUFYLLIN 200MG TABLET   2 Non-Preferred Generic $10.00$20.00None
LUFYLLIN-400 TABLET   2 Non-Preferred Generic $10.00$20.00None
LUMIGAN 0.1mg/mL 1 BOTTLE, DROPPER per CARTON / 5 mL in 1 BOTTLE, DROPPER   3 Preferred Brand $45.00$90.00None
Lumizyme 5mg/mL   5 Specialty Tier 25%25%None
LUNESTA 2MG TABLET   4 Non-Preferred Brand $95.00$190.00None
LUNESTA 3MG TABLET   4 Non-Preferred Brand $95.00$190.00None
LUNESTA TABLETS 1MG 30 BOT   4 Non-Preferred Brand $95.00$190.00None
LUPANETA PACK 11.25-5 MG 3MO KIT   4 Non-Preferred Brand $95.00$190.00None
LUPANETA PACK 3.75-5 MG 1MO KIT   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Lupron Depot 1 KIT per CARTON   3 Preferred Brand $45.00$90.00None
LUPRON DEPOT 22.5 MG 3MO KIT [LUPRON]   3 Preferred Brand $45.00$90.00None
LUPRON DEPOT 3.75 MG KIT   3 Preferred Brand $45.00$90.00None
LUPRON DEPOT 7.5 MG KIT   3 Preferred Brand $45.00$90.00None
LUPRON DEPOT-4 MONTH KIT   3 Preferred Brand $45.00$90.00None
Lupron Depot-PED 1 KIT per CARTON   3 Preferred Brand $45.00$90.00None
LUPRON DEPOT-PED 11.25 MG KIT   3 Preferred Brand $45.00$90.00None
LUPRON DEPOT-PED 15 MG KIT   3 Preferred Brand $45.00$90.00None
LUTERA 0.1-0.02 TABLET   2 Non-Preferred Generic $10.00$20.00None
LUVOX CR 100MG CAPSULE SR 24 HR   4 Non-Preferred Brand $95.00$190.00None
LUVOX CR 150MG CAPSULE SR 24 HR   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LUXIQ 1.2mg/g 1 CAN per CARTON / 100 g in 1 CAN   4 Non-Preferred Brand $95.00$190.00None
LUZU 1% CREAM   4 Non-Preferred Brand $95.00$190.00None
LYRICA 100MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
LYRICA 150MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
LYRICA 20 MG/ML ORAL SOLUTION   4 Non-Preferred Brand $95.00$190.00None
LYRICA 200MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
LYRICA 225MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
LYRICA 25MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
LYRICA 300MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
LYRICA 50MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
LYRICA 75MG CAPSULE   4 Non-Preferred Brand $95.00$190.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LYSODREN 500MG TABLET   3 Preferred Brand $45.00$90.00None
LYSTEDA 650mg/1   4 Non-Preferred Brand $95.00$190.00None
LYZA 0.35 MG TABLET   2 Non-Preferred Generic $10.00$20.00None

Chart Legend:

Below are a few notes to help you understand the above 2014 Medicare Part D Kaiser Permanente Senior Advantage Silver Plan (HMO) 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 intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2850) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2014 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 2014 )

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.