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2014 Medicare Part D Plan Formulary Information
SilverScript Plus (PDP) (S5601-045-0) Benefit Details
The SilverScript Plus (PDP) (S5601-045-0) Formulary Drugs Starting with the Letter L in CMS PDP Region 22 which includes: TX Plan Monthly Premium: $124.20 Deductible: $0 Qualifies for LIS: No
Drugs Starting with Letter L Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter L Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LABETALOL HCL 100MG TABLET	2	Preferred Brand	$17.00	$42.50	None
LABETALOL HCL 200MG TABLET	2	Preferred Brand	$17.00	$42.50	None
LABETALOL HCL 300MG TABLET	2	Preferred Brand	$17.00	$42.50	None
LACTATED RINGERS INJECTION	1	Generic	$0.00	$0.00	None
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT	1	Generic	$0.00	$0.00	None
LAMIVUDINE 150 MG TABLET	2	Preferred Brand	$17.00	$42.50	None
LAMIVUDINE 300 MG TABLET	2	Preferred Brand	$17.00	$42.50	None
Lamivudine hbv 100 mg tablet	3	Non-Preferred Brand	$41.00	$102.50	None
LAMIVUDINE-ZIDOVUDINE TABLET	4	Specialty Tier	33%	33%	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	2	Preferred Brand	$17.00	$42.50	None
LAMOTRIGINE 5MG TABLET DISPERSIBLE	2	Preferred Brand	$17.00	$42.50	None
LAMOTRIGINE ER 100 MG TABLET	3	Non-Preferred Brand	$41.00	$102.50	None
lamotrigine er 200 mg tablet	3	Non-Preferred Brand	$41.00	$102.50	None
lamotrigine er 25 mg tablet	3	Non-Preferred Brand	$41.00	$102.50	None
lamotrigine er 250 mg tablet	3	Non-Preferred Brand	$41.00	$102.50	None
lamotrigine er 300 mg tablet	3	Non-Preferred Brand	$41.00	$102.50	None
lamotrigine er 50 mg tablet	3	Non-Preferred Brand	$41.00	$102.50	None
LAMOTRIGINE TABLET 100MG (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
LANOXIN 0.25MG TABLET	2	Preferred Brand	$17.00	$42.50	None
LANOXIN 125 MCG TABLET	2	Preferred Brand	$17.00	$42.50	None
LANREOTIDE 240 MG/ML PREFILLED SYRINGE [SOMATULINE]	4	Specialty Tier	33%	33%	P
LANSOPRAZOL-AMOXICIL-CLARITHRO	3	Non-Preferred Brand	$41.00	$102.50	None
LANTUS 100U/ML VIAL	2	Preferred Brand	$17.00	$42.50	None
LANTUS SOLOSTAR INJECTION	2	Preferred Brand	$17.00	$42.50	None
LARIN 21 1-20 tablet	2	Preferred Brand	$17.00	$42.50	None
LARIN FE 1-20 TABLET	1	Generic	$0.00	$0.00	None
LARIN FE 1.5-30 TABLET	1	Generic	$0.00	$0.00	None
LATANOPROST 0.005% EYE DROPS	1	Generic	$0.00	$0.00	None
LATUDA 120 MG TABLET	3	Non-Preferred Brand	$41.00	$102.50	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LATUDA 20 MG TABLET	3	Non-Preferred Brand	$41.00	$102.50	None
Latuda 40mg/1	3	Non-Preferred Brand	$41.00	$102.50	Q:30 /30Days
LATUDA 60 MG TABLET	3	Non-Preferred Brand	$41.00	$102.50	Q:60 /30Days
Latuda 80mg/1	3	Non-Preferred Brand	$41.00	$102.50	Q:60 /30Days
LAZANDA 100 MCG NASAL SPRAY	4	Specialty Tier	33%	33%	P Q:30 /30Days
LAZANDA 400 MCG NASAL SPRAY	4	Specialty Tier	33%	33%	P Q:30 /30Days
LEENA 7-9-5 TABLET	2	Preferred Brand	$17.00	$42.50	None
LEFLUNOMIDE 10MG TABLET	2	Preferred Brand	$17.00	$42.50	None
LEFLUNOMIDE 20 MG TABLET	2	Preferred Brand	$17.00	$42.50	None
Lessina 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK	2	Preferred Brand	$17.00	$42.50	None
LETAIRIS 10MG TABLET	4	Specialty Tier	33%	33%	P Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LETAIRIS 5MG TABLET	4	Specialty Tier	33%	33%	P Q:30 /30Days
Letrozole 2.5mg/1 500 FILM COATED TABLETS in BOTTLE, PLASTIC	2	Preferred Brand	$17.00	$42.50	None
LEUCOVORIN CALCIUM 100MG VL	3	Non-Preferred Brand	$41.00	$102.50	P
LEUCOVORIN CALCIUM 10MG TABLET	2	Preferred Brand	$17.00	$42.50	None
Leucovorin Calcium 15mg/1 24 TABLET BOTTLE	2	Preferred Brand	$17.00	$42.50	None
LEUCOVORIN CALCIUM 25MG TABLET	2	Preferred Brand	$17.00	$42.50	None
LEUCOVORIN CALCIUM 350MG VL	3	Non-Preferred Brand	$41.00	$102.50	P
LEUCOVORIN CALCIUM 5MG TABLET	2	Preferred Brand	$17.00	$42.50	None
LEUKERAN 2 MG TABLET	3	Non-Preferred Brand	$41.00	$102.50	None
LEUKINE 250 MCG VIAL	4	Specialty Tier	33%	33%	P
LEUPROLIDE ACETATE 1MG/0.2ML INJECTION	3	Non-Preferred Brand	$41.00	$102.50	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LEVALBUTEROL 1.25 MG/0.5 ML	3	Non-Preferred Brand	$41.00	$102.50	P
LEVEMIR 100UNITS/ML VIAL	2	Preferred Brand	$17.00	$42.50	None
Levemir 14.2mg/mL 5 SYRINGE, PLASTIC per CARTON / 3 mL in 1 SYRINGE, PLASTIC	2	Preferred Brand	$17.00	$42.50	None
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT	2	Preferred Brand	$17.00	$42.50	None
LEVETIRACETAM 100MG/ML INJECTION	3	Non-Preferred Brand	$41.00	$102.50	None
LEVETIRACETAM 500 MG TABLET 120 BOT	2	Preferred Brand	$17.00	$42.50	None
LEVETIRACETAM ER 500 MG TABLET	3	Non-Preferred Brand	$41.00	$102.50	None
LEVETIRACETAM ER 750 MG TABLET	3	Non-Preferred Brand	$41.00	$102.50	None
LEVETIRACETAM TABLETS 1000MG 60 BOT	2	Preferred Brand	$17.00	$42.50	None
LEVETIRACETAM TABLETS 250MG 500 BOT	2	Preferred Brand	$17.00	$42.50	None
LEVETIRACETAM TABLETS 750MG 500 BOT	2	Preferred Brand	$17.00	$42.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION	2	Preferred Brand	$17.00	$42.50	None
LEVOCARNITINE 100MG/ML SOLUTION ORAL	2	Preferred Brand	$17.00	$42.50	P
LEVOCARNITINE 200MG/ML VIAL	2	Preferred Brand	$17.00	$42.50	P
LEVOCARNITINE TABLET 330MG 90 BLPK	2	Preferred Brand	$17.00	$42.50	P
LEVOCETIRIZINE 2.5 MG/5 ML SOL	3	Non-Preferred Brand	$41.00	$102.50	None
Levocetirizine dihydrochloride 5mg/1 30 TABLET BOTTLE	1	Generic	$0.00	$0.00	None
Levofloxacin 250mg/1 [LEVAQUIN]	1	Generic	$0.00	$0.00	None
Levofloxacin 25mg/mL 1 BOTTLE per CARTON / 100 mL in 1 BOTTLE [LEVAQUIN]	3	Non-Preferred Brand	$41.00	$102.50	None
Levofloxacin 25mg/mL 1 VIAL per CARTON / 30 mL in 1 VIAL	3	Non-Preferred Brand	$41.00	$102.50	None
Levofloxacin 500mg/1 [LEVAQUIN]	1	Generic	$0.00	$0.00	None
Levofloxacin 5mg/mL 24 POUCH per CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG [LEVAQUIN]	2	Preferred Brand	$17.00	$42.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Levofloxacin 750mg/1 [LEVAQUIN]	1	Generic	$0.00	$0.00	None
LEVONEST-28 TABLET	1	Generic	$0.00	$0.00	None
levonor-eth estrad 0.15-0.03	2	Preferred Brand	$17.00	$42.50	None
LEVORA-28 TABLET 0.15/30	2	Preferred Brand	$17.00	$42.50	None
Levothyroxine Sodium 100ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA	1	Generic	$0.00	$0.00	None
Levothyroxine Sodium 112ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA	1	Generic	$0.00	$0.00	None
Levothyroxine Sodium 125ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA	1	Generic	$0.00	$0.00	None
LEVOTHYROXINE SODIUM 137MCG TABLET	1	Generic	$0.00	$0.00	None
Levothyroxine Sodium 150ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA	1	Generic	$0.00	$0.00	None
Levothyroxine Sodium 175ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA	1	Generic	$0.00	$0.00	None
Levothyroxine Sodium 200ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA	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 25ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS	1	Generic	$0.00	$0.00	None
Levothyroxine Sodium 300ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA	1	Generic	$0.00	$0.00	None
Levothyroxine Sodium 50ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS	1	Generic	$0.00	$0.00	None
Levothyroxine Sodium 75ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS	1	Generic	$0.00	$0.00	None
Levothyroxine Sodium 88ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS	1	Generic	$0.00	$0.00	None
LEXIVA 50mg/mL 225 mL in 1 BOTTLE	3	Non-Preferred Brand	$41.00	$102.50	None
LEXIVA 700MG TABLETS	3	Non-Preferred Brand	$41.00	$102.50	None
LIALDA 1.2G TABLET DELAYED RELEASE	3	Non-Preferred Brand	$41.00	$102.50	None
LIDOCAINE 5% OINTMENT	2	Preferred Brand	$17.00	$42.50	None
LIDOCAINE HCL 1% VIAL	1	Generic	$0.00	$0.00	P
lidocaine hcl 2% jelly	1	Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
lidocaine hcl 2% jelly	1	Generic	$0.00	$0.00	None
LIDOCAINE HCL 2% JELLY 30ML TUBE	1	Generic	$0.00	$0.00	None
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT	1	Generic	$0.00	$0.00	None
Lidocaine Hydrochloride 5mg/mL 25 VIAL, SINGLE-DOSE in 1 CONTAINER / 50 mL in 1 VIAL, SINGLE-DOSE	1	Generic	$0.00	$0.00	P
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT	1	Generic	$0.00	$0.00	None
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM	2	Preferred Brand	$17.00	$42.50	P
LIDODERM 5% PATCH	2	Preferred Brand	$17.00	$42.50	Q:3 /1Days
LINZESS 145 MCG CAPSULE	2	Preferred Brand	$17.00	$42.50	Q:60 /30Days
LINZESS 290 MCG CAPSULE	2	Preferred Brand	$17.00	$42.50	Q:30 /30Days
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT	2	Preferred Brand	$17.00	$42.50	None
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT	2	Preferred Brand	$17.00	$42.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT	2	Preferred Brand	$17.00	$42.50	None
LIPTRUZET 10-10 MG TABLET	3	Non-Preferred Brand	$41.00	$102.50	Q:30 /30Days
LIPTRUZET 10-20 MG TABLET	3	Non-Preferred Brand	$41.00	$102.50	Q:30 /30Days
LIPTRUZET 10-40 MG TABLET	3	Non-Preferred Brand	$41.00	$102.50	Q:30 /30Days
LIPTRUZET 10-80 MG TABLET	3	Non-Preferred Brand	$41.00	$102.50	Q:30 /30Days
LISINOPRIL 10MG TABLET (100 CT)	1	Generic	$0.00	$0.00	None
LISINOPRIL 2.5 MG TABLET	1	Generic	$0.00	$0.00	None
Lisinopril 20 mg tablet	1	Generic	$0.00	$0.00	None
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 5mg/1 1000 TABLET BOTTLE	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 with Hydrochlorothiazide 12.5; 10mg/1; mg/1 100 TABLET BOTTLE, PLASTIC	1	Generic	$0.00	$0.00	None
Lisinopril with Hydrochlorothiazide 12.5; 20mg/1; mg/1 100 TABLET BOTTLE, PLASTIC	1	Generic	$0.00	$0.00	None
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT)	1	Generic	$0.00	$0.00	None
Lithium Carbonate 150mg/1 100 CAPSULE BOTTLE, PLASTIC	1	Generic	$0.00	$0.00	None
LITHIUM CARBONATE 300MG CAPSULE (100 CT)	1	Generic	$0.00	$0.00	None
Lithium Carbonate 300mg/1 1000 TABLET BOTTLE	1	Generic	$0.00	$0.00	None
Lithium Carbonate 450mg/1	1	Generic	$0.00	$0.00	None
LITHIUM CARBONATE 600 MG CAP	1	Generic	$0.00	$0.00	None
LITHIUM CARBONATE ER TABLET 300MG (100 CT)	1	Generic	$0.00	$0.00	None
LITHIUM CIT 8MEQ/5ML SYRUP	2	Preferred Brand	$17.00	$42.50	None
LODOSYN TAB 25MG	3	Non-Preferred Brand	$41.00	$102.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LOKARA 0.05% LOTION	3	Non-Preferred Brand	$41.00	$102.50	None
LOMUSTINE 10 MG CAPSULE [Ceenu]	2	Preferred Brand	$17.00	$42.50	None
LOMUSTINE 100 MG CAPSULE [Ceenu]	2	Preferred Brand	$17.00	$42.50	None
LOMUSTINE 40 MG CAPSULE [Ceenu]	2	Preferred Brand	$17.00	$42.50	None
LOPERAMIDE HCL 2MG CAPSULE	1	Generic	$0.00	$0.00	None
LORAZEPAM 0.5 MG TABLET	1	Generic	$0.00	$0.00	Q:150 /30Days
Lorazepam 1mg/1 100 TABLET BOTTLE	1	Generic	$0.00	$0.00	Q:150 /30Days
Lorazepam 2mg/1 100 TABLET BOTTLE	1	Generic	$0.00	$0.00	Q:150 /30Days
Lorazepam 2mg/mL 30 mL in 1 BOTTLE, DROPPER	2	Preferred Brand	$17.00	$42.50	Q:150 /30Days
lorcet 5-325 mg tablet	1	Generic	$0.00	$0.00	Q:360 /30Days
lorcet hd 10-325 mg tablet	1	Generic	$0.00	$0.00	Q:360 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
lortab 10-325 mg tablet	1	Generic	$0.00	$0.00	Q:360 /30Days
lortab 5-325 mg tablet	1	Generic	$0.00	$0.00	Q:360 /30Days
lortab 7.5-325 mg tablet	1	Generic	$0.00	$0.00	Q:360 /30Days
Loryna (drospirenone and ethinyl estradiol) 3 CARTON in 1 BOX / 1 KIT per CARTON	2	Preferred Brand	$17.00	$42.50	None
LOSARTAN POTASSIUM 100 MG TAB	1	Generic	$0.00	$0.00	None
LOSARTAN POTASSIUM 25 MG TAB	1	Generic	$0.00	$0.00	Q:60 /30Days
LOSARTAN POTASSIUM 50 MG TAB	1	Generic	$0.00	$0.00	Q:60 /30Days
LOSARTAN-HCTZ 100-12.5 MG TAB	1	Generic	$0.00	$0.00	Q:30 /30Days
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	Q:30 /30Days
LOTEMAX 0.5% EYE DROPS	2	Preferred Brand	$17.00	$42.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LOTEMAX 0.5% OPHTHALMIC GEL	2	Preferred Brand	$17.00	$42.50	None
Lotemax 5mg/g 1 TUBE per CARTON / 3.5 g in 1 TUBE	2	Preferred Brand	$17.00	$42.50	None
LOTRONEX TABLETS .5MG 30 BOTPL	3	Non-Preferred Brand	$41.00	$102.50	P
LOTRONEX TABLETS 1MG 30 BOTPL	3	Non-Preferred Brand	$41.00	$102.50	P
Lovastatin 10mg 60 TABLET BOTTLE	1	Generic	$0.00	$0.00	Q:30 /30Days
Lovastatin 20mg 500 TABLET BOTTLE	1	Generic	$0.00	$0.00	Q:120 /30Days
LOVASTATIN 40 MG ORAL TABLET	1	Generic	$0.00	$0.00	Q:60 /30Days
LOVAZA 1g/ 120 LIQUID FILLED CAPSULES in BOTTLE	2	Preferred Brand	$17.00	$42.50	None
LOW-OGESTREL-28 TABLET	2	Preferred Brand	$17.00	$42.50	None
LOXAPINE 25MG CAPSULE (100 CT)	2	Preferred Brand	$17.00	$42.50	None
LOXAPINE CAPSULES 10MG 100 BOT	2	Preferred Brand	$17.00	$42.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LOXAPINE CAPSULES 50MG 100 BOT	2	Preferred Brand	$17.00	$42.50	None
LOXAPINE CAPSULES 5MG 100 BOT	2	Preferred Brand	$17.00	$42.50	None
LUMIGAN 0.1mg/mL 1 BOTTLE, DROPPER per CARTON / 5 mL in 1 BOTTLE, DROPPER	2	Preferred Brand	$17.00	$42.50	None
Lumizyme 5mg/mL	4	Specialty Tier	33%	33%	P
LUNESTA 2MG TABLET	2	Preferred Brand	$17.00	$42.50	Q:30 /30Days
LUNESTA 3MG TABLET	2	Preferred Brand	$17.00	$42.50	Q:30 /30Days
LUNESTA TABLETS 1MG 30 BOT	2	Preferred Brand	$17.00	$42.50	Q:30 /30Days
LUPRON DEPOT 3.75 MG KIT	4	Specialty Tier	33%	33%	P Q:1 /30Days
Lupron Depot-PED 1 KIT per CARTON	4	Specialty Tier	33%	33%	P Q:1 /84Days
LUPRON DEPOT-PED 11.25 MG KIT	4	Specialty Tier	33%	33%	P
LUPRON DEPOT-PED 15 MG KIT	4	Specialty Tier	33%	33%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LUTERA 0.1-0.02 TABLET	2	Preferred Brand	$17.00	$42.50	None
LYRICA 100MG CAPSULE	2	Preferred Brand	$17.00	$42.50	Q:120 /30Days
LYRICA 150MG CAPSULE	2	Preferred Brand	$17.00	$42.50	Q:120 /30Days
LYRICA 20 MG/ML ORAL SOLUTION	2	Preferred Brand	$17.00	$42.50	Q:946 /30Days
LYRICA 200MG CAPSULE	2	Preferred Brand	$17.00	$42.50	Q:90 /30Days
LYRICA 225MG CAPSULE	2	Preferred Brand	$17.00	$42.50	Q:60 /30Days
LYRICA 25MG CAPSULE	2	Preferred Brand	$17.00	$42.50	Q:120 /30Days
LYRICA 300MG CAPSULE	2	Preferred Brand	$17.00	$42.50	Q:60 /30Days
LYRICA 50MG CAPSULE	2	Preferred Brand	$17.00	$42.50	Q:120 /30Days
LYRICA 75MG CAPSULE	2	Preferred Brand	$17.00	$42.50	Q:120 /30Days
LYSODREN 500MG TABLET	2	Preferred Brand	$17.00	$42.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LYZA 0.35 MG TABLET	2	Preferred Brand	$17.00	$42.50	None

Chart Legend:

Below are a few notes to help you understand the above 2014 Medicare Part D SilverScript Plus (PDP) Plan Formulary.

Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).
Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.
Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $310 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.
Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
- Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
- No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.
Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
- Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
- Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
- Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the 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.