2015 Medicare Part D Plan Formulary Information |
Humana Preferred Rx Plan (PDP) (S5884-147-0)
Benefit Details
 |
The Humana Preferred Rx Plan (PDP) (S5884-147-0) Formulary Drugs Starting with the Letter L in CMS PDP Region 31 which includes: ID UT Plan Monthly Premium: $29.00 Deductible: $320 Qualifies for LIS: Yes |
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 |
$2.00 | $0.00 | None |
LABETALOL HCL 200MG TABLET  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
LABETALOL HCL 300MG TABLET  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
LABETALOL HCL 5MG/20ML VIAL  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
LACRISERT 5 MG EYE INSERT  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LACTATED RINGERS INJECTION  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
LACTATED RINGERS IRRIGATION 4 CONTAINER in 1 CASE / 40  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
LAMICTAL 25MG TABLET STARTER KIT  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LAMICTAL 25MG/100MG TABLET STARTER KIT  |
4 |
Non-Preferred Brand |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMICTAL KIT 100;25MG;MG  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LAMICTAL ODT 100mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LAMICTAL ODT 200mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LAMICTAL ODT 25mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LAMICTAL ODT 50mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LAMICTAL XR START KIT (BLUE)  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LAMICTAL XR START KIT (GREEN)  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LAMICTAL XR START KIT (ORANGE)  |
4 |
Non-Preferred Brand |
35% | 35% | None |
Lamivudine 10 mg/ml oral soln  |
4 |
Non-Preferred Brand |
35% | 35% | Q:960 /30Days |
LAMIVUDINE 150 MG TABLET  |
4 |
Non-Preferred Brand |
35% | 35% | Q:60 /30Days |
LAMIVUDINE 300 MG TABLET  |
4 |
Non-Preferred Brand |
35% | 35% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Lamivudine hbv 100 mg tablet  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LAMIVUDINE-ZIDOVUDINE TABLET  |
4 |
Non-Preferred Brand |
35% | 35% | Q:60 /30Days |
LAMOTRIGINE 150MG TABLET (60 CT)  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
LAMOTRIGINE 200MG TABLET (60 CT)  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
LAMOTRIGINE 25MG TABLET (100 CT)  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
LAMOTRIGINE ER 100 MG TABLET  |
4 |
Non-Preferred Brand |
35% | 35% | None |
lamotrigine er 200 mg tablet  |
4 |
Non-Preferred Brand |
35% | 35% | None |
lamotrigine er 25 mg tablet  |
4 |
Non-Preferred Brand |
35% | 35% | None |
lamotrigine er 250 mg tablet  |
4 |
Non-Preferred Brand |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
lamotrigine er 300 mg tablet  |
4 |
Non-Preferred Brand |
35% | 35% | None |
lamotrigine er 50 mg tablet  |
4 |
Non-Preferred Brand |
35% | 35% | None |
Lamotrigine ODT 100 MG Tablet  |
4 |
Non-Preferred Brand |
35% | 35% | None |
Lamotrigine ODT 200 MG Tablet  |
4 |
Non-Preferred Brand |
35% | 35% | None |
Lamotrigine ODT 25 MG Tablet  |
4 |
Non-Preferred Brand |
35% | 35% | None |
Lamotrigine ODT 50 MG Tablet  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LAMOTRIGINE TABLET 100MG (100 CT)  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
LANOXIN 0.25 MG/ML AMPUL  |
4 |
Non-Preferred Brand |
35% | 35% | P |
LANOXIN 125 MCG TABLET  |
4 |
Non-Preferred Brand |
35% | 35% | Q:30 /30Days |
LANOXIN 187.5 MCG TABLET  |
4 |
Non-Preferred Brand |
35% | 35% | P Q:30 /30Days |
LANOXIN 250 MCG TABLET  |
4 |
Non-Preferred Brand |
35% | 35% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LANOXIN 62.5 MCG TABLET  |
4 |
Non-Preferred Brand |
35% | 35% | Q:30 /30Days |
LANREOTIDE 240 MG/ML PREFILLED SYRINGE [SOMATULINE] ![Compare how all Medicare Part D PDP plans in ID cover LANREOTIDE 240 MG/ML PREFILLED SYRINGE [SOMATULINE].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P Q:1 /28Days |
Lansoprazole 15mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE, PLASTIC  |
3 |
Preferred Brand |
20% | 17% | Q:60 /30Days |
Lansoprazole 30mg/1 30 CAPSULE, DELAYED RELEASE in 1 BOTTLE  |
3 |
Preferred Brand |
20% | 17% | Q:30 /30Days |
LANTUS 100U/ML VIAL  |
3 |
Preferred Brand |
20% | 17% | None |
LANTUS SOLOSTAR INJECTION  |
3 |
Preferred Brand |
20% | 17% | None |
LARIN 1.5 MG-30 MCG TABLET  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LARIN 21 1-20 tablet  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LARIN FE 1-20 TABLET  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LARIN FE 1.5-30 TABLET  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LATANOPROST 0.005% EYE DROPS  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | Q:3 /25Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LATUDA 120 MG TABLET  |
4 |
Non-Preferred Brand |
35% | 35% | P Q:30 /30Days |
LATUDA 20 MG TABLET  |
4 |
Non-Preferred Brand |
35% | 35% | P Q:30 /30Days |
Latuda 40mg/1  |
4 |
Non-Preferred Brand |
35% | 35% | P Q:30 /30Days |
LATUDA 60 MG TABLET  |
4 |
Non-Preferred Brand |
35% | 35% | P Q:30 /30Days |
Latuda 80mg/1  |
4 |
Non-Preferred Brand |
35% | 35% | P Q:60 /30Days |
LAZANDA 100 MCG NASAL SPRAY  |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
LAZANDA 400 MCG NASAL SPRAY  |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
LEFLUNOMIDE 10MG TABLET  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days |
LEFLUNOMIDE 20 MG TABLET  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days |
LENVIMA 10 MG DAILY DOSE  |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
LENVIMA 14 MG DAILY DOSE  |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LENVIMA 20 MG DAILY DOSE  |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
LENVIMA 24 MG DAILY DOSE  |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
Lessina 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LETAIRIS 10MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
LETAIRIS 5MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
LETROZOLE 2.5mg/1  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days |
LEUCOVORIN CALCIUM 100MG VL  |
3 |
Preferred Brand |
20% | 17% | None |
LEUCOVORIN CALCIUM 10MG TABLET  |
3 |
Preferred Brand |
20% | 17% | None |
Leucovorin Calcium 15mg/1 24 TABLET BOTTLE  |
3 |
Preferred Brand |
20% | 17% | None |
LEUCOVORIN CALCIUM 25MG TABLET  |
3 |
Preferred Brand |
20% | 17% | None |
LEUCOVORIN CALCIUM 350MG VL  |
3 |
Preferred Brand |
20% | 17% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUCOVORIN CALCIUM 5MG TABLET  |
3 |
Preferred Brand |
20% | 17% | None |
LEUKERAN 2 MG TABLET  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LEUKINE 250 MCG VIAL  |
5 |
Specialty Tier |
25% | N/A | P |
Leuprolide 2wk 1 mg/0.2 ml kit  |
3 |
Preferred Brand |
20% | 17% | P Q:3 /14Days |
LEVEMIR 100UNITS/ML VIAL  |
3 |
Preferred Brand |
20% | 17% | None |
LEVEMIR FLEXTOUCH 100 UNITS/ML  |
3 |
Preferred Brand |
20% | 17% | None |
Levetiracetam 100mg/mL 473 mL in 1 BOTTLE, PLASTIC  |
3 |
Preferred Brand |
20% | 17% | None |
LEVETIRACETAM 100MG/ML INJECTION  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LEVETIRACETAM 500 MG TABLET 120 BOT  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
Levetiracetam 500mg/1 60 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
LEVETIRACETAM ER 750 MG TABLET  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
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 Generic |
$2.00 | $0.00 | None |
LEVETIRACETAM TABLETS 250MG 500 BOT  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
LEVETIRACETAM TABLETS 750MG 500 BOT  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
LEVOCARNITINE 100MG/ML SOLUTION ORAL  |
3 |
Preferred Brand |
20% | 17% | None |
LEVOCARNITINE 200MG/ML VIAL  |
3 |
Preferred Brand |
20% | 17% | None |
LEVOCARNITINE TABLET 330MG 90 BLPK  |
3 |
Preferred Brand |
20% | 17% | None |
LEVOCETIRIZINE 5 MG TABLET  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days |
Levofloxacin 250mg/1 [LEVAQUIN] ![Compare how all Medicare Part D PDP plans in ID cover Levofloxacin 250mg/1 [LEVAQUIN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
Levofloxacin 25mg/mL 1 BOTTLE per CARTON / 100 mL in 1 BOTTLE [LEVAQUIN] ![Compare how all Medicare Part D PDP plans in ID cover Levofloxacin 25mg/mL 1 BOTTLE per CARTON / 100 mL in 1 BOTTLE [LEVAQUIN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 17% | None |
LEVOFLOXACIN 500 MG/20 ML VIAL [LEVAQUIN] ![Compare how all Medicare Part D PDP plans in ID cover LEVOFLOXACIN 500 MG/20 ML VIAL [LEVAQUIN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levofloxacin 500mg/1 [LEVAQUIN] ![Compare how all Medicare Part D PDP plans in ID cover Levofloxacin 500mg/1 [LEVAQUIN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
Levofloxacin 5mg/mL 1 BOTTLE, DROPPER per CARTON / 5 mL in 1 BOTTLE, DROPPER [LEVAQUIN] ![Compare how all Medicare Part D PDP plans in ID cover Levofloxacin 5mg/mL 1 BOTTLE, DROPPER per CARTON / 5 mL in 1 BOTTLE, DROPPER [LEVAQUIN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 17% | None |
Levofloxacin 5mg/mL 24 POUCH per CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG [LEVAQUIN] ![Compare how all Medicare Part D PDP plans in ID cover Levofloxacin 5mg/mL 24 POUCH per CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG [LEVAQUIN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
35% | 35% | None |
Levofloxacin 750mg/1 [LEVAQUIN] ![Compare how all Medicare Part D PDP plans in ID cover Levofloxacin 750mg/1 [LEVAQUIN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
LEVOLEUCOVORIN 175 MG/17.5 ML [Fusilev] ![Compare how all Medicare Part D PDP plans in ID cover LEVOLEUCOVORIN 175 MG/17.5 ML [Fusilev].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P |
LEVONEST-28 TABLET  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LEVONOR-ETH ESTRAD 0.1-0.02 MG  |
4 |
Non-Preferred Brand |
35% | 35% | None |
levonor-eth estrad 0.15-0.03  |
4 |
Non-Preferred Brand |
35% | 35% | Q:91 /90Days |
LEVORA-28 TABLET 0.15/30  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LEVORPHANOL TARTRATE 2mg 100 TABLET BOTTLE  |
4 |
Non-Preferred Brand |
35% | 35% | Q:240 /30Days |
Levothyroxine Sodium 100ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levothyroxine Sodium 112ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
Levothyroxine Sodium 125ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
Levothyroxine Sodium 150ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
Levothyroxine Sodium 175ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
Levothyroxine Sodium 200ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
Levothyroxine Sodium 25ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
Levothyroxine Sodium 300ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
Levothyroxine Sodium 50ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
Levothyroxine Sodium 75ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
Levothyroxine Sodium 88ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 100 MCG TABLET  |
3 |
Preferred Brand |
20% | 17% | None |
LEVOXYL 112 MCG TABLET  |
3 |
Preferred Brand |
20% | 17% | None |
LEVOXYL 125 MCG TABLET  |
3 |
Preferred Brand |
20% | 17% | None |
LEVOXYL 137 MCG TABLET  |
3 |
Preferred Brand |
20% | 17% | None |
LEVOXYL 150MCG TABLET (1000 CT)  |
3 |
Preferred Brand |
20% | 17% | None |
LEVOXYL 175MCG TABLET (1000 CT)  |
3 |
Preferred Brand |
20% | 17% | None |
LEVOXYL 200 MCG TABLET  |
3 |
Preferred Brand |
20% | 17% | None |
LEVOXYL 25 MCG TABLET  |
3 |
Preferred Brand |
20% | 17% | None |
LEVOXYL 50 MCG TABLET  |
3 |
Preferred Brand |
20% | 17% | None |
LEVOXYL 75MCG TABLET (1000 CT)  |
3 |
Preferred Brand |
20% | 17% | None |
LEVOXYL 88 MCG TABLET  |
3 |
Preferred Brand |
20% | 17% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEXIVA 50mg/mL 225 mL in 1 BOTTLE  |
3 |
Preferred Brand |
20% | 17% | Q:1575 /28Days |
LEXIVA 700MG TABLETS  |
5 |
Specialty Tier |
25% | N/A | Q:120 /30Days |
LIALDA 1.2G TABLET DELAYED RELEASE  |
3 |
Preferred Brand |
20% | 17% | Q:120 /30Days |
LIDOCAINE 5% OINTMENT  |
4 |
Non-Preferred Brand |
35% | 35% | None |
Lidocaine 5% patch  |
4 |
Non-Preferred Brand |
35% | 35% | P Q:90 /30Days |
lidocaine hcl 2% jelly  |
3 |
Preferred Brand |
20% | 17% | None |
lidocaine hcl 2% jelly  |
3 |
Preferred Brand |
20% | 17% | None |
LIDOCAINE HCL 2% JELLY 30ML TUBE  |
3 |
Preferred Brand |
20% | 17% | None |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
Lidocaine Hydrochloride 20mg/mL 25 VIAL, MULTI-DOSE in 1 TRAY / 20 mL in 1 VIAL, MULTI-DOSE  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
Lidocaine Hydrochloride 5mg/mL 25 VIAL, SINGLE-DOSE in 1 CONTAINER / 50 mL in 1 VIAL, SINGLE-DOSE  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
LIDOCAINE-PRILOCAINE CREAM  |
3 |
Preferred Brand |
20% | 17% | None |
Lindane 10mg/mL  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LINDANE SHAMPOO 1MG 2 FLO BOT  |
4 |
Non-Preferred Brand |
35% | 35% | None |
Linezolid 600 mg tablet [Zyvox] ![Compare how all Medicare Part D PDP plans in ID cover Linezolid 600 mg tablet [Zyvox].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | None |
Linezolid 600 mg/300 ml iv sol [Zyvox] ![Compare how all Medicare Part D PDP plans in ID cover Linezolid 600 mg/300 ml iv sol [Zyvox].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | None |
LINZESS 145 MCG CAPSULE  |
3 |
Preferred Brand |
20% | 17% | Q:30 /30Days |
LINZESS 290 MCG CAPSULE  |
3 |
Preferred Brand |
20% | 17% | Q:30 /30Days |
liothyronine sodium 10ug/mL 1 VIAL per CARTON / 1 mL in 1 VIAL  |
3 |
Preferred Brand |
20% | 17% | None |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT  |
3 |
Preferred Brand |
20% | 17% | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT  |
3 |
Preferred Brand |
20% | 17% | 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  |
3 |
Preferred Brand |
20% | 17% | None |
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 |
35% | 35% | 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 |
35% | 35% | P |
LISINOPRIL 10MG TABLET (100 CT)  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
LISINOPRIL 2.5 MG TABLET  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
LISINOPRIL 20 MG TABLET  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
LISINOPRIL 30MG TABLET (100 CT)  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
LISINOPRIL 40MG TABLET (500 CT)  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
Lisinopril 5mg/1 1000 TABLET BOTTLE  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
Lisinopril with Hydrochlorothiazide 12.5; 10mg/1; mg/1 100 TABLET BOTTLE, PLASTIC  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
Lisinopril with Hydrochlorothiazide 12.5; 20mg/1; mg/1 100 TABLET BOTTLE, PLASTIC  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT)  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
Lithium Carbonate 150mg/1 100 CAPSULE BOTTLE, PLASTIC  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
Lithium Carbonate 300 mg tab  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT)  |
1 |
Preferred Generic |
$1.00 | $0.00 | None |
Lithium Carbonate 450mg/1  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
LITHIUM CARBONATE 600 MG CAP  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT)  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
LITHOSTAT 250 MG TABLET  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LOKARA 0.05% LOTION  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LOMUSTINE 10 MG CAPSULE [Ceenu] ![Compare how all Medicare Part D PDP plans in ID cover LOMUSTINE 10 MG CAPSULE [Ceenu].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
35% | 35% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOMUSTINE 100 MG CAPSULE [Ceenu] ![Compare how all Medicare Part D PDP plans in ID cover LOMUSTINE 100 MG CAPSULE [Ceenu].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
35% | 35% | None |
LOMUSTINE 40 MG CAPSULE [Ceenu] ![Compare how all Medicare Part D PDP plans in ID cover LOMUSTINE 40 MG CAPSULE [Ceenu].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
35% | 35% | None |
LOPERAMIDE HCL 2MG CAPSULE  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None |
LORAZEPAM 0.5 MG TABLET  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | Q:90 /30Days |
Lorazepam 1mg/1 100 TABLET BOTTLE  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | Q:90 /30Days |
Lorazepam 2mg/1 100 TABLET BOTTLE  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | Q:150 /30Days |
Lorazepam 2mg/mL 30 mL in 1 BOTTLE, DROPPER  |
3 |
Preferred Brand |
20% | 17% | Q:150 /30Days |
Loryna (drospirenone and ethinyl estradiol) 3 CARTON in 1 BOX / 1 KIT per CARTON  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LOSARTAN POTASSIUM 100 MG TAB  |
1 |
Preferred Generic |
$1.00 | $0.00 | Q:60 /30Days |
LOSARTAN POTASSIUM 25 MG TAB  |
1 |
Preferred Generic |
$1.00 | $0.00 | Q:60 /30Days |
LOSARTAN POTASSIUM 50 MG TAB  |
1 |
Preferred Generic |
$1.00 | $0.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOSARTAN-HCTZ 100-12.5 MG TAB  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | Q:60 /30Days |
LOSARTAN-HCTZ 100-25 MG TAB  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | Q:60 /30Days |
LOSARTAN-HCTZ 50-12.5 MG TAB  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | Q:60 /30Days |
LOTEMAX 0.5% EYE DROPS  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LOTEMAX 0.5% OPHTHALMIC GEL  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LOTEMAX 5mg/g 1 TUBE per CARTON / 3.5 g in 1 TUBE  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LOTRONEX TABLETS .5MG 30 BOTPL  |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
LOTRONEX TABLETS 1MG 30 BOTPL  |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
Lovastatin 10mg 60 TABLET BOTTLE  |
1 |
Preferred Generic |
$1.00 | $0.00 | Q:60 /30Days |
LOVASTATIN 20 MG TABLET  |
1 |
Preferred Generic |
$1.00 | $0.00 | Q:60 /30Days |
LOVASTATIN 40 MG ORAL TABLET  |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOW-OGESTREL-28 TABLET  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LOXAPINE 25MG CAPSULE (100 CT)  |
3 |
Preferred Brand |
20% | 17% | None |
LOXAPINE CAPSULES 10MG 100 BOT  |
3 |
Preferred Brand |
20% | 17% | None |
LOXAPINE CAPSULES 50MG 100 BOT  |
3 |
Preferred Brand |
20% | 17% | None |
LOXAPINE CAPSULES 5MG 100 BOT  |
3 |
Preferred Brand |
20% | 17% | None |
LUMIGAN 0.1mg/mL 1 BOTTLE, DROPPER per CARTON / 5 mL in 1 BOTTLE, DROPPER  |
3 |
Preferred Brand |
20% | 17% | Q:3 /25Days |
Lumizyme 5mg/mL  |
5 |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT 11.25 MG 3MO KIT  |
4 |
Non-Preferred Brand |
35% | 35% | P Q:1 /90Days |
LUPRON DEPOT 22.5 MG 3MO KIT [LUPRON] ![Compare how all Medicare Part D PDP plans in ID cover LUPRON DEPOT 22.5 MG 3MO KIT [LUPRON].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
35% | 35% | P Q:1 /90Days |
LUPRON DEPOT 3.75 MG KIT  |
4 |
Non-Preferred Brand |
35% | 35% | P Q:1 /30Days |
LUPRON DEPOT 45 MG 6MO KIT  |
5 |
Specialty Tier |
25% | N/A | P Q:1 /168Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUPRON DEPOT 7.5 MG KIT  |
5 |
Specialty Tier |
25% | N/A | P Q:1 /30Days |
LUPRON DEPOT-4 MONTH KIT  |
4 |
Non-Preferred Brand |
35% | 35% | P Q:1 /112Days |
LUPRON DEPOT-PED 11.25 MG KIT  |
5 |
Specialty Tier |
25% | N/A | P Q:1 /28Days |
LUPRON DEPOT-PED 15 MG KIT  |
5 |
Specialty Tier |
25% | N/A | P Q:1 /28Days |
LUTERA 0.1-0.02 TABLET  |
4 |
Non-Preferred Brand |
35% | 35% | None |
LYNPARZA 50 MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P Q:448 /28Days |
LYRICA 100MG CAPSULE  |
4 |
Non-Preferred Brand |
35% | 35% | Q:90 /30Days |
LYRICA 150MG CAPSULE  |
4 |
Non-Preferred Brand |
35% | 35% | Q:90 /30Days |
LYRICA 20 MG/ML ORAL SOLUTION  |
4 |
Non-Preferred Brand |
35% | 35% | Q:900 /30Days |
LYRICA 200MG CAPSULE  |
4 |
Non-Preferred Brand |
35% | 35% | Q:90 /30Days |
LYRICA 225MG CAPSULE  |
4 |
Non-Preferred Brand |
35% | 35% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYRICA 25MG CAPSULE  |
4 |
Non-Preferred Brand |
35% | 35% | Q:90 /30Days |
LYRICA 300MG CAPSULE  |
4 |
Non-Preferred Brand |
35% | 35% | Q:60 /30Days |
LYRICA 50MG CAPSULE  |
4 |
Non-Preferred Brand |
35% | 35% | Q:90 /30Days |
LYRICA 75MG CAPSULE  |
4 |
Non-Preferred Brand |
35% | 35% | Q:90 /30Days |
LYSODREN 500MG TABLET  |
3 |
Preferred Brand |
20% | 17% | None |
LYZA 0.35 MG TABLET  |
4 |
Non-Preferred Brand |
35% | 35% | None |