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2016 Medicare Part D Plan Formulary Information
Coventry Vista Maximum (HMO SNP) (H5414-029-0) Benefit Details
The Coventry Vista Maximum (HMO SNP) (H5414-029-0) Formulary Drugs Starting with the Letter L in Miami-Dade County, FL: CMS MA Region 9 which includes: FL Plan Monthly Premium: $7.20 Deductible: $0
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	1	Generic	$0.00	$0.00	None
LABETALOL HCL 200MG TABLET	1	Generic	$0.00	$0.00	None
LABETALOL HCL 300MG TABLET	1	Generic	$0.00	$0.00	None
LABETALOL HCL 5MG/20ML VIAL	3	Non-Preferred Brand	50%	50%	None
LACRISERT 5 MG INS	3	Non-Preferred Brand	50%	50%	None
LACTATED RINGERS INJECTION	3	Non-Preferred Brand	50%	50%	None
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT	1	Generic	$0.00	$0.00	None
Lamivudine 10 mg/ml oral soln	2	Preferred Brand	$47.00	$94.00	None
LAMIVUDINE 150 MG TABLET	2	Preferred Brand	$47.00	$94.00	None
LAMIVUDINE 300 MG TABLET	2	Preferred Brand	$47.00	$94.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Lamivudine hbv 100 mg tablet	2	Preferred Brand	$47.00	$94.00	None
LAMIVUDINE-ZIDOVUDINE TABLET	4	Specialty Tier	33%	N/A	None
LAMOTRIGINE 150MG TABLET (60 CT)	1	Generic	$0.00	$0.00	None
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	1	Generic	$0.00	$0.00	None
LAMOTRIGINE 5MG TABLET DISPERSIBLE	1	Generic	$0.00	$0.00	None
Lamotrigine ODT 100 MG Tablet	3	Non-Preferred Brand	50%	50%	None
Lamotrigine ODT 200 MG Tablet	3	Non-Preferred Brand	50%	50%	None
Lamotrigine ODT 25 MG Tablet	3	Non-Preferred Brand	50%	50%	None
Lamotrigine ODT 50 MG Tablet	3	Non-Preferred Brand	50%	50%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LAMOTRIGINE TABLET 100MG (100 CT)	1	Generic	$0.00	$0.00	None
Lansoprazole 15mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE, PLASTIC	2	Preferred Brand	$47.00	$94.00	Q:30 /30Days
Lansoprazole 30mg/1 30 CAPSULE, DELAYED RELEASE in 1 BOTTLE	2	Preferred Brand	$47.00	$94.00	Q:30 /30Days
LANTUS 100U/ML VIAL	1	Generic	$0.00	$0.00	None
LANTUS SOLOSTAR INJECTION	1	Generic	$0.00	$0.00	None
LARIN 1.5 MG-30 MCG TABLET	3	Non-Preferred Brand	50%	50%	None
LARIN 21 1-20 tablet	3	Non-Preferred Brand	50%	50%	None
LARIN FE 1-20 TABLET	3	Non-Preferred Brand	50%	50%	None
LARIN FE 1.5-30 TABLET	3	Non-Preferred Brand	50%	50%	None
LATANOPROST 0.005% EYE DROPS	1	Generic	$0.00	$0.00	None
LATUDA 120 MG TABLET	3	Non-Preferred Brand	50%	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	50%	50%	Q:30 /30Days
Latuda 40mg/1	3	Non-Preferred Brand	50%	50%	Q:30 /30Days
LATUDA 60 MG TABLET	3	Non-Preferred Brand	50%	50%	Q:30 /30Days
Latuda 80mg/1	3	Non-Preferred Brand	50%	50%	Q:30 /30Days
LAYOLIS FE CHEWABLE TABLET	3	Non-Preferred Brand	50%	50%	None
LEENA 7-9-5 TABLET	3	Non-Preferred Brand	50%	50%	None
LEFLUNOMIDE 10MG TABLET	1	Generic	$0.00	$0.00	None
LEFLUNOMIDE 20 MG TABLET	1	Generic	$0.00	$0.00	None
LENVIMA 10 MG DAILY DOSE	4	Specialty Tier	33%	N/A	P
LENVIMA 14 MG DAILY DOSE	4	Specialty Tier	33%	N/A	P
LENVIMA 18 MG DAILY DOSE	4	Specialty Tier	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LENVIMA 20 MG DAILY DOSE	4	Specialty Tier	33%	N/A	P
LENVIMA 24 MG DAILY DOSE	4	Specialty Tier	33%	N/A	P
LENVIMA 8 MG DAILY DOSE	4	Specialty Tier	33%	N/A	P
LENVIMA CAPSULE 8 MG	4	Specialty Tier	33%	N/A	P
Lessina 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK	3	Non-Preferred Brand	50%	50%	None
LETAIRIS 10MG TABLET	4	Specialty Tier	33%	N/A	P Q:30 /30Days
LETAIRIS 5MG TABLET	4	Specialty Tier	33%	N/A	P Q:30 /30Days
LETROZOLE 2.5 MG TABLET	3	Non-Preferred Brand	50%	50%	None
LEUCOVORIN CALCIUM 100MG VL	3	Non-Preferred Brand	50%	50%	None
LEUCOVORIN CALCIUM 10MG TABLET	3	Non-Preferred Brand	50%	50%	None
Leucovorin Calcium 15mg/1 24 TABLET BOTTLE	3	Non-Preferred Brand	50%	50%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LEUCOVORIN CALCIUM 25MG TABLET	3	Non-Preferred Brand	50%	50%	None
LEUCOVORIN CALCIUM 350MG VL	3	Non-Preferred Brand	50%	50%	None
LEUCOVORIN CALCIUM 5MG TABLET	3	Non-Preferred Brand	50%	50%	None
LEUKERAN 2 MG TABLET	3	Non-Preferred Brand	50%	50%	None
LEUKINE 250 MCG VIAL	4	Specialty Tier	33%	N/A	P
Leuprolide 2wk 1 mg/0.2 ml kit	2	Preferred Brand	$47.00	$94.00	P
Levalbuterol 0.31 mg/3 ml sol	3	Non-Preferred Brand	50%	50%	P
Levalbuterol 0.63 mg/3 ml sol	3	Non-Preferred Brand	50%	50%	P
LEVALBUTEROL 1.25 MG/0.5 ML	3	Non-Preferred Brand	50%	50%	P
LEVEMIR 100UNITS/ML VIAL	1	Generic	$0.00	$0.00	None
LEVEMIR FLEXTOUCH 100 UNITS/ML	1	Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Levetiracetam 100mg/mL 473 mL in 1 BOTTLE, PLASTIC	1	Generic	$0.00	$0.00	None
LEVETIRACETAM 100MG/ML INJECTION	3	Non-Preferred Brand	50%	50%	None
LEVETIRACETAM 500 MG TABLET 120 BOT	1	Generic	$0.00	$0.00	None
LEVETIRACETAM TABLETS 1000MG 60 BOT	1	Generic	$0.00	$0.00	None
LEVETIRACETAM TABLETS 250MG 500 BOT	1	Generic	$0.00	$0.00	None
LEVETIRACETAM TABLETS 750MG 500 BOT	1	Generic	$0.00	$0.00	None
LEVETIRACETAM-NACL 1,000 MG/100 ML	3	Non-Preferred Brand	50%	50%	None
LEVETIRACETAM-NACL 1,500 MG/100 ML	3	Non-Preferred Brand	50%	50%	None
LEVETIRACETAM-NACL 500 MG/100 ML	3	Non-Preferred Brand	50%	50%	None
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION	1	Generic	$0.00	$0.00	None
LEVOCARNITINE TABLET 330MG 90 BLPK	2	Preferred Brand	$47.00	$94.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LEVOCETIRIZINE 2.5 MG/5 ML SOL	3	Non-Preferred Brand	50%	50%	Q:300 /30Days
LEVOCETIRIZINE 5 MG TABLET	3	Non-Preferred Brand	50%	50%	Q:30 /30Days
Levofloxacin 250mg/1 [LEVAQUIN]	2	Preferred Brand	$47.00	$94.00	None
Levofloxacin 25mg/mL 1 BOTTLE per CARTON / 100 mL in 1 BOTTLE [LEVAQUIN]	2	Preferred Brand	$47.00	$94.00	None
Levofloxacin 500 MG [LEVAQUIN]	2	Preferred Brand	$47.00	$94.00	None
LEVOFLOXACIN 500 MG/20 ML VIAL [LEVAQUIN]	3	Non-Preferred Brand	50%	50%	None
Levofloxacin 5mg/mL 1 BOTTLE, DROPPER per CARTON / 5 mL in 1 BOTTLE, DROPPER [LEVAQUIN]	2	Preferred Brand	$47.00	$94.00	None
Levofloxacin 5mg/mL 24 POUCH per CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG [LEVAQUIN]	3	Non-Preferred Brand	50%	50%	None
Levofloxacin 750 MG [LEVAQUIN]	2	Preferred Brand	$47.00	$94.00	None
LEVOFLOXACIN-D5W 750 MG/150 ML [LEVAQUIN]	3	Non-Preferred Brand	50%	50%	None
LEVOLEUCOVORIN 175 MG/17.5 ML [Fusilev]	4	Specialty Tier	33%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LEVONEST-28 TABLET	3	Non-Preferred Brand	50%	50%	None
LEVONOR-ETH ESTRAD 0.09-0.02 MG	3	Non-Preferred Brand	50%	50%	None
LEVONOR-ETH ESTRAD 0.1-0.02 MG	3	Non-Preferred Brand	50%	50%	None
levonor-eth estrad 0.15-0.03	3	Non-Preferred Brand	50%	50%	None
Levonor-eth Estrad 0.15-0.03-0.01	3	Non-Preferred Brand	50%	50%	None
LEVONOR-ETH ESTRAD TRIPHASIC	3	Non-Preferred Brand	50%	50%	None
LEVORA-28 TABLET 0.15/30	3	Non-Preferred Brand	50%	50%	None
LEVOTHYROXINE 100 MCG VIAL	1	Generic	$0.00	$0.00	None
LEVOTHYROXINE 125 MCG TABLET	1	Generic	$0.00	$0.00	None
LEVOTHYROXINE 137 MCG TABLET	1	Generic	$0.00	$0.00	None
LEVOTHYROXINE 175 MCG TABLET	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 300 MCG TABLET	1	Generic	$0.00	$0.00	None
LEVOTHYROXINE 75 MCG TABLET	1	Generic	$0.00	$0.00	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 150ug/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
Levothyroxine Sodium 25ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS	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 88ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS	1	Generic	$0.00	$0.00	None
LEVOXYL 100 MCG TABLET	2	Preferred Brand	$47.00	$94.00	None
LEVOXYL 112 MCG TABLET	2	Preferred Brand	$47.00	$94.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LEVOXYL 125 MCG TABLET	2	Preferred Brand	$47.00	$94.00	None
LEVOXYL 137 MCG TABLET	2	Preferred Brand	$47.00	$94.00	None
LEVOXYL 150MCG TABLET (1000 CT)	2	Preferred Brand	$47.00	$94.00	None
LEVOXYL 175MCG TABLET (1000 CT)	2	Preferred Brand	$47.00	$94.00	None
LEVOXYL 200 MCG TABLET	2	Preferred Brand	$47.00	$94.00	None
LEVOXYL 25 MCG TABLET	2	Preferred Brand	$47.00	$94.00	None
LEVOXYL 50 MCG TABLET	2	Preferred Brand	$47.00	$94.00	None
LEVOXYL 75MCG TABLET (1000 CT)	2	Preferred Brand	$47.00	$94.00	None
LEVOXYL 88 MCG TABLET	2	Preferred Brand	$47.00	$94.00	None
LEXIVA 50mg/mL 225 mL in 1 BOTTLE	3	Non-Preferred Brand	50%	50%	None
LEXIVA 700MG TABLETS	4	Specialty Tier	33%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LIALDA 1.2G TABLET DELAYED RELEASE	3	Non-Preferred Brand	50%	50%	None
LIDOCAINE 5% OINTMENT	2	Preferred Brand	$47.00	$94.00	None
Lidocaine 5% patch	2	Preferred Brand	$47.00	$94.00	P Q:90 /30Days
lidocaine hcl 2% jelly	2	Preferred Brand	$47.00	$94.00	None
lidocaine hcl 2% jelly	2	Preferred Brand	$47.00	$94.00	None
LIDOCAINE HCL 2% JELLY 30ML TUBE	2	Preferred Brand	$47.00	$94.00	None
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT	2	Preferred Brand	$47.00	$94.00	None
Lidocaine Hydrochloride 20mg/mL 25 VIAL, MULTI-DOSE in 1 TRAY / 20 mL in 1 VIAL, MULTI-DOSE	3	Non-Preferred Brand	50%	50%	None
Lidocaine Hydrochloride 5mg/mL 25 VIAL, SINGLE-DOSE in 1 CONTAINER / 50 mL in 1 VIAL, SINGLE-DOSE	3	Non-Preferred Brand	50%	50%	None
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT	2	Preferred Brand	$47.00	$94.00	None
LIDOCAINE-PRILOCAINE CREAM	2	Preferred Brand	$47.00	$94.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LIDODERM 5% PATCH	3	Non-Preferred Brand	50%	50%	P Q:90 /30Days
LINDANE SHAMPOO 1MG 2 FLO BOT	3	Non-Preferred Brand	50%	50%	None
LINEZOLID 100 MG/5 ML SUSP [Zyvox]	4	Specialty Tier	33%	N/A	P Q:1800 /28Days
Linezolid 600 mg tablet [Zyvox]	4	Specialty Tier	33%	N/A	P Q:56 /28Days
Linezolid 600 mg/300 ml iv sol [Zyvox]	4	Specialty Tier	33%	N/A	P
LINZESS 145 MCG CAPSULE	2	Preferred Brand	$47.00	$94.00	Q:30 /30Days
LINZESS 290 MCG CAPSULE	2	Preferred Brand	$47.00	$94.00	Q:30 /30Days
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT	2	Preferred Brand	$47.00	$94.00	None
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT	2	Preferred Brand	$47.00	$94.00	None
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT	2	Preferred Brand	$47.00	$94.00	None
LIPOFEN 150MG CAPSULES	2	Preferred Brand	$47.00	$94.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
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
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 300 mg tab	1	Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LITHIUM CARBONATE 300MG CAPSULE (100 CT)	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	1	Generic	$0.00	$0.00	None
Lo Loestrin Fe 5 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK	3	Non-Preferred Brand	50%	50%	None
LOMEDIA 24 FE 24MG TABLET	3	Non-Preferred Brand	50%	50%	None
LONSURF 15 MG-6.14 MG TABLET	4	Specialty Tier	33%	N/A	P Q:100 /28Days
LONSURF 20 MG-8.19 MG TABLET	4	Specialty Tier	33%	N/A	P Q:80 /28Days
LOPERAMIDE HCL 2MG CAPSULE	1	Generic	$0.00	$0.00	None
LOPREEZA 0.5 MG-0.1 MG TABLET	3	Non-Preferred Brand	50%	50%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LOPREEZA 1 MG-0.5 MG TABLET	3	Non-Preferred Brand	50%	50%	P
LORAZEPAM 0.5 MG TABLET	2	Preferred Brand	$47.00	$94.00	Q:90 /30Days
Lorazepam 1 MG 100 TABLET BOTTLE	2	Preferred Brand	$47.00	$94.00	Q:90 /30Days
Lorazepam 2 MG 100 TABLET BOTTLE	2	Preferred Brand	$47.00	$94.00	Q:90 /30Days
Lorazepam 2mg/mL 30 mL in 1 BOTTLE, DROPPER	2	Preferred Brand	$47.00	$94.00	Q:150 /30Days
Lorcet 5-325 mg tablet	3	Non-Preferred Brand	50%	50%	Q:360 /30Days
Lorcet hd 10-325 mg tablet	3	Non-Preferred Brand	50%	50%	Q:360 /30Days
Lorcet plus 7.5-325 mg tablet	3	Non-Preferred Brand	50%	50%	Q:360 /30Days
lortab 10-325 mg tablet	3	Non-Preferred Brand	50%	50%	Q:360 /30Days
lortab 5-325 mg tablet	3	Non-Preferred Brand	50%	50%	Q:360 /30Days
lortab 7.5-325 mg tablet	3	Non-Preferred Brand	50%	50%	Q:360 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Loryna (drospirenone and ethinyl estradiol) 3 CARTON in 1 BOX / 1 KIT per CARTON	3	Non-Preferred Brand	50%	50%	None
LOSARTAN POTASSIUM 100 MG TAB	1	Generic	$0.00	$0.00	Q:30 /30Days
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	Q:30 /30Days
LOSARTAN-HCTZ 50-12.5 MG TAB	1	Generic	$0.00	$0.00	Q:30 /30Days
LOTEMAX 0.5% EYE DROPS	2	Preferred Brand	$47.00	$94.00	None
LOTEMAX 0.5% OPHTHALMIC GEL	2	Preferred Brand	$47.00	$94.00	None
Lotemax 5mg/g 1 TUBE per CARTON / 3.5 g in 1 TUBE	2	Preferred Brand	$47.00	$94.00	None
Lovastatin 10mg 60 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
LOVASTATIN 20 MG TABLET	1	Generic	$0.00	$0.00	None
LOVASTATIN 40 MG ORAL TABLET	1	Generic	$0.00	$0.00	None
LOVAZA 1 GM CAPSULE	3	Non-Preferred Brand	50%	50%	S Q:120 /30Days
LOXAPINE 25MG CAPSULE (100 CT)	3	Non-Preferred Brand	50%	50%	None
LOXAPINE CAPSULES 10MG 100 BOT	3	Non-Preferred Brand	50%	50%	None
LOXAPINE CAPSULES 50MG 100 BOT	3	Non-Preferred Brand	50%	50%	None
LOXAPINE CAPSULES 5MG 100 BOT	3	Non-Preferred Brand	50%	50%	None
LUMIGAN 0.1mg/mL 1 BOTTLE, DROPPER per CARTON / 5 mL in 1 BOTTLE, DROPPER	2	Preferred Brand	$47.00	$94.00	None
Lumizyme 5mg/mL	4	Specialty Tier	33%	N/A	None
LUPRON DEPOT 11.25 MG 3MO KIT	4	Specialty Tier	33%	N/A	P
LUPRON DEPOT 22.5 MG 3MO KIT [LUPRON]	4	Specialty Tier	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LUPRON DEPOT 3.75 MG KIT	4	Specialty Tier	33%	N/A	P
LUPRON DEPOT 45 MG 6MO KIT	4	Specialty Tier	33%	N/A	P
LUPRON DEPOT 7.5 MG KIT	4	Specialty Tier	33%	N/A	P
LUPRON DEPOT-4 MONTH KIT	4	Specialty Tier	33%	N/A	P
LUPRON DEPOT-PED 11.25 MG KIT	4	Specialty Tier	33%	N/A	P
LUPRON DEPOT-PED 15 MG KIT	4	Specialty Tier	33%	N/A	P
LUTERA 0.1-0.02 TABLET	3	Non-Preferred Brand	50%	50%	None
LYNPARZA 50 MG CAPSULE	4	Specialty Tier	33%	N/A	P Q:448 /28Days
LYRICA 100MG CAPSULE	3	Non-Preferred Brand	50%	50%	P Q:90 /30Days
LYRICA 150MG CAPSULE	3	Non-Preferred Brand	50%	50%	P Q:90 /30Days
LYRICA 20 MG/ML ORAL SOLUTION	3	Non-Preferred Brand	50%	50%	P Q:900 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LYRICA 200MG CAPSULE	3	Non-Preferred Brand	50%	50%	P Q:90 /30Days
LYRICA 225MG CAPSULE	3	Non-Preferred Brand	50%	50%	P Q:60 /30Days
LYRICA 25MG CAPSULE	3	Non-Preferred Brand	50%	50%	P Q:90 /30Days
LYRICA 300MG CAPSULE	3	Non-Preferred Brand	50%	50%	P Q:60 /30Days
LYRICA 50MG CAPSULE	3	Non-Preferred Brand	50%	50%	P Q:90 /30Days
LYRICA 75MG CAPSULE	3	Non-Preferred Brand	50%	50%	P Q:90 /30Days
LYSODREN 500MG TABLET	2	Preferred Brand	$47.00	$94.00	None
LYZA 0.35 MG TABLET	3	Non-Preferred Brand	50%	50%	None

Chart Legend:

Below are a few notes to help you understand the above 2016 Medicare Part D Coventry Vista Maximum (HMO SNP) 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 $360 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 $3310) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2016 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 2016 )

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.