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EnvisionRxPlus (PDP) (S7694-025-0)
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Tier 2 (532)
Tier 3 (259)
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A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2017 Medicare Part D Plan Formulary Information
EnvisionRxPlus (PDP) (S7694-025-0)
Benefit Details           
The EnvisionRxPlus (PDP) (S7694-025-0)
Formulary Drugs Starting with the Letter L
in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
Plan Monthly Premium: $52.70 Deductible: $400 Qualifies for LIS: No
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 Generic 12%12%None
LABETALOL HCL 200MG TABLET   2 Generic 12%12%None
LABETALOL HCL 300MG TABLET   2 Generic 12%12%None
LACTATED RINGERS INJECTION   4 Non-Preferred Drug 33%33%None
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT   1 Preferred Generic 10%10%None
Lamivudine 10 mg/ml oral soln   4 Non-Preferred Drug 33%33%None
LAMIVUDINE 150 MG TABLET   4 Non-Preferred Drug 33%33%Q:60
/30Days
LAMIVUDINE 300 MG TABLET   4 Non-Preferred Drug 33%33%Q:30
/30Days
Lamivudine hbv 100 mg tablet   4 Non-Preferred Drug 33%33%None
LAMIVUDINE-ZIDOVUDINE TABLET   4 Non-Preferred Drug 33%33%Q:60
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LAMOTRIGINE 150MG TABLET (60 CT)   2 Generic 12%12%None
LAMOTRIGINE 200MG TABLET (60 CT)   2 Generic 12%12%None
LAMOTRIGINE 25MG TABLET (100 CT)   2 Generic 12%12%None
LAMOTRIGINE 25MG TABLET DISPERSIBLE   4 Non-Preferred Drug 33%33%None
LAMOTRIGINE 5MG TABLET DISPERSIBLE   2 Generic 12%12%None
LAMOTRIGINE ER 100 MG TABLET   4 Non-Preferred Drug 33%33%None
lamotrigine er 200 mg tablet   4 Non-Preferred Drug 33%33%None
lamotrigine er 25 mg tablet   4 Non-Preferred Drug 33%33%None
lamotrigine er 250 mg tablet   4 Non-Preferred Drug 33%33%None
lamotrigine er 300 mg tablet   4 Non-Preferred Drug 33%33%None
lamotrigine er 50 mg tablet   4 Non-Preferred Drug 33%33%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Lamotrigine ODT 100 MG Tablet   4 Non-Preferred Drug 33%33%None
Lamotrigine ODT 200 MG Tablet   4 Non-Preferred Drug 33%33%None
LAMOTRIGINE TABLET 100MG (100 CT)   2 Generic 12%12%None
LANTUS 100U/ML VIAL   3 Preferred Brand 15%15%None
LANTUS SOLOSTAR INJECTION   3 Preferred Brand 15%15%None
LARIN 1.5 MG-30 MCG TABLET   4 Non-Preferred Drug 33%33%None
LARIN 21 1-20 tablet   4 Non-Preferred Drug 33%33%None
LARIN FE 1-20 TABLET   4 Non-Preferred Drug 33%33%None
LARIN FE 1.5-30 TABLET   4 Non-Preferred Drug 33%33%None
Larissia-28 tablet   4 Non-Preferred Drug 33%33%None
LARTRUVO 500 MG/50 ML VIAL   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LATANOPROST 0.005% EYE DROPS   4 Non-Preferred Drug 33%33%None
LATUDA 120 MG TABLET   3 Preferred Brand 15%15%None
LATUDA 20 MG TABLET   3 Preferred Brand 15%15%None
Latuda 40mg/1   3 Preferred Brand 15%15%None
LATUDA 60 MG TABLET   3 Preferred Brand 15%15%None
Latuda 80mg/1   3 Preferred Brand 15%15%None
LEENA 28 TABLET   4 Non-Preferred Drug 33%33%None
LEFLUNOMIDE 10MG TABLET   2 Generic 12%12%None
Leflunomide 20 mg tablet   4 Non-Preferred Drug 33%33%None
LENVIMA 10 MG DAILY DOSE   5 Specialty Tier 25%N/AP Q:60
/30Days
LENVIMA 14 MG DAILY DOSE   5 Specialty Tier 25%N/AP Q:60
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LENVIMA 18 MG DAILY DOSE   5 Specialty Tier 25%N/AP
LENVIMA 20 MG DAILY DOSE   5 Specialty Tier 25%N/AP Q:60
/30Days
LENVIMA 24 MG DAILY DOSE   5 Specialty Tier 25%N/AP Q:60
/30Days
LENVIMA 8 MG DAILY DOSE   5 Specialty Tier 25%N/AP
Lessina 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK   4 Non-Preferred Drug 33%33%None
LETAIRIS 10 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
LETAIRIS 5 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
LETROZOLE 2.5 MG TABLET   2 Generic 12%12%Q:30
/30Days
LEUCOVORIN CALCIUM 100MG VL   4 Non-Preferred Drug 33%33%P
LEUCOVORIN CALCIUM 10MG TABLET   4 Non-Preferred Drug 33%33%None
Leucovorin Calcium 15mg/1 24 TABLET BOTTLE   2 Generic 12%12%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LEUCOVORIN CALCIUM 25MG TABLET   4 Non-Preferred Drug 33%33%None
LEUCOVORIN CALCIUM 350MG VL   4 Non-Preferred Drug 33%33%P
LEUCOVORIN CALCIUM 5MG TABLET   2 Generic 12%12%None
LEUKERAN 2 MG TABLET   4 Non-Preferred Drug 33%33%None
LEUKINE 250 MCG VIAL   5 Specialty Tier 25%N/AP
Leuprolide 2wk 1 mg/0.2 ml kit   3 Preferred Brand 15%15%P
LEVEMIR 100UNITS/ML VIAL   3 Preferred Brand 15%15%None
LEVEMIR FLEXTOUCH 100 UNITS/ML   3 Preferred Brand 15%15%None
Levetiracetam 100 ML 10 MG/ML Injection   4 Non-Preferred Drug 33%33%None
Levetiracetam 100 ML 15 MG/ML Injection   4 Non-Preferred Drug 33%33%None
Levetiracetam 100 ML 5 MG/ML Injection   4 Non-Preferred Drug 33%33%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   4 Non-Preferred Drug 33%33%None
LEVETIRACETAM 500 MG TABLET 120 BOT   2 Generic 12%12%None
Levetiracetam 500 mg/5 ml vial   4 Non-Preferred Drug 33%33%P
Levetiracetam 500mg/1 60 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   4 Non-Preferred Drug 33%33%None
LEVETIRACETAM ER 750 MG TABLET   4 Non-Preferred Drug 33%33%None
LEVETIRACETAM TABLETS 1000MG 60 BOT   4 Non-Preferred Drug 33%33%None
LEVETIRACETAM TABLETS 250MG 500 BOT   2 Generic 12%12%None
LEVETIRACETAM TABLETS 750MG 500 BOT   4 Non-Preferred Drug 33%33%None
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION   2 Generic 12%12%None
LEVOCARNITINE 1 G/10 ML SOLN   4 Non-Preferred Drug 33%33%None
LEVOCARNITINE 330 MG TABLET   4 Non-Preferred Drug 33%33%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Levofloxacin 250mg/1 [LEVAQUIN]   1 Preferred Generic 10%10%None
Levofloxacin 25mg/mL 1 BOTTLE per CARTON / 100 mL in 1 BOTTLE [LEVAQUIN]   4 Non-Preferred Drug 33%33%None
Levofloxacin 500 MG [LEVAQUIN]   1 Preferred Generic 10%10%None
LEVOFLOXACIN 500 MG/20 ML VIAL [LEVAQUIN]   4 Non-Preferred Drug 33%33%None
Levofloxacin 5mg/mL 24 POUCH per CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG [LEVAQUIN]   4 Non-Preferred Drug 33%33%None
Levofloxacin 750 MG [LEVAQUIN]   1 Preferred Generic 10%10%None
LEVOFLOXACIN-D5W 750 MG/150 ML [LEVAQUIN]   4 Non-Preferred Drug 33%33%None
LEVOLEUCOVORIN 175 MG/17.5 ML [Fusilev]   5 Specialty Tier 25%N/AP
Levoleucovorin 50 mg vial [Fusilev]   4 Non-Preferred Drug 33%33%P
LEVONEST-28 TABLET   4 Non-Preferred Drug 33%33%None
LEVONOR-ETH ESTRAD 0.1-0.02 MG   4 Non-Preferred Drug 33%33%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
levonor-eth estrad 0.15-0.03   4 Non-Preferred Drug 33%33%None
LEVONOR-ETH ESTRAD TRIPHASIC   4 Non-Preferred Drug 33%33%None
Levora-28 tablet   4 Non-Preferred Drug 33%33%None
Levothyroxine 100 mcg tablet   1 Preferred Generic 10%10%None
LEVOTHYROXINE 112 MCG TABLET   1 Preferred Generic 10%10%None
LEVOTHYROXINE 125 MCG TABLET   1 Preferred Generic 10%10%None
LEVOTHYROXINE 137 MCG TABLET   1 Preferred Generic 10%10%None
LEVOTHYROXINE 150 MCG TABLET   1 Preferred Generic 10%10%None
LEVOTHYROXINE 175 MCG TABLET   1 Preferred Generic 10%10%None
LEVOTHYROXINE 200 MCG TABLET   1 Preferred Generic 10%10%None
Levothyroxine 25 mcg tablet   1 Preferred Generic 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LEVOTHYROXINE 300 MCG TABLET   1 Preferred Generic 10%10%None
LEVOTHYROXINE 50 MCG TABLET   1 Preferred Generic 10%10%None
LEVOTHYROXINE 75 MCG TABLET   1 Preferred Generic 10%10%None
LEVOTHYROXINE 88 MCG TABLET   1 Preferred Generic 10%10%None
LEVOXYL 100 MCG TABLET   1 Preferred Generic 10%10%None
LEVOXYL 112 MCG TABLET   1 Preferred Generic 10%10%None
LEVOXYL 125 MCG TABLET   1 Preferred Generic 10%10%None
LEVOXYL 137 MCG TABLET   1 Preferred Generic 10%10%None
LEVOXYL 150MCG TABLET (1000 CT)   1 Preferred Generic 10%10%None
LEVOXYL 175 MCG TABLET   1 Preferred Generic 10%10%None
LEVOXYL 200 MCG TABLET   1 Preferred Generic 10%10%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LEVOXYL 25 MCG TABLET   1 Preferred Generic 10%10%None
LEVOXYL 50 MCG TABLET   1 Preferred Generic 10%10%None
LEVOXYL 75MCG TABLET (1000 CT)   1 Preferred Generic 10%10%None
LEVOXYL 88 MCG TABLET   1 Preferred Generic 10%10%None
LEXIVA 50mg/mL 225 mL in 1 BOTTLE   4 Non-Preferred Drug 33%33%Q:1575
/28Days
LEXIVA 700MG TABLETS   5 Specialty Tier 25%N/AQ:120
/30Days
Lidocaine 2% viscous soln   4 Non-Preferred Drug 33%33%None
LIDOCAINE 5% OINTMENT   4 Non-Preferred Drug 33%33%None
Lidocaine 5% patch   4 Non-Preferred Drug 33%33%P Q:90
/30Days
lidocaine hcl 2% jelly   2 Generic 12%12%None
lidocaine hcl 2% jelly   2 Generic 12%12%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LIDOCAINE HCL 2% JELLY 30ML TUBE   2 Generic 12%12%None
Lidocaine hcl 4% solution   2 Generic 12%12%None
Lidocaine Hydrochloride 20mg/mL 25 VIAL, MULTI-DOSE in 1 TRAY / 20 mL in 1 VIAL, MULTI-DOSE   2 Generic 12%12%None
Lidocaine Hydrochloride 5 ML 10 MG/ML Injection   2 Generic 12%12%None
Lidocaine Hydrochloride 5mg/mL 25 VIAL, SINGLE-DOSE in 1 CONTAINER / 50 mL in 1 VIAL, SINGLE-DOSE   2 Generic 12%12%None
LIDOCAINE-PRILOCAINE CREAM   4 Non-Preferred Drug 33%33%None
Linezolid 20 MG/ML Oral Suspension [Zyvox]   4 Non-Preferred Drug 33%33%None
LINEZOLID 600 MG TABLET [Zyvox]   5 Specialty Tier 25%N/AP
Linezolid 600 mg/300 ml iv sol [Zyvox]   5 Specialty Tier 25%N/AP
LINZESS 145 MCG CAPSULE   3 Preferred Brand 15%15%Q:30
/30Days
LINZESS 290 MCG CAPSULE   3 Preferred Brand 15%15%Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LINZESS 72 MCG CAPSULE   3 Preferred Brand 15%15%Q:30
/30Days
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT   2 Generic 12%12%None
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT   2 Generic 12%12%None
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT   2 Generic 12%12%None
LIPOFEN 150MG CAPSULES   3 Preferred Brand 15%15%None
LISINOPRIL 10MG TABLET (100 CT)   1 Preferred Generic 10%10%None
LISINOPRIL 2.5 MG TABLET   1 Preferred Generic 10%10%None
LISINOPRIL 20 MG TABLET   1 Preferred Generic 10%10%None
LISINOPRIL 30MG TABLET (100 CT)   1 Preferred Generic 10%10%None
LISINOPRIL 40MG TABLET (500 CT)   1 Preferred Generic 10%10%None
Lisinopril 5mg/1 1000 TABLET BOTTLE   1 Preferred Generic 10%10%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 Preferred Generic 10%10%None
Lisinopril with Hydrochlorothiazide 12.5; 20mg/1; mg/1 100 TABLET BOTTLE, PLASTIC   1 Preferred Generic 10%10%None
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT)   1 Preferred Generic 10%10%None
Lithium Carbonate 150mg/1 100 CAPSULE BOTTLE, PLASTIC   1 Preferred Generic 10%10%None
Lithium Carbonate 300 mg tab   4 Non-Preferred Drug 33%33%None
LITHIUM CARBONATE 300MG CAPSULE (100 CT)   1 Preferred Generic 10%10%None
Lithium Carbonate 450mg/1   4 Non-Preferred Drug 33%33%None
LITHIUM CARBONATE 600 MG CAP   4 Non-Preferred Drug 33%33%None
LITHIUM CARBONATE ER TABLET 300MG (100 CT)   4 Non-Preferred Drug 33%33%None
LITHIUM CIT 8MEQ/5ML SYRUP   4 Non-Preferred Drug 33%33%None
LIVALO 1 MG TABLET   3 Preferred Brand 15%15%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LIVALO 2 MG TABLET   3 Preferred Brand 15%15%None
LIVALO 4 MG TABLET   3 Preferred Brand 15%15%None
LONSURF 15 MG-6.14 MG TABLET   5 Specialty Tier 25%N/AP
LONSURF 20 MG-8.19 MG TABLET   5 Specialty Tier 25%N/AP
LOPERAMIDE HCL 2MG CAPSULE   2 Generic 12%12%None
Lopinavir-Ritonavir 80-20mg/ml [Kaletra]   4 Non-Preferred Drug 33%33%Q:400
/30Days
LORAZEPAM 0.5 MG TABLET   1 Preferred Generic 10%10%Q:600
/30Days
Lorazepam 1 MG 100 TABLET BOTTLE   1 Preferred Generic 10%10%Q:300
/30Days
Lorazepam 2 MG 100 TABLET BOTTLE   1 Preferred Generic 10%10%Q:150
/30Days
Lorazepam 2mg/mL 30 mL in 1 BOTTLE, DROPPER   4 Non-Preferred Drug 33%33%Q:240
/30Days
Lorcet 5-325 mg tablet   2 Generic 12%12%Q:370
/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   4 Non-Preferred Drug 33%33%None
LOSARTAN POTASSIUM 100 MG TAB   1 Preferred Generic 10%10%Q:30
/30Days
LOSARTAN POTASSIUM 25 MG TAB   1 Preferred Generic 10%10%Q:30
/30Days
LOSARTAN POTASSIUM 50 MG TAB   1 Preferred Generic 10%10%Q:60
/30Days
LOSARTAN-HCTZ 100-12.5 MG TAB   1 Preferred Generic 10%10%None
LOSARTAN-HCTZ 100-25 MG TAB   1 Preferred Generic 10%10%None
LOSARTAN-HCTZ 50-12.5 MG TAB   1 Preferred Generic 10%10%None
LOTEMAX 0.5% EYE DROPS   4 Non-Preferred Drug 33%33%None
LOTEMAX 0.5% OPHTHALMIC GEL   4 Non-Preferred Drug 33%33%None
Lotemax 5mg/g 1 TUBE per CARTON / 3.5 g in 1 TUBE   4 Non-Preferred Drug 33%33%None
Lovastatin 10mg 60 TABLET BOTTLE   1 Preferred Generic 10%10%Q:45
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LOVASTATIN 20 MG TABLET   1 Preferred Generic 10%10%Q:30
/30Days
LOVASTATIN 40 MG ORAL TABLET   1 Preferred Generic 10%10%Q:60
/30Days
Low-ogestrel-28 tablet   4 Non-Preferred Drug 33%33%None
LOXAPINE 25MG CAPSULE (100 CT)   4 Non-Preferred Drug 33%33%None
LOXAPINE CAPSULES 10MG 100 BOT   4 Non-Preferred Drug 33%33%None
LOXAPINE CAPSULES 50MG 100 BOT   4 Non-Preferred Drug 33%33%None
LOXAPINE CAPSULES 5MG 100 BOT   4 Non-Preferred Drug 33%33%None
LUMIGAN 0.1mg/mL 1 BOTTLE, DROPPER per CARTON / 5 mL in 1 BOTTLE, DROPPER   3 Preferred Brand 15%15%None
Lumizyme 5mg/mL   5 Specialty Tier 25%N/AP
LUPRON DEPOT 11.25 MG 3MO KIT   5 Specialty Tier 25%N/AP Q:1
/28Days
LUPRON DEPOT 22.5 MG 3MO KIT [LUPRON]   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LUPRON DEPOT 3.75 MG KIT   5 Specialty Tier 25%N/AP Q:1
/28Days
LUPRON DEPOT 45 MG 6MO KIT   5 Specialty Tier 25%N/AP
LUPRON DEPOT 7.5 MG KIT   5 Specialty Tier 25%N/AP
LUPRON DEPOT-4 MONTH KIT   5 Specialty Tier 25%N/AP
LUPRON DEPOT-PED 11.25 MG KIT   5 Specialty Tier 25%N/AP
LUPRON DEPOT-PED 15 MG KIT   5 Specialty Tier 25%N/AP
Lutera-28 tablet   4 Non-Preferred Drug 33%33%None
LYNPARZA 50 MG CAPSULE   5 Specialty Tier 25%N/AP Q:448
/28Days
LYRICA 100MG CAPSULE   3 Preferred Brand 15%15%Q:90
/30Days
LYRICA 150MG CAPSULE   3 Preferred Brand 15%15%Q:90
/30Days
LYRICA 20 MG/ML ORAL SOLUTION   3 Preferred Brand 15%15%Q:900
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LYRICA 200MG CAPSULE   3 Preferred Brand 15%15%Q:60
/30Days
LYRICA 225MG CAPSULE   3 Preferred Brand 15%15%Q:60
/30Days
LYRICA 25MG CAPSULE   3 Preferred Brand 15%15%Q:90
/30Days
LYRICA 300MG CAPSULE   3 Preferred Brand 15%15%Q:60
/30Days
LYRICA 50MG CAPSULE   3 Preferred Brand 15%15%Q:90
/30Days
LYRICA 75MG CAPSULE   3 Preferred Brand 15%15%Q:120
/30Days
LYSODREN 500MG TABLET   5 Specialty Tier 25%N/ANone
LYZA 0.35 MG TABLET   4 Non-Preferred Drug 33%33%None

Chart Legend:

Below are a few notes to help you understand the above 2017 Medicare Part D EnvisionRxPlus (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 $400 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 $3700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2017 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 2017 )

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.