2019 Medicare Part D Plan Formulary Information |
Mutual of Omaha Rx Value (PDP) (S7126-044-0)
Benefit Details
|
The Mutual of Omaha Rx Value (PDP) (S7126-044-0) Formulary Drugs Starting with the Letter L in CMS PDP Region 12 which includes: AL TN Plan Monthly Premium: $28.80 Deductible: $415 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 100 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
LABETALOL HCL 200 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
LABETALOL HCL 300 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
LACTULOSE 10 GM/15 ML SOLUTION [Constulose] |
2* |
Generic |
$4.00 | $8.00 | None |
Lamivudine 10 mg/ml oral soln |
3 |
Preferred Brand |
15% | 18% | Q:900 /30Days |
LAMIVUDINE 150 MG TABLET |
3 |
Preferred Brand |
15% | 18% | Q:60 /30Days |
LAMIVUDINE 300 MG TABLET |
3 |
Preferred Brand |
15% | 18% | Q:30 /30Days |
Lamivudine hbv 100 mg tablet |
2* |
Generic |
$4.00 | $8.00 | Q:90 /30Days |
LAMIVUDINE-ZIDOVUDINE TABLET |
3 |
Preferred Brand |
15% | 18% | Q:60 /30Days |
LAMOTRIGINE 150MG TABLET (60 CT) |
2* |
Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE 200MG TABLET (60 CT) |
2* |
Generic |
$4.00 | $8.00 | None |
LAMOTRIGINE 25 MG DISPER TAB CHW DSP [Lamictal CD] |
2* |
Generic |
$4.00 | $8.00 | None |
LAMOTRIGINE 25 MG TABLET [Subvenite] |
2* |
Generic |
$4.00 | $8.00 | None |
LAMOTRIGINE 5 MG DISPER TABLET CHW DSP [Lamictal CD] |
2* |
Generic |
$4.00 | $8.00 | None |
LAMOTRIGINE START KIT-BLUE TAB DS PK [Subvenite] |
3 |
Preferred Brand |
15% | 18% | None |
LAMOTRIGINE START KIT-GREEN TAB DS PK [Subvenite] |
3 |
Preferred Brand |
15% | 18% | None |
LAMOTRIGINE START KIT-ORANG TAB DS PK [Subvenite] |
3 |
Preferred Brand |
15% | 18% | None |
LAMOTRIGINE TABLET 100MG (100 CT) |
2* |
Generic |
$4.00 | $8.00 | None |
LANOXIN 62.5 MCG TABLET |
3 |
Preferred Brand |
15% | 18% | None |
LANTHANUM CARB 1,000 MG TAB CHEW [Fosrenol] |
3 |
Preferred Brand |
15% | 18% | None |
LANTHANUM CARB 500 MG TAB CHEW [Fosrenol] |
3 |
Preferred Brand |
15% | 18% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LANTHANUM CARB 750 MG TAB CHEW [Fosrenol] |
3 |
Preferred Brand |
15% | 18% | None |
LANTUS 100U/ML VIAL |
3 |
Preferred Brand |
15% | 18% | None |
LANTUS SOLOSTAR INJECTION |
3 |
Preferred Brand |
15% | 18% | None |
Larissia-28 tablet |
4 |
Non-Preferred Drug |
35% | N/A | None |
LATANOPROST 0.005% EYE DROPS |
2* |
Generic |
$4.00 | $8.00 | None |
LATUDA 120 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | P Q:30 /30Days |
LATUDA 20 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | P Q:30 /30Days |
LATUDA 40 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | P Q:30 /30Days |
LATUDA 60 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | P Q:30 /30Days |
LATUDA 80 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | P Q:60 /30Days |
LEFLUNOMIDE 10 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEFLUNOMIDE 20 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | Q:30 /30Days |
LENVIMA 10 MG DAILY DOSE |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
LENVIMA 12 MG DAILY DOSE Capsule |
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 |
LENVIMA 18 MG DAILY DOSE |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
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 |
LENVIMA 4 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
LENVIMA 8 MG DAILY DOSE |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
LETAIRIS 10 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
LETAIRIS 5 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LETROZOLE 2.5 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
LEUCOVORIN CALCIUM 10MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
Leucovorin Calcium 15mg/1 24 TABLET BOTTLE |
2* |
Generic |
$4.00 | $8.00 | None |
LEUCOVORIN CALCIUM 25MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
LEUCOVORIN CALCIUM 5 MG TAB |
2* |
Generic |
$4.00 | $8.00 | None |
LEUKERAN 2 MG TABLET |
3 |
Preferred Brand |
15% | 18% | None |
LEUPROLIDE 2WK 14 MG/2.8 ML KT |
4 |
Non-Preferred Drug |
35% | N/A | None |
LEVEMIR 100UNITS/ML VIAL |
4 |
Non-Preferred Drug |
35% | N/A | S |
LEVEMIR FLEXTOUCH 100 UNITS/ML |
4 |
Non-Preferred Drug |
35% | N/A | S |
LEVETIRACETAM 1,000 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
LEVETIRACETAM 100 MG/ML SOLN |
3 |
Preferred Brand |
15% | 18% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM 250 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
LEVETIRACETAM 500 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
LEVETIRACETAM 750 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION |
2* |
Generic |
$4.00 | $8.00 | None |
LEVOCARNITINE 1 G/10 ML SOLN |
4 |
Non-Preferred Drug |
35% | N/A | None |
LEVOCARNITINE 330 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | None |
LEVOCETIRIZINE 2.5 MG/5 ML SOL |
4 |
Non-Preferred Drug |
35% | N/A | None |
LEVOCETIRIZINE 5 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | Q:30 /30Days |
LEVOFLOXACIN 25 MG/ML SOLUTION [LEVAQUIN] |
4 |
Non-Preferred Drug |
35% | N/A | None |
LEVOFLOXACIN 250 MG TABLET [LEVAQUIN] |
2* |
Generic |
$4.00 | $8.00 | None |
LEVOFLOXACIN 500 MG TABLET [LEVAQUIN] |
2* |
Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOFLOXACIN 500 MG/20 ML VIAL [Levaquin] |
4 |
Non-Preferred Drug |
35% | N/A | None |
Levofloxacin 5mg/mL 24 POUCH per CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG [LEVAQUIN] |
4 |
Non-Preferred Drug |
35% | N/A | None |
LEVOFLOXACIN 750 MG TABLET [LEVAQUIN] |
2* |
Generic |
$4.00 | $8.00 | None |
LEVOFLOXACIN 750 MG/150 ML-D5W [LEVAQUIN] |
3 |
Preferred Brand |
15% | 18% | None |
LEVONOR-ETH ESTRAD 0.09-0.02 MG |
4 |
Non-Preferred Drug |
35% | N/A | None |
LEVONOR-ETH ESTRAD 0.1-0.02 MG |
4 |
Non-Preferred Drug |
35% | N/A | None |
LEVONOR-ETH ESTRAD 0.15-0.03 |
4 |
Non-Preferred Drug |
35% | N/A | None |
Levonor-eth Estrad 0.15-0.03-0.01 |
4 |
Non-Preferred Drug |
35% | N/A | None |
LEVONOR-ETH ESTRAD TRIPHASIC |
4 |
Non-Preferred Drug |
35% | N/A | None |
LEVONORG 0.15MG-EE 20-25-30MCG |
4 |
Non-Preferred Drug |
35% | N/A | None |
LEVOTHYROXINE 100 MCG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE 112 MCG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
LEVOTHYROXINE 125 MCG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
LEVOTHYROXINE 137 MCG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
LEVOTHYROXINE 150 MCG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
LEVOTHYROXINE 175 MCG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
LEVOTHYROXINE 200 MCG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
LEVOTHYROXINE 25 MCG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
LEVOTHYROXINE 300 MCG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
LEVOTHYROXINE 50 MCG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
LEVOTHYROXINE 75 MCG TABLET |
2* |
Generic |
$4.00 | $8.00 | None |
LEVOTHYROXINE 88 MCG TABLET |
2* |
Generic |
$4.00 | $8.00 | 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 |
15% | 18% | None |
LEVOXYL 112 MCG TABLET |
3 |
Preferred Brand |
15% | 18% | None |
LEVOXYL 125 MCG TABLET |
3 |
Preferred Brand |
15% | 18% | None |
LEVOXYL 137 MCG TABLET |
3 |
Preferred Brand |
15% | 18% | None |
LEVOXYL 150 MCG TABLET |
3 |
Preferred Brand |
15% | 18% | None |
LEVOXYL 175 MCG TABLET |
3 |
Preferred Brand |
15% | 18% | None |
LEVOXYL 200 MCG TABLET |
3 |
Preferred Brand |
15% | 18% | None |
LEVOXYL 25 MCG TABLET |
3 |
Preferred Brand |
15% | 18% | None |
LEVOXYL 50 MCG TABLET |
3 |
Preferred Brand |
15% | 18% | None |
LEVOXYL 75 MCG TABLET |
3 |
Preferred Brand |
15% | 18% | None |
LEVOXYL 88 MCG TABLET |
3 |
Preferred Brand |
15% | 18% | 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 |
15% | 18% | Q:1680 /30Days |
LIDOCAINE 2% VISCOUS SOLN |
2* |
Generic |
$4.00 | $8.00 | None |
LIDOCAINE 5% OINTMENT |
4 |
Non-Preferred Drug |
35% | N/A | Q:36 /30Days |
Lidocaine 5% patch |
2* |
Generic |
$4.00 | $8.00 | P Q:90 /30Days |
LIDOCAINE HCL 2% JELLY 30ML TUBE |
2* |
Generic |
$4.00 | $8.00 | Q:60 /30Days |
LIDOCAINE HCL IV 4% SOLUTION |
2* |
Generic |
$4.00 | $8.00 | None |
LIDOCAINE-PRILOCAINE CREAM |
4 |
Non-Preferred Drug |
35% | N/A | Q:30 /30Days |
LINDANE SHAMPOO 1MG 2 FLO BOT |
4 |
Non-Preferred Drug |
35% | N/A | None |
Linezolid 20 MG/ML Oral Suspension [Zyvox] |
5 |
Specialty Tier |
25% | N/A | Q:1800 /30Days |
LINEZOLID 600 MG TABLET [Zyvox] |
5 |
Specialty Tier |
25% | N/A | Q:60 /30Days |
LINEZOLID 600 MG/300 ML IV SOL [Zyvox] |
4 |
Non-Preferred Drug |
35% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIOTHYRONINE SOD 25 MCG TAB |
2* |
Generic |
$4.00 | $8.00 | None |
LIOTHYRONINE SOD 5 MCG TAB |
2* |
Generic |
$4.00 | $8.00 | None |
LIOTHYRONINE SOD 50 MCG TABLET [Cytomel] |
2* |
Generic |
$4.00 | $8.00 | None |
LISINOPRIL 10 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LISINOPRIL 2.5 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LISINOPRIL 20 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LISINOPRIL 30 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LISINOPRIL 40 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LISINOPRIL 5 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LISINOPRIL-HCTZ 10-12.5 MG TAB |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LISINOPRIL-HCTZ 20-12.5 MG TAB |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL-HCTZ 20-25 MG TAB |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LITHIUM CARBONATE 150 MG CAP |
2* |
Generic |
$4.00 | $8.00 | None |
LITHIUM CARBONATE 300 MG Capsule [Eskalith] |
2* |
Generic |
$4.00 | $8.00 | None |
Lithium Carbonate 300 mg tab |
2* |
Generic |
$4.00 | $8.00 | None |
Lithium Carbonate 450mg/1 |
2* |
Generic |
$4.00 | $8.00 | None |
LITHIUM CARBONATE 600 MG CAP |
2* |
Generic |
$4.00 | $8.00 | None |
LITHIUM CARBONATE ER 300 MG TB |
2* |
Generic |
$4.00 | $8.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP |
2* |
Generic |
$4.00 | $8.00 | None |
LONSURF 15 MG-6.14 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:100 /28Days |
LONSURF 20 MG-8.19 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:80 /28Days |
LOPERAMIDE HCL 2MG CAPSULE |
2* |
Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOPINAVIR-RITONAVIR 80-20MG/ML Solution [Kaletra] |
5 |
Specialty Tier |
25% | N/A | None |
LORAZEPAM 0.5 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | P Q:90 /30Days |
LORAZEPAM 1 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | P Q:90 /30Days |
LORAZEPAM 2 MG TABLET |
2* |
Generic |
$4.00 | $8.00 | P Q:150 /30Days |
LORAZEPAM 2 MG/ML ORAL CONCENT |
3 |
Preferred Brand |
15% | 18% | P Q:150 /30Days |
LORBRENA 100 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
LORBRENA 25 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
LOSARTAN POTASSIUM 100 MG TAB |
2* |
Generic |
$4.00 | $8.00 | Q:30 /30Days |
LOSARTAN POTASSIUM 25 MG TAB |
2* |
Generic |
$4.00 | $8.00 | Q:30 /30Days |
LOSARTAN POTASSIUM 50 MG TAB |
2* |
Generic |
$4.00 | $8.00 | Q:30 /30Days |
LOSARTAN-HCTZ 100-12.5 MG TAB |
2* |
Generic |
$4.00 | $8.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOSARTAN-HCTZ 100-25 MG TAB |
2* |
Generic |
$4.00 | $8.00 | Q:30 /30Days |
LOSARTAN-HCTZ 50-12.5 MG TAB |
2* |
Generic |
$4.00 | $8.00 | Q:30 /30Days |
LOTEPREDNOL ETABONATE 0.5% EYE DROPPER [Lotemax] |
3 |
Preferred Brand |
15% | 18% | None |
LOW-OGESTREL-28 TABLET |
4 |
Non-Preferred Drug |
35% | N/A | None |
LOXAPINE 10 MG CAPSULE |
2* |
Generic |
$4.00 | $8.00 | None |
LOXAPINE 25MG CAPSULE (100 CT) |
2* |
Generic |
$4.00 | $8.00 | None |
LOXAPINE CAPSULES 50MG 100 BOT |
2* |
Generic |
$4.00 | $8.00 | None |
LOXAPINE CAPSULES 5MG 100 BOT |
2* |
Generic |
$4.00 | $8.00 | None |
LUMIGAN 0.01% EYE DROPS |
3 |
Preferred Brand |
15% | 18% | None |
LUPRON DEPOT 11.25 MG 3MO KIT |
5 |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT 22.5 MG 3MO KIT SYRINGEKIT |
5 |
Specialty Tier |
25% | 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 |
5 |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT 45 MG 6MO KIT |
5 |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT 7.5 MG KIT |
5 |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT-4 MONTH KIT |
5 |
Specialty Tier |
25% | N/A | P |
LYNPARZA 100 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | P Q:120 /30Days |
LYNPARZA 150 MG TABLET |
4 |
Non-Preferred Drug |
35% | N/A | P Q:120 /30Days |
LYRICA 100MG CAPSULE |
3 |
Preferred Brand |
15% | 18% | P Q:90 /30Days |
LYRICA 150MG CAPSULE |
3 |
Preferred Brand |
15% | 18% | P Q:90 /30Days |
LYRICA 20 MG/ML ORAL SOLUTION |
3 |
Preferred Brand |
15% | 18% | P Q:900 /30Days |
LYRICA 200MG CAPSULE |
3 |
Preferred Brand |
15% | 18% | P Q:90 /30Days |
LYRICA 225MG CAPSULE |
3 |
Preferred Brand |
15% | 18% | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYRICA 25MG CAPSULE |
3 |
Preferred Brand |
15% | 18% | P Q:90 /30Days |
LYRICA 300MG CAPSULE |
3 |
Preferred Brand |
15% | 18% | P Q:60 /30Days |
LYRICA 50MG CAPSULE |
3 |
Preferred Brand |
15% | 18% | P Q:90 /30Days |
LYRICA 75MG CAPSULE |
3 |
Preferred Brand |
15% | 18% | P Q:90 /30Days |
LYSODREN 500MG TABLET |
3 |
Preferred Brand |
15% | 18% | None |