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Solis Health Plans (HMO) (H0982-001-0)
Tier 1 (689)
Tier 2 (1760)
Tier 3 (502)
Tier 4 (1632)
Tier 5 (592)
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2019 Medicare Part D Plan Formulary Information
Solis Health Plans (HMO) (H0982-001-0)
Benefit Details           
The Solis Health Plans (HMO) (H0982-001-0)
Formulary Drugs Starting with the Letter L

in Miami-Dade County, FL: CMS MA Region 9 which includes: FL
Plan Monthly Premium: $0.00 Deductible: $0
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 $0.00$0.00None
LABETALOL HCL 200 MG TABLET   2 Generic $0.00$0.00None
LABETALOL HCL 300 MG TABLET   2 Generic $0.00$0.00None
LACRISERT 5 MG INS   3 Preferred Brand $10.00$20.00None
LACTULOSE 10 GM PACKET [Kristalose]   4 Non-Preferred Brand $30.00$75.00None
LACTULOSE 10 GM/15 ML SOLUTION [Constulose]   1 Preferred Generic $0.00$0.00None
LAMICTAL 100MG TABLET   4 Non-Preferred Brand $30.00$75.00None
LAMICTAL 150MG TABLET   4 Non-Preferred Brand $30.00$75.00None
LAMICTAL 200MG TABLET   4 Non-Preferred Brand $30.00$75.00None
LAMICTAL 25MG DISPER TABLET CHEW   4 Non-Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LAMICTAL 25MG TABLET   4 Non-Preferred Brand $30.00$75.00None
LAMICTAL 25MG TABLET STARTER KIT   4 Non-Preferred Brand $30.00$75.00None
LAMICTAL 25MG/100MG TABLET STARTER KIT   4 Non-Preferred Brand $30.00$75.00None
LAMICTAL 5MG DISPER TABLET CHEW   4 Non-Preferred Brand $30.00$75.00None
LAMICTAL KIT 100;25MG;MG   4 Non-Preferred Brand $30.00$75.00None
LAMICTAL ODT 100mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK   4 Non-Preferred Brand $30.00$75.00None
LAMICTAL ODT 200mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK   4 Non-Preferred Brand $30.00$75.00None
LAMICTAL ODT 25mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK   4 Non-Preferred Brand $30.00$75.00None
LAMICTAL ODT 50mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK   4 Non-Preferred Brand $30.00$75.00None
LAMICTAL XR 100 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
LAMICTAL XR 200 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LAMICTAL XR 25 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
LAMICTAL XR 250 MG ER 30 TABLET, FILM COATED in BOTTLE   4 Non-Preferred Brand $30.00$75.00None
LAMICTAL XR 300 MG ER 30 TABLET, FILM COATED in BOTTLE   4 Non-Preferred Brand $30.00$75.00None
LAMICTAL XR 50 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
LAMICTAL XR START KIT (BLUE)   4 Non-Preferred Brand $30.00$75.00None
LAMICTAL XR START KIT (GREEN)   4 Non-Preferred Brand $30.00$75.00None
LAMICTAL XR START KIT (ORANGE)   4 Non-Preferred Brand $30.00$75.00None
Lamivudine 10 mg/ml oral soln   2 Generic $0.00$0.00None
LAMIVUDINE 150 MG TABLET   2 Generic $0.00$0.00None
LAMIVUDINE 300 MG TABLET   2 Generic $0.00$0.00None
Lamivudine hbv 100 mg tablet   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LAMIVUDINE-ZIDOVUDINE TABLET   2 Generic $0.00$0.00None
LAMOTRIGINE 150MG TABLET (60 CT)   1 Preferred Generic $0.00$0.00None
LAMOTRIGINE 200MG TABLET (60 CT)   1 Preferred Generic $0.00$0.00None
LAMOTRIGINE 25 MG DISPER TAB CHW DSP [Lamictal CD]   2 Generic $0.00$0.00None
LAMOTRIGINE 25 MG TABLET [Subvenite]   1 Preferred Generic $0.00$0.00None
LAMOTRIGINE 5 MG DISPER TABLET CHW DSP [Lamictal CD]   2 Generic $0.00$0.00None
LAMOTRIGINE ER 100 MG TABLET   2 Generic $0.00$0.00None
LAMOTRIGINE ER 200 MG TABLET   2 Generic $0.00$0.00None
LAMOTRIGINE ER 25 MG TABLET   2 Generic $0.00$0.00None
LAMOTRIGINE ER 250 MG TABLET   2 Generic $0.00$0.00None
LAMOTRIGINE ER 300 MG TABLET   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LAMOTRIGINE ER 50 MG TABLET   2 Generic $0.00$0.00None
LAMOTRIGINE ODT 100 MG TABLET RAPDIS [Lamictal ODT]   2 Generic $0.00$0.00None
LAMOTRIGINE ODT 200 MG TABLET RAPDIS [Lamictal ODT]   2 Generic $0.00$0.00None
LAMOTRIGINE ODT 25 MG TABLET   2 Generic $0.00$0.00None
LAMOTRIGINE ODT 50 MG TABLET RAPDIS [Lamictal ODT]   2 Generic $0.00$0.00None
LAMOTRIGINE START KIT-BLUE TAB DS PK [Subvenite]   2 Generic $0.00$0.00None
LAMOTRIGINE START KIT-GREEN TAB DS PK [Subvenite]   2 Generic $0.00$0.00None
LAMOTRIGINE START KIT-ORANG TAB DS PK [Subvenite]   2 Generic $0.00$0.00None
LAMOTRIGINE TABLET 100MG (100 CT)   1 Preferred Generic $0.00$0.00None
LANOXIN 125 MCG TABLET   4 Non-Preferred Brand $30.00$75.00None
LANOXIN 250 MCG TABLET   4 Non-Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LANSOPRAZOL-AMOXICIL-CLARITHRO   2 Generic $0.00$0.00None
LANSOPRAZOLE DR 15 MG CAPSULE DR [Prevacid]   2 Generic $0.00$0.00None
LANSOPRAZOLE DR 30 MG CAPSULE [Prevacid]   2 Generic $0.00$0.00None
LANSOPRAZOLE ODT 15 MG TABLET RAP DR [Prevacid]   2 Generic $0.00$0.00None
LANSOPRAZOLE ODT 30 MG TABLET RAP DR [Prevacid]   2 Generic $0.00$0.00None
LANTHANUM CARB 1,000 MG TAB CHEW [Fosrenol]   2 Generic $0.00$0.00None
LANTHANUM CARB 500 MG TAB CHEW [Fosrenol]   2 Generic $0.00$0.00None
LANTHANUM CARB 750 MG TAB CHEW [Fosrenol]   2 Generic $0.00$0.00None
LANTUS 100U/ML VIAL   3 Preferred Brand $10.00$20.00None
LANTUS SOLOSTAR INJECTION   3 Preferred Brand $10.00$20.00None
LARIN 1.5 MG-30 MCG TABLET   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LARIN 21 1-20 TABLET   2 Generic $0.00$0.00None
LARIN FE 1-20 TABLET   2 Generic $0.00$0.00None
LARIN FE 1.5-30 TABLET   2 Generic $0.00$0.00None
Larissia-28 tablet   2 Generic $0.00$0.00None
LASIX 20 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
LASIX 40 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
LASIX 80 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
LASTACAFT 2.5mg/mL 1 BOTTLE, PLASTIC per CARTON / 3 mL in 1 BOTTLE, PLASTIC   4 Non-Preferred Brand $30.00$75.00None
LATANOPROST 0.005% EYE DROPS   1 Preferred Generic $0.00$0.00Q:5
/30Days
LATUDA 120 MG TABLET   4 Non-Preferred Brand $30.00$75.00P Q:30
/30Days
LATUDA 20 MG TABLET   4 Non-Preferred Brand $30.00$75.00P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LATUDA 40 MG TABLET   4 Non-Preferred Brand $30.00$75.00P Q:30
/30Days
LATUDA 60 MG TABLET   4 Non-Preferred Brand $30.00$75.00P Q:30
/30Days
LATUDA 80 MG TABLET   4 Non-Preferred Brand $30.00$75.00P Q:30
/30Days
LAYOLIS FE CHEWABLE TABLET   2 Generic $0.00$0.00None
LAZANDA 100 MCG NASAL SPRAY   4 Non-Preferred Brand $30.00$75.00P Q:30
/30Days
LAZANDA 300 MCG NASAL SPRAY   4 Non-Preferred Brand $30.00$75.00P Q:30
/30Days
LAZANDA 400 MCG NASAL SPRAY   4 Non-Preferred Brand $30.00$75.00P Q:30
/30Days
LEENA 28 TABLET [Tri-Norinyl]   2 Generic $0.00$0.00None
LEFLUNOMIDE 10 MG TABLET   2 Generic $0.00$0.00None
LEFLUNOMIDE 20 MG TABLET   2 Generic $0.00$0.00None
LENVIMA 10 MG DAILY DOSE   5 Specialty Tier 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LENVIMA 12 MG DAILY DOSE Capsule   5 Specialty Tier 33%33%P
LENVIMA 14 MG DAILY DOSE   5 Specialty Tier 33%33%P
LENVIMA 18 MG DAILY DOSE   5 Specialty Tier 33%33%P
LENVIMA 20 MG DAILY DOSE   5 Specialty Tier 33%33%P
LENVIMA 24 MG DAILY DOSE   5 Specialty Tier 33%33%P
LENVIMA 4 MG CAPSULE   5 Specialty Tier 33%33%P
LENVIMA 8 MG DAILY DOSE   5 Specialty Tier 33%33%P
LESCOL XL 80 MG TABLET   4 Non-Preferred Brand $30.00$75.00S
Lessina 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK   2 Generic $0.00$0.00None
LETAIRIS 10 MG TABLET   5 Specialty Tier 33%33%P Q:30
/30Days
LETAIRIS 5 MG TABLET   5 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
LETROZOLE 2.5 MG TABLET   1 Preferred Generic $0.00$0.00None
LEUCOVORIN CALCIUM 10MG TABLET   2 Generic $0.00$0.00None
Leucovorin Calcium 15mg/1 24 TABLET BOTTLE   2 Generic $0.00$0.00None
LEUCOVORIN CALCIUM 25MG TABLET   2 Generic $0.00$0.00None
LEUCOVORIN CALCIUM 5 MG TAB   2 Generic $0.00$0.00None
LEUKERAN 2 MG TABLET   3 Preferred Brand $10.00$20.00None
LEUKINE 250 MCG VIAL   5 Specialty Tier 33%33%P
LEUPROLIDE 2WK 14 MG/2.8 ML KT   2 Generic $0.00$0.00None
LEVALBUTEROL 0.31 MG/3 ML SOL VIAL-NEB [Xopenex Pediatric]   2 Generic $0.00$0.00P
LEVALBUTEROL 0.63 MG/3 ML SOL VIAL-NEB [Xopenex]   2 Generic $0.00$0.00P
LEVALBUTEROL 1.25 MG/0.5 ML   2 Generic $0.00$0.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVALBUTEROL 1.25 MG/3 ML SOL VIAL-NEB [Xopenex]   2 Generic $0.00$0.00P
LEVALBUTEROL TAR HFA 45MCG INH [Xopenex]   4 Non-Preferred Brand $30.00$75.00S Q:30
/30Days
LEVAQUIN 500mg/1 50 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Brand $30.00$75.00None
LEVAQUIN 750 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
LEVEMIR 100UNITS/ML VIAL   3 Preferred Brand $10.00$20.00None
LEVEMIR FLEXTOUCH 100 UNITS/ML   3 Preferred Brand $10.00$20.00None
LEVETIRACETAM 1,000 MG TABLET   1 Preferred Generic $0.00$0.00None
LEVETIRACETAM 100 MG/ML SOLN   1 Preferred Generic $0.00$0.00None
LEVETIRACETAM 250 MG TABLET   1 Preferred Generic $0.00$0.00None
LEVETIRACETAM 500 MG TABLET   1 Preferred Generic $0.00$0.00None
LEVETIRACETAM 750 MG TABLET   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVETIRACETAM ER 500 MG TABLET   1 Preferred Generic $0.00$0.00None
LEVETIRACETAM ER 750 MG TABLET   1 Preferred Generic $0.00$0.00None
LEVO-T 100 MCG TABLET   2 Generic $0.00$0.00None
LEVO-T 112 MCG TABLET   2 Generic $0.00$0.00None
LEVO-T 125 MCG TABLET   2 Generic $0.00$0.00None
LEVO-T 137 MCG TABLET   2 Generic $0.00$0.00None
LEVO-T 150 MCG TABLET   2 Generic $0.00$0.00None
LEVO-T 175 MCG TABLET   2 Generic $0.00$0.00None
LEVO-T 200 MCG TABLET   2 Generic $0.00$0.00None
LEVO-T 25 MCG TABLET   2 Generic $0.00$0.00None
LEVO-T 300 MCG TABLET   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVO-T 50 MCG TABLET   2 Generic $0.00$0.00None
LEVO-T 75 MCG TABLET   2 Generic $0.00$0.00None
LEVO-T 88 MCG TABLET   2 Generic $0.00$0.00None
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION   2 Generic $0.00$0.00None
LEVOCARNITINE 1 G/10 ML SOLN   2 Generic $0.00$0.00P
LEVOCARNITINE 330 MG TABLET   2 Generic $0.00$0.00P
LEVOCETIRIZINE 2.5 MG/5 ML SOL   2 Generic $0.00$0.00None
LEVOCETIRIZINE 5 MG TABLET   1 Preferred Generic $0.00$0.00None
LEVOFLOXACIN 0.5% EYE DROPS [LEVAQUIN]   1 Preferred Generic $0.00$0.00None
LEVOFLOXACIN 25 MG/ML SOLUTION [LEVAQUIN]   2 Generic $0.00$0.00None
LEVOFLOXACIN 250 MG TABLET [LEVAQUIN]   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVOFLOXACIN 500 MG TABLET [LEVAQUIN]   1 Preferred Generic $0.00$0.00None
LEVOFLOXACIN 500 MG/20 ML VIAL [Levaquin]   2 Generic $0.00$0.00None
Levofloxacin 5mg/mL 24 POUCH per CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG [LEVAQUIN]   2 Generic $0.00$0.00None
LEVOFLOXACIN 750 MG TABLET [LEVAQUIN]   1 Preferred Generic $0.00$0.00None
LEVOFLOXACIN 750 MG/150 ML-D5W [LEVAQUIN]   2 Generic $0.00$0.00None
LEVONEST-28 TABLET   2 Generic $0.00$0.00None
LEVONO-E ESTRAD 0.10-0.02-0.01   2 Generic $0.00$0.00None
LEVONOR-ETH ESTRAD 0.09-0.02 MG   2 Generic $0.00$0.00None
LEVONOR-ETH ESTRAD 0.1-0.02 MG   2 Generic $0.00$0.00None
LEVONOR-ETH ESTRAD 0.15-0.03   2 Generic $0.00$0.00None
LEVONOR-ETH ESTRAD 0.15-0.03   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Levonor-eth Estrad 0.15-0.03-0.01   2 Generic $0.00$0.00None
LEVONOR-ETH ESTRAD TRIPHASIC   2 Generic $0.00$0.00None
LEVONORG 0.15MG-EE 20-25-30MCG   2 Generic $0.00$0.00None
Levora-28 tablet   2 Generic $0.00$0.00None
LEVORPHANOL 2 MG TABLET   3 Preferred Brand $10.00$20.00Q:240
/30Days
LEVORPHANOL 3 MG TABLET   3 Preferred Brand $10.00$20.00Q:120
/30Days
LEVOTHYROXINE 100 MCG TABLET   2 Generic $0.00$0.00None
LEVOTHYROXINE 112 MCG TABLET   2 Generic $0.00$0.00None
LEVOTHYROXINE 125 MCG TABLET   2 Generic $0.00$0.00None
LEVOTHYROXINE 137 MCG TABLET   2 Generic $0.00$0.00None
LEVOTHYROXINE 150 MCG TABLET   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVOTHYROXINE 175 MCG TABLET   2 Generic $0.00$0.00None
LEVOTHYROXINE 200 MCG TABLET   2 Generic $0.00$0.00None
LEVOTHYROXINE 25 MCG TABLET   2 Generic $0.00$0.00None
LEVOTHYROXINE 300 MCG TABLET   2 Generic $0.00$0.00None
LEVOTHYROXINE 50 MCG TABLET   2 Generic $0.00$0.00None
LEVOTHYROXINE 75 MCG TABLET   2 Generic $0.00$0.00None
LEVOTHYROXINE 88 MCG TABLET   2 Generic $0.00$0.00None
LEVOXYL 100 MCG TABLET   2 Generic $0.00$0.00None
LEVOXYL 112 MCG TABLET   2 Generic $0.00$0.00None
LEVOXYL 125 MCG TABLET   2 Generic $0.00$0.00None
LEVOXYL 137 MCG TABLET   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVOXYL 150 MCG TABLET   2 Generic $0.00$0.00None
LEVOXYL 175 MCG TABLET   2 Generic $0.00$0.00None
LEVOXYL 200 MCG TABLET   2 Generic $0.00$0.00None
LEVOXYL 25 MCG TABLET   2 Generic $0.00$0.00None
LEVOXYL 50 MCG TABLET   2 Generic $0.00$0.00None
LEVOXYL 75 MCG TABLET   2 Generic $0.00$0.00None
LEVOXYL 88 MCG TABLET   2 Generic $0.00$0.00None
LEXAPRO 10MG TABLET   4 Non-Preferred Brand $30.00$75.00None
LEXAPRO 20MG TABLET   4 Non-Preferred Brand $30.00$75.00None
LEXAPRO 5MG TABLET   4 Non-Preferred Brand $30.00$75.00None
LEXIVA 50mg/mL 225 mL in 1 BOTTLE   3 Preferred Brand $10.00$20.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEXIVA 700MG TABLETS   4 Non-Preferred Brand $30.00$75.00None
LIALDA 1.2G TABLET DELAYED RELEASE   3 Preferred Brand $10.00$20.00None
LIDOCAINE 2% VISCOUS SOLN   2 Generic $0.00$0.00None
LIDOCAINE 5% OINTMENT   2 Generic $0.00$0.00P Q:107
/30Days
Lidocaine 5% patch   2 Generic $0.00$0.00P Q:90
/30Days
LIDOCAINE HCL 2% JELLY 30ML TUBE   2 Generic $0.00$0.00None
LIDOCAINE HCL IV 4% SOLUTION   2 Generic $0.00$0.00None
LIDOCAINE-PRILOCAINE CREAM   2 Generic $0.00$0.00P
LIDODERM 5% PATCH   4 Non-Preferred Brand $30.00$75.00P Q:90
/30Days
LINDANE SHAMPOO 1MG 2 FLO BOT   2 Generic $0.00$0.00None
Linezolid 20 MG/ML Oral Suspension [Zyvox]   2 Generic $0.00$0.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LINEZOLID 600 MG TABLET [Zyvox]   2 Generic $0.00$0.00P
LINEZOLID 600 MG/300 ML IV SOL [Zyvox]   5 Specialty Tier 33%33%P
LINZESS 145 MCG CAPSULE   3 Preferred Brand $10.00$20.00P
LINZESS 290 MCG CAPSULE   3 Preferred Brand $10.00$20.00P
LINZESS 72 MCG CAPSULE   3 Preferred Brand $10.00$20.00P
LIOTHYRONINE SOD 25 MCG TAB   2 Generic $0.00$0.00None
LIOTHYRONINE SOD 5 MCG TAB   2 Generic $0.00$0.00None
LIOTHYRONINE SOD 50 MCG TABLET [Cytomel]   2 Generic $0.00$0.00None
LIPITOR 10MG TABLET   4 Non-Preferred Brand $30.00$75.00S
LIPITOR 20 MG TABLET   4 Non-Preferred Brand $30.00$75.00S
LIPITOR 40 MG TABLET   4 Non-Preferred Brand $30.00$75.00S
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LIPITOR 80 MG TABLET   4 Non-Preferred Brand $30.00$75.00S
LIPOFEN 150MG CAPSULES   4 Non-Preferred Brand $30.00$75.00None
LISINOPRIL 10 MG TABLET   1 Preferred Generic $0.00$0.00None
LISINOPRIL 2.5 MG TABLET   1 Preferred Generic $0.00$0.00None
LISINOPRIL 20 MG TABLET   1 Preferred Generic $0.00$0.00None
LISINOPRIL 30 MG TABLET   1 Preferred Generic $0.00$0.00None
LISINOPRIL 40 MG TABLET   1 Preferred Generic $0.00$0.00None
LISINOPRIL 5 MG TABLET   1 Preferred Generic $0.00$0.00None
LISINOPRIL-HCTZ 10-12.5 MG TAB   1 Preferred Generic $0.00$0.00None
LISINOPRIL-HCTZ 20-12.5 MG TAB   1 Preferred Generic $0.00$0.00None
LISINOPRIL-HCTZ 20-25 MG TAB   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LITHIUM CARBONATE 150 MG CAP   1 Preferred Generic $0.00$0.00None
LITHIUM CARBONATE 300 MG Capsule [Eskalith]   1 Preferred Generic $0.00$0.00None
Lithium Carbonate 300 mg tab   1 Preferred Generic $0.00$0.00None
Lithium Carbonate 450mg/1   1 Preferred Generic $0.00$0.00None
LITHIUM CARBONATE 600 MG CAP   1 Preferred Generic $0.00$0.00None
LITHIUM CARBONATE ER 300 MG TB   1 Preferred Generic $0.00$0.00None
LITHIUM CIT 8MEQ/5ML SYRUP   1 Preferred Generic $0.00$0.00None
LITHOBID ER 300 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
LITHOSTAT 250 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
LIVALO 1 MG TABLET   4 Non-Preferred Brand $30.00$75.00S
LIVALO 2 MG TABLET   4 Non-Preferred Brand $30.00$75.00S
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LIVALO 4 MG TABLET   4 Non-Preferred Brand $30.00$75.00S
Lo Loestrin Fe 5 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK   4 Non-Preferred Brand $30.00$75.00None
LODINE 400 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
LODOSYN TAB 25MG   4 Non-Preferred Brand $30.00$75.00None
LOESTRIN 21 1.5/30 TABLET   4 Non-Preferred Brand $30.00$75.00None
LOESTRIN 21 1/20 TABLET   4 Non-Preferred Brand $30.00$75.00None
LOESTRIN FE 1.5/30 TABLET   4 Non-Preferred Brand $30.00$75.00None
LOESTRIN FE 1/20 TABLET   4 Non-Preferred Brand $30.00$75.00None
LOKELMA 10 GRAM POWDER PACKET   3 Preferred Brand $10.00$20.00P
LOKELMA 5 GRAM POWDER PACKET   3 Preferred Brand $10.00$20.00P
Lomotil 0.025; 2.5mg/1; mg/1 100 TABLET BOTTLE   4 Non-Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LONHALA MAGNAIR 25 MCG STARTER VIAL-NEB   3 Preferred Brand $10.00$20.00S
LONSURF 15 MG-6.14 MG TABLET   5 Specialty Tier 33%33%P
LONSURF 20 MG-8.19 MG TABLET   5 Specialty Tier 33%33%P
LOPERAMIDE HCL 2MG CAPSULE   1 Preferred Generic $0.00$0.00None
LOPID 600 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
LOPINAVIR-RITONAVIR 80-20MG/ML Solution [Kaletra]   5 Specialty Tier 33%33%None
LOPREEZA 1 MG-0.5 MG TABLET [Mimvey]   2 Generic $0.00$0.00None
LOPRESSOR 100 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
LOPRESSOR HCT 50-25 TABLET   4 Non-Preferred Brand $30.00$75.00None
LOPROX 1% SHAMPOO   4 Non-Preferred Brand $30.00$75.00None
LOPROX CREAM 90 GM   4 Non-Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LORAZEPAM 0.5 MG TABLET   1 Preferred Generic $0.00$0.00None
LORAZEPAM 1 MG TABLET   1 Preferred Generic $0.00$0.00None
LORAZEPAM 2 MG TABLET   1 Preferred Generic $0.00$0.00None
LORAZEPAM 2 MG/ML ORAL CONCENT   2 Generic $0.00$0.00None
LORBRENA 100 MG TABLET   5 Specialty Tier 33%33%P Q:30
/30Days
LORBRENA 25 MG TABLET   5 Specialty Tier 33%33%P Q:90
/30Days
LORCET HD 10-325 MG TABLET   2 Generic $0.00$0.00Q:360
/30Days
Lorcet plus 7.5-325 mg tablet   2 Generic $0.00$0.00Q:360
/30Days
LORYNA 3 MG-0.02 MG TABLET [Yaz]   2 Generic $0.00$0.00None
LOSARTAN POTASSIUM 100 MG TAB   1 Preferred Generic $0.00$0.00None
LOSARTAN POTASSIUM 25 MG TAB   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LOSARTAN POTASSIUM 50 MG TAB   1 Preferred Generic $0.00$0.00None
LOSARTAN-HCTZ 100-12.5 MG TAB   2 Generic $0.00$0.00None
LOSARTAN-HCTZ 100-25 MG TAB   2 Generic $0.00$0.00None
LOSARTAN-HCTZ 50-12.5 MG TAB   2 Generic $0.00$0.00None
LOSEASONIQUE TABLET   4 Non-Preferred Brand $30.00$75.00None
LOTEMAX 0.5% EYE DROPS   3 Preferred Brand $10.00$20.00None
LOTEMAX 0.5% OPHTHALMIC GEL   3 Preferred Brand $10.00$20.00None
Lotemax 5mg/g 1 TUBE per CARTON / 3.5 g in 1 TUBE   3 Preferred Brand $10.00$20.00None
LOTENSIN 10 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
LOTENSIN 20 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
LOTENSIN 40 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LOTEPREDNOL ETABONATE 0.5% EYE DROPPER [Lotemax]   2 Generic $0.00$0.00None
LOTREL 10/20MG CAPSULE   4 Non-Preferred Brand $30.00$75.00None
LOTREL 10/40MG CAPSULE   4 Non-Preferred Brand $30.00$75.00None
LOTREL 5/10MG CAPSULE   4 Non-Preferred Brand $30.00$75.00None
LOTREL 5/20MG CAPSULE   4 Non-Preferred Brand $30.00$75.00None
LOTRISONE CREAM   4 Non-Preferred Brand $30.00$75.00None
LOTRONEX 0.5 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
LOTRONEX 1 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
LOVASTATIN 10 MG TABLET   1 Preferred Generic $0.00$0.00None
LOVASTATIN 20 MG TABLET   1 Preferred Generic $0.00$0.00None
LOVASTATIN 40 MG TABLET   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LOVAZA 1 GM CAPSULE   4 Non-Preferred Brand $30.00$75.00None
LOVENOX 100 MG/ML SYRINGE   4 Non-Preferred Brand $30.00$75.00Q:60
/30Days
LOVENOX 120 MG/0.8 ML SYRINGE   4 Non-Preferred Brand $30.00$75.00Q:48
/30Days
LOVENOX 150MG PREFILLED SYR   4 Non-Preferred Brand $30.00$75.00Q:60
/30Days
LOVENOX 30MG PREFILLED SYRN   4 Non-Preferred Brand $30.00$75.00Q:18
/30Days
LOVENOX 40MG PREFILLED SYRN   4 Non-Preferred Brand $30.00$75.00Q:24
/30Days
LOVENOX 60MG PREFILLED SYRN   4 Non-Preferred Brand $30.00$75.00Q:36
/30Days
LOVENOX 80 MG/0.8 ML SYRINGE   4 Non-Preferred Brand $30.00$75.00Q:48
/30Days
LOW-OGESTREL-28 TABLET   2 Generic $0.00$0.00None
LOXAPINE 10 MG CAPSULE   2 Generic $0.00$0.00None
LOXAPINE 25MG CAPSULE (100 CT)   2 Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LOXAPINE CAPSULES 50MG 100 BOT   2 Generic $0.00$0.00None
LOXAPINE CAPSULES 5MG 100 BOT   2 Generic $0.00$0.00None
LUCEMYRA 0.18 MG TABLET   4 Non-Preferred Brand $30.00$75.00P Q:84
/7Days
LUMIGAN 0.01% EYE DROPS   3 Preferred Brand $10.00$20.00Q:5
/30Days
LUNESTA 2MG TABLET   4 Non-Preferred Brand $30.00$75.00Q:30
/30Days
LUNESTA 3MG TABLET   4 Non-Preferred Brand $30.00$75.00Q:30
/30Days
LUNESTA TABLETS 1MG 30 BOT   4 Non-Preferred Brand $30.00$75.00Q:30
/30Days
LUPANETA PACK 11.25-5 MG 3MO KIT   5 Specialty Tier 33%33%None
LUPANETA PACK 3.75-5 MG 1MO KIT   5 Specialty Tier 33%33%None
LUPRON DEPOT 11.25 MG 3MO KIT   5 Specialty Tier 33%33%None
LUPRON DEPOT 22.5 MG 3MO KIT SYRINGEKIT   5 Specialty Tier 33%33%None
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 33%33%None
LUPRON DEPOT 45 MG 6MO KIT   5 Specialty Tier 33%33%None
LUPRON DEPOT 7.5 MG KIT   5 Specialty Tier 33%33%None
LUPRON DEPOT-4 MONTH KIT   5 Specialty Tier 33%33%None
LUTERA-28 TABLET   2 Generic $0.00$0.00None
LYNPARZA 100 MG TABLET   5 Specialty Tier 33%33%P Q:120
/30Days
LYNPARZA 150 MG TABLET   5 Specialty Tier 33%33%P Q:120
/30Days
LYRICA 100MG CAPSULE   3 Preferred Brand $10.00$20.00None
LYRICA 150MG CAPSULE   3 Preferred Brand $10.00$20.00None
LYRICA 20 MG/ML ORAL SOLUTION   3 Preferred Brand $10.00$20.00None
LYRICA 200MG CAPSULE   3 Preferred Brand $10.00$20.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LYRICA 225MG CAPSULE   3 Preferred Brand $10.00$20.00None
LYRICA 25MG CAPSULE   3 Preferred Brand $10.00$20.00None
LYRICA 300MG CAPSULE   3 Preferred Brand $10.00$20.00None
LYRICA 50MG CAPSULE   3 Preferred Brand $10.00$20.00None
LYRICA 75MG CAPSULE   3 Preferred Brand $10.00$20.00None
LYSODREN 500MG TABLET   3 Preferred Brand $10.00$20.00None
LYSTEDA 650 MG TABLET   4 Non-Preferred Brand $30.00$75.00None
LYZA 0.35 MG TABLET   2 Generic $0.00$0.00None

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D Solis Health Plans (HMO) 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). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)

  • 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 $415 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 five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs. *Some Part D plans exclude one or more drug tiers from the deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
    • Tier 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 $3820) at a "Preferred" network pharmacy. In most cases, the "Preferred" network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
    • 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 2019 )

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.








Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.