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AARP MedicareRx Preferred (PDP) (S5820-010-0)
Tier 1 (124)
Tier 2 (729)
Tier 3 (966)
Tier 4 (1121)
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Cick on the first letter of your drug name to browse the formulary:

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 
2019 Medicare Part D Plan Formulary Information
AARP MedicareRx Preferred (PDP) (S5820-010-0)
Benefit Details           
The AARP MedicareRx Preferred (PDP) (S5820-010-0)
Formulary Drugs Starting with the Letter L

in CMS PDP Region 11 which includes: FL
Plan Monthly Premium: $76.60 Deductible: $0 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 $10.00$0.00None
LABETALOL HCL 200 MG TABLET   2 Generic $10.00$0.00None
LABETALOL HCL 300 MG TABLET   2 Generic $10.00$0.00None
LACRISERT 5 MG INS   4 Non-Preferred Drug 40%40%None
LACTULOSE 10 GM/15 ML SOLUTION [Constulose]   2 Generic $10.00$0.00None
Lamivudine 10 mg/ml oral soln   3 Preferred Brand $40.00$105.00Q:1440
/30Days
LAMIVUDINE 150 MG TABLET   3 Preferred Brand $40.00$105.00Q:90
/30Days
LAMIVUDINE 300 MG TABLET   3 Preferred Brand $40.00$105.00Q:60
/30Days
Lamivudine hbv 100 mg tablet   3 Preferred Brand $40.00$105.00None
LAMIVUDINE-ZIDOVUDINE TABLET   4 Non-Preferred Drug 40%40%Q:90
/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 $10.00$0.00None
LAMOTRIGINE 200MG TABLET (60 CT)   2 Generic $10.00$0.00None
LAMOTRIGINE 25 MG DISPER TAB CHW DSP [Lamictal CD]   3 Preferred Brand $40.00$105.00None
LAMOTRIGINE 25 MG TABLET [Subvenite]   2 Generic $10.00$0.00None
LAMOTRIGINE 5 MG DISPER TABLET CHW DSP [Lamictal CD]   3 Preferred Brand $40.00$105.00None
LAMOTRIGINE TABLET 100MG (100 CT)   2 Generic $10.00$0.00None
LANOXIN 125 MCG TABLET   4 Non-Preferred Drug 40%40%None
LANOXIN 250 MCG TABLET   4 Non-Preferred Drug 40%40%None
LANOXIN 62.5 MCG TABLET   4 Non-Preferred Drug 40%40%None
LANTHANUM CARB 1,000 MG TAB CHEW [Fosrenol]   4 Non-Preferred Drug 40%40%None
LANTHANUM CARB 500 MG TAB CHEW [Fosrenol]   4 Non-Preferred Drug 40%40%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]   4 Non-Preferred Drug 40%40%None
LANTUS 100U/ML VIAL   3 Preferred Brand $40.00$105.00None
LANTUS SOLOSTAR INJECTION   3 Preferred Brand $40.00$105.00None
LARIN 1.5 MG-30 MCG TABLET   4 Non-Preferred Drug 40%40%None
LARIN 21 1-20 TABLET   4 Non-Preferred Drug 40%40%None
LARIN FE 1-20 TABLET   4 Non-Preferred Drug 40%40%None
LARIN FE 1.5-30 TABLET   4 Non-Preferred Drug 40%40%None
Larissia-28 tablet   4 Non-Preferred Drug 40%40%None
LASTACAFT 2.5mg/mL 1 BOTTLE, PLASTIC per CARTON / 3 mL in 1 BOTTLE, PLASTIC   3 Preferred Brand $40.00$105.00None
LATANOPROST 0.005% EYE DROPS   2 Generic $10.00$0.00None
LATUDA 120 MG TABLET   5 Specialty Tier 33%33%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LATUDA 20 MG TABLET   5 Specialty Tier 33%33%Q:30
/30Days
LATUDA 40 MG TABLET   5 Specialty Tier 33%33%Q:30
/30Days
LATUDA 60 MG TABLET   5 Specialty Tier 33%33%Q:30
/30Days
LATUDA 80 MG TABLET   5 Specialty Tier 33%33%Q:60
/30Days
LAYOLIS FE CHEWABLE TABLET   4 Non-Preferred Drug 40%40%None
LEDIPASVIR-SOFOSBUVIR 90-400MG TABLET [Harvoni]   5 Specialty Tier 33%33%P Q:30
/30Days
LEENA 28 TABLET [Tri-Norinyl]   4 Non-Preferred Drug 40%40%None
LEFLUNOMIDE 10 MG TABLET   3 Preferred Brand $40.00$105.00None
LEFLUNOMIDE 20 MG TABLET   3 Preferred Brand $40.00$105.00None
LENVIMA 10 MG DAILY DOSE   5 Specialty Tier 33%33%P
LENVIMA 12 MG DAILY DOSE Capsule   5 Specialty Tier 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
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
Lessina 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK   4 Non-Preferred Drug 40%40%None
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
LETROZOLE 2.5 MG TABLET   2 Generic $10.00$0.00None
LEUCOVORIN CALCIUM 10MG TABLET   3 Preferred Brand $40.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Leucovorin Calcium 15mg/1 24 TABLET BOTTLE   3 Preferred Brand $40.00$105.00None
LEUCOVORIN CALCIUM 25MG TABLET   4 Non-Preferred Drug 40%40%None
LEUCOVORIN CALCIUM 5 MG TAB   3 Preferred Brand $40.00$105.00None
LEUKERAN 2 MG TABLET   4 Non-Preferred Drug 40%40%None
LEUKINE 250 MCG VIAL   5 Specialty Tier 33%33%P
LEUPROLIDE 2WK 14 MG/2.8 ML KT   4 Non-Preferred Drug 40%40%P
LEVALBUTEROL 0.31 MG/3 ML SOL VIAL-NEB [Xopenex Pediatric]   4 Non-Preferred Drug 40%40%P
LEVALBUTEROL 0.63 MG/3 ML SOL VIAL-NEB [Xopenex]   4 Non-Preferred Drug 40%40%P
LEVALBUTEROL 1.25 MG/0.5 ML   4 Non-Preferred Drug 40%40%P
LEVALBUTEROL 1.25 MG/3 ML SOL VIAL-NEB [Xopenex]   4 Non-Preferred Drug 40%40%P
LEVEMIR 100UNITS/ML VIAL   3 Preferred Brand $40.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVEMIR FLEXTOUCH 100 UNITS/ML   3 Preferred Brand $40.00$105.00None
LEVETIRACETAM 1,000 MG TABLET   2 Generic $10.00$0.00None
LEVETIRACETAM 100 MG/ML SOLN   2 Generic $10.00$0.00None
LEVETIRACETAM 250 MG TABLET   2 Generic $10.00$0.00None
LEVETIRACETAM 500 MG TABLET   2 Generic $10.00$0.00None
LEVETIRACETAM 750 MG TABLET   2 Generic $10.00$0.00None
LEVETIRACETAM ER 500 MG TABLET   3 Preferred Brand $40.00$105.00None
LEVETIRACETAM ER 750 MG TABLET   3 Preferred Brand $40.00$105.00None
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION   2 Generic $10.00$0.00None
LEVOCARNITINE 1 G/10 ML SOLN   3 Preferred Brand $40.00$105.00None
LEVOCARNITINE 330 MG TABLET   3 Preferred Brand $40.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVOCETIRIZINE 5 MG TABLET   3 Preferred Brand $40.00$105.00Q:30
/30Days
LEVOFLOXACIN 0.5% EYE DROPS [LEVAQUIN]   3 Preferred Brand $40.00$105.00None
LEVOFLOXACIN 25 MG/ML SOLUTION [LEVAQUIN]   4 Non-Preferred Drug 40%40%None
LEVOFLOXACIN 250 MG TABLET [LEVAQUIN]   3 Preferred Brand $40.00$105.00None
LEVOFLOXACIN 500 MG TABLET [LEVAQUIN]   3 Preferred Brand $40.00$105.00None
LEVOFLOXACIN 500 MG/20 ML VIAL [Levaquin]   4 Non-Preferred Drug 40%40%None
Levofloxacin 5mg/mL 24 POUCH per CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG [LEVAQUIN]   4 Non-Preferred Drug 40%40%None
LEVOFLOXACIN 750 MG TABLET [LEVAQUIN]   3 Preferred Brand $40.00$105.00None
LEVOFLOXACIN 750 MG/150 ML-D5W [LEVAQUIN]   4 Non-Preferred Drug 40%40%None
LEVONEST-28 TABLET   4 Non-Preferred Drug 40%40%None
LEVONO-E ESTRAD 0.10-0.02-0.01   4 Non-Preferred Drug 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVONOR-ETH ESTRAD 0.09-0.02 MG   4 Non-Preferred Drug 40%40%None
LEVONOR-ETH ESTRAD 0.1-0.02 MG   4 Non-Preferred Drug 40%40%None
LEVONOR-ETH ESTRAD 0.15-0.03   4 Non-Preferred Drug 40%40%None
LEVONOR-ETH ESTRAD 0.15-0.03   4 Non-Preferred Drug 40%40%None
Levonor-eth Estrad 0.15-0.03-0.01   4 Non-Preferred Drug 40%40%None
LEVONOR-ETH ESTRAD TRIPHASIC   4 Non-Preferred Drug 40%40%None
LEVONORG 0.15MG-EE 20-25-30MCG   4 Non-Preferred Drug 40%40%None
Levora-28 tablet   4 Non-Preferred Drug 40%40%None
LEVORPHANOL 2 MG TABLET   4 Non-Preferred Drug 40%40%Q:180
/30Days
LEVORPHANOL 3 MG TABLET   4 Non-Preferred Drug 40%40%Q:180
/30Days
LEVOTHYROXINE 100 MCG TABLET   1 Preferred Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVOTHYROXINE 112 MCG TABLET   1 Preferred Generic $5.00$0.00None
LEVOTHYROXINE 125 MCG TABLET   1 Preferred Generic $5.00$0.00None
LEVOTHYROXINE 137 MCG TABLET   1 Preferred Generic $5.00$0.00None
LEVOTHYROXINE 150 MCG TABLET   1 Preferred Generic $5.00$0.00None
LEVOTHYROXINE 175 MCG TABLET   1 Preferred Generic $5.00$0.00None
LEVOTHYROXINE 200 MCG TABLET   1 Preferred Generic $5.00$0.00None
LEVOTHYROXINE 25 MCG TABLET   1 Preferred Generic $5.00$0.00None
LEVOTHYROXINE 300 MCG TABLET   1 Preferred Generic $5.00$0.00None
LEVOTHYROXINE 50 MCG TABLET   1 Preferred Generic $5.00$0.00None
LEVOTHYROXINE 75 MCG TABLET   1 Preferred Generic $5.00$0.00None
LEVOTHYROXINE 88 MCG TABLET   1 Preferred Generic $5.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVOXYL 100 MCG TABLET   3 Preferred Brand $40.00$105.00None
LEVOXYL 112 MCG TABLET   3 Preferred Brand $40.00$105.00None
LEVOXYL 125 MCG TABLET   3 Preferred Brand $40.00$105.00None
LEVOXYL 137 MCG TABLET   3 Preferred Brand $40.00$105.00None
LEVOXYL 150 MCG TABLET   3 Preferred Brand $40.00$105.00None
LEVOXYL 175 MCG TABLET   3 Preferred Brand $40.00$105.00None
LEVOXYL 200 MCG TABLET   3 Preferred Brand $40.00$105.00None
LEVOXYL 25 MCG TABLET   3 Preferred Brand $40.00$105.00None
LEVOXYL 50 MCG TABLET   3 Preferred Brand $40.00$105.00None
LEVOXYL 75 MCG TABLET   3 Preferred Brand $40.00$105.00None
LEVOXYL 88 MCG TABLET   3 Preferred Brand $40.00$105.00None
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   4 Non-Preferred Drug 40%40%Q:2700
/30Days
LIALDA 1.2G TABLET DELAYED RELEASE   3 Preferred Brand $40.00$105.00Q:120
/30Days
LIDOCAINE 2% VISCOUS SOLN   2 Generic $10.00$0.00None
LIDOCAINE 5% OINTMENT   4 Non-Preferred Drug 40%40%Q:152
/30Days
Lidocaine 5% patch   4 Non-Preferred Drug 40%40%P Q:90
/30Days
LIDOCAINE HCL 2% JELLY 30ML TUBE   2 Generic $10.00$0.00None
LIDOCAINE HCL IV 4% SOLUTION   2 Generic $10.00$0.00None
LIDOCAINE-PRILOCAINE CREAM   3 Preferred Brand $40.00$105.00None
LINDANE SHAMPOO 1MG 2 FLO BOT   4 Non-Preferred Drug 40%40%None
Linezolid 20 MG/ML Oral Suspension [Zyvox]   5 Specialty Tier 33%33%None
LINEZOLID 600 MG TABLET [Zyvox]   4 Non-Preferred Drug 40%40%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LINEZOLID 600 MG/300 ML IV SOL [Zyvox]   4 Non-Preferred Drug 40%40%None
LINZESS 145 MCG CAPSULE   3 Preferred Brand $40.00$105.00Q:30
/30Days
LINZESS 290 MCG CAPSULE   3 Preferred Brand $40.00$105.00Q:30
/30Days
LINZESS 72 MCG CAPSULE   3 Preferred Brand $40.00$105.00Q:30
/30Days
LIOTHYRONINE SOD 25 MCG TAB   2 Generic $10.00$0.00None
LIOTHYRONINE SOD 5 MCG TAB   2 Generic $10.00$0.00None
LIOTHYRONINE SOD 50 MCG TABLET [Cytomel]   2 Generic $10.00$0.00None
LISINOPRIL 10 MG TABLET   1 Preferred Generic $5.00$0.00Q:60
/30Days
LISINOPRIL 2.5 MG TABLET   1 Preferred Generic $5.00$0.00Q:60
/30Days
LISINOPRIL 20 MG TABLET   1 Preferred Generic $5.00$0.00Q:60
/30Days
LISINOPRIL 30 MG TABLET   1 Preferred Generic $5.00$0.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LISINOPRIL 40 MG TABLET   1 Preferred Generic $5.00$0.00Q:60
/30Days
LISINOPRIL 5 MG TABLET   1 Preferred Generic $5.00$0.00Q:60
/30Days
LISINOPRIL-HCTZ 10-12.5 MG TAB   1 Preferred Generic $5.00$0.00Q:30
/30Days
LISINOPRIL-HCTZ 20-12.5 MG TAB   1 Preferred Generic $5.00$0.00Q:120
/30Days
LISINOPRIL-HCTZ 20-25 MG TAB   1 Preferred Generic $5.00$0.00Q:60
/30Days
LITHIUM CARBONATE 150 MG CAP   2 Generic $10.00$0.00None
LITHIUM CARBONATE 300 MG Capsule [Eskalith]   2 Generic $10.00$0.00None
Lithium Carbonate 300 mg tab   2 Generic $10.00$0.00None
Lithium Carbonate 450mg/1   2 Generic $10.00$0.00None
LITHIUM CARBONATE 600 MG CAP   2 Generic $10.00$0.00None
LITHIUM CARBONATE ER 300 MG TB   2 Generic $10.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LITHIUM CIT 8MEQ/5ML SYRUP   3 Preferred Brand $40.00$105.00None
LIVALO 1 MG TABLET   3 Preferred Brand $40.00$105.00Q:30
/30Days
LIVALO 2 MG TABLET   3 Preferred Brand $40.00$105.00Q:30
/30Days
LIVALO 4 MG TABLET   3 Preferred Brand $40.00$105.00Q:30
/30Days
LOKELMA 10 GRAM POWDER PACKET   4 Non-Preferred Drug 40%40%Q:90
/30Days
LOKELMA 5 GRAM POWDER PACKET   4 Non-Preferred Drug 40%40%Q:90
/30Days
LONHALA MAGNAIR 25 MCG STARTER VIAL-NEB   5 Specialty Tier 33%33%Q:60
/30Days
LONSURF 15 MG-6.14 MG TABLET   5 Specialty Tier 33%33%P Q:300
/30Days
LONSURF 20 MG-8.19 MG TABLET   5 Specialty Tier 33%33%P Q:240
/30Days
LOPERAMIDE HCL 2MG CAPSULE   2 Generic $10.00$0.00None
LOPINAVIR-RITONAVIR 80-20MG/ML Solution [Kaletra]   4 Non-Preferred Drug 40%40%Q:480
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LOPREEZA 1 MG-0.5 MG TABLET [Mimvey]   3 Preferred Brand $40.00$105.00None
LORAZEPAM 0.5 MG TABLET   2 Generic $10.00$0.00Q:120
/30Days
LORAZEPAM 1 MG TABLET   2 Generic $10.00$0.00Q:120
/30Days
LORAZEPAM 2 MG TABLET   2 Generic $10.00$0.00Q:150
/30Days
LORAZEPAM 2 MG/ML ORAL CONCENT   2 Generic $10.00$0.00Q:150
/30Days
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   3 Preferred Brand $40.00$105.00Q:360
/30Days
Lorcet plus 7.5-325 mg tablet   3 Preferred Brand $40.00$105.00Q:360
/30Days
LORYNA 3 MG-0.02 MG TABLET [Yaz]   4 Non-Preferred Drug 40%40%None
LOSARTAN POTASSIUM 100 MG TAB   1 Preferred Generic $5.00$0.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LOSARTAN POTASSIUM 25 MG TAB   1 Preferred Generic $5.00$0.00Q:60
/30Days
LOSARTAN POTASSIUM 50 MG TAB   1 Preferred Generic $5.00$0.00Q:60
/30Days
LOSARTAN-HCTZ 100-12.5 MG TAB   1 Preferred Generic $5.00$0.00Q:30
/30Days
LOSARTAN-HCTZ 100-25 MG TAB   1 Preferred Generic $5.00$0.00Q:30
/30Days
LOSARTAN-HCTZ 50-12.5 MG TAB   1 Preferred Generic $5.00$0.00Q:60
/30Days
LOTEMAX 0.5% EYE DROPS   4 Non-Preferred Drug 40%40%None
LOTEMAX 0.5% OPHTHALMIC GEL   4 Non-Preferred Drug 40%40%None
Lotemax 5mg/g 1 TUBE per CARTON / 3.5 g in 1 TUBE   4 Non-Preferred Drug 40%40%None
LOTEMAX SM 0.38% OPHTH GEL DROPS   4 Non-Preferred Drug 40%40%None
LOTEPREDNOL ETABONATE 0.5% EYE DROPPER [Lotemax]   4 Non-Preferred Drug 40%40%None
LOVASTATIN 10 MG TABLET   2 Generic $10.00$0.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LOVASTATIN 20 MG TABLET   2 Generic $10.00$0.00Q:30
/30Days
LOVASTATIN 40 MG TABLET   2 Generic $10.00$0.00Q:60
/30Days
LOW-OGESTREL-28 TABLET   4 Non-Preferred Drug 40%40%None
LOXAPINE 10 MG CAPSULE   2 Generic $10.00$0.00None
LOXAPINE 25MG CAPSULE (100 CT)   2 Generic $10.00$0.00None
LOXAPINE CAPSULES 50MG 100 BOT   2 Generic $10.00$0.00None
LOXAPINE CAPSULES 5MG 100 BOT   2 Generic $10.00$0.00None
LUMIGAN 0.01% EYE DROPS   3 Preferred Brand $40.00$105.00None
LUPRON DEPOT 11.25 MG 3MO KIT   5 Specialty Tier 33%33%P
LUPRON DEPOT 22.5 MG 3MO KIT SYRINGEKIT   5 Specialty Tier 33%33%P
LUPRON DEPOT 3.75 MG KIT   5 Specialty Tier 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LUPRON DEPOT 45 MG 6MO KIT   5 Specialty Tier 33%33%P
LUPRON DEPOT 7.5 MG KIT   5 Specialty Tier 33%33%P
LUPRON DEPOT-4 MONTH KIT   5 Specialty Tier 33%33%P
LUTERA-28 TABLET   4 Non-Preferred Drug 40%40%None
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 $40.00$105.00Q:90
/30Days
LYRICA 150MG CAPSULE   3 Preferred Brand $40.00$105.00Q:90
/30Days
LYRICA 20 MG/ML ORAL SOLUTION   3 Preferred Brand $40.00$105.00Q:900
/30Days
LYRICA 200MG CAPSULE   3 Preferred Brand $40.00$105.00Q:90
/30Days
LYRICA 225MG CAPSULE   3 Preferred Brand $40.00$105.00Q: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 $40.00$105.00Q:90
/30Days
LYRICA 300MG CAPSULE   3 Preferred Brand $40.00$105.00Q:60
/30Days
LYRICA 50MG CAPSULE   3 Preferred Brand $40.00$105.00Q:90
/30Days
LYRICA 75MG CAPSULE   3 Preferred Brand $40.00$105.00Q:90
/30Days
LYSODREN 500MG TABLET   5 Specialty Tier 33%33%None
LYZA 0.35 MG TABLET   3 Preferred Brand $40.00$105.00None

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D AARP MedicareRx Preferred (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). 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.