Q1Medicare.com 2021 Medicare Part D or Medicare Advantage Plan Formulary Browser

2021 Medicare Part D Plan Formulary Information
WPS MedicareRx Plan 1 (PDP) (S5753-006-0) Benefit Details
The WPS MedicareRx Plan 1 (PDP) (S5753-006-0) Formulary Drugs Starting with the Letter L in CMS PDP Region 16 which includes: WI Plan Monthly Premium: $79.30 Deductible: $445 Qualifies for LIS: No
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 100 MG TABLET	2	Generic	$15.00	$37.50	None
LABETALOL HCL 200 MG TABLET [Trandate]	2	Generic	$15.00	$37.50	None
LABETALOL HCL 300 MG TABLET [Trandate]	2	Generic	$15.00	$37.50	None
LACTULOSE 10 GM/15 ML SOLUTION [Constulose]	2	Generic	$15.00	$37.50	None
LAMIVUDINE 10 MG/ML ORAL SOLUTION [Epivir]	2	Generic	$15.00	$37.50	None
LAMIVUDINE 150 MG TABLET [Epivir]	2	Generic	$15.00	$37.50	None
LAMIVUDINE 300 MG TABLET [Epivir]	2	Generic	$15.00	$37.50	None
LAMIVUDINE HBV 100 MG TABLET [Epivir HBV]	2	Generic	$15.00	$37.50	None
LAMIVUDINE-ZIDOVUDINE TABLET [Combivir]	2	Generic	$15.00	$37.50	None
LAMOTRIGINE 100 MG TABLET [Subvenite]	1	Preferred Generic	$3.00	$7.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LAMOTRIGINE 150 MG TABLET [Subvenite]	1	Preferred Generic	$3.00	$7.50	None
LAMOTRIGINE 200 MG TABLET [Subvenite]	1	Preferred Generic	$3.00	$7.50	None
LAMOTRIGINE 25 MG DISPER TABLET CHW [Lamictal CD]	2	Generic	$15.00	$37.50	None
LAMOTRIGINE 25 MG TABLET [Subvenite]	1	Preferred Generic	$3.00	$7.50	None
LAMOTRIGINE 5 MG DISPER TABLET CHW [Lamictal CD]	2	Generic	$15.00	$37.50	None
LAMOTRIGINE ER 100 MG TABLET ER 24 [Lamictal XR]	4	Non-Preferred Drug	49%	49%	None
LAMOTRIGINE ER 200 MG TABLET	4	Non-Preferred Drug	49%	49%	None
LAMOTRIGINE ER 25 MG TABLET ER 24 [Lamictal XR]	4	Non-Preferred Drug	49%	49%	None
LAMOTRIGINE ER 250 MG TABLET	4	Non-Preferred Drug	49%	49%	None
LAMOTRIGINE ER 300 MG TABLET ER 24 [Lamictal XR]	4	Non-Preferred Drug	49%	49%	None
LAMOTRIGINE ER 50 MG TABLET ER 24 [Lamictal XR]	4	Non-Preferred Drug	49%	49%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LAMOTRIGINE ODT 100 MG TABLET RAPDIS [Lamictal ODT]	4	Non-Preferred Drug	49%	49%	None
LAMOTRIGINE ODT 200 MG TABLET RAPDIS [Lamictal ODT]	4	Non-Preferred Drug	49%	49%	None
LAMOTRIGINE ODT 25 MG TABLET	4	Non-Preferred Drug	49%	49%	None
LAMOTRIGINE ODT 50 MG TABLET RAPDIS [Lamictal ODT]	4	Non-Preferred Drug	49%	49%	None
LAMOTRIGINE ODT KIT (ORANGE) TB RD DSPK [Lamictal ODT]	2	Generic	$15.00	$37.50	None
LAMOTRIGINE START KIT-BLUE TABLET DS PK [Subvenite]	2	Generic	$15.00	$37.50	None
LAMOTRIGINE START KIT-GREEN TABLET DS PK [Subvenite]	2	Generic	$15.00	$37.50	None
LAMOTRIGINE START KIT-ORANG TABLET DS PK [Subvenite]	2	Generic	$15.00	$37.50	None
LANOXIN 62.5 MCG TABLET	3	Preferred Brand	$42.00	$105.00	None
LANSOPRAZOLE DR 15 MG CAPSULE DR [Prevacid]	2	Generic	$15.00	$37.50	Q:30 /30Days
LANSOPRAZOLE DR 30 MG CAPSULE DR [Prevacid]	2	Generic	$15.00	$37.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LANTHANUM CARB 1,000 MG CHEWABLE TABLET [Fosrenol]	4	Non-Preferred Drug	49%	49%	None
LANTHANUM CARB 500 MG TABLET CHEW [Fosrenol]	4	Non-Preferred Drug	49%	49%	None
LANTHANUM CARB 750 MG TABLET CHEW [Fosrenol]	4	Non-Preferred Drug	49%	49%	None
LANTUS 100U/ML VIAL	3	Preferred Brand	$42.00	$105.00	None
LANTUS SOLOSTAR INJECTION	3	Preferred Brand	$42.00	$105.00	None
LAPATINIB 250 MG TABLET [Tykerb]	5	Specialty Tier	25%	N/A	P Q:180 /30Days
LARIN 1.5 MG-30 MCG TABLET	2	Generic	$15.00	$37.50	None
LARIN 21 1-20 TABLET	2	Generic	$15.00	$37.50	None
LARIN FE 1-20 TABLET	2	Generic	$15.00	$37.50	None
LARIN FE 1.5-30 TABLET	2	Generic	$15.00	$37.50	None
LARISSIA-28 TABLET [Vienva]	2	Generic	$15.00	$37.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LATANOPROST 0.005% EYE DROPS	2	Generic	$15.00	$37.50	None
LATUDA 120 MG TABLET	5	Specialty Tier	25%	N/A	Q:30 /30Days
LATUDA 20 MG TABLET	5	Specialty Tier	25%	N/A	Q:30 /30Days
LATUDA 40 MG TABLET	5	Specialty Tier	25%	N/A	Q:30 /30Days
LATUDA 60 MG TABLET	5	Specialty Tier	25%	N/A	Q:30 /30Days
LATUDA 80 MG TABLET	5	Specialty Tier	25%	N/A	Q:60 /30Days
LEFLUNOMIDE 10 MG TABLET [Arava]	2	Generic	$15.00	$37.50	Q:30 /30Days
LEFLUNOMIDE 20 MG TABLET [Arava]	2	Generic	$15.00	$37.50	Q:30 /30Days
LENVIMA 10 MG DAILY DOSE	5	Specialty Tier	25%	N/A	P
LENVIMA 12 MG DAILY DOSE CAPSULE	5	Specialty Tier	25%	N/A	P
LENVIMA 14 MG DAILY DOSE	5	Specialty Tier	25%	N/A	P
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/A	P
LENVIMA 20 MG DAILY DOSE	5	Specialty Tier	25%	N/A	P
LENVIMA 24 MG DAILY DOSE	5	Specialty Tier	25%	N/A	P
LENVIMA 4 MG CAPSULE	5	Specialty Tier	25%	N/A	P
LENVIMA 8 MG DAILY DOSE	5	Specialty Tier	25%	N/A	P
Lessina 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK	2	Generic	$15.00	$37.50	None
LETROZOLE 2.5 MG TABLET [Femara]	2	Generic	$15.00	$37.50	None
LEUCOVORIN CALCIUM 10MG TABLET	2	Generic	$15.00	$37.50	None
LEUCOVORIN CALCIUM 15MG 24 TABLET BOTTLE	2	Generic	$15.00	$37.50	None
LEUCOVORIN CALCIUM 25 MG TABLET	2	Generic	$15.00	$37.50	None
LEUCOVORIN CALCIUM 5 MG TABLET	2	Generic	$15.00	$37.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LEUKERAN 2 MG TABLET	3	Preferred Brand	$42.00	$105.00	None
LEUKINE 250 MCG VIAL	5	Specialty Tier	25%	N/A	P
LEUPROLIDE 2WK 14 MG/2.8 ML KT	5	Specialty Tier	25%	N/A	P
LEVALBUTEROL 0.31 MG/3 ML SOL VIAL-NEB [Xopenex Pediatric]	2	Generic	$15.00	$37.50	P
LEVALBUTEROL 0.63 MG/3 ML SOL VIAL-NEB [Xopenex]	2	Generic	$15.00	$37.50	P
LEVALBUTEROL 1.25 MG/0.5 ML	2	Generic	$15.00	$37.50	P
LEVALBUTEROL 1.25 MG/3 ML SOL VIAL-NEB [Xopenex]	2	Generic	$15.00	$37.50	P
LEVETIRACETAM 1,000 MG TABLET	2	Generic	$15.00	$37.50	None
LEVETIRACETAM 100 MG/ML SOLUTION [Keppra]	2	Generic	$15.00	$37.50	None
LEVETIRACETAM 250 MG TABLET [Keppra]	2	Generic	$15.00	$37.50	None
LEVETIRACETAM 500 MG TABLET [Roweepra]	2	Generic	$15.00	$37.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LEVETIRACETAM 750 MG TABLET [Keppra]	2	Generic	$15.00	$37.50	None
LEVETIRACETAM ER 500 MG TABLET ER 24H [Roweepra]	2	Generic	$15.00	$37.50	None
LEVETIRACETAM ER 750 MG TABLET ER 24H [Roweepra]	2	Generic	$15.00	$37.50	None
LEVO-T 100 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVO-T 112 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVO-T 125 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVO-T 137 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVO-T 150 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVO-T 175 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVO-T 200 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVO-T 25 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LEVO-T 300 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVO-T 50 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVO-T 75 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVO-T 88 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVOBUNOLOL 0.5% EYE DROPS [Betagan]	2	Generic	$15.00	$37.50	None
LEVOCARNITINE 1 G/10 ML SOLUTION	2	Generic	$15.00	$37.50	None
LEVOCARNITINE 330 MG TABLET	2	Generic	$15.00	$37.50	None
LEVOCETIRIZINE 2.5 MG/5 ML SOLUTION	2	Generic	$15.00	$37.50	None
LEVOCETIRIZINE 5 MG TABLET [Xyzal Allergy 24 Hour]	2	Generic	$15.00	$37.50	Q:30 /30Days
LEVOFLOXACIN 0.5% EYE DROPS [LEVAQUIN]	2	Generic	$15.00	$37.50	None
LEVOFLOXACIN 25 MG/ML SOLUTION [LEVAQUIN]	2	Generic	$15.00	$37.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LEVOFLOXACIN 250 MG TABLET [LEVAQUIN]	2	Generic	$15.00	$37.50	None
LEVOFLOXACIN 500 MG TABLET [Levaquin]	2	Generic	$15.00	$37.50	None
LEVOFLOXACIN 500 MG/100 ML-D5W PIGGYBACK [Levaquin]	2	Generic	$15.00	$37.50	P
LEVOFLOXACIN 500 MG/20 ML VIAL [Levaquin]	2	Generic	$15.00	$37.50	P
LEVOFLOXACIN 750 MG TABLET [Levaquin Leva-Pak]	2	Generic	$15.00	$37.50	None
LEVOFLOXACIN 750 MG/150 ML-D5W PIGGYBACK [Levaquin]	2	Generic	$15.00	$37.50	P
LEVONEST-28 TABLET	2	Generic	$15.00	$37.50	None
LEVONO-E ESTRAD 0.10-0.02-0.01 TBDSPK 3MO [LoSeasonique]	2	Generic	$15.00	$37.50	None
LEVONOR-ETH ESTRAD 0.09-0.02 MG	2	Generic	$15.00	$37.50	None
LEVONOR-ETH ESTRAD 0.1-0.02 MG Tablet [Vienva]	2	Generic	$15.00	$37.50	None
LEVONOR-ETH ESTRAD 0.15-0.03	2	Generic	$15.00	$37.50	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	2	Generic	$15.00	$37.50	None
Levonor-eth Estrad 0.15-0.03-0.01	2	Generic	$15.00	$37.50	None
LEVONOR-ETH ESTRAD TRIPHASIC TABLET [Trivora]	2	Generic	$15.00	$37.50	None
LEVONORG 0.15MG-EE 20-25-30MCG	2	Generic	$15.00	$37.50	None
Levora-28 tablet	2	Generic	$15.00	$37.50	None
LEVORPHANOL 2 MG TABLET	5	Specialty Tier	25%	N/A	Q:120 /30Days
LEVOTHYROXINE 100 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVOTHYROXINE 112 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVOTHYROXINE 125 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVOTHYROXINE 137 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVOTHYROXINE 150 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LEVOTHYROXINE 175 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVOTHYROXINE 200 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVOTHYROXINE 25 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVOTHYROXINE 300 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVOTHYROXINE 50 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVOTHYROXINE 75 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVOTHYROXINE 88 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVOXYL 100 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVOXYL 112 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVOXYL 125 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVOXYL 137 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LEVOXYL 150 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVOXYL 175 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVOXYL 200 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVOXYL 25 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVOXYL 50 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVOXYL 75 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEVOXYL 88 MCG TABLET	1	Preferred Generic	$3.00	$7.50	None
LEXIVA 50mg/mL 225 mL in 1 BOTTLE	4	Non-Preferred Drug	49%	49%	None
LIDOCAINE 2% VISCOUS SOLUTION	2	Generic	$15.00	$37.50	None
LIDOCAINE 5% OINTMENT	4	Non-Preferred Drug	49%	49%	Q:36 /30Days
LIDOCAINE 5% PATCH [Lidoderm]	2	Generic	$15.00	$37.50	P Q:90 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LIDOCAINE HCL IV 4% SOLUTION	2	Generic	$15.00	$37.50	None
LIDOCAINE-PRILOCAINE CREAM (g) [SOLUPICC]	2	Generic	$15.00	$37.50	Q:30 /30Days
LINDANE SHAMPOO 1MG 2 FLO BOTTLE	2	Generic	$15.00	$37.50	None
LINEZOLID 100 MG/5 ML ORAL SUSPENSION [Zyvox]	5	Specialty Tier	25%	N/A	None
LINEZOLID 600 MG TABLET [Zyvox]	2	Generic	$15.00	$37.50	None
LINEZOLID 600 MG/300 ML-D5W PIGGYBACK [Zyvox]	5	Specialty Tier	25%	N/A	P
LIOTHYRONINE SOD 25 MCG TABLET [Cytomel]	2	Generic	$15.00	$37.50	None
LIOTHYRONINE SOD 5 MCG TABLET [Cytomel]	2	Generic	$15.00	$37.50	None
LIOTHYRONINE SOD 50 MCG TABLET [Cytomel]	2	Generic	$15.00	$37.50	None
LISINOPRIL 10 MG TABLET	1	Preferred Generic	$3.00	$7.50	None
LISINOPRIL 2.5 MG TABLET	1	Preferred Generic	$3.00	$7.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LISINOPRIL 20 MG TABLET	1	Preferred Generic	$3.00	$7.50	None
LISINOPRIL 30 MG TABLET	1	Preferred Generic	$3.00	$7.50	None
LISINOPRIL 40 MG TABLET	1	Preferred Generic	$3.00	$7.50	None
LISINOPRIL 5 MG TABLET	1	Preferred Generic	$3.00	$7.50	None
LISINOPRIL-HCTZ 10-12.5 MG TABLET	1	Preferred Generic	$3.00	$7.50	None
LISINOPRIL-HCTZ 20-12.5 MG TABLET	1	Preferred Generic	$3.00	$7.50	None
LISINOPRIL-HCTZ 20-25 MG TABLET	1	Preferred Generic	$3.00	$7.50	None
LITHIUM CARBONATE 150 MG CAPSULE	1	Preferred Generic	$3.00	$7.50	None
LITHIUM CARBONATE 300 MG CAPSULE [Eskalith]	1	Preferred Generic	$3.00	$7.50	None
LITHIUM CARBONATE 300 MG TABLET	1	Preferred Generic	$3.00	$7.50	None
LITHIUM CARBONATE 600 MG CAPSULE	1	Preferred Generic	$3.00	$7.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LITHIUM CARBONATE ER 300 MG TABLET	1	Preferred Generic	$3.00	$7.50	None
LITHIUM CARBONATE ER 450 MG TABLET [Eskalith CR]	1	Preferred Generic	$3.00	$7.50	None
LITHIUM CIT 8MEQ/5ML SYRUP	2	Generic	$15.00	$37.50	None
LOKELMA 10 GRAM POWDER PACKET	3	Preferred Brand	$42.00	$105.00	None
LOKELMA 5 GRAM POWDER PACKET	3	Preferred Brand	$42.00	$105.00	None
LONSURF 15 MG-6.14 MG TABLET	5	Specialty Tier	25%	N/A	P
LONSURF 20 MG-8.19 MG TABLET	5	Specialty Tier	25%	N/A	P
LOPERAMIDE 2 MG CAPSULE	2	Generic	$15.00	$37.50	None
LOPINAVIR-RITONAVIR 80-20MG/ML Solution [Kaletra]	2	Generic	$15.00	$37.50	None
LORAZEPAM 0.5 MG TABLET	2	Generic	$15.00	$37.50	P Q:90 /30Days
LORAZEPAM 1 MG TABLET	2	Generic	$15.00	$37.50	P Q:90 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LORAZEPAM 2 MG TABLET	2	Generic	$15.00	$37.50	P Q:150 /30Days
LORAZEPAM INTENSOL 2 MG/ML ORAL CONC	2	Generic	$15.00	$37.50	P Q:150 /30Days
LORBRENA 100 MG TABLET	5	Specialty Tier	25%	N/A	P Q:30 /30Days
LORBRENA 25 MG TABLET	5	Specialty Tier	25%	N/A	P Q:90 /30Days
LORYNA 3 MG-0.02 MG TABLET [Yaz]	2	Generic	$15.00	$37.50	None
LOSARTAN POTASSIUM 100 MG TABLET	1	Preferred Generic	$3.00	$7.50	None
LOSARTAN POTASSIUM 25 MG TABLET [Cozaar]	1	Preferred Generic	$3.00	$7.50	None
LOSARTAN POTASSIUM 50 MG TABLET	1	Preferred Generic	$3.00	$7.50	None
LOSARTAN-HCTZ 100-12.5 MG TABLET [Hyzaar]	1	Preferred Generic	$3.00	$7.50	None
LOSARTAN-HCTZ 100-25 MG TABLET [Hyzaar]	1	Preferred Generic	$3.00	$7.50	None
LOSARTAN-HCTZ 50-12.5 MG TABLET [Hyzaar]	1	Preferred Generic	$3.00	$7.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LOTEPREDNOL 0.5% OPHTHALMC GEL DROPS [Lotemax]	3	Preferred Brand	$42.00	$105.00	None
LOTEPREDNOL ETABONATE 0.5% DRP EYE DROPPER [Lotemax]	2	Generic	$15.00	$37.50	None
LOVASTATIN 10 MG TABLET	1	Preferred Generic	$3.00	$7.50	Q:30 /30Days
LOVASTATIN 20 MG TABLET	1	Preferred Generic	$3.00	$7.50	Q:60 /30Days
LOVASTATIN 40 MG TABLET	1	Preferred Generic	$3.00	$7.50	Q:60 /30Days
LOW-OGESTREL-28 TABLET [Low-Ogestrel]	2	Generic	$15.00	$37.50	None
LOXAPINE 10 MG CAPSULE [Loxitane]	2	Generic	$15.00	$37.50	None
LOXAPINE 25 MG CAPSULE [Loxitane]	2	Generic	$15.00	$37.50	None
LOXAPINE 5 MG CAPSULE [Loxitane]	2	Generic	$15.00	$37.50	None
LOXAPINE 50 MG CAPSULE [Loxitane]	2	Generic	$15.00	$37.50	None
LUPRON DEPOT 11.25 MG 3MO KIT	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 22.5 MG 3MO KIT SYRINGEKIT	5	Specialty Tier	25%	N/A	P
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
LUTERA-28 TABLET	2	Generic	$15.00	$37.50	None
LYLLANA 0.025 MG PATCH TDSW [Vivelle-Dot]	2	Generic	$15.00	$37.50	P Q:8 /28Days
LYLLANA 0.0375 MG PATCH TDSW [Vivelle-Dot]	2	Generic	$15.00	$37.50	P Q:8 /28Days
LYLLANA 0.05 MG PATCH TDSW [Vivelle-Dot]	2	Generic	$15.00	$37.50	P Q:8 /28Days
LYLLANA 0.075 MG PATCH TDSW [Vivelle-Dot]	2	Generic	$15.00	$37.50	P Q:8 /28Days
LYLLANA 0.1 MG PATCH TDSW [Vivelle-Dot]	2	Generic	$15.00	$37.50	P Q:8 /28Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LYNPARZA 100 MG TABLET	5	Specialty Tier	25%	N/A	P Q:120 /30Days
LYNPARZA 150 MG TABLET	5	Specialty Tier	25%	N/A	P Q:120 /30Days
LYSODREN 500 MG TABLET	3	Preferred Brand	$42.00	$105.00	None
LYUMJEV 100 UNIT/ML KWIKPEN INSULN PEN	3	Preferred Brand	$42.00	$105.00	None
LYUMJEV 100 UNIT/ML VIAL	3	Preferred Brand	$42.00	$105.00	None
LYUMJEV 200 UNIT/ML KWIKPEN INSULN PEN	3	Preferred Brand	$42.00	$105.00	None
LYZA 0.35 MG TABLET	2	Generic	$15.00	$37.50	None

Chart Legend:

Below are a few notes to help you understand the above 2021 Medicare Part D WPS MedicareRx Plan 1 (PDP) Plan Formulary.

Plan Name: This is the official Medicare Part D prescription drug or Medicare Advantage 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 $445 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.
- Tier Number* - Some Part D drug plans exclude one or more drug tiers from the plan’s 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 - This is what you will pay for formulary drugs in 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 initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $4,130) 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.
  
  * When the insulin copay is in green, example: $35.00, this Part D plan may offer particular forms of insulin as part of the Senior Savings Model. The Senior Savings Model stipulates that some insulin will cost no more than $35 in the deductible, initial coverage, and coverage gap phases of your Part D plan. Please contact the drug plan for more details.
- 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 2021 )

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 Medicare plan provider.