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2023 Medicare Part D and Medicare Advantage Plan Formulary Browser

This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
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Blue Rx Standard (PDP) (S3375-001-0)
Tier 1 (64)
Tier 2 (398)
Tier 3 (1092)
Tier 4 (935)
Tier 5 (486)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
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Has Quantity Limits:
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  *required
 
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 
2023 Medicare Part D Plan Formulary Information
Blue Rx Standard (PDP) (S3375-001-0)
Benefit Details           
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less.
Call drug plan for more details.
The Blue Rx Standard (PDP) (S3375-001-0)
Formulary Drugs Starting with the Letter L

in CMS PDP Region 3 which includes: NY
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   3 Preferred Brand $46.00$138.00None
LABETALOL HCL 200 MG TABLET [Trandate]   3 Preferred Brand $46.00$138.00None
LABETALOL HCL 300 MG TABLET [Trandate]   3 Preferred Brand $46.00$138.00None
LACOSAMIDE 10 MG/ML SOLUTION [Vimpat]   4 Non-Preferred Drug 40%40%Q:1200
/30Days
LACOSAMIDE 100 MG TABLET [Vimpat]   4 Non-Preferred Drug 40%40%Q:60
/30Days
LACOSAMIDE 150 MG TABLET [Vimpat]   4 Non-Preferred Drug 40%40%Q:60
/30Days
LACOSAMIDE 200 MG TABLET [Vimpat]   4 Non-Preferred Drug 40%40%Q:60
/30Days
LACOSAMIDE 50 MG TABLET [Vimpat]   4 Non-Preferred Drug 40%40%Q:60
/30Days
LACTULOSE 10 GM/15 ML SOLUTION [Generlac]   2* Generic $1.00$3.00None
LAMIVUDINE 10 MG/ML ORAL SOLUTION [Epivir]   3 Preferred Brand $46.00$138.00Q:960
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LAMIVUDINE 150 MG TABLET [Epivir]   3 Preferred Brand $46.00$138.00Q:60
/30Days
LAMIVUDINE 300 MG TABLET [Epivir]   4 Non-Preferred Drug 40%40%Q:30
/30Days
LAMIVUDINE HBV 100 MG TABLET [Epivir HBV]   3 Preferred Brand $46.00$138.00None
LAMIVUDINE-ZIDOVUDINE TABLET [Combivir]   4 Non-Preferred Drug 40%40%Q:60
/30Days
LAMOTRIGINE 100 MG TABLET [Subvenite]   2* Generic $1.00$3.00None
LAMOTRIGINE 150 MG TABLET [Subvenite]   2* Generic $1.00$3.00None
LAMOTRIGINE 200 MG TABLET [Subvenite]   2* Generic $1.00$3.00None
LAMOTRIGINE 25 MG DISPER TABLET CHEWABLE [Lamictal CD]   3 Preferred Brand $46.00$138.00None
LAMOTRIGINE 25 MG TABLET [Subvenite]   2* Generic $1.00$3.00None
LAMOTRIGINE 5 MG DISPER TABLET CHEWABLE [Lamictal CD]   3 Preferred Brand $46.00$138.00None
LANSOPRAZOLE DR 15 MG CAPSULE DR [Prevacid]   3 Preferred Brand $46.00$138.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LANSOPRAZOLE DR 30 MG CAPSULE DR [Prevacid]   3 Preferred Brand $46.00$138.00Q:30
/30Days
LANTUS 100U/ML VIAL   3 Preferred Brand $35 max*$138.00None
LANTUS SOLOSTAR INJECTION   3 Preferred Brand $35 max*$138.00None
LAPATINIB 250 MG TABLET [Tykerb]   5 Specialty Tier 25%N/AP Q:180
/30Days
LARIN 1.5 MG-30 MCG TABLET   3 Preferred Brand $46.00$138.00None
LARIN 21 1-20 TABLET   3 Preferred Brand $46.00$138.00None
LARIN FE 1-20 TABLET   3 Preferred Brand $46.00$138.00None
LARIN FE 1.5-30 TABLET   3 Preferred Brand $46.00$138.00None
LATANOPROST 0.005% EYE DROPS   2* Generic $1.00$3.00None
LATUDA 120 MG TABLET   4 Non-Preferred Drug 40%40%Q:30
/30Days
LATUDA 20 MG TABLET   4 Non-Preferred Drug 40%40%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 Drug 40%40%Q:30
/30Days
LATUDA 60 MG TABLET   4 Non-Preferred Drug 40%40%Q:30
/30Days
LATUDA 80 MG TABLET   4 Non-Preferred Drug 40%40%Q:60
/30Days
LEENA 28 TABLET [Tri-Norinyl]   3 Preferred Brand $46.00$138.00None
LEFLUNOMIDE 10 MG TABLET [Arava]   4 Non-Preferred Drug 40%40%None
LEFLUNOMIDE 20 MG TABLET [Arava]   3 Preferred Brand $46.00$138.00None
LENALIDOMIDE 10 MG CAPSULE [Revlimid]   5 Specialty Tier 25%N/AP Q:60
/30Days
LENALIDOMIDE 15 MG CAPSULE [Revlimid]   5 Specialty Tier 25%N/AP Q:30
/30Days
LENALIDOMIDE 2.5 MG CAPSULE [Revlimid]   5 Specialty Tier 25%N/AP Q:30
/30Days
LENALIDOMIDE 20 MG CAPSULE [Revlimid]   5 Specialty Tier 25%N/AP Q:30
/30Days
LENALIDOMIDE 25 MG CAPSULE [Revlimid]   5 Specialty Tier 25%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LENALIDOMIDE 5 MG CAPSULE [Revlimid]   5 Specialty Tier 25%N/AP Q:150
/30Days
LENVIMA 10 MG DAILY DOSE   5 Specialty Tier 25%N/AP Q:30
/30Days
LENVIMA 12 MG DAILY DOSE CAPSULE   5 Specialty Tier 25%N/AP Q:90
/30Days
LENVIMA 14 MG DAILY DOSE   5 Specialty Tier 25%N/AP Q:60
/30Days
LENVIMA 18 MG DAILY DOSE   5 Specialty Tier 25%N/AP Q:90
/30Days
LENVIMA 20 MG DAILY DOSE   5 Specialty Tier 25%N/AP Q:60
/30Days
LENVIMA 24 MG DAILY DOSE   5 Specialty Tier 25%N/AP Q:90
/30Days
LENVIMA 4 MG CAPSULE   5 Specialty Tier 25%N/AP Q:30
/30Days
LENVIMA 8 MG DAILY DOSE   5 Specialty Tier 25%N/AP Q:60
/30Days
Lessina 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK   3 Preferred Brand $46.00$138.00None
LETROZOLE 2.5 MG TABLET [Femara]   3 Preferred Brand $46.00$138.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEUCOVORIN CALCIUM 10MG TABLET   4 Non-Preferred Drug 40%40%None
LEUCOVORIN CALCIUM 15MG 24 TABLET BOTTLE   4 Non-Preferred Drug 40%40%None
LEUCOVORIN CALCIUM 25 MG TABLET   4 Non-Preferred Drug 40%40%None
LEUCOVORIN CALCIUM 5 MG TABLET   3 Preferred Brand $46.00$138.00None
LEUKERAN 2 MG TABLET   4 Non-Preferred Drug 40%40%None
LEUPROLIDE 2WK 14 MG/2.8 ML KT   4 Non-Preferred Drug 40%40%P
LEUPROLIDE DEPOT 22.5 MG VIAL   4 Non-Preferred Drug 40%40%P
LEVETIRACETAM 1,000 MG TABLET [Keppra]   3 Preferred Brand $46.00$138.00None
LEVETIRACETAM 100 MG/ML SOLUTION [Keppra]   3 Preferred Brand $46.00$138.00None
LEVETIRACETAM 250 MG TABLET [Keppra]   3 Preferred Brand $46.00$138.00None
LEVETIRACETAM 500 MG TABLET [Roweepra]   3 Preferred Brand $46.00$138.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVETIRACETAM 750 MG TABLET [Keppra]   3 Preferred Brand $46.00$138.00None
LEVOBUNOLOL 0.5% EYE DROPS [Betagan]   2* Generic $1.00$3.00None
LEVOCARNITINE 1 G/10 ML SOLUTION [Carnitor]   4 Non-Preferred Drug 40%40%P
LEVOCARNITINE 330 MG TABLET [Carnitor]   4 Non-Preferred Drug 40%40%P
LEVOCETIRIZINE 5 MG TABLET [Xyzal Allergy 24 Hour]   2* Generic $1.00$3.00None
LEVOFLOXACIN 25 MG/ML SOLUTION [Levaquin]   4 Non-Preferred Drug 40%40%None
LEVOFLOXACIN 250 MG TABLET [LEVAQUIN]   2* Generic $1.00$3.00None
LEVOFLOXACIN 500 MG TABLET [Levaquin]   2* Generic $1.00$3.00None
LEVOFLOXACIN 500 MG/100 ML-D5W PIGGYBACK [Levaquin]   4 Non-Preferred Drug 40%40%None
LEVOFLOXACIN 750 MG TABLET [Levaquin Leva-Pak]   2* Generic $1.00$3.00None
LEVOFLOXACIN 750 MG/150 ML-D5W PIGGYBACK [Levaquin]   4 Non-Preferred Drug 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVONEST-28 TABLET   3 Preferred Brand $46.00$138.00None
LEVONOR-ETH ESTRAD 0.1-0.02 MG TABLET [Vienva]   3 Preferred Brand $46.00$138.00None
LEVONOR-ETH ESTRAD 0.15-0.03   3 Preferred Brand $46.00$138.00None
LEVONOR-ETH ESTRAD 0.15-0.03   3 Preferred Brand $46.00$138.00None
LEVONOR-ETH ESTRAD TRIPHASIC TABLET [Trivora]   3 Preferred Brand $46.00$138.00None
LEVORA-28 TABLET   3 Preferred Brand $46.00$138.00None
LEVOTHYROXINE 100 MCG TABLET   4 Non-Preferred Drug 40%40%None
LEVOTHYROXINE 112 MCG TABLET   4 Non-Preferred Drug 40%40%None
LEVOTHYROXINE 125 MCG TABLET [Unithroid]   4 Non-Preferred Drug 40%40%None
LEVOTHYROXINE 137 MCG TABLET   4 Non-Preferred Drug 40%40%None
LEVOTHYROXINE 150 MCG TABLET   4 Non-Preferred Drug 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVOTHYROXINE 175 MCG TABLET   4 Non-Preferred Drug 40%40%None
LEVOTHYROXINE 200 MCG TABLET [Unithroid]   4 Non-Preferred Drug 40%40%None
LEVOTHYROXINE 25 MCG TABLET   4 Non-Preferred Drug 40%40%None
LEVOTHYROXINE 300 MCG TABLET [Unithroid]   4 Non-Preferred Drug 40%40%None
LEVOTHYROXINE 50 MCG TABLET   4 Non-Preferred Drug 40%40%None
LEVOTHYROXINE 75 MCG TABLET   4 Non-Preferred Drug 40%40%None
LEVOTHYROXINE 88 MCG TABLET   4 Non-Preferred Drug 40%40%None
LEVOXYL 100 MCG TABLET   4 Non-Preferred Drug 40%40%None
LEVOXYL 112 MCG TABLET   4 Non-Preferred Drug 40%40%None
LEVOXYL 125 MCG TABLET   4 Non-Preferred Drug 40%40%None
LEVOXYL 137 MCG TABLET   4 Non-Preferred Drug 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVOXYL 150 MCG TABLET   4 Non-Preferred Drug 40%40%None
LEVOXYL 175 MCG TABLET   4 Non-Preferred Drug 40%40%None
LEVOXYL 200 MCG TABLET   4 Non-Preferred Drug 40%40%None
LEVOXYL 25 MCG TABLET   4 Non-Preferred Drug 40%40%None
LEVOXYL 50 MCG TABLET   4 Non-Preferred Drug 40%40%None
LEVOXYL 75 MCG TABLET   4 Non-Preferred Drug 40%40%None
LEVOXYL 88 MCG TABLET   4 Non-Preferred Drug 40%40%None
LEXIVA 50mg/mL 225 mL in 1 BOTTLE   4 Non-Preferred Drug 40%40%Q:1800
/30Days
LIDOCAINE 2% VISCOUS SOLUTION [Xylocaine Viscous]   2* Generic $1.00$3.00None
LIDOCAINE 5% PATCH [Lidoderm]   4 Non-Preferred Drug 40%40%P Q:90
/30Days
LIDOCAINE HCL 4% SOLUTION [Xylocaine]   3 Preferred Brand $46.00$138.00P Q:300
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LIDOCAINE-PRILOCAINE CREAM (G) [SOLUPICC]   3 Preferred Brand $46.00$138.00Q:30
/30Days
LINEZOLID 100 MG/5 ML ORAL SUSPENSION [Zyvox Powder]   4 Non-Preferred Drug 40%40%P Q:1800
/30Days
LINEZOLID 600 MG TABLET [Zyvox]   4 Non-Preferred Drug 40%40%P Q:56
/28Days
LINEZOLID 600 MG/300 ML-D5W PIGGYBACK [Zyvox]   4 Non-Preferred Drug 40%40%None
LINZESS 145 MCG CAPSULE   4 Non-Preferred Drug 40%40%Q:30
/30Days
LINZESS 290 MCG CAPSULE   4 Non-Preferred Drug 40%40%Q:30
/30Days
LINZESS 72 MCG CAPSULE   4 Non-Preferred Drug 40%40%Q:30
/30Days
LIOTHYRONINE SOD 25 MCG TABLET [Cytomel]   3 Preferred Brand $46.00$138.00None
LIOTHYRONINE SOD 5 MCG TABLET [Cytomel]   3 Preferred Brand $46.00$138.00None
LIOTHYRONINE SOD 50 MCG TABLET [Cytomel]   3 Preferred Brand $46.00$138.00None
LISINOPRIL 10 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
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 [Zestril]   1* Preferred Generic $0.00$0.00None
LISINOPRIL 5 MG TABLET   1* Preferred Generic $0.00$0.00None
LISINOPRIL-HCTZ 10-12.5 MG TABLET   1* Preferred Generic $0.00$0.00None
LISINOPRIL-HCTZ 20-12.5 MG TABLET   1* Preferred Generic $0.00$0.00None
LISINOPRIL-HCTZ 20-25 MG TABLET   1* Preferred Generic $0.00$0.00None
LITHIUM CARBONATE 150 MG CAPSULE CAPSULE   2* Generic $1.00$3.00None
LITHIUM CARBONATE 300 MG CAPSULE [Eskalith]   2* Generic $1.00$3.00None
LITHIUM CARBONATE 300 MG TABLET   2* Generic $1.00$3.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LITHIUM CARBONATE 600 MG CAPSULE   2* Generic $1.00$3.00None
LITHIUM CARBONATE ER 300 MG TABLET   2* Generic $1.00$3.00None
LITHIUM CARBONATE ER 450 MG TABLET [Eskalith CR]   2* Generic $1.00$3.00None
LOESTRIN 21 1.5/30 TABLET   3 Preferred Brand $46.00$138.00None
LOESTRIN 21 1/20 TABLET   3 Preferred Brand $46.00$138.00None
LOESTRIN FE 1.5/30 TABLET   3 Preferred Brand $46.00$138.00None
LOESTRIN FE 1/20 TABLET   3 Preferred Brand $46.00$138.00None
LOKELMA 10 GRAM POWDER PACKET   3 Preferred Brand $46.00$138.00None
LOKELMA 5 GRAM POWDER PACKET   3 Preferred Brand $46.00$138.00None
LONSURF 15 MG-6.14 MG TABLET   5 Specialty Tier 25%N/AP
LONSURF 20 MG-8.19 MG TABLET   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LOPERAMIDE 2 MG CAPSULE   3 Preferred Brand $46.00$138.00None
LOPINAVIR-RITONAVIR 80-20MG/ML Solution [Kaletra]   4 Non-Preferred Drug 40%40%Q:480
/30Days
LOPINAVIR-RITONAVR 100-25MG TABLET [Kaletra]   4 Non-Preferred Drug 40%40%Q:300
/30Days
LOPINAVIR-RITONAVR 200-50MG TABLET [Kaletra]   5 Specialty Tier 25%N/AQ:120
/30Days
LORAZEPAM 0.5 MG TABLET [Ativan]   2* Generic $1.00$3.00Q:90
/30Days
LORAZEPAM 1 MG TABLET [Ativan]   2* Generic $1.00$3.00Q:90
/30Days
LORAZEPAM 2 MG TABLET [Ativan]   2* Generic $1.00$3.00Q:150
/30Days
LORAZEPAM INTENSOL 2 MG/ML ORAL CONC   4 Non-Preferred Drug 40%40%Q:150
/30Days
LORBRENA 100 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
LORBRENA 25 MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
LORYNA 3 MG-0.02 MG TABLET [Yaz]   3 Preferred Brand $46.00$138.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LOSARTAN POTASSIUM 100 MG TABLET [Cozaar]   2* Generic $1.00$3.00None
LOSARTAN POTASSIUM 25 MG TABLET [Cozaar]   2* Generic $1.00$3.00None
LOSARTAN POTASSIUM 50 MG TABLET [Cozaar]   2* Generic $1.00$3.00None
LOSARTAN-HCTZ 100-12.5 MG TABLET [Hyzaar]   2* Generic $1.00$3.00None
LOSARTAN-HCTZ 100-25 MG TABLET [Hyzaar]   2* Generic $1.00$3.00None
LOSARTAN-HCTZ 50-12.5 MG TABLET [Hyzaar]   2* Generic $1.00$3.00None
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 [Mevacor]   1* Preferred Generic $0.00$0.00None
LOW-OGESTREL-28 TABLET [Low-Ogestrel]   3 Preferred Brand $46.00$138.00None
LOXAPINE 10 MG CAPSULE [Loxitane]   3 Preferred Brand $46.00$138.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LOXAPINE 25 MG CAPSULE [Loxitane]   3 Preferred Brand $46.00$138.00None
LOXAPINE 5 MG CAPSULE [Loxitane]   3 Preferred Brand $46.00$138.00None
LOXAPINE 50 MG CAPSULE [Loxitane]   3 Preferred Brand $46.00$138.00None
LUMAKRAS 120 MG TABLET   5 Specialty Tier 25%N/AP Q:240
/30Days
LUMAKRAS 320 MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
LUMIGAN 0.01% EYE DROPS   3 Preferred Brand $46.00$138.00None
LUPRON DEPOT 3.75 MG KIT   5 Specialty Tier 25%N/AP Q:1
/28Days
LUPRON DEPOT 7.5 MG KIT   5 Specialty Tier 25%N/AP Q:1
/28Days
LUPRON DEPOT-PED 7.5 MG KIT   5 Specialty Tier 25%N/AP Q:1
/28Days
LURASIDONE HCL 120 MG TABLET [Latuda]   4 Non-Preferred Drug 40%40%Q:30
/30Days
LURASIDONE HCL 20 MG TABLET [Latuda]   4 Non-Preferred Drug 40%40%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LURASIDONE HCL 40 MG TABLET [Latuda]   4 Non-Preferred Drug 40%40%Q:30
/30Days
LURASIDONE HCL 60 MG TABLET [Latuda]   4 Non-Preferred Drug 40%40%Q:30
/30Days
LURASIDONE HCL 80 MG TABLET [Latuda]   4 Non-Preferred Drug 40%40%Q:60
/30Days
LUTERA-28 TABLET   3 Preferred Brand $46.00$138.00None
LYBALVI 10-10 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
LYBALVI 15-10 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
LYBALVI 20-10 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
LYBALVI 5-10 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
LYLEQ 0.35 MG TABLET [Sharobel 28-Day]   3 Preferred Brand $46.00$138.00None
LYLLANA 0.025 MG PATCH TDSW [Vivelle-Dot]   3 Preferred Brand $46.00$138.00P Q:8
/28Days
LYLLANA 0.0375 MG PATCH TDSW [Vivelle-Dot]   3 Preferred Brand $46.00$138.00P Q:8
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LYLLANA 0.05 MG PATCH TDSW [Vivelle-Dot]   3 Preferred Brand $46.00$138.00P Q:8
/28Days
LYLLANA 0.075 MG PATCH TDSW [Vivelle-Dot]   3 Preferred Brand $46.00$138.00P Q:8
/28Days
LYLLANA 0.1 MG PATCH TDSW [Vivelle-Dot]   3 Preferred Brand $46.00$138.00P Q:8
/28Days
LYNPARZA 100 MG TABLET   5 Specialty Tier 25%N/AP Q:120
/30Days
LYNPARZA 150 MG TABLET   5 Specialty Tier 25%N/AP Q:120
/30Days
LYSODREN 500 MG TABLET   3 Preferred Brand $46.00$138.00None
LYTGOBI 12 MG DOSE (3X 4MG TB) TABLET   5 Specialty Tier 25%N/AP
LYTGOBI 16 MG DOSE (4X 4MG TB) TABLET   5 Specialty Tier 25%N/AP
LYTGOBI 20 MG DOSE (5X 4MG TB) TABLET   5 Specialty Tier 25%N/AP
LYUMJEV 100 UNIT/ML KWIKPEN INSULN PEN   3 Preferred Brand $35 max*$138.00None
LYUMJEV 100 UNIT/ML VIAL   3 Preferred Brand $35 max*$138.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LYUMJEV 200 UNIT/ML KWIKPEN INSULN PEN   3 Preferred Brand $35 max*$138.00None
LYZA 0.35 MG TABLET   3 Preferred Brand $46.00$138.00None

Chart Legend:

Below are a few notes to help you understand the above 2023 Medicare Part D Blue Rx Standard (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 $505 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 $4,660) 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.

      *All forms of insulin covered by any Medicare Part D plan will have a copay of $35 or less through all phases of coverage. 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 2023)

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.







Tips & Disclaimers
  • Q1Medicare®, Q1Rx®, and Q1Group® are registered Service Marks of Q1Group LLC and may not be used in any advertising, publicity, or for commercial purposes without the express authorization of Q1Group.
  • 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 PDPCompare.com and MACompare.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.
    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • 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.