.
.
.
. . .
. . .
Q1 Medicare.com Click to Enter Your Drugs and Compare Medicare Part D Plans
Powered by Q1Group LLC Powered by Q1Group LLC.
Education and Decision Support Tools for the Medicare Community
.
. . .
. . .
. . .
.
. Home Contact Us Enroll . .
. . MAPD PDP 2014 FAQ Blog
.
. . .
. . . . . . .
.
.
: : Compare 2013 Medicare Rx and Health Plans by Drug Costs
: : See 2013 Medicare Drug Plans
: : 2013 Medicare Advantage Plans
: : Browse Any 2013 Plan Formulary
: : Compare a Drug's Coverage Across All 2013 Drug Plans
: : Newsletter Sign-up
. . . .
Special Features
Find a 2013 Part D Plan (Rx Only)
Find a 2013 Medicare Advantage Plan (Health and Health w/Rx Plans)
Browse Any 2013 Medicare Plan Formulary (or Drug List) Updated!
Find a 2013 Medicare Part D or Medicare Advantage Plan by Drug
Compare Part D and Medicare Advantage Plans by Drug Costs
2013 National Plan Overview by State
PDP and MAPD Overview by State
PDP Overview by CMS Region
Medicare Part D
Medicare Part D - Blog
Enrollment Tips
2013 Medicare Part D Plan Information
2014 Medicare Part D Outlook
Medicare.gov Tutorial
The Basics of Medicare Part D
The Donut Hole and Beyond
How Part D Plans Work
Which Drugs are Covered?
Which Drugs are Excluded?
Understanding Your Explanation of Benefits
Formulary Exceptions
(Coverage Determinations),
Appeals & Grievances
Choosing a Plan: The Basics
Your Medicare Part D Checklist
Tips from CMS
Important Dates
The Late Enrollment Penalty
Out-of-Pocket Cost Estimator
After Enrollment into Part D
Financial "Extra Help"
Part D Scams - Watch Out!
Doughnut Hole Calculator
Medicare Advantage Plans
2013 Medicare Advantage Plan Benefit Details
Medicare Advantage Plans State Overview
Find a Medicare Advantage Plan by Drug Costs
Medicare Overview
Medicare & You Handbook
Guide to Rx Coverage
Plan Archives
2012 Medicare Part D Archive
2012 Medicare Part D Plan Information
2012 Medicare Part D Plans (PDP-Finder: Rx Only)
2012 Medicare Advantage Plans (Health and Health w/Rx Plans)
2012 Medicare Part D or Medicare Advantage Plan by Drug
Browse Any 2012 Medicare Plan Formulary (Drug List)
2012 Plan’s Retail Drug Price Details
2012 National Plan Overview by State
2012 PDP & MAPD Overview by State
2012 Overview by CMS PDP Region
Guided Help on 2012 Medicare Prescription Drug Plans
PDP-Compare: How will each 2011 Part D Plan Change in 2012?
MA-Compare: Review Changes in each 2011 Medicare Advantage Plan for 2012
Search for 2012 Medicare Plans by Plan ID
Search for 2012 Medicare Plans by Formulary ID
2012 Part D Plan Facts & Figures
2012 Part D Facts & Figures in Plain Text
2012 PDP-Planner & Donut Hole Calculator
2012 Cost Estimator
2011 Medicare Part D Archive
2010 Medicare Part D Archive
2009 Medicare Part D Archive
2008 Medicare Part D Archive
2007 Medicare Part D Archive
2006 Medicare Part D Archive
Pre-2010 Medicare.gov Tutorial
Support Center
Medicare.gov Tutorial


. .

2012 Medicare Part D and Medicare Advantage Plan Formulary Browser
. .
Search by   State & Plan   ZIP & Plan   PlanID   FormularyID .
Search Criteria
PlanType:* PDP     MAPD
State:*
Plan Family:*
Selected Plan:United American - Preferred (PDP) (S5755-025-0)
Browse Formulary by
First Letter of Drug Name:		   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 
  *required
: :Example: AARP MedicareRx Preferred (PDP) Formulary in Florida
 
: :Go to TX’s 2012 Plan Page for plan materials
: :Print Version
: :2012 Plan Finder
: :Compare 2011 & 2012 Plans
2012 Medicare Part D Plan Formulary Information
United American - Preferred (PDP) (S5755-025-0)          
The United American - Preferred (PDP) (S5755-025-0) Formulary for Drugs Starting with the Letter L
in CMS PDP Region 22 which includes: TX
Plan Monthly Premium: $55.20 Deductible: $110 Qualifies for LIS: No
Drugs Start 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
L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE 16 VACCINE 0.04 MG/ML / L1 PROTEIN, HUMAN PAPILLOMAVIRU   3 Preferred Brand Drugs $45.00 $90.00 P
L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE 16 VACCINE 0.04 MG/ML / L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE   3 Preferred Brand Drugs $45.00 $90.00 P
LABETALOL HCL 100MG TABLET   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LABETALOL HCL 200MG TABLET   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LABETALOL HCL 300MG TABLET   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LABETALOL HCL 5MG/20ML VIAL   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LACLOTION 12% LOTION   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LACRISERT OPTHALMIC INSERT 5MG 60 BLPK   3 Preferred Brand Drugs $45.00 $90.00 None
LACTATED RINGERS INJECTION   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT   2 Non-Preferred Generic Drugs $9.00 $21.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LAMICTAL ODT 100mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK   3 Preferred Brand Drugs $45.00 $90.00 None
LAMICTAL ODT 200mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK   3 Preferred Brand Drugs $45.00 $90.00 None
LAMICTAL ODT 25mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK   3 Preferred Brand Drugs $45.00 $90.00 None
LAMICTAL ODT 50mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK   3 Preferred Brand Drugs $45.00 $90.00 None
LAMICTAL XR 100 MG TABLET   3 Preferred Brand Drugs $45.00 $90.00 None
LAMICTAL XR 200 MG TABLET   3 Preferred Brand Drugs $45.00 $90.00 None
LAMICTAL XR 25 MG TABLET   3 Preferred Brand Drugs $45.00 $90.00 None
LAMICTAL XR 250mg/1 30 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE   3 Preferred Brand Drugs $45.00 $90.00 None
LAMICTAL XR 50 MG TABLET   3 Preferred Brand Drugs $45.00 $90.00 None
LAMICTAL XR START KIT (BLUE)   3 Preferred Brand Drugs $45.00 $90.00 None
LAMICTAL XR START KIT (GREEN)   3 Preferred Brand Drugs $45.00 $90.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LAMICTAL XR START KIT (ORANGE)   3 Preferred Brand Drugs $45.00 $90.00 None
LAMIVUDINE 150 MG TABLET   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LAMIVUDINE 300 MG TABLET   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LAMIVUDINE-ZIDOVUDINE TABLET   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LAMOTRIGINE 150MG TABLET (60 CT)   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LAMOTRIGINE 200MG TABLET (60 CT)   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LAMOTRIGINE 25MG TABLET (100 CT)   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LAMOTRIGINE 25MG TABLET DISPERSIBLE   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LAMOTRIGINE 5MG TABLET DISPERSIBLE   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LAMOTRIGINE TABLET 100MG (100 CT)   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LANOXIN 0.125MG TABLET   3 Preferred Brand Drugs $45.00 $90.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LANOXIN 0.25MG TABLET   3 Preferred Brand Drugs $45.00 $90.00 None
LANOXIN 250ug/mL 10 AMPULE in 1 BOX / 2 mL in 1 AMPULE   3 Preferred Brand Drugs $45.00 $90.00 None
LANOXIN PED 0.1MG/ML AMPUL   3 Preferred Brand Drugs $45.00 $90.00 None
LANREOTIDE 240 MG/ML PREFILLED SYRINGE [SOMATULINE]   5 Specialty Tier Drugs 30% 30% None
lansoprazole 15mg/1 10 BLISTER PACK in 1 CARTON / 10 TABLET, ORALLY DISINTEGRATING, DELAYED RELEASE   2 Non-Preferred Generic Drugs $9.00 $21.00 Q:180/90Days
Lansoprazole 15mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $9.00 $21.00 Q:180/90Days
lansoprazole 30mg/1 10 BLISTER PACK in 1 CARTON / 10 TABLET, ORALLY DISINTEGRATING, DELAYED RELEASE   2 Non-Preferred Generic Drugs $9.00 $21.00 Q:180/90Days
Lansoprazole 30mg/1 30 CAPSULE, DELAYED RELEASE in 1 BOTTLE   2 Non-Preferred Generic Drugs $9.00 $21.00 Q:180/90Days
LANTUS 100U/ML VIAL   3 Preferred Brand Drugs $45.00 $90.00 Q:30/30Days
LANTUS SOLOSTAR INJECTION   3 Preferred Brand Drugs $45.00 $90.00 Q:30/30Days
LATANOPROST OPHTHALMIC SOLUTION .005%   2 Non-Preferred Generic Drugs $9.00 $21.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LATUDA 20 MG TABLET   3 Preferred Brand Drugs $45.00 $90.00 None
Latuda 40mg/1   3 Preferred Brand Drugs $45.00 $90.00 Q:180/90Days
Latuda 80mg/1   3 Preferred Brand Drugs $45.00 $90.00 Q:90/90Days
LEENA 7-9-5 TABLET   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEFLUNOMIDE 10MG TABLET   2 Non-Preferred Generic Drugs $9.00 $21.00 Q:90/90Days
LEFLUNOMIDE TABLETS   2 Non-Preferred Generic Drugs $9.00 $21.00 Q:102/90Days
Lessina 3 POUCH in 1 CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER PACK   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LETAIRIS 10MG TABLET   5 Specialty Tier Drugs 30% 30% P Q:90/90Days
LETAIRIS 5MG TABLET   5 Specialty Tier Drugs 30% 30% P Q:90/90Days
Letrozole 2.5mg/1 500 TABLET, FILM COATED in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEUCOVORIN CALCIUM 100MG VL   2 Non-Preferred Generic Drugs $9.00 $21.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LEUCOVORIN CALCIUM 10MG TABLET   3 Preferred Brand Drugs $45.00 $90.00 None
Leucovorin Calcium 15mg/1 24 TABLET in 1 BOTTLE   3 Preferred Brand Drugs $45.00 $90.00 None
LEUCOVORIN CALCIUM 25MG TABLET   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEUCOVORIN CALCIUM 350MG VL   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEUCOVORIN CALCIUM 5MG TABLET   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEUKERAN 2MG TABLET   3 Preferred Brand Drugs $45.00 $90.00 None
LEUKINE 500 MCG/ML   5 Specialty Tier Drugs 30% 30% P
LEUKINE INJECTION 250 MCG/ML   5 Specialty Tier Drugs 30% 30% P
LEUPROLIDE ACETATE INJECTION   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEVAQUIN 250mg/1 10 BLISTER PACK in 1 CARTON / 10 TABLET, FILM COATED in 1 BLISTER PACK   4 Non-Preferred Brand Drugs $95.00 $190.00 None
LEVAQUIN 25mg/mL 480 mL in 1 BOTTLE   4 Non-Preferred Brand Drugs $95.00 $190.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LEVAQUIN 500mg/1 50 TABLET, FILM COATED in 1 BOTTLE   4 Non-Preferred Brand Drugs $95.00 $190.00 None
LEVAQUIN 750 MG TABLET   4 Non-Preferred Brand Drugs $95.00 $190.00 None
LEVAQUIN INJECTION 25 MG/ML   4 Non-Preferred Brand Drugs $95.00 $190.00 None
LEVAQUIN INJECTION 5 MG/ML   4 Non-Preferred Brand Drugs $95.00 $190.00 None
LEVEMIR 100UNITS/ML VIAL   3 Preferred Brand Drugs $45.00 $90.00 None
Levemir 14.2mg/mL 5 SYRINGE, PLASTIC in 1 CARTON / 3 mL in 1 SYRINGE, PLASTIC   3 Preferred Brand Drugs $45.00 $90.00 None
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEVETIRACETAM 500 MG TABLET 120 BOT   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEVETIRACETAM ER 500 MG TABLET   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEVETIRACETAM ER 750 MG TABLET   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEVETIRACETAM INJECTION   2 Non-Preferred Generic Drugs $9.00 $21.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LEVETIRACETAM TABLETS 1000MG 60 BOT   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEVETIRACETAM TABLETS 250MG 500 BOT   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEVETIRACETAM TABLETS 750MG 500 BOT   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEVOBUNOLOL 0.25% EYE DROPS   1 Preferred Generic Drugs $3.00 $0.00 None
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEVOCARNITINE 100MG/ML SOLUTION ORAL   2 Non-Preferred Generic Drugs $9.00 $21.00 P
LEVOCARNITINE TABLET 330MG 90 BLPK   2 Non-Preferred Generic Drugs $9.00 $21.00 P
LEVOCETIRIZINE 2.5 MG/5 ML SOL   2 Non-Preferred Generic Drugs $9.00 $21.00 None
Levocetirizine dihydrochloride 5mg/1 30 TABLET in 1 BOTTLE   2 Non-Preferred Generic Drugs $9.00 $21.00 Q:90/90Days
Levofloxacin 250mg/1   2 Non-Preferred Generic Drugs $9.00 $21.00 None
Levofloxacin 25mg/mL 1 BOTTLE in 1 CARTON / 100 mL in 1 BOTTLE   2 Non-Preferred Generic Drugs $9.00 $21.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Levofloxacin 25mg/mL 1 VIAL in 1 CARTON / 30 mL in 1 VIAL   2 Non-Preferred Generic Drugs $9.00 $21.00 None
Levofloxacin 500mg/1   2 Non-Preferred Generic Drugs $9.00 $21.00 None
Levofloxacin 5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER   2 Non-Preferred Generic Drugs $9.00 $21.00 None
Levofloxacin 5mg/mL 24 POUCH in 1 CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG   2 Non-Preferred Generic Drugs $9.00 $21.00 None
Levofloxacin 750mg/1   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEVORA-28 TABLET 0.15/30   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEVORPHANOL TARTRATE 2mg/1 100 TABLET in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT)   1 Preferred Generic Drugs $3.00 $0.00 None
LEVOTHYROXINE SODIUM .150MG TABLET (100 CT)   1 Preferred Generic Drugs $3.00 $0.00 None
LEVOTHYROXINE SODIUM 100MCG TABLET   1 Preferred Generic Drugs $3.00 $0.00 None
LEVOTHYROXINE SODIUM 112MCG TABLET   1 Preferred Generic Drugs $3.00 $0.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LEVOTHYROXINE SODIUM 125MCG TABLET   1 Preferred Generic Drugs $3.00 $0.00 None
LEVOTHYROXINE SODIUM 137MCG TABLET   1 Preferred Generic Drugs $3.00 $0.00 None
LEVOTHYROXINE SODIUM 175MCG TABLET   1 Preferred Generic Drugs $3.00 $0.00 None
LEVOTHYROXINE SODIUM 200MCG TABLET   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEVOTHYROXINE SODIUM 25MCG TABLET   1 Preferred Generic Drugs $3.00 $0.00 None
LEVOTHYROXINE SODIUM 300MCG TABLET   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEVOTHYROXINE SODIUM 50MCG TABLET   1 Preferred Generic Drugs $3.00 $0.00 None
LEVOTHYROXINE SODIUM 88MCG TABLET   1 Preferred Generic Drugs $3.00 $0.00 None
LEVOXYL 100MCG TABLET (1000 CT)   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEVOXYL 112MCG TABLET (1000 CT)   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEVOXYL 125MCG TABLET (1000 CT)   2 Non-Preferred Generic Drugs $9.00 $21.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LEVOXYL 137MCG TABLET (1000 CT)   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEVOXYL 150MCG TABLET (1000 CT)   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEVOXYL 175MCG TABLET (1000 CT)   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEVOXYL 200MCG TABLET (1000 CT)   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEVOXYL 25MCG TABLET (1000 CT)   1 Preferred Generic Drugs $3.00 $0.00 None
LEVOXYL 50MCG TABLET (1000 CT)   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEVOXYL 75MCG TABLET (1000 CT)   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEVOXYL 88MCG TABLET (1000 CT)   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LEXAPRO 10MG TABLET   3 Preferred Brand Drugs $45.00 $90.00 Q:90/90Days
LEXAPRO 20MG TABLET   3 Preferred Brand Drugs $45.00 $90.00 Q:90/90Days
LEXAPRO 5MG TABLET   3 Preferred Brand Drugs $45.00 $90.00 Q:90/90Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LEXAPRO 5MG/5ML SOLUTION   3 Preferred Brand Drugs $45.00 $90.00 None
LEXIVA 50mg/mL 225 mL in 1 BOTTLE   3 Preferred Brand Drugs $45.00 $90.00 None
LEXIVA TABLETS   5 Specialty Tier Drugs 30% 30% None
LIALDA 1.2G TABLET DELAYED RELEASE   3 Preferred Brand Drugs $45.00 $90.00 None
LIDOCAINE 5% OINTMENT   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LIDOCAINE HCL 0.5% VIAL   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LIDOCAINE HCL 1% VIAL   2 Non-Preferred Generic Drugs $9.00 $21.00 None
lidocaine hcl 2% jelly   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LIDOCAINE HCL 2% JELLY 30ML TUBE   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT   2 Non-Preferred Generic Drugs $9.00 $21.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LIDODERM 5% PATCH   3 Preferred Brand Drugs $45.00 $90.00 P
Lindane 10mg/mL   2 Non-Preferred Generic Drugs $9.00 $21.00 Q:1800/365Days
LINDANE SHAMPOO 1MG 2 FLO BOT   2 Non-Preferred Generic Drugs $9.00 $21.00 Q:1800/365Days
Lioresal 0.05mg/mL   3 Preferred Brand Drugs $45.00 $90.00 P
Lioresal 0.5mg/mL   3 Preferred Brand Drugs $45.00 $90.00 P
Lioresal 2mg/mL   3 Preferred Brand Drugs $45.00 $90.00 P
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LIPOFEN CAPSULES   3 Preferred Brand Drugs $45.00 $90.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LIPOSYN II 10% IV FAT EMUL   3 Preferred Brand Drugs $45.00 $90.00 None
Liposyn III 1.2; 2.5; 10g/100mL; g/100mL; g/100mL 12 BOTTLE, GLASS in 1 CASE / 250 mL in 1 BOTTLE,   3 Preferred Brand Drugs $45.00 $90.00 None
LIPOSYN III 30% IV FAT EMUL   3 Preferred Brand Drugs $45.00 $90.00 None
LISINOPRIL 10MG TABLET (100 CT)   1 Preferred Generic Drugs $3.00 $0.00 None
Lisinopril 2.5mg 100 TABLET BOTTLE   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LISINOPRIL 20MG TABLET   1 Preferred Generic Drugs $3.00 $0.00 None
LISINOPRIL 30MG TABLET (100 CT)   1 Preferred Generic Drugs $3.00 $0.00 None
LISINOPRIL 40MG TABLET (500 CT)   2 Non-Preferred Generic Drugs $9.00 $21.00 None
Lisinopril 5mg/1 1000 TABLET in 1 BOTTLE   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LISINOPRIL-HCTZ 10/12.5 TABLET   1 Preferred Generic Drugs $3.00 $0.00 Q:90/90Days
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT)   2 Non-Preferred Generic Drugs $9.00 $21.00 Q:360/90Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LISINOPRIL-HCTZ 20/12.5 TABLET   2 Non-Preferred Generic Drugs $9.00 $21.00 Q:90/90Days
LITHIUM CARBONATE 150MG CAPSULE   1 Preferred Generic Drugs $3.00 $0.00 None
LITHIUM CARBONATE 300MG CAPSULE (100 CT)   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LITHIUM CARBONATE 300MG TABLET   2 Non-Preferred Generic Drugs $9.00 $21.00 None
Lithium Carbonate 450mg/1   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LITHIUM CARBONATE CAPSULES   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LITHIUM CARBONATE ER TABLET 300MG (100 CT)   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LITHIUM CIT 8MEQ/5ML SYRUP   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LOCOID LOTN 0.1 %   3 Preferred Brand Drugs $45.00 $90.00 None
LODOSYN TAB 25MG   3 Preferred Brand Drugs $45.00 $90.00 None
LOPERAMIDE HCL 2MG CAPSULE   2 Non-Preferred Generic Drugs $9.00 $21.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LOSARTAN POTASSIUM 100 MG TAB   2 Non-Preferred Generic Drugs $9.00 $21.00 Q:90/90Days
LOSARTAN POTASSIUM 25 MG TAB   2 Non-Preferred Generic Drugs $9.00 $21.00 Q:180/90Days
LOSARTAN POTASSIUM 50 MG TAB   2 Non-Preferred Generic Drugs $9.00 $21.00 Q:180/90Days
LOSARTAN-HCTZ 100-12.5 MG TAB   2 Non-Preferred Generic Drugs $9.00 $21.00 Q:90/90Days
LOSARTAN-HCTZ 100-25 MG TAB   2 Non-Preferred Generic Drugs $9.00 $21.00 Q:90/90Days
LOSARTAN-HCTZ 50-12.5 MG TAB   2 Non-Preferred Generic Drugs $9.00 $21.00 Q:180/90Days
LOTEMAX 0.5% EYE DROPS   3 Preferred Brand Drugs $45.00 $90.00 None
Lotemax 5mg/g 1 TUBE in 1 CARTON / 3.5 g in 1 TUBE   3 Preferred Brand Drugs $45.00 $90.00 None
LOTRONEX TABLETS .5MG 30 BOTPL   3 Preferred Brand Drugs $45.00 $90.00 Q:180/90Days
LOTRONEX TABLETS 1MG 30 BOTPL   3 Preferred Brand Drugs $45.00 $90.00 Q:180/90Days
Lovastatin 10mg 60 TABLET BOTTLE   2 Non-Preferred Generic Drugs $9.00 $21.00 Q:90/90Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Lovastatin 20mg 500 TABLET BOTTLE   2 Non-Preferred Generic Drugs $9.00 $21.00 Q:180/90Days
LOVASTATIN 40 MG ORAL TABLET   2 Non-Preferred Generic Drugs $9.00 $21.00 Q:180/90Days
LOVAZA 1g/ 120 LIQUID FILLED CAPSULES in BOTTLE   3 Preferred Brand Drugs $45.00 $90.00 None
LOVENOX 300MG VIAL   3 Preferred Brand Drugs $45.00 $90.00 None
LOW-OGESTREL-28 TABLET   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LOXAPINE 25MG CAPSULE (100 CT)   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LOXAPINE CAPSULES 10MG 100 BOT   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LOXAPINE CAPSULES 50MG 100 BOT   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LOXAPINE CAPSULES 5MG 100 BOT   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LUMIGAN 0.03% EYE DROPS   3 Preferred Brand Drugs $45.00 $90.00 None
LUMIGAN 0.1mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER   3 Preferred Brand Drugs $45.00 $90.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LUNESTA 2MG TABLET   4 Non-Preferred Brand Drugs $95.00 $190.00 None
LUNESTA 3MG TABLET   4 Non-Preferred Brand Drugs $95.00 $190.00 None
LUNESTA TABLETS 1MG 30 BOT   4 Non-Preferred Brand Drugs $95.00 $190.00 None
Lupron Depot 1 KIT in 1 CARTON   5 Specialty Tier Drugs 30% 30% None
LUPRON DEPOT 11.25 MG 3MO KIT   5 Specialty Tier Drugs 30% 30% None
LUPRON DEPOT 22.5 MG 3MO KIT [LUPRON]   5 Specialty Tier Drugs 30% 30% None
LUPRON DEPOT 3.75 MG KIT   3 Preferred Brand Drugs $45.00 $90.00 None
LUPRON DEPOT 7.5 MG KIT   5 Specialty Tier Drugs 30% 30% None
LUPRON DEPOT-4 MONTH KIT   5 Specialty Tier Drugs 30% 30% None
LUPRON DEPOT-PED 11.25 MG KIT   5 Specialty Tier Drugs 30% 30% None
LUPRON DEPOT-PED 15 MG KIT   5 Specialty Tier Drugs 30% 30% None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LUTERA 0.1-0.02 TABLET   2 Non-Preferred Generic Drugs $9.00 $21.00 None
LUXIQ 0.12% FOAM   3 Preferred Brand Drugs $45.00 $90.00 None
LYRICA 100MG CAPSULE   3 Preferred Brand Drugs $45.00 $90.00 Q:270/90Days
LYRICA 150MG CAPSULE   3 Preferred Brand Drugs $45.00 $90.00 Q:270/90Days
LYRICA 200MG CAPSULE   3 Preferred Brand Drugs $45.00 $90.00 Q:270/90Days
LYRICA 225MG CAPSULE   3 Preferred Brand Drugs $45.00 $90.00 Q:180/90Days
LYRICA 25MG CAPSULE   3 Preferred Brand Drugs $45.00 $90.00 Q:270/90Days
LYRICA 300MG CAPSULE   3 Preferred Brand Drugs $45.00 $90.00 Q:180/90Days
LYRICA 50MG CAPSULE   3 Preferred Brand Drugs $45.00 $90.00 Q:270/90Days
LYRICA 75MG CAPSULE   3 Preferred Brand Drugs $45.00 $90.00 Q:270/90Days
LYSODREN 500MG TABLET   3 Preferred Brand Drugs $45.00 $90.00 None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
LYSTEDA TABLETS   4 Non-Preferred Brand Drugs $95.00 $190.00 Q:120/90Days



What does all this mean? Here are a few notes to help you understand the above 2012 Medicare Part D United American - 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).
  • 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 the standard $320 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 wit 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 four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
    • Drug 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 which tier the drug is in. 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 $2930) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2012 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
    • 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 2012 )

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.



Click the +1 button if you have found this page useful:  

.
.
Medicare Supplements
fill the gaps in your
Original Medicare
1. Select Your State:
.


.
.

.
Medicare PartD MAPD and PDP plan comparisons .
Quick Links
: : Find a 2013 Plan by Drug Costs
: : 2013 Part D Plan Facts & Figures
: : 2013 Part D PDP-Finder (Drug Only) Plan Finder
: : Compare 2012/2013 PDP Plans
: : 2013 MA-Finder: Medicare Advantage Plan Finder
: : Compare 2012/2013 Medicare Advantage Plans
: : Guided Help Finding a 2013 Prescription Drug Plan
: : 2013 Part D Drug Finder
: : Browse Any 2013 Part D Plan Formulary
: : 2013 Browse Drugs By Letter
: : RxSavings-Center
: : 2014 Plan Information Reminder Service
.

: : Click here to link to this page on your website
.

    Follow Q1Medicare on Twitter
.

   
. . .
. . .
.
.
What’s New Most Viewed Press . .
.
. . .
.
Sitemap About Us Privacy Policy Newsletter Sign-up Blog FAQ Contact Us Terms Of Use Newsroom
. Enroll in Medicare Part D © Q1Group LLC 2005 - 2013 . .
. . .
. . .
.
.
. .

.
.
.