2017 AARP MedicareRx Walgreens (PDP) Formulary



Below is the Formulary, or drug list, for AARP MedicareRx Walgreens (PDP) from Unitedhealthcare Ins. Co. And Unitedhealthcare Ny This formulary is a list of prescription medications that are covered under Unitedhealthcare Ins. Co. And Unitedhealthcare Ny's 2017 Part-D Plan. The AARP MedicareRx Walgreens (PDP) plan has a $400 drug deductible. This deductible is the amount of expenses that must be paid out of pocket before the Initial Coverage period begins. However some drugs do not require that the deductible is met before you receive coverage. You can see if the deductible is required below in the "Does the Deductible Apply" column. The Initial Coverage Limit (ICL) for this plan is $3700. The Initial Coverage Period is the period after the Deductible has been met but before the Coverage Gap phase. Once you and your plan provider have spent $3700 on covered drugs. (combined amount plus your deductible) You will enter the coverage gap. (AKA "donut hole") Once you reach the coverage gap you will be required to pay 45% of the plan's cost for covered brand-name prescription drugs unless your plan offers additional coverage. You can see if this plan offers coverage in the "donut hole" be clicking the "Coverage Gap" link on the left above the chart. In 2017 if you have spent $4700 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. AARP MedicareRx Walgreens (PDP) will begin paying approximately 95% of your covered medication expenses. You can see if this plan covers your drugs in the Catastrophic Phase by clicking the "Catastrophic" link on the left above the chart.

See More on AARP MedicareRx Walgreens (PDP)





Plan Name:
AARP MedicareRx Walgreens (PDP)
Plan ID:
S5921-383
Provider: Unitedhealthcare Ins. Co. And Unitedhealthcare Ny
Plan Year:2017
Premium:$22.50
Deductible:$400
Initial Coverage Limit:$3700
Coverage Area:Florida




Current Table info:


Coverage Level:
Initial Coverage
Days Supply:
30 Days
Drugs Starting With Letter: L

Change Table Options:


Drugs Starting Letter:
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 
Coverage Level:
Drug Days Pricing:60 Day
90 Day











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(Click the Drug Name to Compare every Plans Price)

Drug Name Drug Strength Units in Package Tier Level Amount Limit Days Limit Prior Authorization
Y/N
Step Therapy
Y/N
Does the Deduct Apply Cost Preferred Max Cost Non Preferred Max Cost Mail Max
Labetalol Hydrochloride 100mg 500 Tablet, Film Coated In 1 Bottle
2
N N N $3N$18NNAN
Labetalol Hydrochloride 200mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N $3N$18NNAN
Labetalol Hydrochloride 300mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N $3N$18NNAN
Labetalol Hydrochloride 5mg/mL 1 Vial, Multi-dose In 1 Box > 20 Ml In 1 Vial, Multi-dose
4
N N Y 32%N33%NNAN
Lactated Ringers .02; .03; .6; .31g/100mL; g/100mL; g/100mL; g/100mL 4 Container In 1 Case > 4000 Ml In 1 Container
3
N N Y $27N$47NNAN
Lactated Ringers 20; 30; 600; 310mg/100mL; mg/100mL; mg/100mL; mg/100mL 1000 Ml In 1 Bag
4
N N Y 32%N33%NNAN
Lactated Ringers And Dextrose 20; 5; 30; 600; 310mg/100mL; g/100mL; mg/100mL; mg/100mL; mg/100mL 1000 Ml In 1 Bag
4
N N Y 32%N33%NNAN
Lactulose 10g/15mL 946 Ml In 1 Bottle
2
N N N $3N$18NNAN
Lamisil 125mg 3 Carton In 1 Package
4
N N Y 32%N33%NNAN
Lamisil 187.5mg 14 Packet In 1 Carton
4
N N Y 32%N33%NNAN
Lamivudine 100mg 60 Tablet, Film Coated In 1 Bottle
3
N N Y $27N$47NNAN
Lamivudine 150mg 60 Tablet, Film Coated In 1 Bottle
3
90 30 N N Y $27N$47NNAN
Lamivudine 300mg 30 Tablet, Film Coated In 1 Bottle
3
60 30 N N Y $27N$47NNAN
Lamivudine And Zidovudine 150; 300mg/1; mg 60 Tablet, Film Coated In 1 Bottle
4
90 30 N N Y 32%N33%NNAN
Lamotrigine 25mg 100 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Lamotrigine 25mg 100 Tablet, Chewable In 1 Bottle
3
N N Y $27N$47NNAN
Lamotrigine 100mg 100 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Lamotrigine 5mg 100 Tablet, Chewable In 1 Bottle
3
N N Y $27N$47NNAN
Lamotrigine 150mg 60 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Lamotrigine 200mg 60 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Lanoxin .0625mg 100 Tablet In 1 Bottle
3
N N Y $27N$47NNAN
Lanoxin 1000 Tablet In 1 Bottle
3
N N Y $27N$47NNAN
Lanoxin 1000 Tablet In 1 Bottle
3
N N Y $27N$47NNAN
Lantus 100[iU]/mL 10 Ml In 1 Vial, Glass
3
N N Y $27N$47NNAN
Lantus Solostar 100[iU]/mL 5 Syringe In 1 Package > 3 Ml In 1 Syringe
3
N N Y $27N$47NNAN
Larin 1.5/30 1 Blister Pack In 1 Packet > 1 Kit In 1 Blister Pack
4
N N Y 32%N33%NNAN
Larin 1/20 1 Blister Pack In 1 Packet > 1 Kit In 1 Blister Pack
4
N N Y 32%N33%NNAN
Larin Fe 1.5/30 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
4
N N Y 32%N33%NNAN
Larin Fe 1/20 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
4
N N Y 32%N33%NNAN
Lastacaft 2.5mg/mL 1 Bottle, Plastic In 1 Carton > 3 Ml In 1 Bottle, Plastic
3
N N Y $27N$47NNAN
Latanoprost 50ug/mL 2.5 Ml In 1 Bottle
2
N N N $3N$18NNAN
Latuda 20mg 30 Tablet, Film Coated In 1 Bottle
5
30 30 N N Y 25%N25%NNAN
Latuda 40mg 10 Blister Pack In 1 Carton
5
30 30 N N Y 25%N25%NNAN
Latuda 60mg 30 Tablet, Film Coated In 1 Bottle
5
30 30 N N Y 25%N25%NNAN
Latuda 80mg 10 Blister Pack In 1 Carton
5
60 30 N N Y 25%N25%NNAN
Latuda 120mg 30 Tablet, Film Coated In 1 Bottle
5
30 30 N N Y 25%N25%NNAN
Leena 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
4
N N Y 32%N33%NNAN
Leflunomide 20mg 30 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Leflunomide 10mg 30 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Lessina 3 Pouch In 1 Carton > 1 Blister Pack In 1 Pouch > 1 Kit In 1 Blister Pack
4
N N Y 32%N33%NNAN
Letairis 5mg 3 Blister Pack In 1 Carton > 10 Tablet, Film Coated In 1 Blister Pack
5
30 30 Y N Y 25%N25%NNAN
Letairis 10mg 3 Blister Pack In 1 Carton > 10 Tablet, Film Coated In 1 Blister Pack
5
30 30 Y N Y 25%N25%NNAN
Letrozole 1000 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Leucovorin Calcium 5mg 30 Tablet In 1 Bottle
3
N N Y $27N$47NNAN
Leucovorin Calcium 10mg 24 Tablet In 1 Bottle
3
N N Y $27N$47NNAN
Leucovorin Calcium 15mg 24 Tablet In 1 Bottle
3
N N Y $27N$47NNAN
Leucovorin Calcium 25mg 25 Tablet In 1 Bottle
3
N N Y $27N$47NNAN
Leucovorin Calcium 100mg/10mL 1 Vial, Single-use In 1 Carton > 10 Ml In 1 Vial, Single-use
4
N N Y 32%N33%NNAN
Leucovorin Calcium 350mg/17.5mL 1 Vial, Single-use In 1 Carton > 17.5 Ml In 1 Vial, Single-use
4
N N Y 32%N33%NNAN
Leukeran 2mg 50 Tablet, Film Coated In 1 Bottle
3
N N Y $27N$47NNAN
Leukine 250ug/mL 5 Vial In 1 Carton
5
Y N Y 25%N25%NNAN
Levemir 14.2mg/mL 1 Vial, Glass In 1 Carton > 10 Ml In 1 Vial, Glass
3
N N Y $27N$47NNAN
Levemir 5 Syringe, Plastic In 1 Carton > 3 Ml In 1 Syringe, Plastic
3
N N Y $27N$47NNAN
Levetiracetam 250mg 500 Tablet, Film Coated In 1 Bottle, Plastic
3
N N Y $27N$47NNAN
Levetiracetam 500mg 120 Tablet, Film Coated In 1 Bottle, Plastic
3
N N Y $27N$47NNAN
Levetiracetam 750mg 500 Tablet, Film Coated In 1 Bottle, Plastic
3
N N Y $27N$47NNAN
Levetiracetam 473 Ml In 1 Bottle, Plastic
3
N N Y $27N$47NNAN
Levetiracetam 60 Tablet, Film Coated, Extended Release In 1 Bottle, Plastic
3
N N Y $27N$47NNAN
Levetiracetam 1000mg 60 Tablet In 1 Bottle
3
N N Y $27N$47NNAN
Levetiracetam 100mg/mL 10 Vial, Single-use In 1 Carton > 5 Ml In 1 Vial, Single-use
4
N N Y 32%N33%NNAN
Levetiracetam 10 Bag In 1 Carton
4
N N Y 32%N33%NNAN
Levetiracetam 10 Bag In 1 Carton
4
N N Y 32%N33%NNAN
Levetiracetam 10 Bag In 1 Carton
4
N N Y 32%N33%NNAN
Levetiracetam 60 Tablet, Extended Release In 1 Bottle
3
N N Y $27N$47NNAN
Levobunolol Hydrochloride 5mg/mL 1 Bottle, Dropper In 1 Carton > 5 Ml In 1 Bottle, Dropper
2
N N N $3N$18NNAN
Levocarnitine 330mg 9 Blister Pack In 1 Box > 10 Tablet In 1 Blister Pack
3
Y N Y $27N$47NNAN
Levocarnitine 1g/10mL 118 Ml In 1 Bottle, Plastic
3
Y N Y $27N$47NNAN
Levofloxacin 24 Pouch In 1 Carton > 1 Bag In 1 Pouch > 150 Ml In 1 Bag
4
N N Y 32%N33%NNAN
Levofloxacin 25mg/mL 1 Vial, Glass In 1 Carton > 20 Ml In 1 Vial, Glass
4
N N Y 32%N33%NNAN
Levofloxacin 5mg/mL 24 Pouch In 1 Carton > 1 Bag In 1 Pouch > 100 Ml In 1 Bag
4
N N Y 32%N33%NNAN
Levofloxacin 5mg/mL 1 Bottle, Dropper In 1 Carton > 5 Ml In 1 Bottle, Dropper
3
N N Y $27N$47NNAN
Levofloxacin 25mg/mL 1 Bottle In 1 Carton > 100 Ml In 1 Bottle
4
N N Y 32%N33%NNAN
Levofloxacin 250mg 100 Tablet, Film Coated In 1 Bottle
3
N N Y $27N$47NNAN
Levofloxacin 500mg 500 Tablet, Film Coated In 1 Bottle
3
N N Y $27N$47NNAN
Levofloxacin 750mg 100 Tablet, Film Coated In 1 Bottle
3
N N Y $27N$47NNAN
Levonest 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
4
N N Y 32%N33%NNAN
Levonorgestrel And Ethinyl Estradiol 3 Blister Pack In 1 Carton
4
N N Y 32%N33%NNAN
Levora 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
4
N N Y 32%N33%NNAN
Levothyroxine Sodium 25ug 100 Tablet In 1 Bottle, Plastic
1
N N N $0N$15NNAN
Levothyroxine Sodium 50ug 100 Tablet In 1 Bottle, Plastic
1
N N N $0N$15NNAN
Levothyroxine Sodium 88ug 100 Tablet In 1 Bottle, Plastic
1
N N N $0N$15NNAN
Levothyroxine Sodium 100ug 100 Tablet In 1 Bottle, Plastic
1
N N N $0N$15NNAN
Levothyroxine Sodium 112ug 100 Tablet In 1 Bottle, Plastic
1
N N N $0N$15NNAN
Levothyroxine Sodium 1000 Tablet In 1 Bottle, Plastic
1
N N N $0N$15NNAN
Levothyroxine Sodium 150ug 100 Tablet In 1 Bottle, Plastic
1
N N N $0N$15NNAN
Levothyroxine Sodium 1000 Tablet In 1 Bottle, Plastic
1
N N N $0N$15NNAN
Levothyroxine Sodium 200ug 100 Tablet In 1 Bottle, Plastic
1
N N N $0N$15NNAN
Levothyroxine Sodium 1000 Tablet In 1 Bottle, Plastic
1
N N N $0N$15NNAN
Levothyroxine Sodium 100 Tablet In 1 Bottle, Plastic
1
N N N $0N$15NNAN
Levothyroxine Sodium 100 Tablet In 1 Bottle, Plastic
1
N N N $0N$15NNAN
Levothyroxine Sodium 100ug/5mL 1 Vial, Single-use In 1 Carton > 5 Ml In 1 Vial, Single-use
5
N N Y 25%N25%NNAN
Levoxyl 25ug 100 Tablet In 1 Bottle
3
N N Y $27N$47NNAN
Levoxyl 1000 Tablet In 1 Bottle
3
N N Y $27N$47NNAN
Levoxyl 75ug 1000 Tablet In 1 Bottle
3
N N Y $27N$47NNAN
Levoxyl 1000 Tablet In 1 Bottle
3
N N Y $27N$47NNAN
Levoxyl 1000 Tablet In 1 Bottle
3
N N Y $27N$47NNAN
Levoxyl 1000 Tablet In 1 Bottle
3
N N Y $27N$47NNAN
Levoxyl 125ug 100 Tablet In 1 Bottle
3
N N Y $27N$47NNAN
Levoxyl 137ug 100 Tablet In 1 Bottle
3
N N Y $27N$47NNAN
Levoxyl 150ug 1000 Tablet In 1 Bottle
3
N N Y $27N$47NNAN
Levoxyl 100 Tablet In 1 Bottle
3
N N Y $27N$47NNAN
Levoxyl 200ug 100 Tablet In 1 Bottle
3
N N Y $27N$47NNAN
Lexiva 700mg 60 Tablet, Film Coated In 1 Bottle
5
180 30 N N Y 25%N25%NNAN
Lexiva 50mg/mL 225 Ml In 1 Bottle
4
2700 30 N N Y 32%N33%NNAN
Lialda 1.2g 120 Tablet, Delayed Release In 1 Bottle
3
120 30 N N Y $27N$47NNAN
Lidocaine 50mg/g 1 Tube In 1 Carton > 35.44 G In 1 Tube
4
N N Y 32%N33%NNAN
Lidocaine 20mg/mL 1 Tube, With Applicator In 1 Carton > 30 Ml In 1 Tube, With Applicator
2
N N N $3N$18NNAN
Lidocaine And Prilocaine 1 Tube In 1 Carton > 30 G In 1 Tube
3
N N Y $27N$47NNAN
Lidocaine Hydrochloride 20mg/mL 25 Vial, Multi-dose In 1 Tray > 20 Ml In 1 Vial, Multi-dose
4
Y N Y 32%N33%NNAN
Lidocaine Hydrochloride 5mg/mL 25 Vial, Single-dose In 1 Container > 50 Ml In 1 Vial, Single-dose
4
Y N Y 32%N33%NNAN
Lidocaine Hydrochloride 20mg/mL 100 Ml In 1 Bottle
2
N N N $3N$18NNAN
Lidocaine Hydrochloride 40mg/mL 50 Ml In 1 Bottle
2
N N N $3N$18NNAN
Lidocaine Hydrochloride 20mg/mL 25 Vial, Single-use In 1 Box > 5 Ml In 1 Vial, Single-use
2
N N N $3N$18NNAN
Lidocaine Hydrochloride 20mg/mL 25 Vial, Single-use In 1 Box > 10 Ml In 1 Vial, Single-use
2
N N N $3N$18NNAN
Lindane 10mg/mL 60 Ml In 1 Bottle, Glass
4
N N Y 32%N33%NNAN
Linzess 145ug 30 Capsule, Gelatin Coated In 1 Bottle
3
30 30 N N Y $27N$47NNAN
Linzess 290ug 30 Capsule, Gelatin Coated In 1 Bottle
3
30 30 N N Y $27N$47NNAN
Liothyronine Sodium 5ug 100 Tablet In 1 Bottle, Plastic
2
N N N $3N$18NNAN
Liothyronine Sodium 25ug 100 Tablet In 1 Bottle, Plastic
2
N N N $3N$18NNAN
Liothyronine Sodium 50ug 100 Tablet In 1 Bottle, Plastic
2
N N N $3N$18NNAN
Liothyronine Sodium 10ug/mL 1 Vial In 1 Carton > 1 Ml In 1 Vial
4
N N Y 32%N33%NNAN
Lisinopril 10mg 100 Tablet In 1 Bottle
1
60 30 N N N $0N$15NNAN
Lisinopril 2.5mg 100 Tablet In 1 Bottle, Plastic
1
60 30 N N N $0N$15NNAN
Lisinopril 20mg 1000 Tablet In 1 Bottle, Plastic
1
60 30 N N N $0N$15NNAN
Lisinopril 40mg 500 Tablet In 1 Bottle, Plastic
1
60 30 N N N $0N$15NNAN
Lisinopril 30mg 100 Tablet In 1 Bottle, Plastic
1
60 30 N N N $0N$15NNAN
Lisinopril 5mg 1000 Tablet In 1 Bottle
1
60 30 N N N $0N$15NNAN
Lisinopril And Hydrochlorothiazide 25; 20mg/1; mg 100 Tablet In 1 Bottle
1
60 30 N N N $0N$15NNAN
Lisinopril With Hydrochlorothiazide 12.5; 10mg/1; mg 100 Tablet In 1 Bottle, Plastic
1
30 30 N N N $0N$15NNAN
Lisinopril With Hydrochlorothiazide 12.5; 20mg/1; mg 100 Tablet In 1 Bottle, Plastic
1
120 30 N N N $0N$15NNAN
Lithium 8meq/5mL 500 Ml In 1 Bottle
3
N N Y $27N$47NNAN
Lithium Carbonate 300mg 100 Tablet, Extended Release In 1 Bottle, Plastic
2
N N N $3N$18NNAN
Lithium Carbonate 150mg 100 Capsule In 1 Bottle, Plastic
2
N N N $3N$18NNAN
Lithium Carbonate 300mg 100 Capsule In 1 Bottle, Plastic
2
N N N $3N$18NNAN
Lithium Carbonate 1000 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Lithium Carbonate 600mg 100 Capsule In 1 Bottle
2
N N N $3N$18NNAN
Lithium Carbonate 450mg 100 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Lomedia 24 Fe 3 Blister Pack In 1 Carton
4
N N Y 32%N33%NNAN
Loperamide Hydrochloride 2mg 100 Capsule In 1 Bottle
2
N N N $3N$18NNAN
Lorazepam 2mg/mL 30 Ml In 1 Bottle, Dropper
2
150 30 N N N $3N$18NNAN
Lorazepam 100 Tablet In 1 Bottle, Plastic
2
120 30 N N N $3N$18NNAN
Lorazepam 1mg 100 Tablet In 1 Bottle, Plastic
2
120 30 N N N $3N$18NNAN
Lorazepam 2mg 100 Tablet In 1 Bottle
2
150 30 N N N $3N$18NNAN
Lorcet 100 Tablet In 1 Bottle, Plastic
3
360 30 N N Y $27N$47NNAN
Lorcet Plus 100 Tablet In 1 Bottle, Plastic
3
360 30 N N Y $27N$47NNAN
Lortab 10/325 325; 10mg/1; mg 100 Tablet In 1 Bottle
3
360 30 N N Y $27N$47NNAN
Lortab 5/325 325; 5mg/1; mg 100 Tablet In 1 Bottle
3
360 30 N N Y $27N$47NNAN
Lortab 7.5/325 325; 7.5mg/1; mg 100 Tablet In 1 Bottle
3
360 30 N N Y $27N$47NNAN
Loryna 3 Carton In 1 Box > 1 Kit In 1 Carton
4
N N Y 32%N33%NNAN
Losartan Potassium 25mg 1000 Tablet, Film Coated In 1 Bottle
1
60 30 N N N $0N$15NNAN
Losartan Potassium 50mg 30 Tablet, Film Coated In 1 Bottle
1
60 30 N N N $0N$15NNAN
Losartan Potassium 100mg 90 Tablet, Film Coated In 1 Bottle
1
30 30 N N N $0N$15NNAN
Losartan Potassium And Hydrochlorothiazide 12.5; 50mg/1; mg 30 Tablet, Film Coated In 1 Bottle
1
60 30 N N N $0N$15NNAN
Losartan Potassium And Hydrochlorothiazide 25; 100mg/1; mg 30 Tablet, Film Coated In 1 Bottle
1
30 30 N N N $0N$15NNAN
Losartan Potassium And Hydrochlorothiazide 12.5; 100mg/1; mg 30 Tablet, Film Coated In 1 Bottle
1
30 30 N N N $0N$15NNAN
Lotemax 5mg/mL 1 Bottle In 1 Carton > 10 Ml In 1 Bottle
4
N N Y 32%N33%NNAN
Lotemax 5mg/g 1 Tube In 1 Carton > 3.5 G In 1 Tube
4
N N Y 32%N33%NNAN
Lotemax 5mg/g 5 G In 1 Bottle
4
N N Y 32%N33%NNAN
Lovastatin 100 Tablet In 1 Bottle
2
30 30 N N N $3N$18NNAN
Lovastatin 10mg 60 Tablet In 1 Bottle
2
30 30 N N N $3N$18NNAN
Lovastatin 40mg 100 Tablet In 1 Bottle
2
60 30 N N N $3N$18NNAN
Loxapine 25mg 100 Capsule In 1 Bottle, Plastic
2
N N N $3N$18NNAN
Loxapine 5mg 100 Capsule In 1 Bottle, Plastic
2
120 30 N N N $3N$18NNAN
Loxapine 10mg 100 Capsule In 1 Bottle, Plastic
2
120 30 N N N $3N$18NNAN
Loxapine 50mg 100 Capsule In 1 Bottle, Plastic
2
N N N $3N$18NNAN
Lumigan .1mg/mL 1 Bottle, Dropper In 1 Carton > 5 Ml In 1 Bottle, Dropper
3
N N Y $27N$47NNAN
Lumizyme 5mg/mL 1 Vial, Single-use In 1 Carton > 10.5 Ml In 1 Vial, Single-use
5
N N Y 25%N25%NNAN
Lupron Depot 1 Kit In 1 Carton * 1.5 Ml In 1 Syringe * 1 Swab In 1 Packet
5
Y N Y 25%N25%NNAN
Lupron Depot 1 Kit In 1 Carton * 1.5 Ml In 1 Syringe * 1 Swab In 1 Packet
5
Y N Y 25%N25%NNAN
Lupron Depot 1 Kit In 1 Carton * 1 Ml In 1 Syringe * 1 Ml In 1 Packet
5
Y N Y 25%N25%NNAN
Lupron Depot 1 Kit In 1 Carton * 1 Ml In 1 Syringe * 1 Swab In 1 Packet
5
Y N Y 25%N25%NNAN
Lupron Depot 1 Kit In 1 Carton * 1.5 Ml In 1 Syringe * 1 Ml In 1 Packet
5
Y N Y 25%N25%NNAN
Lupron Depot 1 Kit In 1 Carton * 1.5 Ml In 1 Syringe * 1 Swab In 1 Packet
5
Y N Y 25%N25%NNAN
Lupron Depot-ped 1 Kit In 1 Carton * 1 Ml In 1 Syringe * 1 Swab In 1 Packet
5
Y N Y 25%N25%NNAN
Lupron Depot-ped 1 Kit In 1 Carton * 1 Ml In 1 Syringe * 1 Swab In 1 Packet
5
Y N Y 25%N25%NNAN
Lutera 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
4
N N Y 32%N33%NNAN
Lyrica 25mg 90 Capsule In 1 Bottle
3
90 30 N N Y $27N$47NNAN
Lyrica 50mg 90 Capsule In 1 Bottle
3
90 30 N N Y $27N$47NNAN
Lyrica 75mg 90 Capsule In 1 Bottle
3
90 30 N N Y $27N$47NNAN
Lyrica 100mg 90 Capsule In 1 Bottle
3
90 30 N N Y $27N$47NNAN
Lyrica 150mg 90 Capsule In 1 Bottle
3
90 30 N N Y $27N$47NNAN
Lyrica 200mg 90 Capsule In 1 Bottle
3
90 30 N N Y $27N$47NNAN
Lyrica 300mg 90 Capsule In 1 Bottle
3
60 30 N N Y $27N$47NNAN
Lyrica 225mg 90 Capsule In 1 Bottle
3
60 30 N N Y $27N$47NNAN
Lyrica 20mg/mL 473 Ml In 1 Bottle
3
900 30 N N Y $27N$47NNAN
Lysodren 500mg 100 Tablet In 1 Bottle
3
N N Y $27N$47NNAN
Lyza .35mg 28 Tablet In 1 Carton
3
N N Y $27N$47NNAN



Medicare Help's Additional Notes:

Coverage Levels for S5921-383

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible of $400. Some plans offer select Pre-deductible drug Coverage
2.Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit of $3700
3.Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $4950 in 2017.
4.Catastrophic: Anything over $4950 you will receive a significant increase in coverage.

Definitions:

Premium: A monthly flat fee that varies by plan.
Deductible: The amount you must pay each year for your prescriptions before your plan begins to pay its share of your covered drugs. The max in 2017 is $320. Some plans have a $0 Deductible.
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization in order to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Does the Deduct Apply: Some drugs do not require that the deductible is met before you receive coverage.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Cost Prefered: Your Cost for the Drug at the Providers In Network Prefered Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non Pref: Your Cost for the Prescription Drug at a Non-Prefered Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.


What if a drug I need is not listed?

Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plans formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.

Source:CMS Formulary Data Oct. 2016
Source:NDC Directory by FDA.gov

**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.