2026 HealthSpring Extra Rx (PDP) formulary (drug list)
Contract S5617, plan 363 · Michigan · 3,270 drugs on file · formulary ID 00026094. Each drug links to its cost in every CMS PDP Region 13 plan.
213 drugs starting with L.
| Drug name | Tier | 30-day preferred pharmacy | 90-day mail order | Usage management |
|---|---|---|---|---|
| L-GLUTAMINE 5 g Powder, For Solution | 5Specialty Tier | 25% | N/A |
|
| LABETALOL HYDROCHLORIDE 100 mg Tablet, Film Coated | 2Generic | $5.00 | $3.00 | None |
| LABETALOL HYDROCHLORIDE 200 mg Tablet, Film Coated | 2Generic | $5.00 | $3.00 | None |
| LABETALOL HYDROCHLORIDE 300 mg Tablet, Film Coated | 2Generic | $5.00 | $3.00 | None |
| LACOSAMIDE 100 mg Tablet, Film Coated | 4Non-Preferred Drug | 32% | 32% |
|
| LACOSAMIDE 150 mg Tablet, Film Coated | 4Non-Preferred Drug | 32% | 32% |
|
| LACOSAMIDE 200 mg Tablet, Film Coated | 4Non-Preferred Drug | 32% | 32% |
|
| LACOSAMIDE 50 mg Tablet, Film Coated | 4Non-Preferred Drug | 32% | 32% |
|
| LACOSAMIDE ORAL SOLUTION 10 mg/mL Solution | 4Non-Preferred Drug | 32% | 32% |
|
| LACTULOSE 10 g/15mL Solution | 3Preferred Brand | 17% | 17% | None |
| LAMIVUDINE 100 mg Tablet, Film Coated | 3Preferred Brand | 17% | 17% |
|
| LAMIVUDINE 150 mg Tablet | 3Preferred Brand | 17% | 17% |
|
| LAMIVUDINE 300 mg Tablet, Film Coated | 3Preferred Brand | 17% | 17% |
|
| LAMIVUDINE AND ZIDOVUDINE 150/300 mg Tablet, Film Coated | 3Preferred Brand | 17% | 17% |
|
| LAMOTRIGINE 100 mg Tablet | 2Generic | $5.00 | $3.00 | None |
| LAMOTRIGINE 150 mg Tablet | 2Generic | $5.00 | $3.00 | None |
| LAMOTRIGINE 200 mg Tablet | 2Generic | $5.00 | $3.00 | None |
| LAMOTRIGINE 25 mg Tablet | 2Generic | $5.00 | $3.00 | None |
| LAMOTRIGINE 25 mg Tablet | 2Generic | $5.00 | $3.00 | None |
| LAMOTRIGINE 25 mg Tablet, Chewable | 3Preferred Brand | 17% | 17% | None |
| LAMOTRIGINE 5 mg Tablet, Chewable | 3Preferred Brand | 17% | 17% | None |
| LAMOTRIGINE KIT KitLamotrigine | 2Generic | $5.00 | $3.00 | None |
| LAMOTRIGINE KIT KitLamotrigine | 2Generic | $5.00 | $3.00 | None |
| LANSOPRAZOLE 15 mg Capsule, Delayed Release | 3Preferred Brand | 17% | 17% |
|
| LANSOPRAZOLE 30 mg Capsule, Delayed Release | 3Preferred Brand | 17% | 17% |
|
| LANTUS 100 [iU]/mL Injection, SolutionInsulin Glargine | 3Preferred Brand | 17% | 17% | None |
| LANTUS SOLOSTAR 100 [iU]/mL Injection, SolutionInsulin Glargine | 3Preferred Brand | 17% | 17% | None |
| LAPATINIB 250 mg Tablet | 5Specialty Tier | 25% | N/A |
|
| LARIN 1.5/30 KitNorethindrone Acetate/Ethinyl Estradiol | 3Preferred Brand | 17% | 17% | None |
| LARIN 1/20 KitNorethindrone Acetate/Ethinyl Estradiol | 3Preferred Brand | 17% | 17% | None |
| LARIN FE 1.5/30 KitNorethindrone Acetate/Ethinyl Estradiol And Ferrous Fumarate | 3Preferred Brand | 17% | 17% | None |
| LARIN FE 1/20 KitNorethindrone Acetate/Ethinyl Estradiol And Ferrous Fumarate | 3Preferred Brand | 17% | 17% | None |
| LATANOPROST 50 ug/mL Solution | 1Preferred Generic | $0.00 | $0.00 | None |
| LAZCLUZE 240 mg Tablet, Film CoatedLazertinib | 5Specialty Tier | 25% | N/A |
|
| LAZCLUZE 80 mg Tablet, Film CoatedLazertinib | 5Specialty Tier | 25% | N/A |
|
| LEFLUNOMIDE 10 mg Tablet | 3Preferred Brand | 17% | 17% |
|
| LEFLUNOMIDE 20 mg Tablet | 3Preferred Brand | 17% | 17% |
|
| LENALIDOMIDE 10 mg Capsule | 5Specialty Tier | 25% | N/A |
|
| LENALIDOMIDE 15 mg Capsule | 5Specialty Tier | 25% | N/A |
|
| LENALIDOMIDE 2.5 mg Capsule | 5Specialty Tier | 25% | N/A |
|
| LENALIDOMIDE 20 mg Capsule | 5Specialty Tier | 25% | N/A |
|
| LENALIDOMIDE 25 mg Capsule | 5Specialty Tier | 25% | N/A |
|
| LENALIDOMIDE 5 mg Capsule | 5Specialty Tier | 25% | N/A |
|
| LENVIMA 10 mg CapsuleLenvatinib | 5Specialty Tier | 25% | N/A |
|
| LENVIMA 10 mg CapsuleLenvatinib | 5Specialty Tier | 25% | N/A |
|
| LENVIMA 4 mg CapsuleLenvatinib | 5Specialty Tier | 25% | N/A |
|
| LENVIMA 4 mg CapsuleLenvatinib | 5Specialty Tier | 25% | N/A |
|
| LENVIMA 4 mg CapsuleLenvatinib | 5Specialty Tier | 25% | N/A |
|
| LENVIMA KitLenvatinib | 5Specialty Tier | 25% | N/A |
|
| LENVIMA KitLenvatinib | 5Specialty Tier | 25% | N/A |
|
| LENVIMA KitLenvatinib | 5Specialty Tier | 25% | N/A |
|
| LESSINA KitLevonorgestrel And Ethinyl Estradiol | 3Preferred Brand | 17% | 17% | None |
| LETROZOLE 2.5 mg Tablet | 2Generic | $5.00 | $3.00 | None |
| LEUCOVORIN CALCIUM 10 mg Tablet | 4Non-Preferred Drug | 32% | 32% | None |
| LEUCOVORIN CALCIUM 15 mg Tablet | 4Non-Preferred Drug | 32% | 32% | None |
| LEUCOVORIN CALCIUM 25 mg Tablet | 3Preferred Brand | 17% | 17% | None |
| LEUCOVORIN CALCIUM 5 mg Tablet | 3Preferred Brand | 17% | 17% | None |
| LEUKERAN 2 mg Tablet, Film CoatedChlorambucil | 4Non-Preferred Drug | 32% | 32% | None |
| LEUPROLIDE ACETATE DEPOT KitLeuprolide Acetate | 4Non-Preferred Drug | 32% | 32% |
|
| LEUPROLIDE ACETATE Kit | 4Non-Preferred Drug | 32% | 32% |
|
| LEVETIRACETAM 100 mg/mL SolutionLevetiracetam Oral | 3Preferred Brand | 17% | 17% | None |
| LEVETIRACETAM 1000 mg Tablet, Film Coated | 2Generic | $5.00 | $3.00 | None |
| LEVETIRACETAM 250 mg Tablet, Film Coated | 2Generic | $5.00 | $3.00 | None |
| LEVETIRACETAM 250 mg Tablet, For Suspension | 4Non-Preferred Drug | 32% | 32% | None |
| LEVETIRACETAM 500 mg Tablet | 2Generic | $5.00 | $3.00 | None |
| LEVETIRACETAM 500 mg Tablet, Extended Release | 3Preferred Brand | 17% | 17% | None |
| LEVETIRACETAM 500 mg Tablet, Film Coated | 2Generic | $5.00 | $3.00 | None |
| LEVETIRACETAM 500 mg Tablet, For Suspension | 4Non-Preferred Drug | 32% | 32% | None |
| LEVETIRACETAM 750 mg Tablet, Extended Release | 3Preferred Brand | 17% | 17% | None |
| LEVETIRACETAM 750 mg Tablet, Film Coated | 2Generic | $5.00 | $3.00 | None |
| LEVOBUNOLOL HYDROCHLORIDE 5 mg/mL Solution/ Drops | 1Preferred Generic | $0.00 | $0.00 | None |
| LEVOCARNITINE 1 g/10mL Solution | 4Non-Preferred Drug | 32% | 32% | None |
| LEVOCARNITINE 330 mg Tablet | 4Non-Preferred Drug | 32% | 32% | None |
| LEVOCETIRIZINE DIHYDROCHLORIDE 5 mg Tablet | 3Preferred Brand | 17% | 17% |
|
| LEVOFLOXACIN 25 mg/mL Solution | 4Non-Preferred Drug | 32% | 32% | None |
| LEVOFLOXACIN 250 mg Tablet, Film Coated | 2Generic | $5.00 | $3.00 | None |
| LEVOFLOXACIN 5 mg/mL Injection, Solution | 4Non-Preferred Drug | 32% | 32% |
|
| LEVOFLOXACIN 5 mg/mL Injection, Solution | 4Non-Preferred Drug | 32% | 32% |
|
| LEVOFLOXACIN 500 mg Tablet, Film Coated | 2Generic | $5.00 | $3.00 | None |
| LEVOFLOXACIN 750 mg Tablet, Film Coated | 2Generic | $5.00 | $3.00 | None |
| LEVONEST KitLevonorgestrel And Ethinyl Estradiol | 3Preferred Brand | 17% | 17% | None |
| LEVONORGESTREL AND ETHINYL ESTRADIOL 90/20 ug Tablet | 3Preferred Brand | 17% | 17% | None |
| LEVONORGESTREL AND ETHINYL ESTRADIOL AND ETHINYL ESTRADIOL KitLevonorgestrel And Ethinyl Estradiol | 3Preferred Brand | 17% | 17% | None |
| LEVONORGESTREL AND ETHINYL ESTRADIOL Kit | 3Preferred Brand | 17% | 17% | None |
| LEVONORGESTREL AND ETHINYL ESTRADIOL Kit | 3Preferred Brand | 17% | 17% | None |
| LEVONORGESTREL AND ETHINYL ESTRADIOL Kit | 3Preferred Brand | 17% | 17% | None |
| LEVOTHYROXINE SODIUM .2 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| LEVOTHYROXINE SODIUM .3 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| LEVOTHYROXINE SODIUM 100 ug Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| LEVOTHYROXINE SODIUM 112 ug Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| LEVOTHYROXINE SODIUM 125 ug Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| LEVOTHYROXINE SODIUM 137 ug Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| LEVOTHYROXINE SODIUM 150 ug Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| LEVOTHYROXINE SODIUM 175 ug Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| LEVOTHYROXINE SODIUM 25 ug Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| LEVOTHYROXINE SODIUM 50 ug Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| LEVOTHYROXINE SODIUM 75 ug Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| LEVOTHYROXINE SODIUM 88 ug Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| LEVOXYL 100 ug TabletLevothyroxine Sodium | 3Preferred Brand | 17% | 17% | None |
| LEVOXYL 112 ug TabletLevothyroxine Sodium | 3Preferred Brand | 17% | 17% | None |
| LEVOXYL 125 ug TabletLevothyroxine Sodium | 3Preferred Brand | 17% | 17% | None |
| LEVOXYL 137 ug TabletLevothyroxine Sodium | 3Preferred Brand | 17% | 17% | None |
| LEVOXYL 150 ug TabletLevothyroxine Sodium | 3Preferred Brand | 17% | 17% | None |
| LEVOXYL 175 ug TabletLevothyroxine Sodium | 3Preferred Brand | 17% | 17% | None |
| LEVOXYL 200 ug TabletLevothyroxine Sodium | 3Preferred Brand | 17% | 17% | None |
| LEVOXYL 25 ug TabletLevothyroxine Sodium | 3Preferred Brand | 17% | 17% | None |
| LEVOXYL 50 ug TabletLevothyroxine Sodium | 3Preferred Brand | 17% | 17% | None |
| LEVOXYL 75 ug TabletLevothyroxine Sodium | 3Preferred Brand | 17% | 17% | None |
| LEVOXYL 88 ug TabletLevothyroxine Sodium | 3Preferred Brand | 17% | 17% | None |
| LIDOCAINE 50 mg/g Ointment | 4Non-Preferred Drug | 32% | 32% |
|
| LIDOCAINE 700 mg Patch | 4Non-Preferred Drug | 32% | 32% |
|
| LIDOCAINE AND PRILOCAINE 25/25 mg/g Cream | 3Preferred Brand | 17% | 17% |
|
| LIDOCAINE HYDROCHLORIDE 40 mg/mL Solution | 3Preferred Brand | 17% | 17% | None |
| LIDOCAINE VISCOUS 20 mg/mL SolutionLidocaine Hydrochloride | 2Generic | $5.00 | $3.00 | None |
| LILETTA 52 mg Intrauterine DeviceLevonorgestrel | 3Preferred Brand | 17% | 17% | None |
| LINEZOLID 100 mg/5mL Granule, For Suspension | 5Specialty Tier | 25% | N/A |
|
| LINEZOLID 600 mg Tablet, Film Coated | 3Preferred Brand | 17% | 17% |
|
| LINEZOLID 600 mg/300mL Injection, Solution | 4Non-Preferred Drug | 32% | 32% |
|
| LINZESS 145 ug Capsule, Gelatin CoatedLinaclotide | 3Preferred Brand | 17% | 17% |
|
| LINZESS 290 ug Capsule, Gelatin CoatedLinaclotide | 3Preferred Brand | 17% | 17% |
|
| LINZESS 72 ug Capsule, Gelatin CoatedLinaclotide | 3Preferred Brand | 17% | 17% |
|
| LIOMNY 25 ug TabletLiothyronine Sodium | 3Preferred Brand | 17% | 17% | None |
| LIOMNY 5 ug TabletLiothyronine Sodium | 3Preferred Brand | 17% | 17% | None |
| LIOMNY 50 ug TabletLiothyronine Sodium | 3Preferred Brand | 17% | 17% | None |
| LIOTHYRONINE SODIUM 25 ug Tablet | 3Preferred Brand | 17% | 17% | None |
| LIOTHYRONINE SODIUM 5 ug Tablet | 3Preferred Brand | 17% | 17% | None |
| LIOTHYRONINE SODIUM 50 ug Tablet | 3Preferred Brand | 17% | 17% | None |
| LISDEXAMFETAMINE DIMESYLATE 10 mg Tablet, Chewable | 4Non-Preferred Drug | 32% | 32% |
|
| LISDEXAMFETAMINE DIMESYLATE 20 mg Tablet, Chewable | 4Non-Preferred Drug | 32% | 32% |
|
| LISDEXAMFETAMINE DIMESYLATE 30 mg Tablet, Chewable | 4Non-Preferred Drug | 32% | 32% |
|
| LISDEXAMFETAMINE DIMESYLATE 40 mg Tablet, Chewable | 4Non-Preferred Drug | 32% | 32% |
|
| LISDEXAMFETAMINE DIMESYLATE 50 mg Tablet, Chewable | 4Non-Preferred Drug | 32% | 32% |
|
| LISDEXAMFETAMINE DIMESYLATE 60 mg Tablet, Chewable | 4Non-Preferred Drug | 32% | 32% |
|
| LISINOPRIL 10 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| LISINOPRIL 2.5 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| LISINOPRIL 20 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| LISINOPRIL 30 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| LISINOPRIL 40 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| LISINOPRIL 5 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| LISINOPRIL AND HYDROCHLOROTHIAZIDE 12.5/10 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| LISINOPRIL AND HYDROCHLOROTHIAZIDE 12.5/20 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| LISINOPRIL AND HYDROCHLOROTHIAZIDE 25/20 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| LITHIUM 8 meq/5mL Solution | 1Preferred Generic | $0.00 | $0.00 | None |
| LITHIUM CARBONATE 150 mg Capsule | 1Preferred Generic | $0.00 | $0.00 | None |
| LITHIUM CARBONATE 300 mg Capsule | 1Preferred Generic | $0.00 | $0.00 | None |
| LITHIUM CARBONATE 300 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| LITHIUM CARBONATE 300 mg Tablet, Film Coated, Extended Release | 2Generic | $5.00 | $3.00 | None |
| LITHIUM CARBONATE 600 mg Capsule, Gelatin Coated | 1Preferred Generic | $0.00 | $0.00 | None |
| LITHIUM CARBONATE ER 450 mg TabletLithium Carbonate | 2Generic | $5.00 | $3.00 | None |
| LIVTENCITY 200 mg Tablet, CoatedMaribavir | 5Specialty Tier | 25% | N/A |
|
| LOMUSTINE 10 mg Capsule | 4Non-Preferred Drug | 32% | 32% | None |
| LOMUSTINE 100 mg Capsule | 4Non-Preferred Drug | 32% | 32% | None |
| LOMUSTINE 40 mg Capsule | 4Non-Preferred Drug | 32% | 32% | None |
| LONSURF 15/6.14 mg Tablet, Film CoatedTrifluridine And Tipiracil | 5Specialty Tier | 25% | N/A |
|
| LONSURF 20/8.19 mg Tablet, Film CoatedTrifluridine And Tipiracil | 5Specialty Tier | 25% | N/A |
|
| LOPERAMIDE HYDROCHLORIDE 2 mg Capsule | 2Generic | $5.00 | $3.00 | None |
| LOPINAVIR AND RITONAVIR 100/25 mg Tablet, Film Coated | 4Non-Preferred Drug | 32% | 32% |
|
| LOPINAVIR AND RITONAVIR 200/50 mg Tablet, Film Coated | 4Non-Preferred Drug | 32% | 32% |
|
| LORAZEPAM .5 mg Tablet | 2Generic | $5.00 | $3.00 |
|
| LORAZEPAM 1 mg Tablet | 2Generic | $5.00 | $3.00 |
|
| LORAZEPAM 2 mg Tablet | 2Generic | $5.00 | $3.00 |
|
| LORAZEPAM 2 mg/mL Solution, Concentrate | 3Preferred Brand | 17% | 17% |
|
| LORBRENA 100 mg Tablet, Film CoatedLorlatinib | 5Specialty Tier | 25% | N/A |
|
| LORBRENA 25 mg Tablet, Film CoatedLorlatinib | 5Specialty Tier | 25% | N/A |
|
| LORYNA KitDrospirenone And Ethinyl Estradiol Tablets | 3Preferred Brand | 17% | 17% | None |
| LOSARTAN POTASSIUM 100 mg Tablet, Film Coated | 1Preferred Generic | $0.00 | $0.00 |
|
| LOSARTAN POTASSIUM 25 mg Tablet, Film Coated | 1Preferred Generic | $0.00 | $0.00 |
|
| LOSARTAN POTASSIUM 50 mg Tablet, Film Coated | 1Preferred Generic | $0.00 | $0.00 |
|
| LOSARTAN POTASSIUM AND HYDROCHLOROTHIAZIDE 12.5/100 mg Tablet | 1Preferred Generic | $0.00 | $0.00 |
|
| LOSARTAN POTASSIUM AND HYDROCHLOROTHIAZIDE 12.5/50 mg Tablet | 1Preferred Generic | $0.00 | $0.00 |
|
| LOSARTAN POTASSIUM AND HYDROCHLOROTHIAZIDE 25/100 mg Tablet | 1Preferred Generic | $0.00 | $0.00 |
|
| LOTEMAX 5 mg/g OintmentLoteprednol Etabonate | 4Non-Preferred Drug | 32% | 32% | None |
| LOTEMAX SM 3.8 mg/g GelLoteprednol Etabonate | 4Non-Preferred Drug | 32% | 32% | None |
| LOTEPREDNOL ETABONATE 2 mg/mL Suspension/ Drops | 4Non-Preferred Drug | 32% | 32% | None |
| LOTEPREDNOL ETABONATE 5 mg/g Gel | 4Non-Preferred Drug | 32% | 32% | None |
| LOTEPREDNOL ETABONATE 5 mg/mL Suspension/ Drops | 4Non-Preferred Drug | 32% | 32% | None |
| LOVASTATIN 10 mg Tablet | 1Preferred Generic | $0.00 | $0.00 |
|
| LOVASTATIN 20 mg Tablet | 1Preferred Generic | $0.00 | $0.00 |
|
| LOVASTATIN 40 mg Tablet | 1Preferred Generic | $0.00 | $0.00 |
|
| LOW-OGESTREL KitNorgestrel And Ethinyl Estradiol | 3Preferred Brand | 17% | 17% | None |
| LOXAPINE 10 mg Capsule | 3Preferred Brand | 17% | 17% | None |
| LOXAPINE 25 mg Capsule | 3Preferred Brand | 17% | 17% | None |
| LOXAPINE 5 mg Capsule | 3Preferred Brand | 17% | 17% | None |
| LOXAPINE 50 mg Capsule | 3Preferred Brand | 17% | 17% | None |
| LUBIPROSTONE 24 ug Capsule, Gelatin Coated | 3Preferred Brand | 17% | 17% |
|
| LUBIPROSTONE 8 ug Capsule, Gelatin Coated | 3Preferred Brand | 17% | 17% |
|
| LUIZZA 1.5/30 30/1.5 ug/mg TabletNorethindrone Acetate And Ethinyl Estradiol | 3Preferred Brand | 17% | 17% | None |
| LUIZZA 1/20 .02/1 mg TabletNorethindrone Acetate And Ethinyl Estradiol | 3Preferred Brand | 17% | 17% | None |
| LUMAKRAS 120 mg Tablet, CoatedSotorasib | 5Specialty Tier | 25% | N/A |
|
| LUMAKRAS 240 mg Tablet, CoatedSotorasib | 5Specialty Tier | 25% | N/A |
|
| LUMAKRAS 320 mg Tablet, CoatedSotorasib | 5Specialty Tier | 25% | N/A |
|
| LUMIGAN .1 mg/mL Solution/ DropsBimatoprost | 3Preferred Brand | 17% | 17% | None |
| LUPRON DEPOT KitLeuprolide Acetate | 5Specialty Tier | 25% | N/A |
|
| LUPRON DEPOT KitLeuprolide Acetate | 5Specialty Tier | 25% | N/A |
|
| LUPRON DEPOT KitLeuprolide Acetate | 4Non-Preferred Drug | 32% | 32% |
|
| LUPRON DEPOT KitLeuprolide Acetate | 4Non-Preferred Drug | 32% | 32% |
|
| LUPRON DEPOT KitLeuprolide Acetate | 4Non-Preferred Drug | 32% | 32% |
|
| LUPRON DEPOT KitLeuprolide Acetate | 4Non-Preferred Drug | 32% | 32% |
|
| LUPRON DEPOT-PED KitLeuprolide Acetate | 5Specialty Tier | 25% | N/A |
|
| LUPRON DEPOT-PED KitLeuprolide Acetate | 4Non-Preferred Drug | 32% | 32% |
|
| LUPRON DEPOT-PED KitLeuprolide Acetate | 4Non-Preferred Drug | 32% | 32% |
|
| LURASIDONE HYDROCHLORIDE 120 mg Tablet, Film Coated | 4Non-Preferred Drug | 32% | 32% |
|
| LURASIDONE HYDROCHLORIDE 20 mg Tablet, Film Coated | 4Non-Preferred Drug | 32% | 32% |
|
| LURASIDONE HYDROCHLORIDE 40 mg Tablet, Film Coated | 4Non-Preferred Drug | 32% | 32% |
|
| LURASIDONE HYDROCHLORIDE 60 mg Tablet, Film Coated | 4Non-Preferred Drug | 32% | 32% |
|
| LURASIDONE HYDROCHLORIDE 80 mg Tablet, Film Coated | 4Non-Preferred Drug | 32% | 32% |
|
| LUTRATE DEPOT KitLeuprolide Acetate | 4Non-Preferred Drug | 32% | 32% |
|
| LYNPARZA 100 mg Tablet, Film CoatedOlaparib | 5Specialty Tier | 25% | N/A |
|
| LYNPARZA 150 mg Tablet, Film CoatedOlaparib | 5Specialty Tier | 25% | N/A |
|
| LYSODREN 500 mg TabletMitotane | 5Specialty Tier | 25% | N/A | None |
| LYTGOBI 4 mg TabletFutibatinib | 5Specialty Tier | 25% | N/A |
|
| LYTGOBI 4 mg TabletFutibatinib | 5Specialty Tier | 25% | N/A |
|
| LYTGOBI 4 mg TabletFutibatinib | 5Specialty Tier | 25% | N/A |
|
PA = prior authorization, ST = step therapy, QL = quantity limit. Costs are the plan’s initial-coverage cost-sharing from the CMS 2026 formulary files; a drug not listed here is not on this plan’s formulary, though a formulary exception may still be possible.