2009 Medicare Part D Plan Formulary Information |
CIGNA Medicare Rx Plan Two (S5617-125-0)
Benefit Details
|
The CIGNA Medicare Rx Plan Two (S5617-125-0) Formulary Drugs Starting with the Letter L in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
|
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 100MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LABETALOL HCL 200MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LABETALOL HCL 300MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LABETALOL HCL 5MG/20ML VIAL |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LACLOTION 12% LOTION |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LACTATED RINGERS INJECTION |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LACTATED RINGERS IRRIGATION 20-30-600MG 3000ML BAG |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LAMICTAL 100MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LAMICTAL 150MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMICTAL 200MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LAMICTAL 25MG DISPER TABLET CHEW |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LAMICTAL 25MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LAMICTAL 25MG TABLET STARTER KIT |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LAMICTAL 5MG DISPER TABLET CHEW |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LAMICTAL TABLET STARTER KIT |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LAMICTAL TABLET STARTER KIT |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LAMOTRIGINE 150MG TABLET (60 CT) |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LAMOTRIGINE 200MG TABLET (60 CT) |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LAMOTRIGINE 25MG TABLET (100 CT) |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE 5MG TABLET DISPERSIBLE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LAMOTRIGINE TABLET 100MG (100 CT) |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LANOXIN 0.125MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LANOXIN 0.25MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LANOXIN 0.25MG/ML AMPUL |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LANOXIN PED 0.1MG/ML AMPUL |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LANREOTIDE INJECTION 30MG |
5 |
Tier 5 |
33% | 33% | P |
LANTUS 100U/ML VIAL |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LANTUS 100UNITS/ML CARTRIDGE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LANTUS INJECTION |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LAPASE 15-1.2-15 CAPSULE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEENA 7-9-5 TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEFLUNOMIDE 10MG TABLET (500 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | P |
LEFLUNOMIDE 20MG TABLET (500 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | P |
LESCOL 20MG CAPSULE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LESCOL 40MG CAPSULE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LESCOL XL 80MG TABLET SA |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LESSINA 0.1-0.02 TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LETAIRIS 10MG TABLET |
5 |
Tier 5 |
33% | 33% | None |
LETAIRIS 5MG TABLET |
5 |
Tier 5 |
33% | 33% | None |
LEUCOVORIN CALCIUM 100MG VL |
2 |
Tier 2 |
$6.00 | $15.00 | P |
LEUCOVORIN CALCIUM 10MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUCOVORIN CALCIUM 15MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEUCOVORIN CALCIUM 200MG VL |
2 |
Tier 2 |
$6.00 | $15.00 | P |
LEUCOVORIN CALCIUM 25MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEUCOVORIN CALCIUM 350MG VL |
2 |
Tier 2 |
$6.00 | $15.00 | P |
LEUCOVORIN CALCIUM 500MG VL |
2 |
Tier 2 |
$6.00 | $15.00 | P |
LEUCOVORIN CALCIUM 50MG VL |
2 |
Tier 2 |
$6.00 | $15.00 | P |
LEUCOVORIN CALCIUM 5MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEUCOVORIN CALCIUM INJECTION 10MG/ML 1X50ML VIL CRTN |
2 |
Tier 2 |
$6.00 | $15.00 | P |
LEUKERAN 2MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LEUKINE 250MCG VIAL |
5 |
Tier 5 |
33% | 33% | P |
LEUKINE 500MCG/ML VIAL |
5 |
Tier 5 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUPROLIDE 1MG/0.2ML VIAL |
2 |
Tier 2 |
$6.00 | $15.00 | P |
LEUPROLIDE 2WK 1MG/0.2ML KT |
2 |
Tier 2 |
$6.00 | $15.00 | P |
LEUPROLIDE ACETATE INJECTION 14 DAY PATIENT ADMINISTRATION KIT 1-.7 1 X 2.8ML PKGCOM |
2 |
Tier 2 |
$6.00 | $15.00 | P |
LEUSTATIN 1MG/ML VIAL |
3 |
Tier 3 |
$38.00 | $95.00 | P |
LEVAQUIN 250MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LEVAQUIN 25MG/ML SOLUTION |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LEVAQUIN 500MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LEVAQUIN 750MG LEVA-PAK TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LEVAQUIN 750MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LEVAQUIN IV 25MG/ML VIAL |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LEVAQUIN/D5W INJ 250/50ML |
3 |
Tier 3 |
$38.00 | $95.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVAQUIN/D5W INJ 750/150 |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LEVEMIR 100UNITS/ML VIAL |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LEVEMIR FLEXPEN 100UNITS/ML |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVETIRACETAM 500 MG TABLET 120 BOT |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVETIRACETAM TABLETS 1000MG 60 BOT |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVETIRACETAM TABLETS 250MG 500 BOT |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVETIRACETAM TABLETS 750MG 500 BOT |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVLITE-28 .02-1 TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOBUNOLOL 0.5% EYE DROPS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LEVOBUNOLOL HCL OPHTHALMIC SOLUTION 0.25% 10ML BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOCARNITINE 100MG/ML SOLUTION ORAL |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOCARNITINE 200MG/ML VIAL |
2 |
Tier 2 |
$6.00 | $15.00 | P |
LEVOCARNITINE TABLET 330MG 90 BLPK |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVORA-28 TABLET 0.15/30 |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVORPHANOL 2MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOTHROID 100MCG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOTHROID 112MCG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOTHROID 125MCG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOTHROID 137MCG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOTHROID 150MCG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOTHROID 175MCG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHROID 200MCG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOTHROID 25MCG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOTHROID 300MCG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOTHROID 50MCG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOTHROID 75MCG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOTHROID 88MCG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOTHYROXINE SODIUM .150MG TABLET (100 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 100MCG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 112MCG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 125MCG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE SODIUM 137MCG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 175MCG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 200MCG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 25MCG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 300MCG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 50MCG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 88MCG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOXYL 100MCG TABLET (1000 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOXYL 112MCG TABLET (1000 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOXYL 125MCG TABLET (1000 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOXYL 137MCG TABLET (1000 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 150MCG TABLET (1000 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOXYL 175MCG TABLET (1000 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOXYL 200MCG TABLET (1000 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOXYL 25MCG TABLET (1000 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOXYL 50MCG TABLET (1000 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOXYL 75MCG TABLET (1000 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEVOXYL 88MCG TABLET (1000 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LEXAPRO 10MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | Q:30 /30Days |
LEXAPRO 20MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | Q:30 /30Days |
LEXAPRO 5MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | Q:30 /30Days |
LEXAPRO 5MG/5ML SOLUTION |
3 |
Tier 3 |
$38.00 | $95.00 | Q:600 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEXIVA 50MG/ML SUSPENSION ORAL |
5 |
Tier 5 |
33% | 33% | None |
LEXIVA 700MG TABLET |
5 |
Tier 5 |
33% | 33% | None |
LIALDA 1.2G TABLET DELAYED RELEASE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LIDOCAINE 5% OINTMENT |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LIDOCAINE HCL 0.5% VIAL |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LIDOCAINE HCL 1% SYRINGE 10 X 5ML SYR |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LIDOCAINE HCL 1% VIAL |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LIDOCAINE HCL 2% JELLY |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LIDOCAINE HCL 2% JELLY 30ML TUBE |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM |
2 |
Tier 2 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIDODERM 5% PATCH |
3 |
Tier 3 |
$38.00 | $95.00 | Q:90 /30Days |
LIDOMAR VISCOUS 20MG/ML SOLUTION NON-ORAL |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LIMBITROL DS TABLET 10-25MG |
4 |
Tier 4 |
$85.00 | $212.50 | None |
LIMBITROL TABLET 5-12.5MG |
4 |
Tier 4 |
$85.00 | $212.50 | None |
LINCOCIN 300MG/ML VIAL |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LINDANE 1% LOTION |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LINDANE 1% SHAMPOO |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LIOTHYRONINE SODIUM INJECTION 10MCG |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LIPITOR 10MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | Q:30 /30Days |
LIPITOR 20MG TABLET (5000 CT) |
3 |
Tier 3 |
$38.00 | $95.00 | Q:30 /30Days |
LIPITOR 40MG TABLET (500 CT) |
3 |
Tier 3 |
$38.00 | $95.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIPITOR 80MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | Q:30 /30Days |
LIPRAM 4500 CAPSULE EC |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LIPRAM-PN10 CAPSULE EC |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LIPRAM-PN16 CAPSULE EC |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LIPRAM-PN20 CAPSULE EC |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LIPRAM-UL12 CAPSULE EC |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LIPRAM-UL18 CAPSULE EC |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LIPRAM-UL20 CAPSULE EC |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LISINOPRIL 10MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LISINOPRIL 2.5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LISINOPRIL 20MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL 30MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LISINOPRIL 40MG TABLET (500 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LISINOPRIL 5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LISINOPRIL-HCTZ 10/12.5 TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LISINOPRIL-HCTZ 20/12.5 TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LITHIUM CARBONATE |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LITHIUM CARBONATE 150MG CAPSULE |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LITHIUM CARBONATE 300MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LITHIUM CARBONATE 450MG TABLET SA |
2 |
Tier 2 |
$6.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LITHIUM CARBONATE 600MG CAP |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LITHOBID 300MG TABLET SA |
4 |
Tier 4 |
$85.00 | $212.50 | None |
LITHOSTAT 250MG TABLET |
4 |
Tier 4 |
$85.00 | $212.50 | None |
LO/OVRAL-28 TABLET |
4 |
Tier 4 |
$85.00 | $212.50 | None |
LODOSYN 25MG TABLET |
4 |
Tier 4 |
$85.00 | $212.50 | None |
LOESTRIN 21 1.5/30 TABLET |
4 |
Tier 4 |
$85.00 | $212.50 | None |
LOESTRIN 21 1/20 TABLET |
4 |
Tier 4 |
$85.00 | $212.50 | None |
LOESTRIN 24 FE TABLET |
4 |
Tier 4 |
$85.00 | $212.50 | None |
LOESTRIN FE 1-0.02MG TABLET |
4 |
Tier 4 |
$85.00 | $212.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOFENE 2.5MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LOKARA 0.05% LOTION |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LONOX 2.5MG TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LOPERAMIDE HCL 2MG CAPSULE |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LOTREL 10/20MG CAPSULE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LOTREL 10/40MG CAPSULE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LOTREL 2.5/10MG CAPSULE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LOTREL 5/10MG CAPSULE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LOTREL 5/20MG CAPSULE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LOTREL 5/40MG CAPSULE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LOTRONEX 0.5MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOTRONEX 1MG TABLET |
3 |
Tier 3 |
$38.00 | $95.00 | P |
LOVASTATIN 10MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
LOVASTATIN 20MG TABLET (1000 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
LOVASTATIN 40MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
LOVAZA 1G CAPSULE |
4 |
Tier 4 |
$85.00 | $212.50 | None |
LOVENOX 100MG PREFILLED SYR |
5 |
Tier 5 |
33% | 33% | Q:60 /365Days |
LOVENOX 120MG PREFILLED SYR |
5 |
Tier 5 |
33% | 33% | Q:48 /365Days |
LOVENOX 150MG PREFILLED SYR |
5 |
Tier 5 |
33% | 33% | Q:60 /365Days |
LOVENOX 300MG VIAL |
5 |
Tier 5 |
33% | 33% | Q:60 /365Days |
LOVENOX 30MG PREFILLED SYRN |
5 |
Tier 5 |
33% | 33% | Q:18 /365Days |
LOVENOX 40MG PREFILLED SYRN |
4 |
Tier 4 |
$85.00 | $212.50 | Q:24 /365Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOVENOX 60MG PREFILLED SYRN |
5 |
Tier 5 |
33% | 33% | Q:36 /365Days |
LOVENOX 80MG PREFILLED SYRN |
5 |
Tier 5 |
33% | 33% | Q:48 /365Days |
LOW-OGESTREL-28 TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LOXAPINE 10MG CAPSULE (1000 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LOXAPINE 25MG CAPSULE (100 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LOXAPINE 50MG CAPSULE (1000 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LOXAPINE 5MG CAPSULE (100 CT) |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LUNESTA 1MG TABLET |
4 |
Tier 4 |
$85.00 | $212.50 | S Q:30 /30Days |
LUNESTA 2MG TABLET |
4 |
Tier 4 |
$85.00 | $212.50 | S Q:30 /30Days |
LUNESTA 3MG TABLET |
4 |
Tier 4 |
$85.00 | $212.50 | S Q:30 /30Days |
LUPRON DEPOT 3.75MG KIT |
4 |
Tier 4 |
$85.00 | $212.50 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUPRON DEPOT 7.5MG KIT |
5 |
Tier 5 |
33% | 33% | P |
LUPRON DEPOT-3 MONTH KIT |
4 |
Tier 4 |
$85.00 | $212.50 | P |
LUPRON DEPOT-3 MONTH KIT |
5 |
Tier 5 |
33% | 33% | P |
LUPRON DEPOT-4 MONTH KIT |
5 |
Tier 5 |
33% | 33% | P |
LUPRON DEPOT-PED 11.25MG KT |
5 |
Tier 5 |
33% | 33% | P |
LUPRON DEPOT-PED 15MG KIT |
5 |
Tier 5 |
33% | 33% | P |
LUPRON DEPOT-PED 7.5MG KIT |
5 |
Tier 5 |
33% | 33% | P |
LUTERA 0.1-0.02 TABLET |
2 |
Tier 2 |
$6.00 | $15.00 | None |
LYBREL 90-20MCG TABLET |
4 |
Tier 4 |
$85.00 | $212.50 | None |
LYRICA 100MG CAPSULE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LYRICA 150MG CAPSULE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYRICA 200MG CAPSULE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LYRICA 225MG CAPSULE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LYRICA 25MG CAPSULE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LYRICA 300MG CAPSULE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LYRICA 50MG CAPSULE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LYRICA 75MG CAPSULE |
3 |
Tier 3 |
$38.00 | $95.00 | None |
LYSODREN 500MG TABLET |
5 |
Tier 5 |
33% | 33% | None |