2009 Medicare Part D Plan Formulary Information |
SierraRx (S5917-003-0)
Benefit Details
|
The SierraRx (S5917-003-0) Formulary Drugs Starting with the Letter L in CMS PDP Region 27 which includes: CO
|
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 |
1 |
Generic |
$10.00 | $30.00 | None |
LABETALOL HCL 200MG TABLET |
1 |
Generic |
$10.00 | $30.00 | None |
LABETALOL HCL 300MG TABLET |
1 |
Generic |
$10.00 | $30.00 | None |
LACLOTION 12% LOTION |
1 |
Generic |
$10.00 | $30.00 | Q:400 /30Days |
LACTATED RINGERS IRRIGATION 20-30-600MG 3000ML BAG |
1 |
Generic |
$10.00 | $30.00 | None |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT |
1 |
Generic |
$10.00 | $30.00 | None |
LAMICTAL 25MG TABLET STARTER KIT |
2 |
Brand |
$50.00 | $150.00 | Q:35 /365Days |
LAMICTAL TABLET STARTER KIT |
2 |
Brand |
$50.00 | $150.00 | Q:49 /365Days |
LAMICTAL TABLET STARTER KIT |
2 |
Brand |
$50.00 | $150.00 | Q:98 /365Days |
LAMOTRIGINE 150MG TABLET (60 CT) |
1 |
Generic |
$10.00 | $30.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE 200MG TABLET (60 CT) |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LAMOTRIGINE 25MG TABLET (100 CT) |
1 |
Generic |
$10.00 | $30.00 | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE |
1 |
Generic |
$10.00 | $30.00 | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE |
1 |
Generic |
$10.00 | $30.00 | None |
LAMOTRIGINE TABLET 100MG (100 CT) |
1 |
Generic |
$10.00 | $30.00 | Q:150 /30Days |
LANOXIN 0.125MG TABLET |
2 |
Brand |
$50.00 | $150.00 | None |
LANOXIN 0.25MG TABLET |
2 |
Brand |
$50.00 | $150.00 | None |
LANTUS 100U/ML VIAL |
2 |
Brand |
$50.00 | $150.00 | None |
LEENA 7-9-5 TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:28 /28Days |
LEFLUNOMIDE 10MG TABLET (500 CT) |
1 |
Generic |
$10.00 | $30.00 | Q:30 /30Days |
LEFLUNOMIDE 20MG TABLET (500 CT) |
1 |
Generic |
$10.00 | $30.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LESSINA 0.1-0.02 TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:28 /28Days |
LETAIRIS 10MG TABLET |
3 |
Specialty |
33% | 33% | P |
LETAIRIS 5MG TABLET |
3 |
Specialty |
33% | 33% | P |
LEUCOVORIN CALCIUM 100MG VL |
1 |
Generic |
$10.00 | $30.00 | None |
LEUCOVORIN CALCIUM 10MG TABLET |
1 |
Generic |
$10.00 | $30.00 | None |
LEUCOVORIN CALCIUM 15MG TABLET |
1 |
Generic |
$10.00 | $30.00 | None |
LEUCOVORIN CALCIUM 200MG VL |
1 |
Generic |
$10.00 | $30.00 | None |
LEUCOVORIN CALCIUM 25MG TABLET |
1 |
Generic |
$10.00 | $30.00 | None |
LEUCOVORIN CALCIUM 350MG VL |
1 |
Generic |
$10.00 | $30.00 | None |
LEUCOVORIN CALCIUM 500MG VL |
1 |
Generic |
$10.00 | $30.00 | None |
LEUCOVORIN CALCIUM 50MG VL |
1 |
Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUCOVORIN CALCIUM 5MG TABLET |
1 |
Generic |
$10.00 | $30.00 | None |
LEUCOVORIN CALCIUM INJECTION 10MG/ML 1X50ML VIL CRTN |
1 |
Generic |
$10.00 | $30.00 | None |
LEUKERAN 2MG TABLET |
2 |
Brand |
$50.00 | $150.00 | None |
LEUPROLIDE 1MG/0.2ML VIAL |
1 |
Generic |
$10.00 | $30.00 | P Q:30 /30Days |
LEUPROLIDE 2WK 1MG/0.2ML KT |
1 |
Generic |
$10.00 | $30.00 | P |
LEUPROLIDE ACETATE INJECTION 14 DAY PATIENT ADMINISTRATION KIT 1-.7 1 X 2.8ML PKGCOM |
1 |
Generic |
$10.00 | $30.00 | P |
LEVAQUIN/D5W INJ 250/50ML |
2 |
Brand |
$50.00 | $150.00 | P |
LEVEMIR 100UNITS/ML VIAL |
2 |
Brand |
$50.00 | $150.00 | None |
LEVEMIR FLEXPEN 100UNITS/ML |
2 |
Brand |
$50.00 | $150.00 | None |
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT |
1 |
Generic |
$10.00 | $30.00 | None |
LEVETIRACETAM 500 MG TABLET 120 BOT |
1 |
Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM TABLETS 1000MG 60 BOT |
1 |
Generic |
$10.00 | $30.00 | None |
LEVETIRACETAM TABLETS 250MG 500 BOT |
1 |
Generic |
$10.00 | $30.00 | None |
LEVETIRACETAM TABLETS 750MG 500 BOT |
1 |
Generic |
$10.00 | $30.00 | None |
LEVOBUNOLOL 0.5% EYE DROPS |
1 |
Generic |
$10.00 | $30.00 | None |
LEVOBUNOLOL HCL OPHTHALMIC SOLUTION 0.25% 10ML BOT |
1 |
Generic |
$10.00 | $30.00 | None |
LEVORA-28 TABLET 0.15/30 |
1 |
Generic |
$10.00 | $30.00 | Q:28 /28Days |
LEVOTHROID 100MCG TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOTHROID 112MCG TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOTHROID 125MCG TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOTHROID 137MCG TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOTHROID 150MCG TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHROID 175MCG TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOTHROID 200MCG TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOTHROID 25MCG TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOTHROID 300MCG TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOTHROID 50MCG TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOTHROID 75MCG TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOTHROID 88MCG TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT) |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOTHYROXINE SODIUM .150MG TABLET (100 CT) |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOTHYROXINE SODIUM 100MCG TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOTHYROXINE SODIUM 112MCG TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE SODIUM 125MCG TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOTHYROXINE SODIUM 137MCG TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOTHYROXINE SODIUM 175MCG TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOTHYROXINE SODIUM 200MCG TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOTHYROXINE SODIUM 25MCG TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOTHYROXINE SODIUM 300MCG TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOTHYROXINE SODIUM 50MCG TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOTHYROXINE SODIUM 88MCG TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOXYL 100MCG TABLET (1000 CT) |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOXYL 112MCG TABLET (1000 CT) |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOXYL 125MCG TABLET (1000 CT) |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 137MCG TABLET (1000 CT) |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOXYL 150MCG TABLET (1000 CT) |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOXYL 175MCG TABLET (1000 CT) |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOXYL 200MCG TABLET (1000 CT) |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOXYL 25MCG TABLET (1000 CT) |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOXYL 50MCG TABLET (1000 CT) |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOXYL 75MCG TABLET (1000 CT) |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEVOXYL 88MCG TABLET (1000 CT) |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LEXAPRO 10MG TABLET |
2 |
Brand |
$50.00 | $150.00 | S Q:30 /30Days |
LEXAPRO 20MG TABLET |
2 |
Brand |
$50.00 | $150.00 | S Q:30 /30Days |
LEXAPRO 5MG TABLET |
2 |
Brand |
$50.00 | $150.00 | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEXAPRO 5MG/5ML SOLUTION |
2 |
Brand |
$50.00 | $150.00 | S Q:600 /30Days |
LEXIVA 50MG/ML SUSPENSION ORAL |
3 |
Specialty |
33% | 33% | Q:1680 /30Days |
LEXIVA 700MG TABLET |
3 |
Specialty |
33% | 33% | Q:120 /30Days |
LIDOCAINE 5% OINTMENT |
1 |
Generic |
$10.00 | $30.00 | None |
LIDOCAINE HCL 0.5% VIAL |
1 |
Generic |
$10.00 | $30.00 | None |
LIDOCAINE HCL 1% VIAL |
1 |
Generic |
$10.00 | $30.00 | None |
LIDOCAINE HCL 2% JELLY |
1 |
Generic |
$10.00 | $30.00 | None |
LIDOCAINE HCL 2% JELLY 30ML TUBE |
1 |
Generic |
$10.00 | $30.00 | None |
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM |
1 |
Generic |
$10.00 | $30.00 | None |
LIDODERM 5% PATCH |
2 |
Brand |
$50.00 | $150.00 | Q:90 /30Days |
LIDOMAR VISCOUS 20MG/ML SOLUTION NON-ORAL |
1 |
Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LINDANE 1% LOTION |
1 |
Generic |
$10.00 | $30.00 | None |
LINDANE 1% SHAMPOO |
1 |
Generic |
$10.00 | $30.00 | None |
LISINOPRIL 10MG TABLET (100 CT) |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LISINOPRIL 2.5MG TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LISINOPRIL 20MG TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LISINOPRIL 30MG TABLET (100 CT) |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LISINOPRIL 40MG TABLET (500 CT) |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LISINOPRIL 5MG TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LISINOPRIL-HCTZ 10/12.5 TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT) |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LISINOPRIL-HCTZ 20/12.5 TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LITHIUM CARBONATE 150MG CAPSULE |
1 |
Generic |
$10.00 | $30.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) |
1 |
Generic |
$10.00 | $30.00 | None |
LITHIUM CARBONATE 300MG TABLET |
1 |
Generic |
$10.00 | $30.00 | None |
LITHIUM CARBONATE 450MG TABLET SA |
1 |
Generic |
$10.00 | $30.00 | None |
LITHIUM CARBONATE 600MG CAP |
1 |
Generic |
$10.00 | $30.00 | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) |
1 |
Generic |
$10.00 | $30.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP |
1 |
Generic |
$10.00 | $30.00 | None |
LITHOBID 300MG TABLET SA |
2 |
Brand |
$50.00 | $150.00 | None |
LOFENE 2.5MG TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:240 /30Days |
LOKARA 0.05% LOTION |
1 |
Generic |
$10.00 | $30.00 | None |
LONOX 2.5MG TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOTEMAX 0.5% EYE DROPS |
2 |
Brand |
$50.00 | $150.00 | Q:20 /30Days |
LOTRONEX 0.5MG TABLET |
2 |
Brand |
$50.00 | $150.00 | P Q:60 /30Days |
LOTRONEX 1MG TABLET |
2 |
Brand |
$50.00 | $150.00 | P Q:60 /30Days |
LOVASTATIN 10MG TABLET (100 CT) |
1 |
Generic |
$10.00 | $30.00 | Q:30 /30Days |
LOVASTATIN 20MG TABLET (1000 CT) |
1 |
Generic |
$10.00 | $30.00 | Q:30 /30Days |
LOVASTATIN 40MG TABLET (100 CT) |
1 |
Generic |
$10.00 | $30.00 | Q:60 /30Days |
LOVAZA 1G CAPSULE |
2 |
Brand |
$50.00 | $150.00 | Q:120 /30Days |
LOW-OGESTREL-28 TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:28 /28Days |
LOXAPINE 10MG CAPSULE (1000 CT) |
1 |
Generic |
$10.00 | $30.00 | None |
LOXAPINE 25MG CAPSULE (100 CT) |
1 |
Generic |
$10.00 | $30.00 | None |
LOXAPINE 50MG CAPSULE (1000 CT) |
1 |
Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOXAPINE 5MG CAPSULE (100 CT) |
1 |
Generic |
$10.00 | $30.00 | None |
LUMIGAN 0.03% EYE DROPS |
2 |
Brand |
$50.00 | $150.00 | Q:7 /30Days |
LUTERA 0.1-0.02 TABLET |
1 |
Generic |
$10.00 | $30.00 | Q:28 /28Days |
LYRICA 100MG CAPSULE |
2 |
Brand |
$50.00 | $150.00 | S Q:90 /30Days |
LYRICA 150MG CAPSULE |
2 |
Brand |
$50.00 | $150.00 | S Q:90 /30Days |
LYRICA 200MG CAPSULE |
2 |
Brand |
$50.00 | $150.00 | S Q:90 /30Days |
LYRICA 225MG CAPSULE |
2 |
Brand |
$50.00 | $150.00 | S Q:60 /30Days |
LYRICA 25MG CAPSULE |
2 |
Brand |
$50.00 | $150.00 | S Q:90 /30Days |
LYRICA 300MG CAPSULE |
2 |
Brand |
$50.00 | $150.00 | S Q:60 /30Days |
LYRICA 50MG CAPSULE |
2 |
Brand |
$50.00 | $150.00 | S Q:90 /30Days |
LYRICA 75MG CAPSULE |
2 |
Brand |
$50.00 | $150.00 | S Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYSODREN 500MG TABLET |
3 |
Specialty |
33% | 33% | P Q:1140 /30Days |