2010 Medicare Part D Plan Formulary Information |
EnvisionRxPlus Gold (PDP) (S7694-068-0)
Benefit Details
|
The EnvisionRxPlus Gold (PDP) (S7694-068-0) Formulary Drugs Starting with the Letter L in CMS PDP Region 34 which includes: AK
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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 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LABETALOL HCL 200MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LABETALOL HCL 300MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LABETALOL HCL 5MG/20ML VIAL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LACLOTION 12% LOTION |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LACRISERT OPTHALMIC INSERT 5MG 60 BLPK |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
LACTATED RINGERS INJECTION |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LACTATED RINGERS IRRIGATION 20-30-600MG 3000ML BAG |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LAMOTRIGINE 150MG TABLET (60 CT) |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE 200MG TABLET (60 CT) |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
LAMOTRIGINE 25MG TABLET (100 CT) |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
LAMOTRIGINE TABLET 100MG (100 CT) |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
LANTUS 100U/ML VIAL |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LANTUS INJECTION |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEFLUNOMIDE 10MG TABLET (500 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LEFLUNOMIDE 20MG TABLET (500 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LETAIRIS 10MG TABLET |
5 |
Tier 5 Specialty |
25% | N/A | None |
LETAIRIS 5MG TABLET |
5 |
Tier 5 Specialty |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUKERAN 2MG TABLET |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEUPROLIDE ACETATE INJECTION 14 DAY PATIENT ADMINISTRATION KIT 1-.7 1 X 2.8ML PKGCOM |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
LEVAQUIN 250MG TABLET |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEVAQUIN 25MG/ML SOLUTION |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEVAQUIN 500MG TABLET |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEVAQUIN 750MG TABLET |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEVAQUIN IV 25MG/ML VIAL |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEVAQUIN/D5W INJ 250/50ML |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEVEMIR 100UNITS/ML VIAL |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEVEMIR FLEXPEN 100UNITS/ML |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM 500 MG TABLET 120 BOT |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
LEVETIRACETAM TABLETS 1000MG 60 BOT |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
LEVETIRACETAM TABLETS 250MG 500 BOT |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
LEVETIRACETAM TABLETS 750MG 500 BOT |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
LEVOBUNOLOL 0.5% EYE DROPS |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LEVOBUNOLOL HCL OPHTHALMIC SOLUTION 0.25% 10ML BOT |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LEVOCARNITINE 100MG/ML SOLUTION ORAL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LEVOCARNITINE 200MG/ML VIAL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LEVOCARNITINE TABLET 330MG 90 BLPK |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LEVOTHYROXINE SODIUM .150MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE SODIUM 100MCG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LEVOTHYROXINE SODIUM 112MCG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LEVOTHYROXINE SODIUM 125MCG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LEVOTHYROXINE SODIUM 175MCG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LEVOTHYROXINE SODIUM 200MCG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LEVOTHYROXINE SODIUM 25MCG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LEVOTHYROXINE SODIUM 300MCG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LEVOTHYROXINE SODIUM 50MCG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LEVOTHYROXINE SODIUM 88MCG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LEXAPRO 10MG TABLET |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEXAPRO 20MG TABLET |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEXAPRO 5MG TABLET |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEXAPRO 5MG/5ML SOLUTION |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEXIVA 50MG/ML SUSPENSION ORAL |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEXIVA 700MG TABLET |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LIDOCAINE 5% OINTMENT |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LIDOCAINE HCL 0.5% VIAL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LIDOCAINE HCL 1% VIAL |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LIDOCAINE HCL 2% JELLY 30ML TUBE |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIDODERM 5% PATCH |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
LINCOCIN 300MG/ML VIAL |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
LINDANE 1% LOTION |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LINDANE SHAMPOO 1MG 2 FLO BOT |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
LIPRAM 4500 CAPSULE EC |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
LISINOPRIL 10MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LISINOPRIL 2.5MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LISINOPRIL 20MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | 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 Preferred Generic |
$4.00 | $12.00 | None |
LISINOPRIL 40MG TABLET (500 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LISINOPRIL 5MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LISINOPRIL-HCTZ 10/12.5 TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LISINOPRIL-HCTZ 20/12.5 TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LITHIUM CARBONATE 150MG CAPSULE |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LITHIUM CARBONATE 300MG TABLET |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LITHIUM CARBONATE 450MG TABLET SA |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LITHIUM CARBONATE 600MG CAP |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LOKARA 0.05% LOTION |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LOPERAMIDE HCL 2MG CAPSULE |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LOTRONEX TABLETS .5MG 30 BOTPL |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LOTRONEX TABLETS 1MG 30 BOTPL |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LOVAZA CAPSULES 1GM 120 BOT |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
LOVENOX 100MG PREFILLED SYR |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
LOVENOX 120MG PREFILLED SYR |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
LOVENOX 150MG PREFILLED SYR |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
LOVENOX 300MG VIAL |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOVENOX 30MG PREFILLED SYRN |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
LOVENOX 40MG PREFILLED SYRN |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
LOVENOX 60MG PREFILLED SYRN |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
LOVENOX 80MG PREFILLED SYRN |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
LOXAPINE 25MG CAPSULE (100 CT) |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
LOXAPINE CAPSULES 10MG 100 BOT |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
LOXAPINE CAPSULES 50MG 100 BOT |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
LOXAPINE CAPSULES 5MG 100 BOT |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
LUPRON DEPOT 3.75MG KIT |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LUPRON DEPOT 7.5MG KIT |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LUPRON DEPOT-3 MONTH KIT |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUPRON DEPOT-3 MONTH KIT |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LUPRON DEPOT-4 MONTH KIT |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LUPRON DEPOT-PED 11.25MG KT |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LUPRON DEPOT-PED 15MG KIT |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LYRICA 100MG CAPSULE |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
LYRICA 150MG CAPSULE |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
LYRICA 200MG CAPSULE |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
LYRICA 225MG CAPSULE |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
LYRICA 25MG CAPSULE |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
LYRICA 300MG CAPSULE |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
LYRICA 50MG CAPSULE |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYRICA 75MG CAPSULE |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
LYSODREN 500MG TABLET |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |