2010 Medicare Part D Plan Formulary Information |
Humana Gold Choice H2944-044 (PFFS) (H2944-044-0)
Benefit Details
|
The Humana Gold Choice H2944-044 (PFFS) (H2944-044-0) Formulary Drugs Starting with the Letter L in Statewide County, MI: CMS MA Region 11 which includes: MI
|
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 |
$7.00 | $0.00 | None |
LABETALOL HCL 200MG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LABETALOL HCL 300MG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LABETALOL HCL 5MG/20ML VIAL |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LAC HYDRIN LOTION 12% 225 G BOTPL |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LAC-HYDRIN 12% CREAM |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LACLOTION 12% LOTION |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LACRISERT OPTHALMIC INSERT 5MG 60 BLPK |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LACTATED RINGERS INJECTION |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LACTATED RINGERS IRRIGATION 20-30-600MG 3000ML BAG |
1 |
Tier 1 |
$7.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LAMICTAL ODT 100MG TABLET 30 EA |
3 |
Tier 3 |
$80.00 | $200.00 | S Q:120 /30Days |
LAMICTAL ODT 200MG TABLET 30 EA |
3 |
Tier 3 |
$80.00 | $200.00 | S Q:90 /30Days |
LAMICTAL ODT 25MG TABLET 30 EA |
3 |
Tier 3 |
$80.00 | $200.00 | S Q:90 /30Days |
LAMICTAL ODT 50MG TABLET 30 EA |
3 |
Tier 3 |
$80.00 | $200.00 | S Q:90 /30Days |
LAMOTRIGINE 150MG TABLET (60 CT) |
1 |
Tier 1 |
$7.00 | $0.00 | Q:90 /30Days |
LAMOTRIGINE 200MG TABLET (60 CT) |
1 |
Tier 1 |
$7.00 | $0.00 | Q:60 /30Days |
LAMOTRIGINE 25MG TABLET (100 CT) |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LAMOTRIGINE TABLET 100MG (100 CT) |
1 |
Tier 1 |
$7.00 | $0.00 | Q:150 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LANOXIN 0.125MG TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LANOXIN 0.25MG TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LANOXIN 0.25MG/ML AMPUL |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LANOXIN PED 0.1MG/ML AMPUL |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LANREOTIDE INJECTION 30MG |
4 |
Tier 4 |
33% | N/A | P Q:1 /28Days |
LANTUS 100U/ML VIAL |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LANTUS INJECTION |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LARIAM 250MG TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LASIX 20MG TABLET (1000 CT) |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LASIX 40MG TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LASIX 80MG TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEENA 7-9-5 TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEFLUNOMIDE 10MG TABLET (500 CT) |
1 |
Tier 1 |
$7.00 | $0.00 | Q:30 /30Days |
LEFLUNOMIDE 20MG TABLET (500 CT) |
1 |
Tier 1 |
$7.00 | $0.00 | Q:30 /30Days |
LESCOL 20MG CAPSULE |
2 |
Tier 2 |
$40.00 | $100.00 | Q:60 /30Days |
LESCOL 40MG CAPSULE |
2 |
Tier 2 |
$40.00 | $100.00 | Q:60 /30Days |
LESCOL XL 80MG TABLET SA |
2 |
Tier 2 |
$40.00 | $100.00 | Q:30 /30Days |
LESSINA 0.1-0.02 TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LETAIRIS 10MG TABLET |
4 |
Tier 4 |
33% | N/A | P Q:30 /30Days |
LETAIRIS 5MG TABLET |
4 |
Tier 4 |
33% | N/A | P Q:30 /30Days |
LEUCOVORIN CALCIUM 100MG VL |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEUCOVORIN CALCIUM 10MG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUCOVORIN CALCIUM 15MG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEUCOVORIN CALCIUM 25MG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEUCOVORIN CALCIUM 350MG VL |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEUCOVORIN CALCIUM 5MG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEUKERAN 2MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LEUKINE 250MCG VIAL |
4 |
Tier 4 |
33% | N/A | P |
LEUKINE LIQUID INJECTION 500MCG/VIAL 500 MCG X 5 VILMD CRTN |
4 |
Tier 4 |
33% | N/A | P |
LEUPROLIDE ACETATE INJECTION 14 DAY PATIENT ADMINISTRATION KIT 1-.7 1 X 2.8ML PKGCOM |
2 |
Tier 2 |
$40.00 | $100.00 | P |
LEUSTATIN 1MG/ML VIAL |
4 |
Tier 4 |
33% | N/A | None |
LEVAQUIN 250MG TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LEVAQUIN 25MG/ML SOLUTION |
3 |
Tier 3 |
$80.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVAQUIN 500MG TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LEVAQUIN 750MG TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LEVAQUIN IV 25MG/ML VIAL |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LEVAQUIN/D5W INJ 250/50ML |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LEVATOL 20MG TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LEVEMIR 100UNITS/ML VIAL |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LEVEMIR FLEXPEN 100UNITS/ML |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT |
1 |
Tier 1 |
$7.00 | $0.00 | Q:900 /30Days |
LEVETIRACETAM 500 MG TABLET 120 BOT |
1 |
Tier 1 |
$7.00 | $0.00 | Q:120 /30Days |
LEVETIRACETAM TABLETS 1000MG 60 BOT |
1 |
Tier 1 |
$7.00 | $0.00 | Q:90 /30Days |
LEVETIRACETAM TABLETS 250MG 500 BOT |
1 |
Tier 1 |
$7.00 | $0.00 | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM TABLETS 750MG 500 BOT |
1 |
Tier 1 |
$7.00 | $0.00 | Q:120 /30Days |
LEVO-DROMORAN 2MG/ML AMPUL |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LEVOBUNOLOL 0.5% EYE DROPS |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEVOBUNOLOL HCL OPHTHALMIC SOLUTION 0.25% 10ML BOT |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEVOCARNITINE 100MG/ML SOLUTION ORAL |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LEVOCARNITINE 200MG/ML VIAL |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LEVOCARNITINE TABLET 330MG 90 BLPK |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LEVORA-28 TABLET 0.15/30 |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEVORPHANOL 2MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LEVOTHROID 100MCG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEVOTHROID 112MCG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHROID 125MCG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEVOTHROID 137MCG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEVOTHROID 150MCG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEVOTHROID 175MCG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEVOTHROID 200MCG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEVOTHROID 25MCG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEVOTHROID 300MCG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEVOTHROID 50MCG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEVOTHROID 75MCG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEVOTHROID 88MCG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT) |
1 |
Tier 1 |
$7.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE SODIUM .150MG TABLET (100 CT) |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 100MCG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 112MCG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 125MCG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 175MCG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 200MCG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 25MCG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 300MCG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 50MCG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 88MCG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 100MCG TABLET (1000 CT) |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LEVOXYL 112MCG TABLET (1000 CT) |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LEVOXYL 125MCG TABLET (1000 CT) |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LEVOXYL 137MCG TABLET (1000 CT) |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LEVOXYL 150MCG TABLET (1000 CT) |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LEVOXYL 175MCG TABLET (1000 CT) |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LEVOXYL 200MCG TABLET (1000 CT) |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LEVOXYL 25MCG TABLET (1000 CT) |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LEVOXYL 50MCG TABLET (1000 CT) |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LEVOXYL 75MCG TABLET (1000 CT) |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LEVOXYL 88MCG TABLET (1000 CT) |
2 |
Tier 2 |
$40.00 | $100.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEXAPRO 10MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | Q:30 /30Days |
LEXAPRO 20MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | Q:30 /30Days |
LEXAPRO 5MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | Q:30 /30Days |
LEXAPRO 5MG/5ML SOLUTION |
2 |
Tier 2 |
$40.00 | $100.00 | Q:600 /30Days |
LEXIVA 50MG/ML SUSPENSION ORAL |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LEXIVA 700MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LIDOCAINE 5% OINTMENT |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LIDOCAINE HCL 0.5% VIAL |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LIDOCAINE HCL 1% VIAL |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LIDOCAINE HCL 2% JELLY |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LIDOCAINE HCL 2% JELLY 30ML TUBE |
1 |
Tier 1 |
$7.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LIDODERM 5% PATCH |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:90 /30Days |
LIMBITROL TABLET 5-12.5MG |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LINCOCIN 300MG/ML VIAL |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LINDANE 1% LOTION |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LINDANE SHAMPOO 1MG 2 FLO BOT |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LIOTHYRONINE SODIUM INJECTION 10MCG |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT |
1 |
Tier 1 |
$7.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LIPITOR 10MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | Q:30 /30Days |
LIPITOR 20MG TABLET (5000 CT) |
2 |
Tier 2 |
$40.00 | $100.00 | Q:30 /30Days |
LIPITOR 40MG TABLET (500 CT) |
2 |
Tier 2 |
$40.00 | $100.00 | Q:30 /30Days |
LIPITOR 80MG TABLET |
2 |
Tier 2 |
$40.00 | $100.00 | Q:30 /30Days |
LIPRAM 4500 CAPSULE EC |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LIPRAM-PN10 CAPSULE EC |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LIPRAM-PN16 CAPSULE EC |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LIPRAM-PN20 CAPSULE EC |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LIPRAM-UL12 CAPSULE EC |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LIPRAM-UL18 CAPSULE EC |
3 |
Tier 3 |
$80.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIPRAM-UL20 CAPSULE EC |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LIQUADD 5MG/5ML SOLUTION |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LISINOPRIL 10MG TABLET (100 CT) |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LISINOPRIL 2.5MG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LISINOPRIL 20MG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LISINOPRIL 30MG TABLET (100 CT) |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LISINOPRIL 40MG TABLET (500 CT) |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LISINOPRIL 5MG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LISINOPRIL-HCTZ 10/12.5 TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT) |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LISINOPRIL-HCTZ 20/12.5 TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LITHIUM CARBONATE 150MG CAPSULE |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LITHIUM CARBONATE 300MG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LITHIUM CARBONATE 450MG TABLET SA |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LITHIUM CARBONATE 600MG CAP |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LITHOSTAT 250MG TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LO/OVRAL-28 TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LOCOID 0.1% OINTMENT 15GM TUBE |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LOCOID 0.1% SOLUTION |
3 |
Tier 3 |
$80.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOCOID LIPOCREAM CREAM 0.1% 15 GM TUBE |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LOCOID LOTN 0.1 % |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LODOSYN 25MG TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LOESTRIN 21 1.5/30 TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LOESTRIN 21 1/20 TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LOESTRIN 24 FE TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LOESTRIN FE 1-0.02MG TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LOESTRIN FE 1.5/30 28 DAY REGIMEN TABLETS 30;1.5;75MCG;MG;MG 5 DISPENSERS CTR |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LOKARA 0.05% LOTION |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LOMOTIL LIQ 2.5/5 |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LOMOTIL TABLET 0.025-2.5MG (500 CT) |
3 |
Tier 3 |
$80.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LONOX 2.5MG TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LOPERAMIDE HCL 2MG CAPSULE |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LOPID 600MG TABLET (500 CT) |
3 |
Tier 3 |
$80.00 | $200.00 | Q:60 /30Days |
LOPRESSOR 100MG TABLET (100 CT) |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LOPRESSOR 1MG/ML AMPUL |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LOPRESSOR 50MG TABLET (100 CT) |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LOPRESSOR HCT 100/25 TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LOPRESSOR HCT 50/25 TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LOPROX 1% SHAMPOO |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LOTENSIN 10MG TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LOTENSIN 20MG TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOTENSIN 40MG TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LOTENSIN 5MG TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LOTENSIN HCT 10/12.5 TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LOTENSIN HCT 20/12.5 TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LOTENSIN HCT 20/25 TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LOTENSIN HCT 5/6.25 TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LOTRISONE CREAM |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LOTRISONE LOTION |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LOTRONEX TABLETS .5MG 30 BOTPL |
2 |
Tier 2 |
$40.00 | $100.00 | Q:60 /30Days |
LOTRONEX TABLETS 1MG 30 BOTPL |
2 |
Tier 2 |
$40.00 | $100.00 | Q:60 /30Days |
LOVASTATIN 10MG TABLET (100 CT) |
1 |
Tier 1 |
$7.00 | $0.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOVASTATIN 20MG TABLET (1000 CT) |
1 |
Tier 1 |
$7.00 | $0.00 | Q:60 /30Days |
LOVASTATIN 40MG TABLET (100 CT) |
1 |
Tier 1 |
$7.00 | $0.00 | Q:60 /30Days |
LOVAZA CAPSULES 1GM 120 BOT |
2 |
Tier 2 |
$40.00 | $100.00 | Q:120 /30Days |
LOVENOX 100MG PREFILLED SYR |
3 |
Tier 3 |
$80.00 | $200.00 | Q:14 /30Days |
LOVENOX 120MG PREFILLED SYR |
3 |
Tier 3 |
$80.00 | $200.00 | Q:14 /30Days |
LOVENOX 150MG PREFILLED SYR |
3 |
Tier 3 |
$80.00 | $200.00 | Q:14 /30Days |
LOVENOX 300MG VIAL |
3 |
Tier 3 |
$80.00 | $200.00 | Q:14 /30Days |
LOVENOX 30MG PREFILLED SYRN |
3 |
Tier 3 |
$80.00 | $200.00 | Q:14 /30Days |
LOVENOX 40MG PREFILLED SYRN |
3 |
Tier 3 |
$80.00 | $200.00 | Q:14 /30Days |
LOVENOX 60MG PREFILLED SYRN |
3 |
Tier 3 |
$80.00 | $200.00 | Q:14 /30Days |
LOVENOX 80MG PREFILLED SYRN |
3 |
Tier 3 |
$80.00 | $200.00 | Q:14 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOW-OGESTREL-28 TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LOXAPINE 25MG CAPSULE (100 CT) |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LOXAPINE CAPSULES 10MG 100 BOT |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LOXAPINE CAPSULES 50MG 100 BOT |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LOXAPINE CAPSULES 5MG 100 BOT |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LOXITANE 10MG CAPSULE |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LOXITANE 25MG CAPSULE |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LOXITANE 50MG CAPSULE |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LOXITANE 5MG CAPSULE |
2 |
Tier 2 |
$40.00 | $100.00 | None |
LUFYLLIN 200MG TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LUFYLLIN-400 TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUMIGAN 0.03% EYE DROPS |
2 |
Tier 2 |
$40.00 | $100.00 | Q:3 /25Days |
LUPRON 2-WK 1MG/0.2ML KIT |
4 |
Tier 4 |
33% | N/A | P Q:28 /30Days |
LUPRON DEPOT 3.75MG KIT |
3 |
Tier 3 |
$80.00 | $200.00 | P |
LUPRON DEPOT 7.5MG KIT |
3 |
Tier 3 |
$80.00 | $200.00 | P |
LUPRON DEPOT-3 MONTH KIT |
3 |
Tier 3 |
$80.00 | $200.00 | P |
LUPRON DEPOT-3 MONTH KIT |
3 |
Tier 3 |
$80.00 | $200.00 | P |
LUPRON DEPOT-4 MONTH KIT |
3 |
Tier 3 |
$80.00 | $200.00 | P |
LUPRON DEPOT-PED 11.25MG KT |
4 |
Tier 4 |
33% | N/A | P |
LUPRON DEPOT-PED 15MG KIT |
4 |
Tier 4 |
33% | N/A | P |
LUTERA 0.1-0.02 TABLET |
1 |
Tier 1 |
$7.00 | $0.00 | None |
LUXIQ 0.12% FOAM |
3 |
Tier 3 |
$80.00 | $200.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYBREL 90-20MCG TABLET |
3 |
Tier 3 |
$80.00 | $200.00 | None |
LYRICA 100MG CAPSULE |
3 |
Tier 3 |
$80.00 | $200.00 | S Q:90 /30Days |
LYRICA 150MG CAPSULE |
3 |
Tier 3 |
$80.00 | $200.00 | S Q:90 /30Days |
LYRICA 200MG CAPSULE |
3 |
Tier 3 |
$80.00 | $200.00 | S Q:90 /30Days |
LYRICA 225MG CAPSULE |
3 |
Tier 3 |
$80.00 | $200.00 | S Q:60 /30Days |
LYRICA 25MG CAPSULE |
3 |
Tier 3 |
$80.00 | $200.00 | S Q:90 /30Days |
LYRICA 300MG CAPSULE |
3 |
Tier 3 |
$80.00 | $200.00 | S Q:60 /30Days |
LYRICA 50MG CAPSULE |
3 |
Tier 3 |
$80.00 | $200.00 | S Q:90 /30Days |
LYRICA 75MG CAPSULE |
3 |
Tier 3 |
$80.00 | $200.00 | S Q:90 /30Days |
LYSODREN 500MG TABLET |
4 |
Tier 4 |
33% | N/A | None |