2011 Medicare Part D Plan Formulary Information |
Community CCRx Choice (PDP) (S5803-170-0)
Benefit Details
|
The Community CCRx Choice (PDP) (S5803-170-0) Formulary Drugs Starting with the Letter L in CMS PDP Region 33 which includes: HI
|
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 |
L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE 16 VACCINE 0.04 MG/ML / L1 PROTEIN, HUMAN PAPILLOMAVIRU |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | None |
L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE 16 VACCINE 0.04 MG/ML / L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | None |
LABETALOL HCL 100MG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LABETALOL HCL 200MG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LABETALOL HCL 300MG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LACLOTION 12% LOTION |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LACRISERT OPTHALMIC INSERT 5MG 60 BLPK |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | None |
LACTATED RINGERS IRRIGATION 20-30-600MG 3000ML BAG |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LAMICTAL ODT 100MG TABLET 30 EA |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMICTAL ODT 200MG TABLET 30 EA |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | P |
LAMICTAL ODT 25MG TABLET 30 EA |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | P |
LAMICTAL ODT 50MG TABLET 30 EA |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | P |
LAMOTRIGINE 150MG TABLET (60 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LAMOTRIGINE 200MG TABLET (60 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LAMOTRIGINE 25MG TABLET (100 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
LAMOTRIGINE TABLET 100MG (100 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LANOXIN 0.125MG TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
LANOXIN 0.25MG TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LANOXIN 0.25MG/ML AMPUL |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
LANOXIN PED 0.1MG/ML AMPUL |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
LANREOTIDE 240 MG/ML PREFILLED SYRINGE [SOMATULINE] |
4 |
Specialty Tier |
33% | N/A | P |
LANREOTIDE INJECTION 30MG |
4 |
Specialty Tier |
33% | N/A | P |
LANTUS 100U/ML VIAL |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
LANTUS SOLOSTAR INJECTION |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
LEENA 7-9-5 TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:28 /28Days |
LEFLUNOMIDE 10MG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEFLUNOMIDE TABLETS |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LESSINA 0.1-0.02 TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:28 /28Days |
LETAIRIS 10MG TABLET |
4 |
Specialty Tier |
33% | N/A | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LETAIRIS 5MG TABLET |
4 |
Specialty Tier |
33% | N/A | S Q:30 /30Days |
LEUCOVORIN CALCIUM 100MG VL |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEUCOVORIN CALCIUM 10MG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEUCOVORIN CALCIUM 15MG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEUCOVORIN CALCIUM 25MG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEUCOVORIN CALCIUM 350MG VL |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEUCOVORIN CALCIUM 5MG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEUKERAN 2MG TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
LEUKINE 250MCG VIAL |
4 |
Specialty Tier |
33% | N/A | P |
LEUKINE LIQUID INJECTION 500MCG/VIAL 500 MCG X 5 VILMD CRTN |
4 |
Specialty Tier |
33% | N/A | P |
LEUPROLIDE 11.25 MG/ML PREFILLED SYRINGE [LUPRON] |
4 |
Specialty Tier |
33% | N/A | P Q:1 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUPROLIDE 15 MG/ML PREFILLED SYRINGE [LUPRON] |
4 |
Specialty Tier |
33% | N/A | P Q:1 /28Days |
LEUPROLIDE 3.75 MG/ML PREFILLED SYRINGE [LUPRON] |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | P Q:1 /30Days |
LEUPROLIDE ACETATE INJECTION |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | P |
LEUPROLIDE7.5 MG/ML PREFILLED SYRINGE [LUPRON] |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | P Q:1 /84Days |
LEVAQUIN 750 MG TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:30 /30Days |
LEVAQUIN INJECTION 25 MG/ML |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | None |
LEVAQUIN INJECTION 5 MG/ML |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | None |
LEVEMIR 100UNITS/ML VIAL |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
LEVEMIR FLEXPEN 100UNITS/ML |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:900 /30Days |
LEVETIRACETAM 500 MG TABLET 120 BOT |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM INJECTION |
4 |
Specialty Tier |
33% | N/A | None |
LEVETIRACETAM TABLETS 1000MG 60 BOT |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:90 /30Days |
LEVETIRACETAM TABLETS 250MG 500 BOT |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:90 /30Days |
LEVETIRACETAM TABLETS 750MG 500 BOT |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:120 /30Days |
LEVOBUNOLOL 0.25% EYE DROPS |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOCARNITINE 100MG/ML SOLUTION ORAL |
1 |
Generic and Preferred Brand |
$0.00 | N/A | P |
LEVOCARNITINE 200MG/ML VIAL |
1 |
Generic and Preferred Brand |
$0.00 | N/A | P |
LEVOCARNITINE TABLET 330MG 90 BLPK |
1 |
Generic and Preferred Brand |
$0.00 | N/A | P |
LEVOFLOXACIN 25 MG/ML ORAL SOLUTION [LEVAQUIN] |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
LEVOFLOXACIN 250 MG ORAL TABLET [LEVAQUIN] |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOFLOXACIN 500 MG ORAL TABLET [LEVAQUIN] |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:30 /30Days |
LEVORA-28 TABLET 0.15/30 |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:28 /28Days |
LEVOTHROID 100MCG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOTHROID 112MCG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOTHROID 125MCG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOTHROID 137MCG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOTHROID 150MCG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOTHROID 175MCG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOTHROID 200MCG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOTHROID 25MCG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOTHROID 300MCG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHROID 50MCG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOTHROID 75MCG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOTHROID 88MCG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOTHYROXINE SODIUM .150MG TABLET (100 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOTHYROXINE SODIUM 100MCG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOTHYROXINE SODIUM 112MCG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOTHYROXINE SODIUM 125MCG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOTHYROXINE SODIUM 137MCG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOTHYROXINE SODIUM 175MCG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOTHYROXINE SODIUM 200MCG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE SODIUM 25MCG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOTHYROXINE SODIUM 300MCG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOTHYROXINE SODIUM 50MCG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOTHYROXINE SODIUM 88MCG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOXYL 100MCG TABLET (1000 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOXYL 112MCG TABLET (1000 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOXYL 125MCG TABLET (1000 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOXYL 137MCG TABLET (1000 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOXYL 150MCG TABLET (1000 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOXYL 175MCG TABLET (1000 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOXYL 200MCG TABLET (1000 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 25MCG TABLET (1000 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOXYL 50MCG TABLET (1000 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOXYL 75MCG TABLET (1000 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEVOXYL 88MCG TABLET (1000 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LEXAPRO 10MG TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:45 /30Days |
LEXAPRO 20MG TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:30 /30Days |
LEXAPRO 5MG TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:30 /30Days |
LEXAPRO 5MG/5ML SOLUTION |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:600 /30Days |
LEXIVA 50MG/ML SUSPENSION ORAL |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
LEXIVA TABLETS |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
LIDOCAINE 5% OINTMENT |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIDOCAINE HCL 0.5% VIAL |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LIDOCAINE HCL 1% VIAL |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LIDOCAINE HCL 2% JELLY |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LIDOCAINE HCL 2% JELLY 30ML TUBE |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LIDODERM 5% PATCH |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:3 /1Days |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIPITOR 10MG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:30 /30Days |
LIPITOR 20MG TABLET (5000 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:30 /30Days |
LIPITOR 40MG TABLET (500 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:30 /30Days |
LIPITOR 80MG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:30 /30Days |
LISINOPRIL 10MG TABLET (100 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LISINOPRIL 2.5MG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LISINOPRIL 20MG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LISINOPRIL 30MG TABLET (100 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LISINOPRIL 40MG TABLET (500 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LISINOPRIL TABLETS 5 MG |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LISINOPRIL-HCTZ 10/12.5 TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LISINOPRIL-HCTZ 20/12.5 TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LITHIUM CARBONATE 150MG CAPSULE |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LITHIUM CARBONATE 300MG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LITHIUM CARBONATE CAPSULES |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LITHIUM CIT 8MEQ/5ML SYRUP |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LITHIUM ER 450 MG TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LODOSYN 25MG TABLET |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | None |
LOKARA 0.05% LOTION |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOPERAMIDE HCL 2MG CAPSULE |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LOSARTAN POTASSIUM 100 MG TAB |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:30 /30Days |
LOSARTAN POTASSIUM 25 MG TAB |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:30 /30Days |
LOSARTAN POTASSIUM 50 MG TAB |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:30 /30Days |
LOSARTAN-HCTZ 100-12.5 MG TAB |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:30 /30Days |
LOSARTAN-HCTZ 100-25 MG TAB |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:30 /30Days |
LOSARTAN-HCTZ 50-12.5 MG TAB |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:30 /30Days |
LOTEMAX 0.5% EYE DROPS |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |
LOTREL 10/20MG CAPSULE |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:30 /30Days |
LOTREL 10/40MG CAPSULE |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:30 /30Days |
LOTREL 2.5/10MG CAPSULE |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOTREL 5/10MG CAPSULE |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:30 /30Days |
LOTREL 5/20MG CAPSULE |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:30 /30Days |
LOTREL 5/40MG CAPSULE |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:30 /30Days |
LOTRONEX TABLETS .5MG 30 BOTPL |
4 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
LOTRONEX TABLETS 1MG 30 BOTPL |
4 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
LOVASTATIN 10MG TABLET (100 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:30 /30Days |
LOVASTATIN 20 MG ORAL TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:60 /30Days |
LOVASTATIN 40 MG ORAL TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:60 /30Days |
LOVAZA CAPSULES 1GM 120 BOT |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | Q:120 /30Days |
LOVENOX 100MG PREFILLED SYR |
4 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
LOVENOX 120MG PREFILLED SYR |
4 |
Specialty Tier |
33% | N/A | Q:24 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOVENOX 150MG PREFILLED SYR |
4 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
LOVENOX 300MG VIAL |
4 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
LOVENOX 30MG PREFILLED SYRN |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | Q:9 /30Days |
LOVENOX 40MG PREFILLED SYRN |
3 |
Non-Preferred Generic/ Non-Preferred Brand |
$65.00 | N/A | Q:12 /30Days |
LOVENOX 60MG PREFILLED SYRN |
4 |
Specialty Tier |
33% | N/A | Q:18 /30Days |
LOVENOX 80MG PREFILLED SYRN |
4 |
Specialty Tier |
33% | N/A | Q:24 /30Days |
LOW-OGESTREL-28 TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:28 /28Days |
LOXAPINE 25MG CAPSULE (100 CT) |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LOXAPINE CAPSULES 10MG 100 BOT |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LOXAPINE CAPSULES 50MG 100 BOT |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
LOXAPINE CAPSULES 5MG 100 BOT |
1 |
Generic and Preferred Brand |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUNESTA 2MG TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:30 /30Days |
LUNESTA 3MG TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:30 /30Days |
LUNESTA TABLETS 1MG 30 BOT |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:30 /30Days |
LUTERA 0.1-0.02 TABLET |
1 |
Generic and Preferred Brand |
$0.00 | N/A | Q:28 /28Days |
LYRICA 100MG CAPSULE |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:90 /30Days |
LYRICA 150MG CAPSULE |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:90 /30Days |
LYRICA 200MG CAPSULE |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:90 /30Days |
LYRICA 225MG CAPSULE |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:90 /30Days |
LYRICA 25MG CAPSULE |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:90 /30Days |
LYRICA 300MG CAPSULE |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:90 /30Days |
LYRICA 50MG CAPSULE |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYRICA 75MG CAPSULE |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | Q:90 /30Days |
LYSODREN 500MG TABLET |
2 |
Non-Preferred Generic/Preferred Brand |
$35.00 | N/A | None |