2012 Medicare Part D Plan Formulary Information |
Medco Medicare Prescription Plan - Value (PDP) (S5660-119-0)
Benefit Details
|
The Medco Medicare Prescription Plan - Value (PDP) (S5660-119-0) Formulary Drugs Starting with the Letter L in CMS PDP Region 17 which includes: IL
|
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 |
Preferred Brand Drugs |
25% | 25% | P |
L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE 16 VACCINE 0.04 MG/ML / L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE |
3 |
Preferred Brand Drugs |
25% | 25% | P |
LABETALOL HCL 100MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LABETALOL HCL 200MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LABETALOL HCL 300MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LABETALOL HCL 5MG/20ML VIAL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LACLOTION 12% LOTION |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LACRISERT OPTHALMIC INSERT 5MG 60 BLPK |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LACTATED RINGERS INJECTION |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMICTAL ODT 100mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LAMICTAL ODT 200mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LAMICTAL ODT 25mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LAMICTAL ODT 50mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LAMICTAL XR 100 MG TABLET |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LAMICTAL XR 200 MG TABLET |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LAMICTAL XR 25 MG TABLET |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LAMICTAL XR 250mg/1 30 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LAMICTAL XR 50 MG TABLET |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LAMICTAL XR START KIT (BLUE) |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LAMICTAL XR START KIT (GREEN) |
3 |
Preferred Brand Drugs |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMICTAL XR START KIT (ORANGE) |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LAMIVUDINE 150 MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LAMIVUDINE 300 MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LAMIVUDINE-ZIDOVUDINE TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LAMOTRIGINE 150MG TABLET (60 CT) |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LAMOTRIGINE 200MG TABLET (60 CT) |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LAMOTRIGINE 25MG TABLET (100 CT) |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LAMOTRIGINE TABLET 100MG (100 CT) |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LANOXIN 0.125MG TABLET |
3 |
Preferred Brand Drugs |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LANOXIN 0.25MG TABLET |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LANOXIN 250ug/mL 10 AMPULE in 1 BOX / 2 mL in 1 AMPULE |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LANOXIN PED 0.1MG/ML AMPUL |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LANREOTIDE 240 MG/ML PREFILLED SYRINGE [SOMATULINE] |
5 |
Specialty Tier Drugs |
25% | 25% | None |
lansoprazole 15mg/1 10 BLISTER PACK in 1 CARTON / 10 TABLET, ORALLY DISINTEGRATING, DELAYED RELEASE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | Q:180 /90Days |
Lansoprazole 15mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | Q:180 /90Days |
lansoprazole 30mg/1 10 BLISTER PACK in 1 CARTON / 10 TABLET, ORALLY DISINTEGRATING, DELAYED RELEASE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | Q:180 /90Days |
Lansoprazole 30mg/1 30 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | Q:180 /90Days |
LANTUS 100U/ML VIAL |
3 |
Preferred Brand Drugs |
25% | 25% | Q:30 /30Days |
LANTUS SOLOSTAR INJECTION |
3 |
Preferred Brand Drugs |
25% | 25% | Q:30 /30Days |
LATANOPROST OPHTHALMIC SOLUTION .005% |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LATUDA 20 MG TABLET |
3 |
Preferred Brand Drugs |
25% | 25% | None |
Latuda 40mg/1 |
3 |
Preferred Brand Drugs |
25% | 25% | Q:180 /90Days |
Latuda 80mg/1 |
3 |
Preferred Brand Drugs |
25% | 25% | Q:90 /90Days |
LEENA 7-9-5 TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LEFLUNOMIDE 10MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | Q:90 /90Days |
LEFLUNOMIDE TABLETS |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | Q:102 /90Days |
Lessina 3 POUCH in 1 CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER PACK |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LETAIRIS 10MG TABLET |
5 |
Specialty Tier Drugs |
25% | 25% | P Q:90 /90Days |
LETAIRIS 5MG TABLET |
5 |
Specialty Tier Drugs |
25% | 25% | P Q:90 /90Days |
Letrozole 2.5mg/1 500 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LEUCOVORIN CALCIUM 100MG VL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUCOVORIN CALCIUM 10MG TABLET |
3 |
Preferred Brand Drugs |
25% | 25% | None |
Leucovorin Calcium 15mg/1 24 TABLET in 1 BOTTLE |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LEUCOVORIN CALCIUM 25MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LEUCOVORIN CALCIUM 350MG VL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LEUCOVORIN CALCIUM 5MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LEUKERAN 2MG TABLET |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LEUKINE 500 MCG/ML |
5 |
Specialty Tier Drugs |
25% | 25% | P |
LEUKINE INJECTION 250 MCG/ML |
5 |
Specialty Tier Drugs |
25% | 25% | P |
LEUPROLIDE ACETATE INJECTION |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LEVAQUIN 250mg/1 10 BLISTER PACK in 1 CARTON / 10 TABLET, FILM COATED in 1 BLISTER PACK |
4 |
Non-Preferred Brand Drugs |
40% | 40% | None |
LEVAQUIN 25mg/mL 480 mL in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
40% | 40% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVAQUIN 500mg/1 50 TABLET, FILM COATED in 1 BOTTLE |
4 |
Non-Preferred Brand Drugs |
40% | 40% | None |
LEVAQUIN 750 MG TABLET |
4 |
Non-Preferred Brand Drugs |
40% | 40% | None |
LEVAQUIN INJECTION 25 MG/ML |
4 |
Non-Preferred Brand Drugs |
40% | 40% | None |
LEVAQUIN INJECTION 5 MG/ML |
4 |
Non-Preferred Brand Drugs |
40% | 40% | None |
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LEVETIRACETAM 500 MG TABLET 120 BOT |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LEVETIRACETAM ER 500 MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LEVETIRACETAM ER 750 MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LEVETIRACETAM INJECTION |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LEVETIRACETAM TABLETS 1000MG 60 BOT |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LEVETIRACETAM TABLETS 250MG 500 BOT |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM TABLETS 750MG 500 BOT |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LEVOBUNOLOL 0.25% EYE DROPS |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LEVOCARNITINE 100MG/ML SOLUTION ORAL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | P |
LEVOCARNITINE TABLET 330MG 90 BLPK |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | P |
LEVOCETIRIZINE 2.5 MG/5 ML SOL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Levocetirizine dihydrochloride 5mg/1 30 TABLET in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | Q:90 /90Days |
Levofloxacin 250mg/1 |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Levofloxacin 25mg/mL 1 BOTTLE in 1 CARTON / 100 mL in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Levofloxacin 25mg/mL 1 VIAL in 1 CARTON / 30 mL in 1 VIAL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Levofloxacin 500mg/1 |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levofloxacin 5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Levofloxacin 5mg/mL 24 POUCH in 1 CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Levofloxacin 750mg/1 |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LEVORA-28 TABLET 0.15/30 |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LEVORPHANOL TARTRATE 2mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LEVOTHYROXINE SODIUM .150MG TABLET (100 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LEVOTHYROXINE SODIUM 100MCG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LEVOTHYROXINE SODIUM 112MCG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LEVOTHYROXINE SODIUM 125MCG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE SODIUM 175MCG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LEVOTHYROXINE SODIUM 200MCG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LEVOTHYROXINE SODIUM 25MCG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LEVOTHYROXINE SODIUM 300MCG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LEVOTHYROXINE SODIUM 50MCG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LEVOTHYROXINE SODIUM 88MCG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LEVOXYL 100MCG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LEVOXYL 112MCG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LEVOXYL 125MCG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LEVOXYL 137MCG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LEVOXYL 150MCG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 175MCG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LEVOXYL 200MCG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LEVOXYL 25MCG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LEVOXYL 50MCG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LEVOXYL 75MCG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LEVOXYL 88MCG TABLET (1000 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LEXAPRO 10MG TABLET |
3 |
Preferred Brand Drugs |
25% | 25% | Q:90 /90Days |
LEXAPRO 20MG TABLET |
3 |
Preferred Brand Drugs |
25% | 25% | Q:90 /90Days |
LEXAPRO 5MG TABLET |
3 |
Preferred Brand Drugs |
25% | 25% | Q:90 /90Days |
LEXAPRO 5MG/5ML SOLUTION |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LEXIVA 50mg/mL 225 mL in 1 BOTTLE |
3 |
Preferred Brand Drugs |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEXIVA TABLETS |
5 |
Specialty Tier Drugs |
25% | 25% | None |
LIALDA 1.2G TABLET DELAYED RELEASE |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LIDOCAINE 5% OINTMENT |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LIDOCAINE HCL 0.5% VIAL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LIDOCAINE HCL 1% VIAL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
lidocaine hcl 2% jelly |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LIDOCAINE HCL 2% JELLY 30ML TUBE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LIDODERM 5% PATCH |
3 |
Preferred Brand Drugs |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Lindane 10mg/mL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | Q:1800 /365Days |
LINDANE SHAMPOO 1MG 2 FLO BOT |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | Q:1800 /365Days |
Lioresal 0.05mg/mL |
3 |
Preferred Brand Drugs |
25% | 25% | P |
Lioresal 0.5mg/mL |
3 |
Preferred Brand Drugs |
25% | 25% | P |
Lioresal 2mg/mL |
3 |
Preferred Brand Drugs |
25% | 25% | P |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LIPITOR 10MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | Q:90 /90Days |
LIPITOR 20MG TABLET (5000 CT) |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | Q:90 /90Days |
LIPITOR 40MG TABLET (500 CT) |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | Q:90 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIPITOR 80MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | Q:90 /90Days |
LIPOFEN CAPSULES |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LIPOSYN II 10% IV FAT EMUL |
3 |
Preferred Brand Drugs |
25% | 25% | None |
Liposyn III 1.2; 2.5; 10g/100mL; g/100mL; g/100mL 12 BOTTLE, GLASS in 1 CASE / 250 mL in 1 BOTTLE, |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LIPOSYN III 30% IV FAT EMUL |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LISINOPRIL 10MG TABLET (100 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
Lisinopril 2.5mg 100 TABLET BOTTLE |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LISINOPRIL 20MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LISINOPRIL 30MG TABLET (100 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LISINOPRIL 40MG TABLET (500 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
Lisinopril 5mg/1 1000 TABLET in 1 BOTTLE |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL-HCTZ 10/12.5 TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | Q:90 /90Days |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | Q:360 /90Days |
LISINOPRIL-HCTZ 20/12.5 TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | Q:90 /90Days |
LITHIUM CARBONATE 150MG CAPSULE |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LITHIUM CARBONATE 300MG TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
Lithium Carbonate 450mg/1 |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LITHIUM CARBONATE CAPSULES |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LOCOID LOTN 0.1 % |
3 |
Preferred Brand Drugs |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LODOSYN TAB 25MG |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LOPERAMIDE HCL 2MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LOSARTAN POTASSIUM 100 MG TAB |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | Q:90 /90Days |
LOSARTAN POTASSIUM 25 MG TAB |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | Q:180 /90Days |
LOSARTAN POTASSIUM 50 MG TAB |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | Q:180 /90Days |
LOSARTAN-HCTZ 100-12.5 MG TAB |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | Q:90 /90Days |
LOSARTAN-HCTZ 100-25 MG TAB |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | Q:90 /90Days |
LOSARTAN-HCTZ 50-12.5 MG TAB |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | Q:180 /90Days |
LOTEMAX 0.5% EYE DROPS |
3 |
Preferred Brand Drugs |
25% | 25% | None |
Lotemax 5mg/g 1 TUBE in 1 CARTON / 3.5 g in 1 TUBE |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LOTRONEX TABLETS .5MG 30 BOTPL |
3 |
Preferred Brand Drugs |
25% | 25% | Q:180 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOTRONEX TABLETS 1MG 30 BOTPL |
3 |
Preferred Brand Drugs |
25% | 25% | Q:180 /90Days |
Lovastatin 10mg 60 TABLET BOTTLE |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | Q:90 /90Days |
Lovastatin 20mg 500 TABLET BOTTLE |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | Q:180 /90Days |
LOVASTATIN 40 MG ORAL TABLET |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | Q:180 /90Days |
LOVAZA 1g/ 120 LIQUID FILLED CAPSULES in BOTTLE |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LOVENOX 300MG VIAL |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LOW-OGESTREL-28 TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LOXAPINE 25MG CAPSULE (100 CT) |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LOXAPINE CAPSULES 10MG 100 BOT |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LOXAPINE CAPSULES 50MG 100 BOT |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LOXAPINE CAPSULES 5MG 100 BOT |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUMIGAN 0.03% EYE DROPS |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LUMIGAN 0.1mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LUNESTA 2MG TABLET |
4 |
Non-Preferred Brand Drugs |
40% | 40% | None |
LUNESTA 3MG TABLET |
4 |
Non-Preferred Brand Drugs |
40% | 40% | None |
LUNESTA TABLETS 1MG 30 BOT |
4 |
Non-Preferred Brand Drugs |
40% | 40% | None |
Lupron Depot 1 KIT in 1 CARTON |
5 |
Specialty Tier Drugs |
25% | 25% | None |
LUPRON DEPOT 11.25 MG 3MO KIT |
5 |
Specialty Tier Drugs |
25% | 25% | None |
LUPRON DEPOT 22.5 MG 3MO KIT [LUPRON] |
5 |
Specialty Tier Drugs |
25% | 25% | None |
LUPRON DEPOT 3.75 MG KIT |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LUPRON DEPOT 7.5 MG KIT |
5 |
Specialty Tier Drugs |
25% | 25% | None |
LUPRON DEPOT-4 MONTH KIT |
5 |
Specialty Tier Drugs |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUPRON DEPOT-PED 11.25 MG KIT |
5 |
Specialty Tier Drugs |
25% | 25% | None |
LUPRON DEPOT-PED 15 MG KIT |
5 |
Specialty Tier Drugs |
25% | 25% | None |
LUTERA 0.1-0.02 TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $16.00 | None |
LUXIQ 0.12% FOAM |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LYRICA 100MG CAPSULE |
3 |
Preferred Brand Drugs |
25% | 25% | Q:270 /90Days |
LYRICA 150MG CAPSULE |
3 |
Preferred Brand Drugs |
25% | 25% | Q:270 /90Days |
LYRICA 200MG CAPSULE |
3 |
Preferred Brand Drugs |
25% | 25% | Q:270 /90Days |
LYRICA 225MG CAPSULE |
3 |
Preferred Brand Drugs |
25% | 25% | Q:180 /90Days |
LYRICA 25MG CAPSULE |
3 |
Preferred Brand Drugs |
25% | 25% | Q:270 /90Days |
LYRICA 300MG CAPSULE |
3 |
Preferred Brand Drugs |
25% | 25% | Q:180 /90Days |
LYRICA 50MG CAPSULE |
3 |
Preferred Brand Drugs |
25% | 25% | Q:270 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYRICA 75MG CAPSULE |
3 |
Preferred Brand Drugs |
25% | 25% | Q:270 /90Days |
LYSODREN 500MG TABLET |
3 |
Preferred Brand Drugs |
25% | 25% | None |
LYSTEDA TABLETS |
4 |
Non-Preferred Brand Drugs |
40% | 40% | Q:120 /90Days |