2012 Medicare Part D Plan Formulary Information |
WindsorSterling Gold Plus Plan (PPO) (H5162-018-0)
Benefit Details
|
The WindsorSterling Gold Plus Plan (PPO) (H5162-018-0) Formulary Drugs Starting with the Letter L in BOONE County, KY: CMS MA Region 13 which includes: KY
|
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 |
Tier 3 |
$36.00 | $108.00 | None |
L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE 16 VACCINE 0.04 MG/ML / L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE |
3 |
Tier 3 |
$36.00 | $108.00 | None |
LABETALOL HCL 100MG TABLET |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LABETALOL HCL 200MG TABLET |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LABETALOL HCL 300MG TABLET |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LABETALOL HCL 5MG/20ML VIAL |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LACTATED RINGERS INJECTION |
2 |
Tier 2 |
$16.00 | $48.00 | P |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LAMIVUDINE 150 MG TABLET |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LAMIVUDINE 300 MG TABLET |
2 |
Tier 2 |
$16.00 | $48.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMIVUDINE-ZIDOVUDINE TABLET |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LAMOTRIGINE 150MG TABLET (60 CT) |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LAMOTRIGINE 200MG TABLET (60 CT) |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LAMOTRIGINE 25MG TABLET (100 CT) |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LAMOTRIGINE TABLET 100MG (100 CT) |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LANOXIN 0.125MG TABLET |
4 |
Tier 4 |
$90.00 | $270.00 | None |
LANOXIN 0.25MG TABLET |
4 |
Tier 4 |
$90.00 | $270.00 | None |
LANOXIN PED 0.1MG/ML AMPUL |
4 |
Tier 4 |
$90.00 | $270.00 | P |
LANREOTIDE 240 MG/ML PREFILLED SYRINGE [SOMATULINE] |
5 |
Tier 5 |
30% | 30% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LANTUS 100U/ML VIAL |
3 |
Tier 3 |
$36.00 | $108.00 | None |
LANTUS SOLOSTAR INJECTION |
3 |
Tier 3 |
$36.00 | $108.00 | None |
LATANOPROST OPHTHALMIC SOLUTION .005% |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LATUDA 20 MG TABLET |
4 |
Tier 4 |
$90.00 | $270.00 | Q:60 /30Days |
Latuda 40mg/1 |
4 |
Tier 4 |
$90.00 | $270.00 | Q:60 /30Days |
Latuda 80mg/1 |
4 |
Tier 4 |
$90.00 | $270.00 | Q:60 /30Days |
LEFLUNOMIDE 10MG TABLET |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEFLUNOMIDE TABLETS |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LETAIRIS 10MG TABLET |
5 |
Tier 5 |
30% | 30% | P |
LETAIRIS 5MG TABLET |
5 |
Tier 5 |
30% | 30% | P |
Letrozole 2.5mg/1 500 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
2 |
Tier 2 |
$16.00 | $48.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUCOVORIN CALCIUM 100MG VL |
2 |
Tier 2 |
$16.00 | $48.00 | P |
LEUCOVORIN CALCIUM 10MG TABLET |
2 |
Tier 2 |
$16.00 | $48.00 | None |
Leucovorin Calcium 15mg/1 24 TABLET in 1 BOTTLE |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEUCOVORIN CALCIUM 25MG TABLET |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEUCOVORIN CALCIUM 350MG VL |
2 |
Tier 2 |
$16.00 | $48.00 | P |
LEUCOVORIN CALCIUM 5MG TABLET |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEUKERAN 2MG TABLET |
3 |
Tier 3 |
$36.00 | $108.00 | None |
LEUKINE 500 MCG/ML |
5 |
Tier 5 |
30% | 30% | None |
LEUKINE INJECTION 250 MCG/ML |
5 |
Tier 5 |
30% | 30% | None |
LEUPROLIDE ACETATE INJECTION |
2 |
Tier 2 |
$16.00 | $48.00 | P |
LEVALBUTEROL 1.25 MG/0.5 ML |
1 |
Tier 1 |
$5.00 | $15.00 | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVATOL 20MG TABLET |
4 |
Tier 4 |
$90.00 | $270.00 | None |
LEVEMIR 100UNITS/ML VIAL |
3 |
Tier 3 |
$36.00 | $108.00 | None |
Levemir 14.2mg/mL 5 SYRINGE, PLASTIC in 1 CARTON / 3 mL in 1 SYRINGE, PLASTIC |
3 |
Tier 3 |
$36.00 | $108.00 | None |
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEVETIRACETAM 500 MG TABLET 120 BOT |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEVETIRACETAM ER 500 MG TABLET |
4 |
Tier 4 |
$90.00 | $270.00 | Q:180 /30Days |
LEVETIRACETAM ER 750 MG TABLET |
4 |
Tier 4 |
$90.00 | $270.00 | Q:120 /30Days |
LEVETIRACETAM INJECTION |
2 |
Tier 2 |
$16.00 | $48.00 | P |
LEVETIRACETAM TABLETS 1000MG 60 BOT |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEVETIRACETAM TABLETS 250MG 500 BOT |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEVETIRACETAM TABLETS 750MG 500 BOT |
2 |
Tier 2 |
$16.00 | $48.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOBUNOLOL 0.25% EYE DROPS |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEVOCARNITINE 100MG/ML SOLUTION ORAL |
1 |
Tier 1 |
$5.00 | $15.00 | P |
LEVOCARNITINE TABLET 330MG 90 BLPK |
1 |
Tier 1 |
$5.00 | $15.00 | P |
Levocetirizine dihydrochloride 5mg/1 30 TABLET in 1 BOTTLE |
2 |
Tier 2 |
$16.00 | $48.00 | None |
Levofloxacin 250mg/1 |
2 |
Tier 2 |
$16.00 | $48.00 | Q:28 /30Days |
Levofloxacin 25mg/mL 1 VIAL in 1 CARTON / 30 mL in 1 VIAL |
2 |
Tier 2 |
$16.00 | $48.00 | P |
Levofloxacin 500mg/1 |
2 |
Tier 2 |
$16.00 | $48.00 | Q:28 /30Days |
Levofloxacin 5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER |
2 |
Tier 2 |
$16.00 | $48.00 | None |
Levofloxacin 750mg/1 |
2 |
Tier 2 |
$16.00 | $48.00 | Q:15 /30Days |
Levothroid 100ug/1 100 TABLET BOTTLE |
2 |
Tier 2 |
$16.00 | $48.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levothroid 112ug/1 100 TABLET BOTTLE |
2 |
Tier 2 |
$16.00 | $48.00 | None |
Levothroid 125ug/1 100 TABLET BOTTLE |
2 |
Tier 2 |
$16.00 | $48.00 | None |
Levothroid 137ug/1 100 TABLET BOTTLE |
2 |
Tier 2 |
$16.00 | $48.00 | None |
Levothroid 150ug/1 100 TABLET BOTTLE |
2 |
Tier 2 |
$16.00 | $48.00 | None |
Levothroid 175ug/1 100 TABLET BOTTLE |
2 |
Tier 2 |
$16.00 | $48.00 | None |
Levothroid 200ug/1 100 TABLET BOTTLE |
2 |
Tier 2 |
$16.00 | $48.00 | None |
Levothroid 25ug/1 100 TABLET BOTTLE |
2 |
Tier 2 |
$16.00 | $48.00 | None |
Levothroid 300ug/1 100 TABLET BOTTLE |
2 |
Tier 2 |
$16.00 | $48.00 | None |
Levothroid 50ug/1 100 TABLET BOTTLE |
2 |
Tier 2 |
$16.00 | $48.00 | None |
Levothroid 75ug/1 100 TABLET BOTTLE |
2 |
Tier 2 |
$16.00 | $48.00 | None |
Levothroid 88ug/1 100 TABLET BOTTLE |
2 |
Tier 2 |
$16.00 | $48.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT) |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEVOTHYROXINE SODIUM .150MG TABLET (100 CT) |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEVOTHYROXINE SODIUM 100MCG TABLET |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEVOTHYROXINE SODIUM 112MCG TABLET |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEVOTHYROXINE SODIUM 125MCG TABLET |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEVOTHYROXINE SODIUM 175MCG TABLET |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEVOTHYROXINE SODIUM 200MCG TABLET |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEVOTHYROXINE SODIUM 25MCG TABLET |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEVOTHYROXINE SODIUM 300MCG TABLET |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEVOTHYROXINE SODIUM 50MCG TABLET |
2 |
Tier 2 |
$16.00 | $48.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE SODIUM 88MCG TABLET |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEVOXYL 100MCG TABLET (1000 CT) |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEVOXYL 112MCG TABLET (1000 CT) |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEVOXYL 125MCG TABLET (1000 CT) |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEVOXYL 137MCG TABLET (1000 CT) |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEVOXYL 150MCG TABLET (1000 CT) |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEVOXYL 175MCG TABLET (1000 CT) |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEVOXYL 200MCG TABLET (1000 CT) |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEVOXYL 25MCG TABLET (1000 CT) |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEVOXYL 50MCG TABLET (1000 CT) |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEVOXYL 75MCG TABLET (1000 CT) |
2 |
Tier 2 |
$16.00 | $48.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 88MCG TABLET (1000 CT) |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LEXAPRO 10MG TABLET |
4 |
Tier 4 |
$90.00 | $270.00 | Q:45 /30Days |
LEXAPRO 20MG TABLET |
4 |
Tier 4 |
$90.00 | $270.00 | Q:30 /30Days |
LEXAPRO 5MG TABLET |
4 |
Tier 4 |
$90.00 | $270.00 | Q:45 /30Days |
LEXAPRO 5MG/5ML SOLUTION |
4 |
Tier 4 |
$90.00 | $270.00 | Q:600 /30Days |
LEXIVA 50mg/mL 225 mL in 1 BOTTLE |
3 |
Tier 3 |
$36.00 | $108.00 | None |
LEXIVA TABLETS |
3 |
Tier 3 |
$36.00 | $108.00 | None |
LIDOCAINE 5% OINTMENT |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LIDOCAINE HCL 0.5% VIAL |
2 |
Tier 2 |
$16.00 | $48.00 | P |
LIDOCAINE HCL 1% VIAL |
2 |
Tier 2 |
$16.00 | $48.00 | P |
lidocaine hcl 2% jelly |
2 |
Tier 2 |
$16.00 | $48.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIDOCAINE HCL 2% JELLY 30ML TUBE |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM |
2 |
Tier 2 |
$16.00 | $48.00 | P |
LIDODERM 5% PATCH |
4 |
Tier 4 |
$90.00 | $270.00 | P Q:90 /30Days |
LINCOCIN 300MG/ML VIAL |
3 |
Tier 3 |
$36.00 | $108.00 | P |
Lindane 10mg/mL |
4 |
Tier 4 |
$90.00 | $270.00 | None |
LINDANE SHAMPOO 1MG 2 FLO BOT |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT |
2 |
Tier 2 |
$16.00 | $48.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIPITOR 10MG TABLET |
3 |
Tier 3 |
$36.00 | $108.00 | Q:30 /30Days |
LIPITOR 20MG TABLET (5000 CT) |
3 |
Tier 3 |
$36.00 | $108.00 | Q:30 /30Days |
LIPITOR 40MG TABLET (500 CT) |
3 |
Tier 3 |
$36.00 | $108.00 | Q:30 /30Days |
LIPITOR 80MG TABLET |
3 |
Tier 3 |
$36.00 | $108.00 | None |
LISINOPRIL 10MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
Lisinopril 2.5mg 100 TABLET BOTTLE |
1 |
Tier 1 |
$5.00 | $15.00 | None |
LISINOPRIL 20MG TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
LISINOPRIL 30MG TABLET (100 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
LISINOPRIL 40MG TABLET (500 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
Lisinopril 5mg/1 1000 TABLET in 1 BOTTLE |
1 |
Tier 1 |
$5.00 | $15.00 | None |
LISINOPRIL-HCTZ 10/12.5 TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | 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 |
Tier 1 |
$5.00 | $15.00 | None |
LISINOPRIL-HCTZ 20/12.5 TABLET |
1 |
Tier 1 |
$5.00 | $15.00 | None |
LITHIUM CARBONATE 150MG CAPSULE |
1 |
Tier 1 |
$5.00 | $15.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) |
1 |
Tier 1 |
$5.00 | $15.00 | None |
Lithium Carbonate 450mg/1 |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LITHIUM CARBONATE CAPSULES |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP |
4 |
Tier 4 |
$90.00 | $270.00 | None |
LOPERAMIDE HCL 2MG CAPSULE |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LOSARTAN POTASSIUM 100 MG TAB |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LOSARTAN POTASSIUM 25 MG TAB |
2 |
Tier 2 |
$16.00 | $48.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOSARTAN POTASSIUM 50 MG TAB |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LOSARTAN-HCTZ 100-12.5 MG TAB |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LOSARTAN-HCTZ 100-25 MG TAB |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LOSARTAN-HCTZ 50-12.5 MG TAB |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LOTRONEX TABLETS .5MG 30 BOTPL |
3 |
Tier 3 |
$36.00 | $108.00 | P |
LOTRONEX TABLETS 1MG 30 BOTPL |
5 |
Tier 5 |
30% | 30% | P |
Lovastatin 10mg 60 TABLET BOTTLE |
2 |
Tier 2 |
$16.00 | $48.00 | None |
Lovastatin 20mg 500 TABLET BOTTLE |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LOVASTATIN 40 MG ORAL TABLET |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LOVAZA 1g/ 120 LIQUID FILLED CAPSULES in BOTTLE |
4 |
Tier 4 |
$90.00 | $270.00 | Q:120 /30Days |
LOW-OGESTREL-28 TABLET |
2 |
Tier 2 |
$16.00 | $48.00 | Q:28 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOXAPINE 25MG CAPSULE (100 CT) |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LOXAPINE CAPSULES 10MG 100 BOT |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LOXAPINE CAPSULES 50MG 100 BOT |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LOXAPINE CAPSULES 5MG 100 BOT |
2 |
Tier 2 |
$16.00 | $48.00 | None |
LUMIGAN 0.03% EYE DROPS |
3 |
Tier 3 |
$36.00 | $108.00 | Q:3 /30Days |
LUMIGAN 0.1mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER |
3 |
Tier 3 |
$36.00 | $108.00 | Q:3 /30Days |
Lumizyme 5mg/mL |
5 |
Tier 5 |
30% | 30% | P |
LUPRON DEPOT 11.25 MG 3MO KIT |
4 |
Tier 4 |
$90.00 | $270.00 | P |
LUPRON DEPOT 22.5 MG 3MO KIT [LUPRON] |
5 |
Tier 5 |
30% | 30% | P |
LUPRON DEPOT 3.75 MG KIT |
4 |
Tier 4 |
$90.00 | $270.00 | P |
LUPRON DEPOT 7.5 MG KIT |
5 |
Tier 5 |
30% | 30% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUPRON DEPOT-4 MONTH KIT |
5 |
Tier 5 |
30% | 30% | P |
LUPRON DEPOT-PED 11.25 MG KIT |
5 |
Tier 5 |
30% | 30% | P |
LUPRON DEPOT-PED 15 MG KIT |
5 |
Tier 5 |
30% | 30% | P |
LYRICA 100MG CAPSULE |
4 |
Tier 4 |
$90.00 | $270.00 | P Q:120 /30Days |
LYRICA 150MG CAPSULE |
4 |
Tier 4 |
$90.00 | $270.00 | P Q:120 /30Days |
LYRICA 200MG CAPSULE |
4 |
Tier 4 |
$90.00 | $270.00 | P Q:90 /30Days |
LYRICA 225MG CAPSULE |
4 |
Tier 4 |
$90.00 | $270.00 | P Q:60 /30Days |
LYRICA 25MG CAPSULE |
4 |
Tier 4 |
$90.00 | $270.00 | P Q:120 /30Days |
LYRICA 300MG CAPSULE |
4 |
Tier 4 |
$90.00 | $270.00 | P Q:60 /30Days |
LYRICA 50MG CAPSULE |
4 |
Tier 4 |
$90.00 | $270.00 | P Q:120 /30Days |
LYRICA 75MG CAPSULE |
4 |
Tier 4 |
$90.00 | $270.00 | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYSODREN 500MG TABLET |
5 |
Tier 5 |
30% | 30% | None |