2012 Medicare Part D Plan Formulary Information |
Triple-S FarmaMed Plus (PDP) (S5907-002-0)
Benefit Details
|
The Triple-S FarmaMed Plus (PDP) (S5907-002-0) Formulary Drugs Starting with the Letter L in CMS PDP Region 38 which includes: PR
|
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 Brand Drugs Greater of $40 or |
25% | 25% | P |
L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE 16 VACCINE 0.04 MG/ML / L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | P |
LABETALOL HCL 100MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LABETALOL HCL 200MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LABETALOL HCL 300MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
Lac-Hydrin 120mg/g 400 g in 1 BOTTLE, PLASTIC |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LACTATED RINGERS INJECTION |
1 |
Generic Drugs |
$5.00 | $15.00 | P |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LAMICTAL 100MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LAMICTAL 150MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMICTAL 200MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LAMICTAL 25MG DISPER TABLET CHEW |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LAMICTAL 25MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LAMICTAL 5MG DISPER TABLET CHEW |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LAMISIL 250MG TABLET (30 CT) |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LAMIVUDINE 150 MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LAMIVUDINE 300 MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LAMIVUDINE-ZIDOVUDINE TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LAMOTRIGINE 150MG TABLET (60 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LAMOTRIGINE 200MG TABLET (60 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LAMOTRIGINE 25MG TABLET (100 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE 25MG TABLET DISPERSIBLE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LAMOTRIGINE TABLET 100MG (100 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LANOXIN 0.125MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LANOXIN 0.25MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LANREOTIDE 240 MG/ML PREFILLED SYRINGE [SOMATULINE] |
4 |
Specialty Tier Drugs |
25% | 25% | P |
Lansoprazole 15mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$5.00 | $15.00 | S |
Lansoprazole 30mg/1 30 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
1 |
Generic Drugs |
$5.00 | $15.00 | S |
LANTUS 100U/ML VIAL |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
LANTUS SOLOSTAR INJECTION |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LASIX 40MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LASIX TABLETS |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LASIX TABLETS |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LATANOPROST OPHTHALMIC SOLUTION .005% |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LATUDA 20 MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | S |
Latuda 40mg/1 |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | S |
Latuda 80mg/1 |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | S |
LEFLUNOMIDE 10MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LEFLUNOMIDE TABLETS |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LETAIRIS 10MG TABLET |
4 |
Specialty Tier Drugs |
25% | 25% | P |
LETAIRIS 5MG TABLET |
4 |
Specialty Tier Drugs |
25% | 25% | P |
Letrozole 2.5mg/1 500 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUCOVORIN CALCIUM 5MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LEUKERAN 2MG TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
LEUKINE 500 MCG/ML |
4 |
Specialty Tier Drugs |
25% | 25% | P |
LEUKINE INJECTION 250 MCG/ML |
4 |
Specialty Tier Drugs |
25% | 25% | P |
LEUPROLIDE ACETATE INJECTION |
1 |
Generic Drugs |
$5.00 | $15.00 | P |
LEVAQUIN 250mg/1 10 BLISTER PACK in 1 CARTON / 10 TABLET, FILM COATED in 1 BLISTER PACK |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LEVAQUIN 500mg/1 50 TABLET, FILM COATED in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LEVAQUIN 750 MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LEVETIRACETAM 500 MG TABLET 120 BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LEVETIRACETAM INJECTION |
1 |
Generic Drugs |
$5.00 | $15.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM TABLETS 1000MG 60 BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LEVETIRACETAM TABLETS 250MG 500 BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LEVETIRACETAM TABLETS 750MG 500 BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LEVOBUNOLOL 0.25% EYE DROPS |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LEVOCARNITINE 100MG/ML SOLUTION ORAL |
1 |
Generic Drugs |
$5.00 | $15.00 | P |
LEVOCARNITINE TABLET 330MG 90 BLPK |
1 |
Generic Drugs |
$5.00 | $15.00 | P |
Levofloxacin 250mg/1 |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
Levofloxacin 500mg/1 |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
Levofloxacin 750mg/1 |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | 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 |
Generic Drugs |
$5.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 100MCG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 112MCG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 125MCG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 175MCG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 200MCG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 25MCG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 300MCG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 50MCG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 88MCG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEXAPRO 10MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | S |
LEXAPRO 20MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | S |
LEXAPRO 5MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | S |
LEXAPRO 5MG/5ML SOLUTION |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | S |
LEXIVA 50mg/mL 225 mL in 1 BOTTLE |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
LEXIVA TABLETS |
4 |
Specialty Tier Drugs |
25% | 25% | None |
LIDOCAINE 5% OINTMENT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LIDOCAINE HCL 0.5% VIAL |
1 |
Generic Drugs |
$5.00 | $15.00 | P |
LIDOCAINE HCL 1% VIAL |
1 |
Generic Drugs |
$5.00 | $15.00 | P |
lidocaine hcl 2% jelly |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LIDODERM 5% PATCH |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | P |
LINCOCIN 300MG/ML VIAL |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | P |
Lindane 10mg/mL |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | S |
LINDANE SHAMPOO 1MG 2 FLO BOT |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LIPITOR 10MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | S |
LIPITOR 20MG TABLET (5000 CT) |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | S |
LIPITOR 40MG TABLET (500 CT) |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIPITOR 80MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | S |
Liposyn III 1.2; 2.5; 10g/100mL; g/100mL; g/100mL 12 BOTTLE, GLASS in 1 CASE / 250 mL in 1 BOTTLE, |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | P |
Liposyn III 1.2; 2.5; 20g/100mL; g/100mL; g/100mL 12 BOTTLE, GLASS in 1 CASE / 250 mL in 1 BOTTLE, |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | P |
LIPOSYN III 30% IV FAT EMUL |
1 |
Generic Drugs |
$5.00 | $15.00 | P |
LISINOPRIL 10MG TABLET (100 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
Lisinopril 2.5mg 100 TABLET BOTTLE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LISINOPRIL 20MG TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LISINOPRIL 30MG TABLET (100 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LISINOPRIL 40MG TABLET (500 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
Lisinopril 5mg/1 1000 TABLET in 1 BOTTLE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LISINOPRIL-HCTZ 10/12.5 TABLET |
1 |
Generic Drugs |
$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 |
Generic Drugs |
$5.00 | $15.00 | None |
LISINOPRIL-HCTZ 20/12.5 TABLET |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LITHIUM CARBONATE 150MG CAPSULE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
Lithium Carbonate 450mg/1 |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LITHIUM CARBONATE CAPSULES |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LITHOBID 300MG TABLET SA |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
Lo/Ovral-28 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LODOSYN TAB 25MG |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOFIBRA 134MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOFIBRA 160MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOFIBRA 200MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOFIBRA 54MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOFIBRA 67MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
Lomotil 0.025; 2.5mg/1; mg/1 100 TABLET in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOPERAMIDE HCL 2MG CAPSULE |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LOPID 600MG TABLET (500 CT) |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOPRESSOR 100MG TABLET (100 CT) |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOPRESSOR 50MG TABLET (100 CT) |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOPRESSOR HCT 100/25 TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOPRESSOR HCT 50/25 TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LORCET 10/650 TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LORCET PLUS TABLET 7.5-650 |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LORTAB 10/500MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LORTAB 5/500 TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LORTAB 7.5/500 TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LORTAB ELIXIR 500-7.5MG/15ML |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOSARTAN POTASSIUM 100 MG TAB |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LOSARTAN POTASSIUM 25 MG TAB |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LOSARTAN POTASSIUM 50 MG TAB |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LOSARTAN-HCTZ 100-12.5 MG TAB |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOSARTAN-HCTZ 100-25 MG TAB |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LOSARTAN-HCTZ 50-12.5 MG TAB |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LOTEMAX 0.5% EYE DROPS |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
LOTENSIN 10MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
Lotensin 20mg/1 100 TABLET in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOTENSIN 40MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOTENSIN HCT 10/12.5 TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOTENSIN HCT 20/12.5 TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOTENSIN HCT 20/25 TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOTREL 10/20MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOTREL 10/40MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOTREL 2.5/10MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
Lotrel 5; 40mg/1; mg/1 100 CAPSULE in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOTREL 5/10MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOTREL 5/20MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOTRISONE CREAM |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOTRISONE LOTION |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOTRONEX TABLETS .5MG 30 BOTPL |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
LOTRONEX TABLETS 1MG 30 BOTPL |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
LOVAZA 1g/ 120 LIQUID FILLED CAPSULES in BOTTLE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOVENOX 100MG PREFILLED SYR |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOVENOX 120MG PREFILLED SYR |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOVENOX 150MG PREFILLED SYR |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOVENOX 300MG VIAL |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOVENOX 30MG PREFILLED SYRN |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOVENOX 40MG PREFILLED SYRN |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOVENOX 60MG PREFILLED SYRN |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOVENOX 80MG PREFILLED SYRN |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOXAPINE 25MG CAPSULE (100 CT) |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LOXAPINE CAPSULES 10MG 100 BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LOXAPINE CAPSULES 50MG 100 BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LOXAPINE CAPSULES 5MG 100 BOT |
1 |
Generic Drugs |
$5.00 | $15.00 | None |
LOXITANE 10MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOXITANE 25MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOXITANE 50MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LOXITANE 5MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LUFYLLIN 200MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LUFYLLIN-400 TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LUMIGAN 0.03% EYE DROPS |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
LUMIGAN 0.1mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
LUNESTA 2MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LUNESTA 3MG TABLET |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
LUNESTA TABLETS 1MG 30 BOT |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | None |
Lupron Depot 1 KIT in 1 CARTON |
4 |
Specialty Tier Drugs |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUPRON DEPOT-PED 11.25 MG KIT |
4 |
Specialty Tier Drugs |
25% | 25% | P |
LUPRON DEPOT-PED 15 MG KIT |
4 |
Specialty Tier Drugs |
25% | 25% | P |
LYRICA 100MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | S |
LYRICA 150MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | S |
LYRICA 200MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | S |
LYRICA 225MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | S |
LYRICA 25MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | S |
LYRICA 300MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | S |
LYRICA 50MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | S |
LYRICA 75MG CAPSULE |
3 |
Non-Preferred Brand Drugs Greater of $40 or |
25% | 25% | S |
LYSODREN 500MG TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |