2012 Medicare Part D Plan Formulary Information |
PICA Alante (PDP) (S5775-002-0)
Benefit Details
|
The PICA Alante (PDP) (S5775-002-0) 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 |
$60.00 | $180.00 | P |
L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE 16 VACCINE 0.04 MG/ML / L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
LABETALOL HCL 100MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LABETALOL HCL 200MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LABETALOL HCL 300MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LABETALOL HCL 5MG/20ML VIAL |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Lac Hydrin Cream 120mg/g 140 g in 1 TUBE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
Lac-Hydrin 120mg/g 400 g in 1 BOTTLE, PLASTIC |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LACLOTION 12% LOTION |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
LACRISERT OPTHALMIC INSERT 5MG 60 BLPK |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LACTATED RINGERS INJECTION |
1 |
Generic Drugs |
$6.00 | $18.00 | P |
LACTATED RINGERS IRRIGATION 20-30-600MG 3000ML BAG |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LAMISIL 125MG GRANULES IN PACKET |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LAMISIL 187.5MG GRANULES IN PACKET |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LAMISIL 250MG TABLET (30 CT) |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LAMIVUDINE 150 MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LAMIVUDINE 300 MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LAMIVUDINE-ZIDOVUDINE TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LAMOTRIGINE 150MG TABLET (60 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LAMOTRIGINE 200MG TABLET (60 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE 25MG TABLET (100 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LAMOTRIGINE TABLET 100MG (100 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LANOXIN 0.125MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LANOXIN 0.25MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LANOXIN 250ug/mL 10 AMPULE in 1 BOX / 2 mL in 1 AMPULE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LANOXIN PED 0.1MG/ML AMPUL |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LANREOTIDE 240 MG/ML PREFILLED SYRINGE [SOMATULINE] |
4 |
Specialty Tier Drugs |
27% | 27% | P |
Lansoprazole 15mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Lansoprazole 30mg/1 30 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LANTUS 100U/ML VIAL |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LANTUS SOLOSTAR INJECTION |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LASIX 40MG TABLET |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LASIX TABLETS |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LASIX TABLETS |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LATANOPROST OPHTHALMIC SOLUTION .005% |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LATUDA 20 MG TABLET |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
Latuda 40mg/1 |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
Latuda 80mg/1 |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LEFLUNOMIDE 10MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEFLUNOMIDE TABLETS |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LESCOL 20MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LESCOL 40MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LESCOL XL 80MG TABLET SA |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LETAIRIS 10MG TABLET |
4 |
Specialty Tier Drugs |
27% | 27% | P |
LETAIRIS 5MG TABLET |
4 |
Specialty Tier Drugs |
27% | 27% | P |
Letrozole 2.5mg/1 500 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEUCOVORIN CALCIUM 100MG VL |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
LEUCOVORIN CALCIUM 10MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Leucovorin Calcium 15mg/1 24 TABLET in 1 BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEUCOVORIN CALCIUM 25MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEUCOVORIN CALCIUM 350MG VL |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUCOVORIN CALCIUM 5MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEUKERAN 2MG TABLET |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LEUKINE INJECTION 250 MCG/ML |
4 |
Specialty Tier Drugs |
27% | 27% | P |
LEUPROLIDE ACETATE INJECTION |
1 |
Generic Drugs |
$6.00 | $18.00 | P |
LEVEMIR 100UNITS/ML VIAL |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
Levemir 14.2mg/mL 5 SYRINGE, PLASTIC in 1 CARTON / 3 mL in 1 SYRINGE, PLASTIC |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEVETIRACETAM 500 MG TABLET 120 BOT |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEVETIRACETAM ER 500 MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEVETIRACETAM ER 750 MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEVETIRACETAM INJECTION |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
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 |
$6.00 | $18.00 | None |
LEVETIRACETAM TABLETS 250MG 500 BOT |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEVETIRACETAM TABLETS 750MG 500 BOT |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEVOBUNOLOL 0.25% EYE DROPS |
1 |
Generic Drugs |
$6.00 | $18.00 | Q:15 /25Days |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION |
1 |
Generic Drugs |
$6.00 | $18.00 | Q:15 /25Days |
Levofloxacin 250mg/1 |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Levofloxacin 25mg/mL 1 BOTTLE in 1 CARTON / 100 mL in 1 BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Levofloxacin 25mg/mL 1 VIAL in 1 CARTON / 30 mL in 1 VIAL |
1 |
Generic Drugs |
$6.00 | $18.00 | P |
Levofloxacin 500mg/1 |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Levofloxacin 5mg/mL 24 POUCH in 1 CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG |
1 |
Generic Drugs |
$6.00 | $18.00 | P |
Levofloxacin 750mg/1 |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levothroid 100ug/1 100 TABLET BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Levothroid 112ug/1 100 TABLET BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Levothroid 125ug/1 100 TABLET BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Levothroid 137ug/1 100 TABLET BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Levothroid 150ug/1 100 TABLET BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Levothroid 175ug/1 100 TABLET BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Levothroid 200ug/1 100 TABLET BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Levothroid 25ug/1 100 TABLET BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Levothroid 300ug/1 100 TABLET BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Levothroid 50ug/1 100 TABLET BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Levothroid 75ug/1 100 TABLET BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levothroid 88ug/1 100 TABLET BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEVOTHYROXINE SODIUM .150MG TABLET (100 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEVOTHYROXINE SODIUM 100MCG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEVOTHYROXINE SODIUM 112MCG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEVOTHYROXINE SODIUM 125MCG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEVOTHYROXINE SODIUM 175MCG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEVOTHYROXINE SODIUM 200MCG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEVOTHYROXINE SODIUM 25MCG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEVOTHYROXINE SODIUM 300MCG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE SODIUM 50MCG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEVOTHYROXINE SODIUM 88MCG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEVOXYL 100MCG TABLET (1000 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEVOXYL 112MCG TABLET (1000 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEVOXYL 125MCG TABLET (1000 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEVOXYL 137MCG TABLET (1000 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEVOXYL 150MCG TABLET (1000 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEVOXYL 175MCG TABLET (1000 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEVOXYL 200MCG TABLET (1000 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEVOXYL 25MCG TABLET (1000 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEVOXYL 50MCG TABLET (1000 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 75MCG TABLET (1000 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEVOXYL 88MCG TABLET (1000 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LEXAPRO 10MG TABLET |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LEXAPRO 20MG TABLET |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LEXAPRO 5MG TABLET |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LEXAPRO 5MG/5ML SOLUTION |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LEXIVA 50mg/mL 225 mL in 1 BOTTLE |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
LEXIVA TABLETS |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
LIDOCAINE 5% OINTMENT |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LIDOCAINE HCL 0.5% VIAL |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LIDOCAINE HCL 1% VIAL |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
lidocaine hcl 2% jelly |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LIDOCAINE HCL 2% JELLY 30ML TUBE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LIDODERM 5% PATCH |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LINCOCIN 300MG/ML VIAL |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
Lindane 10mg/mL |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LINDANE SHAMPOO 1MG 2 FLO BOT |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LIPITOR 10MG TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIPITOR 20MG TABLET (5000 CT) |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
LIPITOR 40MG TABLET (500 CT) |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
LIPITOR 80MG TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
LISINOPRIL 10MG TABLET (100 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Lisinopril 2.5mg 100 TABLET BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LISINOPRIL 20MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LISINOPRIL 30MG TABLET (100 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LISINOPRIL 40MG TABLET (500 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Lisinopril 5mg/1 1000 TABLET in 1 BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LISINOPRIL-HCTZ 10/12.5 TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL-HCTZ 20/12.5 TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LITHIUM CARBONATE 150MG CAPSULE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LITHIUM CARBONATE 300MG TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Lithium Carbonate 450mg/1 |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LITHIUM CARBONATE CAPSULES |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LITHOBID 300MG TABLET SA |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
Lomotil 0.025; 2.5mg/1; mg/1 100 TABLET in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LOPERAMIDE HCL 2MG CAPSULE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOPRESSOR 100MG TABLET (100 CT) |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LOPRESSOR 1MG/ML AMPUL |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LOPRESSOR 50MG TABLET (100 CT) |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LOPRESSOR HCT 100/25 TABLET |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LOPRESSOR HCT 50/25 TABLET |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LORCET PLUS TABLET 7.5-650 |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LORTAB 10/500MG TABLET |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LORTAB 5/500 TABLET |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LORTAB 7.5/500 TABLET |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LOSARTAN POTASSIUM 100 MG TAB |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LOSARTAN POTASSIUM 25 MG TAB |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOSARTAN POTASSIUM 50 MG TAB |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LOSARTAN-HCTZ 100-12.5 MG TAB |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LOSARTAN-HCTZ 100-25 MG TAB |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LOSARTAN-HCTZ 50-12.5 MG TAB |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LOTENSIN 10MG TABLET |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
Lotensin 20mg/1 100 TABLET in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LOTENSIN 40MG TABLET |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LOTENSIN HCT 10/12.5 TABLET |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LOTENSIN HCT 20/12.5 TABLET |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LOTENSIN HCT 20/25 TABLET |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LOTREL 10/20MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOTREL 10/40MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LOTREL 2.5/10MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
Lotrel 5; 40mg/1; mg/1 100 CAPSULE in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LOTREL 5/10MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LOTREL 5/20MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | 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 |
Lovastatin 10mg 60 TABLET BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Lovastatin 20mg 500 TABLET BOTTLE |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LOVASTATIN 40 MG ORAL TABLET |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LOVAZA 1g/ 120 LIQUID FILLED CAPSULES in BOTTLE |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOVENOX 100MG PREFILLED SYR |
4 |
Specialty Tier Drugs |
27% | 27% | P |
LOVENOX 120MG PREFILLED SYR |
4 |
Specialty Tier Drugs |
27% | 27% | P |
LOVENOX 150MG PREFILLED SYR |
4 |
Specialty Tier Drugs |
27% | 27% | P |
LOVENOX 300MG VIAL |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
LOVENOX 30MG PREFILLED SYRN |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
LOVENOX 40MG PREFILLED SYRN |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
LOVENOX 60MG PREFILLED SYRN |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
LOVENOX 80MG PREFILLED SYRN |
4 |
Specialty Tier Drugs |
27% | 27% | P |
LOXAPINE 25MG CAPSULE (100 CT) |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LOXAPINE CAPSULES 10MG 100 BOT |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LOXAPINE CAPSULES 50MG 100 BOT |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOXAPINE CAPSULES 5MG 100 BOT |
1 |
Generic Drugs |
$6.00 | $18.00 | None |
LOXITANE 10MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LOXITANE 25MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LOXITANE 50MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LOXITANE 5MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LUFYLLIN 200MG TABLET |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LUFYLLIN-400 TABLET |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LUMIGAN 0.03% EYE DROPS |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LUMIGAN 0.1mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
Lupron Depot 1 KIT in 1 CARTON |
4 |
Specialty Tier Drugs |
27% | 27% | P |
LUPRON DEPOT 11.25 MG 3MO KIT |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUPRON DEPOT 22.5 MG 3MO KIT [LUPRON] |
4 |
Specialty Tier Drugs |
27% | 27% | P |
LUPRON DEPOT 3.75 MG KIT |
4 |
Specialty Tier Drugs |
27% | 27% | P |
LUPRON DEPOT 7.5 MG KIT |
4 |
Specialty Tier Drugs |
27% | 27% | P |
LUPRON DEPOT-4 MONTH KIT |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
LUPRON DEPOT-PED 11.25 MG KIT |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
LUPRON DEPOT-PED 15 MG KIT |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
LUXIQ 0.12% FOAM |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | None |
LYRICA 100MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
LYRICA 150MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
LYRICA 200MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
LYRICA 225MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYRICA 25MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
LYRICA 300MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
LYRICA 50MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
LYRICA 75MG CAPSULE |
3 |
Non-Preferred Brand Drugs |
$60.00 | $180.00 | P |
LYSODREN 500MG TABLET |
2 |
Preferred Brand Drugs |
$30.00 | $90.00 | None |