2013 Medicare Part D Plan Formulary Information |
Blue Medicare Access Value (Regional PPO) (R5941-009-0)
Benefit Details
|
The Blue Medicare Access Value (Regional PPO) (R5941-009-0) Formulary Drugs Starting with the Letter L in Statewide County, IN: CMS MA Region 13 which includes: IN 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 |
Preferred Brand |
$45.00 | $112.50 | None |
LABETALOL HCL 100MG TABLET |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LABETALOL HCL 200MG TABLET |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LABETALOL HCL 300MG TABLET |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LABETALOL HCL 5MG/20ML VIAL |
5* |
Injectable Drugs |
33% | 33% | None |
Lac Hydrin Cream 120mg/g 140 g in 1 TUBE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Lac-Hydrin 120mg/g 400 g in 1 BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LACLOTION 12% LOTION |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LACRISERT 5 MG EYE INSERT |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Lactated Ringers 200; 300; 6; 3.1mg/1000mL; mg/1000mL; g/1000mL; g/1000mL 5000 mL in 1 BAG |
5* |
Injectable Drugs |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LACTATED RINGERS INJECTION |
5* |
Injectable Drugs |
33% | 33% | None |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LAMICTAL 100MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LAMICTAL 150MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LAMICTAL 200MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LAMICTAL 25MG DISPER TABLET CHEW |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LAMICTAL 25MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LAMICTAL 25MG TABLET STARTER KIT |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LAMICTAL 5MG DISPER TABLET CHEW |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LAMICTAL KIT 100;25MG;MG |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LAMICTAL TABLET STARTER KIT |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMISIL 125MG GRANULES IN PACKET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LAMISIL 187.5MG GRANULES IN PACKET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LAMISIL 250MG TABLET (30 CT) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LAMIVUDINE 150 MG TABLET |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LAMIVUDINE 300 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LAMIVUDINE-ZIDOVUDINE TABLET |
6* |
Specialty Tier |
33% | N/A | None |
LAMOTRIGINE 150MG TABLET (60 CT) |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LAMOTRIGINE 200MG TABLET (60 CT) |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LAMOTRIGINE 25MG TABLET (100 CT) |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE TABLET 100MG (100 CT) |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LANOXIN 0.125MG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
LANOXIN 0.25MG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
LANOXIN PED 0.1MG/ML AMPUL |
5* |
Injectable Drugs |
33% | 33% | None |
Lansoprazole 15mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE, PLASTIC |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
Lansoprazole 30mg/1 30 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
LANTUS 100U/ML VIAL |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
LANTUS SOLOSTAR INJECTION |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
LASIX 40MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LASIX TABLETS |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LASIX TABLETS |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LATANOPROST OPHTHALMIC SOLUTION .005% |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LATUDA 120 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:30 /30Days |
LATUDA 20 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:240 /30Days |
Latuda 40mg/1 |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:120 /30Days |
Latuda 80mg/1 |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:60 /30Days |
LEENA 7-9-5 TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
LEFLUNOMIDE 10MG TABLET |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LEFLUNOMIDE TABLETS |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LESCOL 20MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:60 /30Days |
LESCOL 40MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:60 /30Days |
LESCOL XL 80MG TABLET SA |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Lessina 3 POUCH in 1 CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER PACK |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
LETAIRIS 10MG TABLET |
6* |
Specialty Tier |
33% | N/A | P |
LETAIRIS 5MG TABLET |
6* |
Specialty Tier |
33% | N/A | P |
Letrozole 2.5mg/1 500 FILM COATED TABLETS in BOTTLE, PLASTIC |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LEUCOVORIN CALCIUM 100MG VL |
5* |
Injectable Drugs |
33% | 33% | None |
LEUCOVORIN CALCIUM 10MG TABLET |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
Leucovorin Calcium 15mg/1 24 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LEUCOVORIN CALCIUM 25MG TABLET |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LEUCOVORIN CALCIUM 350MG VL |
5* |
Injectable Drugs |
33% | 33% | None |
LEUCOVORIN CALCIUM 5MG TABLET |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LEUKERAN 2MG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUKINE 500 MCG/ML |
6* |
Specialty Tier |
33% | N/A | P |
LEUKINE INJECTION 250 MCG/ML |
6* |
Specialty Tier |
33% | N/A | P |
LEUPROLIDE ACETATE INJECTION |
5* |
Injectable Drugs |
33% | 33% | P |
Levalbuterol 0.31 mg/3 ml sol |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:270 /30Days |
Levalbuterol 0.63 mg/3 ml sol |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:270 /30Days |
LEVALBUTEROL 1.25 MG/0.5 ML |
3 |
Preferred Brand |
$45.00 | $112.50 | P Q:45 /30Days |
LEVAQUIN INJECTION 5 MG/ML |
5* |
Injectable Drugs |
33% | 33% | None |
LEVATOL 20 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LEVEMIR 100UNITS/ML VIAL |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Levemir 14.2mg/mL 5 SYRINGE, PLASTIC in 1 CARTON / 3 mL in 1 SYRINGE, PLASTIC |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM 100MG/ML INJECTION |
5* |
Injectable Drugs |
33% | 33% | None |
LEVETIRACETAM 500 MG TABLET 120 BOT |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
Levetiracetam 750mg/1 60 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | Q:120 /30Days |
Levetiracetam er 500 mg tablet |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | Q:180 /30Days |
LEVETIRACETAM TABLETS 1000MG 60 BOT |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LEVETIRACETAM TABLETS 250MG 500 BOT |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LEVETIRACETAM TABLETS 750MG 500 BOT |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LEVOCARNITINE 100MG/ML SOLUTION ORAL |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | P |
LEVOCARNITINE 200MG/ML VIAL |
5* |
Injectable Drugs |
33% | 33% | P |
LEVOCARNITINE TABLET 330MG 90 BLPK |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levocetirizine dihydrochloride 5mg/1 30 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | Q:30 /30Days |
Levofloxacin 250mg/1 |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | Q:14 /1Days |
Levofloxacin 25mg/mL 1 BOTTLE in 1 CARTON / 100 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Levofloxacin 25mg/mL 1 VIAL in 1 CARTON / 30 mL in 1 VIAL |
5* |
Injectable Drugs |
33% | 33% | None |
Levofloxacin 500mg/1 |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | Q:14 /1Days |
Levofloxacin 5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
Levofloxacin 5mg/mL 24 POUCH in 1 CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG |
5* |
Injectable Drugs |
33% | 33% | None |
Levofloxacin 750mg/1 |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | Q:14 /1Days |
LEVONEST-28 TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
levonor-eth estrad 0.15-0.03 |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
LEVORA-28 TABLET 0.15/30 |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVORPHANOL TARTRATE 2mg 100 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | Q:180 /30Days |
Levothroid 100ug/1 100 TABLET BOTTLE |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothroid 112ug/1 100 TABLET BOTTLE |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothroid 125ug/1 100 TABLET BOTTLE |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothroid 137ug/1 100 TABLET BOTTLE |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothroid 150ug/1 100 TABLET BOTTLE |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothroid 175ug/1 100 TABLET BOTTLE |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothroid 200ug/1 100 TABLET BOTTLE |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothroid 25ug/1 100 TABLET BOTTLE |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothroid 300ug/1 100 TABLET BOTTLE |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothroid 50ug/1 100 TABLET BOTTLE |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levothroid 75ug/1 100 TABLET BOTTLE |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothroid 88ug/1 100 TABLET BOTTLE |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothyroxine Sodium 100ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothyroxine Sodium 112ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothyroxine Sodium 125ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothyroxine Sodium 150ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothyroxine Sodium 175ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothyroxine Sodium 200ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothyroxine Sodium 25ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothyroxine Sodium 300ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levothyroxine Sodium 50ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothyroxine Sodium 75ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothyroxine Sodium 88ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LEVOXYL 100MCG TABLET (1000 CT) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LEVOXYL 112MCG TABLET (1000 CT) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LEVOXYL 125MCG TABLET (1000 CT) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LEVOXYL 137MCG TABLET (1000 CT) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LEVOXYL 150MCG TABLET (1000 CT) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LEVOXYL 175MCG TABLET (1000 CT) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LEVOXYL 200MCG TABLET (1000 CT) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LEVOXYL 25MCG TABLET (1000 CT) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 50MCG TABLET (1000 CT) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LEVOXYL 75MCG TABLET (1000 CT) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LEVOXYL 88MCG TABLET (1000 CT) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LEXAPRO 10MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:60 /30Days |
LEXAPRO 20MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:30 /30Days |
LEXAPRO 5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:120 /30Days |
LEXAPRO 5MG/5ML SOLUTION |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:600 /30Days |
LEXIVA 50mg/mL 225 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LEXIVA TABLETS |
6* |
Specialty Tier |
33% | N/A | None |
LIALDA 1.2G TABLET DELAYED RELEASE |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
LIDOCAINE 5% OINTMENT |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
lidocaine hcl 2% jelly |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LIDOCAINE HCL 2% JELLY 30ML TUBE |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LIDODERM 5% PATCH |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:90 /30Days |
LINCOCIN 300MG/ML VIAL |
5* |
Injectable Drugs |
33% | 33% | None |
Lindane 10mg/mL |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LINDANE SHAMPOO 1MG 2 FLO BOT |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
liothyronine sodium 10ug/mL 1 VIAL in 1 CARTON / 1 mL in 1 VIAL |
6* |
Specialty Tier |
33% | N/A | None |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Liposyn III 1.2; 2.5; 10g/100mL; g/100mL; g/100mL 12 BOTTLE, GLASS in 1 CASE / 250 mL in 1 BOTTLE, |
5* |
Injectable Drugs |
33% | 33% | None |
Liposyn III 1.2; 2.5; 20g/100mL; g/100mL; g/100mL 12 BOTTLE, GLASS in 1 CASE / 250 mL in 1 BOTTLE, |
5* |
Injectable Drugs |
33% | 33% | None |
LISINOPRIL 10MG TABLET (100 CT) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LISINOPRIL 2.5 MG TABLET |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LISINOPRIL 20MG TABLET |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LISINOPRIL 30MG TABLET (100 CT) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LISINOPRIL 40MG TABLET (500 CT) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Lisinopril 5mg/1 1000 TABLET BOTTLE |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LISINOPRIL-HCTZ 10/12.5 TABLET |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | 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) |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LISINOPRIL-HCTZ 20/12.5 TABLET |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
Lithium Carbonate 150mg/1 100 CAPSULE in 1 BOTTLE |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Lithium Carbonate 300 mg tab |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Lithium Carbonate 450mg/1 |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LITHIUM CARBONATE CAPSULES |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LITHOBID 300MG TABLET SA |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LIVALO TABLETS 1 MG |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIVALO TABLETS 2 MG |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:30 /30Days |
LIVALO TABLETS 4 MG |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:30 /30Days |
Lo/Ovral-28 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Locoid Lipocream 1.0mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOCOID LOTN 0.1 % |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LODOSYN TAB 25MG |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S |
LOESTRIN 24 FE TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOFIBRA 134MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:30 /30Days |
LOFIBRA 160MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:30 /30Days |
LOFIBRA 200MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:30 /30Days |
LOFIBRA 54MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOFIBRA 67MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:90 /30Days |
LOKARA 0.05% LOTION |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOPERAMIDE HCL 2MG CAPSULE |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LOPID 600MG TABLET (500 CT) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOPRESSOR 100MG TABLET (100 CT) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOPRESSOR 1MG/ML AMPUL |
5* |
Injectable Drugs |
33% | 33% | None |
LOPRESSOR 50MG TABLET (100 CT) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOPRESSOR HCT 100/25 TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOPRESSOR HCT 50-25 TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOPROX 1% SHAMPOO |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOPROX GEL TOPICAL |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Loryna (drospirenone and ethinyl estradiol) 3 CARTON in 1 BOX / 1 KIT in 1 CARTON |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOSARTAN POTASSIUM 100 MG TAB |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | Q:30 /30Days |
LOSARTAN POTASSIUM 25 MG TAB |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | Q:60 /30Days |
LOSARTAN POTASSIUM 50 MG TAB |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | Q:60 /30Days |
LOSARTAN-HCTZ 100-12.5 MG TAB |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | Q:30 /30Days |
LOSARTAN-HCTZ 100-25 MG TAB |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | Q:30 /30Days |
LOSARTAN-HCTZ 50-12.5 MG TAB |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | Q:30 /30Days |
LOTEMAX 0.5% EYE DROPS |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Lotemax 5mg/g 1 TUBE in 1 CARTON / 3.5 g in 1 TUBE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOTREL 10/20MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOTREL 10/40MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOTREL 2.5/10MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Lotrel 5; 40mg/1; mg/1 100 CAPSULE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOTREL 5/10MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOTREL 5/20MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOTRISONE CREAM |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOTRONEX TABLETS .5MG 30 BOTPL |
3 |
Preferred Brand |
$45.00 | $112.50 | P Q:60 /30Days |
LOTRONEX TABLETS 1MG 30 BOTPL |
3 |
Preferred Brand |
$45.00 | $112.50 | P Q:60 /30Days |
Lovastatin 10mg 60 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | Q:30 /30Days |
Lovastatin 20mg 500 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | Q:30 /30Days |
LOVASTATIN 40 MG ORAL TABLET |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | Q:60 /30Days |
LOVAZA 1g/ 120 LIQUID FILLED CAPSULES in BOTTLE |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOW-OGESTREL-28 TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
LOXAPINE 25MG CAPSULE (100 CT) |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LOXAPINE CAPSULES 10MG 100 BOT |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LOXAPINE CAPSULES 50MG 100 BOT |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LOXAPINE CAPSULES 5MG 100 BOT |
2* |
Non-Preferred Generic |
$12.00 | $18.00 | None |
LOXITANE 10MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOXITANE 25MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOXITANE 50MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOXITANE 5MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LUFYLLIN 200MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LUFYLLIN-400 TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | 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 |
$45.00 | $112.50 | None |
LUMIGAN 0.1mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
LUNESTA 2MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:30 /30Days |
LUNESTA 3MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:30 /30Days |
LUNESTA TABLETS 1MG 30 BOT |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:30 /30Days |
LUPRON DEPOT 3.75 MG KIT |
5* |
Injectable Drugs |
33% | 33% | P |
LUPRON DEPOT 7.5 MG KIT |
5* |
Injectable Drugs |
33% | 33% | P |
LUTERA 0.1-0.02 TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
LUXIQ 1.2mg/g 1 CAN in 1 CARTON / 100 g in 1 CAN |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LYRICA 100MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:180 /30Days |
LYRICA 150MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYRICA 20 MG/ML ORAL SOLUTION |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:900 /30Days |
LYRICA 200MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:90 /30Days |
LYRICA 225MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:60 /30Days |
LYRICA 25MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:720 /30Days |
LYRICA 300MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:60 /30Days |
LYRICA 50MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:360 /30Days |
LYRICA 75MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:240 /30Days |
LYSODREN 500MG TABLET |
3 |
Preferred Brand |
$45.00 | $112.50 | None |