2013 Medicare Part D Plan Formulary Information |
Windsor Medicare Extra Diabetes Plan (HMO SNP) (H5698-155-0)
Benefit Details
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The Windsor Medicare Extra Diabetes Plan (HMO SNP) (H5698-155-0) Formulary Drugs Starting with the Letter L in SUNFLOWER County, MS: CMS MA Region 16 which includes: MS
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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 |
$40.00 | $120.00 | None |
LABETALOL HCL 100MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LABETALOL HCL 200MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LABETALOL HCL 300MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LABETALOL HCL 5MG/20ML VIAL |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LACTATED RINGERS INJECTION |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LAMIVUDINE 150 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LAMIVUDINE 300 MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LAMIVUDINE-ZIDOVUDINE TABLET |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE 150MG TABLET (60 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LAMOTRIGINE 200MG TABLET (60 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LAMOTRIGINE 25MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LAMOTRIGINE TABLET 100MG (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LANOXIN 0.125MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LANOXIN 0.25MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LANOXIN PED 0.1MG/ML AMPUL |
4 |
Non-Preferred Brand |
$60.00 | $180.00 | None |
LANREOTIDE 240 MG/ML PREFILLED SYRINGE [SOMATULINE] |
5 |
Specialty Tier |
33% | 33% | P |
LANTUS 100U/ML VIAL |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LANTUS SOLOSTAR INJECTION |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LATANOPROST OPHTHALMIC SOLUTION .005% |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:3 /30Days |
LATUDA 120 MG TABLET |
4 |
Non-Preferred Brand |
$60.00 | $180.00 | Q:30 /30Days |
LATUDA 20 MG TABLET |
4 |
Non-Preferred Brand |
$60.00 | $180.00 | Q:60 /30Days |
Latuda 40mg/1 |
4 |
Non-Preferred Brand |
$60.00 | $180.00 | Q:60 /30Days |
Latuda 80mg/1 |
4 |
Non-Preferred Brand |
$60.00 | $180.00 | Q:60 /30Days |
LEFLUNOMIDE 10MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEFLUNOMIDE TABLETS |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LETAIRIS 10MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
LETAIRIS 5MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days |
Letrozole 2.5mg/1 500 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUCOVORIN CALCIUM 100MG VL |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEUCOVORIN CALCIUM 10MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Leucovorin Calcium 15mg/1 24 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEUCOVORIN CALCIUM 25MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEUCOVORIN CALCIUM 350MG VL |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEUCOVORIN CALCIUM 5MG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEUKERAN 2MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LEUKINE 500 MCG/ML |
5 |
Specialty Tier |
33% | 33% | P |
LEUKINE INJECTION 250 MCG/ML |
5 |
Specialty Tier |
33% | 33% | P |
LEUPROLIDE ACETATE INJECTION |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levalbuterol 0.31 mg/3 ml sol |
1 |
Preferred Generic |
$4.00 | $12.00 | P Q:270 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levalbuterol 0.63 mg/3 ml sol |
1 |
Preferred Generic |
$4.00 | $12.00 | P Q:270 /30Days |
LEVALBUTEROL 1.25 MG/0.5 ML |
1 |
Preferred Generic |
$4.00 | $12.00 | P Q:90 /30Days |
LEVATOL 20 MG TABLET |
4 |
Non-Preferred Brand |
$60.00 | $180.00 | None |
LEVEMIR 100UNITS/ML VIAL |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
Levemir 14.2mg/mL 5 SYRINGE, PLASTIC in 1 CARTON / 3 mL in 1 SYRINGE, PLASTIC |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEVETIRACETAM 100MG/ML INJECTION |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEVETIRACETAM 500 MG TABLET 120 BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levetiracetam 750mg/1 60 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$60.00 | $180.00 | Q:120 /30Days |
Levetiracetam er 500 mg tablet |
4 |
Non-Preferred Brand |
$60.00 | $180.00 | Q:180 /30Days |
LEVETIRACETAM TABLETS 1000MG 60 BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM TABLETS 250MG 500 BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEVETIRACETAM TABLETS 750MG 500 BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEVOCARNITINE 100MG/ML SOLUTION ORAL |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LEVOCARNITINE TABLET 330MG 90 BLPK |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LEVOCETIRIZINE 2.5 MG/5 ML SOL |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:300 /30Days |
Levocetirizine dihydrochloride 5mg/1 30 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:30 /30Days |
Levofloxacin 250mg/1 |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:28 /30Days |
Levofloxacin 25mg/mL 1 VIAL in 1 CARTON / 30 mL in 1 VIAL |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levofloxacin 500mg/1 |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:28 /30Days |
Levofloxacin 5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levofloxacin 750mg/1 |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:15 /30Days |
LEVONEST-28 TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levothroid 100ug/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levothroid 112ug/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levothroid 125ug/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levothroid 137ug/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levothroid 150ug/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levothroid 175ug/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levothroid 200ug/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levothroid 25ug/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levothroid 300ug/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levothroid 50ug/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levothroid 75ug/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levothroid 88ug/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levothyroxine Sodium 100ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levothyroxine Sodium 112ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levothyroxine Sodium 125ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levothyroxine Sodium 150ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levothyroxine Sodium 175ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levothyroxine Sodium 200ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levothyroxine Sodium 25ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levothyroxine Sodium 300ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levothyroxine Sodium 50ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levothyroxine Sodium 75ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levothyroxine Sodium 88ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEVOXYL 100MCG TABLET (1000 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEVOXYL 112MCG TABLET (1000 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEVOXYL 125MCG TABLET (1000 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEVOXYL 137MCG TABLET (1000 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEVOXYL 150MCG TABLET (1000 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEVOXYL 175MCG TABLET (1000 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEVOXYL 200MCG TABLET (1000 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 25MCG TABLET (1000 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEVOXYL 50MCG TABLET (1000 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEVOXYL 75MCG TABLET (1000 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEVOXYL 88MCG TABLET (1000 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEXIVA 50mg/mL 225 mL in 1 BOTTLE |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LEXIVA TABLETS |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LIALDA 1.2G TABLET DELAYED RELEASE |
4 |
Non-Preferred Brand |
$60.00 | $180.00 | Q:120 /30Days |
LIDOCAINE 5% OINTMENT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LIDOCAINE HCL 1% VIAL |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
lidocaine hcl 2% jelly |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LIDOCAINE HCL 2% JELLY 30ML TUBE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Lidocaine Hydrochloride 5mg/mL 25 VIAL, SINGLE-DOSE in 1 CONTAINER / 50 mL in 1 VIAL, SINGLE-DOSE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LIDODERM 5% PATCH |
4 |
Non-Preferred Brand |
$60.00 | $180.00 | P Q:90 /30Days |
LINCOCIN 300MG/ML VIAL |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
Lindane 10mg/mL |
4 |
Non-Preferred Brand |
$60.00 | $180.00 | None |
LINDANE SHAMPOO 1MG 2 FLO BOT |
4 |
Non-Preferred Brand |
$60.00 | $180.00 | None |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL 10MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LISINOPRIL 2.5 MG TABLET |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LISINOPRIL 20MG TABLET |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LISINOPRIL 30MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LISINOPRIL 40MG TABLET (500 CT) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
Lisinopril 5mg/1 1000 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LISINOPRIL-HCTZ 10/12.5 TABLET |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LISINOPRIL-HCTZ 20/12.5 TABLET |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
Lithium Carbonate 150mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Lithium Carbonate 450mg/1 |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LITHIUM CARBONATE CAPSULES |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP |
4 |
Non-Preferred Brand |
$60.00 | $180.00 | None |
LOPERAMIDE HCL 2MG CAPSULE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Lorazepam 0.5mg/1 500 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:90 /30Days |
Lorazepam 1mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:90 /30Days |
Lorazepam 2mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:150 /30Days |
LOSARTAN POTASSIUM 100 MG TAB |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LOSARTAN POTASSIUM 25 MG TAB |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LOSARTAN POTASSIUM 50 MG TAB |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOSARTAN-HCTZ 100-12.5 MG TAB |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LOSARTAN-HCTZ 100-25 MG TAB |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LOSARTAN-HCTZ 50-12.5 MG TAB |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LOTRONEX TABLETS .5MG 30 BOTPL |
5 |
Specialty Tier |
33% | 33% | P |
LOTRONEX TABLETS 1MG 30 BOTPL |
5 |
Specialty Tier |
33% | 33% | P |
Lovastatin 10mg 60 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Lovastatin 20mg 500 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LOVASTATIN 40 MG ORAL TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LOVAZA 1g/ 120 LIQUID FILLED CAPSULES in BOTTLE |
4 |
Non-Preferred Brand |
$60.00 | $180.00 | Q:120 /30Days |
LOW-OGESTREL-28 TABLET |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:28 /28Days |
LOXAPINE 25MG CAPSULE (100 CT) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOXAPINE CAPSULES 10MG 100 BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LOXAPINE CAPSULES 50MG 100 BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LOXAPINE CAPSULES 5MG 100 BOT |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LUMIGAN 0.03% EYE DROPS |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:3 /30Days |
LUMIGAN 0.1mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:3 /30Days |
Lumizyme 5mg/mL |
5 |
Specialty Tier |
33% | 33% | P |
LUPRON DEPOT 22.5 MG 3MO KIT [LUPRON] |
5 |
Specialty Tier |
33% | 33% | None |
LUPRON DEPOT 3.75 MG KIT |
5 |
Specialty Tier |
33% | 33% | None |
LUPRON DEPOT 7.5 MG KIT |
5 |
Specialty Tier |
33% | 33% | None |
LUPRON DEPOT-4 MONTH KIT |
5 |
Specialty Tier |
33% | 33% | None |
Lupron Depot-PED 1 KIT in 1 CARTON |
5 |
Specialty Tier |
33% | 33% | 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 |
33% | 33% | None |
LUPRON DEPOT-PED 15 MG KIT |
5 |
Specialty Tier |
33% | 33% | None |
LYRICA 100MG CAPSULE |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:120 /30Days |
LYRICA 150MG CAPSULE |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:120 /30Days |
LYRICA 20 MG/ML ORAL SOLUTION |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:900 /30Days |
LYRICA 200MG CAPSULE |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:90 /30Days |
LYRICA 225MG CAPSULE |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:60 /30Days |
LYRICA 25MG CAPSULE |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:120 /30Days |
LYRICA 300MG CAPSULE |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:60 /30Days |
LYRICA 50MG CAPSULE |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:120 /30Days |
LYRICA 75MG CAPSULE |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYSODREN 500MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |