2014 Medicare Part D Plan Formulary Information |
Group Health Cooperative Clear Care Key (HMO) (H5050-014-0)
Benefit Details
|
The Group Health Cooperative Clear Care Key (HMO) (H5050-014-0) Formulary Drugs Starting with the Letter L in KITSAP County, WA: CMS MA Region 23 which includes: WA Plan Monthly Premium: $294.00 Deductible: $200 |
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 |
LABETALOL HCL 100MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LABETALOL HCL 200MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LABETALOL HCL 300MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LABETALOL HCL 5MG/20ML VIAL |
2 |
Non-Preferred Generic |
$15.00 | $45.00 | None |
Lac Hydrin Cream 120mg/g 140 g in 1 TUBE |
4 |
Non-Preferred Brand |
50% | 50% | None |
Lac-Hydrin 120mg/g 400 g in 1 BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
50% | 50% | None |
LACRISERT 5 MG EYE INSERT |
4 |
Non-Preferred Brand |
50% | 50% | None |
LACTATED RINGERS INJECTION |
4 |
Non-Preferred Brand |
50% | 50% | None |
LACTATED RINGERS IRRIGATION |
4 |
Non-Preferred Brand |
50% | 50% | None |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMICTAL 100MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LAMICTAL 150MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LAMICTAL 200MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LAMICTAL 25MG DISPER TABLET CHEW |
4 |
Non-Preferred Brand |
50% | 50% | None |
LAMICTAL 25MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LAMICTAL 25MG TABLET STARTER KIT |
4 |
Non-Preferred Brand |
50% | 50% | None |
LAMICTAL 25MG/100MG TABLET STARTER KIT |
4 |
Non-Preferred Brand |
50% | 50% | None |
LAMICTAL 5MG DISPER TABLET CHEW |
4 |
Non-Preferred Brand |
50% | 50% | None |
LAMICTAL KIT 100;25MG;MG |
4 |
Non-Preferred Brand |
50% | 50% | None |
LAMICTAL ODT 100mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK |
4 |
Non-Preferred Brand |
50% | 50% | None |
LAMICTAL ODT 200mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK |
4 |
Non-Preferred Brand |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMICTAL ODT 25mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK |
4 |
Non-Preferred Brand |
50% | 50% | None |
LAMICTAL ODT 50mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK |
4 |
Non-Preferred Brand |
50% | 50% | None |
LAMICTAL XR 100 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LAMICTAL XR 200 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LAMICTAL XR 25 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LAMICTAL XR 250mg/1 30 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
50% | 50% | None |
LAMICTAL XR 300mg/1 30 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
50% | 50% | None |
LAMICTAL XR 50 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LAMICTAL XR START KIT (BLUE) |
4 |
Non-Preferred Brand |
50% | 50% | None |
LAMICTAL XR START KIT (GREEN) |
4 |
Non-Preferred Brand |
50% | 50% | None |
LAMICTAL XR START KIT (ORANGE) |
4 |
Non-Preferred Brand |
50% | 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 |
50% | 50% | None |
LAMISIL 187.5MG GRANULES IN PACKET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LAMISIL 250MG TABLET (30 CT) |
4 |
Non-Preferred Brand |
50% | 50% | None |
LAMIVUDINE 150 MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LAMIVUDINE 300 MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Lamivudine hbv 100 mg tablet |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LAMIVUDINE-ZIDOVUDINE TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LAMOTRIGINE 150MG TABLET (60 CT) |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LAMOTRIGINE 200MG TABLET (60 CT) |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LAMOTRIGINE 25MG TABLET (100 CT) |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE 5MG TABLET DISPERSIBLE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LAMOTRIGINE ER 100 MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $45.00 | None |
lamotrigine er 200 mg tablet |
2 |
Non-Preferred Generic |
$15.00 | $45.00 | None |
lamotrigine er 25 mg tablet |
2 |
Non-Preferred Generic |
$15.00 | $45.00 | None |
lamotrigine er 250 mg tablet |
2 |
Non-Preferred Generic |
$15.00 | $45.00 | None |
lamotrigine er 300 mg tablet |
2 |
Non-Preferred Generic |
$15.00 | $45.00 | None |
lamotrigine er 50 mg tablet |
2 |
Non-Preferred Generic |
$15.00 | $45.00 | None |
LAMOTRIGINE TABLET 100MG (100 CT) |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LANOXIN 0.25 MG/ML AMPUL |
4 |
Non-Preferred Brand |
50% | 50% | None |
LANOXIN 0.25MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LANOXIN 125 MCG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LANOXIN 187.5 MCG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LANOXIN 62.5 MCG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LANREOTIDE 240 MG/ML PREFILLED SYRINGE [SOMATULINE] |
4 |
Non-Preferred Brand |
50% | 50% | None |
LANSOPRAZOL-AMOXICIL-CLARITHRO |
2 |
Non-Preferred Generic |
$15.00 | $45.00 | None |
Lansoprazole 15mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE, PLASTIC |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Lansoprazole 30mg/1 30 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LANTUS 100U/ML VIAL |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
LANTUS SOLOSTAR INJECTION |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
LARIN 21 1-20 tablet |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LARIN FE 1-20 TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LARIN FE 1.5-30 TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LASIX 20MG TABLETS |
4 |
Non-Preferred Brand |
50% | 50% | None |
LASIX 40MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LASIX 80MG TABLETS |
4 |
Non-Preferred Brand |
50% | 50% | None |
LASTACAFT 2.5mg/mL 1 BOTTLE, PLASTIC per CARTON / 3 mL in 1 BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
50% | 50% | None |
LATANOPROST 0.005% EYE DROPS |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LATUDA 120 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LATUDA 20 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
Latuda 40mg/1 |
4 |
Non-Preferred Brand |
50% | 50% | None |
LATUDA 60 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
Latuda 80mg/1 |
4 |
Non-Preferred Brand |
50% | 50% | None |
LAZANDA 100 MCG NASAL SPRAY |
4 |
Non-Preferred Brand |
50% | 50% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAZANDA 400 MCG NASAL SPRAY |
4 |
Non-Preferred Brand |
50% | 50% | Q:30 /30Days |
LEENA 7-9-5 TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LEFLUNOMIDE 10MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LEFLUNOMIDE 20 MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LESCOL 20MG CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | None |
LESCOL 40MG CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | None |
LESCOL XL 80MG TABLET SA |
4 |
Non-Preferred Brand |
50% | 50% | None |
Lessina 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LETAIRIS 10MG TABLET |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
LETAIRIS 5MG TABLET |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
Letrozole 2.5mg/1 500 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUCOVORIN CALCIUM 100MG VL |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LEUCOVORIN CALCIUM 10MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Leucovorin Calcium 15mg/1 24 TABLET BOTTLE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LEUCOVORIN CALCIUM 25MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LEUCOVORIN CALCIUM 350MG VL |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LEUCOVORIN CALCIUM 5MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LEUKERAN 2 MG TABLET |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
LEUKINE 250 MCG VIAL |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
LEUPROLIDE ACETATE 1MG/0.2ML INJECTION |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Levalbuterol 0.31 mg/3 ml sol |
2 |
Non-Preferred Generic |
$15.00 | $45.00 | P |
Levalbuterol 0.63 mg/3 ml sol |
2 |
Non-Preferred Generic |
$15.00 | $45.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVALBUTEROL 1.25 MG/0.5 ML |
2 |
Non-Preferred Generic |
$15.00 | $45.00 | P |
LEVAQUIN 250mg/1 10 BLISTER PACK per CARTON / 10 FILM COATED TABLETS in BLISTER PACK |
4 |
Non-Preferred Brand |
50% | 50% | None |
LEVAQUIN 25mg/mL 480 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
50% | 50% | None |
LEVAQUIN 500mg/1 50 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
50% | 50% | None |
LEVAQUIN 750 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LEVAQUIN INJECTION 5 MG/ML |
4 |
Non-Preferred Brand |
50% | 50% | None |
LEVATOL 20 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LEVEMIR 100UNITS/ML VIAL |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
Levemir 14.2mg/mL 5 SYRINGE, PLASTIC per CARTON / 3 mL in 1 SYRINGE, PLASTIC |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LEVETIRACETAM 100MG/ML INJECTION |
2 |
Non-Preferred Generic |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM 500 MG TABLET 120 BOT |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LEVETIRACETAM ER 500 MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LEVETIRACETAM ER 750 MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LEVETIRACETAM TABLETS 1000MG 60 BOT |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LEVETIRACETAM TABLETS 250MG 500 BOT |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LEVETIRACETAM TABLETS 750MG 500 BOT |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LEVOCARNITINE 100MG/ML SOLUTION ORAL |
1 |
Preferred Generic |
$5.00 | $15.00 | P |
LEVOCARNITINE 200MG/ML VIAL |
1 |
Preferred Generic |
$5.00 | $15.00 | P |
LEVOCARNITINE TABLET 330MG 90 BLPK |
1 |
Preferred Generic |
$5.00 | $15.00 | P |
LEVOCETIRIZINE 2.5 MG/5 ML SOL |
2 |
Non-Preferred Generic |
$15.00 | $45.00 | None |
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 |
$15.00 | $45.00 | None |
Levofloxacin 250mg/1 [LEVAQUIN] |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Levofloxacin 25mg/mL 1 BOTTLE per CARTON / 100 mL in 1 BOTTLE [LEVAQUIN] |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Levofloxacin 25mg/mL 1 VIAL per CARTON / 30 mL in 1 VIAL |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Levofloxacin 500mg/1 [LEVAQUIN] |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Levofloxacin 5mg/mL 1 BOTTLE, DROPPER per CARTON / 5 mL in 1 BOTTLE, DROPPER [LEVAQUIN] |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Levofloxacin 5mg/mL 24 POUCH per CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG [LEVAQUIN] |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Levofloxacin 750mg/1 [LEVAQUIN] |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LEVONEST-28 TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
levonor-eth estrad 0.15-0.03 |
2 |
Non-Preferred Generic |
$15.00 | $45.00 | None |
LEVORA-28 TABLET 0.15/30 |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVORPHANOL TARTRATE 2mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
$5.00 | $15.00 | Q:180 /30Days |
LEVOTHYROXINE 100 MCG VIAL |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Levothyroxine Sodium 100ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Levothyroxine Sodium 112ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Levothyroxine Sodium 125ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Levothyroxine Sodium 150ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Levothyroxine Sodium 175ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Levothyroxine Sodium 200ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Levothyroxine Sodium 25ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Levothyroxine Sodium 300ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$5.00 | $15.00 | 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 |
$5.00 | $15.00 | None |
Levothyroxine Sodium 75ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Levothyroxine Sodium 88ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LEVOXYL 100MCG TABLET (1000 CT) |
4 |
Non-Preferred Brand |
50% | 50% | None |
LEVOXYL 112MCG TABLET (1000 CT) |
4 |
Non-Preferred Brand |
50% | 50% | None |
LEVOXYL 125MCG TABLET (1000 CT) |
4 |
Non-Preferred Brand |
50% | 50% | None |
LEVOXYL 137MCG TABLET (1000 CT) |
4 |
Non-Preferred Brand |
50% | 50% | None |
LEVOXYL 150MCG TABLET (1000 CT) |
4 |
Non-Preferred Brand |
50% | 50% | None |
LEVOXYL 175MCG TABLET (1000 CT) |
4 |
Non-Preferred Brand |
50% | 50% | None |
LEVOXYL 200MCG TABLET (1000 CT) |
4 |
Non-Preferred Brand |
50% | 50% | None |
LEVOXYL 25MCG TABLET (1000 CT) |
4 |
Non-Preferred Brand |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 50MCG TABLET (1000 CT) |
4 |
Non-Preferred Brand |
50% | 50% | None |
LEVOXYL 75MCG TABLET (1000 CT) |
4 |
Non-Preferred Brand |
50% | 50% | None |
LEVOXYL 88MCG TABLET (1000 CT) |
4 |
Non-Preferred Brand |
50% | 50% | None |
LEXAPRO 10MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LEXAPRO 20MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LEXAPRO 5MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LEXAPRO 5MG/5ML SOLUTION |
4 |
Non-Preferred Brand |
50% | 50% | None |
LEXIVA 50mg/mL 225 mL in 1 BOTTLE |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
LEXIVA 700MG TABLETS |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
LIALDA 1.2G TABLET DELAYED RELEASE |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
LIDOCAINE 5% OINTMENT |
1 |
Preferred Generic |
$5.00 | $15.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Lidocaine 5% patch |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LIDOCAINE HCL 1% VIAL |
1 |
Preferred Generic |
$5.00 | $15.00 | P |
lidocaine hcl 2% jelly |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
lidocaine hcl 2% jelly |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LIDOCAINE HCL 2% JELLY 30ML TUBE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Lidocaine Hydrochloride 5mg/mL 25 VIAL, SINGLE-DOSE in 1 CONTAINER / 50 mL in 1 VIAL, SINGLE-DOSE |
1 |
Preferred Generic |
$5.00 | $15.00 | P |
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM |
1 |
Preferred Generic |
$5.00 | $15.00 | P |
LIDODERM 5% PATCH |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
LINCOCIN 300MG/ML VIAL |
4 |
Non-Preferred Brand |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Lindane 10mg/mL |
2 |
Non-Preferred Generic |
$15.00 | $45.00 | None |
LINDANE SHAMPOO 1MG 2 FLO BOT |
2 |
Non-Preferred Generic |
$15.00 | $45.00 | None |
LINZESS 145 MCG CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | None |
LINZESS 290 MCG CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | None |
Lioresal 0.05mg/mL |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
Lioresal 0.5mg/mL |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
Lioresal 2mg/mL |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
liothyronine sodium 10ug/mL 1 VIAL per CARTON / 1 mL in 1 VIAL |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIPITOR 10MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LIPITOR 20MG TABLET (5000 CT) |
4 |
Non-Preferred Brand |
50% | 50% | None |
LIPITOR 40MG TABLET (500 CT) |
4 |
Non-Preferred Brand |
50% | 50% | None |
LIPITOR 80MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LIPOFEN 150MG CAPSULES |
4 |
Non-Preferred Brand |
50% | 50% | None |
Liposyn III 1.2; 2.5; 10g/100mL; g/100mL; g/100mL 12 BOTTLE, GLASS in 1 CASE / 250 mL in 1 BOTTLE, |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
Liposyn III 1.2; 2.5; 20g/100mL; g/100mL; g/100mL 12 BOTTLE, GLASS in 1 CASE / 250 mL in 1 BOTTLE, |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
LIPTRUZET 10-10 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LIPTRUZET 10-20 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LIPTRUZET 10-40 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LIPTRUZET 10-80 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | 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 |
$5.00 | $15.00 | None |
LISINOPRIL 2.5 MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Lisinopril 20 mg tablet |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LISINOPRIL 30MG TABLET (100 CT) |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LISINOPRIL 40MG TABLET (500 CT) |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Lisinopril 5mg/1 1000 TABLET BOTTLE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Lisinopril with Hydrochlorothiazide 12.5; 10mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Lisinopril with Hydrochlorothiazide 12.5; 20mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT) |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Lithium Carbonate 150mg/1 100 CAPSULE BOTTLE, PLASTIC |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Lithium Carbonate 300mg/1 1000 TABLET BOTTLE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Lithium Carbonate 450mg/1 |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LITHIUM CARBONATE 600 MG CAP |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LITHOBID 300MG TABLET SA |
4 |
Non-Preferred Brand |
50% | 50% | None |
LIVALO 1 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LIVALO 2 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LIVALO 4 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
Lo Loestrin Fe 5 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
4 |
Non-Preferred Brand |
50% | 50% | None |
LO MINASTRIN FE TABLET CHEW |
4 |
Non-Preferred Brand |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Locoid Lipocream 1.0mg/g 1 TUBE per CARTON / 60 g in 1 TUBE |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOCOID LOTN 0.1 % |
4 |
Non-Preferred Brand |
50% | 50% | None |
LODOSYN TAB 25MG |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
LOESTRIN 24 FE TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOFIBRA 134MG CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOFIBRA 160MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOFIBRA 200MG CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOFIBRA 54MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOFIBRA 67MG CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOKARA 0.05% LOTION |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LOMEDIA 24 FE 24MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Lomotil 0.025; 2.5mg/1; mg/1 100 TABLET BOTTLE |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOMUSTINE 10 MG CAPSULE [Ceenu] |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LOMUSTINE 100 MG CAPSULE [Ceenu] |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LOMUSTINE 40 MG CAPSULE [Ceenu] |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LOPERAMIDE HCL 2MG CAPSULE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LOPID 600MG TABLET (500 CT) |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOPRESSOR 100MG TABLET (100 CT) |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOPRESSOR 1MG/ML AMPUL |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOPRESSOR 50MG TABLET (100 CT) |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOPRESSOR HCT 50-25 TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOPROX 1% SHAMPOO |
4 |
Non-Preferred Brand |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LORAZEPAM 0.5 MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Lorazepam 1mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Lorazepam 2mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Lorazepam 2mg/mL 30 mL in 1 BOTTLE, DROPPER |
4 |
Non-Preferred Brand |
50% | 50% | None |
lorcet 5-325 mg tablet |
1 |
Preferred Generic |
$5.00 | $15.00 | Q:360 /30Days |
lorcet hd 10-325 mg tablet |
1 |
Preferred Generic |
$5.00 | $15.00 | Q:360 /30Days |
Lorcet plus 7.5-325 mg tablet |
1 |
Preferred Generic |
$5.00 | $15.00 | Q:360 /30Days |
lortab 10-325 mg tablet |
4 |
Non-Preferred Brand |
50% | 50% | Q:360 /30Days |
lortab 5-325 mg tablet |
4 |
Non-Preferred Brand |
50% | 50% | Q:360 /30Days |
lortab 7.5-325 mg tablet |
4 |
Non-Preferred Brand |
50% | 50% | Q:360 /30Days |
Loryna (drospirenone and ethinyl estradiol) 3 CARTON in 1 BOX / 1 KIT per CARTON |
2 |
Non-Preferred Generic |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LORZONE 375 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LORZONE 750 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOSARTAN POTASSIUM 100 MG TAB |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LOSARTAN POTASSIUM 25 MG TAB |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LOSARTAN POTASSIUM 50 MG TAB |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LOSARTAN-HCTZ 100-12.5 MG TAB |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LOSARTAN-HCTZ 100-25 MG TAB |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LOSARTAN-HCTZ 50-12.5 MG TAB |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LOSEASONIQUE TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOTEMAX 0.5% EYE DROPS |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOTEMAX 0.5% OPHTHALMIC GEL |
4 |
Non-Preferred Brand |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Lotemax 5mg/g 1 TUBE per CARTON / 3.5 g in 1 TUBE |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOTENSIN 20 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOTENSIN 40 MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOTENSIN HCT 10-12.5 TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOTENSIN HCT 20-12.5 TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOTENSIN HCT 20-25 TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOTREL 10/20MG CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOTREL 10/40MG CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOTREL 2.5/10MG CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | None |
Lotrel 5; 40mg/1; mg/1 100 CAPSULE BOTTLE |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOTREL 5/10MG CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOTREL 5/20MG CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOTRISONE CREAM |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOTRONEX TABLETS .5MG 30 BOTPL |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOTRONEX TABLETS 1MG 30 BOTPL |
4 |
Non-Preferred Brand |
50% | 50% | None |
Lovastatin 10mg 60 TABLET BOTTLE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Lovastatin 20mg 500 TABLET BOTTLE |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LOVASTATIN 40 MG ORAL TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LOVAZA 1g/ 120 LIQUID FILLED CAPSULES in BOTTLE |
4 |
Non-Preferred Brand |
50% | 50% | None |
LOVENOX 100MG PREFILLED SYR |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LOVENOX 120MG PREFILLED SYR |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LOVENOX 150MG PREFILLED SYR |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOVENOX 300MG VIAL |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LOVENOX 30MG PREFILLED SYRN |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LOVENOX 40MG PREFILLED SYRN |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LOVENOX 60MG PREFILLED SYRN |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LOVENOX 80MG PREFILLED SYRN |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LOW-OGESTREL-28 TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LOXAPINE 25MG CAPSULE (100 CT) |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LOXAPINE CAPSULES 10MG 100 BOT |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LOXAPINE CAPSULES 50MG 100 BOT |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LOXAPINE CAPSULES 5MG 100 BOT |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LOXITANE 10MG CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOXITANE 5MG CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | None |
LUFYLLIN 200MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LUFYLLIN-400 TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LUMIGAN 0.1mg/mL 1 BOTTLE, DROPPER per CARTON / 5 mL in 1 BOTTLE, DROPPER |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
Lumizyme 5mg/mL |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
LUNESTA 2MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LUNESTA 3MG TABLET |
4 |
Non-Preferred Brand |
50% | 50% | None |
LUNESTA TABLETS 1MG 30 BOT |
4 |
Non-Preferred Brand |
50% | 50% | None |
LUPANETA PACK 11.25-5 MG 3MO KIT |
4 |
Non-Preferred Brand |
50% | 50% | None |
LUPANETA PACK 3.75-5 MG 1MO KIT |
4 |
Non-Preferred Brand |
50% | 50% | None |
Lupron Depot 1 KIT per CARTON |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
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] |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
LUPRON DEPOT 3.75 MG KIT |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
LUPRON DEPOT 7.5 MG KIT |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
LUPRON DEPOT-4 MONTH KIT |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
Lupron Depot-PED 1 KIT per CARTON |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
LUPRON DEPOT-PED 11.25 MG KIT |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
LUPRON DEPOT-PED 15 MG KIT |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
LUTERA 0.1-0.02 TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |
LUVOX CR 100MG CAPSULE SR 24 HR |
4 |
Non-Preferred Brand |
50% | 50% | None |
LUVOX CR 150MG CAPSULE SR 24 HR |
4 |
Non-Preferred Brand |
50% | 50% | None |
LUXIQ 1.2mg/g 1 CAN per CARTON / 100 g in 1 CAN |
4 |
Non-Preferred Brand |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUZU 1% CREAM |
4 |
Non-Preferred Brand |
50% | 50% | None |
LYRICA 100MG CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | None |
LYRICA 150MG CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | None |
LYRICA 20 MG/ML ORAL SOLUTION |
4 |
Non-Preferred Brand |
50% | 50% | None |
LYRICA 200MG CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | None |
LYRICA 225MG CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | None |
LYRICA 25MG CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | None |
LYRICA 300MG CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | None |
LYRICA 50MG CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | None |
LYRICA 75MG CAPSULE |
4 |
Non-Preferred Brand |
50% | 50% | None |
LYSODREN 500MG TABLET |
3 |
Preferred Brand |
$23.00 | $69.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYSTEDA 650mg/1 |
4 |
Non-Preferred Brand |
50% | 50% | Q:30 /30Days |
LYZA 0.35 MG TABLET |
1 |
Preferred Generic |
$5.00 | $15.00 | None |