2014 Medicare Part D Plan Formulary Information |
Optimum Platinum Plan (HMO-POS) (H5594-002-0)
Benefit Details
|
The Optimum Platinum Plan (HMO-POS) (H5594-002-0) Formulary Drugs Starting with the Letter L in HILLSBOROUGH County, FL: CMS MA Region 9 which includes: FL Plan Monthly Premium: $0.00 Deductible: $0 |
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 |
$0.00 | $0.00 | None |
LABETALOL HCL 200MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LABETALOL HCL 300MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LABETALOL HCL 5MG/20ML VIAL |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
LACRISERT 5 MG EYE INSERT |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | None |
LACTATED RINGERS INJECTION |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LAMICTAL 25MG TABLET STARTER KIT |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | None |
LAMICTAL 25MG/100MG TABLET STARTER KIT |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | None |
LAMICTAL KIT 100;25MG;MG |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE 150MG TABLET (60 CT) |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
LAMOTRIGINE 200MG TABLET (60 CT) |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
LAMOTRIGINE 25MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
LAMOTRIGINE ER 100 MG TABLET |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | None |
lamotrigine er 200 mg tablet |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | None |
lamotrigine er 25 mg tablet |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | None |
lamotrigine er 250 mg tablet |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | None |
lamotrigine er 300 mg tablet |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | None |
lamotrigine er 50 mg tablet |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE TABLET 100MG (100 CT) |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
LANREOTIDE 240 MG/ML PREFILLED SYRINGE [SOMATULINE] |
4 |
Specialty Tier |
33% | 33% | P |
Lansoprazole 15mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE, PLASTIC |
2 |
Preferred Brand |
$5.00 | $10.00 | Q:30 /30Days |
Lansoprazole 30mg/1 30 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
2 |
Preferred Brand |
$5.00 | $10.00 | Q:30 /30Days |
LANTUS 100U/ML VIAL |
2 |
Preferred Brand |
$5.00 | $10.00 | Q:40 /30Days |
LANTUS SOLOSTAR INJECTION |
2 |
Preferred Brand |
$5.00 | $10.00 | Q:45 /30Days |
LATANOPROST 0.005% EYE DROPS |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:3 /25Days |
LATUDA 120 MG TABLET |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | S Q:30 /30Days |
LATUDA 20 MG TABLET |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | S Q:90 /90Days |
Latuda 40mg/1 |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | S Q:90 /90Days |
LATUDA 60 MG TABLET |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | S Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Latuda 80mg/1 |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | S Q:30 /30Days |
LAZANDA 100 MCG NASAL SPRAY |
4 |
Specialty Tier |
33% | 33% | None |
LAZANDA 400 MCG NASAL SPRAY |
4 |
Specialty Tier |
33% | 33% | None |
LEFLUNOMIDE 10MG TABLET |
2 |
Preferred Brand |
$5.00 | $10.00 | Q:30 /30Days |
LEFLUNOMIDE 20 MG TABLET |
2 |
Preferred Brand |
$5.00 | $10.00 | Q:30 /30Days |
Lessina 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LETAIRIS 10MG TABLET |
4 |
Specialty Tier |
33% | 33% | P |
LETAIRIS 5MG TABLET |
4 |
Specialty Tier |
33% | 33% | P |
Letrozole 2.5mg/1 500 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
LEUCOVORIN CALCIUM 100MG VL |
2 |
Preferred Brand |
$5.00 | $10.00 | P |
LEUCOVORIN CALCIUM 10MG TABLET |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Leucovorin Calcium 15mg/1 24 TABLET BOTTLE |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
LEUCOVORIN CALCIUM 25MG TABLET |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
LEUCOVORIN CALCIUM 5MG TABLET |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
LEUKERAN 2 MG TABLET |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
LEUKINE 250 MCG VIAL |
4 |
Specialty Tier |
33% | 33% | P |
LEUPROLIDE ACETATE 1MG/0.2ML INJECTION |
2 |
Preferred Brand |
$5.00 | $10.00 | P |
LEVEMIR 100UNITS/ML VIAL |
2 |
Preferred Brand |
$5.00 | $10.00 | Q:40 /30Days |
Levemir 14.2mg/mL 5 SYRINGE, PLASTIC per CARTON / 3 mL in 1 SYRINGE, PLASTIC |
2 |
Preferred Brand |
$5.00 | $10.00 | Q:45 /30Days |
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
LEVETIRACETAM 100MG/ML INJECTION |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
LEVETIRACETAM 500 MG TABLET 120 BOT |
2 |
Preferred Brand |
$5.00 | $10.00 | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM ER 500 MG TABLET |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | Q:120 /30Days |
LEVETIRACETAM ER 750 MG TABLET |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | Q:120 /30Days |
LEVETIRACETAM TABLETS 1000MG 60 BOT |
2 |
Preferred Brand |
$5.00 | $10.00 | Q:90 /30Days |
LEVETIRACETAM TABLETS 250MG 500 BOT |
2 |
Preferred Brand |
$5.00 | $10.00 | Q:90 /30Days |
LEVETIRACETAM TABLETS 750MG 500 BOT |
2 |
Preferred Brand |
$5.00 | $10.00 | Q:120 /30Days |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LEVOCARNITINE 100MG/ML SOLUTION ORAL |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
LEVOCARNITINE 200MG/ML VIAL |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
Levocetirizine dihydrochloride 5mg/1 30 TABLET BOTTLE |
2 |
Preferred Brand |
$5.00 | $10.00 | S Q:30 /30Days |
Levofloxacin 250mg/1 [LEVAQUIN] |
2 |
Preferred Brand |
$5.00 | $10.00 | Q:14 /14Days |
Levofloxacin 25mg/mL 1 VIAL per CARTON / 30 mL in 1 VIAL |
2 |
Preferred Brand |
$5.00 | $10.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levofloxacin 500mg/1 [LEVAQUIN] |
2 |
Preferred Brand |
$5.00 | $10.00 | Q:14 /14Days |
Levofloxacin 750mg/1 [LEVAQUIN] |
2 |
Preferred Brand |
$5.00 | $10.00 | Q:14 /14Days |
Levothyroxine Sodium 100ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Levothyroxine Sodium 112ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Levothyroxine Sodium 125ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Levothyroxine Sodium 150ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Levothyroxine Sodium 175ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Levothyroxine Sodium 200ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Levothyroxine Sodium 25ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Levothyroxine Sodium 300ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$0.00 | $0.00 | 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 |
$0.00 | $0.00 | None |
Levothyroxine Sodium 75ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Levothyroxine Sodium 88ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LEXIVA 50mg/mL 225 mL in 1 BOTTLE |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | None |
LEXIVA 700MG TABLETS |
4 |
Specialty Tier |
33% | 33% | None |
LIDOCAINE 5% OINTMENT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LIDOCAINE HCL 2% JELLY 30ML TUBE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Lidocaine Hydrochloride 5mg/mL 25 VIAL, SINGLE-DOSE in 1 CONTAINER / 50 mL in 1 VIAL, SINGLE-DOSE |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIDODERM 5% PATCH |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | Q:90 /30Days |
LINCOCIN 300MG/ML VIAL |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
LINZESS 145 MCG CAPSULE |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | P Q:30 /30Days |
LINZESS 290 MCG CAPSULE |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | P Q:30 /30Days |
liothyronine sodium 10ug/mL 1 VIAL per CARTON / 1 mL in 1 VIAL |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LISINOPRIL 10MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
LISINOPRIL 2.5 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
Lisinopril 20 mg tablet |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL 30MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
LISINOPRIL 40MG TABLET (500 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days |
Lisinopril 5mg/1 1000 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
Lisinopril with Hydrochlorothiazide 12.5; 10mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Lisinopril with Hydrochlorothiazide 12.5; 20mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Lithium Carbonate 150mg/1 100 CAPSULE BOTTLE, PLASTIC |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Lithium Carbonate 300mg/1 1000 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Lithium Carbonate 450mg/1 |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LITHIUM CARBONATE 600 MG CAP |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LOMUSTINE 10 MG CAPSULE [Ceenu] |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
LOMUSTINE 100 MG CAPSULE [Ceenu] |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
LOMUSTINE 40 MG CAPSULE [Ceenu] |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
LOPERAMIDE HCL 2MG CAPSULE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LORAZEPAM 0.5 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
Lorazepam 1mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
Lorazepam 2mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | P |
LOSARTAN POTASSIUM 100 MG TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
LOSARTAN POTASSIUM 25 MG TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOSARTAN POTASSIUM 50 MG TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
LOSARTAN-HCTZ 100-12.5 MG TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
LOSARTAN-HCTZ 100-25 MG TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
LOSARTAN-HCTZ 50-12.5 MG TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
LOTEMAX 0.5% EYE DROPS |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
LOTRONEX TABLETS .5MG 30 BOTPL |
2 |
Preferred Brand |
$5.00 | $10.00 | Q:60 /30Days |
LOTRONEX TABLETS 1MG 30 BOTPL |
2 |
Preferred Brand |
$5.00 | $10.00 | Q:60 /30Days |
Lovastatin 10mg 60 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
Lovastatin 20mg 500 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
LOVASTATIN 40 MG ORAL TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days |
LOVAZA 1g/ 120 LIQUID FILLED CAPSULES in BOTTLE |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOVENOX 100MG PREFILLED SYR |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | Q:28 /14Days |
LOVENOX 120MG PREFILLED SYR |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | Q:28 /14Days |
LOVENOX 150MG PREFILLED SYR |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | Q:28 /14Days |
LOVENOX 300MG VIAL |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | Q:28 /14Days |
LOVENOX 30MG PREFILLED SYRN |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | Q:28 /14Days |
LOVENOX 40MG PREFILLED SYRN |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | Q:28 /14Days |
LOVENOX 60MG PREFILLED SYRN |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | Q:28 /14Days |
LOVENOX 80MG PREFILLED SYRN |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | Q:28 /14Days |
LOXAPINE 25MG CAPSULE (100 CT) |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
LOXAPINE CAPSULES 10MG 100 BOT |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
LOXAPINE CAPSULES 50MG 100 BOT |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOXAPINE CAPSULES 5MG 100 BOT |
2 |
Preferred Brand |
$5.00 | $10.00 | None |
LUFYLLIN 200MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LUFYLLIN-400 TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LUMIGAN 0.1mg/mL 1 BOTTLE, DROPPER per CARTON / 5 mL in 1 BOTTLE, DROPPER |
2 |
Preferred Brand |
$5.00 | $10.00 | Q:3 /25Days |
Lumizyme 5mg/mL |
4 |
Specialty Tier |
33% | 33% | P |
LUNESTA 2MG TABLET |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | Q:30 /30Days |
LUNESTA 3MG TABLET |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | Q:30 /30Days |
LUNESTA TABLETS 1MG 30 BOT |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | Q:30 /30Days |
LUPRON DEPOT 3.75 MG KIT |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | P |
LYRICA 100MG CAPSULE |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | P Q:90 /30Days |
LYRICA 150MG CAPSULE |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYRICA 20 MG/ML ORAL SOLUTION |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | P |
LYRICA 200MG CAPSULE |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | P Q:90 /30Days |
LYRICA 225MG CAPSULE |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | P Q:90 /30Days |
LYRICA 25MG CAPSULE |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | P Q:90 /30Days |
LYRICA 300MG CAPSULE |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | P Q:90 /30Days |
LYRICA 50MG CAPSULE |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | P Q:90 /30Days |
LYRICA 75MG CAPSULE |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | P Q:90 /30Days |
LYSODREN 500MG TABLET |
2 |
Preferred Brand |
$5.00 | $10.00 | None |