2014 Medicare Part D Plan Formulary Information |
Blue MedicareRx Standard (PDP) (S5596-017-0)
Benefit Details
|
The Blue MedicareRx Standard (PDP) (S5596-017-0) Formulary Drugs Starting with the Letter L in CMS PDP Region 15 which includes: IN KY Plan Monthly Premium: $28.00 Deductible: $310 Qualifies for LIS: Yes |
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 |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
LABETALOL HCL 200MG TABLET |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
LABETALOL HCL 300MG TABLET |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
LACRISERT 5 MG EYE INSERT |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
LAMIVUDINE 150 MG TABLET |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
LAMIVUDINE 300 MG TABLET |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
Lamivudine hbv 100 mg tablet |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
LAMIVUDINE-ZIDOVUDINE TABLET |
6 |
Specialty Tier |
25% | N/A | None |
LAMOTRIGINE 150MG TABLET (60 CT) |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE 200MG TABLET (60 CT) |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
LAMOTRIGINE 25MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
LAMOTRIGINE TABLET 100MG (100 CT) |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
LANOXIN 0.25MG TABLET |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
LANOXIN 125 MCG TABLET |
3 |
Preferred Brand |
$36.00 | $108.00 | Q:30 /30Days |
LANOXIN 62.5 MCG TABLET |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
Lansoprazole 15mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE, PLASTIC |
3 |
Preferred Brand |
$36.00 | $108.00 | Q:30 /30Days |
Lansoprazole 30mg/1 30 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
3 |
Preferred Brand |
$36.00 | $108.00 | Q:30 /30Days |
LANTUS 100U/ML VIAL |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LANTUS SOLOSTAR INJECTION |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
LATANOPROST 0.005% EYE DROPS |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
LATUDA 120 MG TABLET |
6 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
LATUDA 20 MG TABLET |
4 |
Non-Preferred Brand |
$89.00 | $267.00 | Q:240 /30Days |
Latuda 40mg/1 |
4 |
Non-Preferred Brand |
$89.00 | $267.00 | Q:120 /30Days |
LATUDA 60 MG TABLET |
4 |
Non-Preferred Brand |
$89.00 | $267.00 | Q:75 /30Days |
Latuda 80mg/1 |
4 |
Non-Preferred Brand |
$89.00 | $267.00 | Q:60 /30Days |
LAZANDA 100 MCG NASAL SPRAY |
6 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
LAZANDA 400 MCG NASAL SPRAY |
6 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
LEENA 7-9-5 TABLET |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
LEFLUNOMIDE 10MG TABLET |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEFLUNOMIDE 20 MG TABLET |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
Lessina 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
LETAIRIS 10MG TABLET |
6 |
Specialty Tier |
25% | N/A | P |
LETAIRIS 5MG TABLET |
6 |
Specialty Tier |
25% | N/A | P |
Letrozole 2.5mg/1 500 FILM COATED TABLETS in BOTTLE, PLASTIC |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
LEUCOVORIN CALCIUM 100MG VL |
5 |
Injectable Drugs |
$95.00 | $285.00 | None |
LEUCOVORIN CALCIUM 10MG TABLET |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
Leucovorin Calcium 15mg/1 24 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
LEUCOVORIN CALCIUM 25MG TABLET |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
LEUCOVORIN CALCIUM 350MG VL |
5 |
Injectable Drugs |
$95.00 | $285.00 | None |
LEUCOVORIN CALCIUM 5MG TABLET |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUKERAN 2 MG TABLET |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
LEUKINE 250 MCG VIAL |
6 |
Specialty Tier |
25% | N/A | P |
LEUPROLIDE ACETATE 1MG/0.2ML INJECTION |
5 |
Injectable Drugs |
$95.00 | $285.00 | P |
LEVEMIR 100UNITS/ML VIAL |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
Levemir 14.2mg/mL 5 SYRINGE, PLASTIC per CARTON / 3 mL in 1 SYRINGE, PLASTIC |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
LEVETIRACETAM 100MG/ML INJECTION |
5 |
Injectable Drugs |
$95.00 | $285.00 | None |
LEVETIRACETAM 500 MG TABLET 120 BOT |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
LEVETIRACETAM ER 500 MG TABLET |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | Q:180 /30Days |
LEVETIRACETAM ER 750 MG TABLET |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | Q:120 /30Days |
LEVETIRACETAM TABLETS 1000MG 60 BOT |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | 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 |
$5.00 | $10.00 | None |
LEVETIRACETAM TABLETS 750MG 500 BOT |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LEVOCARNITINE 100MG/ML SOLUTION ORAL |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | P |
LEVOCARNITINE TABLET 330MG 90 BLPK |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | P |
Levofloxacin 250mg/1 [LEVAQUIN] |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | Q:14 /1Days |
Levofloxacin 25mg/mL 1 VIAL per CARTON / 30 mL in 1 VIAL |
5 |
Injectable Drugs |
$95.00 | $285.00 | None |
Levofloxacin 500mg/1 [LEVAQUIN] |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | Q:14 /1Days |
Levofloxacin 5mg/mL 1 BOTTLE, DROPPER per CARTON / 5 mL in 1 BOTTLE, DROPPER [LEVAQUIN] |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
Levofloxacin 5mg/mL 24 POUCH per CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG [LEVAQUIN] |
5 |
Injectable Drugs |
$95.00 | $285.00 | None |
Levofloxacin 750mg/1 [LEVAQUIN] |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | Q:14 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVONEST-28 TABLET |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
levonor-eth estrad 0.15-0.03 |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
LEVORA-28 TABLET 0.15/30 |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
Levothyroxine Sodium 100ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
Levothyroxine Sodium 112ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
Levothyroxine Sodium 125ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
Levothyroxine Sodium 150ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
Levothyroxine Sodium 175ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
Levothyroxine Sodium 200ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
Levothyroxine Sodium 25ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1* |
Preferred Generic |
$1.00 | $2.00 | 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 |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
Levothyroxine Sodium 50ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
Levothyroxine Sodium 75ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
Levothyroxine Sodium 88ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LEVOXYL 100MCG TABLET (1000 CT) |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LEVOXYL 112MCG TABLET (1000 CT) |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LEVOXYL 125MCG TABLET (1000 CT) |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LEVOXYL 137MCG TABLET (1000 CT) |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LEVOXYL 150MCG TABLET (1000 CT) |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LEVOXYL 175MCG TABLET (1000 CT) |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LEVOXYL 200MCG TABLET (1000 CT) |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 25MCG TABLET (1000 CT) |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LEVOXYL 50MCG TABLET (1000 CT) |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LEVOXYL 75MCG TABLET (1000 CT) |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LEVOXYL 88MCG TABLET (1000 CT) |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LEXIVA 50mg/mL 225 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$89.00 | $267.00 | None |
LEXIVA 700MG TABLETS |
6 |
Specialty Tier |
25% | N/A | None |
LIDOCAINE 5% OINTMENT |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
Lidocaine 5% patch |
3 |
Preferred Brand |
$36.00 | $108.00 | Q:90 /30Days |
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
LIDODERM 5% PATCH |
3 |
Preferred Brand |
$36.00 | $108.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LINDANE SHAMPOO 1MG 2 FLO BOT |
4 |
Non-Preferred Brand |
$89.00 | $267.00 | None |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | 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 |
$95.00 | $285.00 | None |
Liposyn III 1.2; 2.5; 20g/100mL; g/100mL; g/100mL 12 BOTTLE, GLASS in 1 CASE / 250 mL in 1 BOTTLE, |
5 |
Injectable Drugs |
$95.00 | $285.00 | None |
LISINOPRIL 10MG TABLET (100 CT) |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LISINOPRIL 2.5 MG TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
Lisinopril 20 mg tablet |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LISINOPRIL 30MG TABLET (100 CT) |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LISINOPRIL 40MG TABLET (500 CT) |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Lisinopril 5mg/1 1000 TABLET BOTTLE |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
Lisinopril with Hydrochlorothiazide 12.5; 10mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
Lisinopril with Hydrochlorothiazide 12.5; 20mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT) |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
Lithium Carbonate 150mg/1 100 CAPSULE BOTTLE, PLASTIC |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
Lithium Carbonate 300mg/1 1000 TABLET BOTTLE |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
Lithium Carbonate 450mg/1 |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LITHIUM CARBONATE 600 MG CAP |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) |
1* |
Preferred Generic |
$1.00 | $2.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOMUSTINE 10 MG CAPSULE [Ceenu] |
4 |
Non-Preferred Brand |
$89.00 | $267.00 | None |
LOMUSTINE 100 MG CAPSULE [Ceenu] |
4 |
Non-Preferred Brand |
$89.00 | $267.00 | None |
LOMUSTINE 40 MG CAPSULE [Ceenu] |
4 |
Non-Preferred Brand |
$89.00 | $267.00 | None |
LOPERAMIDE HCL 2MG CAPSULE |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
LOSARTAN POTASSIUM 100 MG TAB |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:30 /30Days |
LOSARTAN POTASSIUM 25 MG TAB |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:60 /30Days |
LOSARTAN POTASSIUM 50 MG TAB |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:60 /30Days |
LOSARTAN-HCTZ 100-12.5 MG TAB |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:30 /30Days |
LOSARTAN-HCTZ 100-25 MG TAB |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:30 /30Days |
LOSARTAN-HCTZ 50-12.5 MG TAB |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:30 /30Days |
LOTRONEX TABLETS .5MG 30 BOTPL |
3 |
Preferred Brand |
$36.00 | $108.00 | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOTRONEX TABLETS 1MG 30 BOTPL |
6 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
Lovastatin 10mg 60 TABLET BOTTLE |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:30 /30Days |
Lovastatin 20mg 500 TABLET BOTTLE |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:30 /30Days |
LOVASTATIN 40 MG ORAL TABLET |
1* |
Preferred Generic |
$1.00 | $2.00 | Q:60 /30Days |
LOVAZA 1g/ 120 LIQUID FILLED CAPSULES in BOTTLE |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
LOW-OGESTREL-28 TABLET |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
LOXAPINE 25MG CAPSULE (100 CT) |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
LOXAPINE CAPSULES 10MG 100 BOT |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
LOXAPINE CAPSULES 50MG 100 BOT |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
LOXAPINE CAPSULES 5MG 100 BOT |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None |
LUPRON DEPOT 3.75 MG KIT |
6 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUPRON DEPOT 7.5 MG KIT |
6 |
Specialty Tier |
25% | N/A | P |
LUTERA 0.1-0.02 TABLET |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
LYRICA 100MG CAPSULE |
4 |
Non-Preferred Brand |
$89.00 | $267.00 | P Q:180 /30Days |
LYRICA 150MG CAPSULE |
4 |
Non-Preferred Brand |
$89.00 | $267.00 | P Q:120 /30Days |
LYRICA 20 MG/ML ORAL SOLUTION |
4 |
Non-Preferred Brand |
$89.00 | $267.00 | P Q:900 /30Days |
LYRICA 200MG CAPSULE |
4 |
Non-Preferred Brand |
$89.00 | $267.00 | P Q:90 /30Days |
LYRICA 225MG CAPSULE |
4 |
Non-Preferred Brand |
$89.00 | $267.00 | P Q:60 /30Days |
LYRICA 25MG CAPSULE |
4 |
Non-Preferred Brand |
$89.00 | $267.00 | P Q:720 /30Days |
LYRICA 300MG CAPSULE |
4 |
Non-Preferred Brand |
$89.00 | $267.00 | P Q:60 /30Days |
LYRICA 50MG CAPSULE |
4 |
Non-Preferred Brand |
$89.00 | $267.00 | P Q:360 /30Days |
LYRICA 75MG CAPSULE |
4 |
Non-Preferred Brand |
$89.00 | $267.00 | P Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYSODREN 500MG TABLET |
3 |
Preferred Brand |
$36.00 | $108.00 | None |
LYZA 0.35 MG TABLET |
3 |
Preferred Brand |
$36.00 | $108.00 | None |