2015 Medicare Part D Plan Formulary Information |
SeniorCare Sr Premium - Basic Rx (Cost) (H4564-001-0)
Benefit Details
|
The SeniorCare Sr Premium - Basic Rx (Cost) (H4564-001-0) Formulary Drugs Starting with the Letter L in MCLENNAN County, TX: CMS MA Region 17 which includes: TX Plan Monthly Premium: $235.50 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 |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LABETALOL HCL 200MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LABETALOL HCL 300MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LABETALOL HCL 5MG/20ML VIAL |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LACRISERT 5 MG EYE INSERT |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
LACTATED RINGERS INJECTION |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
LACTATED RINGERS IRRIGATION 4 CONTAINER in 1 CASE / 40 |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Lamivudine 10 mg/ml oral soln |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LAMIVUDINE 150 MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMIVUDINE 300 MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Lamivudine hbv 100 mg tablet |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LAMIVUDINE-ZIDOVUDINE TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LAMOTRIGINE 150MG TABLET (60 CT) |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LAMOTRIGINE 200MG TABLET (60 CT) |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LAMOTRIGINE 25MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LAMOTRIGINE TABLET 100MG (100 CT) |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LANOXIN 125 MCG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days |
LANOXIN 250 MCG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LANREOTIDE 240 MG/ML PREFILLED SYRINGE [SOMATULINE] |
5 |
Specialty Tier |
33% | 33% | P |
Lansoprazole 15mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Lansoprazole 30mg/1 30 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LANTUS 100U/ML VIAL |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
LANTUS SOLOSTAR INJECTION |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
LARIN 1.5 MG-30 MCG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LARIN 21 1-20 tablet |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LARIN FE 1-20 TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LARIN FE 1.5-30 TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LATANOPROST 0.005% EYE DROPS |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LATUDA 120 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LATUDA 20 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
Latuda 40mg/1 |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
LATUDA 60 MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
Latuda 80mg/1 |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
LAZANDA 100 MCG NASAL SPRAY |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | P Q:30 /30Days |
LAZANDA 400 MCG NASAL SPRAY |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | P Q:30 /30Days |
LEFLUNOMIDE 10MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
LEFLUNOMIDE 20 MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
LENVIMA 10 MG DAILY DOSE |
5 |
Specialty Tier |
33% | 33% | None |
LENVIMA 14 MG DAILY DOSE |
5 |
Specialty Tier |
33% | 33% | None |
LENVIMA 20 MG DAILY DOSE |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LENVIMA 24 MG DAILY DOSE |
5 |
Specialty Tier |
33% | 33% | None |
Lessina 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LETAIRIS 10MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
LETAIRIS 5MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
LETROZOLE 2.5mg/1 |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LEUCOVORIN CALCIUM 100MG VL |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | P |
LEUCOVORIN CALCIUM 10MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
Leucovorin Calcium 15mg/1 24 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
LEUCOVORIN CALCIUM 25MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
LEUCOVORIN CALCIUM 350MG VL |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | P |
LEUCOVORIN CALCIUM 5MG TABLET |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | 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 |
$45.00 | $90.00 | None |
LEUKINE 250 MCG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
Leuprolide 2wk 1 mg/0.2 ml kit |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
LEVEMIR 100UNITS/ML VIAL |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
LEVEMIR FLEXTOUCH 100 UNITS/ML |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Levetiracetam 100mg/mL 473 mL in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LEVETIRACETAM 100MG/ML INJECTION |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
LEVETIRACETAM 500 MG TABLET 120 BOT |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Levetiracetam 500mg/1 60 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LEVETIRACETAM ER 750 MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LEVETIRACETAM TABLETS 1000MG 60 BOT |
2 |
Non-Preferred Generic |
$15.00 | $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 |
$15.00 | $30.00 | None |
LEVETIRACETAM TABLETS 750MG 500 BOT |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LEVETIRACETAM-NACL 1,000 MG/100 ML |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
LEVETIRACETAM-NACL 1,500 MG/100 ML |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
LEVETIRACETAM-NACL 500 MG/100 ML |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LEVOCETIRIZINE 5 MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Levofloxacin 250mg/1 [LEVAQUIN] |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Levofloxacin 25mg/mL 1 BOTTLE per CARTON / 100 mL in 1 BOTTLE [LEVAQUIN] |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
LEVOFLOXACIN 500 MG/20 ML VIAL [LEVAQUIN] |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
Levofloxacin 500mg/1 [LEVAQUIN] |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levofloxacin 5mg/mL 24 POUCH per CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG [LEVAQUIN] |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
Levofloxacin 750mg/1 [LEVAQUIN] |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LEVONOR-ETH ESTRAD 0.09-0.02 MG |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LEVONOR-ETH ESTRAD 0.1-0.02 MG |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
levonor-eth estrad 0.15-0.03 |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LEVORA-28 TABLET 0.15/30 |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LEVORPHANOL TARTRATE 2mg 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | Q:180 /30Days |
Levothyroxine Sodium 100ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Levothyroxine Sodium 112ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Levothyroxine Sodium 125ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levothyroxine Sodium 150ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Levothyroxine Sodium 175ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Levothyroxine Sodium 200ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Levothyroxine Sodium 25ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Levothyroxine Sodium 300ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Levothyroxine Sodium 50ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Levothyroxine Sodium 75ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Levothyroxine Sodium 88ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
LEVOXYL 100 MCG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
LEVOXYL 112 MCG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
LEVOXYL 125 MCG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 137 MCG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
LEVOXYL 150MCG TABLET (1000 CT) |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
LEVOXYL 175MCG TABLET (1000 CT) |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
LEVOXYL 200 MCG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
LEVOXYL 25 MCG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
LEVOXYL 50 MCG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
LEVOXYL 75MCG TABLET (1000 CT) |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
LEVOXYL 88 MCG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
LEXIVA 50mg/mL 225 mL in 1 BOTTLE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
LEXIVA 700MG TABLETS |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
LIALDA 1.2G TABLET DELAYED RELEASE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIDOCAINE 5% OINTMENT |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Lidocaine 5% patch |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | P |
lidocaine hcl 2% jelly |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
lidocaine hcl 2% jelly |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LIDOCAINE HCL 2% JELLY 30ML TUBE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Lidocaine Hydrochloride 20mg/mL 25 VIAL, MULTI-DOSE in 1 TRAY / 20 mL in 1 VIAL, MULTI-DOSE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Lidocaine Hydrochloride 5mg/mL 25 VIAL, SINGLE-DOSE in 1 CONTAINER / 50 mL in 1 VIAL, SINGLE-DOSE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
LIDOCAINE-PRILOCAINE CREAM |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Lindane 10mg/mL |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LINDANE SHAMPOO 1MG 2 FLO BOT |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Linezolid 600 mg tablet [Zyvox] |
5 |
Specialty Tier |
33% | 33% | None |
Linezolid 600 mg/300 ml iv sol [Zyvox] |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Liposyn III 1.2; 2.5; 10g/100mL; g/100mL; g/100mL 12 BOTTLE, GLASS in 1 CASE / 250 mL in 1 BOTTLE, |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | P |
Liposyn III 1.2; 2.5; 20g/100mL; g/100mL; g/100mL 12 BOTTLE, GLASS in 1 CASE / 250 mL in 1 BOTTLE, |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | P |
LISINOPRIL 10MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
LISINOPRIL 2.5 MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
LISINOPRIL 20 MG TABLET |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
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 |
$4.00 | $8.00 | None |
LISINOPRIL 40MG TABLET (500 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Lisinopril 5mg/1 1000 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Lisinopril with Hydrochlorothiazide 12.5; 10mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Lisinopril with Hydrochlorothiazide 12.5; 20mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Lithium Carbonate 150mg/1 100 CAPSULE BOTTLE, PLASTIC |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Lithium Carbonate 300 mg tab |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Lithium Carbonate 450mg/1 |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
LITHIUM CARBONATE 600 MG CAP |
1 |
Preferred Generic |
$4.00 | $8.00 | 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 |
$4.00 | $8.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
LOMUSTINE 10 MG CAPSULE [Ceenu] |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LOMUSTINE 100 MG CAPSULE [Ceenu] |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LOMUSTINE 40 MG CAPSULE [Ceenu] |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LOPERAMIDE HCL 2MG CAPSULE |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
LORAZEPAM 0.5 MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Lorazepam 1mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Lorazepam 2mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Lorazepam 2mg/mL 30 mL in 1 BOTTLE, DROPPER |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LOSARTAN POTASSIUM 100 MG TAB |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOSARTAN POTASSIUM 25 MG TAB |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
LOSARTAN POTASSIUM 50 MG TAB |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
LOSARTAN-HCTZ 100-12.5 MG TAB |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
LOSARTAN-HCTZ 100-25 MG TAB |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
LOSARTAN-HCTZ 50-12.5 MG TAB |
1 |
Preferred Generic |
$4.00 | $8.00 | None |
LOTEMAX 0.5% EYE DROPS |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
LOTEMAX 0.5% OPHTHALMIC GEL |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
LOTEMAX 5mg/g 1 TUBE per CARTON / 3.5 g in 1 TUBE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
LOTRONEX TABLETS .5MG 30 BOTPL |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
LOTRONEX TABLETS 1MG 30 BOTPL |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Lovastatin 10mg 60 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOVASTATIN 20 MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LOVASTATIN 40 MG ORAL TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LOW-OGESTREL-28 TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LOXAPINE 25MG CAPSULE (100 CT) |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LOXAPINE CAPSULES 10MG 100 BOT |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LOXAPINE CAPSULES 50MG 100 BOT |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LOXAPINE CAPSULES 5MG 100 BOT |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LUMIGAN 0.1mg/mL 1 BOTTLE, DROPPER per CARTON / 5 mL in 1 BOTTLE, DROPPER |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Lumizyme 5mg/mL |
5 |
Specialty Tier |
33% | 33% | P |
LUPRON DEPOT 11.25 MG 3MO KIT |
5 |
Specialty Tier |
33% | 33% | P |
LUPRON DEPOT 22.5 MG 3MO KIT [LUPRON] |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUPRON DEPOT 3.75 MG KIT |
5 |
Specialty Tier |
33% | 33% | P |
LUPRON DEPOT 45 MG 6MO KIT |
5 |
Specialty Tier |
33% | 33% | P |
LUPRON DEPOT 7.5 MG KIT |
5 |
Specialty Tier |
33% | 33% | P |
LUPRON DEPOT-4 MONTH KIT |
5 |
Specialty Tier |
33% | 33% | P |
LUPRON DEPOT-PED 11.25 MG KIT |
5 |
Specialty Tier |
33% | 33% | P |
LUPRON DEPOT-PED 15 MG KIT |
5 |
Specialty Tier |
33% | 33% | P |
LUTERA 0.1-0.02 TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
LYNPARZA 50 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
LYRICA 100MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
LYRICA 150MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
LYRICA 20 MG/ML ORAL SOLUTION |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYRICA 200MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
LYRICA 225MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
LYRICA 25MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
LYRICA 300MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
LYRICA 50MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
LYRICA 75MG CAPSULE |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | None |
LYSODREN 500MG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |