2015 Medicare Part D Plan Formulary Information |
MCS Classicare Platino M (H5577-009-0)
Benefit Details
|
The MCS Classicare Platino M (H5577-009-0) Formulary Drugs Starting with the Letter L in HATILLO County, PR: CMS MA Region 30 which includes: PR Plan Monthly Premium: $0.00 Deductible: $320 |
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 |
Tier 1 |
15% | 15% | None |
LABETALOL HCL 200MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
LABETALOL HCL 300MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
LABETALOL HCL 5MG/20ML VIAL |
1 |
Tier 1 |
15% | 15% | None |
LACTATED RINGERS INJECTION |
1 |
Tier 1 |
15% | 15% | None |
LACTATED RINGERS IRRIGATION 4 CONTAINER in 1 CASE / 40 |
1 |
Tier 1 |
15% | 15% | None |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT |
1 |
Tier 1 |
15% | 15% | None |
Lamivudine 10 mg/ml oral soln |
1 |
Tier 1 |
15% | 15% | None |
LAMIVUDINE 150 MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
LAMIVUDINE 300 MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Lamivudine hbv 100 mg tablet |
1 |
Tier 1 |
15% | 15% | None |
LAMIVUDINE-ZIDOVUDINE TABLET |
4 |
Tier 4 |
15% | 15% | None |
LAMOTRIGINE 150MG TABLET (60 CT) |
1 |
Tier 1 |
15% | 15% | None |
LAMOTRIGINE 200MG TABLET (60 CT) |
1 |
Tier 1 |
15% | 15% | None |
LAMOTRIGINE 25MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE |
1 |
Tier 1 |
15% | 15% | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE |
1 |
Tier 1 |
15% | 15% | None |
LAMOTRIGINE ER 100 MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
lamotrigine er 200 mg tablet |
1 |
Tier 1 |
15% | 15% | None |
lamotrigine er 25 mg tablet |
1 |
Tier 1 |
15% | 15% | None |
lamotrigine er 250 mg tablet |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
lamotrigine er 300 mg tablet |
1 |
Tier 1 |
15% | 15% | None |
lamotrigine er 50 mg tablet |
1 |
Tier 1 |
15% | 15% | None |
Lamotrigine ODT 100 MG Tablet |
1 |
Tier 1 |
15% | 15% | None |
Lamotrigine ODT 200 MG Tablet |
1 |
Tier 1 |
15% | 15% | None |
Lamotrigine ODT 25 MG Tablet |
1 |
Tier 1 |
15% | 15% | None |
Lamotrigine ODT 50 MG Tablet |
1 |
Tier 1 |
15% | 15% | None |
LAMOTRIGINE TABLET 100MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
LANREOTIDE 240 MG/ML PREFILLED SYRINGE [SOMATULINE] |
4 |
Tier 4 |
15% | 15% | P |
LANSOPRAZOL-AMOXICIL-CLARITHRO |
1 |
Tier 1 |
15% | 15% | None |
Lansoprazole 15mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
Lansoprazole 30mg/1 30 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LANTUS 100U/ML VIAL |
2 |
Tier 2 |
15% | 15% | Q:40 /28Days |
LANTUS SOLOSTAR INJECTION |
2 |
Tier 2 |
15% | 15% | Q:40 /28Days |
LATANOPROST 0.005% EYE DROPS |
1 |
Tier 1 |
15% | 15% | Q:5 /25Days |
LATUDA 120 MG TABLET |
3 |
Tier 3 |
15% | 15% | S Q:30 /30Days |
LATUDA 20 MG TABLET |
3 |
Tier 3 |
15% | 15% | S Q:30 /30Days |
Latuda 40mg/1 |
3 |
Tier 3 |
15% | 15% | S Q:30 /30Days |
LATUDA 60 MG TABLET |
3 |
Tier 3 |
15% | 15% | S Q:60 /30Days |
Latuda 80mg/1 |
3 |
Tier 3 |
15% | 15% | S Q:60 /30Days |
LEFLUNOMIDE 10MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
LEFLUNOMIDE 20 MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
LENVIMA 10 MG DAILY DOSE |
4 |
Tier 4 |
15% | 15% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LENVIMA 14 MG DAILY DOSE |
4 |
Tier 4 |
15% | 15% | P |
LENVIMA 20 MG DAILY DOSE |
4 |
Tier 4 |
15% | 15% | P |
LENVIMA 24 MG DAILY DOSE |
4 |
Tier 4 |
15% | 15% | P |
LETAIRIS 10MG TABLET |
4 |
Tier 4 |
15% | 15% | P Q:30 /30Days |
LETAIRIS 5MG TABLET |
4 |
Tier 4 |
15% | 15% | P Q:30 /30Days |
LETROZOLE 2.5mg/1 |
1 |
Tier 1 |
15% | 15% | None |
LEUCOVORIN CALCIUM 100MG VL |
1 |
Tier 1 |
15% | 15% | None |
LEUCOVORIN CALCIUM 10MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Leucovorin Calcium 15mg/1 24 TABLET BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
LEUCOVORIN CALCIUM 25MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
LEUCOVORIN CALCIUM 350MG VL |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUCOVORIN CALCIUM 5MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
LEUKERAN 2 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
LEUKINE 250 MCG VIAL |
4 |
Tier 4 |
15% | 15% | P |
Leuprolide 2wk 1 mg/0.2 ml kit |
1 |
Tier 1 |
15% | 15% | P |
Levalbuterol 0.31 mg/3 ml sol |
1 |
Tier 1 |
15% | 15% | P Q:540 /30Days |
Levalbuterol 0.63 mg/3 ml sol |
1 |
Tier 1 |
15% | 15% | P Q:540 /30Days |
LEVALBUTEROL 1.25 MG/0.5 ML |
1 |
Tier 1 |
15% | 15% | P |
LEVEMIR 100UNITS/ML VIAL |
2 |
Tier 2 |
15% | 15% | Q:40 /28Days |
LEVEMIR FLEXTOUCH 100 UNITS/ML |
2 |
Tier 2 |
15% | 15% | Q:40 /28Days |
Levetiracetam 100mg/mL 473 mL in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
15% | 15% | None |
LEVETIRACETAM 100MG/ML INJECTION |
1 |
Tier 1 |
15% | 15% | 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 |
Tier 1 |
15% | 15% | Q:180 /30Days |
Levetiracetam 500mg/1 60 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
15% | 15% | Q:180 /30Days |
LEVETIRACETAM ER 750 MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:120 /30Days |
LEVETIRACETAM TABLETS 1000MG 60 BOT |
1 |
Tier 1 |
15% | 15% | Q:90 /30Days |
LEVETIRACETAM TABLETS 250MG 500 BOT |
1 |
Tier 1 |
15% | 15% | Q:120 /30Days |
LEVETIRACETAM TABLETS 750MG 500 BOT |
1 |
Tier 1 |
15% | 15% | Q:120 /30Days |
LEVETIRACETAM-NACL 1,000 MG/100 ML |
1 |
Tier 1 |
15% | 15% | None |
LEVETIRACETAM-NACL 1,500 MG/100 ML |
1 |
Tier 1 |
15% | 15% | None |
LEVETIRACETAM-NACL 500 MG/100 ML |
1 |
Tier 1 |
15% | 15% | None |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION |
1 |
Tier 1 |
15% | 15% | Q:10 /25Days |
LEVOCARNITINE 200MG/ML VIAL |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOCARNITINE TABLET 330MG 90 BLPK |
1 |
Tier 1 |
15% | 15% | None |
LEVOCETIRIZINE 2.5 MG/5 ML SOL |
1 |
Tier 1 |
15% | 15% | None |
LEVOCETIRIZINE 5 MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
Levofloxacin 250mg/1 [LEVAQUIN] |
1 |
Tier 1 |
15% | 15% | None |
Levofloxacin 25mg/mL 1 BOTTLE per CARTON / 100 mL in 1 BOTTLE [LEVAQUIN] |
1 |
Tier 1 |
15% | 15% | None |
LEVOFLOXACIN 500 MG/20 ML VIAL [LEVAQUIN] |
1 |
Tier 1 |
15% | 15% | None |
Levofloxacin 500mg/1 [LEVAQUIN] |
1 |
Tier 1 |
15% | 15% | None |
Levofloxacin 5mg/mL 1 BOTTLE, DROPPER per CARTON / 5 mL in 1 BOTTLE, DROPPER [LEVAQUIN] |
1 |
Tier 1 |
15% | 15% | None |
Levofloxacin 5mg/mL 24 POUCH per CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG [LEVAQUIN] |
1 |
Tier 1 |
15% | 15% | None |
Levofloxacin 750mg/1 [LEVAQUIN] |
1 |
Tier 1 |
15% | 15% | None |
LEVOLEUCOVORIN 175 MG/17.5 ML [Fusilev] |
4 |
Tier 4 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVONEST-28 TABLET |
1 |
Tier 1 |
15% | 15% | P |
levonor-eth estrad 0.15-0.03 |
1 |
Tier 1 |
15% | 15% | P Q:91 /91Days |
Levothyroxine Sodium 100ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Tier 1 |
15% | 15% | None |
Levothyroxine Sodium 112ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Tier 1 |
15% | 15% | None |
Levothyroxine Sodium 125ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Tier 1 |
15% | 15% | None |
LEVOTHYROXINE SODIUM 137MCG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Levothyroxine Sodium 150ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Tier 1 |
15% | 15% | None |
Levothyroxine Sodium 175ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Tier 1 |
15% | 15% | None |
Levothyroxine Sodium 200ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Tier 1 |
15% | 15% | None |
Levothyroxine Sodium 25ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1 |
Tier 1 |
15% | 15% | None |
Levothyroxine Sodium 300ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Tier 1 |
15% | 15% | 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 |
Tier 1 |
15% | 15% | None |
Levothyroxine Sodium 75ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1 |
Tier 1 |
15% | 15% | None |
Levothyroxine Sodium 88ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1 |
Tier 1 |
15% | 15% | None |
LEVOXYL 100 MCG TABLET |
1 |
Tier 1 |
15% | 15% | None |
LEVOXYL 112 MCG TABLET |
1 |
Tier 1 |
15% | 15% | None |
LEVOXYL 125 MCG TABLET |
1 |
Tier 1 |
15% | 15% | None |
LEVOXYL 137 MCG TABLET |
1 |
Tier 1 |
15% | 15% | None |
LEVOXYL 150MCG TABLET (1000 CT) |
1 |
Tier 1 |
15% | 15% | None |
LEVOXYL 175MCG TABLET (1000 CT) |
1 |
Tier 1 |
15% | 15% | None |
LEVOXYL 200 MCG TABLET |
1 |
Tier 1 |
15% | 15% | None |
LEVOXYL 25 MCG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 50 MCG TABLET |
1 |
Tier 1 |
15% | 15% | None |
LEVOXYL 75MCG TABLET (1000 CT) |
1 |
Tier 1 |
15% | 15% | None |
LEVOXYL 88 MCG TABLET |
1 |
Tier 1 |
15% | 15% | None |
LEXIVA 50mg/mL 225 mL in 1 BOTTLE |
3 |
Tier 3 |
15% | 15% | None |
LEXIVA 700MG TABLETS |
4 |
Tier 4 |
15% | 15% | None |
LIDOCAINE 5% OINTMENT |
1 |
Tier 1 |
15% | 15% | None |
Lidocaine 5% patch |
1 |
Tier 1 |
15% | 15% | P |
lidocaine hcl 2% jelly |
1 |
Tier 1 |
15% | 15% | None |
lidocaine hcl 2% jelly |
1 |
Tier 1 |
15% | 15% | None |
LIDOCAINE HCL 2% JELLY 30ML TUBE |
1 |
Tier 1 |
15% | 15% | None |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIDOCAINE-PRILOCAINE CREAM |
1 |
Tier 1 |
15% | 15% | None |
LINCOCIN 300MG/ML VIAL |
3 |
Tier 3 |
15% | 15% | None |
Linezolid 600 mg tablet [Zyvox] |
4 |
Tier 4 |
15% | 15% | Q:60 /30Days |
Linezolid 600 mg/300 ml iv sol [Zyvox] |
1 |
Tier 1 |
15% | 15% | None |
LINZESS 145 MCG CAPSULE |
3 |
Tier 3 |
15% | 15% | P Q:30 /30Days |
LINZESS 290 MCG CAPSULE |
3 |
Tier 3 |
15% | 15% | P Q:30 /30Days |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT |
1 |
Tier 1 |
15% | 15% | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT |
1 |
Tier 1 |
15% | 15% | None |
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT |
1 |
Tier 1 |
15% | 15% | None |
LISINOPRIL 10MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
LISINOPRIL 2.5 MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL 20 MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
LISINOPRIL 30MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
LISINOPRIL 40MG TABLET (500 CT) |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
Lisinopril 5mg/1 1000 TABLET BOTTLE |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
Lisinopril with Hydrochlorothiazide 12.5; 10mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
Lisinopril with Hydrochlorothiazide 12.5; 20mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | Q:120 /30Days |
Lithium Carbonate 150mg/1 100 CAPSULE BOTTLE, PLASTIC |
1 |
Tier 1 |
15% | 15% | None |
Lithium Carbonate 300 mg tab |
1 |
Tier 1 |
15% | 15% | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
Lithium Carbonate 450mg/1 |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LITHIUM CARBONATE 600 MG CAP |
1 |
Tier 1 |
15% | 15% | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
LITHIUM CIT 8MEQ/5ML SYRUP |
1 |
Tier 1 |
15% | 15% | None |
LOMUSTINE 10 MG CAPSULE [Ceenu] |
1 |
Tier 1 |
15% | 15% | None |
LOMUSTINE 100 MG CAPSULE [Ceenu] |
1 |
Tier 1 |
15% | 15% | None |
LOMUSTINE 40 MG CAPSULE [Ceenu] |
1 |
Tier 1 |
15% | 15% | None |
LOPERAMIDE HCL 2MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
LORAZEPAM 0.5 MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Lorazepam 1mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
Lorazepam 2mg/1 100 TABLET BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
Lorcet plus 7.5-325 mg tablet |
1 |
Tier 1 |
15% | 15% | Q:360 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Loryna (drospirenone and ethinyl estradiol) 3 CARTON in 1 BOX / 1 KIT per CARTON |
1 |
Tier 1 |
15% | 15% | None |
LOSARTAN POTASSIUM 100 MG TAB |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
LOSARTAN POTASSIUM 25 MG TAB |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
LOSARTAN POTASSIUM 50 MG TAB |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
LOSARTAN-HCTZ 100-12.5 MG TAB |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
LOSARTAN-HCTZ 100-25 MG TAB |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
LOSARTAN-HCTZ 50-12.5 MG TAB |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
LOTRONEX TABLETS .5MG 30 BOTPL |
2 |
Tier 2 |
15% | 15% | None |
LOTRONEX TABLETS 1MG 30 BOTPL |
2 |
Tier 2 |
15% | 15% | None |
Lovastatin 10mg 60 TABLET BOTTLE |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
LOVASTATIN 20 MG TABLET |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOVASTATIN 40 MG ORAL TABLET |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days |
LOXAPINE 25MG CAPSULE (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
LOXAPINE CAPSULES 10MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
LOXAPINE CAPSULES 50MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
LOXAPINE CAPSULES 5MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
Lumizyme 5mg/mL |
4 |
Tier 4 |
15% | 15% | P |
LUPRON DEPOT 11.25 MG 3MO KIT |
4 |
Tier 4 |
15% | 15% | P Q:1 /28Days |
LUPRON DEPOT 22.5 MG 3MO KIT [LUPRON] |
4 |
Tier 4 |
15% | 15% | P Q:1 /84Days |
LUPRON DEPOT 3.75 MG KIT |
4 |
Tier 4 |
15% | 15% | P Q:1 /28Days |
LUPRON DEPOT 45 MG 6MO KIT |
4 |
Tier 4 |
15% | 15% | P Q:1 /168Days |
LUPRON DEPOT 7.5 MG KIT |
4 |
Tier 4 |
15% | 15% | P Q:1 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUPRON DEPOT-4 MONTH KIT |
4 |
Tier 4 |
15% | 15% | P Q:1 /112Days |
LUPRON DEPOT-PED 11.25 MG KIT |
4 |
Tier 4 |
15% | 15% | P Q:1 /28Days |
LUPRON DEPOT-PED 15 MG KIT |
4 |
Tier 4 |
15% | 15% | P Q:1 /28Days |
LYNPARZA 50 MG CAPSULE |
4 |
Tier 4 |
15% | 15% | P |
LYRICA 100MG CAPSULE |
2 |
Tier 2 |
15% | 15% | Q:90 /30Days |
LYRICA 150MG CAPSULE |
2 |
Tier 2 |
15% | 15% | Q:60 /30Days |
LYRICA 20 MG/ML ORAL SOLUTION |
2 |
Tier 2 |
15% | 15% | Q:900 /30Days |
LYRICA 200MG CAPSULE |
2 |
Tier 2 |
15% | 15% | Q:90 /30Days |
LYRICA 225MG CAPSULE |
2 |
Tier 2 |
15% | 15% | Q:60 /30Days |
LYRICA 25MG CAPSULE |
2 |
Tier 2 |
15% | 15% | Q:60 /30Days |
LYRICA 300MG CAPSULE |
2 |
Tier 2 |
15% | 15% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYRICA 50MG CAPSULE |
2 |
Tier 2 |
15% | 15% | Q:90 /30Days |
LYRICA 75MG CAPSULE |
2 |
Tier 2 |
15% | 15% | Q:60 /30Days |
LYSODREN 500MG TABLET |
2 |
Tier 2 |
15% | 15% | None |