2015 Medicare Part D Plan Formulary Information |
Managed Health Services Advantage (HMO SNP) (H8189-001-0)
Benefit Details
|
The Managed Health Services Advantage (HMO SNP) (H8189-001-0) Formulary Drugs Starting with the Letter L in ADAMS County, WI: CMS MA Region 14 which includes: WI Plan Monthly Premium: $35.30 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* |
Generic |
$0.00 | $0.00 | None |
LABETALOL HCL 200MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
LABETALOL HCL 300MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
LABETALOL HCL 5MG/20ML VIAL |
4 |
Injectable Drugs |
$95.00 | $95.00 | None |
LACTATED RINGERS INJECTION |
4 |
Injectable Drugs |
$95.00 | $95.00 | None |
LACTATED RINGERS IRRIGATION 4 CONTAINER in 1 CASE / 40 |
1* |
Generic |
$0.00 | $0.00 | None |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT |
1* |
Generic |
$0.00 | $0.00 | None |
Lamivudine 10 mg/ml oral soln |
1* |
Generic |
$0.00 | $0.00 | None |
LAMIVUDINE 150 MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
LAMIVUDINE 300 MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Lamivudine hbv 100 mg tablet |
1* |
Generic |
$0.00 | $0.00 | None |
LAMIVUDINE-ZIDOVUDINE TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
LAMOTRIGINE 150MG TABLET (60 CT) |
1* |
Generic |
$0.00 | $0.00 | None |
LAMOTRIGINE 200MG TABLET (60 CT) |
1* |
Generic |
$0.00 | $0.00 | None |
LAMOTRIGINE 25MG TABLET (100 CT) |
1* |
Generic |
$0.00 | $0.00 | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE |
1* |
Generic |
$0.00 | $0.00 | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE |
1* |
Generic |
$0.00 | $0.00 | None |
Lamotrigine ODT 100 MG Tablet |
1* |
Generic |
$0.00 | $0.00 | None |
Lamotrigine ODT 200 MG Tablet |
1* |
Generic |
$0.00 | $0.00 | None |
Lamotrigine ODT 25 MG Tablet |
1* |
Generic |
$0.00 | $0.00 | None |
Lamotrigine ODT 50 MG Tablet |
1* |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE TABLET 100MG (100 CT) |
1* |
Generic |
$0.00 | $0.00 | None |
LANOXIN 0.25 MG/ML AMPUL |
4 |
Injectable Drugs |
$95.00 | $95.00 | P |
LANOXIN 125 MCG TABLET |
2 |
Preferred Brand |
$45.00 | $45.00 | None |
LANOXIN 250 MCG TABLET |
2 |
Preferred Brand |
$45.00 | $45.00 | P |
LANREOTIDE 240 MG/ML PREFILLED SYRINGE [SOMATULINE] |
4 |
Injectable Drugs |
$95.00 | $95.00 | None |
LANTUS 100U/ML VIAL |
2 |
Preferred Brand |
$45.00 | $45.00 | Q:30 /30Days |
LANTUS SOLOSTAR INJECTION |
2 |
Preferred Brand |
$45.00 | $45.00 | None |
LARIN 1.5 MG-30 MCG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
LATANOPROST 0.005% EYE DROPS |
1* |
Generic |
$0.00 | $0.00 | None |
LATUDA 120 MG TABLET |
2 |
Preferred Brand |
$45.00 | $45.00 | Q:30 /30Days |
LATUDA 20 MG TABLET |
2 |
Preferred Brand |
$45.00 | $45.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Latuda 40mg/1 |
2 |
Preferred Brand |
$45.00 | $45.00 | Q:30 /30Days |
LATUDA 60 MG TABLET |
2 |
Preferred Brand |
$45.00 | $45.00 | Q:30 /30Days |
Latuda 80mg/1 |
2 |
Preferred Brand |
$45.00 | $45.00 | Q:30 /30Days |
LAZANDA 100 MCG NASAL SPRAY |
2 |
Preferred Brand |
$45.00 | $45.00 | P Q:600 /30Days |
LAZANDA 400 MCG NASAL SPRAY |
2 |
Preferred Brand |
$45.00 | $45.00 | P Q:150 /30Days |
LEENA 7-9-5 TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
LEFLUNOMIDE 10MG TABLET |
1* |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
LEFLUNOMIDE 20 MG TABLET |
1* |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
LENVIMA 10 MG DAILY DOSE |
2 |
Preferred Brand |
$45.00 | $45.00 | Q:30 /30Days |
LENVIMA 14 MG DAILY DOSE |
2 |
Preferred Brand |
$45.00 | $45.00 | Q:60 /30Days |
LENVIMA 20 MG DAILY DOSE |
2 |
Preferred Brand |
$45.00 | $45.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LENVIMA 24 MG DAILY DOSE |
2 |
Preferred Brand |
$45.00 | $45.00 | Q:90 /30Days |
Lessina 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK |
1* |
Generic |
$0.00 | $0.00 | None |
LETAIRIS 10MG TABLET |
2 |
Preferred Brand |
$45.00 | $45.00 | None |
LETAIRIS 5MG TABLET |
2 |
Preferred Brand |
$45.00 | $45.00 | None |
LETROZOLE 2.5mg/1 |
1* |
Generic |
$0.00 | $0.00 | None |
LEUCOVORIN CALCIUM 100MG VL |
4 |
Injectable Drugs |
$95.00 | $95.00 | None |
LEUCOVORIN CALCIUM 10MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
Leucovorin Calcium 15mg/1 24 TABLET BOTTLE |
1* |
Generic |
$0.00 | $0.00 | None |
LEUCOVORIN CALCIUM 25MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
LEUCOVORIN CALCIUM 350MG VL |
4 |
Injectable Drugs |
$95.00 | $95.00 | None |
LEUCOVORIN CALCIUM 5MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUKERAN 2 MG TABLET |
2 |
Preferred Brand |
$45.00 | $45.00 | None |
LEUKINE 250 MCG VIAL |
4 |
Injectable Drugs |
$95.00 | $95.00 | None |
Leuprolide 2wk 1 mg/0.2 ml kit |
4 |
Injectable Drugs |
$95.00 | $95.00 | None |
Levalbuterol 0.31 mg/3 ml sol |
1* |
Generic |
$0.00 | $0.00 | P |
Levalbuterol 0.63 mg/3 ml sol |
1* |
Generic |
$0.00 | $0.00 | P |
LEVEMIR 100UNITS/ML VIAL |
2 |
Preferred Brand |
$45.00 | $45.00 | Q:30 /30Days |
LEVEMIR FLEXTOUCH 100 UNITS/ML |
2 |
Preferred Brand |
$45.00 | $45.00 | None |
Levetiracetam 100mg/mL 473 mL in 1 BOTTLE, PLASTIC |
1* |
Generic |
$0.00 | $0.00 | None |
LEVETIRACETAM 100MG/ML INJECTION |
4 |
Injectable Drugs |
$95.00 | $95.00 | None |
LEVETIRACETAM 500 MG TABLET 120 BOT |
1* |
Generic |
$0.00 | $0.00 | Q:180 /30Days |
LEVETIRACETAM TABLETS 1000MG 60 BOT |
1* |
Generic |
$0.00 | $0.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM TABLETS 250MG 500 BOT |
1* |
Generic |
$0.00 | $0.00 | Q:180 /30Days |
LEVETIRACETAM TABLETS 750MG 500 BOT |
1* |
Generic |
$0.00 | $0.00 | Q:120 /30Days |
LEVETIRACETAM-NACL 1,000 MG/100 ML |
4 |
Injectable Drugs |
$95.00 | $95.00 | None |
LEVETIRACETAM-NACL 1,500 MG/100 ML |
4 |
Injectable Drugs |
$95.00 | $95.00 | None |
LEVETIRACETAM-NACL 500 MG/100 ML |
4 |
Injectable Drugs |
$95.00 | $95.00 | None |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION |
1* |
Generic |
$0.00 | $0.00 | None |
LEVOCARNITINE 100MG/ML SOLUTION ORAL |
1* |
Generic |
$0.00 | $0.00 | None |
LEVOCARNITINE 200MG/ML VIAL |
4 |
Injectable Drugs |
$95.00 | $95.00 | None |
LEVOCARNITINE TABLET 330MG 90 BLPK |
1* |
Generic |
$0.00 | $0.00 | None |
LEVOCETIRIZINE 2.5 MG/5 ML SOL |
1* |
Generic |
$0.00 | $0.00 | None |
LEVOCETIRIZINE 5 MG TABLET |
1* |
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 |
Levofloxacin 250mg/1 [LEVAQUIN] |
1* |
Generic |
$0.00 | $0.00 | Q:10 /10Days |
Levofloxacin 25mg/mL 1 BOTTLE per CARTON / 100 mL in 1 BOTTLE [LEVAQUIN] |
1* |
Generic |
$0.00 | $0.00 | None |
LEVOFLOXACIN 500 MG/20 ML VIAL [LEVAQUIN] |
4 |
Injectable Drugs |
$95.00 | $95.00 | None |
Levofloxacin 500mg/1 [LEVAQUIN] |
1* |
Generic |
$0.00 | $0.00 | Q:14 /14Days |
Levofloxacin 5mg/mL 24 POUCH per CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG [LEVAQUIN] |
4 |
Injectable Drugs |
$95.00 | $95.00 | None |
Levofloxacin 750mg/1 [LEVAQUIN] |
1* |
Generic |
$0.00 | $0.00 | Q:14 /14Days |
LEVOLEUCOVORIN 175 MG/17.5 ML [Fusilev] |
4 |
Injectable Drugs |
$95.00 | $95.00 | None |
LEVONOR-ETH ESTRAD 0.09-0.02 MG |
1* |
Generic |
$0.00 | $0.00 | None |
LEVONOR-ETH ESTRAD 0.1-0.02 MG |
1* |
Generic |
$0.00 | $0.00 | None |
Levonor-eth Estrad 0.15-0.03-0.01 |
1* |
Generic |
$0.00 | $0.00 | None |
LEVORA-28 TABLET 0.15/30 |
1* |
Generic |
$0.00 | $0.00 | 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* |
Generic |
$0.00 | $0.00 | Q:240 /30Days |
Levothyroxine Sodium 100ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1* |
Generic |
$0.00 | $0.00 | None |
Levothyroxine Sodium 112ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1* |
Generic |
$0.00 | $0.00 | None |
Levothyroxine Sodium 125ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1* |
Generic |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
Levothyroxine Sodium 150ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1* |
Generic |
$0.00 | $0.00 | None |
Levothyroxine Sodium 175ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1* |
Generic |
$0.00 | $0.00 | None |
Levothyroxine Sodium 200ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1* |
Generic |
$0.00 | $0.00 | None |
Levothyroxine Sodium 25ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1* |
Generic |
$0.00 | $0.00 | None |
Levothyroxine Sodium 300ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1* |
Generic |
$0.00 | $0.00 | None |
Levothyroxine Sodium 50ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1* |
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 75ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1* |
Generic |
$0.00 | $0.00 | None |
Levothyroxine Sodium 88ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1* |
Generic |
$0.00 | $0.00 | None |
LEVOXYL 100 MCG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
LEVOXYL 112 MCG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
LEVOXYL 125 MCG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
LEVOXYL 137 MCG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
LEVOXYL 150MCG TABLET (1000 CT) |
1* |
Generic |
$0.00 | $0.00 | None |
LEVOXYL 175MCG TABLET (1000 CT) |
1* |
Generic |
$0.00 | $0.00 | None |
LEVOXYL 200 MCG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
LEVOXYL 25 MCG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
LEVOXYL 50 MCG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 75MCG TABLET (1000 CT) |
1* |
Generic |
$0.00 | $0.00 | None |
LEVOXYL 88 MCG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
LEXIVA 50mg/mL 225 mL in 1 BOTTLE |
2 |
Preferred Brand |
$45.00 | $45.00 | None |
LEXIVA 700MG TABLETS |
2 |
Preferred Brand |
$45.00 | $45.00 | None |
LIDOCAINE 5% OINTMENT |
1* |
Generic |
$0.00 | $0.00 | None |
Lidocaine 5% patch |
1* |
Generic |
$0.00 | $0.00 | P Q:90 /30Days |
lidocaine hcl 2% jelly |
1* |
Generic |
$0.00 | $0.00 | None |
LIDOCAINE HCL 2% JELLY 30ML TUBE |
1* |
Generic |
$0.00 | $0.00 | None |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT |
1* |
Generic |
$0.00 | $0.00 | None |
Lidocaine Hydrochloride 5mg/mL 25 VIAL, SINGLE-DOSE in 1 CONTAINER / 50 mL in 1 VIAL, SINGLE-DOSE |
4 |
Injectable Drugs |
$95.00 | $95.00 | None |
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT |
1* |
Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIDOCAINE-PRILOCAINE CREAM |
1* |
Generic |
$0.00 | $0.00 | None |
LINCOCIN 300MG/ML VIAL |
4 |
Injectable Drugs |
$95.00 | $95.00 | None |
Lindane 10mg/mL |
1* |
Generic |
$0.00 | $0.00 | None |
Linezolid 600 mg tablet [Zyvox] |
1* |
Generic |
$0.00 | $0.00 | Q:20 /10Days |
Linezolid 600 mg/300 ml iv sol [Zyvox] |
4 |
Injectable Drugs |
$95.00 | $95.00 | None |
liothyronine sodium 10ug/mL 1 VIAL per CARTON / 1 mL in 1 VIAL |
4 |
Injectable Drugs |
$95.00 | $95.00 | None |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT |
1* |
Generic |
$0.00 | $0.00 | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT |
1* |
Generic |
$0.00 | $0.00 | None |
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT |
1* |
Generic |
$0.00 | $0.00 | None |
LISINOPRIL 10MG TABLET (100 CT) |
1* |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
LISINOPRIL 2.5 MG TABLET |
1* |
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 20 MG TABLET |
1* |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
LISINOPRIL 30MG TABLET (100 CT) |
1* |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
LISINOPRIL 40MG TABLET (500 CT) |
1* |
Generic |
$0.00 | $0.00 | None |
Lisinopril 5mg/1 1000 TABLET BOTTLE |
1* |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
Lisinopril with Hydrochlorothiazide 12.5; 10mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1* |
Generic |
$0.00 | $0.00 | None |
Lisinopril with Hydrochlorothiazide 12.5; 20mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1* |
Generic |
$0.00 | $0.00 | None |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT) |
1* |
Generic |
$0.00 | $0.00 | None |
Lithium Carbonate 150mg/1 100 CAPSULE BOTTLE, PLASTIC |
1* |
Generic |
$0.00 | $0.00 | None |
Lithium Carbonate 300 mg tab |
1* |
Generic |
$0.00 | $0.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) |
1* |
Generic |
$0.00 | $0.00 | None |
Lithium Carbonate 450mg/1 |
1* |
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 600 MG CAP |
1* |
Generic |
$0.00 | $0.00 | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) |
1* |
Generic |
$0.00 | $0.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP |
1* |
Generic |
$0.00 | $0.00 | None |
LITHOBID ER 300 MG TABLET |
2 |
Preferred Brand |
$45.00 | $45.00 | None |
LOMUSTINE 10 MG CAPSULE [Ceenu] |
1* |
Generic |
$0.00 | $0.00 | None |
LOMUSTINE 100 MG CAPSULE [Ceenu] |
1* |
Generic |
$0.00 | $0.00 | None |
LOMUSTINE 40 MG CAPSULE [Ceenu] |
1* |
Generic |
$0.00 | $0.00 | None |
LOPERAMIDE HCL 2MG CAPSULE |
1* |
Generic |
$0.00 | $0.00 | None |
LORAZEPAM 0.5 MG TABLET |
1* |
Generic |
$0.00 | $0.00 | Q:120 /30Days |
Lorazepam 1mg/1 100 TABLET BOTTLE |
1* |
Generic |
$0.00 | $0.00 | Q:150 /30Days |
Lorazepam 2mg/1 100 TABLET BOTTLE |
1* |
Generic |
$0.00 | $0.00 | Q:150 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Lorazepam 2mg/mL 30 mL in 1 BOTTLE, DROPPER |
1* |
Generic |
$0.00 | $0.00 | None |
LOSARTAN POTASSIUM 100 MG TAB |
1* |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
LOSARTAN POTASSIUM 25 MG TAB |
1* |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
LOSARTAN POTASSIUM 50 MG TAB |
1* |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
LOSARTAN-HCTZ 100-12.5 MG TAB |
1* |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
LOSARTAN-HCTZ 100-25 MG TAB |
1* |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
LOSARTAN-HCTZ 50-12.5 MG TAB |
1* |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
LOTEMAX 0.5% EYE DROPS |
2 |
Preferred Brand |
$45.00 | $45.00 | None |
LOTRONEX TABLETS .5MG 30 BOTPL |
3 |
Non-Preferred Brand |
$95.00 | $95.00 | P Q:60 /30Days |
LOTRONEX TABLETS 1MG 30 BOTPL |
3 |
Non-Preferred Brand |
$95.00 | $95.00 | P Q:60 /30Days |
Lovastatin 10mg 60 TABLET BOTTLE |
1* |
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 |
LOVASTATIN 20 MG TABLET |
1* |
Generic |
$0.00 | $0.00 | Q:30 /30Days |
LOVASTATIN 40 MG ORAL TABLET |
1* |
Generic |
$0.00 | $0.00 | Q:60 /30Days |
LOW-OGESTREL-28 TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
LOXAPINE 25MG CAPSULE (100 CT) |
1* |
Generic |
$0.00 | $0.00 | None |
LOXAPINE CAPSULES 10MG 100 BOT |
1* |
Generic |
$0.00 | $0.00 | None |
LOXAPINE CAPSULES 50MG 100 BOT |
1* |
Generic |
$0.00 | $0.00 | None |
LOXAPINE CAPSULES 5MG 100 BOT |
1* |
Generic |
$0.00 | $0.00 | None |
LUMIGAN 0.1mg/mL 1 BOTTLE, DROPPER per CARTON / 5 mL in 1 BOTTLE, DROPPER |
2 |
Preferred Brand |
$45.00 | $45.00 | None |
Lumizyme 5mg/mL |
4 |
Injectable Drugs |
$95.00 | $95.00 | None |
LUPRON DEPOT 11.25 MG 3MO KIT |
4 |
Injectable Drugs |
$95.00 | $95.00 | None |
LUPRON DEPOT 22.5 MG 3MO KIT [LUPRON] |
4 |
Injectable Drugs |
$95.00 | $95.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUPRON DEPOT 3.75 MG KIT |
4 |
Injectable Drugs |
$95.00 | $95.00 | None |
LUPRON DEPOT 7.5 MG KIT |
4 |
Injectable Drugs |
$95.00 | $95.00 | None |
LUPRON DEPOT-4 MONTH KIT |
4 |
Injectable Drugs |
$95.00 | $95.00 | None |
LUPRON DEPOT-PED 11.25 MG KIT |
4 |
Injectable Drugs |
$95.00 | $95.00 | None |
LUPRON DEPOT-PED 15 MG KIT |
4 |
Injectable Drugs |
$95.00 | $95.00 | None |
LUTERA 0.1-0.02 TABLET |
1* |
Generic |
$0.00 | $0.00 | None |
LYNPARZA 50 MG CAPSULE |
3 |
Non-Preferred Brand |
$95.00 | $95.00 | Q:480 /30Days |
LYRICA 100MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $45.00 | Q:90 /30Days |
LYRICA 150MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $45.00 | Q:60 /30Days |
LYRICA 20 MG/ML ORAL SOLUTION |
2 |
Preferred Brand |
$45.00 | $45.00 | None |
LYRICA 200MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $45.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYRICA 225MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $45.00 | Q:60 /30Days |
LYRICA 25MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $45.00 | Q:90 /30Days |
LYRICA 300MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $45.00 | Q:60 /30Days |
LYRICA 50MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $45.00 | Q:90 /30Days |
LYRICA 75MG CAPSULE |
2 |
Preferred Brand |
$45.00 | $45.00 | Q:90 /30Days |
LYSODREN 500MG TABLET |
2 |
Preferred Brand |
$45.00 | $45.00 | None |
LYZA 0.35 MG TABLET |
1* |
Generic |
$0.00 | $0.00 | None |