2016 Medicare Part D Plan Formulary Information |
MedicareBlue Rx Standard (PDP) (S5743-001-0)
Benefit Details
|
The MedicareBlue Rx Standard (PDP) (S5743-001-0) Formulary Drugs Starting with the Letter L in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY Plan Monthly Premium: $35.10 Deductible: $360 Qualifies for LIS: No |
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 |
3 |
Preferred Brand |
20% | 20% | None |
LABETALOL HCL 200MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
LABETALOL HCL 300MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
LACTATED RINGERS INJECTION |
2 |
Generic |
$3.00 | $6.00 | None |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT |
2 |
Generic |
$3.00 | $6.00 | None |
Lamivudine 10 mg/ml oral soln |
3 |
Preferred Brand |
20% | 20% | None |
LAMIVUDINE 150 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
LAMIVUDINE 300 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
Lamivudine hbv 100 mg tablet |
4 |
Non-Preferred Brand |
45% | 45% | None |
LAMIVUDINE-ZIDOVUDINE TABLET |
5 |
Specialty Tier |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE 150MG TABLET (60 CT) |
2 |
Generic |
$3.00 | $6.00 | None |
LAMOTRIGINE 200MG TABLET (60 CT) |
2 |
Generic |
$3.00 | $6.00 | None |
LAMOTRIGINE 25MG TABLET (100 CT) |
2 |
Generic |
$3.00 | $6.00 | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE |
3 |
Preferred Brand |
20% | 20% | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE |
3 |
Preferred Brand |
20% | 20% | None |
LAMOTRIGINE TABLET 100MG (100 CT) |
2 |
Generic |
$3.00 | $6.00 | None |
LANTUS 100U/ML VIAL |
3 |
Preferred Brand |
20% | 20% | None |
LANTUS SOLOSTAR INJECTION |
3 |
Preferred Brand |
20% | 20% | None |
LARIN FE 1-20 TABLET |
2 |
Generic |
$3.00 | $6.00 | None |
LARIN FE 1.5-30 TABLET |
3 |
Preferred Brand |
20% | 20% | None |
LASTACAFT 2.5mg/mL 1 BOTTLE, PLASTIC per CARTON / 3 mL in 1 BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
45% | 45% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LATANOPROST 0.005% EYE DROPS |
2 |
Generic |
$3.00 | $6.00 | None |
LATUDA 120 MG TABLET |
4 |
Non-Preferred Brand |
45% | 45% | Q:30 /30Days |
LATUDA 20 MG TABLET |
4 |
Non-Preferred Brand |
45% | 45% | Q:240 /30Days |
Latuda 40mg/1 |
4 |
Non-Preferred Brand |
45% | 45% | Q:30 /30Days |
LATUDA 60 MG TABLET |
4 |
Non-Preferred Brand |
45% | 45% | Q:60 /30Days |
Latuda 80mg/1 |
4 |
Non-Preferred Brand |
45% | 45% | Q:60 /30Days |
LEFLUNOMIDE 10MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
LEFLUNOMIDE 20 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
LENVIMA 10 MG DAILY DOSE |
5 |
Specialty Tier |
25% | 25% | P |
LENVIMA 14 MG DAILY DOSE |
5 |
Specialty Tier |
25% | 25% | P |
LENVIMA 18 MG DAILY DOSE |
5 |
Specialty Tier |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LENVIMA 20 MG DAILY DOSE |
5 |
Specialty Tier |
25% | 25% | P |
LENVIMA 24 MG DAILY DOSE |
5 |
Specialty Tier |
25% | 25% | P |
LENVIMA 8 MG DAILY DOSE |
5 |
Specialty Tier |
25% | 25% | P |
LENVIMA CAPSULE 8 MG |
5 |
Specialty Tier |
25% | 25% | P |
LETAIRIS 10MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
LETAIRIS 5MG TABLET |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days |
LETROZOLE 2.5 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
LEUCOVORIN CALCIUM 100MG VL |
4 |
Non-Preferred Brand |
45% | 45% | P |
LEUCOVORIN CALCIUM 10MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
Leucovorin Calcium 15mg/1 24 TABLET BOTTLE |
3 |
Preferred Brand |
20% | 20% | None |
LEUCOVORIN CALCIUM 25MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUCOVORIN CALCIUM 350MG VL |
4 |
Non-Preferred Brand |
45% | 45% | P |
LEUCOVORIN CALCIUM 5MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
LEUKERAN 2 MG TABLET |
4 |
Non-Preferred Brand |
45% | 45% | None |
LEUKINE 250 MCG VIAL |
5 |
Specialty Tier |
25% | 25% | P |
Leuprolide 2wk 1 mg/0.2 ml kit |
3 |
Preferred Brand |
20% | 20% | P |
LEVEMIR 100UNITS/ML VIAL |
3 |
Preferred Brand |
20% | 20% | None |
LEVEMIR FLEXTOUCH 100 UNITS/ML |
3 |
Preferred Brand |
20% | 20% | None |
Levetiracetam 100mg/mL 473 mL in 1 BOTTLE, PLASTIC |
3 |
Preferred Brand |
20% | 20% | None |
LEVETIRACETAM 100MG/ML INJECTION |
4 |
Non-Preferred Brand |
45% | 45% | None |
LEVETIRACETAM 500 MG TABLET 120 BOT |
3 |
Preferred Brand |
20% | 20% | None |
LEVETIRACETAM TABLETS 1000MG 60 BOT |
3 |
Preferred Brand |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM TABLETS 250MG 500 BOT |
3 |
Preferred Brand |
20% | 20% | None |
LEVETIRACETAM TABLETS 750MG 500 BOT |
3 |
Preferred Brand |
20% | 20% | None |
LEVETIRACETAM-NACL 1,000 MG/100 ML |
4 |
Non-Preferred Brand |
45% | 45% | None |
LEVETIRACETAM-NACL 1,500 MG/100 ML |
4 |
Non-Preferred Brand |
45% | 45% | None |
LEVETIRACETAM-NACL 500 MG/100 ML |
4 |
Non-Preferred Brand |
45% | 45% | None |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION |
3 |
Preferred Brand |
20% | 20% | None |
LEVOCARNITINE 100MG/ML SOLUTION ORAL |
3 |
Preferred Brand |
20% | 20% | P |
LEVOCARNITINE 200MG/ML VIAL |
3 |
Preferred Brand |
20% | 20% | P |
LEVOCARNITINE TABLET 330MG 90 BLPK |
3 |
Preferred Brand |
20% | 20% | P |
LEVOCETIRIZINE 2.5 MG/5 ML SOL |
4 |
Non-Preferred Brand |
45% | 45% | None |
LEVOCETIRIZINE 5 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levofloxacin 250mg/1 [LEVAQUIN] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Levofloxacin 25mg/mL 1 BOTTLE per CARTON / 100 mL in 1 BOTTLE [LEVAQUIN] |
4 |
Non-Preferred Brand |
45% | 45% | None |
Levofloxacin 500 MG [LEVAQUIN] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LEVOFLOXACIN 500 MG/20 ML VIAL [LEVAQUIN] |
4 |
Non-Preferred Brand |
45% | 45% | None |
Levofloxacin 5mg/mL 24 POUCH per CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG [LEVAQUIN] |
3 |
Preferred Brand |
20% | 20% | None |
Levofloxacin 750 MG [LEVAQUIN] |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LEVOFLOXACIN-D5W 750 MG/150 ML [LEVAQUIN] |
3 |
Preferred Brand |
20% | 20% | None |
LEVOLEUCOVORIN 175 MG/17.5 ML [Fusilev] |
5 |
Specialty Tier |
25% | 25% | P |
LEVONEST-28 TABLET |
2 |
Generic |
$3.00 | $6.00 | None |
LEVONOR-ETH ESTRAD TRIPHASIC |
2 |
Generic |
$3.00 | $6.00 | None |
LEVOTHYROXINE 125 MCG TABLET |
2 |
Generic |
$3.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE 137 MCG TABLET |
2 |
Generic |
$3.00 | $6.00 | None |
LEVOTHYROXINE 175 MCG TABLET |
2 |
Generic |
$3.00 | $6.00 | None |
LEVOTHYROXINE 300 MCG TABLET |
2 |
Generic |
$3.00 | $6.00 | None |
LEVOTHYROXINE 75 MCG TABLET |
2 |
Generic |
$3.00 | $6.00 | None |
Levothyroxine Sodium 100ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
2 |
Generic |
$3.00 | $6.00 | None |
Levothyroxine Sodium 112ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
2 |
Generic |
$3.00 | $6.00 | None |
Levothyroxine Sodium 150ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
2 |
Generic |
$3.00 | $6.00 | None |
Levothyroxine Sodium 200ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
2 |
Generic |
$3.00 | $6.00 | None |
Levothyroxine Sodium 25ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
2 |
Generic |
$3.00 | $6.00 | None |
Levothyroxine Sodium 50ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
2 |
Generic |
$3.00 | $6.00 | None |
Levothyroxine Sodium 88ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
2 |
Generic |
$3.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 100 MCG TABLET |
2 |
Generic |
$3.00 | $6.00 | None |
LEVOXYL 112 MCG TABLET |
2 |
Generic |
$3.00 | $6.00 | None |
LEVOXYL 125 MCG TABLET |
2 |
Generic |
$3.00 | $6.00 | None |
LEVOXYL 137 MCG TABLET |
2 |
Generic |
$3.00 | $6.00 | None |
LEVOXYL 150MCG TABLET (1000 CT) |
2 |
Generic |
$3.00 | $6.00 | None |
LEVOXYL 175MCG TABLET (1000 CT) |
2 |
Generic |
$3.00 | $6.00 | None |
LEVOXYL 200 MCG TABLET |
2 |
Generic |
$3.00 | $6.00 | None |
LEVOXYL 25 MCG TABLET |
2 |
Generic |
$3.00 | $6.00 | None |
LEVOXYL 50 MCG TABLET |
2 |
Generic |
$3.00 | $6.00 | None |
LEVOXYL 75MCG TABLET (1000 CT) |
2 |
Generic |
$3.00 | $6.00 | None |
LEVOXYL 88 MCG TABLET |
2 |
Generic |
$3.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEXIVA 50mg/mL 225 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
45% | 45% | None |
LEXIVA 700MG TABLETS |
5 |
Specialty Tier |
25% | 25% | None |
LIDOCAINE 5% OINTMENT |
4 |
Non-Preferred Brand |
45% | 45% | None |
Lidocaine 5% patch |
4 |
Non-Preferred Brand |
45% | 45% | P Q:3 /1Days |
lidocaine hcl 2% jelly |
2 |
Generic |
$3.00 | $6.00 | None |
lidocaine hcl 2% jelly |
2 |
Generic |
$3.00 | $6.00 | None |
LIDOCAINE HCL 2% JELLY 30ML TUBE |
2 |
Generic |
$3.00 | $6.00 | None |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Lidocaine Hydrochloride 20mg/mL 25 VIAL, MULTI-DOSE in 1 TRAY / 20 mL in 1 VIAL, MULTI-DOSE |
2 |
Generic |
$3.00 | $6.00 | P |
Lidocaine Hydrochloride 5mg/mL 25 VIAL, SINGLE-DOSE in 1 CONTAINER / 50 mL in 1 VIAL, SINGLE-DOSE |
2 |
Generic |
$3.00 | $6.00 | P |
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT |
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 |
LIDOCAINE-PRILOCAINE CREAM |
3 |
Preferred Brand |
20% | 20% | P |
LINEZOLID 100 MG/5 ML SUSP [Zyvox] |
5 |
Specialty Tier |
25% | 25% | None |
Linezolid 600 mg tablet [Zyvox] |
5 |
Specialty Tier |
25% | 25% | None |
Linezolid 600 mg/300 ml iv sol [Zyvox] |
5 |
Specialty Tier |
25% | 25% | None |
LINZESS 145 MCG CAPSULE |
3 |
Preferred Brand |
20% | 20% | Q:60 /30Days |
LINZESS 290 MCG CAPSULE |
3 |
Preferred Brand |
20% | 20% | Q:30 /30Days |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT |
3 |
Preferred Brand |
20% | 20% | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT |
3 |
Preferred Brand |
20% | 20% | None |
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT |
3 |
Preferred Brand |
20% | 20% | None |
LISINOPRIL 10MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LISINOPRIL 2.5 MG TABLET |
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 |
LISINOPRIL 20 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LISINOPRIL 30MG TABLET (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LISINOPRIL 40MG TABLET (500 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Lisinopril 5mg/1 1000 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
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 300 mg tab |
2 |
Generic |
$3.00 | $6.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
Lithium Carbonate 450mg/1 |
2 |
Generic |
$3.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LITHIUM CARBONATE 600 MG CAP |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) |
2 |
Generic |
$3.00 | $6.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP |
3 |
Preferred Brand |
20% | 20% | None |
LONSURF 15 MG-6.14 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
LONSURF 20 MG-8.19 MG TABLET |
5 |
Specialty Tier |
25% | 25% | P |
LOPERAMIDE HCL 2MG CAPSULE |
2 |
Generic |
$3.00 | $6.00 | None |
LORAZEPAM 0.5 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:150 /30Days |
Lorazepam 1 MG 100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:150 /30Days |
Lorazepam 2 MG 100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:150 /30Days |
Lorazepam 2mg/mL 30 mL in 1 BOTTLE, DROPPER |
3 |
Preferred Brand |
20% | 20% | Q:150 /30Days |
Lorcet 5-325 mg tablet |
2 |
Generic |
$3.00 | $6.00 | Q:360 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Lorcet hd 10-325 mg tablet |
2 |
Generic |
$3.00 | $6.00 | Q:360 /30Days |
Lorcet plus 7.5-325 mg tablet |
2 |
Generic |
$3.00 | $6.00 | Q:360 /30Days |
lortab 10-325 mg tablet |
2 |
Generic |
$3.00 | $6.00 | Q:360 /30Days |
lortab 5-325 mg tablet |
2 |
Generic |
$3.00 | $6.00 | Q:360 /30Days |
lortab 7.5-325 mg tablet |
2 |
Generic |
$3.00 | $6.00 | Q:360 /30Days |
LOSARTAN POTASSIUM 100 MG TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LOSARTAN POTASSIUM 25 MG TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LOSARTAN POTASSIUM 50 MG TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LOSARTAN-HCTZ 100-12.5 MG TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LOSARTAN-HCTZ 100-25 MG TAB |
1 |
Preferred Generic |
$0.00 | $0.00 | None |
LOSARTAN-HCTZ 50-12.5 MG TAB |
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 |
LOTEMAX 0.5% EYE DROPS |
3 |
Preferred Brand |
20% | 20% | None |
LOTEMAX 0.5% OPHTHALMIC GEL |
3 |
Preferred Brand |
20% | 20% | None |
Lotemax 5mg/g 1 TUBE per CARTON / 3.5 g in 1 TUBE |
3 |
Preferred Brand |
20% | 20% | None |
Lovastatin 10mg 60 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
LOVASTATIN 20 MG TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:120 /30Days |
LOVASTATIN 40 MG ORAL TABLET |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days |
LOXAPINE 25MG CAPSULE (100 CT) |
3 |
Preferred Brand |
20% | 20% | None |
LOXAPINE CAPSULES 10MG 100 BOT |
3 |
Preferred Brand |
20% | 20% | None |
LOXAPINE CAPSULES 50MG 100 BOT |
3 |
Preferred Brand |
20% | 20% | None |
LOXAPINE CAPSULES 5MG 100 BOT |
3 |
Preferred Brand |
20% | 20% | None |
LUMIGAN 0.1mg/mL 1 BOTTLE, DROPPER per CARTON / 5 mL in 1 BOTTLE, DROPPER |
3 |
Preferred Brand |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Lumizyme 5mg/mL |
5 |
Specialty Tier |
25% | 25% | P |
LUPRON DEPOT 3.75 MG KIT |
5 |
Specialty Tier |
25% | 25% | P |
LYNPARZA 50 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | P |
LYRICA 100MG CAPSULE |
3 |
Preferred Brand |
20% | 20% | Q:120 /30Days |
LYRICA 150MG CAPSULE |
3 |
Preferred Brand |
20% | 20% | Q:120 /30Days |
LYRICA 20 MG/ML ORAL SOLUTION |
3 |
Preferred Brand |
20% | 20% | Q:946 /30Days |
LYRICA 200MG CAPSULE |
3 |
Preferred Brand |
20% | 20% | Q:90 /30Days |
LYRICA 225MG CAPSULE |
3 |
Preferred Brand |
20% | 20% | Q:60 /30Days |
LYRICA 25MG CAPSULE |
3 |
Preferred Brand |
20% | 20% | Q:120 /30Days |
LYRICA 300MG CAPSULE |
3 |
Preferred Brand |
20% | 20% | Q:60 /30Days |
LYRICA 50MG CAPSULE |
3 |
Preferred Brand |
20% | 20% | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYRICA 75MG CAPSULE |
3 |
Preferred Brand |
20% | 20% | Q:120 /30Days |
LYSODREN 500MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
LYZA 0.35 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |