2016 Medicare Part D Plan Formulary Information |
Humana Gold Plus SNP-DE H4007-016 (HMO SNP) (H4007-016-0)
Benefit Details
|
The Humana Gold Plus SNP-DE H4007-016 (HMO SNP) (H4007-016-0) Formulary Drugs Starting with the Letter L in Dorado County, PR: CMS MA Region 30 which includes: PR Plan Monthly Premium: $0.00 Deductible: $360 |
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 |
25% | 25% | None |
LABETALOL HCL 200MG TABLET |
1 |
Generic |
25% | 25% | None |
LABETALOL HCL 300MG TABLET |
1 |
Generic |
25% | 25% | None |
LABETALOL HCL 5MG/20ML VIAL |
1 |
Generic |
25% | 25% | None |
LACRISERT 5 MG INS |
3* |
Non-Preferred Brand |
25% | 25% | None |
LACTATED RINGERS INJECTION |
1 |
Generic |
25% | 25% | None |
LACTATED RINGERS IRRIGATION 4 CONTAINER in 1 CASE / 40 |
1 |
Generic |
25% | 25% | None |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT |
1 |
Generic |
25% | 25% | None |
LAMICTAL 25MG TABLET STARTER KIT |
3* |
Non-Preferred Brand |
25% | 25% | None |
LAMICTAL 25MG/100MG TABLET STARTER KIT |
3* |
Non-Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMICTAL KIT 100;25MG;MG |
3* |
Non-Preferred Brand |
25% | 25% | None |
LAMICTAL ODT 100mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK |
3* |
Non-Preferred Brand |
25% | 25% | None |
LAMICTAL ODT 200mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK |
3* |
Non-Preferred Brand |
25% | 25% | None |
LAMICTAL ODT 25mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK |
3* |
Non-Preferred Brand |
25% | 25% | None |
LAMICTAL ODT 50mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK |
3* |
Non-Preferred Brand |
25% | 25% | None |
LAMICTAL XR START KIT (BLUE) |
3* |
Non-Preferred Brand |
25% | 25% | None |
LAMICTAL XR START KIT (GREEN) |
3* |
Non-Preferred Brand |
25% | 25% | None |
LAMICTAL XR START KIT (ORANGE) |
3* |
Non-Preferred Brand |
25% | 25% | None |
Lamivudine 10 mg/ml oral soln |
2 |
Preferred Brand |
25% | 25% | Q:960 /30Days |
LAMIVUDINE 150 MG TABLET |
1 |
Generic |
25% | 25% | Q:60 /30Days |
LAMIVUDINE 300 MG TABLET |
1 |
Generic |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Lamivudine hbv 100 mg tablet |
1 |
Generic |
25% | 25% | None |
LAMIVUDINE-ZIDOVUDINE TABLET |
1 |
Generic |
25% | 25% | Q:60 /30Days |
LAMOTRIGINE 150MG TABLET (60 CT) |
1 |
Generic |
25% | 25% | None |
LAMOTRIGINE 200MG TABLET (60 CT) |
1 |
Generic |
25% | 25% | None |
LAMOTRIGINE 25MG TABLET (100 CT) |
1 |
Generic |
25% | 25% | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE |
1 |
Generic |
25% | 25% | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE |
1 |
Generic |
25% | 25% | None |
LAMOTRIGINE ER 100 MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
lamotrigine er 200 mg tablet |
3* |
Non-Preferred Brand |
25% | 25% | None |
lamotrigine er 25 mg tablet |
3* |
Non-Preferred Brand |
25% | 25% | None |
lamotrigine er 250 mg tablet |
3* |
Non-Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
lamotrigine er 300 mg tablet |
3* |
Non-Preferred Brand |
25% | 25% | None |
lamotrigine er 50 mg tablet |
3* |
Non-Preferred Brand |
25% | 25% | None |
Lamotrigine ODT 100 MG Tablet |
3* |
Non-Preferred Brand |
25% | 25% | None |
Lamotrigine ODT 200 MG Tablet |
3* |
Non-Preferred Brand |
25% | 25% | None |
Lamotrigine ODT 25 MG Tablet |
3* |
Non-Preferred Brand |
25% | 25% | None |
Lamotrigine ODT 50 MG Tablet |
3* |
Non-Preferred Brand |
25% | 25% | None |
LAMOTRIGINE TABLET 100MG (100 CT) |
1 |
Generic |
25% | 25% | None |
LANOXIN 0.25 MG/ML AMPUL |
3* |
Non-Preferred Brand |
25% | 25% | None |
LANOXIN 125 MCG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | Q:30 /30Days |
LANOXIN 187.5 MCG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | Q:30 /30Days |
LANOXIN 250 MCG TABLET |
2 |
Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LANOXIN 62.5 MCG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | Q:30 /30Days |
Lansoprazole 15mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE, PLASTIC |
2 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
Lansoprazole 30mg/1 30 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
2 |
Preferred Brand |
25% | 25% | Q:30 /30Days |
LANTUS 100U/ML VIAL |
2 |
Preferred Brand |
25% | 25% | None |
LANTUS SOLOSTAR INJECTION |
2 |
Preferred Brand |
25% | 25% | None |
LARIN 1.5 MG-30 MCG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
LARIN 21 1-20 tablet |
3* |
Non-Preferred Brand |
25% | 25% | None |
LARIN FE 1-20 TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
LARIN FE 1.5-30 TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
LATANOPROST 0.005% EYE DROPS |
1 |
Generic |
25% | 25% | Q:3 /25Days |
LATUDA 120 MG TABLET |
2 |
Preferred Brand |
25% | 25% | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LATUDA 20 MG TABLET |
2 |
Preferred Brand |
25% | 25% | P Q:30 /30Days |
Latuda 40mg/1 |
2 |
Preferred Brand |
25% | 25% | P Q:30 /30Days |
LATUDA 60 MG TABLET |
2 |
Preferred Brand |
25% | 25% | P Q:30 /30Days |
Latuda 80mg/1 |
2 |
Preferred Brand |
25% | 25% | P Q:60 /30Days |
LAZANDA 100 MCG NASAL SPRAY |
4* |
Specialty Tier |
25% | N/A | P |
LAZANDA 300 MCG NASAL SPRAY |
4* |
Specialty Tier |
25% | N/A | P |
LAZANDA 400 MCG NASAL SPRAY |
4* |
Specialty Tier |
25% | N/A | P |
LEENA 7-9-5 TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
LEFLUNOMIDE 10MG TABLET |
1 |
Generic |
25% | 25% | Q:30 /30Days |
LEFLUNOMIDE 20 MG TABLET |
1 |
Generic |
25% | 25% | Q:30 /30Days |
LENVIMA 10 MG DAILY DOSE |
4* |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LENVIMA 14 MG DAILY DOSE |
4* |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
LENVIMA 18 MG DAILY DOSE |
4* |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
LENVIMA 20 MG DAILY DOSE |
4* |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
LENVIMA 24 MG DAILY DOSE |
4* |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
LENVIMA 8 MG DAILY DOSE |
4* |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
LENVIMA CAPSULE 8 MG |
4* |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
LESCOL XL 80MG TABLET SA |
3* |
Non-Preferred Brand |
25% | 25% | S Q:30 /30Days |
Lessina 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK |
3* |
Non-Preferred Brand |
25% | 25% | None |
LETAIRIS 10MG TABLET |
4* |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
LETAIRIS 5MG TABLET |
4* |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
LETROZOLE 2.5 MG TABLET |
1 |
Generic |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUCOVORIN CALCIUM 100MG VL |
1 |
Generic |
25% | 25% | P |
LEUCOVORIN CALCIUM 10MG TABLET |
1 |
Generic |
25% | 25% | None |
Leucovorin Calcium 15mg/1 24 TABLET BOTTLE |
1 |
Generic |
25% | 25% | None |
LEUCOVORIN CALCIUM 25MG TABLET |
1 |
Generic |
25% | 25% | None |
LEUCOVORIN CALCIUM 350MG VL |
1 |
Generic |
25% | 25% | P |
LEUCOVORIN CALCIUM 5MG TABLET |
1 |
Generic |
25% | 25% | None |
LEUKERAN 2 MG TABLET |
2 |
Preferred Brand |
25% | 25% | None |
LEUKINE 250 MCG VIAL |
2 |
Preferred Brand |
25% | 25% | P |
Leuprolide 2wk 1 mg/0.2 ml kit |
2 |
Preferred Brand |
25% | 25% | P |
LEVEMIR 100UNITS/ML VIAL |
2 |
Preferred Brand |
25% | 25% | None |
LEVEMIR FLEXTOUCH 100 UNITS/ML |
2 |
Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levetiracetam 100mg/mL 473 mL in 1 BOTTLE, PLASTIC |
1 |
Generic |
25% | 25% | None |
LEVETIRACETAM 100MG/ML INJECTION |
3* |
Non-Preferred Brand |
25% | 25% | None |
LEVETIRACETAM 500 MG TABLET 120 BOT |
1 |
Generic |
25% | 25% | None |
Levetiracetam 500mg/1 60 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
Generic |
25% | 25% | None |
LEVETIRACETAM ER 750 MG TABLET |
1 |
Generic |
25% | 25% | None |
LEVETIRACETAM TABLETS 1000MG 60 BOT |
1 |
Generic |
25% | 25% | None |
LEVETIRACETAM TABLETS 250MG 500 BOT |
1 |
Generic |
25% | 25% | None |
LEVETIRACETAM TABLETS 750MG 500 BOT |
1 |
Generic |
25% | 25% | None |
LEVETIRACETAM-NACL 1,000 MG/100 ML |
1 |
Generic |
25% | 25% | None |
LEVETIRACETAM-NACL 1,500 MG/100 ML |
1 |
Generic |
25% | 25% | None |
LEVETIRACETAM-NACL 500 MG/100 ML |
1 |
Generic |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION |
1 |
Generic |
25% | 25% | None |
LEVOCARNITINE 100MG/ML SOLUTION ORAL |
1 |
Generic |
25% | 25% | None |
LEVOCARNITINE 200MG/ML VIAL |
2 |
Preferred Brand |
25% | 25% | None |
LEVOCARNITINE TABLET 330MG 90 BLPK |
1 |
Generic |
25% | 25% | None |
LEVOCETIRIZINE 5 MG TABLET |
1 |
Generic |
25% | 25% | Q:30 /30Days |
Levofloxacin 250mg/1 [LEVAQUIN] |
1 |
Generic |
25% | 25% | None |
Levofloxacin 25mg/mL 1 BOTTLE per CARTON / 100 mL in 1 BOTTLE [LEVAQUIN] |
2 |
Preferred Brand |
25% | 25% | None |
Levofloxacin 500 MG [LEVAQUIN] |
1 |
Generic |
25% | 25% | None |
LEVOFLOXACIN 500 MG/20 ML VIAL [LEVAQUIN] |
3* |
Non-Preferred Brand |
25% | 25% | None |
Levofloxacin 5mg/mL 1 BOTTLE, DROPPER per CARTON / 5 mL in 1 BOTTLE, DROPPER [LEVAQUIN] |
1 |
Generic |
25% | 25% | None |
Levofloxacin 5mg/mL 24 POUCH per CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG [LEVAQUIN] |
3* |
Non-Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levofloxacin 750 MG [LEVAQUIN] |
1 |
Generic |
25% | 25% | None |
LEVOFLOXACIN-D5W 750 MG/150 ML [LEVAQUIN] |
3* |
Non-Preferred Brand |
25% | 25% | None |
LEVOLEUCOVORIN 175 MG/17.5 ML [Fusilev] |
4* |
Specialty Tier |
25% | N/A | P |
LEVONEST-28 TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
LEVONOR-ETH ESTRAD 0.09-0.02 MG |
3* |
Non-Preferred Brand |
25% | 25% | None |
LEVONOR-ETH ESTRAD 0.1-0.02 MG |
3* |
Non-Preferred Brand |
25% | 25% | None |
levonor-eth estrad 0.15-0.03 |
3* |
Non-Preferred Brand |
25% | 25% | Q:91 /90Days |
Levonor-eth Estrad 0.15-0.03-0.01 |
3* |
Non-Preferred Brand |
25% | 25% | None |
LEVONOR-ETH ESTRAD TRIPHASIC |
3* |
Non-Preferred Brand |
25% | 25% | None |
LEVORA-28 TABLET 0.15/30 |
3* |
Non-Preferred Brand |
25% | 25% | None |
LEVORPHANOL 2 MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE 100 MCG VIAL |
1 |
Generic |
25% | 25% | None |
LEVOTHYROXINE 125 MCG TABLET |
1 |
Generic |
25% | 25% | None |
LEVOTHYROXINE 137 MCG TABLET |
1 |
Generic |
25% | 25% | None |
LEVOTHYROXINE 175 MCG TABLET |
1 |
Generic |
25% | 25% | None |
LEVOTHYROXINE 300 MCG TABLET |
1 |
Generic |
25% | 25% | None |
LEVOTHYROXINE 75 MCG TABLET |
1 |
Generic |
25% | 25% | None |
Levothyroxine Sodium 100ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Generic |
25% | 25% | None |
Levothyroxine Sodium 112ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Generic |
25% | 25% | None |
Levothyroxine Sodium 150ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Generic |
25% | 25% | None |
Levothyroxine Sodium 200ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA |
1 |
Generic |
25% | 25% | None |
Levothyroxine Sodium 25ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1 |
Generic |
25% | 25% | 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 |
Generic |
25% | 25% | None |
Levothyroxine Sodium 88ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS |
1 |
Generic |
25% | 25% | None |
LEVOXYL 100 MCG TABLET |
2 |
Preferred Brand |
25% | 25% | None |
LEVOXYL 112 MCG TABLET |
2 |
Preferred Brand |
25% | 25% | None |
LEVOXYL 125 MCG TABLET |
2 |
Preferred Brand |
25% | 25% | None |
LEVOXYL 137 MCG TABLET |
2 |
Preferred Brand |
25% | 25% | None |
LEVOXYL 150MCG TABLET (1000 CT) |
2 |
Preferred Brand |
25% | 25% | None |
LEVOXYL 175MCG TABLET (1000 CT) |
2 |
Preferred Brand |
25% | 25% | None |
LEVOXYL 200 MCG TABLET |
2 |
Preferred Brand |
25% | 25% | None |
LEVOXYL 25 MCG TABLET |
2 |
Preferred Brand |
25% | 25% | None |
LEVOXYL 50 MCG TABLET |
2 |
Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 75MCG TABLET (1000 CT) |
2 |
Preferred Brand |
25% | 25% | None |
LEVOXYL 88 MCG TABLET |
2 |
Preferred Brand |
25% | 25% | None |
LEXIVA 50mg/mL 225 mL in 1 BOTTLE |
2 |
Preferred Brand |
25% | 25% | Q:1575 /28Days |
LEXIVA 700MG TABLETS |
4* |
Specialty Tier |
25% | N/A | Q:120 /30Days |
LIALDA 1.2G TABLET DELAYED RELEASE |
2 |
Preferred Brand |
25% | 25% | Q:120 /30Days |
LIDOCAINE 5% OINTMENT |
3* |
Non-Preferred Brand |
25% | 25% | None |
Lidocaine 5% patch |
3* |
Non-Preferred Brand |
25% | 25% | P Q:90 /30Days |
lidocaine hcl 2% jelly |
2 |
Preferred Brand |
25% | 25% | None |
lidocaine hcl 2% jelly |
2 |
Preferred Brand |
25% | 25% | None |
LIDOCAINE HCL 2% JELLY 30ML TUBE |
1 |
Generic |
25% | 25% | None |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT |
1 |
Generic |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Lidocaine Hydrochloride 20mg/mL 25 VIAL, MULTI-DOSE in 1 TRAY / 20 mL in 1 VIAL, MULTI-DOSE |
1 |
Generic |
25% | 25% | None |
Lidocaine Hydrochloride 5mg/mL 25 VIAL, SINGLE-DOSE in 1 CONTAINER / 50 mL in 1 VIAL, SINGLE-DOSE |
1 |
Generic |
25% | 25% | None |
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT |
1 |
Generic |
25% | 25% | None |
LIDOCAINE-PRILOCAINE CREAM |
3* |
Non-Preferred Brand |
25% | 25% | None |
LINCOCIN 300MG/ML VIAL |
3* |
Non-Preferred Brand |
25% | 25% | None |
Lincomycin hcl 600 mg/2 ml vl [Lincocin] |
3* |
Non-Preferred Brand |
25% | 25% | None |
LINDANE SHAMPOO 1MG 2 FLO BOT |
3* |
Non-Preferred Brand |
25% | 25% | None |
LINEZOLID 100 MG/5 ML SUSP [Zyvox] |
4* |
Specialty Tier |
25% | N/A | None |
Linezolid 600 mg tablet [Zyvox] |
4* |
Specialty Tier |
25% | N/A | None |
Linezolid 600 mg/300 ml iv sol [Zyvox] |
4* |
Specialty Tier |
25% | N/A | None |
LINZESS 145 MCG CAPSULE |
2 |
Preferred Brand |
25% | 25% | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LINZESS 290 MCG CAPSULE |
2 |
Preferred Brand |
25% | 25% | Q:30 /30Days |
Lioresal 0.05mg/mL |
3* |
Non-Preferred Brand |
25% | 25% | P |
Lioresal 0.5mg/mL |
3* |
Non-Preferred Brand |
25% | 25% | P |
Lioresal 2mg/mL |
4* |
Specialty Tier |
25% | N/A | P |
liothyronine sodium 10ug/mL 1 VIAL per CARTON / 1 mL in 1 VIAL |
1 |
Generic |
25% | 25% | None |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT |
2 |
Preferred Brand |
25% | 25% | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT |
2 |
Preferred Brand |
25% | 25% | None |
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT |
2 |
Preferred Brand |
25% | 25% | None |
LISINOPRIL 10MG TABLET (100 CT) |
1 |
Generic |
25% | 25% | None |
LISINOPRIL 2.5 MG TABLET |
1 |
Generic |
25% | 25% | None |
LISINOPRIL 20 MG TABLET |
1 |
Generic |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL 30MG TABLET (100 CT) |
1 |
Generic |
25% | 25% | None |
LISINOPRIL 40MG TABLET (500 CT) |
1 |
Generic |
25% | 25% | None |
Lisinopril 5mg/1 1000 TABLET BOTTLE |
1 |
Generic |
25% | 25% | None |
Lisinopril with Hydrochlorothiazide 12.5; 10mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Generic |
25% | 25% | None |
Lisinopril with Hydrochlorothiazide 12.5; 20mg/1; mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Generic |
25% | 25% | None |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT) |
1 |
Generic |
25% | 25% | None |
Lithium Carbonate 150mg/1 100 CAPSULE BOTTLE, PLASTIC |
1 |
Generic |
25% | 25% | None |
Lithium Carbonate 300 mg tab |
1 |
Generic |
25% | 25% | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) |
1 |
Generic |
25% | 25% | None |
Lithium Carbonate 450mg/1 |
1 |
Generic |
25% | 25% | None |
LITHIUM CARBONATE 600 MG CAP |
1 |
Generic |
25% | 25% | 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 |
Generic |
25% | 25% | None |
LITHIUM CIT 8MEQ/5ML SYRUP |
1 |
Generic |
25% | 25% | None |
LITHOSTAT 250 MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
LIVALO 1 MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | S Q:30 /30Days |
LIVALO 2 MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | S Q:30 /30Days |
LIVALO 4 MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | S Q:30 /30Days |
LOESTRIN 21 1.5/30 TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
LOESTRIN 21 1/20 TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
LOESTRIN FE 1.5/30 TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
LOESTRIN FE 1/20 TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
LOKARA 0.05% LOTION |
3* |
Non-Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOMEDIA 24 FE 24MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
LONSURF 15 MG-6.14 MG TABLET |
4* |
Specialty Tier |
25% | N/A | P Q:100 /30Days |
LONSURF 20 MG-8.19 MG TABLET |
4* |
Specialty Tier |
25% | N/A | P Q:80 /30Days |
LOPERAMIDE HCL 2MG CAPSULE |
1 |
Generic |
25% | 25% | None |
LORAZEPAM 0.5 MG TABLET |
1 |
Generic |
25% | 25% | Q:90 /30Days |
Lorazepam 1 MG 100 TABLET BOTTLE |
1 |
Generic |
25% | 25% | Q:90 /30Days |
Lorazepam 2 MG 100 TABLET BOTTLE |
1 |
Generic |
25% | 25% | Q:150 /30Days |
Lorazepam 2mg/mL 30 mL in 1 BOTTLE, DROPPER |
1 |
Generic |
25% | 25% | Q:150 /30Days |
Loryna (drospirenone and ethinyl estradiol) 3 CARTON in 1 BOX / 1 KIT per CARTON |
3* |
Non-Preferred Brand |
25% | 25% | None |
LOSARTAN POTASSIUM 100 MG TAB |
1 |
Generic |
25% | 25% | Q:60 /30Days |
LOSARTAN POTASSIUM 25 MG TAB |
1 |
Generic |
25% | 25% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOSARTAN POTASSIUM 50 MG TAB |
1 |
Generic |
25% | 25% | Q:60 /30Days |
LOSARTAN-HCTZ 100-12.5 MG TAB |
1 |
Generic |
25% | 25% | Q:60 /30Days |
LOSARTAN-HCTZ 100-25 MG TAB |
1 |
Generic |
25% | 25% | Q:60 /30Days |
LOSARTAN-HCTZ 50-12.5 MG TAB |
1 |
Generic |
25% | 25% | Q:60 /30Days |
LOTRONEX TABLETS .5MG 30 BOTPL |
4* |
Specialty Tier |
25% | N/A | Q:60 /30Days |
LOTRONEX TABLETS 1MG 30 BOTPL |
4* |
Specialty Tier |
25% | N/A | Q:60 /30Days |
Lovastatin 10mg 60 TABLET BOTTLE |
1 |
Generic |
25% | 25% | Q:60 /30Days |
LOVASTATIN 20 MG TABLET |
1 |
Generic |
25% | 25% | Q:60 /30Days |
LOVASTATIN 40 MG ORAL TABLET |
1 |
Generic |
25% | 25% | Q:60 /30Days |
LOXAPINE 25MG CAPSULE (100 CT) |
1 |
Generic |
25% | 25% | None |
LOXAPINE CAPSULES 10MG 100 BOT |
1 |
Generic |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOXAPINE CAPSULES 50MG 100 BOT |
1 |
Generic |
25% | 25% | None |
LOXAPINE CAPSULES 5MG 100 BOT |
1 |
Generic |
25% | 25% | None |
LUMIGAN 0.1mg/mL 1 BOTTLE, DROPPER per CARTON / 5 mL in 1 BOTTLE, DROPPER |
2 |
Preferred Brand |
25% | 25% | Q:3 /25Days |
Lumizyme 5mg/mL |
4* |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT 11.25 MG 3MO KIT |
2 |
Preferred Brand |
25% | 25% | P Q:1 /90Days |
LUPRON DEPOT 22.5 MG 3MO KIT [LUPRON] |
2 |
Preferred Brand |
25% | 25% | P Q:1 /90Days |
LUPRON DEPOT 3.75 MG KIT |
2 |
Preferred Brand |
25% | 25% | P Q:1 /30Days |
LUPRON DEPOT 45 MG 6MO KIT |
2 |
Preferred Brand |
25% | 25% | P Q:1 /168Days |
LUPRON DEPOT 7.5 MG KIT |
2 |
Preferred Brand |
25% | 25% | P Q:1 /30Days |
LUPRON DEPOT-4 MONTH KIT |
2 |
Preferred Brand |
25% | 25% | P Q:1 /112Days |
LUPRON DEPOT-PED 11.25 MG KIT |
2 |
Preferred Brand |
25% | 25% | P Q:1 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUPRON DEPOT-PED 15 MG KIT |
2 |
Preferred Brand |
25% | 25% | P Q:1 /28Days |
LUTERA 0.1-0.02 TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |
LYNPARZA 50 MG CAPSULE |
4* |
Specialty Tier |
25% | N/A | P Q:448 /28Days |
LYRICA 100MG CAPSULE |
3* |
Non-Preferred Brand |
25% | 25% | Q:90 /30Days |
LYRICA 150MG CAPSULE |
3* |
Non-Preferred Brand |
25% | 25% | Q:90 /30Days |
LYRICA 20 MG/ML ORAL SOLUTION |
3* |
Non-Preferred Brand |
25% | 25% | Q:900 /30Days |
LYRICA 200MG CAPSULE |
3* |
Non-Preferred Brand |
25% | 25% | Q:90 /30Days |
LYRICA 225MG CAPSULE |
3* |
Non-Preferred Brand |
25% | 25% | Q:60 /30Days |
LYRICA 25MG CAPSULE |
3* |
Non-Preferred Brand |
25% | 25% | Q:90 /30Days |
LYRICA 300MG CAPSULE |
3* |
Non-Preferred Brand |
25% | 25% | Q:60 /30Days |
LYRICA 50MG CAPSULE |
3* |
Non-Preferred Brand |
25% | 25% | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYRICA 75MG CAPSULE |
3* |
Non-Preferred Brand |
25% | 25% | Q:90 /30Days |
LYSODREN 500MG TABLET |
2 |
Preferred Brand |
25% | 25% | None |
LYZA 0.35 MG TABLET |
3* |
Non-Preferred Brand |
25% | 25% | None |