2018 Medicare Part D Plan Formulary Information |
Humana Gold Choice H8145-006 (PFFS) (H8145-006-0)
Benefit Details
|
The Humana Gold Choice H8145-006 (PFFS) (H8145-006-0) Formulary Drugs Starting with the Letter L in Berrien County, MI: CMS MA Region 11 which includes: MI Plan Monthly Premium: $97.00 Deductible: $405 |
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 100 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | None |
LABETALOL HCL 200 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | None |
LABETALOL HCL 300 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | None |
Labetalol hydrochloride 5 MG/ML Injectable Solution |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LACTATED RINGERS INJECTION |
2* |
Generic |
$15.00 | $0.00 | None |
LACTATED RINGERS IRRIGATION 4 CONTAINER in 1 CASE / 40 |
2* |
Generic |
$15.00 | $0.00 | None |
LACTULOSE 10 GM/15 ML SOLUTION [Constulose] |
2* |
Generic |
$15.00 | $0.00 | None |
Lamivudine 10 mg/ml oral soln |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LAMIVUDINE 150 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days |
LAMIVUDINE 300 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | 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 |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:90 /30Days |
LAMIVUDINE-ZIDOVUDINE TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days |
LAMOTRIGINE 150MG TABLET (60 CT) |
2* |
Generic |
$15.00 | $0.00 | None |
LAMOTRIGINE 200MG TABLET (60 CT) |
2* |
Generic |
$15.00 | $0.00 | None |
LAMOTRIGINE 25 MG DISPER TAB CHW DSP [Lamictal CD] |
2* |
Generic |
$15.00 | $0.00 | None |
LAMOTRIGINE 25MG TABLET (100 CT) |
2* |
Generic |
$15.00 | $0.00 | None |
LAMOTRIGINE 5 MG DISPER TABLET CHW DSP [Lamictal CD] |
2* |
Generic |
$15.00 | $0.00 | None |
LAMOTRIGINE ER 100 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LAMOTRIGINE ER 200 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LAMOTRIGINE ER 25 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LAMOTRIGINE ER 250 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE ER 300 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LAMOTRIGINE ER 50 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
Lamotrigine ODT 100 MG Tablet |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
Lamotrigine ODT 200 MG Tablet |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LAMOTRIGINE ODT 25 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
Lamotrigine ODT 50 MG Tablet |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LAMOTRIGINE START KIT-BLUE TAB DS PK [Subvenite] |
2* |
Generic |
$15.00 | $0.00 | None |
LAMOTRIGINE START KIT-GREEN TAB DS PK [Subvenite] |
2* |
Generic |
$15.00 | $0.00 | None |
LAMOTRIGINE START KIT-ORANG TAB DS PK [Subvenite] |
2* |
Generic |
$15.00 | $0.00 | None |
LAMOTRIGINE TABLET 100MG (100 CT) |
2* |
Generic |
$15.00 | $0.00 | None |
LANSOPRAZOL-AMOXICIL-CLARITHRO |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LANSOPRAZOLE DR 15 MG CAPSULE DR [Prevacid]
|
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
LANSOPRAZOLE DR 30 MG CAPSULE [Prevacid] |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days |
LANTUS 100U/ML VIAL |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LANTUS SOLOSTAR INJECTION |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LARIN 1.5 MG-30 MCG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LARIN 21 1-20 TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LARIN FE 1-20 TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LARIN FE 1.5-30 TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
Larissia-28 tablet |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
Lartruvo 19 mL in 1 VIAL, SINGLE-USE |
5 |
Specialty Tier |
25% | N/A | P |
LARTRUVO 500 MG/50 ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LATANOPROST 0.005% EYE DROPS |
1* |
Preferred Generic |
$6.00 | $0.00 | Q:5 /25Days |
LATUDA 120 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
LATUDA 20 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
LATUDA 40 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
LATUDA 60 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
LATUDA 80 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
LEENA 28 TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LEFLUNOMIDE 10 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | Q:30 /30Days |
LEFLUNOMIDE 20 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | Q:30 /30Days |
LENVIMA 10 MG DAILY DOSE |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
LENVIMA 14 MG DAILY DOSE |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LENVIMA 18 MG DAILY DOSE |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
LENVIMA 20 MG DAILY DOSE |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
LENVIMA 24 MG DAILY DOSE |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
LENVIMA 8 MG DAILY DOSE |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
Lessina 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LETAIRIS 10 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
LETAIRIS 5 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
LETROZOLE 2.5 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | Q:30 /30Days |
LEUCOVORIN CALCIUM 100MG VL |
2* |
Generic |
$15.00 | $0.00 | P |
LEUCOVORIN CALCIUM 10MG TABLET |
2* |
Generic |
$15.00 | $0.00 | None |
Leucovorin Calcium 15mg/1 24 TABLET BOTTLE |
2* |
Generic |
$15.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUCOVORIN CALCIUM 25MG TABLET |
2* |
Generic |
$15.00 | $0.00 | None |
LEUCOVORIN CALCIUM 350MG VL |
2* |
Generic |
$15.00 | $0.00 | P |
LEUCOVORIN CALCIUM 5 MG TAB |
2* |
Generic |
$15.00 | $0.00 | None |
LEUKERAN 2 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
LEUKINE 250 MCG VIAL |
5 |
Specialty Tier |
25% | N/A | P |
LEUPROLIDE 2WK 14 MG/2.8 ML KT |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
LEVALBUTEROL 0.31 MG/3 ML SOL |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
LEVALBUTEROL 0.63 MG/3 ML SOL |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
LEVALBUTEROL 1.25 MG/0.5 ML |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
Levalbuterol conc 1.25 mg/0.5 |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
LEVALBUTEROL TAR HFA 45MCG INH [Xopenex] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVEMIR 100UNITS/ML VIAL |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEVEMIR FLEXTOUCH 100 UNITS/ML |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEVETIRACETAM 1,000 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | None |
LEVETIRACETAM 100 MG/ML SOLN |
2* |
Generic |
$15.00 | $0.00 | None |
Levetiracetam 100 ML 10 MG/ML Injection |
2* |
Generic |
$15.00 | $0.00 | None |
Levetiracetam 100 ML 15 MG/ML Injection |
2* |
Generic |
$15.00 | $0.00 | None |
Levetiracetam 100 ML 5 MG/ML Injection |
2* |
Generic |
$15.00 | $0.00 | None |
LEVETIRACETAM 250 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | None |
LEVETIRACETAM 500 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | None |
LEVETIRACETAM 500 MG/5 ML VIAL |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LEVETIRACETAM 750 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM ER 500 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEVETIRACETAM ER 750 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEVO-T 100 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEVO-T 112 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEVO-T 125 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEVO-T 137 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEVO-T 150 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEVO-T 175 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEVO-T 200 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEVO-T 25 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEVO-T 300 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVO-T 50 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEVO-T 75 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEVO-T 88 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
LEVOCARNITINE 1 G/10 ML SOLN |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LEVOCARNITINE 330 MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEVOCETIRIZINE 5 MG TABLET |
1* |
Preferred Generic |
$6.00 | $0.00 | Q:30 /30Days |
LEVOFLOXACIN 0.5% EYE DROPS [LEVAQUIN] |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEVOFLOXACIN 25 MG/ML SOLUTION [LEVAQUIN] |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEVOFLOXACIN 250 MG TABLET [LEVAQUIN] |
2* |
Generic |
$15.00 | $0.00 | None |
Levofloxacin 500 MG per 20 ML Injection [LEVAQUIN] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOFLOXACIN 500 MG TABLET [LEVAQUIN] |
2* |
Generic |
$15.00 | $0.00 | None |
Levofloxacin 5mg/mL 24 POUCH per CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG [LEVAQUIN] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LEVOFLOXACIN 750 MG TABLET [LEVAQUIN] |
2* |
Generic |
$15.00 | $0.00 | None |
LEVOFLOXACIN 750 MG/150 ML-D5W [LEVAQUIN] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LEVOLEUCOVORIN 175 MG/17.5 ML [Fusilev] |
5 |
Specialty Tier |
25% | N/A | P |
LEVOLEUCOVORIN 50 MG VIAL [Fusilev] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
LEVONEST-28 TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LEVONO-E ESTRAD 0.10-0.02-0.01 |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:91 /90Days |
LEVONOR-ETH ESTRAD 0.09-0.02 MG |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LEVONOR-ETH ESTRAD 0.1-0.02 MG |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LEVONOR-ETH ESTRAD 0.15-0.03 |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVONOR-ETH ESTRAD 0.15-0.03 |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:91 /90Days |
Levonor-eth Estrad 0.15-0.03-0.01 |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:91 /90Days |
LEVONOR-ETH ESTRAD TRIPHASIC |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LEVONORG 0.15MG-EE 20-25-30MCG |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:91 /90Days |
Levora-28 tablet |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LEVOTHYROXINE 100 MCG TABLET |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
LEVOTHYROXINE 100 MCG VIAL |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LEVOTHYROXINE 112 MCG TABLET |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
LEVOTHYROXINE 125 MCG TABLET |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
LEVOTHYROXINE 137 MCG TABLET |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
LEVOTHYROXINE 150 MCG TABLET |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE 175 MCG TABLET |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
LEVOTHYROXINE 200 MCG TABLET |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
LEVOTHYROXINE 25 MCG TABLET |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
LEVOTHYROXINE 300 MCG TABLET |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
LEVOTHYROXINE 50 MCG TABLET |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
LEVOTHYROXINE 75 MCG TABLET |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
LEVOTHYROXINE 88 MCG TABLET |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
LEVOXYL 100 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEVOXYL 112 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEVOXYL 125 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEVOXYL 137 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 150 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEVOXYL 175 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEVOXYL 200 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEVOXYL 25 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEVOXYL 50 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEVOXYL 75 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEVOXYL 88 MCG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LEXIVA 50mg/mL 225 mL in 1 BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:1575 /28Days |
LEXIVA 700MG TABLETS |
5 |
Specialty Tier |
25% | N/A | Q:120 /30Days |
LIALDA 1.2G TABLET DELAYED RELEASE |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:120 /30Days |
LIDOCAINE 2% VISCOUS SOLN |
2* |
Generic |
$15.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Lidocaine 5% patch |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:90 /30Days |
LIDOCAINE HCL 2% JELLY 30ML TUBE |
2* |
Generic |
$15.00 | $0.00 | None |
LIDOCAINE-PRILOCAINE CREAM |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
Lincomycin 300 MG/ML Injectable Solution [Lincocin] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LINDANE SHAMPOO 1MG 2 FLO BOT |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
Linezolid 20 MG/ML Oral Suspension [Zyvox] |
5 |
Specialty Tier |
25% | N/A | Q:1800 /30Days |
LINEZOLID 600 MG TABLET [Zyvox] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LINEZOLID 600 MG/300 ML IV SOL [Zyvox] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LINZESS 145 MCG CAPSULE |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days |
LINZESS 290 MCG CAPSULE |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days |
LINZESS 72 MCG CAPSULE |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIORESAL IT 10 MG/20 ML KIT AMPUL |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
LIORESAL IT 10 MG/5 ML KIT AMPUL |
5 |
Specialty Tier |
25% | N/A | P |
LIOTHYRONINE SOD 25 MCG TAB |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LIOTHYRONINE SOD 5 MCG TAB |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
liothyronine sodium 10ug/mL 1 VIAL per CARTON / 1 mL in 1 VIAL |
2* |
Generic |
$15.00 | $0.00 | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LISINOPRIL 10 MG TABLET |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
LISINOPRIL 2.5 MG TABLET |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
LISINOPRIL 20 MG TABLET |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
LISINOPRIL 30 MG TABLET |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
LISINOPRIL 40 MG TABLET |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL 5 MG TABLET |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
LISINOPRIL-HCTZ 10-12.5 MG TAB |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
LISINOPRIL-HCTZ 20-12.5 MG TAB |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
LISINOPRIL-HCTZ 20-25 MG TAB |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
LITHIUM CARBONATE 150 MG CAP |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
Lithium Carbonate 300 mg tab |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
Lithium Carbonate 450mg/1 |
2* |
Generic |
$15.00 | $0.00 | None |
LITHIUM CARBONATE 600 MG CAP |
1* |
Preferred Generic |
$6.00 | $0.00 | None |
LITHIUM CARBONATE ER 300 MG TB |
2* |
Generic |
$15.00 | $0.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP |
2* |
Generic |
$15.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LITHOSTAT 250 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LODOSYN TAB 25MG |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
LOESTRIN 21 1.5/30 TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LOESTRIN 21 1/20 TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LOESTRIN FE 1.5/30 TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LOESTRIN FE 1/20 TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LONSURF 15 MG-6.14 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:100 /30Days |
LONSURF 20 MG-8.19 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:80 /30Days |
LOPERAMIDE HCL 2MG CAPSULE |
2* |
Generic |
$15.00 | $0.00 | None |
LOPINAVIR-RITONAVIR 80-20MG/ML Solution [Kaletra] |
5 |
Specialty Tier |
25% | N/A | None |
LORAZEPAM 0.5 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LORAZEPAM 1 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | Q:90 /30Days |
LORAZEPAM 2 MG TABLET |
2* |
Generic |
$15.00 | $0.00 | Q:150 /30Days |
LORAZEPAM 2 MG/ML ORAL CONCENT |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:150 /30Days |
LORYNA 3 MG-0.02 MG TABLET [Yaz] |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LOSARTAN POTASSIUM 100 MG TAB |
1* |
Preferred Generic |
$6.00 | $0.00 | Q:60 /30Days |
LOSARTAN POTASSIUM 25 MG TAB |
1* |
Preferred Generic |
$6.00 | $0.00 | Q:60 /30Days |
LOSARTAN POTASSIUM 50 MG TAB |
1* |
Preferred Generic |
$6.00 | $0.00 | Q:60 /30Days |
LOSARTAN-HCTZ 100-12.5 MG TAB |
1* |
Preferred Generic |
$6.00 | $0.00 | Q:60 /30Days |
LOSARTAN-HCTZ 100-25 MG TAB |
1* |
Preferred Generic |
$6.00 | $0.00 | Q:60 /30Days |
LOSARTAN-HCTZ 50-12.5 MG TAB |
1* |
Preferred Generic |
$6.00 | $0.00 | Q:60 /30Days |
LOTEMAX 0.5% EYE DROPS |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOTEMAX 0.5% OPHTHALMIC GEL |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
Lotemax 5mg/g 1 TUBE per CARTON / 3.5 g in 1 TUBE |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LOVASTATIN 10 MG TABLET |
1* |
Preferred Generic |
$6.00 | $0.00 | Q:60 /30Days |
LOVASTATIN 20 MG TABLET |
1* |
Preferred Generic |
$6.00 | $0.00 | Q:60 /30Days |
LOVASTATIN 40 MG TABLET |
1* |
Preferred Generic |
$6.00 | $0.00 | Q:60 /30Days |
LOW-OGESTREL-28 TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
LOXAPINE 10 MG CAPSULE |
2* |
Generic |
$15.00 | $0.00 | None |
LOXAPINE 25MG CAPSULE (100 CT) |
2* |
Generic |
$15.00 | $0.00 | None |
LOXAPINE CAPSULES 50MG 100 BOT |
2* |
Generic |
$15.00 | $0.00 | None |
LOXAPINE CAPSULES 5MG 100 BOT |
2* |
Generic |
$15.00 | $0.00 | None |
LUMIGAN 0.01% EYE DROPS |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:3 /25Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Lumizyme 5mg/mL |
5 |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT 11.25 MG 3MO KIT |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:1 /90Days |
LUPRON DEPOT 22.5 MG 3MO KIT SYRINGEKIT |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:1 /90Days |
LUPRON DEPOT 3.75 MG KIT |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:1 /30Days |
LUPRON DEPOT 45 MG 6MO KIT |
5 |
Specialty Tier |
25% | N/A | P Q:1 /168Days |
LUPRON DEPOT 7.5 MG KIT |
5 |
Specialty Tier |
25% | N/A | P Q:1 /30Days |
LUPRON DEPOT-4 MONTH KIT |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:1 /112Days |
LUPRON DEPOT-PED 11.25 MG KIT |
5 |
Specialty Tier |
25% | N/A | P Q:1 /28Days |
LUPRON DEPOT-PED 15 MG KIT |
5 |
Specialty Tier |
25% | N/A | P Q:1 /28Days |
LUPRON DEPOT-PED 30 MG 3MO KIT |
5 |
Specialty Tier |
25% | N/A | P Q:1 /90Days |
LUTERA-28 TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYNPARZA 100 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
LYNPARZA 150 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
LYNPARZA 50 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:448 /28Days |
LYRICA 100MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:90 /30Days |
LYRICA 150MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:90 /30Days |
LYRICA 20 MG/ML ORAL SOLUTION |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:900 /30Days |
LYRICA 200MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:90 /30Days |
LYRICA 225MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
LYRICA 25MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:90 /30Days |
LYRICA 300MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
LYRICA 50MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYRICA 75MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:90 /30Days |
LYSODREN 500MG TABLET |
3 |
Preferred Brand |
$47.00 | $131.00 | None |
LYZA 0.35 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |