2018 Medicare Part D Plan Formulary Information |
Aetna Medicare Rx Select (PDP) (S5810-292-0)
Benefit Details
 |
The Aetna Medicare Rx Select (PDP) (S5810-292-0) Formulary Drugs Starting with the Letter L in CMS PDP Region 21 which includes: LA Plan Monthly Premium: $17.70 Deductible: $405 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 100 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LABETALOL HCL 200 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LABETALOL HCL 300 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Labetalol hydrochloride 5 MG/ML Injectable Solution  |
2* |
Generic |
$3.00 | N/A | None |
LACTATED RINGERS INJECTION  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LACTULOSE 10 GM/15 ML SOLUTION [Constulose] ![Compare how all Medicare Part D PDP plans in LA cover LACTULOSE 10 GM/15 ML SOLUTION [Constulose].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$3.00 | N/A | None |
LAMICTAL 100MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S |
LAMICTAL 150MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S |
LAMICTAL 200MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S |
LAMICTAL 25MG DISPER TABLET CHEW  |
4 |
Non-Preferred Drug |
37% | N/A | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMICTAL 25MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S |
LAMICTAL 25MG TABLET STARTER KIT  |
4 |
Non-Preferred Drug |
37% | N/A | S |
LAMICTAL 25MG/100MG TABLET STARTER KIT  |
4 |
Non-Preferred Drug |
37% | N/A | S |
LAMICTAL 5MG DISPER TABLET CHEW  |
4 |
Non-Preferred Drug |
37% | N/A | S |
LAMICTAL KIT 100;25MG;MG  |
4 |
Non-Preferred Drug |
37% | N/A | S |
LAMICTAL ODT 100mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK  |
4 |
Non-Preferred Drug |
37% | N/A | S |
LAMICTAL ODT 200mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK  |
4 |
Non-Preferred Drug |
37% | N/A | S |
LAMICTAL ODT 25mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK  |
4 |
Non-Preferred Drug |
37% | N/A | S |
LAMICTAL ODT 50mg/1 30 TABLET, ORALLY DISINTEGRATING in 1 DOSE PACK  |
4 |
Non-Preferred Drug |
37% | N/A | S |
LAMICTAL XR 100 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S |
LAMICTAL XR 200 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMICTAL XR 25 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S |
LAMICTAL XR 250 MG ER 30 TABLET, FILM COATED in BOTTLE  |
4 |
Non-Preferred Drug |
37% | N/A | S |
LAMICTAL XR 300 MG ER 30 TABLET, FILM COATED in BOTTLE  |
5 |
Specialty Tier |
25% | N/A | S |
LAMICTAL XR 50 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S |
LAMICTAL XR START KIT (BLUE)  |
4 |
Non-Preferred Drug |
37% | N/A | S |
LAMICTAL XR START KIT (GREEN)  |
4 |
Non-Preferred Drug |
37% | N/A | S |
LAMICTAL XR START KIT (ORANGE)  |
4 |
Non-Preferred Drug |
37% | N/A | S |
Lamivudine 10 mg/ml oral soln  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LAMIVUDINE 150 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LAMIVUDINE 300 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Lamivudine hbv 100 mg tablet  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMIVUDINE-ZIDOVUDINE TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LAMOTRIGINE 150MG TABLET (60 CT)  |
2* |
Generic |
$3.00 | N/A | None |
LAMOTRIGINE 200MG TABLET (60 CT)  |
2* |
Generic |
$3.00 | N/A | None |
LAMOTRIGINE 25 MG DISPER TAB CHW DSP [Lamictal CD] ![Compare how all Medicare Part D PDP plans in LA cover LAMOTRIGINE 25 MG DISPER TAB CHW DSP [Lamictal CD].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$3.00 | N/A | None |
LAMOTRIGINE 25MG TABLET (100 CT)  |
2* |
Generic |
$3.00 | N/A | None |
LAMOTRIGINE 5 MG DISPER TABLET CHW DSP [Lamictal CD] ![Compare how all Medicare Part D PDP plans in LA cover LAMOTRIGINE 5 MG DISPER TABLET CHW DSP [Lamictal CD].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$3.00 | N/A | None |
LAMOTRIGINE ER 100 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LAMOTRIGINE ER 200 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LAMOTRIGINE ER 25 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LAMOTRIGINE ER 250 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LAMOTRIGINE ER 300 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE ER 50 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Lamotrigine ODT 100 MG Tablet  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Lamotrigine ODT 200 MG Tablet  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LAMOTRIGINE ODT 25 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Lamotrigine ODT 50 MG Tablet  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LAMOTRIGINE START KIT-BLUE TAB DS PK [Subvenite] ![Compare how all Medicare Part D PDP plans in LA cover LAMOTRIGINE START KIT-BLUE TAB DS PK [Subvenite].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | S |
LAMOTRIGINE START KIT-GREEN TAB DS PK [Subvenite] ![Compare how all Medicare Part D PDP plans in LA cover LAMOTRIGINE START KIT-GREEN TAB DS PK [Subvenite].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | S |
LAMOTRIGINE START KIT-ORANG TAB DS PK [Subvenite] ![Compare how all Medicare Part D PDP plans in LA cover LAMOTRIGINE START KIT-ORANG TAB DS PK [Subvenite].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | S |
LAMOTRIGINE TABLET 100MG (100 CT)  |
2* |
Generic |
$3.00 | N/A | None |
LANOXIN 125 MCG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LANOXIN 187.5 MCG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LANOXIN 250 MCG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LANOXIN 500 MCG/2 ML AMPULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LANOXIN 62.5 MCG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LANSOPRAZOL-AMOXICIL-CLARITHRO  |
4 |
Non-Preferred Drug |
37% | N/A | Q:224 /365Days |
LANSOPRAZOLE DR 15 MG CAPSULE DR [Prevacid]
![Compare how all Medicare Part D PDP plans in LA cover LANSOPRAZOLE DR 15 MG CAPSULE DR [Prevacid]
.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
LANSOPRAZOLE DR 30 MG CAPSULE [Prevacid] ![Compare how all Medicare Part D PDP plans in LA cover LANSOPRAZOLE DR 30 MG CAPSULE [Prevacid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
LANSOPRAZOLE ODT 15 MG TABLET RAP DR [Prevacid] ![Compare how all Medicare Part D PDP plans in LA cover LANSOPRAZOLE ODT 15 MG TABLET RAP DR [Prevacid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
LANSOPRAZOLE ODT 30 MG TABLET RAP DR [Prevacid] ![Compare how all Medicare Part D PDP plans in LA cover LANSOPRAZOLE ODT 30 MG TABLET RAP DR [Prevacid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
LANTUS 100U/ML VIAL  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LANTUS SOLOSTAR INJECTION  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LARIN 1.5 MG-30 MCG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LARIN 21 1-20 TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LARIN FE 1-20 TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LARIN FE 1.5-30 TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Larissia-28 tablet  |
3 |
Preferred Brand |
$46.00 | N/A | 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 |
LASIX 20 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LASIX 40 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LASIX 80 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LASTACAFT 2.5mg/mL 1 BOTTLE, PLASTIC per CARTON / 3 mL in 1 BOTTLE, PLASTIC  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LATANOPROST 0.005% EYE DROPS  |
2* |
Generic |
$3.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LATUDA 120 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
LATUDA 20 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:240 /30Days |
LATUDA 40 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
LATUDA 60 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:60 /30Days |
LATUDA 80 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:60 /30Days |
LAYOLIS FE CHEWABLE TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LEENA 28 TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LEFLUNOMIDE 10 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LEFLUNOMIDE 20 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LENVIMA 10 MG DAILY DOSE  |
5 |
Specialty Tier |
25% | N/A | P |
LENVIMA 14 MG DAILY DOSE  |
5 |
Specialty Tier |
25% | N/A | P |
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 |
LENVIMA 20 MG DAILY DOSE  |
5 |
Specialty Tier |
25% | N/A | P |
LENVIMA 24 MG DAILY DOSE  |
5 |
Specialty Tier |
25% | N/A | P |
LENVIMA 8 MG DAILY DOSE  |
5 |
Specialty Tier |
25% | N/A | P |
LESCOL XL 80 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
Lessina 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK  |
3 |
Preferred Brand |
$46.00 | N/A | 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 |
$3.00 | N/A | None |
LEUCOVORIN CALCIUM 100MG VL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LEUCOVORIN CALCIUM 10MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Leucovorin Calcium 15mg/1 24 TABLET BOTTLE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LEUCOVORIN CALCIUM 25MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LEUCOVORIN CALCIUM 350MG VL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LEUCOVORIN CALCIUM 5 MG TAB  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LEUKERAN 2 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LEUPROLIDE 2WK 14 MG/2.8 ML KT  |
3 |
Preferred Brand |
$46.00 | N/A | P |
LEVALBUTEROL 0.31 MG/3 ML SOL  |
4 |
Non-Preferred Drug |
37% | N/A | P |
LEVALBUTEROL 0.63 MG/3 ML SOL  |
4 |
Non-Preferred Drug |
37% | N/A | P |
LEVALBUTEROL 1.25 MG/0.5 ML  |
4 |
Non-Preferred Drug |
37% | N/A | P |
Levalbuterol conc 1.25 mg/0.5  |
4 |
Non-Preferred Drug |
37% | N/A | P |
LEVALBUTEROL TAR HFA 45MCG INH [Xopenex] ![Compare how all Medicare Part D PDP plans in LA cover LEVALBUTEROL TAR HFA 45MCG INH [Xopenex].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVAQUIN 500mg/1 50 FILM COATED TABLETS in BOTTLE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LEVAQUIN 750 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LEVEMIR 100UNITS/ML VIAL  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LEVEMIR FLEXTOUCH 100 UNITS/ML  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LEVETIRACETAM 1,000 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
LEVETIRACETAM 100 MG/ML SOLN  |
2* |
Generic |
$3.00 | N/A | None |
Levetiracetam 100 ML 10 MG/ML Injection  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Levetiracetam 100 ML 15 MG/ML Injection  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Levetiracetam 100 ML 5 MG/ML Injection  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LEVETIRACETAM 250 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
LEVETIRACETAM 500 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM 500 MG/5 ML VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LEVETIRACETAM 750 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
LEVETIRACETAM ER 500 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LEVETIRACETAM ER 750 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LEVO-T 100 MCG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LEVO-T 112 MCG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LEVO-T 125 MCG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LEVO-T 137 MCG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LEVO-T 150 MCG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LEVO-T 175 MCG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LEVO-T 200 MCG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVO-T 25 MCG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LEVO-T 300 MCG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LEVO-T 50 MCG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LEVO-T 75 MCG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LEVO-T 88 MCG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION  |
2* |
Generic |
$3.00 | N/A | None |
LEVOCARNITINE 1 G/10 ML SOLN  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LEVOCARNITINE 330 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LEVOCETIRIZINE 2.5 MG/5 ML SOL  |
3 |
Preferred Brand |
$46.00 | N/A | Q:300 /30Days |
LEVOCETIRIZINE 5 MG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
LEVOFLOXACIN 0.5% EYE DROPS [LEVAQUIN] ![Compare how all Medicare Part D PDP plans in LA cover LEVOFLOXACIN 0.5% EYE DROPS [LEVAQUIN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$46.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOFLOXACIN 25 MG/ML SOLUTION [LEVAQUIN] ![Compare how all Medicare Part D PDP plans in LA cover LEVOFLOXACIN 25 MG/ML SOLUTION [LEVAQUIN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$46.00 | N/A | None |
LEVOFLOXACIN 250 MG TABLET [LEVAQUIN] ![Compare how all Medicare Part D PDP plans in LA cover LEVOFLOXACIN 250 MG TABLET [LEVAQUIN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$3.00 | N/A | None |
Levofloxacin 500 MG per 20 ML Injection [LEVAQUIN] ![Compare how all Medicare Part D PDP plans in LA cover Levofloxacin 500 MG per 20 ML Injection [LEVAQUIN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | None |
LEVOFLOXACIN 500 MG TABLET [LEVAQUIN] ![Compare how all Medicare Part D PDP plans in LA cover LEVOFLOXACIN 500 MG TABLET [LEVAQUIN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$3.00 | N/A | None |
Levofloxacin 5mg/mL 24 POUCH per CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG [LEVAQUIN] ![Compare how all Medicare Part D PDP plans in LA cover Levofloxacin 5mg/mL 24 POUCH per CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG [LEVAQUIN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | None |
LEVOFLOXACIN 750 MG TABLET [LEVAQUIN] ![Compare how all Medicare Part D PDP plans in LA cover LEVOFLOXACIN 750 MG TABLET [LEVAQUIN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Generic |
$3.00 | N/A | None |
LEVOFLOXACIN 750 MG/150 ML-D5W [LEVAQUIN] ![Compare how all Medicare Part D PDP plans in LA cover LEVOFLOXACIN 750 MG/150 ML-D5W [LEVAQUIN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | None |
LEVOLEUCOVORIN 175 MG/17.5 ML [Fusilev] ![Compare how all Medicare Part D PDP plans in LA cover LEVOLEUCOVORIN 175 MG/17.5 ML [Fusilev].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P |
LEVOLEUCOVORIN 50 MG VIAL [Fusilev] ![Compare how all Medicare Part D PDP plans in LA cover LEVOLEUCOVORIN 50 MG VIAL [Fusilev].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | P |
LEVONEST-28 TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LEVONO-E ESTRAD 0.10-0.02-0.01  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVONOR-ETH ESTRAD 0.09-0.02 MG  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LEVONOR-ETH ESTRAD 0.1-0.02 MG  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LEVONOR-ETH ESTRAD 0.15-0.03  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LEVONOR-ETH ESTRAD 0.15-0.03  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Levonor-eth Estrad 0.15-0.03-0.01  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LEVONOR-ETH ESTRAD TRIPHASIC  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LEVONORG 0.15MG-EE 20-25-30MCG  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Levora-28 tablet  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LEVOTHYROXINE 100 MCG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
LEVOTHYROXINE 100 MCG VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LEVOTHYROXINE 112 MCG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE 125 MCG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
LEVOTHYROXINE 137 MCG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
LEVOTHYROXINE 150 MCG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
LEVOTHYROXINE 175 MCG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
LEVOTHYROXINE 200 MCG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
LEVOTHYROXINE 25 MCG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
LEVOTHYROXINE 300 MCG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
LEVOTHYROXINE 50 MCG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
LEVOTHYROXINE 75 MCG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
LEVOTHYROXINE 88 MCG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
LEVOXYL 100 MCG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 112 MCG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LEVOXYL 125 MCG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LEVOXYL 137 MCG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LEVOXYL 150 MCG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LEVOXYL 175 MCG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LEVOXYL 200 MCG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LEVOXYL 25 MCG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LEVOXYL 50 MCG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LEVOXYL 75 MCG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LEVOXYL 88 MCG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LEXAPRO 10MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:45 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEXAPRO 20MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
LEXAPRO 5MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:45 /30Days |
LEXIVA 50mg/mL 225 mL in 1 BOTTLE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LEXIVA 700MG TABLETS  |
5 |
Specialty Tier |
25% | N/A | None |
LIALDA 1.2G TABLET DELAYED RELEASE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LIDOCAINE 2% VISCOUS SOLN  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LIDOCAINE 5% OINTMENT  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:36 /30Days |
Lidocaine 5% patch  |
3 |
Preferred Brand |
$46.00 | N/A | P Q:90 /30Days |
LIDOCAINE HCL IV 4% SOLUTION  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Lidocaine Hydrochloride 20mg/mL 25 VIAL, MULTI-DOSE in 1 TRAY / 20 mL in 1 VIAL, MULTI-DOSE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Lidocaine Hydrochloride 5mg/mL 25 VIAL, SINGLE-DOSE in 1 CONTAINER / 50 mL in 1 VIAL, SINGLE-DOSE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIDOCAINE-PRILOCAINE CREAM  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:30 /30Days |
LIDODERM 5% PATCH  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:90 /30Days |
LINDANE SHAMPOO 1MG 2 FLO BOT  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Linezolid 20 MG/ML Oral Suspension [Zyvox] ![Compare how all Medicare Part D PDP plans in LA cover Linezolid 20 MG/ML Oral Suspension [Zyvox].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P Q:1800 /28Days |
LINEZOLID 600 MG TABLET [Zyvox] ![Compare how all Medicare Part D PDP plans in LA cover LINEZOLID 600 MG TABLET [Zyvox].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P Q:56 /28Days |
LINEZOLID 600 MG/300 ML IV SOL [Zyvox] ![Compare how all Medicare Part D PDP plans in LA cover LINEZOLID 600 MG/300 ML IV SOL [Zyvox].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P |
LINZESS 145 MCG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | Q:60 /30Days |
LINZESS 290 MCG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | Q:30 /30Days |
LINZESS 72 MCG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | Q:30 /30Days |
LIORESAL IT 10 MG/20 ML KIT AMPUL  |
4 |
Non-Preferred Drug |
37% | N/A | P |
LIORESAL IT 10 MG/5 ML KIT AMPUL  |
4 |
Non-Preferred Drug |
37% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIOTHYRONINE SOD 25 MCG TAB  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LIOTHYRONINE SOD 5 MCG TAB  |
3 |
Preferred Brand |
$46.00 | N/A | None |
liothyronine sodium 10ug/mL 1 VIAL per CARTON / 1 mL in 1 VIAL  |
5 |
Specialty Tier |
25% | N/A | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LIPITOR 10MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
LIPITOR 20 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
LIPITOR 40 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
LIPITOR 80 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
LIPOFEN 150MG CAPSULES  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LISINOPRIL 10 MG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
LISINOPRIL 2.5 MG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | 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 | N/A | None |
LISINOPRIL 30 MG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
LISINOPRIL 40 MG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
LISINOPRIL 5 MG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
LISINOPRIL-HCTZ 10-12.5 MG TAB  |
1* |
Preferred Generic |
$0.00 | N/A | None |
LISINOPRIL-HCTZ 20-12.5 MG TAB  |
1* |
Preferred Generic |
$0.00 | N/A | None |
LISINOPRIL-HCTZ 20-25 MG TAB  |
1* |
Preferred Generic |
$0.00 | N/A | None |
LITHIUM CARBONATE 150 MG CAP  |
1* |
Preferred Generic |
$0.00 | N/A | None |
Lithium Carbonate 300 mg tab  |
1* |
Preferred Generic |
$0.00 | N/A | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT)  |
1* |
Preferred Generic |
$0.00 | N/A | None |
Lithium Carbonate 450mg/1  |
4 |
Non-Preferred Drug |
37% | N/A | 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 | N/A | None |
LITHIUM CARBONATE ER 300 MG TB  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LITHIUM CIT 8MEQ/5ML SYRUP  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LITHOBID ER 300 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LIVALO 1 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
LIVALO 2 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
LIVALO 4 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
LOCOID 0.1% LIPOCREAM  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LOCOID 0.1% LOTION  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LOCOID 0.1% SOLUTION  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LODOSYN TAB 25MG  |
5 |
Specialty Tier |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Lomotil 0.025; 2.5mg/1; mg/1 100 TABLET BOTTLE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LONSURF 15 MG-6.14 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
LONSURF 20 MG-8.19 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
LOPERAMIDE HCL 2MG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LOPID 600 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LOPINAVIR-RITONAVIR 80-20MG/ML Solution [Kaletra] ![Compare how all Medicare Part D PDP plans in LA cover LOPINAVIR-RITONAVIR 80-20MG/ML Solution [Kaletra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | None |
LOPRESSOR 100 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LOPROX 1% SHAMPOO  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LOPROX CREAM 90 GM  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LORAZEPAM 0.5 MG TABLET  |
2* |
Generic |
$3.00 | N/A | Q:120 /30Days |
LORAZEPAM 1 MG TABLET  |
2* |
Generic |
$3.00 | N/A | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LORAZEPAM 2 MG TABLET  |
2* |
Generic |
$3.00 | N/A | Q:150 /30Days |
LORAZEPAM 2 MG/ML ORAL CONCENT  |
2* |
Generic |
$3.00 | N/A | Q:150 /30Days |
LORCET HD 10-325 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:180 /30Days |
Lorcet plus 7.5-325 mg tablet  |
4 |
Non-Preferred Drug |
37% | N/A | Q:180 /30Days |
LORYNA 3 MG-0.02 MG TABLET [Yaz] ![Compare how all Medicare Part D PDP plans in LA cover LORYNA 3 MG-0.02 MG TABLET [Yaz].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$46.00 | N/A | None |
LOSARTAN POTASSIUM 100 MG TAB  |
1* |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
LOSARTAN POTASSIUM 25 MG TAB  |
1* |
Preferred Generic |
$0.00 | N/A | Q:60 /30Days |
LOSARTAN POTASSIUM 50 MG TAB  |
1* |
Preferred Generic |
$0.00 | N/A | Q:60 /30Days |
LOSARTAN-HCTZ 100-12.5 MG TAB  |
1* |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
LOSARTAN-HCTZ 100-25 MG TAB  |
1* |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
LOSARTAN-HCTZ 50-12.5 MG TAB  |
1* |
Preferred Generic |
$0.00 | N/A | Q:30 /30Days |
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 |
$46.00 | N/A | None |
LOTEMAX 0.5% OPHTHALMIC GEL  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Lotemax 5mg/g 1 TUBE per CARTON / 3.5 g in 1 TUBE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LOTENSIN 20 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LOTENSIN 40 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LOTREL 10/20MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
LOTREL 10/40MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
LOTREL 5/10MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
LOTREL 5/20MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
LOTRISONE CREAM  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LOTRONEX 0.5 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | S Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOTRONEX 1 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | S Q:60 /30Days |
LOVASTATIN 10 MG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
LOVASTATIN 20 MG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
LOVASTATIN 40 MG TABLET  |
1* |
Preferred Generic |
$0.00 | N/A | None |
LOVAZA 1 GM CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | Q:120 /30Days |
LOVENOX 100MG PREFILLED SYR  |
5 |
Specialty Tier |
25% | N/A | None |
LOVENOX 120 MG/0.8 ML SYRINGE  |
5 |
Specialty Tier |
25% | N/A | None |
LOVENOX 150MG PREFILLED SYR  |
5 |
Specialty Tier |
25% | N/A | None |
LOVENOX 300MG VIAL  |
5 |
Specialty Tier |
25% | N/A | None |
LOVENOX 30MG PREFILLED SYRN  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LOVENOX 40MG PREFILLED SYRN  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOVENOX 60MG PREFILLED SYRN  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LOVENOX 80 MG/0.8 ML SYRINGE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
LOW-OGESTREL-28 TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LOXAPINE 10 MG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LOXAPINE 25MG CAPSULE (100 CT)  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LOXAPINE CAPSULES 50MG 100 BOT  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LOXAPINE CAPSULES 5MG 100 BOT  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LUMIGAN 0.01% EYE DROPS  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Lumizyme 5mg/mL  |
5 |
Specialty Tier |
25% | N/A | P |
LUNESTA 2MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:30 /30Days |
LUNESTA 3MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUNESTA TABLETS 1MG 30 BOT  |
4 |
Non-Preferred Drug |
37% | N/A | P Q:30 /30Days |
LUPRON DEPOT 11.25 MG 3MO KIT  |
5 |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT 22.5 MG 3MO KIT SYRINGEKIT  |
5 |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT 3.75 MG KIT  |
5 |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT 45 MG 6MO KIT  |
5 |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT 7.5 MG KIT  |
5 |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT-4 MONTH KIT  |
5 |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT-PED 11.25 MG KIT  |
5 |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT-PED 15 MG KIT  |
5 |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT-PED 30 MG 3MO KIT  |
5 |
Specialty Tier |
25% | N/A | P |
LUTERA-28 TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | 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 |
LYNPARZA 150 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
LYNPARZA 50 MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P |
LYRICA 100MG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | Q:120 /30Days |
LYRICA 150MG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | Q:120 /30Days |
LYRICA 20 MG/ML ORAL SOLUTION  |
3 |
Preferred Brand |
$46.00 | N/A | Q:946 /30Days |
LYRICA 200MG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | Q:90 /30Days |
LYRICA 225MG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | Q:60 /30Days |
LYRICA 25MG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | Q:120 /30Days |
LYRICA 300MG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | Q:60 /30Days |
LYRICA 50MG CAPSULE  |
3 |
Preferred Brand |
$46.00 | N/A | 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 |
$46.00 | N/A | Q:120 /30Days |
LYSODREN 500MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
LYSTEDA 650 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
LYZA 0.35 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |