2020 Medicare Part D Plan Formulary Information |
IlliniCare Health - MMAI (Medicare-Medicaid Plan) (H0281-001-0)
Benefit Details
|
The IlliniCare Health - MMAI (Medicare-Medicaid Plan) (H0281-001-0) Formulary Drugs Starting with the Letter L in Will County, IL: CMS MA Region 14 which includes: IL Plan Monthly Premium: $0.00 Deductible: $0 |
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 |
1 |
Tier 1 |
0% | 0% | None |
LABETALOL HCL 200 MG TABLET [Trandate] |
1 |
Tier 1 |
0% | 0% | None |
LABETALOL HCL 300 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LACTULOSE 10 GM/15 ML SOLUTION [Constulose] |
1 |
Tier 1 |
0% | 0% | None |
LAMICTAL XR START KIT (BLUE) |
2 |
Tier 2 |
0% | 0% | None |
LAMICTAL XR START KIT (GREEN) |
2 |
Tier 2 |
0% | 0% | None |
LAMICTAL XR START KIT (ORANGE) |
2 |
Tier 2 |
0% | 0% | None |
LAMIVUDINE 10 MG/ML ORAL SOLUTION [Epivir] |
1 |
Tier 1 |
0% | 0% | None |
LAMIVUDINE 150 MG TABLET [Epivir] |
1 |
Tier 1 |
0% | 0% | None |
LAMIVUDINE 300 MG TABLET [Epivir] |
1 |
Tier 1 |
0% | 0% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMIVUDINE HBV 100 MG TABLET [Epivir HBV] |
1 |
Tier 1 |
0% | 0% | None |
LAMIVUDINE-ZIDOVUDINE TABLET [Combivir] |
1 |
Tier 1 |
0% | 0% | None |
LAMOTRIGINE 100 MG TABLET [Subvenite] |
1 |
Tier 1 |
0% | 0% | None |
LAMOTRIGINE 150 MG TABLET [Subvenite] |
1 |
Tier 1 |
0% | 0% | None |
LAMOTRIGINE 200 MG TABLET [Subvenite] |
1 |
Tier 1 |
0% | 0% | None |
LAMOTRIGINE 25 MG DISPER TABLET CHW [Lamictal CD] |
1 |
Tier 1 |
0% | 0% | None |
LAMOTRIGINE 25 MG TABLET [Subvenite] |
1 |
Tier 1 |
0% | 0% | None |
LAMOTRIGINE 5 MG DISPER TABLET CHW [Lamictal CD] |
1 |
Tier 1 |
0% | 0% | None |
LAMOTRIGINE ER 100 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LAMOTRIGINE ER 200 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LAMOTRIGINE ER 25 MG TABLET 24 [Lamictal XR] |
1 |
Tier 1 |
0% | 0% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE ER 250 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LAMOTRIGINE ER 300 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LAMOTRIGINE ER 50 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LANOXIN 62.5 MCG TABLET |
2 |
Tier 2 |
0% | 0% | None |
LANSOPRAZOL-AMOXICIL-CLARITHRO COMBO PKG [Prevpac] |
1 |
Tier 1 |
0% | 0% | None |
LANSOPRAZOLE DR 15 MG CAPSULE DR [Prevacid]
|
1 |
Tier 1 |
0% | 0% | None |
LANSOPRAZOLE DR 30 MG CAPSULE DR [Prevacid] |
1 |
Tier 1 |
0% | 0% | None |
LANTHANUM CARB 1,000 MG CHEWABLE TABLET [Fosrenol] |
1 |
Tier 1 |
0% | 0% | None |
LANTHANUM CARB 500 MG TABLET CHEW [Fosrenol] |
1 |
Tier 1 |
0% | 0% | None |
LANTHANUM CARB 750 MG TABLET CHEW [Fosrenol] |
1 |
Tier 1 |
0% | 0% | None |
LANTUS 100U/ML VIAL |
2 |
Tier 2 |
0% | 0% | Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LANTUS SOLOSTAR INJECTION |
2 |
Tier 2 |
0% | 0% | Q:2 /1Days |
LARIN 1.5 MG-30 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LARIN 21 1-20 TABLET |
1 |
Tier 1 |
0% | 0% | None |
LARIN FE 1-20 TABLET |
1 |
Tier 1 |
0% | 0% | None |
LARIN FE 1.5-30 TABLET |
1 |
Tier 1 |
0% | 0% | None |
LARISSIA-28 TABLET [Vienva] |
1 |
Tier 1 |
0% | 0% | None |
LATANOPROST 0.005% EYE DROPS |
1 |
Tier 1 |
0% | 0% | None |
LATUDA 120 MG TABLET |
2 |
Tier 2 |
0% | 0% | P |
LATUDA 20 MG TABLET |
2 |
Tier 2 |
0% | 0% | P |
LATUDA 40 MG TABLET |
2 |
Tier 2 |
0% | 0% | P |
LATUDA 60 MG TABLET |
2 |
Tier 2 |
0% | 0% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LATUDA 80 MG TABLET |
2 |
Tier 2 |
0% | 0% | P |
LEFLUNOMIDE 10 MG TABLET [Arava] |
1 |
Tier 1 |
0% | 0% | None |
LEFLUNOMIDE 20 MG TABLET [Arava] |
1 |
Tier 1 |
0% | 0% | None |
LENVIMA 10 MG DAILY DOSE |
2 |
Tier 2 |
0% | 0% | P |
LENVIMA 12 MG DAILY DOSE CAPSULE |
2 |
Tier 2 |
0% | 0% | P |
LENVIMA 14 MG DAILY DOSE |
2 |
Tier 2 |
0% | 0% | P |
LENVIMA 18 MG DAILY DOSE |
2 |
Tier 2 |
0% | 0% | P |
LENVIMA 20 MG DAILY DOSE |
2 |
Tier 2 |
0% | 0% | P |
LENVIMA 24 MG DAILY DOSE |
2 |
Tier 2 |
0% | 0% | P |
LENVIMA 4 MG CAPSULE |
2 |
Tier 2 |
0% | 0% | P |
LENVIMA 8 MG DAILY DOSE |
2 |
Tier 2 |
0% | 0% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Lessina 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK |
1 |
Tier 1 |
0% | 0% | None |
LETROZOLE 2.5 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEUCOVORIN CALCIUM 10MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEUCOVORIN CALCIUM 15MG 24 TABLET BOTTLE |
1 |
Tier 1 |
0% | 0% | None |
LEUCOVORIN CALCIUM 25 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEUCOVORIN CALCIUM 5 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEUKERAN 2 MG TABLET |
2 |
Tier 2 |
0% | 0% | None |
LEUKINE 250 MCG VIAL |
2 |
Tier 2 |
0% | 0% | P |
LEUPROLIDE 2WK 14 MG/2.8 ML KT |
1 |
Tier 1 |
0% | 0% | None |
LEVALBUTEROL 0.31 MG/3 ML SOL VIAL-NEB [Xopenex Pediatric] |
1 |
Tier 1 |
0% | 0% | P |
LEVALBUTEROL 0.63 MG/3 ML SOL VIAL-NEB [Xopenex] |
1 |
Tier 1 |
0% | 0% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVALBUTEROL 1.25 MG/0.5 ML |
1 |
Tier 1 |
0% | 0% | P |
LEVALBUTEROL 1.25 MG/3 ML SOL VIAL-NEB [Xopenex] |
1 |
Tier 1 |
0% | 0% | P |
LEVALBUTEROL TAR HFA 45MCG INH [Xopenex] |
1 |
Tier 1 |
0% | 0% | None |
LEVEMIR 100UNITS/ML VIAL |
2 |
Tier 2 |
0% | 0% | Q:2 /1Days |
LEVEMIR FLEXTOUCH 100 UNITS/ML |
2 |
Tier 2 |
0% | 0% | Q:2 /1Days |
LEVETIRACETAM 1,000 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVETIRACETAM 100 MG/ML SOLUTION [Keppra] |
1 |
Tier 1 |
0% | 0% | None |
LEVETIRACETAM 250 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVETIRACETAM 500 MG TABLET [Roweepra] |
1 |
Tier 1 |
0% | 0% | None |
LEVETIRACETAM 750 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVETIRACETAM ER 500 MG TABLET ER 24H [Roweepra] |
1 |
Tier 1 |
0% | 0% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM ER 750 MG TABLET ER 24H [Roweepra] |
1 |
Tier 1 |
0% | 0% | None |
LEVO-T 100 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVO-T 112 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVO-T 125 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVO-T 137 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVO-T 150 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVO-T 175 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVO-T 200 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVO-T 25 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVO-T 300 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVO-T 50 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVO-T 75 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVO-T 88 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVOBUNOLOL 0.5% EYE DROPS [Betagan] |
1 |
Tier 1 |
0% | 0% | None |
LEVOCARNITINE 330 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVOCETIRIZINE 2.5 MG/5 ML SOLUTION |
1 |
Tier 1 |
0% | 0% | None |
LEVOCETIRIZINE 5 MG TABLET [Xyzal Allergy 24 Hour] |
1 |
Tier 1 |
0% | 0% | None |
LEVOFLOXACIN 0.5% EYE DROPS [LEVAQUIN] |
1 |
Tier 1 |
0% | 0% | None |
LEVOFLOXACIN 25 MG/ML SOLUTION [LEVAQUIN] |
1 |
Tier 1 |
0% | 0% | None |
LEVOFLOXACIN 250 MG TABLET [LEVAQUIN] |
1 |
Tier 1 |
0% | 0% | None |
LEVOFLOXACIN 500 MG TABLET [Levaquin] |
1 |
Tier 1 |
0% | 0% | None |
LEVOFLOXACIN 500 MG/20 ML VIAL [Levaquin] |
1 |
Tier 1 |
0% | 0% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levofloxacin 5mg/mL 24 POUCH per CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG [LEVAQUIN] |
1 |
Tier 1 |
0% | 0% | None |
LEVOFLOXACIN 750 MG TABLET [Levaquin Leva-Pak] |
1 |
Tier 1 |
0% | 0% | None |
LEVOFLOXACIN 750 MG/150 ML-D5W [LEVAQUIN] |
1 |
Tier 1 |
0% | 0% | None |
LEVONEST-28 TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVONO-E ESTRAD 0.10-0.02-0.01 TBDSPK 3MO [LoSeasonique] |
1 |
Tier 1 |
0% | 0% | None |
LEVONOR-ETH ESTRAD 0.1-0.02 MG Tablet [Vienva] |
1 |
Tier 1 |
0% | 0% | None |
LEVONOR-ETH ESTRAD 0.15-0.03 |
1 |
Tier 1 |
0% | 0% | None |
LEVONOR-ETH ESTRAD 0.15-0.03 |
1 |
Tier 1 |
0% | 0% | None |
Levonor-eth Estrad 0.15-0.03-0.01 |
1 |
Tier 1 |
0% | 0% | None |
LEVONOR-ETH ESTRAD TRIPHASIC |
1 |
Tier 1 |
0% | 0% | None |
Levora-28 tablet |
1 |
Tier 1 |
0% | 0% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE 100 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVOTHYROXINE 112 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVOTHYROXINE 125 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVOTHYROXINE 137 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVOTHYROXINE 150 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVOTHYROXINE 175 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVOTHYROXINE 200 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVOTHYROXINE 25 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVOTHYROXINE 300 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVOTHYROXINE 50 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVOTHYROXINE 75 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE 88 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVOXYL 100 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVOXYL 112 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVOXYL 125 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVOXYL 137 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVOXYL 150 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVOXYL 175 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVOXYL 200 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVOXYL 25 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVOXYL 50 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEVOXYL 75 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 88 MCG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LEXIVA 50mg/mL 225 mL in 1 BOTTLE |
2 |
Tier 2 |
0% | 0% | None |
LIDOCAINE 2% VISCOUS SOLUTION |
1 |
Tier 1 |
0% | 0% | None |
LIDOCAINE 5% OINTMENT |
1 |
Tier 1 |
0% | 0% | Q:5 /1Days |
LIDOCAINE 5% PATCH [Lidoderm] |
1 |
Tier 1 |
0% | 0% | P |
LIDOCAINE HCL 2% JELLY 30ML TUBE |
1 |
Tier 1 |
0% | 0% | None |
LIDOCAINE HCL IV 4% SOLUTION |
1 |
Tier 1 |
0% | 0% | Q:7 /1Days |
LIDOCAINE-PRILOCAINE CREAM (g) [SOLUPICC] |
1 |
Tier 1 |
0% | 0% | Q:2 /1Days |
LINEZOLID 100 MG/5 ML ORAL SUSPENSION [Zyvox] |
1 |
Tier 1 |
0% | 0% | None |
LINEZOLID 600 MG TABLET [Zyvox] |
1 |
Tier 1 |
0% | 0% | None |
LINEZOLID 600 MG/300 ML-D5W PIGGYBACK [Zyvox] |
1 |
Tier 1 |
0% | 0% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LINZESS 145 MCG CAPSULE |
2 |
Tier 2 |
0% | 0% | None |
LINZESS 290 MCG CAPSULE |
2 |
Tier 2 |
0% | 0% | None |
LINZESS 72 MCG CAPSULE |
2 |
Tier 2 |
0% | 0% | None |
LIOTHYRONINE SOD 25 MCG TABLET [Cytomel] |
1 |
Tier 1 |
0% | 0% | None |
LIOTHYRONINE SOD 5 MCG TABLET [Cytomel] |
1 |
Tier 1 |
0% | 0% | None |
LIOTHYRONINE SOD 50 MCG TABLET [Cytomel] |
1 |
Tier 1 |
0% | 0% | None |
LISINOPRIL 10 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LISINOPRIL 2.5 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LISINOPRIL 20 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LISINOPRIL 30 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LISINOPRIL 40 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL 5 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LISINOPRIL-HCTZ 10-12.5 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LISINOPRIL-HCTZ 20-12.5 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LISINOPRIL-HCTZ 20-25 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LITHIUM CARBONATE 150 MG CAPSULE |
1 |
Tier 1 |
0% | 0% | None |
LITHIUM CARBONATE 300 MG CAPSULE [Eskalith] |
1 |
Tier 1 |
0% | 0% | None |
LITHIUM CARBONATE 300 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LITHIUM CARBONATE 600 MG CAPSULE |
1 |
Tier 1 |
0% | 0% | None |
LITHIUM CARBONATE ER 300 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LITHIUM CARBONATE ER 450 MG TABLET [Eskalith CR] |
1 |
Tier 1 |
0% | 0% | None |
LITHIUM CIT 8MEQ/5ML SYRUP |
2 |
Tier 2 |
0% | 0% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOKELMA 10 GRAM POWDER PACKET |
2 |
Tier 2 |
0% | 0% | S |
LOKELMA 5 GRAM POWDER PACKET |
2 |
Tier 2 |
0% | 0% | S |
LONSURF 15 MG-6.14 MG TABLET |
2 |
Tier 2 |
0% | 0% | P |
LONSURF 20 MG-8.19 MG TABLET |
2 |
Tier 2 |
0% | 0% | P |
LOPERAMIDE 2 MG CAPSULE [Tagamet] |
1 |
Tier 1 |
0% | 0% | None |
LOPINAVIR-RITONAVIR 80-20MG/ML Solution [Kaletra] |
1 |
Tier 1 |
0% | 0% | None |
LOPREEZA 1 MG-0.5 MG TABLET [Mimvey] |
1 |
Tier 1 |
0% | 0% | P |
LORAZEPAM 0.5 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LORAZEPAM 1 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LORAZEPAM 2 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LORAZEPAM 2 MG/ML ORAL CONCENT |
1 |
Tier 1 |
0% | 0% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LORBRENA 100 MG TABLET |
2 |
Tier 2 |
0% | 0% | P |
LORBRENA 25 MG TABLET |
2 |
Tier 2 |
0% | 0% | P |
LORCET 5-325 MG TABLET [Norco] |
1 |
Tier 1 |
0% | 0% | None |
LORCET HD 10-325 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
Lorcet plus 7.5-325 mg tablet |
1 |
Tier 1 |
0% | 0% | None |
LORYNA 3 MG-0.02 MG TABLET [Yaz] |
1 |
Tier 1 |
0% | 0% | None |
LOSARTAN POTASSIUM 100 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LOSARTAN POTASSIUM 25 MG TABLET [Cozaar] |
1 |
Tier 1 |
0% | 0% | None |
LOSARTAN POTASSIUM 50 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LOSARTAN-HCTZ 100-12.5 MG TABLET [Hyzaar] |
1 |
Tier 1 |
0% | 0% | None |
LOSARTAN-HCTZ 100-25 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOSARTAN-HCTZ 50-12.5 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |
LOTEMAX 0.5% OPHTHALMIC GEL |
2 |
Tier 2 |
0% | 0% | None |
Lotemax 5mg/g 1 TUBE per CARTON / 3.5 g in 1 TUBE |
2 |
Tier 2 |
0% | 0% | None |
LOTEMAX SM 0.38% OPHTH GEL DROPS |
2 |
Tier 2 |
0% | 0% | None |
LOTEPREDNOL ETABONATE 0.5% EYE DROPPER [Lotemax] |
1 |
Tier 1 |
0% | 0% | None |
LOVASTATIN 10 MG TABLET |
1 |
Tier 1 |
0% | 0% | Q:1 /1Days |
LOVASTATIN 20 MG TABLET |
1 |
Tier 1 |
0% | 0% | Q:1 /1Days |
LOVASTATIN 40 MG TABLET |
1 |
Tier 1 |
0% | 0% | Q:2 /1Days |
LOW-OGESTREL-28 TABLET [Low-Ogestrel] |
1 |
Tier 1 |
0% | 0% | None |
LOXAPINE 10 MG CAPSULE [Loxitane] |
1 |
Tier 1 |
0% | 0% | None |
LOXAPINE 25 MG CAPSULE [Loxitane] |
1 |
Tier 1 |
0% | 0% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOXAPINE 5 MG CAPSULE [Loxitane] |
1 |
Tier 1 |
0% | 0% | None |
LOXAPINE 50 MG CAPSULE [Loxitane] |
1 |
Tier 1 |
0% | 0% | None |
LUCEMYRA 0.18 MG TABLET |
2 |
Tier 2 |
0% | 0% | P |
LUMIGAN 0.01% EYE DROPS |
2 |
Tier 2 |
0% | 0% | None |
LUPANETA PACK 11.25-5 MG 3MO KIT |
2 |
Tier 2 |
0% | 0% | None |
LUPANETA PACK 3.75-5 MG 1MO KIT |
2 |
Tier 2 |
0% | 0% | None |
LUPRON DEPOT 11.25 MG 3MO KIT |
2 |
Tier 2 |
0% | 0% | None |
LUPRON DEPOT 22.5 MG 3MO KIT SYRINGEKIT |
2 |
Tier 2 |
0% | 0% | None |
LUPRON DEPOT 3.75 MG KIT |
2 |
Tier 2 |
0% | 0% | None |
LUPRON DEPOT 45 MG 6MO KIT |
2 |
Tier 2 |
0% | 0% | None |
LUPRON DEPOT 7.5 MG KIT |
2 |
Tier 2 |
0% | 0% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUPRON DEPOT-4 MONTH KIT |
2 |
Tier 2 |
0% | 0% | None |
LUTERA-28 TABLET |
1 |
Tier 1 |
0% | 0% | None |
LYNPARZA 100 MG TABLET |
2 |
Tier 2 |
0% | 0% | P |
LYNPARZA 150 MG TABLET |
2 |
Tier 2 |
0% | 0% | P |
LYSODREN 500 MG TABLET |
2 |
Tier 2 |
0% | 0% | None |
LYZA 0.35 MG TABLET |
1 |
Tier 1 |
0% | 0% | None |