2022 Medicare Part D Plan Formulary Information |
BlueMedicare Complete Rx (PDP) (S5904-002-0)
Benefit Details
This plan covers select insulin pay $35 copay.
See individual insulin cost-sharing below. |
The BlueMedicare Complete Rx (PDP) (S5904-002-0) Formulary Drugs Starting with the Letter L in CMS PDP Region 11 which includes: FL
|
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 |
$10.00 | $30.00 | None |
LABETALOL HCL 200 MG TABLET [Trandate] |
2 |
Generic |
$10.00 | $30.00 | None |
LABETALOL HCL 300 MG TABLET [Trandate] |
2 |
Generic |
$10.00 | $30.00 | None |
LACOSAMIDE 10 MG/ML SOLUTION [Vimpat] |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | None |
LACOSAMIDE 100 MG TABLET [Vimpat] |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | None |
LACOSAMIDE 150 MG TABLET [Vimpat] |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | None |
LACOSAMIDE 200 MG TABLET [Vimpat] |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | None |
LACOSAMIDE 50 MG TABLET [Vimpat] |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | None |
LACRISERT 5 MG INS |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | None |
LACTULOSE 10 GM/15 ML SOLUTION [Generlac] |
2 |
Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMIVUDINE 10 MG/ML ORAL SOLUTION [Epivir] |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | Q:960 /30Days |
LAMIVUDINE 150 MG TABLET [Epivir] |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days |
LAMIVUDINE 300 MG TABLET [Epivir] |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days |
LAMIVUDINE HBV 100 MG TABLET [Epivir HBV] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LAMIVUDINE-ZIDOVUDINE TABLET [Combivir] |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days |
LAMOTRIGINE 100 MG TABLET [Subvenite] |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LAMOTRIGINE 150 MG TABLET [Subvenite] |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LAMOTRIGINE 200 MG TABLET [Subvenite] |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LAMOTRIGINE 25 MG DISPER TABLET CHW [Lamictal CD] |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | None |
LAMOTRIGINE 25 MG TABLET [Subvenite] |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LAMOTRIGINE 5 MG DISPER TABLET CHW [Lamictal CD] |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE ER 100 MG TABLET ER 24 [Lamictal XR] |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | None |
LAMOTRIGINE ER 200 MG TABLET ER 24 [Lamictal XR] |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | None |
LAMOTRIGINE ER 25 MG TABLET ER 24 [Lamictal XR] |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | None |
LAMOTRIGINE ER 300 MG TABLET ER 24 [Lamictal XR] |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | None |
LAMOTRIGINE ER 50 MG TABLET ER 24 [Lamictal XR] |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | None |
LANSOPRAZOLE DR 15 MG CAPSULE DR [Prevacid] |
2 |
Generic |
$10.00 | $30.00 | Q:30 /30Days |
LANSOPRAZOLE DR 30 MG CAPSULE DR [Prevacid] |
2 |
Generic |
$10.00 | $30.00 | Q:30 /30Days |
LANTHANUM CARB 1,000 MG CHEWABLE TABLET [Fosrenol] |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | Q:120 /30Days |
LANTHANUM CARB 500 MG TABLET CHEW [Fosrenol] |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | Q:90 /30Days |
LANTHANUM CARB 750 MG TABLET CHEW [Fosrenol] |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | Q:180 /30Days |
LANTUS 100U/ML VIAL |
3 |
Preferred Brand |
$35.00 | $120.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LANTUS SOLOSTAR INJECTION |
3 |
Preferred Brand |
$35.00 | $120.00 | Q:60 /30Days |
LAPATINIB 250 MG TABLET [Tykerb] |
5 |
Specialty Tier |
33% | N/A | P Q:180 /30Days |
LARIN 1.5 MG-30 MCG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LARIN 21 1-20 TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LARIN FE 1-20 TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LARIN FE 1.5-30 TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LARISSIA-28 TABLET [Vienva] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LATANOPROST 0.005% EYE DROPS |
1 |
Preferred Generic |
$3.00 | $9.00 | Q:15 /75Days |
LATUDA 120 MG TABLET |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
LATUDA 20 MG TABLET |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
LATUDA 40 MG TABLET |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LATUDA 60 MG TABLET |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
LATUDA 80 MG TABLET |
5 |
Specialty Tier |
33% | N/A | Q:60 /30Days |
LAYOLIS FE CHEWABLE TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LEDIPASVIR-SOFOSBUVIR 90-400MG TABLET [Harvoni] |
5 |
Specialty Tier |
33% | N/A | P |
LEENA 28 TABLET [Tri-Norinyl] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LEFLUNOMIDE 10 MG TABLET [Arava] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LEFLUNOMIDE 20 MG TABLET [Arava] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LENALIDOMIDE 10 MG CAPSULE [Revlimid] |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
LENALIDOMIDE 15 MG CAPSULE [Revlimid] |
5 |
Specialty Tier |
33% | N/A | P Q:21 /28Days |
LENALIDOMIDE 25 MG CAPSULE [Revlimid] |
5 |
Specialty Tier |
33% | N/A | P Q:21 /28Days |
LENALIDOMIDE 5 MG CAPSULE [Revlimid] |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LENVIMA 10 MG DAILY DOSE |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
LENVIMA 12 MG DAILY DOSE CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:90 /30Days |
LENVIMA 14 MG DAILY DOSE |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
LENVIMA 18 MG DAILY DOSE |
5 |
Specialty Tier |
33% | N/A | P Q:90 /30Days |
LENVIMA 20 MG DAILY DOSE |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
LENVIMA 24 MG DAILY DOSE |
5 |
Specialty Tier |
33% | N/A | P Q:90 /30Days |
LENVIMA 4 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
LENVIMA 8 MG DAILY DOSE |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
Lessina 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LETROZOLE 2.5 MG TABLET [Femara] |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEUCOVORIN CALCIUM 10MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUCOVORIN CALCIUM 15MG 24 TABLET BOTTLE |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LEUCOVORIN CALCIUM 25 MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LEUCOVORIN CALCIUM 5 MG TABLET |
2 |
Generic |
$10.00 | $30.00 | None |
LEUKERAN 2 MG TABLET |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | None |
LEUKINE 250 MCG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
LEUPROLIDE 2WK 14 MG/2.8 ML KT |
5 |
Specialty Tier |
33% | N/A | P |
LEVEMIR 100UNITS/ML VIAL |
3 |
Preferred Brand |
$35.00 | $120.00 | Q:60 /30Days |
LEVEMIR FLEXTOUCH 100 UNITS/ML |
3 |
Preferred Brand |
$35.00 | $120.00 | Q:60 /30Days |
LEVETIRACETAM 1,000 MG TABLET |
2 |
Generic |
$10.00 | $30.00 | None |
LEVETIRACETAM 100 MG/ML SOLUTION [Keppra] |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | None |
LEVETIRACETAM 250 MG TABLET [Keppra] |
2 |
Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM 500 MG TABLET [Roweepra] |
2 |
Generic |
$10.00 | $30.00 | None |
LEVETIRACETAM 750 MG TABLET [Keppra] |
2 |
Generic |
$10.00 | $30.00 | None |
LEVETIRACETAM ER 500 MG TABLET ER 24H [Roweepra] |
2 |
Generic |
$10.00 | $30.00 | None |
LEVETIRACETAM ER 750 MG TABLET ER 24H [Roweepra] |
2 |
Generic |
$10.00 | $30.00 | None |
LEVO-T 100 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVO-T 112 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVO-T 125 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVO-T 137 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVO-T 150 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVO-T 175 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVO-T 200 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVO-T 25 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVO-T 300 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVO-T 50 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVO-T 75 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVO-T 88 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVOBUNOLOL 0.5% EYE DROPS [Betagan] |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | None |
LEVOCARNITINE 1 G/10 ML SOLUTION |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | None |
LEVOCARNITINE 330 MG TABLET |
2 |
Generic |
$10.00 | $30.00 | None |
LEVOCETIRIZINE 5 MG TABLET [Xyzal Allergy 24 Hour] |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVOFLOXACIN 25 MG/ML SOLUTION [Levaquin] |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | None |
LEVOFLOXACIN 250 MG TABLET [LEVAQUIN] |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOFLOXACIN 500 MG TABLET [Levaquin] |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVOFLOXACIN 500 MG/100 ML-D5W PIGGYBACK [Levaquin] |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | None |
LEVOFLOXACIN 500 MG/20 ML VIAL [Levaquin] |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | None |
LEVOFLOXACIN 750 MG TABLET [Levaquin Leva-Pak] |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVOFLOXACIN 750 MG/150 ML-D5W PIGGYBACK [Levaquin] |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | None |
LEVONEST-28 TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LEVONO-E ESTRAD 0.10-0.02-0.01 TBDSPK 3MO [LoSeasonique] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LEVONOR-ETH ESTRAD 0.09-0.02 MG |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LEVONOR-ETH ESTRAD 0.1-0.02 MG Tablet [Vienva] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LEVONOR-ETH ESTRAD 0.15-0.03 |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LEVONOR-ETH ESTRAD 0.15-0.03 |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levonor-eth Estrad 0.15-0.03-0.01 |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LEVONOR-ETH ESTRAD TRIPHASIC TABLET [Trivora] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
Levora-28 tablet |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LEVORPHANOL 2 MG TABLET [Levo-Dromoran] |
5 |
Specialty Tier |
33% | N/A | Q:120 /30Days |
LEVORPHANOL 3 MG TABLET |
5 |
Specialty Tier |
33% | N/A | Q:120 /30Days |
LEVOTHYROXINE 100 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVOTHYROXINE 112 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVOTHYROXINE 125 MCG TABLET [Unithroid] |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVOTHYROXINE 137 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVOTHYROXINE 150 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVOTHYROXINE 175 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE 200 MCG TABLET [Unithroid] |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVOTHYROXINE 25 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVOTHYROXINE 300 MCG TABLET [Unithroid] |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVOTHYROXINE 50 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVOTHYROXINE 75 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVOTHYROXINE 88 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVOXYL 100 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVOXYL 112 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVOXYL 125 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVOXYL 137 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVOXYL 150 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 175 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVOXYL 200 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVOXYL 25 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVOXYL 50 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVOXYL 75 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEVOXYL 88 MCG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LEXIVA 50mg/mL 225 mL in 1 BOTTLE |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | Q:1800 /30Days |
LIDOCAINE 2% VISCOUS SOLUTION |
2 |
Generic |
$10.00 | $30.00 | None |
LIDOCAINE 5% OINTMENT [SOLUPAK] |
2 |
Generic |
$10.00 | $30.00 | P Q:100 /30Days |
LIDOCAINE 5% PATCH [Lidoderm] |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:90 /30Days |
LIDOCAINE HCL 4% SOLUTION [Xylocaine] |
2 |
Generic |
$10.00 | $30.00 | P Q:150 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIDOCAINE-PRILOCAINE CREAM (g) [SOLUPICC] |
2 |
Generic |
$10.00 | $30.00 | P Q:60 /30Days |
LINDANE SHAMPOO 1MG 2 FLO BOTTLE |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LINEZOLID 100 MG/5 ML ORAL SUSPENSION [Zyvox] |
5 |
Specialty Tier |
33% | N/A | P |
LINEZOLID 600 MG TABLET [Zyvox] |
3 |
Preferred Brand |
$40.00 | $120.00 | P |
LINEZOLID 600 MG/300 ML-D5W PIGGYBACK [Zyvox] |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | None |
LINZESS 145 MCG CAPSULE |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days |
LINZESS 290 MCG CAPSULE |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days |
LINZESS 72 MCG CAPSULE |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days |
LIOTHYRONINE SOD 25 MCG TABLET [Cytomel] |
2 |
Generic |
$10.00 | $30.00 | None |
LIOTHYRONINE SOD 5 MCG TABLET [Cytomel] |
2 |
Generic |
$10.00 | $30.00 | None |
LIOTHYRONINE SOD 50 MCG TABLET [Cytomel] |
2 |
Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL 10 MG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LISINOPRIL 2.5 MG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LISINOPRIL 20 MG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LISINOPRIL 30 MG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LISINOPRIL 40 MG TABLET [Zestril] |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LISINOPRIL 5 MG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LISINOPRIL-HCTZ 10-12.5 MG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LISINOPRIL-HCTZ 20-12.5 MG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LISINOPRIL-HCTZ 20-25 MG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LITHIUM CARBONATE 150 MG CAPSULE CAPSULE |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LITHIUM CARBONATE 300 MG CAPSULE [Eskalith] |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LITHIUM CARBONATE 300 MG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LITHIUM CARBONATE 600 MG CAPSULE |
1 |
Preferred Generic |
$3.00 | $9.00 | None |
LITHIUM CARBONATE ER 300 MG TABLET |
2 |
Generic |
$10.00 | $30.00 | None |
LITHIUM CARBONATE ER 450 MG TABLET [Eskalith CR] |
2 |
Generic |
$10.00 | $30.00 | None |
LOESTRIN 21 1.5/30 TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LOESTRIN 21 1/20 TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LOESTRIN FE 1.5/30 TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LOESTRIN FE 1/20 TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LONSURF 15 MG-6.14 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:100 /28Days |
LONSURF 20 MG-8.19 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:80 /28Days |
LOPERAMIDE 2 MG CAPSULE |
2 |
Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOPINAVIR-RITONAVIR 80-20MG/ML Solution [Kaletra] |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | Q:480 /30Days |
LOPINAVIR-RITONAVR 100-25MG TABLET [Kaletra] |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | Q:300 /30Days |
LOPINAVIR-RITONAVR 200-50MG TABLET [Kaletra] |
5 |
Specialty Tier |
33% | N/A | Q:120 /30Days |
LORAZEPAM 0.5 MG TABLET [Ativan] |
1 |
Preferred Generic |
$3.00 | $9.00 | P Q:120 /30Days |
LORAZEPAM 1 MG TABLET [Ativan] |
1 |
Preferred Generic |
$3.00 | $9.00 | P Q:120 /30Days |
LORAZEPAM 2 MG TABLET [Ativan] |
1 |
Preferred Generic |
$3.00 | $9.00 | P Q:150 /30Days |
LORBRENA 100 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
LORBRENA 25 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:90 /30Days |
LORYNA 3 MG-0.02 MG TABLET [Yaz] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LOSARTAN POTASSIUM 100 MG TABLET [Cozaar] |
1 |
Preferred Generic |
$3.00 | $9.00 | Q:30 /30Days |
LOSARTAN POTASSIUM 25 MG TABLET [Cozaar] |
1 |
Preferred Generic |
$3.00 | $9.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOSARTAN POTASSIUM 50 MG TABLET [Cozaar] |
1 |
Preferred Generic |
$3.00 | $9.00 | Q:60 /30Days |
LOSARTAN-HCTZ 100-12.5 MG TABLET [Hyzaar] |
1 |
Preferred Generic |
$3.00 | $9.00 | Q:30 /30Days |
LOSARTAN-HCTZ 100-25 MG TABLET [Hyzaar] |
1 |
Preferred Generic |
$3.00 | $9.00 | Q:30 /30Days |
LOSARTAN-HCTZ 50-12.5 MG TABLET [Hyzaar] |
1 |
Preferred Generic |
$3.00 | $9.00 | Q:30 /30Days |
LOVASTATIN 10 MG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | Q:60 /30Days |
LOVASTATIN 20 MG TABLET |
1 |
Preferred Generic |
$3.00 | $9.00 | Q:60 /30Days |
LOVASTATIN 40 MG TABLET [Mevacor] |
1 |
Preferred Generic |
$3.00 | $9.00 | Q:60 /30Days |
LOW-OGESTREL-28 TABLET [Low-Ogestrel] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LOXAPINE 10 MG CAPSULE [Loxitane] |
2 |
Generic |
$10.00 | $30.00 | P |
LOXAPINE 25 MG CAPSULE [Loxitane] |
2 |
Generic |
$10.00 | $30.00 | P |
LOXAPINE 5 MG CAPSULE [Loxitane] |
2 |
Generic |
$10.00 | $30.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOXAPINE 50 MG CAPSULE [Loxitane] |
2 |
Generic |
$10.00 | $30.00 | P |
LUBIPROSTONE 24 MCG CAPSULE [Amitiza] |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | Q:60 /30Days |
LUBIPROSTONE 8 MCG CAPSULE [Amitiza] |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | Q:120 /30Days |
LUMAKRAS 120 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:240 /30Days |
LUMIGAN 0.01% EYE DROPS |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:15 /75Days |
LUPRON DEPOT 11.25 MG 3MO KIT |
5 |
Specialty Tier |
33% | N/A | P |
LUPRON DEPOT 22.5 MG 3MO KIT SYRINGEKIT |
5 |
Specialty Tier |
33% | N/A | P |
LUPRON DEPOT 3.75 MG KIT |
5 |
Specialty Tier |
33% | N/A | P |
LUPRON DEPOT 45 MG 6MO KIT |
5 |
Specialty Tier |
33% | N/A | P |
LUPRON DEPOT 7.5 MG KIT |
5 |
Specialty Tier |
33% | N/A | P |
LUPRON DEPOT-4 MONTH KIT |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUTERA-28 TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LYBALVI 10-10 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
LYBALVI 15-10 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
LYBALVI 20-10 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
LYBALVI 5-10 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
LYLEQ 0.35 MG TABLET [Sharobel 28-Day] |
3 |
Preferred Brand |
$40.00 | $120.00 | None |
LYLLANA 0.025 MG PATCH TDSW [Vivelle-Dot] |
2 |
Generic |
$10.00 | $30.00 | None |
LYLLANA 0.0375 MG PATCH TDSW [Vivelle-Dot] |
2 |
Generic |
$10.00 | $30.00 | None |
LYLLANA 0.05 MG PATCH TDSW [Vivelle-Dot] |
2 |
Generic |
$10.00 | $30.00 | None |
LYLLANA 0.075 MG PATCH TDSW [Vivelle-Dot] |
2 |
Generic |
$10.00 | $30.00 | None |
LYLLANA 0.1 MG PATCH TDSW [Vivelle-Dot] |
2 |
Generic |
$10.00 | $30.00 | 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 |
33% | N/A | P Q:120 /30Days |
LYNPARZA 150 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
LYSODREN 500 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
LYUMJEV 100 UNIT/ML KWIKPEN INSULN PEN |
3 |
Preferred Brand |
$35.00 | $120.00 | Q:60 /30Days |
LYUMJEV 100 UNIT/ML VIAL |
3 |
Preferred Brand |
$35.00 | $120.00 | Q:60 /30Days |
LYUMJEV 200 UNIT/ML KWIKPEN INSULN PEN |
3 |
Preferred Brand |
$35.00 | $120.00 | Q:60 /30Days |
LYZA 0.35 MG TABLET |
3 |
Preferred Brand |
$40.00 | $120.00 | None |