Drug List - L

L
Drug Name Tier Restrictions
L-METHYL- TAB B6-B12 1
L-METHYLFOLA CAP FORTE 1
LABETALOL HCL 1
LAC-HYDRIN NC Over-the-counter
LACTIC ACID 1 Quantity limit
LACTIC ACID E 1 Quantity limit
LACTINOL 3 Quantity limit
LACTINOL-E 3 Quantity limit
LACTULOSE 1
LAMICTAL 3
LAMICTAL ODT 3
LAMICTAL STARTER/NOT TAKING KIT 3 Prior authorization
LAMICTAL XR 3 Prior authorization
LAMIVUDINE/ZIDOVUDINE 1
LAMOTRIGINE 1
LAMOTRIGINE EXTENDED RELEASE 1
LAMOTRIGINE ODT 1
LANOXIN 1
LANSOPR/AMOX MIS /CLARITH 1
LANSOPRAZOLE 15 MG NC
LANSOPRAZOLE 30 MG NC
LANSOPRAZOLE 3MG/ML SOLUTION (AGE RESTRICTION 4-12 YEARS OLD) 1
LANTANOPROST 1
LANTUS INJ 100U/ML 2
LANTUS SOLOSTAR INJ SOLOSTAR 2
LARIN 24 TAB FE 1/20 1*
LASIX 3 Prior authorization
LATANOPROST SOL 0.005% 1
LATUDA 3 Prior authorization
LAVOCLEN-4 CREAMY WASH LIQ CREM WSH 3 Quantity limit
LAVOCLEN-8 CREAMY WASH LIQ CREM WSH 3 Quantity limit
LAZERFORMALYDE 2 Quantity limit
LEFLUNOMIDE 1
LESCOL 3 Quantity limit
LESCOL XL 3 Quantity limit, Step therapy
LESSINA 1* Quantity limit, Step therapy
LETROZOLE 1
LEUCOVORIN 1 Quantity limit
LEUKERAN 1
LEUKINE INJ 2 Prior authorization, Quantity limit
LEUPROLIDE 1
LEVALBUTEROL INHAL. SOLN. 1
LEVAQUIN 3 Prior authorization
LEVBID 2
LEVEMIR INJ 2
LEVEMIR INJ FLEXPEN 2
LEVETIRACETAM 1
LEVITRA 3 Quantity limit
LEVLITE-28 1
LEVOBUNOLOL HCL 1
LEVOCARNITIN
LEVOCETIRIZINE 1
LEVOFLOXACIN 1
LEVONOR/ETHI TAB ESTRADIO 1
LEVORA 1*
LEVOTHROID 3
LEVOTHYROXINE SODIUM TAB 1
LEVOXYL 3 Prior authorization
LEVSIN 2
LEXAPRO 3 Prior authorization, Step therapy
LIALDA 3
LIDAMANTLE 2 Quantity limit
LIDAZONE HC 1 Quantity limit
LIDEX 3 Prior authorization, Quantity limit
LIDOCAINE HCL 1 Quantity limit
LIDOCAINE PATCH 1 Quantity limit
LIDOCAINE VISCOUS 1 Quantity limit
LIDOCAINE/PRILOCAINE 1 Quantity limit
LIDODERM 3 Quantity limit
LIMBREL 3 Prior authorization
LINDALE 3 Quantity limit
LINEZOLID 1
LINZESS CAP
LIOTHYRONINE TAB 1
LIPITOR 3 Prior authorization
LIPTRUZET 3 Step therapy
LISINOPRIL 1
LISINOPRIL/HYDROCHLOROTHIAZ 1
LITHIUM CARBONATE 1
LITHIUM CARBONATE ER 1
LITHOBID 3 Prior authorization
LIVALO TAB 2MG 3
LO LOESTRIN TAB 3
LOCOID 3 Quantity limit
LOCOID LIPOCREAM 3 Prior authorization, Quantity limit, Step therapy
LOESTRIN 21 TAB 1.5/30 1* Prior authorization
LOESTRIN 24 FE 3 Prior authorization
LOESTRIN FE1/20 3 Prior authorization
LOFIBRA 3
LOMEDIA 24 TAB FE 1*
LOPERAMIDE HCL NC
LOPREEZA 1
LOPROX GEL 3 Prior authorization, Quantity limit, Step therapy
LOPROX SHAMPOO 3 Prior authorization, Quantity limit, Step therapy
LORATADINE NC
LORAZEPAM 1 Travel
LORYNA TAB 3-0.02MG 1
LORZONE TAB 750MG 3 Prior authorization
LOSARTAN 1
LOSARTAN/HCTZ 1
LOTEMAX 3
LOTENSIN 3 Prior authorizaton
LOTENSIN HCT 3 Prior authorization
LOTREL 3 Prior authorization
LOVASTATIN 1
LOVAZA 3 Prior authorization, Quantity limit
LOVENOX INJ 3 Quantity limit
LOW OGESTREL 1*
LUDENT CHW 1*
LUGOL'S SOL 1
LUGOL'S SOL BP 1
LUMIGAN SOL 0.03% 2
LUNESTA 3 Quantity limit, Step therapy
LUPR DEP-PED INJ 3
LUPRON DEPOT 3
LUSTRA NC Quantity limit
LUSTRA-ULTRA NC Quantity limit
LUTERA TAB 1*
LUVERIS INJ 75UNIT UD 3
LUVOX CR 3 Prior authorization
LUXIQ 3 Prior authorization, Quantity limit
LYRICA 2
LYSTEDA 3 Prior authorization