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All A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Product Name Implementation Date Guideline
LANSOPRAZOLE 01/01/00 The limits are 1 capsule or solutab per day.
LAZANDA® 01/01/12 Prior authorization for medical necessity is required. The limits are 1 bottle per day.
LESCOL XL® 01/01/11 Lescol XL may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
LESCOL® 01/01/11 Lescol may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
LEVITRA® 09/01/03 Prior authorization for medical necessity may be required. The limits are 8 tablets per 30 days. Patients must be at least 18 years of age.
LEVORPHANOL 01/01/13 The limits are 4 tablets per day.
LEXIVA 07/01/12 The limits are 4 tablets per 60 mL per day.
LEXXEL® 01/01/11 Lexxel may be subject to step therapy requirements.
LINZESS™ 04/01/13 Prior authorization for medical necessity is required.
LIPITOR® 01/01/11 Lipitor may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
LIPTRUZET® 07/01/13 Liptruzet may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
LIVALO® 01/01/11 Livalo may be subject to step therapy requirements. Patients must have trial and failure of generic statin (lovastatin, pravastatin, simvastatin).
LORCET® 09/01/03 The limits are 6 tablets per day.
LORTAB® 09/01/03 The limits are 8 tablets for the 2.5 mg and 5 mg hydrocodone tablets and 6 tablets for the 7.5 mg and 10 mg tablets per day. The limits for Lortab elixir are 90mL per day. Patients should not take more than a total of 4 grams of acetaminophen per day (3 grams per day if have liver disease).
LOVENOX® 02/01/05 The limits are 30 syringes or 10 vials per 90 days.

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