Drug - Brand Name (Generic Name) PA Status Class Drug Notes lonafarnib - PA PA UNCLASSIFIED DRUG PRODUCTS liothyronine M90 THYROID PREPARATIONS "M90, #" Levoxyl # (levothyroxine-Levoxyl) M90 THYROID PREPARATIONS "M90, #" levothyroxine-Unithroid M90 THYROID PREPARATIONS "M90, #" "levothyroxine-Tirosint BP, M90" THYROID PREPARATIONS "BP, M90" levothyroxine-Thyquidity THYROID PREPARATIONS levothyroxine-Synthroid M90 THYROID PREPARATIONS "M90, #" levothyroxine M90 THYROID PREPARATIONS M90 levothyroxine-Levoxyl M90 THYROID PREPARATIONS "M90, #" levothyroxine-Levo-T M90 THYROID PREPARATIONS "M90, #" levothyroxine-Euthyrox M90 THYROID PREPARATIONS "M90, #" levothyroxine-Ermeza THYROID PREPARATIONS Levo-T # (levothyroxine-Levo-T) M90 THYROID PREPARATIONS "M90, #" Lymepak (doxycycline hyclate 100 mg tablet pack) - PA PA TETRACYCLINES "lumasiran PD, MB - PA" PA SMALL INTERFERING RNA AGENTS "PD, MB" lasmiditan - PA PA SEROTONIN RECEPTOR AGENTS Lunesta # (eszopiclone) - PA 1 unit/day; See Table 15; See Table 71 PA 1 unit/day SEDATIVES # lemborexant - PA; See Table 15; See Table 71 PA "SEDATIVE, NON-BARBITURATE" "lansoprazole orally disintegrating tablet BP, M90 - PA ≥ 2 years" PA ≥ 2 years PROTON PUMP INHIBITORS "BP, M90" lansoprazole capsule M90 - PA > 1 unit/day PA > 1 unit/day PROTON PUMP INHIBITORS "M90, #" Lupaneta Pack (leuprolide / norethindrone) - PA PA OTHER HORMONES levoketoconazole - PA PA OTHER HORMONES leuprolide / norethindrone - PA PA OTHER HORMONES levorphanol tablet - PA PA OPIOID ANALGESICS "Luxturna (voretigene neparvovec) CO, MB - PA" PA OPHTHALMIC PREPARATIONS "CO, MB" Lumigan (bimatoprost 0.01% ophthalmic solution) - PA PA OPHTHALMIC PREPARATIONS Lucentis (ranibizumab) MB OPHTHALMIC PREPARATIONS MB loteprednol 1% suspension - PA PA OPHTHALMIC PREPARATIONS "loteprednol 0.5% BP, A90" OPHTHALMIC PREPARATIONS "BP, A90" loteprednol 0.38% gel - PA PA OPHTHALMIC PREPARATIONS loteprednol 0.25% suspension - PA PA OPHTHALMIC PREPARATIONS loteprednol 0.2% A90 OPHTHALMIC PREPARATIONS "A90, #" Lotemax SM (loteprednol 0.38% gel) - PA PA OPHTHALMIC PREPARATIONS "Lotemax (loteprednol 0.5%) BP, A90" OPHTHALMIC PREPARATIONS "BP, A90" lodoxamide OPHTHALMIC PREPARATIONS lifitegrast - PA PA OPHTHALMIC PREPARATIONS lidocaine ophthalmic gel OPHTHALMIC PREPARATIONS levofloxacin ophthalmic solution A90 - PA PA OPHTHALMIC PREPARATIONS A90 levobunolol M90 OPHTHALMIC PREPARATIONS M90 latanoprost solution - Xalatan M90 OPHTHALMIC PREPARATIONS "M90, #" latanoprost solution - Iyuzeh - PA PA OPHTHALMIC PREPARATIONS latanoprostene - PA PA OPHTHALMIC PREPARATIONS latanoprost emulsion - PA PA OPHTHALMIC PREPARATIONS Lacrisert (hydroxypropyl cellulose ophthalmic insert) OPHTHALMIC PREPARATIONS lomustine - PA PA ONCOLOGY AGENTS Licart (diclofenac topical patch-Licart) - PA PA NONSTEROIDAL ANTI-INFLAMMATORY Lyvispah (baclofen granules) - PA PA MUSCLE RELAXANT Lioresal (baclofen intrathecal injection) MUSCLE RELAXANT Lemtrada (alemtuzumab 12 mg) MB - PA PA MULTIPLE SCLEROSIS AGENTS MB Lovaza # (omega-3 acid ethyl esters) M90 LIPID LOWERING AGENTS "M90, #" lovastatin extended-release - PA PA LIPID LOWERING AGENTS lovastatin 40 mg M90 - PA > 2 units/day PA > 2 units/day LIPID LOWERING AGENTS M90 "lovastatin 10 mg, 20 mg M90 - PA > 1.5 units/day" PA > 1.5 units/day LIPID LOWERING AGENTS M90 Lopid # (gemfibrozil) M90 LIPID LOWERING AGENTS "M90, #" lomitapide - PA PA LIPID LOWERING AGENTS Livalo (pitavastatin calcium) M90 - PA PA LIPID LOWERING AGENTS M90 "Lipofen (fenofibrate 50 mg, 150 mg capsule) M90" LIPID LOWERING AGENTS M90 Lipitor # (atorvastatin 80 mg tablet) M90 - PA > 1 unit/day PA > 1 unit/day LIPID LOWERING AGENTS "M90, #" "Lipitor # (atorvastatin 10 mg, 20 mg, 40 mg tablet) M90 - PA > 1.5 units/day" PA > 1.5 units/day LIPID LOWERING AGENTS "M90, #" Lescol XL (fluvastatin extended-release) M90 - PA PA LIPID LOWERING AGENTS M90 Leqvio (inclisiran) - PA PA LIPID LOWERING AGENTS Lupkynis (voclosporin) - PA PA IMMUNOMODULATOR Litfulo (ritlecitinib) - PA PA IMMUNOMODULATOR leflunomide A90 IMMUNOMODULATOR "A90, #" Lupron (leuprolide) - PA PA HORMONE AGENTS lonapegsomatropin-tcgd PD - PA PA HORMONE AGENTS PD leuprolide - PA PA HORMONE AGENTS Lysteda # (tranexamic acid tablet) HEMOSTATICS # lusutrombopag - PA PA HEMATOLOGIC luspatercept-aamt MB - PA PA HEMATOLOGIC MB low molecular weight iron dextran HEMATINIC AGENT Leukine (sargramostim) HEMATINIC AGENT lansoprazole / amoxicillin / clarithromycin A90 - PA PA H. PYLORI AGENTS A90 Luxiq # (betamethasone valerate foam) A90 GLUCOCORTICOIDS "A90, #" Locoid Lipocream (hydrocortisone butyrate / emollient) A90 - PA PA GLUCOCORTICOIDS A90 Locoid (hydrocortisone butyrate lotion) A90 - PA PA GLUCOCORTICOIDS A90 Lexette (halobetasol foam) A90 - PA PA GLUCOCORTICOIDS A90 "Lialda (mesalamine delayed-release) BP, A90" GI ANTI-INFLAMMATORY "BP, A90" Lotronex (alosetron) A90 - PA PA GASTROINTESTINAL AGENT A90 lactulose solution A90 GASTROINTESTINAL AGENT A90 lactobacillus rhamnosus GG - PA ≥ 22 years PA ≥ 22 years GASTROINTESTINAL AGENT "lactase *, A90" GASTROINTESTINAL AGENT "*, A90" Lyrica CR (pregabalin extended-release) BP - PA; See Table 71; See Table 72 PA GABA ANALOGS BP "Luzu (luliconazole) BP, A90 - PA" PA FUNGICIDES "BP, A90" "luliconazole BP, A90 - PA" PA FUNGICIDES "BP, A90" Loprox # (ciclopirox 0.77% cream) A90 FUNGICIDES "A90, #" Loprox (ciclopirox 1% shampoo) A90 - PA PA FUNGICIDES A90 "Loprox (ciclopirox 0.77% gel, suspension) A90 - PA" PA FUNGICIDES A90 Lumizyme (alglucosidase alfa) MB - PA PA ENZYMES MB laronidase MB - PA PA ENZYMES MB Lamzede (velmanase alfa-tycv) MB - PA PA ENZYMES MB lanreotide ENDOCRINE/METABOLIC AGENTS "Liposyn # (fat emulsions, intravenous-liposyn)" ELECTROLYTES AND NUTRIENTS # l-glutamine - PA PA ELECTROLYTES AND NUTRIENTS "levocarnitine tablet, solution A90" ELECTROLYTES AND NUTRIENTS "A90, #" levocarnitine injection MB ELECTROLYTES AND NUTRIENTS MB levocarnitine ELECTROLYTES AND NUTRIENTS L-Carnitine (levocarnitine) ELECTROLYTES AND NUTRIENTS lanthanum A90 ELECTROLYTES AND NUTRIENTS "A90, #" Lyumjev Tempo (insulin lispro-aabc) - PA PA DIABETIC THERAPY Lyumjev (insulin lispro-aabc) - PA PA DIABETIC AGENTS lixisenatide - PA PA DIABETIC AGENTS liraglutide-Victoza BP - PA >9 mL/30 days PA >9 mL/30 days DIABETIC AGENTS BP linagliptin / metformin extended-release DIABETIC AGENTS linagliptin / metformin DIABETIC AGENTS linagliptin DIABETIC AGENTS Levemir (insulin detemir) DIABETIC AGENTS Lantus (insulin glargine-Lantus) BP DIABETIC AGENTS BP lumacaftor / ivacaftor PD - PA PA CYSTIC FIBROSIS AGENTS PD "Lagevrio (molnupiravir COVID EUA – December 23, 2021)" COVID - 19 related Treatments and Vaccines Loseasonique # (levonorgestrel / ethinyl estradiol-Loseasonique) M90 CONTRACEPTIVES "M90, #" Lo Loestrin Fe (norethindrone / ethinyl estradiol / ferrous fumarate) CONTRACEPTIVES Liletta (levonorgestrel-releasing intrauterine system 52 mg-Liletta) CONTRACEPTIVES levonorgestrel-releasing intrauterine system 52 mg-Mirena CONTRACEPTIVES levonorgestrel-releasing intrauterine system 52 mg-Liletta CONTRACEPTIVES levonorgestrel-releasing intrauterine system 19.5 mg CONTRACEPTIVES levonorgestrel-releasing intrauterine system 13.5 mg CONTRACEPTIVES levonorgestrel 1.5 mg tablet * CONTRACEPTIVES * levonorgestrel / ethinyl estradiol triphasic M90 CONTRACEPTIVES M90 levonorgestrel / ethinyl estradiol-Seasonique M90 CONTRACEPTIVES "M90, #" levonorgestrel / ethinyl estradiol-Quartette M90 CONTRACEPTIVES "M90, #" levonorgestrel / ethinyl estradiol patch CONTRACEPTIVES levonorgestrel / ethinyl estradiol-Loseasonique M90 CONTRACEPTIVES "M90, #" levonorgestrel / ethinyl estradiol 90/20 mcg M90 CONTRACEPTIVES M90 levonorgestrel / ethinyl estradiol 0.15/0.03 mg M90 CONTRACEPTIVES M90 levonorgestrel / ethinyl estradiol 0.10/0.02 mg M90 CONTRACEPTIVES M90 levonorgestrel / ethinyl estradiol / ferrous bisglycinate M90 CONTRACEPTIVES M90 levonorgestrel / ethinyl estradiol CONTRACEPTIVES lactic acid / citric acid / potassium bitartrate vaginal gel CONTRACEPTIVES "lubiprostone BP, M90 - PA" PA CONSTIPATION AGENTS "BP, M90" Linzess (linaclotide 72 mcg) - PA PA CONSTIPATION AGENTS "Linzess (linaclotide 145 mcg, 290 mcg)" CONSTIPATION AGENTS linaclotide 72 mcg - PA PA CONSTIPATION AGENTS "linaclotide 145 mcg, 290 mcg" CONSTIPATION AGENTS lactulose packet - PA PA CONSTIPATION AGENTS lanolin * COMPOUNDING AGENT * Lysodren (mitotane) CHEMOTHERAPY Lynparza (olaparib) - PA PA CHEMOTHERAPY lurbinectedin - PA PA CHEMOTHERAPY Lunsumio (mosunetuzumab-axgb) MB - PA PA CHEMOTHERAPY MB Lumoxiti (moxetumomab pasudotox-tdfk) MB - PA PA CHEMOTHERAPY MB Lumakras (sotorasib) - PA PA CHEMOTHERAPY lorlatinib - PA PA CHEMOTHERAPY Lorbrena (lorlatinib) - PA PA CHEMOTHERAPY Lonsurf (trifluridine / tipiracil) - PA PA CHEMOTHERAPY loncastuximab tesirine-lpyl - PA PA CHEMOTHERAPY "lisocabtagene maraleucel CO, MB - PA" PA CHEMOTHERAPY "CO, MB" Libtayo (cemiplimab-rwlc) MB - PA PA CHEMOTHERAPY MB Levulan (aminolevulinic acid) MB CHEMOTHERAPY MB Leukeran (chlorambucil) - PA PA CHEMOTHERAPY letrozole A90 CHEMOTHERAPY "A90, #" Lenvima (lenvatinib) - PA PA CHEMOTHERAPY lenvatinib - PA PA CHEMOTHERAPY leniolisib - PA PA CHEMOTHERAPY "lenalidomide BP, A90 - PA" PA CHEMOTHERAPY "BP, A90" larotrectinib - PA PA CHEMOTHERAPY "lapatinib BP, A90" CHEMOTHERAPY "BP, A90" Lokelma (sodium zirconium cyclosilicate) - PA > 1 unit/day PA > 1 unit/day CHELATING AGENT lisdexamfetamine chewable tablet BP - PA; See Table 31; See Table 71 PA CEREBRAL STIMULANTS BP lisdexamfetamine capsule BP - PA 2 units/day; See Table 31; See Table 71 PA 2 units/day CEREBRAL STIMULANTS BP Lotrel # (amlodipine / benazepril) M90 CARDIOVASCULAR "M90, #" Lotensin HCT # (benazepril / hydrochlorothiazide) M90 CARDIOVASCULAR "M90, #" Lotensin # (benazepril) M90 CARDIOVASCULAR "M90, #" losartan M90 CARDIOVASCULAR "M90, #" losartan / hydrochlorothiazide M90 CARDIOVASCULAR "M90, #" Lopressor # (metoprolol) M90 CARDIOVASCULAR "M90, #" lisinopril solution - PA PA CARDIOVASCULAR lisinopril M90 CARDIOVASCULAR "M90, #" lisinopril / hydrochlorothiazide M90 CARDIOVASCULAR "M90, #" Liqrev (sildenafil oral suspension-Liqrev) - PA PA CARDIOVASCULAR levamlodipine M90 - PA PA CARDIOVASCULAR M90 Letairis (ambrisentan) A90 - PA PA CARDIOVASCULAR A90 "Lasix # (furosemide tablet, solution, injection) M90" CARDIOVASCULAR "M90, #" Lanoxin # (digoxin) M90 CARDIOVASCULAR "M90, #" labetalol M90 CARDIOVASCULAR M90 Lonhala (glycopyrrolate inhalation solution) - PA PA BRONCHODILATORS levalbuterol inhaler A90 BRONCHODILATORS "A90, #" levalbuterol inhalation solution A90 - PA PA BRONCHODILATORS A90 Leqembi (lecanemab-irmb) - PA PA BIOLOGICAL lecanemab-irmb - PA PA BIOLOGICAL lanadelumab-flyo - PA PA BIOLOGICAL Livmarli (maralixibat) - PA PA BILE THERAPY Loreev XR (lorazepam extended-release) - PA; See Table 69; See Table 71 PA BENZODIAZEPINES "lorazepam solution, tablet - PA < 6 years; See Table 69; See Table 71" PA BENZODIAZEPINES # lorazepam injection BENZODIAZEPINES # lorazepam extended-release - PA; See Table 69; See Table 71 PA BENZODIAZEPINES lopinavir / ritonavir A90 ANTIVIRALS "A90, #" Livtencity (maribavir) - PA PA ANTIVIRALS "Lexiva (fosamprenavir) BP, A90" ANTIVIRALS "BP, A90" letermovir - PA PA ANTIVIRALS lenacapavir - PA PA ANTIVIRALS ledipasvir / sofosbuvir PD - PA PA ANTIVIRALS PD lamivudine 5 mg/mL solution A90 - PA > 20 mL/day PA > 20 mL/day ANTIVIRALS A90 "lamivudine 150 mg, 300 mg tablet A90" ANTIVIRALS "A90, #" lamivudine 10 mg/mL solution A90 ANTIVIRALS "A90, #" lamivudine 100 mg tablet A90 - PA > 1 unit/day PA > 1 unit/day ANTIVIRALS "A90, #" lamivudine / zidovudine A90 ANTIVIRALS "A90, #" lamivudine / tenofovir disoproxil fumarate - PA PA ANTIVIRALS Librax (chlordiazepoxide / clidinium) - PA PA "ANTISPASMODICS,ANTICHOLINERGIC" Lybalvi (olanzapine / samidorphan) - PA; See Table 24; See Table 71 PA ANTIPSYCHOTIC lurasidone A90 - PA; See Table 24; See Table 71 PA ANTIPSYCHOTIC A90 lumateperone - PA; See Table 24; See Table 71 PA ANTIPSYCHOTIC Loxitane # (loxapine capsule) A90 - PA < 6 years; See Table 24; See Table 71 PA ANTIPSYCHOTIC "A90, #" loxapine capsule A90 - PA < 6 years; See Table 24; See Table 71 PA ANTIPSYCHOTIC "A90, #" Lithobid # (lithium) A90 - PA < 6 years PA ANTIPSYCHOTIC "A90, #" lithium A90 - PA < 6 years PA ANTIPSYCHOTIC "A90, #" Latuda (lurasidone) A90 - PA; See Table 24; See Table 71 PA ANTIPSYCHOTIC A90 Lodosyn # (carbidopa) A90 ANTIPARKINSON "A90, #" levodopa - PA PA ANTIPARKINSON lindane shampoo A90 - PA PA ANTIPARASITICS A90 Lomaira (phentermine 8 mg tablet) - PA PA ANTI-OBESITY AGENTS liraglutide-Saxenda - PA PA ANTI-OBESITY AGENTS Lytgobi (futibatinib) - PA PA ANTINEOPLASTICS "loratadine tablet, solution *, M90" ANTIHISTAMINES "*, M90" "loratadine / pseudoephedrine *, A90" ANTIHISTAMINES "*, A90" levocetirizine tablet M90 ANTIHISTAMINES "M90, #" levocetirizine solution M90 - PA PA ANTIHISTAMINES M90 Lifems Naloxone (naloxone syringe kit) - PA PA ANTIDOTES levoleucovorin powder for injection - PA PA ANTIDOTES levoleucovorin injection - PA PA ANTIDOTES leucovorin A90 ANTIDOTES A90 loperamide * ANTIDIARRHEALS * Lomotil # (diphenoxylate / atropine) ANTIDIARRHEALS # Lexapro # (escitalopram) A90 - PA < 6 years; See Table 17; See Table 71 PA ANTIDEPRESSANTS "A90, #" levomilnacipran - PA; See Table 17; See Table 71 PA ANTIDEPRESSANTS Lyrica (pregabalin) - PA; See Table 20; See Table 71 PA ANTICONVULSANTS levetiracetam tablet for oral suspension - PA PA ANTICONVULSANTS "levetiracetam injection, solution, tablet A90" ANTICONVULSANTS "A90, #" levetiracetam extended-release-Keppra XR A90 ANTICONVULSANTS "A90, #" levetiracetam extended-release-Elepsia XR - PA PA ANTICONVULSANTS lamotrigine tablet starter kit - PA; See Table 20; See Table 71 PA ANTICONVULSANTS lamotrigine tablet A90 - PA < 6 years; See Table 20; See Table 71 PA ANTICONVULSANTS "A90, #" lamotrigine orally disintegrating tablet starter kit - PA; See Table 20; See Table 71 PA ANTICONVULSANTS lamotrigine orally disintegrating tablet A90 - PA; See Table 20; See Table 71 PA ANTICONVULSANTS A90 lamotrigine extended-release tablet starter kit - PA; See Table 20; See Table 71 PA ANTICONVULSANTS lamotrigine extended-release tablet A90 - PA; See Table 20; See Table 71 PA ANTICONVULSANTS A90 lamotrigine dispersible tablet A90 - PA < 6 years; See Table 20; See Table 71 PA ANTICONVULSANTS "A90, #" Lamictal XR (lamotrigine extended-release tablet starter kit) - PA; See Table 20; See Table 71 PA ANTICONVULSANTS Lamictal XR (lamotrigine extended-release tablet) A90 - PA; See Table 20; See Table 71 PA ANTICONVULSANTS A90 Lamictal ODT (lamotrigine orally disintegrating tablet starter kit) - PA; See Table 20; See Table 71 PA ANTICONVULSANTS Lamictal ODT (lamotrigine orally disintegrating tablet) A90 - PA; See Table 20; See Table 71 PA ANTICONVULSANTS A90 Lamictal # (lamotrigine tablet) A90 - PA < 6 years; See Table 20; See Table 71 PA ANTICONVULSANTS "A90, #" Lamictal # (lamotrigine dispersible tablet) A90 - PA < 6 years; See Table 20; See Table 71 PA ANTICONVULSANTS "A90, #" Lamictal (lamotrigine tablet starter kit) - PA; See Table 20; See Table 71 PA ANTICONVULSANTS lacosamide A90 ANTICONVULSANTS "A90, #" Lovenox # (enoxaparin) ANTICOAGULANTS # Lithostat (acetohydroxamic acid) ANTIBIOTICS linezolid tablet A90 ANTIBIOTICS "A90, #" linezolid suspension A90 - PA PA ANTIBIOTICS A90 linezolid injection - PA PA ANTIBIOTICS lincomycin ANTIBIOTICS # Lincocin # (lincomycin) ANTIBIOTICS # levofloxacin A90; See Table 35; See Table 66 ANTIBIOTICS A90 Lampit (nifurtimox) - PA PA ANTIBIOTICS Lidoderm # (lidocaine 5% patch) A90 - PA > 3 patches/day PA > 3 patches/day ANESTHETICS "A90, #" lidocaine viscous solution ANESTHETICS "lidocaine vial, preservative free" ANESTHETICS # lidocaine vial ANESTHETICS # "lidocaine topical jelly, solution" ANESTHETICS lidocaine ointment A90 ANESTHETICS A90 lidocaine 5% patch A90 - PA > 3 patches/day PA > 3 patches/day ANESTHETICS "A90, #" lidocaine 1.8% patch - PA PA ANESTHETICS lidocaine / tetracaine - PA > 4 patches/30 days PA > 4 patches/30 days ANESTHETICS lidocaine / prilocaine A90 ANESTHETICS A90 Lucemyra (lofexidine) - PA PA ALPHA-2 ADRENERGIC AGONIST lofexidine - PA PA ALPHA-2 ADRENERGIC AGONIST