2009 Medicare Part D Plan Formulary Information |
Aetna Medicare Rx Plus (S5810-152-0)
Benefit Details
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The Aetna Medicare Rx Plus (S5810-152-0) Formulary Drugs Starting with the Letter L in CMS PDP Region 16 which includes: WI
|
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 100MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LABETALOL HCL 100MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | S |
LABETALOL HCL 200MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LABETALOL HCL 200MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | S |
LABETALOL HCL 300MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LABETALOL HCL 300MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | S |
LABETALOL HCL 5MG/20ML VIAL ![Compare how all Medicare Part D PDP plans in WI cover LABETALOL HCL 5MG/20ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | S |
LAC-HYDRIN 12% CREAM ![Compare how all Medicare Part D PDP plans in WI cover LAC-HYDRIN 12% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LAC-HYDRIN 12% LOTION ![Compare how all Medicare Part D PDP plans in WI cover LAC-HYDRIN 12% LOTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LACLOTION 12% LOTION ![Compare how all Medicare Part D PDP plans in WI cover LACLOTION 12% LOTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LACRISERT OPTHALMIC INSERT 5MG 60 BLPK ![Compare how all Medicare Part D PDP plans in WI cover LACRISERT OPTHALMIC INSERT 5MG 60 BLPK.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LACTATED RINGERS INJECTION ![Compare how all Medicare Part D PDP plans in WI cover LACTATED RINGERS INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LACTATED RINGERS IRRIGATION 20-30-600MG 3000ML BAG ![Compare how all Medicare Part D PDP plans in WI cover LACTATED RINGERS IRRIGATION 20-30-600MG 3000ML BAG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT ![Compare how all Medicare Part D PDP plans in WI cover LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LAMICTAL 100MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LAMICTAL 100MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LAMICTAL 150MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LAMICTAL 150MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LAMICTAL 200MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LAMICTAL 200MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LAMICTAL 25MG DISPER TABLET CHEW ![Compare how all Medicare Part D PDP plans in WI cover LAMICTAL 25MG DISPER TABLET CHEW.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LAMICTAL 25MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LAMICTAL 25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LAMICTAL 25MG TABLET STARTER KIT ![Compare how all Medicare Part D PDP plans in WI cover LAMICTAL 25MG TABLET STARTER KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 - Preferred Brand |
$36.00 | $72.00 | None |
LAMICTAL 5MG DISPER TABLET CHEW ![Compare how all Medicare Part D PDP plans in WI cover LAMICTAL 5MG DISPER TABLET CHEW.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LAMICTAL TABLET STARTER KIT ![Compare how all Medicare Part D PDP plans in WI cover LAMICTAL TABLET STARTER KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 - Preferred Brand |
$36.00 | $72.00 | None |
LAMICTAL TABLET STARTER KIT ![Compare how all Medicare Part D PDP plans in WI cover LAMICTAL TABLET STARTER KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 - Preferred Brand |
$36.00 | $72.00 | None |
LAMISIL 1% SOLUTION ![Compare how all Medicare Part D PDP plans in WI cover LAMISIL 1% SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMISIL 125MG GRANULES IN PACKET ![Compare how all Medicare Part D PDP plans in WI cover LAMISIL 125MG GRANULES IN PACKET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | P S |
LAMISIL 187.5MG GRANULES IN PACKET ![Compare how all Medicare Part D PDP plans in WI cover LAMISIL 187.5MG GRANULES IN PACKET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | P S |
LAMISIL 250MG TABLET (30 CT) ![Compare how all Medicare Part D PDP plans in WI cover LAMISIL 250MG TABLET (30 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | P S |
LAMOTRIGINE 150MG TABLET (60 CT) ![Compare how all Medicare Part D PDP plans in WI cover LAMOTRIGINE 150MG TABLET (60 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LAMOTRIGINE 200MG TABLET (60 CT) ![Compare how all Medicare Part D PDP plans in WI cover LAMOTRIGINE 200MG TABLET (60 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LAMOTRIGINE 25MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in WI cover LAMOTRIGINE 25MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE ![Compare how all Medicare Part D PDP plans in WI cover LAMOTRIGINE 25MG TABLET DISPERSIBLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE ![Compare how all Medicare Part D PDP plans in WI cover LAMOTRIGINE 5MG TABLET DISPERSIBLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LAMOTRIGINE TABLET 100MG (100 CT) ![Compare how all Medicare Part D PDP plans in WI cover LAMOTRIGINE TABLET 100MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LANOXIN 0.125MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LANOXIN 0.125MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LANOXIN 0.25MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LANOXIN 0.25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LANOXIN 0.25MG/ML AMPUL ![Compare how all Medicare Part D PDP plans in WI cover LANOXIN 0.25MG/ML AMPUL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LANOXIN PED 0.1MG/ML AMPUL ![Compare how all Medicare Part D PDP plans in WI cover LANOXIN PED 0.1MG/ML AMPUL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LANREOTIDE INJECTION 30MG ![Compare how all Medicare Part D PDP plans in WI cover LANREOTIDE INJECTION 30MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 - Specialty |
33% | 33% | None |
LANTUS 100U/ML VIAL ![Compare how all Medicare Part D PDP plans in WI cover LANTUS 100U/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LANTUS 100UNITS/ML CARTRIDGE ![Compare how all Medicare Part D PDP plans in WI cover LANTUS 100UNITS/ML CARTRIDGE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LANTUS INJECTION ![Compare how all Medicare Part D PDP plans in WI cover LANTUS INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LAPASE 15-1.2-15 CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LAPASE 15-1.2-15 CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 - Preferred Brand |
$36.00 | $72.00 | None |
LARIAM 250MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LARIAM 250MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LASIX 20MG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LASIX 20MG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LASIX 40MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LASIX 40MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LASIX 80MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LASIX 80MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEENA 7-9-5 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEENA 7-9-5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LEFLUNOMIDE 10MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in WI cover LEFLUNOMIDE 10MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LEFLUNOMIDE 20MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in WI cover LEFLUNOMIDE 20MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LESCOL 20MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LESCOL 20MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S Q:2 /1Days |
LESCOL 40MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LESCOL 40MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S Q:2 /1Days |
LESCOL XL 80MG TABLET SA ![Compare how all Medicare Part D PDP plans in WI cover LESCOL XL 80MG TABLET SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S Q:1 /1Days |
LESSINA 0.1-0.02 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LESSINA 0.1-0.02 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LETAIRIS 10MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LETAIRIS 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 - Specialty |
33% | 33% | None |
LETAIRIS 5MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LETAIRIS 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 - Specialty |
33% | 33% | None |
LEUCOVORIN CALCIUM 100MG VL ![Compare how all Medicare Part D PDP plans in WI cover LEUCOVORIN CALCIUM 100MG VL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | P |
LEUCOVORIN CALCIUM 10MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEUCOVORIN CALCIUM 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUCOVORIN CALCIUM 15MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEUCOVORIN CALCIUM 15MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEUCOVORIN CALCIUM 200MG VL ![Compare how all Medicare Part D PDP plans in WI cover LEUCOVORIN CALCIUM 200MG VL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | P |
LEUCOVORIN CALCIUM 25MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEUCOVORIN CALCIUM 25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LEUCOVORIN CALCIUM 350MG VL ![Compare how all Medicare Part D PDP plans in WI cover LEUCOVORIN CALCIUM 350MG VL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | P |
LEUCOVORIN CALCIUM 500MG VL ![Compare how all Medicare Part D PDP plans in WI cover LEUCOVORIN CALCIUM 500MG VL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | P |
LEUCOVORIN CALCIUM 50MG VL ![Compare how all Medicare Part D PDP plans in WI cover LEUCOVORIN CALCIUM 50MG VL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | P |
LEUCOVORIN CALCIUM 5MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEUCOVORIN CALCIUM 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LEUCOVORIN CALCIUM INJECTION 10MG/ML 1X50ML VIL CRTN ![Compare how all Medicare Part D PDP plans in WI cover LEUCOVORIN CALCIUM INJECTION 10MG/ML 1X50ML VIL CRTN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | P |
LEUKERAN 2MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEUKERAN 2MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 - Preferred Brand |
$36.00 | $72.00 | None |
LEUKINE 250MCG VIAL ![Compare how all Medicare Part D PDP plans in WI cover LEUKINE 250MCG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 - Specialty |
33% | 33% | None |
LEUKINE 500MCG/ML VIAL ![Compare how all Medicare Part D PDP plans in WI cover LEUKINE 500MCG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 - Specialty |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUPROLIDE 1MG/0.2ML VIAL ![Compare how all Medicare Part D PDP plans in WI cover LEUPROLIDE 1MG/0.2ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | P |
LEUPROLIDE 2WK 1MG/0.2ML KT ![Compare how all Medicare Part D PDP plans in WI cover LEUPROLIDE 2WK 1MG/0.2ML KT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | P |
LEUPROLIDE ACETATE INJECTION 14 DAY PATIENT ADMINISTRATION KIT 1-.7 1 X 2.8ML PKGCOM ![Compare how all Medicare Part D PDP plans in WI cover LEUPROLIDE ACETATE INJECTION 14 DAY PATIENT ADMINISTRATION KIT 1-.7 1 X 2.8ML PKGCOM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | P |
LEUSTATIN 1MG/ML VIAL ![Compare how all Medicare Part D PDP plans in WI cover LEUSTATIN 1MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 - Specialty |
33% | 33% | None |
LEVAQUIN 250MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVAQUIN 250MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LEVAQUIN 25MG/ML SOLUTION ![Compare how all Medicare Part D PDP plans in WI cover LEVAQUIN 25MG/ML SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LEVAQUIN 500MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVAQUIN 500MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LEVAQUIN 750MG LEVA-PAK TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVAQUIN 750MG LEVA-PAK TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LEVAQUIN 750MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVAQUIN 750MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LEVAQUIN IV 25MG/ML VIAL ![Compare how all Medicare Part D PDP plans in WI cover LEVAQUIN IV 25MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LEVAQUIN/D5W INJ 250/50ML ![Compare how all Medicare Part D PDP plans in WI cover LEVAQUIN/D5W INJ 250/50ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVAQUIN/D5W INJ 750/150 ![Compare how all Medicare Part D PDP plans in WI cover LEVAQUIN/D5W INJ 750/150.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LEVATOL 20MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVATOL 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S |
LEVEMIR 100UNITS/ML VIAL ![Compare how all Medicare Part D PDP plans in WI cover LEVEMIR 100UNITS/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 - Preferred Brand |
$36.00 | $72.00 | None |
LEVEMIR FLEXPEN 100UNITS/ML ![Compare how all Medicare Part D PDP plans in WI cover LEVEMIR FLEXPEN 100UNITS/ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 - Preferred Brand |
$36.00 | $72.00 | None |
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT ![Compare how all Medicare Part D PDP plans in WI cover LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LEVETIRACETAM 500 MG TABLET 120 BOT ![Compare how all Medicare Part D PDP plans in WI cover LEVETIRACETAM 500 MG TABLET 120 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LEVETIRACETAM TABLETS 1000MG 60 BOT ![Compare how all Medicare Part D PDP plans in WI cover LEVETIRACETAM TABLETS 1000MG 60 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LEVETIRACETAM TABLETS 250MG 500 BOT ![Compare how all Medicare Part D PDP plans in WI cover LEVETIRACETAM TABLETS 250MG 500 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LEVETIRACETAM TABLETS 750MG 500 BOT ![Compare how all Medicare Part D PDP plans in WI cover LEVETIRACETAM TABLETS 750MG 500 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LEVLITE-28 .02-1 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVLITE-28 .02-1 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LEVO-DROMORAN 2MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVO-DROMORAN 2MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVO-DROMORAN 2MG/ML AMPUL ![Compare how all Medicare Part D PDP plans in WI cover LEVO-DROMORAN 2MG/ML AMPUL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LEVOBUNOLOL 0.5% EYE DROPS ![Compare how all Medicare Part D PDP plans in WI cover LEVOBUNOLOL 0.5% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOBUNOLOL HCL OPHTHALMIC SOLUTION 0.25% 10ML BOT ![Compare how all Medicare Part D PDP plans in WI cover LEVOBUNOLOL HCL OPHTHALMIC SOLUTION 0.25% 10ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOCARNITINE 100MG/ML SOLUTION ORAL ![Compare how all Medicare Part D PDP plans in WI cover LEVOCARNITINE 100MG/ML SOLUTION ORAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LEVOCARNITINE 200MG/ML VIAL ![Compare how all Medicare Part D PDP plans in WI cover LEVOCARNITINE 200MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LEVOCARNITINE TABLET 330MG 90 BLPK ![Compare how all Medicare Part D PDP plans in WI cover LEVOCARNITINE TABLET 330MG 90 BLPK.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LEVORA-28 TABLET 0.15/30 ![Compare how all Medicare Part D PDP plans in WI cover LEVORA-28 TABLET 0.15/30.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LEVORPHANOL 2MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVORPHANOL 2MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LEVOTHROID 100MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHROID 100MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOTHROID 112MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHROID 112MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOTHROID 125MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHROID 125MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHROID 137MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHROID 137MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOTHROID 150MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHROID 150MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOTHROID 175MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHROID 175MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOTHROID 200MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHROID 200MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOTHROID 25MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHROID 25MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOTHROID 300MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHROID 300MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOTHROID 50MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHROID 50MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOTHROID 75MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHROID 75MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOTHROID 88MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHROID 88MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM .150MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHYROXINE SODIUM .150MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE SODIUM 100MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHYROXINE SODIUM 100MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 112MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHYROXINE SODIUM 112MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 125MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHYROXINE SODIUM 125MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHYROXINE SODIUM 137MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 175MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHYROXINE SODIUM 175MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 200MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHYROXINE SODIUM 200MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 25MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHYROXINE SODIUM 25MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 300MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHYROXINE SODIUM 300MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 50MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHYROXINE SODIUM 50MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 88MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHYROXINE SODIUM 88MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOXYL 100MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LEVOXYL 100MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 112MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LEVOXYL 112MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOXYL 125MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LEVOXYL 125MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOXYL 137MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LEVOXYL 137MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOXYL 150MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LEVOXYL 150MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOXYL 175MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LEVOXYL 175MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOXYL 200MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LEVOXYL 200MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOXYL 25MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LEVOXYL 25MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOXYL 50MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LEVOXYL 50MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOXYL 75MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LEVOXYL 75MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEVOXYL 88MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LEVOXYL 88MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LEXAPRO 10MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEXAPRO 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEXAPRO 20MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEXAPRO 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S Q:1 /1Days |
LEXAPRO 5MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEXAPRO 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S Q:1 /1Days |
LEXAPRO 5MG/5ML SOLUTION ![Compare how all Medicare Part D PDP plans in WI cover LEXAPRO 5MG/5ML SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S Q:20 /1Days |
LEXIVA 50MG/ML SUSPENSION ORAL ![Compare how all Medicare Part D PDP plans in WI cover LEXIVA 50MG/ML SUSPENSION ORAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LEXIVA 700MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEXIVA 700MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LEXXEL 5 5 TABLET 5-5MG (30 CT) ![Compare how all Medicare Part D PDP plans in WI cover LEXXEL 5 5 TABLET 5-5MG (30 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LIALDA 1.2G TABLET DELAYED RELEASE ![Compare how all Medicare Part D PDP plans in WI cover LIALDA 1.2G TABLET DELAYED RELEASE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | Q:4 /1Days |
LIDOCAINE 5% OINTMENT ![Compare how all Medicare Part D PDP plans in WI cover LIDOCAINE 5% OINTMENT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LIDOCAINE HCL 0.5% VIAL ![Compare how all Medicare Part D PDP plans in WI cover LIDOCAINE HCL 0.5% VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LIDOCAINE HCL 1% SYRINGE 10 X 5ML SYR ![Compare how all Medicare Part D PDP plans in WI cover LIDOCAINE HCL 1% SYRINGE 10 X 5ML SYR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LIDOCAINE HCL 1% VIAL ![Compare how all Medicare Part D PDP plans in WI cover LIDOCAINE HCL 1% VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIDOCAINE HCL 2% JELLY ![Compare how all Medicare Part D PDP plans in WI cover LIDOCAINE HCL 2% JELLY.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LIDOCAINE HCL 2% JELLY 30ML TUBE ![Compare how all Medicare Part D PDP plans in WI cover LIDOCAINE HCL 2% JELLY 30ML TUBE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT ![Compare how all Medicare Part D PDP plans in WI cover LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM ![Compare how all Medicare Part D PDP plans in WI cover LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LIDODERM 5% PATCH ![Compare how all Medicare Part D PDP plans in WI cover LIDODERM 5% PATCH.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 - Preferred Brand |
$36.00 | $72.00 | None |
LIDOMAR VISCOUS 20MG/ML SOLUTION NON-ORAL ![Compare how all Medicare Part D PDP plans in WI cover LIDOMAR VISCOUS 20MG/ML SOLUTION NON-ORAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LIMBITROL DS TABLET 10-25MG ![Compare how all Medicare Part D PDP plans in WI cover LIMBITROL DS TABLET 10-25MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LIMBITROL TABLET 5-12.5MG ![Compare how all Medicare Part D PDP plans in WI cover LIMBITROL TABLET 5-12.5MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LINCOCIN 300MG/ML VIAL ![Compare how all Medicare Part D PDP plans in WI cover LINCOCIN 300MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LINDANE 1% LOTION ![Compare how all Medicare Part D PDP plans in WI cover LINDANE 1% LOTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LINDANE 1% SHAMPOO ![Compare how all Medicare Part D PDP plans in WI cover LINDANE 1% SHAMPOO.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIOTHYRONINE SODIUM INJECTION 10MCG ![Compare how all Medicare Part D PDP plans in WI cover LIOTHYRONINE SODIUM INJECTION 10MCG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LIPITOR 10MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LIPITOR 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 - Preferred Brand |
$36.00 | $72.00 | Q:1 /1Days |
LIPITOR 20MG TABLET (5000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LIPITOR 20MG TABLET (5000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 - Preferred Brand |
$36.00 | $72.00 | Q:1 /1Days |
LIPITOR 40MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in WI cover LIPITOR 40MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 - Preferred Brand |
$36.00 | $72.00 | Q:1 /1Days |
LIPITOR 80MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LIPITOR 80MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 - Preferred Brand |
$36.00 | $72.00 | Q:1 /1Days |
LIPOFEN 150MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LIPOFEN 150MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LIPOFEN 50MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LIPOFEN 50MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LIPRAM 4500 CAPSULE EC ![Compare how all Medicare Part D PDP plans in WI cover LIPRAM 4500 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 - Preferred Brand |
$36.00 | $72.00 | None |
LIPRAM-PN10 CAPSULE EC ![Compare how all Medicare Part D PDP plans in WI cover LIPRAM-PN10 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 - Preferred Brand |
$36.00 | $72.00 | None |
LIPRAM-PN16 CAPSULE EC ![Compare how all Medicare Part D PDP plans in WI cover LIPRAM-PN16 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 - Preferred Brand |
$36.00 | $72.00 | None |
LIPRAM-PN20 CAPSULE EC ![Compare how all Medicare Part D PDP plans in WI cover LIPRAM-PN20 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 - Preferred Brand |
$36.00 | $72.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIPRAM-UL12 CAPSULE EC ![Compare how all Medicare Part D PDP plans in WI cover LIPRAM-UL12 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 - Preferred Brand |
$36.00 | $72.00 | None |
LIPRAM-UL18 CAPSULE EC ![Compare how all Medicare Part D PDP plans in WI cover LIPRAM-UL18 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 - Preferred Brand |
$36.00 | $72.00 | None |
LIPRAM-UL20 CAPSULE EC ![Compare how all Medicare Part D PDP plans in WI cover LIPRAM-UL20 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 - Preferred Brand |
$36.00 | $72.00 | None |
LIQUADD 5MG/5ML SOLUTION ![Compare how all Medicare Part D PDP plans in WI cover LIQUADD 5MG/5ML SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | P Q:60 /1Days |
LISINOPRIL 10MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in WI cover LISINOPRIL 10MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | Q:2 /1Days |
LISINOPRIL 2.5MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LISINOPRIL 2.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | Q:2 /1Days |
LISINOPRIL 20MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LISINOPRIL 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | Q:2 /1Days |
LISINOPRIL 30MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in WI cover LISINOPRIL 30MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | Q:2 /1Days |
LISINOPRIL 40MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in WI cover LISINOPRIL 40MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LISINOPRIL 5MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LISINOPRIL 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | Q:2 /1Days |
LISINOPRIL-HCTZ 10/12.5 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LISINOPRIL-HCTZ 10/12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in WI cover LISINOPRIL-HCTZ 20-25MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LISINOPRIL-HCTZ 20/12.5 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LISINOPRIL-HCTZ 20/12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LITHIUM CARBONATE 150MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LITHIUM CARBONATE 150MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) ![Compare how all Medicare Part D PDP plans in WI cover LITHIUM CARBONATE 300MG CAPSULE (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LITHIUM CARBONATE 300MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LITHIUM CARBONATE 300MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LITHIUM CARBONATE 450MG TABLET SA ![Compare how all Medicare Part D PDP plans in WI cover LITHIUM CARBONATE 450MG TABLET SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LITHIUM CARBONATE 600MG CAP ![Compare how all Medicare Part D PDP plans in WI cover LITHIUM CARBONATE 600MG CAP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) ![Compare how all Medicare Part D PDP plans in WI cover LITHIUM CARBONATE ER TABLET 300MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP ![Compare how all Medicare Part D PDP plans in WI cover LITHIUM CIT 8MEQ/5ML SYRUP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LITHOBID 300MG TABLET SA ![Compare how all Medicare Part D PDP plans in WI cover LITHOBID 300MG TABLET SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LITHOSTAT 250MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LITHOSTAT 250MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LO/OVRAL-28 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LO/OVRAL-28 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOCOID 0.1% CREAM ![Compare how all Medicare Part D PDP plans in WI cover LOCOID 0.1% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOCOID 0.1% LIPOCREAM CREAM 60GM TUBE ![Compare how all Medicare Part D PDP plans in WI cover LOCOID 0.1% LIPOCREAM CREAM 60GM TUBE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOCOID 0.1% OINTMENT 15GM TUBE ![Compare how all Medicare Part D PDP plans in WI cover LOCOID 0.1% OINTMENT 15GM TUBE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOCOID 0.1% SOLUTION ![Compare how all Medicare Part D PDP plans in WI cover LOCOID 0.1% SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOCOID LOTN 0.1 % ![Compare how all Medicare Part D PDP plans in WI cover LOCOID LOTN 0.1 %.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LODOSYN 25MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LODOSYN 25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOESTRIN 21 1.5/30 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOESTRIN 21 1.5/30 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOESTRIN 21 1/20 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOESTRIN 21 1/20 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOESTRIN 24 FE TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOESTRIN 24 FE TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOESTRIN FE 1-0.02MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOESTRIN FE 1-0.02MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOFENE 2.5MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOFENE 2.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | P |
LOFIBRA 134MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOFIBRA 134MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOFIBRA 160MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOFIBRA 160MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOFIBRA 200MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOFIBRA 200MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOFIBRA 54MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOFIBRA 54MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOFIBRA 67MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOFIBRA 67MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOKARA 0.05% LOTION ![Compare how all Medicare Part D PDP plans in WI cover LOKARA 0.05% LOTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LOMOTIL LIQ 2.5/5 ![Compare how all Medicare Part D PDP plans in WI cover LOMOTIL LIQ 2.5/5.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | P |
LOMOTIL TABLET 0.025-2.5MG (500 CT) ![Compare how all Medicare Part D PDP plans in WI cover LOMOTIL TABLET 0.025-2.5MG (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | P |
LONOX 2.5MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LONOX 2.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | P |
LOPERAMIDE HCL 2MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOPERAMIDE HCL 2MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOPID 600MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in WI cover LOPID 600MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOPRESSOR 100MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in WI cover LOPRESSOR 100MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S |
LOPRESSOR 1MG/ML AMPUL ![Compare how all Medicare Part D PDP plans in WI cover LOPRESSOR 1MG/ML AMPUL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S |
LOPRESSOR 50MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in WI cover LOPRESSOR 50MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S |
LOPRESSOR HCT 100/25 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOPRESSOR HCT 100/25 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOPRESSOR HCT 100/50 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOPRESSOR HCT 100/50 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOPRESSOR HCT 50/25 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOPRESSOR HCT 50/25 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOPROX 0.77% CREAM ![Compare how all Medicare Part D PDP plans in WI cover LOPROX 0.77% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOPROX 0.77% TOPICAL SUSP ![Compare how all Medicare Part D PDP plans in WI cover LOPROX 0.77% TOPICAL SUSP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOPROX 1% SHAMPOO ![Compare how all Medicare Part D PDP plans in WI cover LOPROX 1% SHAMPOO.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOPROX GEL TOPICAL ![Compare how all Medicare Part D PDP plans in WI cover LOPROX GEL TOPICAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LORCET 10/650 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LORCET 10/650 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S |
LORCET PLUS TABLET 7.5-650 ![Compare how all Medicare Part D PDP plans in WI cover LORCET PLUS TABLET 7.5-650.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S |
LORTAB 10/500MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LORTAB 10/500MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S |
LORTAB 2.5/500 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LORTAB 2.5/500 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S |
LORTAB 5/500 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LORTAB 5/500 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S |
LORTAB 7.5/500 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LORTAB 7.5/500 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S |
LORTAB ELIXIR 500-7.5MG/15ML ![Compare how all Medicare Part D PDP plans in WI cover LORTAB ELIXIR 500-7.5MG/15ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S |
LOTEMAX 0.5% EYE DROPS ![Compare how all Medicare Part D PDP plans in WI cover LOTEMAX 0.5% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 - Preferred Brand |
$36.00 | $72.00 | None |
LOTENSIN 10MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOTENSIN 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | Q:2 /1Days |
LOTENSIN 20MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOTENSIN 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | Q:2 /1Days |
LOTENSIN 40MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOTENSIN 40MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOTENSIN 5MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOTENSIN 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | Q:2 /1Days |
LOTENSIN HCT 10/12.5 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOTENSIN HCT 10/12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOTENSIN HCT 20/12.5 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOTENSIN HCT 20/12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOTENSIN HCT 20/25 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOTENSIN HCT 20/25 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOTENSIN HCT 5/6.25 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOTENSIN HCT 5/6.25 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOTREL 10/20MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOTREL 10/20MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOTREL 10/40MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOTREL 10/40MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOTREL 2.5/10MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOTREL 2.5/10MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOTREL 5/10MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOTREL 5/10MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOTREL 5/20MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOTREL 5/20MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOTREL 5/40MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOTREL 5/40MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOTRISONE CREAM ![Compare how all Medicare Part D PDP plans in WI cover LOTRISONE CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOTRISONE LOTION ![Compare how all Medicare Part D PDP plans in WI cover LOTRISONE LOTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOTRONEX 0.5MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOTRONEX 0.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 - Preferred Brand |
$36.00 | $72.00 | P |
LOTRONEX 1MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOTRONEX 1MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 - Preferred Brand |
$36.00 | $72.00 | P |
LOVASTATIN 10MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in WI cover LOVASTATIN 10MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:2 /1Days |
LOVASTATIN 20MG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LOVASTATIN 20MG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:2 /1Days |
LOVASTATIN 40MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in WI cover LOVASTATIN 40MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | Q:2 /1Days |
LOVAZA 1G CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOVAZA 1G CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 - Preferred Brand |
$36.00 | $72.00 | None |
LOVENOX 100MG PREFILLED SYR ![Compare how all Medicare Part D PDP plans in WI cover LOVENOX 100MG PREFILLED SYR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 - Specialty |
33% | 33% | None |
LOVENOX 120MG PREFILLED SYR ![Compare how all Medicare Part D PDP plans in WI cover LOVENOX 120MG PREFILLED SYR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 - Specialty |
33% | 33% | None |
LOVENOX 150MG PREFILLED SYR ![Compare how all Medicare Part D PDP plans in WI cover LOVENOX 150MG PREFILLED SYR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 - Specialty |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOVENOX 300MG VIAL ![Compare how all Medicare Part D PDP plans in WI cover LOVENOX 300MG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 - Specialty |
33% | 33% | None |
LOVENOX 30MG PREFILLED SYRN ![Compare how all Medicare Part D PDP plans in WI cover LOVENOX 30MG PREFILLED SYRN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOVENOX 40MG PREFILLED SYRN ![Compare how all Medicare Part D PDP plans in WI cover LOVENOX 40MG PREFILLED SYRN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOVENOX 60MG PREFILLED SYRN ![Compare how all Medicare Part D PDP plans in WI cover LOVENOX 60MG PREFILLED SYRN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 - Specialty |
33% | 33% | None |
LOVENOX 80MG PREFILLED SYRN ![Compare how all Medicare Part D PDP plans in WI cover LOVENOX 80MG PREFILLED SYRN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 - Specialty |
33% | 33% | None |
LOW-OGESTREL-28 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOW-OGESTREL-28 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LOXAPINE 10MG CAPSULE (1000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LOXAPINE 10MG CAPSULE (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LOXAPINE 25MG CAPSULE (100 CT) ![Compare how all Medicare Part D PDP plans in WI cover LOXAPINE 25MG CAPSULE (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LOXAPINE 50MG CAPSULE (1000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LOXAPINE 50MG CAPSULE (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LOXAPINE 5MG CAPSULE (100 CT) ![Compare how all Medicare Part D PDP plans in WI cover LOXAPINE 5MG CAPSULE (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LOXITANE 10MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOXITANE 10MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOXITANE 25MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOXITANE 25MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOXITANE 50MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOXITANE 50MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LOXITANE 5MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOXITANE 5MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LUFYLLIN 200MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LUFYLLIN 200MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LUFYLLIN-400 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LUFYLLIN-400 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LUMIGAN 0.03% EYE DROPS ![Compare how all Medicare Part D PDP plans in WI cover LUMIGAN 0.03% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 - Preferred Brand |
$36.00 | $72.00 | None |
LUNESTA 1MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LUNESTA 1MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S Q:1 /1Days |
LUNESTA 2MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LUNESTA 2MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S Q:1 /1Days |
LUNESTA 3MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LUNESTA 3MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S Q:1 /1Days |
LUPRON 2-WK 1MG/0.2ML KIT ![Compare how all Medicare Part D PDP plans in WI cover LUPRON 2-WK 1MG/0.2ML KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 - Specialty |
33% | 33% | P |
LUPRON 6-PK INJ 5MG/ML ![Compare how all Medicare Part D PDP plans in WI cover LUPRON 6-PK INJ 5MG/ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 - Specialty |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUPRON DEPOT 3.75MG KIT ![Compare how all Medicare Part D PDP plans in WI cover LUPRON DEPOT 3.75MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | P |
LUPRON DEPOT 7.5MG KIT ![Compare how all Medicare Part D PDP plans in WI cover LUPRON DEPOT 7.5MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 - Specialty |
33% | 33% | P |
LUPRON DEPOT-3 MONTH KIT ![Compare how all Medicare Part D PDP plans in WI cover LUPRON DEPOT-3 MONTH KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 - Specialty |
33% | 33% | P |
LUPRON DEPOT-3 MONTH KIT ![Compare how all Medicare Part D PDP plans in WI cover LUPRON DEPOT-3 MONTH KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | P |
LUPRON DEPOT-4 MONTH KIT ![Compare how all Medicare Part D PDP plans in WI cover LUPRON DEPOT-4 MONTH KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 - Specialty |
33% | 33% | P |
LUPRON DEPOT-PED 11.25MG KT ![Compare how all Medicare Part D PDP plans in WI cover LUPRON DEPOT-PED 11.25MG KT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 - Specialty |
33% | 33% | P |
LUPRON DEPOT-PED 15MG KIT ![Compare how all Medicare Part D PDP plans in WI cover LUPRON DEPOT-PED 15MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 - Specialty |
33% | 33% | P |
LUPRON DEPOT-PED 7.5MG KIT ![Compare how all Medicare Part D PDP plans in WI cover LUPRON DEPOT-PED 7.5MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 - Specialty |
33% | 33% | P |
LUTERA 0.1-0.02 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LUTERA 0.1-0.02 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 - Non-Preferred Generic |
$10.00 | $20.00 | None |
LUVOX CR 100MG CAPSULE SR 24 HR ![Compare how all Medicare Part D PDP plans in WI cover LUVOX CR 100MG CAPSULE SR 24 HR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S Q:2 /1Days |
LUVOX CR 150MG CAPSULE SR 24 HR ![Compare how all Medicare Part D PDP plans in WI cover LUVOX CR 150MG CAPSULE SR 24 HR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUXIQ 0.12% FOAM ![Compare how all Medicare Part D PDP plans in WI cover LUXIQ 0.12% FOAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LYBREL 90-20MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LYBREL 90-20MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | None |
LYRICA 100MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LYRICA 100MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S Q:3 /1Days |
LYRICA 150MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LYRICA 150MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S Q:3 /1Days |
LYRICA 200MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LYRICA 200MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S Q:3 /1Days |
LYRICA 225MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LYRICA 225MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S Q:2 /1Days |
LYRICA 25MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LYRICA 25MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S Q:3 /1Days |
LYRICA 300MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LYRICA 300MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S Q:2 /1Days |
LYRICA 50MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LYRICA 50MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S Q:3 /1Days |
LYRICA 75MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LYRICA 75MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 - Non-Preferred Brand |
$77.00 | $154.00 | S Q:3 /1Days |
LYSODREN 500MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LYSODREN 500MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 - Specialty |
33% | 33% | None |