2009 Medicare Part D Plan Formulary Information |
MedicareRx Rewards Value (S5960-006-0)
Sanctioned Plan
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The MedicareRx Rewards Value (S5960-006-0) Formulary Drugs Starting with the Letter L in CMS PDP Region 6 which includes: PA WV
|
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 PA cover LABETALOL HCL 100MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LABETALOL HCL 200MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LABETALOL HCL 200MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LABETALOL HCL 300MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LABETALOL HCL 300MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LABETALOL HCL 5MG/20ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover LABETALOL HCL 5MG/20ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
LACLOTION 12% LOTION ![Compare how all Medicare Part D PDP plans in PA cover LACLOTION 12% LOTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LACRISERT OPTHALMIC INSERT 5MG 60 BLPK ![Compare how all Medicare Part D PDP plans in PA cover LACRISERT OPTHALMIC INSERT 5MG 60 BLPK.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | Q:120 /30Days |
LACTATED RINGERS INJECTION ![Compare how all Medicare Part D PDP plans in PA cover LACTATED RINGERS INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
LACTATED RINGERS IRRIGATION 20-30-600MG 3000ML BAG ![Compare how all Medicare Part D PDP plans in PA cover LACTATED RINGERS IRRIGATION 20-30-600MG 3000ML BAG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT ![Compare how all Medicare Part D PDP plans in PA cover LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LAMICTAL 25MG TABLET STARTER KIT ![Compare how all Medicare Part D PDP plans in PA cover LAMICTAL 25MG TABLET STARTER KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMICTAL TABLET STARTER KIT ![Compare how all Medicare Part D PDP plans in PA cover LAMICTAL TABLET STARTER KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | None |
LAMICTAL TABLET STARTER KIT ![Compare how all Medicare Part D PDP plans in PA cover LAMICTAL TABLET STARTER KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | None |
LAMOTRIGINE 150MG TABLET (60 CT) ![Compare how all Medicare Part D PDP plans in PA cover LAMOTRIGINE 150MG TABLET (60 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:60 /30Days |
LAMOTRIGINE 200MG TABLET (60 CT) ![Compare how all Medicare Part D PDP plans in PA cover LAMOTRIGINE 200MG TABLET (60 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:60 /30Days |
LAMOTRIGINE 25MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover LAMOTRIGINE 25MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:90 /30Days |
LAMOTRIGINE 25MG TABLET DISPERSIBLE ![Compare how all Medicare Part D PDP plans in PA cover LAMOTRIGINE 25MG TABLET DISPERSIBLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:90 /30Days |
LAMOTRIGINE 5MG TABLET DISPERSIBLE ![Compare how all Medicare Part D PDP plans in PA cover LAMOTRIGINE 5MG TABLET DISPERSIBLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:120 /30Days |
LAMOTRIGINE TABLET 100MG (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover LAMOTRIGINE TABLET 100MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:150 /30Days |
LANOXIN 0.125MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LANOXIN 0.125MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | None |
LANOXIN 0.25MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LANOXIN 0.25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | None |
LANOXIN 0.25MG/ML AMPUL ![Compare how all Medicare Part D PDP plans in PA cover LANOXIN 0.25MG/ML AMPUL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LANOXIN PED 0.1MG/ML AMPUL ![Compare how all Medicare Part D PDP plans in PA cover LANOXIN PED 0.1MG/ML AMPUL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
LANTUS 100U/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover LANTUS 100U/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | None |
LANTUS 100UNITS/ML CARTRIDGE ![Compare how all Medicare Part D PDP plans in PA cover LANTUS 100UNITS/ML CARTRIDGE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | None |
LANTUS INJECTION ![Compare how all Medicare Part D PDP plans in PA cover LANTUS INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | None |
LAPASE 15-1.2-15 CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover LAPASE 15-1.2-15 CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEENA 7-9-5 TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEENA 7-9-5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:28 /28Days |
LEFLUNOMIDE 10MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in PA cover LEFLUNOMIDE 10MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEFLUNOMIDE 20MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in PA cover LEFLUNOMIDE 20MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LESSINA 0.1-0.02 TABLET ![Compare how all Medicare Part D PDP plans in PA cover LESSINA 0.1-0.02 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:28 /28Days |
LETAIRIS 10MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LETAIRIS 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5. |
29% | N/A | None |
LETAIRIS 5MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LETAIRIS 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5. |
29% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUCOVORIN CALCIUM 100MG VL ![Compare how all Medicare Part D PDP plans in PA cover LEUCOVORIN CALCIUM 100MG VL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
LEUCOVORIN CALCIUM 10MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEUCOVORIN CALCIUM 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEUCOVORIN CALCIUM 15MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEUCOVORIN CALCIUM 15MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEUCOVORIN CALCIUM 200MG VL ![Compare how all Medicare Part D PDP plans in PA cover LEUCOVORIN CALCIUM 200MG VL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
LEUCOVORIN CALCIUM 25MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEUCOVORIN CALCIUM 25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEUCOVORIN CALCIUM 350MG VL ![Compare how all Medicare Part D PDP plans in PA cover LEUCOVORIN CALCIUM 350MG VL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
LEUCOVORIN CALCIUM 500MG VL ![Compare how all Medicare Part D PDP plans in PA cover LEUCOVORIN CALCIUM 500MG VL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
LEUCOVORIN CALCIUM 50MG VL ![Compare how all Medicare Part D PDP plans in PA cover LEUCOVORIN CALCIUM 50MG VL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
LEUCOVORIN CALCIUM 5MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEUCOVORIN CALCIUM 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEUCOVORIN CALCIUM INJECTION 10MG/ML 1X50ML VIL CRTN ![Compare how all Medicare Part D PDP plans in PA cover LEUCOVORIN CALCIUM INJECTION 10MG/ML 1X50ML VIL CRTN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
LEUKERAN 2MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEUKERAN 2MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUKINE 250MCG VIAL ![Compare how all Medicare Part D PDP plans in PA cover LEUKINE 250MCG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5. |
29% | N/A | P |
LEUKINE 500MCG/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover LEUKINE 500MCG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5. |
29% | N/A | P |
LEUPROLIDE 1MG/0.2ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover LEUPROLIDE 1MG/0.2ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5. |
29% | N/A | P |
LEUPROLIDE 2WK 1MG/0.2ML KT ![Compare how all Medicare Part D PDP plans in PA cover LEUPROLIDE 2WK 1MG/0.2ML KT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | 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 PA 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) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | P |
LEUSTATIN 1MG/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover LEUSTATIN 1MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5. |
29% | N/A | None |
LEVAQUIN 250MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEVAQUIN 250MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | Q:21 /1Days |
LEVAQUIN 25MG/ML SOLUTION ![Compare how all Medicare Part D PDP plans in PA cover LEVAQUIN 25MG/ML SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | None |
LEVAQUIN 500MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEVAQUIN 500MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | Q:21 /1Days |
LEVAQUIN 750MG LEVA-PAK TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEVAQUIN 750MG LEVA-PAK TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | Q:5 /1Days |
LEVAQUIN 750MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEVAQUIN 750MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | Q:21 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVAQUIN IV 25MG/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover LEVAQUIN IV 25MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
LEVAQUIN/D5W INJ 250/50ML ![Compare how all Medicare Part D PDP plans in PA cover LEVAQUIN/D5W INJ 250/50ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
LEVAQUIN/D5W INJ 750/150 ![Compare how all Medicare Part D PDP plans in PA cover LEVAQUIN/D5W INJ 750/150.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
LEVEMIR 100UNITS/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover LEVEMIR 100UNITS/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | None |
LEVEMIR FLEXPEN 100UNITS/ML ![Compare how all Medicare Part D PDP plans in PA cover LEVEMIR FLEXPEN 100UNITS/ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | None |
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT ![Compare how all Medicare Part D PDP plans in PA cover LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVETIRACETAM 500 MG TABLET 120 BOT ![Compare how all Medicare Part D PDP plans in PA cover LEVETIRACETAM 500 MG TABLET 120 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVETIRACETAM TABLETS 1000MG 60 BOT ![Compare how all Medicare Part D PDP plans in PA cover LEVETIRACETAM TABLETS 1000MG 60 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVETIRACETAM TABLETS 250MG 500 BOT ![Compare how all Medicare Part D PDP plans in PA cover LEVETIRACETAM TABLETS 250MG 500 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVETIRACETAM TABLETS 750MG 500 BOT ![Compare how all Medicare Part D PDP plans in PA cover LEVETIRACETAM TABLETS 750MG 500 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVLITE-28 .02-1 TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEVLITE-28 .02-1 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:28 /28Days |
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 PA cover LEVO-DROMORAN 2MG/ML AMPUL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
LEVOBUNOLOL 0.5% EYE DROPS ![Compare how all Medicare Part D PDP plans in PA cover LEVOBUNOLOL 0.5% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:30 /30Days |
LEVOBUNOLOL HCL OPHTHALMIC SOLUTION 0.25% 10ML BOT ![Compare how all Medicare Part D PDP plans in PA 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 |
$10.00 | $15.00 | Q:30 /30Days |
LEVOCARNITINE 100MG/ML SOLUTION ORAL ![Compare how all Medicare Part D PDP plans in PA cover LEVOCARNITINE 100MG/ML SOLUTION ORAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOCARNITINE 200MG/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover LEVOCARNITINE 200MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
LEVOCARNITINE TABLET 330MG 90 BLPK ![Compare how all Medicare Part D PDP plans in PA cover LEVOCARNITINE TABLET 330MG 90 BLPK.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVORA-28 TABLET 0.15/30 ![Compare how all Medicare Part D PDP plans in PA cover LEVORA-28 TABLET 0.15/30.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:28 /28Days |
LEVORPHANOL 2MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEVORPHANOL 2MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOTHROID 100MCG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEVOTHROID 100MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOTHROID 112MCG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEVOTHROID 112MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOTHROID 125MCG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEVOTHROID 125MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | 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 PA cover LEVOTHROID 137MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOTHROID 150MCG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEVOTHROID 150MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOTHROID 175MCG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEVOTHROID 175MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOTHROID 200MCG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEVOTHROID 200MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOTHROID 25MCG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEVOTHROID 25MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOTHROID 300MCG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEVOTHROID 300MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOTHROID 50MCG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEVOTHROID 50MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOTHROID 75MCG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEVOTHROID 75MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOTHROID 88MCG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEVOTHROID 88MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in PA cover LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOTHYROXINE SODIUM .150MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover LEVOTHYROXINE SODIUM .150MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | 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 PA cover LEVOTHYROXINE SODIUM 100MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 112MCG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEVOTHYROXINE SODIUM 112MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 125MCG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEVOTHYROXINE SODIUM 125MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEVOTHYROXINE SODIUM 137MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 175MCG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEVOTHYROXINE SODIUM 175MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 200MCG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEVOTHYROXINE SODIUM 200MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 25MCG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEVOTHYROXINE SODIUM 25MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 300MCG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEVOTHYROXINE SODIUM 300MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 50MCG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEVOTHYROXINE SODIUM 50MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOTHYROXINE SODIUM 88MCG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEVOTHYROXINE SODIUM 88MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOXYL 100MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in PA cover LEVOXYL 100MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | 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 PA cover LEVOXYL 112MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOXYL 125MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in PA cover LEVOXYL 125MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOXYL 137MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in PA cover LEVOXYL 137MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOXYL 150MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in PA cover LEVOXYL 150MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOXYL 175MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in PA cover LEVOXYL 175MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOXYL 200MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in PA cover LEVOXYL 200MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOXYL 25MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in PA cover LEVOXYL 25MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOXYL 50MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in PA cover LEVOXYL 50MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOXYL 75MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in PA cover LEVOXYL 75MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEVOXYL 88MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in PA cover LEVOXYL 88MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LEXAPRO 10MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEXAPRO 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | Q:30 /30Days |
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 PA cover LEXAPRO 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | Q:30 /30Days |
LEXAPRO 5MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEXAPRO 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | Q:30 /30Days |
LEXAPRO 5MG/5ML SOLUTION ![Compare how all Medicare Part D PDP plans in PA cover LEXAPRO 5MG/5ML SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | Q:600 /30Days |
LEXIVA 50MG/ML SUSPENSION ORAL ![Compare how all Medicare Part D PDP plans in PA cover LEXIVA 50MG/ML SUSPENSION ORAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5. |
29% | N/A | None |
LEXIVA 700MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEXIVA 700MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5. |
29% | N/A | None |
LIDOCAINE 5% OINTMENT ![Compare how all Medicare Part D PDP plans in PA cover LIDOCAINE 5% OINTMENT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LIDOCAINE HCL 0.5% VIAL ![Compare how all Medicare Part D PDP plans in PA cover LIDOCAINE HCL 0.5% VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
LIDOCAINE HCL 1% SYRINGE 10 X 5ML SYR ![Compare how all Medicare Part D PDP plans in PA cover LIDOCAINE HCL 1% SYRINGE 10 X 5ML SYR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | P |
LIDOCAINE HCL 1% VIAL ![Compare how all Medicare Part D PDP plans in PA cover LIDOCAINE HCL 1% VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
LIDOCAINE HCL 2% JELLY ![Compare how all Medicare Part D PDP plans in PA cover LIDOCAINE HCL 2% JELLY.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LIDOCAINE HCL 2% JELLY 30ML TUBE ![Compare how all Medicare Part D PDP plans in PA cover LIDOCAINE HCL 2% JELLY 30ML TUBE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT ![Compare how all Medicare Part D PDP plans in PA cover LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM ![Compare how all Medicare Part D PDP plans in PA cover LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:30 /30Days |
LIDODERM 5% PATCH ![Compare how all Medicare Part D PDP plans in PA cover LIDODERM 5% PATCH.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | None |
LIDOMAR VISCOUS 20MG/ML SOLUTION NON-ORAL ![Compare how all Medicare Part D PDP plans in PA cover LIDOMAR VISCOUS 20MG/ML SOLUTION NON-ORAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LINCOCIN 300MG/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover LINCOCIN 300MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
LINDANE 1% LOTION ![Compare how all Medicare Part D PDP plans in PA cover LINDANE 1% LOTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LINDANE 1% SHAMPOO ![Compare how all Medicare Part D PDP plans in PA cover LINDANE 1% SHAMPOO.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LIOTHYRONINE SODIUM INJECTION 10MCG ![Compare how all Medicare Part D PDP plans in PA cover LIOTHYRONINE SODIUM INJECTION 10MCG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5. |
29% | N/A | None |
LIPITOR 10MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LIPITOR 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | Q:30 /30Days |
LIPITOR 20MG TABLET (5000 CT) ![Compare how all Medicare Part D PDP plans in PA cover LIPITOR 20MG TABLET (5000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | Q:30 /30Days |
LIPITOR 40MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in PA cover LIPITOR 40MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIPITOR 80MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LIPITOR 80MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | Q:30 /30Days |
LIPRAM 4500 CAPSULE EC ![Compare how all Medicare Part D PDP plans in PA cover LIPRAM 4500 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LIPRAM-PN10 CAPSULE EC ![Compare how all Medicare Part D PDP plans in PA cover LIPRAM-PN10 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LIPRAM-PN16 CAPSULE EC ![Compare how all Medicare Part D PDP plans in PA cover LIPRAM-PN16 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LIPRAM-PN20 CAPSULE EC ![Compare how all Medicare Part D PDP plans in PA cover LIPRAM-PN20 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LIPRAM-UL12 CAPSULE EC ![Compare how all Medicare Part D PDP plans in PA cover LIPRAM-UL12 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LIPRAM-UL18 CAPSULE EC ![Compare how all Medicare Part D PDP plans in PA cover LIPRAM-UL18 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LIPRAM-UL20 CAPSULE EC ![Compare how all Medicare Part D PDP plans in PA cover LIPRAM-UL20 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LISINOPRIL 10MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover LISINOPRIL 10MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LISINOPRIL 2.5MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LISINOPRIL 2.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LISINOPRIL 20MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LISINOPRIL 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL 30MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover LISINOPRIL 30MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LISINOPRIL 40MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in PA cover LISINOPRIL 40MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LISINOPRIL 5MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LISINOPRIL 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LISINOPRIL-HCTZ 10/12.5 TABLET ![Compare how all Medicare Part D PDP plans in PA cover LISINOPRIL-HCTZ 10/12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover LISINOPRIL-HCTZ 20-25MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LISINOPRIL-HCTZ 20/12.5 TABLET ![Compare how all Medicare Part D PDP plans in PA cover LISINOPRIL-HCTZ 20/12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LITHIUM CARBONATE ![Compare how all Medicare Part D PDP plans in PA cover LITHIUM CARBONATE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LITHIUM CARBONATE 150MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover LITHIUM CARBONATE 150MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover LITHIUM CARBONATE 300MG CAPSULE (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LITHIUM CARBONATE 300MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LITHIUM CARBONATE 300MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LITHIUM CARBONATE 450MG TABLET SA ![Compare how all Medicare Part D PDP plans in PA cover LITHIUM CARBONATE 450MG TABLET SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LITHIUM CARBONATE 600MG CAP ![Compare how all Medicare Part D PDP plans in PA cover LITHIUM CARBONATE 600MG CAP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover LITHIUM CARBONATE ER TABLET 300MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP ![Compare how all Medicare Part D PDP plans in PA cover LITHIUM CIT 8MEQ/5ML SYRUP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LITHOBID 300MG TABLET SA ![Compare how all Medicare Part D PDP plans in PA cover LITHOBID 300MG TABLET SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | None |
LOFENE 2.5MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LOFENE 2.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LOKARA 0.05% LOTION ![Compare how all Medicare Part D PDP plans in PA cover LOKARA 0.05% LOTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LONOX 2.5MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LONOX 2.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LOPERAMIDE HCL 2MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover LOPERAMIDE HCL 2MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
LOPRESSOR 1MG/ML AMPUL ![Compare how all Medicare Part D PDP plans in PA cover LOPRESSOR 1MG/ML AMPUL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
LOTREL 10/40MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover LOTREL 10/40MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | None |
LOTREL 5/40MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover LOTREL 5/40MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOTRONEX 0.5MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LOTRONEX 0.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | P Q:60 /30Days |
LOTRONEX 1MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LOTRONEX 1MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | P Q:60 /30Days |
LOVASTATIN 10MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover LOVASTATIN 10MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:30 /30Days |
LOVASTATIN 20MG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in PA cover LOVASTATIN 20MG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:30 /30Days |
LOVASTATIN 40MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover LOVASTATIN 40MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:60 /30Days |
LOVAZA 1G CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover LOVAZA 1G CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | None |
LOVENOX 100MG PREFILLED SYR ![Compare how all Medicare Part D PDP plans in PA cover LOVENOX 100MG PREFILLED SYR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5. |
29% | N/A | None |
LOVENOX 120MG PREFILLED SYR ![Compare how all Medicare Part D PDP plans in PA cover LOVENOX 120MG PREFILLED SYR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5. |
29% | N/A | None |
LOVENOX 150MG PREFILLED SYR ![Compare how all Medicare Part D PDP plans in PA cover LOVENOX 150MG PREFILLED SYR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5. |
29% | N/A | None |
LOVENOX 300MG VIAL ![Compare how all Medicare Part D PDP plans in PA cover LOVENOX 300MG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5. |
29% | N/A | None |
LOVENOX 30MG PREFILLED SYRN ![Compare how all Medicare Part D PDP plans in PA cover LOVENOX 30MG PREFILLED SYRN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOVENOX 40MG PREFILLED SYRN ![Compare how all Medicare Part D PDP plans in PA cover LOVENOX 40MG PREFILLED SYRN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
LOVENOX 60MG PREFILLED SYRN ![Compare how all Medicare Part D PDP plans in PA cover LOVENOX 60MG PREFILLED SYRN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5. |
29% | N/A | None |
LOVENOX 80MG PREFILLED SYRN ![Compare how all Medicare Part D PDP plans in PA cover LOVENOX 80MG PREFILLED SYRN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5. |
29% | N/A | None |
LOW-OGESTREL-28 TABLET ![Compare how all Medicare Part D PDP plans in PA cover LOW-OGESTREL-28 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:28 /28Days |
LOXAPINE 10MG CAPSULE (1000 CT) ![Compare how all Medicare Part D PDP plans in PA cover LOXAPINE 10MG CAPSULE (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:120 /30Days |
LOXAPINE 25MG CAPSULE (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover LOXAPINE 25MG CAPSULE (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:120 /30Days |
LOXAPINE 50MG CAPSULE (1000 CT) ![Compare how all Medicare Part D PDP plans in PA cover LOXAPINE 50MG CAPSULE (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:150 /30Days |
LOXAPINE 5MG CAPSULE (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover LOXAPINE 5MG CAPSULE (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:120 /30Days |
LUMIGAN 0.03% EYE DROPS ![Compare how all Medicare Part D PDP plans in PA cover LUMIGAN 0.03% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | None |
LUNESTA 1MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LUNESTA 1MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred Brand or Generic |
$85.00 | $212.50 | P Q:30 /30Days |
LUNESTA 2MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LUNESTA 2MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred Brand or Generic |
$85.00 | $212.50 | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUNESTA 3MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LUNESTA 3MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred Brand or Generic |
$85.00 | $212.50 | P Q:30 /30Days |
LUPRON 2-WK 1MG/0.2ML KIT ![Compare how all Medicare Part D PDP plans in PA cover LUPRON 2-WK 1MG/0.2ML KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5. |
29% | N/A | P |
LUPRON 6-PK INJ 5MG/ML ![Compare how all Medicare Part D PDP plans in PA cover LUPRON 6-PK INJ 5MG/ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5. |
29% | N/A | P |
LUPRON DEPOT 3.75MG KIT ![Compare how all Medicare Part D PDP plans in PA cover LUPRON DEPOT 3.75MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | P |
LUPRON DEPOT 7.5MG KIT ![Compare how all Medicare Part D PDP plans in PA cover LUPRON DEPOT 7.5MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | P |
LUPRON DEPOT-3 MONTH KIT ![Compare how all Medicare Part D PDP plans in PA cover LUPRON DEPOT-3 MONTH KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5. |
29% | N/A | P |
LUPRON DEPOT-3 MONTH KIT ![Compare how all Medicare Part D PDP plans in PA cover LUPRON DEPOT-3 MONTH KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | P |
LUPRON DEPOT-4 MONTH KIT ![Compare how all Medicare Part D PDP plans in PA cover LUPRON DEPOT-4 MONTH KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5. |
29% | N/A | P |
LUPRON DEPOT-PED 11.25MG KT ![Compare how all Medicare Part D PDP plans in PA cover LUPRON DEPOT-PED 11.25MG KT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5. |
29% | N/A | P |
LUPRON DEPOT-PED 15MG KIT ![Compare how all Medicare Part D PDP plans in PA cover LUPRON DEPOT-PED 15MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5. |
29% | N/A | P |
LUPRON DEPOT-PED 7.5MG KIT ![Compare how all Medicare Part D PDP plans in PA cover LUPRON DEPOT-PED 7.5MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5. |
29% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUTERA 0.1-0.02 TABLET ![Compare how all Medicare Part D PDP plans in PA cover LUTERA 0.1-0.02 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:28 /28Days |
LYRICA 100MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover LYRICA 100MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred Brand or Generic |
$85.00 | $212.50 | P Q:90 /30Days |
LYRICA 150MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover LYRICA 150MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred Brand or Generic |
$85.00 | $212.50 | P Q:90 /30Days |
LYRICA 200MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover LYRICA 200MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred Brand or Generic |
$85.00 | $212.50 | P Q:90 /30Days |
LYRICA 225MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover LYRICA 225MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred Brand or Generic |
$85.00 | $212.50 | P Q:60 /30Days |
LYRICA 25MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover LYRICA 25MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred Brand or Generic |
$85.00 | $212.50 | P Q:90 /30Days |
LYRICA 300MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover LYRICA 300MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred Brand or Generic |
$85.00 | $212.50 | P Q:60 /30Days |
LYRICA 50MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover LYRICA 50MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred Brand or Generic |
$85.00 | $212.50 | P Q:90 /30Days |
LYRICA 75MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover LYRICA 75MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred Brand or Generic |
$85.00 | $212.50 | P Q:60 /30Days |
LYSODREN 500MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LYSODREN 500MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$40.50 | $101.25 | None |