2009 Medicare Part D Plan Formulary Information |
EnvisionRxPlus Silver (S7694-006-0)
Benefit Details
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The EnvisionRxPlus Silver (S7694-006-0) 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 |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | 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) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | None |
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) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | 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) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | 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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | 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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | 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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | 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) |
2 |
Tier 2 Non Preferred Generics |
$32.00 | $96.00 | None |
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) |
2 |
Tier 2 Non Preferred Generics |
$32.00 | $96.00 | None |
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) |
2 |
Tier 2 Non Preferred Generics |
$32.00 | $96.00 | None |
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) |
2 |
Tier 2 Non Preferred Generics |
$32.00 | $96.00 | None |
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) |
2 |
Tier 2 Non Preferred Generics |
$32.00 | $96.00 | None |
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) |
2 |
Tier 2 Non Preferred Generics |
$32.00 | $96.00 | 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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | 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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | 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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
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 |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
$4.00 | $12.00 | 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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
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) |
2 |
Tier 2 Non Preferred Generics |
$32.00 | $96.00 | None |
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) |
2 |
Tier 2 Non Preferred Generics |
$32.00 | $96.00 | None |
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) |
2 |
Tier 2 Non Preferred Generics |
$32.00 | $96.00 | 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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | 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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | 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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | 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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | 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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | 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) |
2 |
Tier 2 Non Preferred Generics |
$32.00 | $96.00 | 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) |
2 |
Tier 2 Non Preferred Generics |
$32.00 | $96.00 | 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) |
2 |
Tier 2 Non Preferred Generics |
$32.00 | $96.00 | 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) |
2 |
Tier 2 Non Preferred Generics |
$32.00 | $96.00 | 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) |
2 |
Tier 2 Non Preferred Generics |
$32.00 | $96.00 | 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 |
$4.00 | $12.00 | None |
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 |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
$4.00 | $12.00 | 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) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | None |
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 |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | 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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | 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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | 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 |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | 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) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
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) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | None |
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 |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | None |
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) |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | 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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | 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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | 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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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) |
2 |
Tier 2 Non Preferred Generics |
$32.00 | $96.00 | 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 |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | None |
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 |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | None |
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 |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | None |
LOCOID 0.1% CREAM ![Compare how all Medicare Part D PDP plans in PA cover LOCOID 0.1% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LOCOID 0.1% OINTMENT 15GM TUBE ![Compare how all Medicare Part D PDP plans in PA cover LOCOID 0.1% OINTMENT 15GM TUBE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
LOCOID 0.1% SOLUTION ![Compare how all Medicare Part D PDP plans in PA cover LOCOID 0.1% SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
$4.00 | $12.00 | None |
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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | 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) |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | 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) |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | 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) |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | 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) |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | 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 NonPreferred Brand |
$75.00 | $225.00 | None |
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 NonPreferred Brand |
$75.00 | $225.00 | 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) |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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) |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | None |
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) |
2 |
Tier 2 Non Preferred Generics |
$32.00 | $96.00 | None |
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) |
2 |
Tier 2 Non Preferred Generics |
$32.00 | $96.00 | None |
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) |
2 |
Tier 2 Non Preferred Generics |
$32.00 | $96.00 | None |
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) |
2 |
Tier 2 Non Preferred Generics |
$32.00 | $96.00 | None |
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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |
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) |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | None |
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) |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | None |
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) |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | None |
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) |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | None |
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) |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | None |
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) |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | None |
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) |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | None |
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) |
4 |
Tier 4 NonPreferred Brand |
$75.00 | $225.00 | None |
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) |
3 |
Tier 3 Preferred Brand |
$22.00 | $66.00 | None |