2010 Medicare Part D Plan Formulary Information |
Health Net Orange Option 2 (PDP) (S5678-012-0)
Benefit Details
![Email Prescription and/or Health Benefit details for Health Net Orange Option 2 (PDP). This function does not email the formulary drug list.](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
The Health Net Orange Option 2 (PDP) (S5678-012-0) Formulary Drugs Starting with the Letter L in CMS PDP Region 30 which includes: OR WA
|
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 WA cover LABETALOL HCL 100MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LABETALOL HCL 200MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LABETALOL HCL 200MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LABETALOL HCL 300MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LABETALOL HCL 300MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LABETALOL HCL 5MG/20ML VIAL ![Compare how all Medicare Part D PDP plans in WA cover LABETALOL HCL 5MG/20ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | None |
LAC HYDRIN LOTION 12% 225 G BOTPL ![Compare how all Medicare Part D PDP plans in WA cover LAC HYDRIN LOTION 12% 225 G BOTPL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LAC-HYDRIN 12% CREAM ![Compare how all Medicare Part D PDP plans in WA cover LAC-HYDRIN 12% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LACLOTION 12% LOTION ![Compare how all Medicare Part D PDP plans in WA cover LACLOTION 12% LOTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LACRISERT OPTHALMIC INSERT 5MG 60 BLPK ![Compare how all Medicare Part D PDP plans in WA cover LACRISERT OPTHALMIC INSERT 5MG 60 BLPK.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LACTATED RINGERS INJECTION ![Compare how all Medicare Part D PDP plans in WA cover LACTATED RINGERS INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | P |
LACTATED RINGERS IRRIGATION 20-30-600MG 3000ML BAG ![Compare how all Medicare Part D PDP plans in WA 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 |
$5.00 | $10.00 | 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 WA cover LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LAMICTAL 100MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LAMICTAL 100MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LAMICTAL 150MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LAMICTAL 150MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LAMICTAL 200MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LAMICTAL 200MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LAMICTAL 25MG DISPER TABLET CHEW ![Compare how all Medicare Part D PDP plans in WA cover LAMICTAL 25MG DISPER TABLET CHEW.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LAMICTAL 25MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LAMICTAL 25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LAMICTAL 25MG TABLET STARTER KIT ![Compare how all Medicare Part D PDP plans in WA cover LAMICTAL 25MG TABLET STARTER KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LAMICTAL 5MG DISPER TABLET CHEW ![Compare how all Medicare Part D PDP plans in WA cover LAMICTAL 5MG DISPER TABLET CHEW.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LAMICTAL ODT 100MG TABLET 30 EA ![Compare how all Medicare Part D PDP plans in WA cover LAMICTAL ODT 100MG TABLET 30 EA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LAMICTAL ODT 200MG TABLET 30 EA ![Compare how all Medicare Part D PDP plans in WA cover LAMICTAL ODT 200MG TABLET 30 EA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LAMICTAL ODT 25MG TABLET 30 EA ![Compare how all Medicare Part D PDP plans in WA cover LAMICTAL ODT 25MG TABLET 30 EA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMICTAL ODT 50MG TABLET 30 EA ![Compare how all Medicare Part D PDP plans in WA cover LAMICTAL ODT 50MG TABLET 30 EA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LAMICTAL TABLET STARTER KIT ![Compare how all Medicare Part D PDP plans in WA cover LAMICTAL TABLET STARTER KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:98 /28Days |
LAMICTAL TABLET STARTER KIT ![Compare how all Medicare Part D PDP plans in WA cover LAMICTAL TABLET STARTER KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:49 /14Days |
LAMISIL 1% SOLUTION ![Compare how all Medicare Part D PDP plans in WA cover LAMISIL 1% SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | None |
LAMISIL 125MG GRANULES IN PACKET ![Compare how all Medicare Part D PDP plans in WA cover LAMISIL 125MG GRANULES IN PACKET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | P |
LAMISIL 187.5MG GRANULES IN PACKET ![Compare how all Medicare Part D PDP plans in WA cover LAMISIL 187.5MG GRANULES IN PACKET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | P |
LAMISIL 250MG TABLET (30 CT) ![Compare how all Medicare Part D PDP plans in WA cover LAMISIL 250MG TABLET (30 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | P |
LAMOTRIGINE 150MG TABLET (60 CT) ![Compare how all Medicare Part D PDP plans in WA cover LAMOTRIGINE 150MG TABLET (60 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LAMOTRIGINE 200MG TABLET (60 CT) ![Compare how all Medicare Part D PDP plans in WA cover LAMOTRIGINE 200MG TABLET (60 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LAMOTRIGINE 25MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in WA cover LAMOTRIGINE 25MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE ![Compare how all Medicare Part D PDP plans in WA cover LAMOTRIGINE 25MG TABLET DISPERSIBLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE 5MG TABLET DISPERSIBLE ![Compare how all Medicare Part D PDP plans in WA cover LAMOTRIGINE 5MG TABLET DISPERSIBLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LAMOTRIGINE TABLET 100MG (100 CT) ![Compare how all Medicare Part D PDP plans in WA cover LAMOTRIGINE TABLET 100MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LANOXIN 0.125MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LANOXIN 0.125MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LANOXIN 0.25MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LANOXIN 0.25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LANOXIN 0.25MG/ML AMPUL ![Compare how all Medicare Part D PDP plans in WA cover LANOXIN 0.25MG/ML AMPUL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | None |
LANOXIN PED 0.1MG/ML AMPUL ![Compare how all Medicare Part D PDP plans in WA cover LANOXIN PED 0.1MG/ML AMPUL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | None |
LANREOTIDE INJECTION 30MG ![Compare how all Medicare Part D PDP plans in WA cover LANREOTIDE INJECTION 30MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty |
33% | N/A | P |
LANTUS 100U/ML VIAL ![Compare how all Medicare Part D PDP plans in WA cover LANTUS 100U/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | Q:1 /1Days |
LANTUS INJECTION ![Compare how all Medicare Part D PDP plans in WA cover LANTUS INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | Q:45 /30Days |
LARIAM 250MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LARIAM 250MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LASIX 20MG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WA cover LASIX 20MG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LASIX 40MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LASIX 40MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LASIX 80MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LASIX 80MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LEENA 7-9-5 TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEENA 7-9-5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | Q:1 /1Days |
LEFLUNOMIDE 10MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in WA cover LEFLUNOMIDE 10MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:1 /1Days |
LEFLUNOMIDE 20MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in WA cover LEFLUNOMIDE 20MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:1 /1Days |
LESCOL 20MG CAPSULE ![Compare how all Medicare Part D PDP plans in WA cover LESCOL 20MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:1 /1Days |
LESCOL 40MG CAPSULE ![Compare how all Medicare Part D PDP plans in WA cover LESCOL 40MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:2 /1Days |
LESCOL XL 80MG TABLET SA ![Compare how all Medicare Part D PDP plans in WA cover LESCOL XL 80MG TABLET SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:1 /1Days |
LESSINA 0.1-0.02 TABLET ![Compare how all Medicare Part D PDP plans in WA cover LESSINA 0.1-0.02 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | Q:1 /1Days |
LETAIRIS 10MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LETAIRIS 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty |
33% | N/A | Q:1 /1Days |
LETAIRIS 5MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LETAIRIS 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty |
33% | N/A | Q:1 /1Days |
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 WA cover LEUCOVORIN CALCIUM 100MG VL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | None |
LEUCOVORIN CALCIUM 10MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEUCOVORIN CALCIUM 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | None |
LEUCOVORIN CALCIUM 15MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEUCOVORIN CALCIUM 15MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | None |
LEUCOVORIN CALCIUM 25MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEUCOVORIN CALCIUM 25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEUCOVORIN CALCIUM 350MG VL ![Compare how all Medicare Part D PDP plans in WA cover LEUCOVORIN CALCIUM 350MG VL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | None |
LEUCOVORIN CALCIUM 5MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEUCOVORIN CALCIUM 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEUKERAN 2MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEUKERAN 2MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | None |
LEUKINE 250MCG VIAL ![Compare how all Medicare Part D PDP plans in WA cover LEUKINE 250MCG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty |
33% | N/A | P |
LEUKINE LIQUID INJECTION 500MCG/VIAL 500 MCG X 5 VILMD CRTN ![Compare how all Medicare Part D PDP plans in WA cover LEUKINE LIQUID INJECTION 500MCG/VIAL 500 MCG X 5 VILMD CRTN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty |
33% | N/A | 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 WA 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 Injectable |
33% | N/A | None |
LEUSTATIN 1MG/ML VIAL ![Compare how all Medicare Part D PDP plans in WA cover LEUSTATIN 1MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVAQUIN 250MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEVAQUIN 250MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | Q:14 /14Days |
LEVAQUIN 25MG/ML SOLUTION ![Compare how all Medicare Part D PDP plans in WA cover LEVAQUIN 25MG/ML SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | None |
LEVAQUIN 500MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEVAQUIN 500MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | Q:14 /14Days |
LEVAQUIN 750MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEVAQUIN 750MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | Q:14 /14Days |
LEVAQUIN IV 25MG/ML VIAL ![Compare how all Medicare Part D PDP plans in WA cover LEVAQUIN IV 25MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | None |
LEVAQUIN/D5W INJ 250/50ML ![Compare how all Medicare Part D PDP plans in WA cover LEVAQUIN/D5W INJ 250/50ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | None |
LEVATOL 20MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEVATOL 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LEVEMIR 100UNITS/ML VIAL ![Compare how all Medicare Part D PDP plans in WA cover LEVEMIR 100UNITS/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | Q:1 /1Days |
LEVEMIR FLEXPEN 100UNITS/ML ![Compare how all Medicare Part D PDP plans in WA cover LEVEMIR FLEXPEN 100UNITS/ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | Q:45 /30Days |
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT ![Compare how all Medicare Part D PDP plans in WA 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 |
$5.00 | $10.00 | None |
LEVETIRACETAM 500 MG TABLET 120 BOT ![Compare how all Medicare Part D PDP plans in WA cover LEVETIRACETAM 500 MG TABLET 120 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM TABLETS 1000MG 60 BOT ![Compare how all Medicare Part D PDP plans in WA cover LEVETIRACETAM TABLETS 1000MG 60 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVETIRACETAM TABLETS 250MG 500 BOT ![Compare how all Medicare Part D PDP plans in WA cover LEVETIRACETAM TABLETS 250MG 500 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVETIRACETAM TABLETS 750MG 500 BOT ![Compare how all Medicare Part D PDP plans in WA cover LEVETIRACETAM TABLETS 750MG 500 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVO-DROMORAN 2MG/ML AMPUL ![Compare how all Medicare Part D PDP plans in WA cover LEVO-DROMORAN 2MG/ML AMPUL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | None |
LEVOBUNOLOL 0.5% EYE DROPS ![Compare how all Medicare Part D PDP plans in WA cover LEVOBUNOLOL 0.5% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOBUNOLOL HCL OPHTHALMIC SOLUTION 0.25% 10ML BOT ![Compare how all Medicare Part D PDP plans in WA 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 |
$5.00 | $10.00 | None |
LEVOCARNITINE 100MG/ML SOLUTION ORAL ![Compare how all Medicare Part D PDP plans in WA cover LEVOCARNITINE 100MG/ML SOLUTION ORAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LEVOCARNITINE 200MG/ML VIAL ![Compare how all Medicare Part D PDP plans in WA cover LEVOCARNITINE 200MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | None |
LEVOCARNITINE TABLET 330MG 90 BLPK ![Compare how all Medicare Part D PDP plans in WA cover LEVOCARNITINE TABLET 330MG 90 BLPK.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LEVORA-28 TABLET 0.15/30 ![Compare how all Medicare Part D PDP plans in WA cover LEVORA-28 TABLET 0.15/30.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | Q:1 /1Days |
LEVORPHANOL 2MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEVORPHANOL 2MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHROID 100MCG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEVOTHROID 100MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOTHROID 112MCG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEVOTHROID 112MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOTHROID 125MCG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEVOTHROID 125MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOTHROID 137MCG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEVOTHROID 137MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOTHROID 150MCG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEVOTHROID 150MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOTHROID 175MCG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEVOTHROID 175MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOTHROID 200MCG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEVOTHROID 200MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOTHROID 25MCG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEVOTHROID 25MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOTHROID 300MCG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEVOTHROID 300MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOTHROID 50MCG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEVOTHROID 50MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOTHROID 75MCG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEVOTHROID 75MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHROID 88MCG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEVOTHROID 88MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WA cover LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOTHYROXINE SODIUM .150MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in WA cover LEVOTHYROXINE SODIUM .150MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOTHYROXINE SODIUM 100MCG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEVOTHYROXINE SODIUM 100MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOTHYROXINE SODIUM 112MCG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEVOTHYROXINE SODIUM 112MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOTHYROXINE SODIUM 125MCG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEVOTHYROXINE SODIUM 125MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEVOTHYROXINE SODIUM 137MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOTHYROXINE SODIUM 175MCG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEVOTHYROXINE SODIUM 175MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOTHYROXINE SODIUM 200MCG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEVOTHYROXINE SODIUM 200MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOTHYROXINE SODIUM 25MCG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEVOTHYROXINE SODIUM 25MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOTHYROXINE SODIUM 300MCG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEVOTHYROXINE SODIUM 300MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE SODIUM 50MCG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEVOTHYROXINE SODIUM 50MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOTHYROXINE SODIUM 88MCG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEVOTHYROXINE SODIUM 88MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOXYL 100MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WA cover LEVOXYL 100MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOXYL 112MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WA cover LEVOXYL 112MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOXYL 125MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WA cover LEVOXYL 125MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOXYL 137MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WA cover LEVOXYL 137MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOXYL 150MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WA cover LEVOXYL 150MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOXYL 175MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WA cover LEVOXYL 175MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOXYL 200MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WA cover LEVOXYL 200MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOXYL 25MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WA cover LEVOXYL 25MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOXYL 50MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WA cover LEVOXYL 50MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 75MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WA cover LEVOXYL 75MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEVOXYL 88MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WA cover LEVOXYL 88MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LEXAPRO 10MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEXAPRO 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:2 /1Days |
LEXAPRO 20MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEXAPRO 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:2 /1Days |
LEXAPRO 5MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEXAPRO 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:1 /1Days |
LEXAPRO 5MG/5ML SOLUTION ![Compare how all Medicare Part D PDP plans in WA cover LEXAPRO 5MG/5ML SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:20 /1Days |
LEXIVA 50MG/ML SUSPENSION ORAL ![Compare how all Medicare Part D PDP plans in WA cover LEXIVA 50MG/ML SUSPENSION ORAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | None |
LEXIVA 700MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LEXIVA 700MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | None |
LIALDA 1.2G TABLET DELAYED RELEASE ![Compare how all Medicare Part D PDP plans in WA cover LIALDA 1.2G TABLET DELAYED RELEASE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LIDOCAINE 5% OINTMENT ![Compare how all Medicare Part D PDP plans in WA cover LIDOCAINE 5% OINTMENT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LIDOCAINE HCL 0.5% VIAL ![Compare how all Medicare Part D PDP plans in WA cover LIDOCAINE HCL 0.5% VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIDOCAINE HCL 1% VIAL ![Compare how all Medicare Part D PDP plans in WA cover LIDOCAINE HCL 1% VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | None |
LIDOCAINE HCL 2% JELLY ![Compare how all Medicare Part D PDP plans in WA cover LIDOCAINE HCL 2% JELLY.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LIDOCAINE HCL 2% JELLY 30ML TUBE ![Compare how all Medicare Part D PDP plans in WA cover LIDOCAINE HCL 2% JELLY 30ML TUBE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT ![Compare how all Medicare Part D PDP plans in WA cover LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT ![Compare how all Medicare Part D PDP plans in WA cover LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM ![Compare how all Medicare Part D PDP plans in WA cover LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | Q:1 /1Days |
LIDODERM 5% PATCH ![Compare how all Medicare Part D PDP plans in WA cover LIDODERM 5% PATCH.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | None |
LIMBITROL TABLET 5-12.5MG ![Compare how all Medicare Part D PDP plans in WA cover LIMBITROL TABLET 5-12.5MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LINCOCIN 300MG/ML VIAL ![Compare how all Medicare Part D PDP plans in WA cover LINCOCIN 300MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | None |
LINDANE 1% LOTION ![Compare how all Medicare Part D PDP plans in WA cover LINDANE 1% LOTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | Q:2 /1Days |
LINDANE SHAMPOO 1MG 2 FLO BOT ![Compare how all Medicare Part D PDP plans in WA cover LINDANE SHAMPOO 1MG 2 FLO BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | Q:2 /1Days |
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 WA cover LIOTHYRONINE SODIUM INJECTION 10MCG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | None |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT ![Compare how all Medicare Part D PDP plans in WA cover LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT ![Compare how all Medicare Part D PDP plans in WA cover LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT ![Compare how all Medicare Part D PDP plans in WA cover LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LIPITOR 10MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LIPITOR 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | None |
LIPITOR 20MG TABLET (5000 CT) ![Compare how all Medicare Part D PDP plans in WA cover LIPITOR 20MG TABLET (5000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | None |
LIPITOR 40MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in WA cover LIPITOR 40MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | None |
LIPITOR 80MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LIPITOR 80MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | None |
LIPOFEN 150MG CAPSULE ![Compare how all Medicare Part D PDP plans in WA cover LIPOFEN 150MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LIPOFEN 50MG CAPSULE ![Compare how all Medicare Part D PDP plans in WA cover LIPOFEN 50MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LIPRAM 4500 CAPSULE EC ![Compare how all Medicare Part D PDP plans in WA cover LIPRAM 4500 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIPRAM-PN10 CAPSULE EC ![Compare how all Medicare Part D PDP plans in WA cover LIPRAM-PN10 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | None |
LIPRAM-PN16 CAPSULE EC ![Compare how all Medicare Part D PDP plans in WA cover LIPRAM-PN16 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | None |
LIPRAM-PN20 CAPSULE EC ![Compare how all Medicare Part D PDP plans in WA cover LIPRAM-PN20 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LIPRAM-UL12 CAPSULE EC ![Compare how all Medicare Part D PDP plans in WA cover LIPRAM-UL12 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | None |
LIPRAM-UL18 CAPSULE EC ![Compare how all Medicare Part D PDP plans in WA cover LIPRAM-UL18 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | None |
LIPRAM-UL20 CAPSULE EC ![Compare how all Medicare Part D PDP plans in WA cover LIPRAM-UL20 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | None |
LIQUADD 5MG/5ML SOLUTION ![Compare how all Medicare Part D PDP plans in WA cover LIQUADD 5MG/5ML SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LISINOPRIL 10MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in WA cover LISINOPRIL 10MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | Q:2 /1Days |
LISINOPRIL 2.5MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LISINOPRIL 2.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | Q:2 /1Days |
LISINOPRIL 20MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LISINOPRIL 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | Q:2 /1Days |
LISINOPRIL 30MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in WA cover LISINOPRIL 30MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL 40MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in WA cover LISINOPRIL 40MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | Q:2 /1Days |
LISINOPRIL 5MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LISINOPRIL 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | Q:2 /1Days |
LISINOPRIL-HCTZ 10/12.5 TABLET ![Compare how all Medicare Part D PDP plans in WA cover LISINOPRIL-HCTZ 10/12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | Q:1 /1Days |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in WA cover LISINOPRIL-HCTZ 20-25MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | Q:2 /1Days |
LISINOPRIL-HCTZ 20/12.5 TABLET ![Compare how all Medicare Part D PDP plans in WA cover LISINOPRIL-HCTZ 20/12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | Q:4 /1Days |
LITHIUM CARBONATE 150MG CAPSULE ![Compare how all Medicare Part D PDP plans in WA cover LITHIUM CARBONATE 150MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) ![Compare how all Medicare Part D PDP plans in WA cover LITHIUM CARBONATE 300MG CAPSULE (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LITHIUM CARBONATE 300MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LITHIUM CARBONATE 300MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LITHIUM CARBONATE 450MG TABLET SA ![Compare how all Medicare Part D PDP plans in WA cover LITHIUM CARBONATE 450MG TABLET SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LITHIUM CARBONATE 600MG CAP ![Compare how all Medicare Part D PDP plans in WA cover LITHIUM CARBONATE 600MG CAP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) ![Compare how all Medicare Part D PDP plans in WA cover LITHIUM CARBONATE ER TABLET 300MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LITHIUM CIT 8MEQ/5ML SYRUP ![Compare how all Medicare Part D PDP plans in WA cover LITHIUM CIT 8MEQ/5ML SYRUP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LITHOBID 300MG TABLET SA ![Compare how all Medicare Part D PDP plans in WA cover LITHOBID 300MG TABLET SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LITHOSTAT 250MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LITHOSTAT 250MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LO/OVRAL-28 TABLET ![Compare how all Medicare Part D PDP plans in WA cover LO/OVRAL-28 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:1 /1Days |
LOCOID 0.1% OINTMENT 15GM TUBE ![Compare how all Medicare Part D PDP plans in WA cover LOCOID 0.1% OINTMENT 15GM TUBE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:2 /1Days |
LOCOID 0.1% SOLUTION ![Compare how all Medicare Part D PDP plans in WA cover LOCOID 0.1% SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:4 /1Days |
LOCOID LIPOCREAM CREAM 0.1% 15 GM TUBE ![Compare how all Medicare Part D PDP plans in WA cover LOCOID LIPOCREAM CREAM 0.1% 15 GM TUBE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | Q:2 /1Days |
LOCOID LOTN 0.1 % ![Compare how all Medicare Part D PDP plans in WA cover LOCOID LOTN 0.1 %.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:4 /1Days |
LODOSYN 25MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LODOSYN 25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LOESTRIN 21 1.5/30 TABLET ![Compare how all Medicare Part D PDP plans in WA cover LOESTRIN 21 1.5/30 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:1 /1Days |
LOESTRIN 21 1/20 TABLET ![Compare how all Medicare Part D PDP plans in WA cover LOESTRIN 21 1/20 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOESTRIN 24 FE TABLET ![Compare how all Medicare Part D PDP plans in WA cover LOESTRIN 24 FE TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:1 /1Days |
LOESTRIN FE 1-0.02MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LOESTRIN FE 1-0.02MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:1 /1Days |
LOESTRIN FE 1.5/30 28 DAY REGIMEN TABLETS 30;1.5;75MCG;MG;MG 5 DISPENSERS CTR ![Compare how all Medicare Part D PDP plans in WA cover LOESTRIN FE 1.5/30 28 DAY REGIMEN TABLETS 30;1.5;75MCG;MG;MG 5 DISPENSERS CTR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:1 /1Days |
LOFIBRA 134MG CAPSULE ![Compare how all Medicare Part D PDP plans in WA cover LOFIBRA 134MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LOFIBRA 160MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LOFIBRA 160MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LOFIBRA 200MG CAPSULE ![Compare how all Medicare Part D PDP plans in WA cover LOFIBRA 200MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LOFIBRA 54MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LOFIBRA 54MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LOFIBRA 67MG CAPSULE ![Compare how all Medicare Part D PDP plans in WA cover LOFIBRA 67MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LOKARA 0.05% LOTION ![Compare how all Medicare Part D PDP plans in WA cover LOKARA 0.05% LOTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | Q:4 /1Days |
LOMOTIL LIQ 2.5/5 ![Compare how all Medicare Part D PDP plans in WA cover LOMOTIL LIQ 2.5/5.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LOMOTIL TABLET 0.025-2.5MG (500 CT) ![Compare how all Medicare Part D PDP plans in WA cover LOMOTIL TABLET 0.025-2.5MG (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LONOX 2.5MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LONOX 2.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LOPERAMIDE HCL 2MG CAPSULE ![Compare how all Medicare Part D PDP plans in WA cover LOPERAMIDE HCL 2MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LOPID 600MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in WA cover LOPID 600MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LOPRESSOR 100MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in WA cover LOPRESSOR 100MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LOPRESSOR 1MG/ML AMPUL ![Compare how all Medicare Part D PDP plans in WA cover LOPRESSOR 1MG/ML AMPUL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | None |
LOPRESSOR 50MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in WA cover LOPRESSOR 50MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LOPRESSOR HCT 100/25 TABLET ![Compare how all Medicare Part D PDP plans in WA cover LOPRESSOR HCT 100/25 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LOPRESSOR HCT 50/25 TABLET ![Compare how all Medicare Part D PDP plans in WA cover LOPRESSOR HCT 50/25 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LOPROX 1% SHAMPOO ![Compare how all Medicare Part D PDP plans in WA cover LOPROX 1% SHAMPOO.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LOPROX GEL TOPICAL ![Compare how all Medicare Part D PDP plans in WA cover LOPROX GEL TOPICAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:2 /1Days |
LORCET 10/650 TABLET ![Compare how all Medicare Part D PDP plans in WA cover LORCET 10/650 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LORCET PLUS TABLET 7.5-650 ![Compare how all Medicare Part D PDP plans in WA cover LORCET PLUS TABLET 7.5-650.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LORTAB 10/500MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LORTAB 10/500MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LORTAB 5/500 TABLET ![Compare how all Medicare Part D PDP plans in WA cover LORTAB 5/500 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LORTAB 7.5/500 TABLET ![Compare how all Medicare Part D PDP plans in WA cover LORTAB 7.5/500 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LORTAB ELIXIR 500-7.5MG/15ML ![Compare how all Medicare Part D PDP plans in WA cover LORTAB ELIXIR 500-7.5MG/15ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LOTEMAX 0.5% EYE DROPS ![Compare how all Medicare Part D PDP plans in WA cover LOTEMAX 0.5% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | Q:1 /1Days |
LOTENSIN 10MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LOTENSIN 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:2 /1Days |
LOTENSIN 20MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LOTENSIN 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:2 /1Days |
LOTENSIN 40MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LOTENSIN 40MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:2 /1Days |
LOTENSIN 5MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LOTENSIN 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:2 /1Days |
LOTENSIN HCT 10/12.5 TABLET ![Compare how all Medicare Part D PDP plans in WA cover LOTENSIN HCT 10/12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOTENSIN HCT 20/12.5 TABLET ![Compare how all Medicare Part D PDP plans in WA cover LOTENSIN HCT 20/12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:2 /1Days |
LOTENSIN HCT 20/25 TABLET ![Compare how all Medicare Part D PDP plans in WA cover LOTENSIN HCT 20/25 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:2 /1Days |
LOTENSIN HCT 5/6.25 TABLET ![Compare how all Medicare Part D PDP plans in WA cover LOTENSIN HCT 5/6.25 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:2 /1Days |
LOTREL 10/20MG CAPSULE ![Compare how all Medicare Part D PDP plans in WA cover LOTREL 10/20MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:1 /1Days |
LOTREL 10/40MG CAPSULE ![Compare how all Medicare Part D PDP plans in WA cover LOTREL 10/40MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:1 /1Days |
LOTREL 2.5/10MG CAPSULE ![Compare how all Medicare Part D PDP plans in WA cover LOTREL 2.5/10MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:1 /1Days |
LOTREL 5/10MG CAPSULE ![Compare how all Medicare Part D PDP plans in WA cover LOTREL 5/10MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:1 /1Days |
LOTREL 5/20MG CAPSULE ![Compare how all Medicare Part D PDP plans in WA cover LOTREL 5/20MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:1 /1Days |
LOTREL 5/40MG CAPSULE ![Compare how all Medicare Part D PDP plans in WA cover LOTREL 5/40MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:1 /1Days |
LOTRISONE CREAM ![Compare how all Medicare Part D PDP plans in WA cover LOTRISONE CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:2 /1Days |
LOTRISONE LOTION ![Compare how all Medicare Part D PDP plans in WA cover LOTRISONE LOTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOTRONEX TABLETS .5MG 30 BOTPL ![Compare how all Medicare Part D PDP plans in WA cover LOTRONEX TABLETS .5MG 30 BOTPL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | None |
LOTRONEX TABLETS 1MG 30 BOTPL ![Compare how all Medicare Part D PDP plans in WA cover LOTRONEX TABLETS 1MG 30 BOTPL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | None |
LOVASTATIN 10MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in WA cover LOVASTATIN 10MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | Q:1 /1Days |
LOVASTATIN 20MG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WA cover LOVASTATIN 20MG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | Q:1 /1Days |
LOVASTATIN 40MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in WA cover LOVASTATIN 40MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | Q:2 /1Days |
LOVAZA CAPSULES 1GM 120 BOT ![Compare how all Medicare Part D PDP plans in WA cover LOVAZA CAPSULES 1GM 120 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:4 /1Days |
LOVENOX 100MG PREFILLED SYR ![Compare how all Medicare Part D PDP plans in WA cover LOVENOX 100MG PREFILLED SYR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | Q:20 /10Days |
LOVENOX 120MG PREFILLED SYR ![Compare how all Medicare Part D PDP plans in WA cover LOVENOX 120MG PREFILLED SYR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | Q:20 /10Days |
LOVENOX 150MG PREFILLED SYR ![Compare how all Medicare Part D PDP plans in WA cover LOVENOX 150MG PREFILLED SYR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | Q:20 /10Days |
LOVENOX 300MG VIAL ![Compare how all Medicare Part D PDP plans in WA cover LOVENOX 300MG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | Q:20 /10Days |
LOVENOX 30MG PREFILLED SYRN ![Compare how all Medicare Part D PDP plans in WA cover LOVENOX 30MG PREFILLED SYRN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | Q:20 /10Days |
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 WA cover LOVENOX 40MG PREFILLED SYRN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | Q:20 /10Days |
LOVENOX 60MG PREFILLED SYRN ![Compare how all Medicare Part D PDP plans in WA cover LOVENOX 60MG PREFILLED SYRN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | Q:20 /10Days |
LOVENOX 80MG PREFILLED SYRN ![Compare how all Medicare Part D PDP plans in WA cover LOVENOX 80MG PREFILLED SYRN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | Q:20 /10Days |
LOW-OGESTREL-28 TABLET ![Compare how all Medicare Part D PDP plans in WA cover LOW-OGESTREL-28 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | Q:1 /1Days |
LOXAPINE 25MG CAPSULE (100 CT) ![Compare how all Medicare Part D PDP plans in WA cover LOXAPINE 25MG CAPSULE (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LOXAPINE CAPSULES 10MG 100 BOT ![Compare how all Medicare Part D PDP plans in WA cover LOXAPINE CAPSULES 10MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LOXAPINE CAPSULES 50MG 100 BOT ![Compare how all Medicare Part D PDP plans in WA cover LOXAPINE CAPSULES 50MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LOXAPINE CAPSULES 5MG 100 BOT ![Compare how all Medicare Part D PDP plans in WA cover LOXAPINE CAPSULES 5MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | None |
LOXITANE 10MG CAPSULE ![Compare how all Medicare Part D PDP plans in WA cover LOXITANE 10MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LOXITANE 25MG CAPSULE ![Compare how all Medicare Part D PDP plans in WA cover LOXITANE 25MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LOXITANE 50MG CAPSULE ![Compare how all Medicare Part D PDP plans in WA cover LOXITANE 50MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOXITANE 5MG CAPSULE ![Compare how all Medicare Part D PDP plans in WA cover LOXITANE 5MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LUFYLLIN 200MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LUFYLLIN 200MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LUFYLLIN-400 TABLET ![Compare how all Medicare Part D PDP plans in WA cover LUFYLLIN-400 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
LUMIGAN 0.03% EYE DROPS ![Compare how all Medicare Part D PDP plans in WA cover LUMIGAN 0.03% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | None |
LUNESTA 2MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LUNESTA 2MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | S Q:1 /1Days |
LUNESTA 3MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LUNESTA 3MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | S Q:1 /1Days |
LUNESTA TABLETS 1MG 30 BOT ![Compare how all Medicare Part D PDP plans in WA cover LUNESTA TABLETS 1MG 30 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | S Q:1 /1Days |
LUPRON 2-WK 1MG/0.2ML KIT ![Compare how all Medicare Part D PDP plans in WA cover LUPRON 2-WK 1MG/0.2ML KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | P |
LUPRON DEPOT 3.75MG KIT ![Compare how all Medicare Part D PDP plans in WA cover LUPRON DEPOT 3.75MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | P |
LUPRON DEPOT 7.5MG KIT ![Compare how all Medicare Part D PDP plans in WA cover LUPRON DEPOT 7.5MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty |
33% | N/A | P |
LUPRON DEPOT-3 MONTH KIT ![Compare how all Medicare Part D PDP plans in WA cover LUPRON DEPOT-3 MONTH KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUPRON DEPOT-3 MONTH KIT ![Compare how all Medicare Part D PDP plans in WA cover LUPRON DEPOT-3 MONTH KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | P |
LUPRON DEPOT-4 MONTH KIT ![Compare how all Medicare Part D PDP plans in WA cover LUPRON DEPOT-4 MONTH KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty |
33% | N/A | P |
LUPRON DEPOT-PED 11.25MG KT ![Compare how all Medicare Part D PDP plans in WA cover LUPRON DEPOT-PED 11.25MG KT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | P |
LUPRON DEPOT-PED 15MG KIT ![Compare how all Medicare Part D PDP plans in WA cover LUPRON DEPOT-PED 15MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable |
33% | N/A | P |
LUTERA 0.1-0.02 TABLET ![Compare how all Medicare Part D PDP plans in WA cover LUTERA 0.1-0.02 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$5.00 | $10.00 | Q:1 /1Days |
LUVOX CR 100MG CAPSULE SR 24 HR ![Compare how all Medicare Part D PDP plans in WA cover LUVOX CR 100MG CAPSULE SR 24 HR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:2 /1Days |
LUVOX CR 150MG CAPSULE SR 24 HR ![Compare how all Medicare Part D PDP plans in WA cover LUVOX CR 150MG CAPSULE SR 24 HR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:2 /1Days |
LUXIQ 0.12% FOAM ![Compare how all Medicare Part D PDP plans in WA cover LUXIQ 0.12% FOAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:3 /1Days |
LYBREL 90-20MCG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LYBREL 90-20MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:1 /1Days |
LYRICA 100MG CAPSULE ![Compare how all Medicare Part D PDP plans in WA cover LYRICA 100MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | P Q:3 /1Days |
LYRICA 150MG CAPSULE ![Compare how all Medicare Part D PDP plans in WA cover LYRICA 150MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | P Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYRICA 200MG CAPSULE ![Compare how all Medicare Part D PDP plans in WA cover LYRICA 200MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | P Q:3 /1Days |
LYRICA 225MG CAPSULE ![Compare how all Medicare Part D PDP plans in WA cover LYRICA 225MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | P Q:2 /1Days |
LYRICA 25MG CAPSULE ![Compare how all Medicare Part D PDP plans in WA cover LYRICA 25MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | P Q:3 /1Days |
LYRICA 300MG CAPSULE ![Compare how all Medicare Part D PDP plans in WA cover LYRICA 300MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | P Q:2 /1Days |
LYRICA 50MG CAPSULE ![Compare how all Medicare Part D PDP plans in WA cover LYRICA 50MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | P Q:3 /1Days |
LYRICA 75MG CAPSULE ![Compare how all Medicare Part D PDP plans in WA cover LYRICA 75MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | P Q:3 /1Days |
LYSODREN 500MG TABLET ![Compare how all Medicare Part D PDP plans in WA cover LYSODREN 500MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Preferred Brand |
$35.00 | $70.00 | None |