2010 Medicare Part D Plan Formulary Information |
Mercy MedicareAdvantage Silver (PPO) (H2611-018-0)
Benefit Details
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The Mercy MedicareAdvantage Silver (PPO) (H2611-018-0) Formulary Drugs Starting with the Letter L in Polk County, MO: CMS MA Region 15 which includes: MO
|
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 MO cover LABETALOL HCL 100MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LABETALOL HCL 200MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LABETALOL HCL 200MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LABETALOL HCL 300MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LABETALOL HCL 300MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LABETALOL HCL 5MG/20ML VIAL ![Compare how all Medicare Part D PDP plans in MO cover LABETALOL HCL 5MG/20ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LACLOTION 12% LOTION ![Compare how all Medicare Part D PDP plans in MO cover LACLOTION 12% LOTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LACRISERT OPTHALMIC INSERT 5MG 60 BLPK ![Compare how all Medicare Part D PDP plans in MO cover LACRISERT OPTHALMIC INSERT 5MG 60 BLPK.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LACTATED RINGERS INJECTION ![Compare how all Medicare Part D PDP plans in MO cover LACTATED RINGERS INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT ![Compare how all Medicare Part D PDP plans in MO cover LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LAMOTRIGINE 150MG TABLET (60 CT) ![Compare how all Medicare Part D PDP plans in MO cover LAMOTRIGINE 150MG TABLET (60 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LAMOTRIGINE 200MG TABLET (60 CT) ![Compare how all Medicare Part D PDP plans in MO cover LAMOTRIGINE 200MG TABLET (60 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE 25MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in MO cover LAMOTRIGINE 25MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE ![Compare how all Medicare Part D PDP plans in MO cover LAMOTRIGINE 25MG TABLET DISPERSIBLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE ![Compare how all Medicare Part D PDP plans in MO cover LAMOTRIGINE 5MG TABLET DISPERSIBLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LAMOTRIGINE TABLET 100MG (100 CT) ![Compare how all Medicare Part D PDP plans in MO cover LAMOTRIGINE TABLET 100MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LANOXIN 0.125MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LANOXIN 0.125MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LANOXIN 0.25MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LANOXIN 0.25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LANREOTIDE INJECTION 30MG ![Compare how all Medicare Part D PDP plans in MO cover LANREOTIDE INJECTION 30MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
25% | N/A | P |
LANTUS 100U/ML VIAL ![Compare how all Medicare Part D PDP plans in MO cover LANTUS 100U/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LANTUS INJECTION ![Compare how all Medicare Part D PDP plans in MO cover LANTUS INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LEFLUNOMIDE 10MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEFLUNOMIDE 10MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEFLUNOMIDE 20MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEFLUNOMIDE 20MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LESCOL 20MG CAPSULE ![Compare how all Medicare Part D PDP plans in MO cover LESCOL 20MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$70.00 | $175.00 | None |
LESCOL 40MG CAPSULE ![Compare how all Medicare Part D PDP plans in MO cover LESCOL 40MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$70.00 | $175.00 | None |
LESCOL XL 80MG TABLET SA ![Compare how all Medicare Part D PDP plans in MO cover LESCOL XL 80MG TABLET SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$70.00 | $175.00 | None |
LESSINA 0.1-0.02 TABLET ![Compare how all Medicare Part D PDP plans in MO cover LESSINA 0.1-0.02 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LETAIRIS 10MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LETAIRIS 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
25% | N/A | None |
LETAIRIS 5MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LETAIRIS 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
25% | N/A | None |
LEUCOVORIN CALCIUM 100MG VL ![Compare how all Medicare Part D PDP plans in MO cover LEUCOVORIN CALCIUM 100MG VL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEUCOVORIN CALCIUM 10MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEUCOVORIN CALCIUM 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEUCOVORIN CALCIUM 15MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEUCOVORIN CALCIUM 15MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEUCOVORIN CALCIUM 25MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEUCOVORIN CALCIUM 25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEUCOVORIN CALCIUM 350MG VL ![Compare how all Medicare Part D PDP plans in MO cover LEUCOVORIN CALCIUM 350MG VL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUCOVORIN CALCIUM 5MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEUCOVORIN CALCIUM 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEUKERAN 2MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEUKERAN 2MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | 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 MO 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) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVAQUIN 250MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVAQUIN 250MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LEVAQUIN 25MG/ML SOLUTION ![Compare how all Medicare Part D PDP plans in MO cover LEVAQUIN 25MG/ML SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LEVAQUIN 500MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVAQUIN 500MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LEVAQUIN 750MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVAQUIN 750MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LEVAQUIN IV 25MG/ML VIAL ![Compare how all Medicare Part D PDP plans in MO cover LEVAQUIN IV 25MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LEVAQUIN/D5W INJ 250/50ML ![Compare how all Medicare Part D PDP plans in MO cover LEVAQUIN/D5W INJ 250/50ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LEVEMIR 100UNITS/ML VIAL ![Compare how all Medicare Part D PDP plans in MO cover LEVEMIR 100UNITS/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LEVEMIR FLEXPEN 100UNITS/ML ![Compare how all Medicare Part D PDP plans in MO cover LEVEMIR FLEXPEN 100UNITS/ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT ![Compare how all Medicare Part D PDP plans in MO 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 |
$7.00 | $17.50 | None |
LEVETIRACETAM 500 MG TABLET 120 BOT ![Compare how all Medicare Part D PDP plans in MO cover LEVETIRACETAM 500 MG TABLET 120 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVETIRACETAM TABLETS 1000MG 60 BOT ![Compare how all Medicare Part D PDP plans in MO cover LEVETIRACETAM TABLETS 1000MG 60 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVETIRACETAM TABLETS 250MG 500 BOT ![Compare how all Medicare Part D PDP plans in MO cover LEVETIRACETAM TABLETS 250MG 500 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVETIRACETAM TABLETS 750MG 500 BOT ![Compare how all Medicare Part D PDP plans in MO cover LEVETIRACETAM TABLETS 750MG 500 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOBUNOLOL 0.5% EYE DROPS ![Compare how all Medicare Part D PDP plans in MO cover LEVOBUNOLOL 0.5% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOBUNOLOL HCL OPHTHALMIC SOLUTION 0.25% 10ML BOT ![Compare how all Medicare Part D PDP plans in MO cover LEVOBUNOLOL HCL OPHTHALMIC SOLUTION 0.25% 10ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVORA-28 TABLET 0.15/30 ![Compare how all Medicare Part D PDP plans in MO cover LEVORA-28 TABLET 0.15/30.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOTHROID 100MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHROID 100MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOTHROID 112MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHROID 112MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOTHROID 125MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHROID 125MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHROID 137MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHROID 137MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOTHROID 150MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHROID 150MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOTHROID 175MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHROID 175MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOTHROID 200MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHROID 200MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOTHROID 25MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHROID 25MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOTHROID 300MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHROID 300MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOTHROID 50MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHROID 50MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOTHROID 75MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHROID 75MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOTHROID 88MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHROID 88MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOTHYROXINE SODIUM .150MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHYROXINE SODIUM .150MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE SODIUM 100MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHYROXINE SODIUM 100MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOTHYROXINE SODIUM 112MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHYROXINE SODIUM 112MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOTHYROXINE SODIUM 125MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHYROXINE SODIUM 125MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHYROXINE SODIUM 137MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOTHYROXINE SODIUM 175MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHYROXINE SODIUM 175MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOTHYROXINE SODIUM 200MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHYROXINE SODIUM 200MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOTHYROXINE SODIUM 25MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHYROXINE SODIUM 25MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOTHYROXINE SODIUM 300MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHYROXINE SODIUM 300MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOTHYROXINE SODIUM 50MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHYROXINE SODIUM 50MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOTHYROXINE SODIUM 88MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHYROXINE SODIUM 88MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOXYL 100MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEVOXYL 100MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 112MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEVOXYL 112MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOXYL 125MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEVOXYL 125MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOXYL 137MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEVOXYL 137MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOXYL 150MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEVOXYL 150MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOXYL 175MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEVOXYL 175MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOXYL 200MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEVOXYL 200MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOXYL 25MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEVOXYL 25MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOXYL 50MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEVOXYL 50MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOXYL 75MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEVOXYL 75MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEVOXYL 88MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEVOXYL 88MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LEXAPRO 10MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEXAPRO 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEXAPRO 20MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEXAPRO 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LEXAPRO 5MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEXAPRO 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LEXAPRO 5MG/5ML SOLUTION ![Compare how all Medicare Part D PDP plans in MO cover LEXAPRO 5MG/5ML SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LEXIVA 50MG/ML SUSPENSION ORAL ![Compare how all Medicare Part D PDP plans in MO cover LEXIVA 50MG/ML SUSPENSION ORAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LEXIVA 700MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEXIVA 700MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LIALDA 1.2G TABLET DELAYED RELEASE ![Compare how all Medicare Part D PDP plans in MO cover LIALDA 1.2G TABLET DELAYED RELEASE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LIDOCAINE HCL 0.5% VIAL ![Compare how all Medicare Part D PDP plans in MO cover LIDOCAINE HCL 0.5% VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LIDOCAINE HCL 1% VIAL ![Compare how all Medicare Part D PDP plans in MO cover LIDOCAINE HCL 1% VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT ![Compare how all Medicare Part D PDP plans in MO cover LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT ![Compare how all Medicare Part D PDP plans in MO cover LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM ![Compare how all Medicare Part D PDP plans in MO cover LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIDODERM 5% PATCH ![Compare how all Medicare Part D PDP plans in MO cover LIDODERM 5% PATCH.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | P |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT ![Compare how all Medicare Part D PDP plans in MO cover LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT ![Compare how all Medicare Part D PDP plans in MO cover LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT ![Compare how all Medicare Part D PDP plans in MO cover LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LIPITOR 10MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LIPITOR 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LIPITOR 20MG TABLET (5000 CT) ![Compare how all Medicare Part D PDP plans in MO cover LIPITOR 20MG TABLET (5000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LIPITOR 40MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in MO cover LIPITOR 40MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LIPITOR 80MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LIPITOR 80MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LIPRAM 4500 CAPSULE EC ![Compare how all Medicare Part D PDP plans in MO cover LIPRAM 4500 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LIPRAM-PN10 CAPSULE EC ![Compare how all Medicare Part D PDP plans in MO cover LIPRAM-PN10 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LIPRAM-PN16 CAPSULE EC ![Compare how all Medicare Part D PDP plans in MO cover LIPRAM-PN16 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIPRAM-PN20 CAPSULE EC ![Compare how all Medicare Part D PDP plans in MO cover LIPRAM-PN20 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LIPRAM-UL12 CAPSULE EC ![Compare how all Medicare Part D PDP plans in MO cover LIPRAM-UL12 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LIPRAM-UL18 CAPSULE EC ![Compare how all Medicare Part D PDP plans in MO cover LIPRAM-UL18 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LIPRAM-UL20 CAPSULE EC ![Compare how all Medicare Part D PDP plans in MO cover LIPRAM-UL20 CAPSULE EC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LISINOPRIL 10MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in MO cover LISINOPRIL 10MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LISINOPRIL 2.5MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LISINOPRIL 2.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LISINOPRIL 20MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LISINOPRIL 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LISINOPRIL 30MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in MO cover LISINOPRIL 30MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LISINOPRIL 40MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in MO cover LISINOPRIL 40MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LISINOPRIL 5MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LISINOPRIL 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LISINOPRIL-HCTZ 10/12.5 TABLET ![Compare how all Medicare Part D PDP plans in MO cover LISINOPRIL-HCTZ 10/12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in MO cover LISINOPRIL-HCTZ 20-25MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LISINOPRIL-HCTZ 20/12.5 TABLET ![Compare how all Medicare Part D PDP plans in MO cover LISINOPRIL-HCTZ 20/12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LITHIUM CARBONATE 150MG CAPSULE ![Compare how all Medicare Part D PDP plans in MO cover LITHIUM CARBONATE 150MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) ![Compare how all Medicare Part D PDP plans in MO cover LITHIUM CARBONATE 300MG CAPSULE (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LITHIUM CARBONATE 300MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LITHIUM CARBONATE 300MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LITHIUM CARBONATE 450MG TABLET SA ![Compare how all Medicare Part D PDP plans in MO cover LITHIUM CARBONATE 450MG TABLET SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LITHIUM CARBONATE 600MG CAP ![Compare how all Medicare Part D PDP plans in MO cover LITHIUM CARBONATE 600MG CAP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) ![Compare how all Medicare Part D PDP plans in MO cover LITHIUM CARBONATE ER TABLET 300MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LITHIUM CIT 8MEQ/5ML SYRUP ![Compare how all Medicare Part D PDP plans in MO cover LITHIUM CIT 8MEQ/5ML SYRUP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LOCOID LIPOCREAM CREAM 0.1% 15 GM TUBE ![Compare how all Medicare Part D PDP plans in MO cover LOCOID LIPOCREAM CREAM 0.1% 15 GM TUBE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$70.00 | $175.00 | None |
LONOX 2.5MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LONOX 2.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | 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 MO cover LOPERAMIDE HCL 2MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LOPROX 1% SHAMPOO ![Compare how all Medicare Part D PDP plans in MO cover LOPROX 1% SHAMPOO.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LOTEMAX 0.5% EYE DROPS ![Compare how all Medicare Part D PDP plans in MO cover LOTEMAX 0.5% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$70.00 | $175.00 | None |
LOTREL 10/40MG CAPSULE ![Compare how all Medicare Part D PDP plans in MO cover LOTREL 10/40MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LOTREL 5/40MG CAPSULE ![Compare how all Medicare Part D PDP plans in MO cover LOTREL 5/40MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LOTRONEX TABLETS .5MG 30 BOTPL ![Compare how all Medicare Part D PDP plans in MO cover LOTRONEX TABLETS .5MG 30 BOTPL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LOTRONEX TABLETS 1MG 30 BOTPL ![Compare how all Medicare Part D PDP plans in MO cover LOTRONEX TABLETS 1MG 30 BOTPL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LOVASTATIN 10MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in MO cover LOVASTATIN 10MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LOVASTATIN 20MG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in MO cover LOVASTATIN 20MG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LOVASTATIN 40MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in MO cover LOVASTATIN 40MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LOVENOX 100MG PREFILLED SYR ![Compare how all Medicare Part D PDP plans in MO cover LOVENOX 100MG PREFILLED SYR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOVENOX 120MG PREFILLED SYR ![Compare how all Medicare Part D PDP plans in MO cover LOVENOX 120MG PREFILLED SYR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LOVENOX 150MG PREFILLED SYR ![Compare how all Medicare Part D PDP plans in MO cover LOVENOX 150MG PREFILLED SYR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LOVENOX 300MG VIAL ![Compare how all Medicare Part D PDP plans in MO cover LOVENOX 300MG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LOVENOX 30MG PREFILLED SYRN ![Compare how all Medicare Part D PDP plans in MO cover LOVENOX 30MG PREFILLED SYRN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LOVENOX 40MG PREFILLED SYRN ![Compare how all Medicare Part D PDP plans in MO cover LOVENOX 40MG PREFILLED SYRN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LOVENOX 60MG PREFILLED SYRN ![Compare how all Medicare Part D PDP plans in MO cover LOVENOX 60MG PREFILLED SYRN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LOVENOX 80MG PREFILLED SYRN ![Compare how all Medicare Part D PDP plans in MO cover LOVENOX 80MG PREFILLED SYRN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LOW-OGESTREL-28 TABLET ![Compare how all Medicare Part D PDP plans in MO cover LOW-OGESTREL-28 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LOXAPINE 25MG CAPSULE (100 CT) ![Compare how all Medicare Part D PDP plans in MO cover LOXAPINE 25MG CAPSULE (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LOXAPINE CAPSULES 10MG 100 BOT ![Compare how all Medicare Part D PDP plans in MO cover LOXAPINE CAPSULES 10MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LOXAPINE CAPSULES 50MG 100 BOT ![Compare how all Medicare Part D PDP plans in MO cover LOXAPINE CAPSULES 50MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOXAPINE CAPSULES 5MG 100 BOT ![Compare how all Medicare Part D PDP plans in MO cover LOXAPINE CAPSULES 5MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LUMIGAN 0.03% EYE DROPS ![Compare how all Medicare Part D PDP plans in MO cover LUMIGAN 0.03% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LUNESTA 2MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LUNESTA 2MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$70.00 | $175.00 | Q:180 /365Days |
LUNESTA 3MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LUNESTA 3MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$70.00 | $175.00 | Q:180 /365Days |
LUNESTA TABLETS 1MG 30 BOT ![Compare how all Medicare Part D PDP plans in MO cover LUNESTA TABLETS 1MG 30 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$70.00 | $175.00 | Q:180 /365Days |
LUPRON DEPOT 3.75MG KIT ![Compare how all Medicare Part D PDP plans in MO cover LUPRON DEPOT 3.75MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LUPRON DEPOT 7.5MG KIT ![Compare how all Medicare Part D PDP plans in MO cover LUPRON DEPOT 7.5MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
25% | N/A | None |
LUPRON DEPOT-3 MONTH KIT ![Compare how all Medicare Part D PDP plans in MO cover LUPRON DEPOT-3 MONTH KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
25% | N/A | None |
LUPRON DEPOT-3 MONTH KIT ![Compare how all Medicare Part D PDP plans in MO cover LUPRON DEPOT-3 MONTH KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |
LUPRON DEPOT-4 MONTH KIT ![Compare how all Medicare Part D PDP plans in MO cover LUPRON DEPOT-4 MONTH KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
25% | N/A | None |
LUPRON DEPOT-PED 11.25MG KT ![Compare how all Medicare Part D PDP plans in MO cover LUPRON DEPOT-PED 11.25MG KT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
25% | N/A | 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 MO cover LUPRON DEPOT-PED 15MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
25% | N/A | None |
LUTERA 0.1-0.02 TABLET ![Compare how all Medicare Part D PDP plans in MO cover LUTERA 0.1-0.02 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$7.00 | $17.50 | None |
LUXIQ 0.12% FOAM ![Compare how all Medicare Part D PDP plans in MO cover LUXIQ 0.12% FOAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$70.00 | $175.00 | None |
LYRICA 100MG CAPSULE ![Compare how all Medicare Part D PDP plans in MO cover LYRICA 100MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | Q:120 /25Days |
LYRICA 150MG CAPSULE ![Compare how all Medicare Part D PDP plans in MO cover LYRICA 150MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | Q:120 /25Days |
LYRICA 200MG CAPSULE ![Compare how all Medicare Part D PDP plans in MO cover LYRICA 200MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | Q:120 /25Days |
LYRICA 225MG CAPSULE ![Compare how all Medicare Part D PDP plans in MO cover LYRICA 225MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | Q:120 /25Days |
LYRICA 25MG CAPSULE ![Compare how all Medicare Part D PDP plans in MO cover LYRICA 25MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | Q:120 /25Days |
LYRICA 300MG CAPSULE ![Compare how all Medicare Part D PDP plans in MO cover LYRICA 300MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | Q:60 /25Days |
LYRICA 50MG CAPSULE ![Compare how all Medicare Part D PDP plans in MO cover LYRICA 50MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | Q:120 /25Days |
LYRICA 75MG CAPSULE ![Compare how all Medicare Part D PDP plans in MO cover LYRICA 75MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | Q:120 /25Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYSODREN 500MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LYSODREN 500MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$35.00 | $87.50 | None |