2011 Medicare Part D Plan Formulary Information |
Triple-S Medicare Optimo Premier (HMO) (H5732-001-0)
Benefit Details
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The Triple-S Medicare Optimo Premier (HMO) (H5732-001-0) Formulary Drugs Starting with the Letter L in Jayuya County, PR: CMS MA Region 0 which includes: PR
|
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 |
L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE 16 VACCINE 0.04 MG/ML / L1 PROTEIN, HUMAN PAPILLOMAVIRU ![Compare how all Medicare Part D PDP plans in PR cover L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE 16 VACCINE 0.04 MG/ML / L1 PROTEIN, HUMAN PAPILLOMAVIRU.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | P |
L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE 16 VACCINE 0.04 MG/ML / L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE ![Compare how all Medicare Part D PDP plans in PR cover L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE 16 VACCINE 0.04 MG/ML / L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE .](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | P |
LABETALOL HCL 100MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LABETALOL HCL 100MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LABETALOL HCL 200MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LABETALOL HCL 200MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LABETALOL HCL 300MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LABETALOL HCL 300MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT ![Compare how all Medicare Part D PDP plans in PR cover LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LAMICTAL 100MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LAMICTAL 100MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LAMICTAL 150MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LAMICTAL 150MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LAMICTAL 200MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LAMICTAL 200MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LAMICTAL 25MG DISPER TABLET CHEW ![Compare how all Medicare Part D PDP plans in PR cover LAMICTAL 25MG DISPER TABLET CHEW.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMICTAL 25MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LAMICTAL 25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LAMICTAL 5MG DISPER TABLET CHEW ![Compare how all Medicare Part D PDP plans in PR cover LAMICTAL 5MG DISPER TABLET CHEW.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LAMISIL 250MG TABLET (30 CT) ![Compare how all Medicare Part D PDP plans in PR cover LAMISIL 250MG TABLET (30 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | Q:84 /90Days |
LAMOTRIGINE 150MG TABLET (60 CT) ![Compare how all Medicare Part D PDP plans in PR cover LAMOTRIGINE 150MG TABLET (60 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LAMOTRIGINE 200MG TABLET (60 CT) ![Compare how all Medicare Part D PDP plans in PR cover LAMOTRIGINE 200MG TABLET (60 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LAMOTRIGINE 25MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PR cover LAMOTRIGINE 25MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE ![Compare how all Medicare Part D PDP plans in PR cover LAMOTRIGINE 25MG TABLET DISPERSIBLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE ![Compare how all Medicare Part D PDP plans in PR cover LAMOTRIGINE 5MG TABLET DISPERSIBLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LAMOTRIGINE TABLET 100MG (100 CT) ![Compare how all Medicare Part D PDP plans in PR cover LAMOTRIGINE TABLET 100MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LANOXIN 0.125MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LANOXIN 0.125MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LANOXIN 0.25MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LANOXIN 0.25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LANREOTIDE 240 MG/ML PREFILLED SYRINGE [SOMATULINE] ![Compare how all Medicare Part D PDP plans in PR cover LANREOTIDE 240 MG/ML PREFILLED SYRINGE [SOMATULINE].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 |
25% | 25% | P |
LANREOTIDE INJECTION 30MG ![Compare how all Medicare Part D PDP plans in PR cover LANREOTIDE INJECTION 30MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 |
25% | 25% | P |
LANSOPRAZOLE 15 MG ENTERIC COATED CAPSULE ![Compare how all Medicare Part D PDP plans in PR cover LANSOPRAZOLE 15 MG ENTERIC COATED CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | S |
LANSOPRAZOLE 30 MG ENTERIC COATED CAPSULE ![Compare how all Medicare Part D PDP plans in PR cover LANSOPRAZOLE 30 MG ENTERIC COATED CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | S |
LANTUS 100U/ML VIAL ![Compare how all Medicare Part D PDP plans in PR cover LANTUS 100U/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $60.00 | Q:40 /30Days |
LANTUS SOLOSTAR INJECTION ![Compare how all Medicare Part D PDP plans in PR cover LANTUS SOLOSTAR INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | Q:40 /30Days |
LASIX 20MG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in PR cover LASIX 20MG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LASIX 40MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LASIX 40MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LASIX 80MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LASIX 80MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LEFLUNOMIDE 10MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LEFLUNOMIDE 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LEFLUNOMIDE TABLETS ![Compare how all Medicare Part D PDP plans in PR cover LEFLUNOMIDE TABLETS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LETAIRIS 10MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LETAIRIS 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 |
25% | 25% | P |
LETAIRIS 5MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LETAIRIS 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 |
25% | 25% | P |
LEUCOVORIN CALCIUM 5MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LEUCOVORIN CALCIUM 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LEUKERAN 2MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LEUKERAN 2MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $60.00 | None |
LEUKINE 250MCG VIAL ![Compare how all Medicare Part D PDP plans in PR cover LEUKINE 250MCG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 |
25% | 25% | P |
LEUKINE LIQUID INJECTION 500MCG/VIAL 500 MCG X 5 VILMD CRTN ![Compare how all Medicare Part D PDP plans in PR 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 |
25% | 25% | P |
LEUPROLIDE 11.25 MG/ML PREFILLED SYRINGE [LUPRON] ![Compare how all Medicare Part D PDP plans in PR cover LEUPROLIDE 11.25 MG/ML PREFILLED SYRINGE [LUPRON].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 |
25% | 25% | P |
LEUPROLIDE 15 MG/ML PREFILLED SYRINGE [LUPRON] ![Compare how all Medicare Part D PDP plans in PR cover LEUPROLIDE 15 MG/ML PREFILLED SYRINGE [LUPRON].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 |
25% | 25% | P |
LEUPROLIDE ACETATE INJECTION ![Compare how all Medicare Part D PDP plans in PR cover LEUPROLIDE ACETATE INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | P |
LEVEMIR 100UNITS/ML VIAL ![Compare how all Medicare Part D PDP plans in PR cover LEVEMIR 100UNITS/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | Q:40 /30Days |
LEVEMIR FLEXPEN 100UNITS/ML ![Compare how all Medicare Part D PDP plans in PR cover LEVEMIR FLEXPEN 100UNITS/ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | Q:40 /30Days |
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 PR 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 |
$5.00 | $10.00 | None |
LEVETIRACETAM 500 MG TABLET 120 BOT ![Compare how all Medicare Part D PDP plans in PR cover LEVETIRACETAM 500 MG TABLET 120 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LEVETIRACETAM TABLETS 1000MG 60 BOT ![Compare how all Medicare Part D PDP plans in PR cover LEVETIRACETAM TABLETS 1000MG 60 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LEVETIRACETAM TABLETS 250MG 500 BOT ![Compare how all Medicare Part D PDP plans in PR cover LEVETIRACETAM TABLETS 250MG 500 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LEVETIRACETAM TABLETS 750MG 500 BOT ![Compare how all Medicare Part D PDP plans in PR cover LEVETIRACETAM TABLETS 750MG 500 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LEVOBUNOLOL 0.25% EYE DROPS ![Compare how all Medicare Part D PDP plans in PR cover LEVOBUNOLOL 0.25% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | Q:15 /30Days |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION ![Compare how all Medicare Part D PDP plans in PR cover LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | Q:15 /30Days |
LEVOCARNITINE 100MG/ML SOLUTION ORAL ![Compare how all Medicare Part D PDP plans in PR cover LEVOCARNITINE 100MG/ML SOLUTION ORAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LEVOCARNITINE TABLET 330MG 90 BLPK ![Compare how all Medicare Part D PDP plans in PR cover LEVOCARNITINE TABLET 330MG 90 BLPK.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in PR cover LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LEVOTHYROXINE SODIUM .150MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PR cover LEVOTHYROXINE SODIUM .150MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE SODIUM 100MCG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LEVOTHYROXINE SODIUM 100MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LEVOTHYROXINE SODIUM 112MCG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LEVOTHYROXINE SODIUM 112MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LEVOTHYROXINE SODIUM 125MCG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LEVOTHYROXINE SODIUM 125MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LEVOTHYROXINE SODIUM 137MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LEVOTHYROXINE SODIUM 175MCG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LEVOTHYROXINE SODIUM 175MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LEVOTHYROXINE SODIUM 200MCG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LEVOTHYROXINE SODIUM 200MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LEVOTHYROXINE SODIUM 25MCG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LEVOTHYROXINE SODIUM 25MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LEVOTHYROXINE SODIUM 300MCG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LEVOTHYROXINE SODIUM 300MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LEVOTHYROXINE SODIUM 50MCG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LEVOTHYROXINE SODIUM 50MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LEVOTHYROXINE SODIUM 88MCG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LEVOTHYROXINE SODIUM 88MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LEXAPRO 10MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LEXAPRO 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | S |
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 PR cover LEXAPRO 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | S |
LEXAPRO 5MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LEXAPRO 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | S |
LEXAPRO 5MG/5ML SOLUTION ![Compare how all Medicare Part D PDP plans in PR cover LEXAPRO 5MG/5ML SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | S |
LEXIVA 50MG/ML SUSPENSION ORAL ![Compare how all Medicare Part D PDP plans in PR cover LEXIVA 50MG/ML SUSPENSION ORAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LEXIVA TABLETS ![Compare how all Medicare Part D PDP plans in PR cover LEXIVA TABLETS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 |
25% | 25% | None |
LIDOCAINE 5% OINTMENT ![Compare how all Medicare Part D PDP plans in PR cover LIDOCAINE 5% OINTMENT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT ![Compare how all Medicare Part D PDP plans in PR cover LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT ![Compare how all Medicare Part D PDP plans in PR cover LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LIDODERM 5% PATCH ![Compare how all Medicare Part D PDP plans in PR cover LIDODERM 5% PATCH.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | P |
LINCOCIN 300MG/ML VIAL ![Compare how all Medicare Part D PDP plans in PR cover LINCOCIN 300MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | P |
LINDANE 1% LOTION ![Compare how all Medicare Part D PDP plans in PR cover LINDANE 1% LOTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | S Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LINDANE SHAMPOO 1MG 2 FLO BOT ![Compare how all Medicare Part D PDP plans in PR cover LINDANE SHAMPOO 1MG 2 FLO BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | Q:60 /30Days |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT ![Compare how all Medicare Part D PDP plans in PR cover LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$45.00 | $90.00 | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT ![Compare how all Medicare Part D PDP plans in PR cover LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$45.00 | $90.00 | None |
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT ![Compare how all Medicare Part D PDP plans in PR cover LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$45.00 | $90.00 | None |
LISINOPRIL 10 MG ORAL TABLET [ZESTRIL] ![Compare how all Medicare Part D PDP plans in PR cover LISINOPRIL 10 MG ORAL TABLET [ZESTRIL].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LISINOPRIL 10MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PR cover LISINOPRIL 10MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LISINOPRIL 2.5MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LISINOPRIL 2.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LISINOPRIL 20MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LISINOPRIL 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LISINOPRIL 30MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PR cover LISINOPRIL 30MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LISINOPRIL 40MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in PR cover LISINOPRIL 40MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LISINOPRIL 5 MG ORAL TABLET [ZESTRIL] ![Compare how all Medicare Part D PDP plans in PR cover LISINOPRIL 5 MG ORAL TABLET [ZESTRIL].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL TABLETS 5 MG ![Compare how all Medicare Part D PDP plans in PR cover LISINOPRIL TABLETS 5 MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LISINOPRIL-HCTZ 10/12.5 TABLET ![Compare how all Medicare Part D PDP plans in PR cover LISINOPRIL-HCTZ 10/12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PR cover LISINOPRIL-HCTZ 20-25MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LISINOPRIL-HCTZ 20/12.5 TABLET ![Compare how all Medicare Part D PDP plans in PR cover LISINOPRIL-HCTZ 20/12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LITHIUM CARBONATE 150MG CAPSULE ![Compare how all Medicare Part D PDP plans in PR cover LITHIUM CARBONATE 150MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) ![Compare how all Medicare Part D PDP plans in PR cover LITHIUM CARBONATE 300MG CAPSULE (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LITHIUM CARBONATE CAPSULES ![Compare how all Medicare Part D PDP plans in PR cover LITHIUM CARBONATE CAPSULES.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) ![Compare how all Medicare Part D PDP plans in PR cover LITHIUM CARBONATE ER TABLET 300MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP ![Compare how all Medicare Part D PDP plans in PR cover LITHIUM CIT 8MEQ/5ML SYRUP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LITHIUM ER 450 MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LITHIUM ER 450 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LITHOBID 300MG TABLET SA ![Compare how all Medicare Part D PDP plans in PR cover LITHOBID 300MG TABLET SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LO/OVRAL-28 TABLET ![Compare how all Medicare Part D PDP plans in PR cover LO/OVRAL-28 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LOFIBRA 134MG CAPSULE ![Compare how all Medicare Part D PDP plans in PR cover LOFIBRA 134MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LOFIBRA 160MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LOFIBRA 160MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LOFIBRA 200MG CAPSULE ![Compare how all Medicare Part D PDP plans in PR cover LOFIBRA 200MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LOFIBRA 54MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LOFIBRA 54MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LOFIBRA 67MG CAPSULE ![Compare how all Medicare Part D PDP plans in PR cover LOFIBRA 67MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LOPERAMIDE HCL 2MG CAPSULE ![Compare how all Medicare Part D PDP plans in PR cover LOPERAMIDE HCL 2MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LOPID 600MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in PR cover LOPID 600MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LOPRESSOR 100MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PR cover LOPRESSOR 100MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LOPRESSOR 50MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PR cover LOPRESSOR 50MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LORCET 10/650 TABLET ![Compare how all Medicare Part D PDP plans in PR cover LORCET 10/650 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | 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 PR cover LORCET PLUS TABLET 7.5-650.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LORTAB 10/500MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LORTAB 10/500MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LORTAB 5/500 TABLET ![Compare how all Medicare Part D PDP plans in PR cover LORTAB 5/500 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LORTAB 7.5/500 TABLET ![Compare how all Medicare Part D PDP plans in PR cover LORTAB 7.5/500 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LORTAB ELIXIR 500-7.5MG/15ML ![Compare how all Medicare Part D PDP plans in PR cover LORTAB ELIXIR 500-7.5MG/15ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LOSARTAN POTASSIUM 100 MG TAB ![Compare how all Medicare Part D PDP plans in PR cover LOSARTAN POTASSIUM 100 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LOSARTAN POTASSIUM 25 MG TAB ![Compare how all Medicare Part D PDP plans in PR cover LOSARTAN POTASSIUM 25 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LOSARTAN POTASSIUM 50 MG TAB ![Compare how all Medicare Part D PDP plans in PR cover LOSARTAN POTASSIUM 50 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LOSARTAN-HCTZ 100-12.5 MG TAB ![Compare how all Medicare Part D PDP plans in PR cover LOSARTAN-HCTZ 100-12.5 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LOSARTAN-HCTZ 100-25 MG TAB ![Compare how all Medicare Part D PDP plans in PR cover LOSARTAN-HCTZ 100-25 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LOSARTAN-HCTZ 50-12.5 MG TAB ![Compare how all Medicare Part D PDP plans in PR cover LOSARTAN-HCTZ 50-12.5 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOTEMAX 0.5% EYE DROPS ![Compare how all Medicare Part D PDP plans in PR cover LOTEMAX 0.5% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $60.00 | Q:15 /15Days |
LOTENSIN 10MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LOTENSIN 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LOTENSIN 20MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LOTENSIN 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LOTENSIN 40MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LOTENSIN 40MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LOTENSIN 5MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LOTENSIN 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LOTENSIN HCT 10/12.5 TABLET ![Compare how all Medicare Part D PDP plans in PR cover LOTENSIN HCT 10/12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LOTENSIN HCT 20/12.5 TABLET ![Compare how all Medicare Part D PDP plans in PR cover LOTENSIN HCT 20/12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LOTENSIN HCT 20/25 TABLET ![Compare how all Medicare Part D PDP plans in PR cover LOTENSIN HCT 20/25 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LOTENSIN HCT 5/6.25 TABLET ![Compare how all Medicare Part D PDP plans in PR cover LOTENSIN HCT 5/6.25 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LOTREL 10/20MG CAPSULE ![Compare how all Medicare Part D PDP plans in PR cover LOTREL 10/20MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LOTREL 10/40MG CAPSULE ![Compare how all Medicare Part D PDP plans in PR cover LOTREL 10/40MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOTREL 2.5/10MG CAPSULE ![Compare how all Medicare Part D PDP plans in PR cover LOTREL 2.5/10MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LOTREL 5/10MG CAPSULE ![Compare how all Medicare Part D PDP plans in PR cover LOTREL 5/10MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LOTREL 5/20MG CAPSULE ![Compare how all Medicare Part D PDP plans in PR cover LOTREL 5/20MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LOTREL 5/40MG CAPSULE ![Compare how all Medicare Part D PDP plans in PR cover LOTREL 5/40MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LOTRISONE CREAM ![Compare how all Medicare Part D PDP plans in PR cover LOTRISONE CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | Q:45 /15Days |
LOTRISONE LOTION ![Compare how all Medicare Part D PDP plans in PR cover LOTRISONE LOTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | Q:30 /15Days |
LOTRONEX TABLETS .5MG 30 BOTPL ![Compare how all Medicare Part D PDP plans in PR cover LOTRONEX TABLETS .5MG 30 BOTPL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $60.00 | None |
LOTRONEX TABLETS 1MG 30 BOTPL ![Compare how all Medicare Part D PDP plans in PR cover LOTRONEX TABLETS 1MG 30 BOTPL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $60.00 | None |
LOVENOX 100MG PREFILLED SYR ![Compare how all Medicare Part D PDP plans in PR cover LOVENOX 100MG PREFILLED SYR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$45.00 | $90.00 | P |
LOVENOX 150MG PREFILLED SYR ![Compare how all Medicare Part D PDP plans in PR cover LOVENOX 150MG PREFILLED SYR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$45.00 | $90.00 | P |
LOW-OGESTREL-28 TABLET ![Compare how all Medicare Part D PDP plans in PR cover LOW-OGESTREL-28 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOXAPINE 25MG CAPSULE (100 CT) ![Compare how all Medicare Part D PDP plans in PR cover LOXAPINE 25MG CAPSULE (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LOXAPINE CAPSULES 10MG 100 BOT ![Compare how all Medicare Part D PDP plans in PR cover LOXAPINE CAPSULES 10MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LOXAPINE CAPSULES 50MG 100 BOT ![Compare how all Medicare Part D PDP plans in PR cover LOXAPINE CAPSULES 50MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LOXAPINE CAPSULES 5MG 100 BOT ![Compare how all Medicare Part D PDP plans in PR cover LOXAPINE CAPSULES 5MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 |
$5.00 | $10.00 | None |
LOXITANE 10MG CAPSULE ![Compare how all Medicare Part D PDP plans in PR cover LOXITANE 10MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LOXITANE 25MG CAPSULE ![Compare how all Medicare Part D PDP plans in PR cover LOXITANE 25MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LOXITANE 50MG CAPSULE ![Compare how all Medicare Part D PDP plans in PR cover LOXITANE 50MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LOXITANE 5MG CAPSULE ![Compare how all Medicare Part D PDP plans in PR cover LOXITANE 5MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | None |
LUFYLLIN 200MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LUFYLLIN 200MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$45.00 | $90.00 | None |
LUFYLLIN-400 TABLET ![Compare how all Medicare Part D PDP plans in PR cover LUFYLLIN-400 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$45.00 | $90.00 | None |
LUMIGAN 0.03% EYE DROPS ![Compare how all Medicare Part D PDP plans in PR cover LUMIGAN 0.03% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$45.00 | $90.00 | Q:8 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYRICA 100MG CAPSULE ![Compare how all Medicare Part D PDP plans in PR cover LYRICA 100MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | S |
LYRICA 150MG CAPSULE ![Compare how all Medicare Part D PDP plans in PR cover LYRICA 150MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | S |
LYRICA 200MG CAPSULE ![Compare how all Medicare Part D PDP plans in PR cover LYRICA 200MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | S |
LYRICA 225MG CAPSULE ![Compare how all Medicare Part D PDP plans in PR cover LYRICA 225MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | S |
LYRICA 25MG CAPSULE ![Compare how all Medicare Part D PDP plans in PR cover LYRICA 25MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | S |
LYRICA 300MG CAPSULE ![Compare how all Medicare Part D PDP plans in PR cover LYRICA 300MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | S |
LYRICA 50MG CAPSULE ![Compare how all Medicare Part D PDP plans in PR cover LYRICA 50MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | S |
LYRICA 75MG CAPSULE ![Compare how all Medicare Part D PDP plans in PR cover LYRICA 75MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$50.00 | $100.00 | S |
LYSODREN 500MG TABLET ![Compare how all Medicare Part D PDP plans in PR cover LYSODREN 500MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 |
$30.00 | $60.00 | None |