2011 Medicare Part D Plan Formulary Information |
MedicareRx Rewards Standard (PDP) (S5960-131-0)
Benefit Details
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The MedicareRx Rewards Standard (PDP) (S5960-131-0) Formulary Drugs Starting with the Letter L in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
|
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 NE 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) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | None |
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 NE 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) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | None |
LABETALOL HCL 5MG/20ML VIAL ![Compare how all Medicare Part D PDP plans in NE cover LABETALOL HCL 5MG/20ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable Drugs |
25% | 25% | None |
LACRISERT OPTHALMIC INSERT 5MG 60 BLPK ![Compare how all Medicare Part D PDP plans in NE cover LACRISERT OPTHALMIC INSERT 5MG 60 BLPK.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | Q:120 /30Days |
LACTATED RINGERS IRRIGATION 20-30-600MG 3000ML BAG ![Compare how all Medicare Part D PDP plans in NE cover LACTATED RINGERS IRRIGATION 20-30-600MG 3000ML BAG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable Drugs |
25% | 25% | P |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT ![Compare how all Medicare Part D PDP plans in NE cover LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LAMICTAL ODT 100MG TABLET 30 EA ![Compare how all Medicare Part D PDP plans in NE cover LAMICTAL ODT 100MG TABLET 30 EA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | None |
LAMICTAL ODT 200MG TABLET 30 EA ![Compare how all Medicare Part D PDP plans in NE cover LAMICTAL ODT 200MG TABLET 30 EA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | Q:60 /30Days |
LAMICTAL ODT 25MG TABLET 30 EA ![Compare how all Medicare Part D PDP plans in NE cover LAMICTAL ODT 25MG TABLET 30 EA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | Q:90 /30Days |
LAMICTAL ODT 50MG TABLET 30 EA ![Compare how all Medicare Part D PDP plans in NE cover LAMICTAL ODT 50MG TABLET 30 EA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMICTAL XR 100 MG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LAMICTAL XR 100 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | P |
LAMICTAL XR 200 MG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LAMICTAL XR 200 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | P Q:60 /30Days |
LAMICTAL XR 25 MG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LAMICTAL XR 25 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | P Q:90 /30Days |
LAMICTAL XR 50 MG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LAMICTAL XR 50 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | P Q:90 /30Days |
LAMICTAL XR START KIT (BLUE) ![Compare how all Medicare Part D PDP plans in NE cover LAMICTAL XR START KIT (BLUE).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | P Q:28 /28Days |
LAMICTAL XR START KIT (GREEN) ![Compare how all Medicare Part D PDP plans in NE cover LAMICTAL XR START KIT (GREEN).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | P Q:35 /35Days |
LAMICTAL XR START KIT (ORANGE) ![Compare how all Medicare Part D PDP plans in NE cover LAMICTAL XR START KIT (ORANGE).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | P Q:35 /35Days |
LAMOTRIGINE 150MG TABLET (60 CT) ![Compare how all Medicare Part D PDP plans in NE cover LAMOTRIGINE 150MG TABLET (60 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:60 /30Days |
LAMOTRIGINE 200MG TABLET (60 CT) ![Compare how all Medicare Part D PDP plans in NE cover LAMOTRIGINE 200MG TABLET (60 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:60 /30Days |
LAMOTRIGINE 25MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in NE cover LAMOTRIGINE 25MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE ![Compare how all Medicare Part D PDP plans in NE cover LAMOTRIGINE 25MG TABLET DISPERSIBLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | 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 NE cover LAMOTRIGINE 5MG TABLET DISPERSIBLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LAMOTRIGINE TABLET 100MG (100 CT) ![Compare how all Medicare Part D PDP plans in NE cover LAMOTRIGINE TABLET 100MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LANOXIN 0.125MG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LANOXIN 0.125MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | None |
LANOXIN 0.25MG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LANOXIN 0.25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | None |
LANOXIN 0.25MG/ML AMPUL ![Compare how all Medicare Part D PDP plans in NE cover LANOXIN 0.25MG/ML AMPUL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable Drugs |
25% | 25% | None |
LANOXIN PED 0.1MG/ML AMPUL ![Compare how all Medicare Part D PDP plans in NE cover LANOXIN PED 0.1MG/ML AMPUL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable Drugs |
25% | 25% | None |
LANSOPRAZOLE 15 MG ENTERIC COATED CAPSULE ![Compare how all Medicare Part D PDP plans in NE cover LANSOPRAZOLE 15 MG ENTERIC COATED CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | S Q:30 /30Days |
LANSOPRAZOLE 30 MG ENTERIC COATED CAPSULE ![Compare how all Medicare Part D PDP plans in NE cover LANSOPRAZOLE 30 MG ENTERIC COATED CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | S Q:30 /30Days |
LANSOPRAZOLE ORALLY DISINTEGRATING TABLETS DELAYED RELEASE ![Compare how all Medicare Part D PDP plans in NE cover LANSOPRAZOLE ORALLY DISINTEGRATING TABLETS DELAYED RELEASE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | S Q:30 /30Days |
LANSOPRAZOLE ORALLY DISINTEGRATING TABLETS DELAYED RELEASE ![Compare how all Medicare Part D PDP plans in NE cover LANSOPRAZOLE ORALLY DISINTEGRATING TABLETS DELAYED RELEASE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | S Q:30 /30Days |
LANTUS 100U/ML VIAL ![Compare how all Medicare Part D PDP plans in NE cover LANTUS 100U/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LANTUS SOLOSTAR INJECTION ![Compare how all Medicare Part D PDP plans in NE cover LANTUS SOLOSTAR INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | None |
LEENA 7-9-5 TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEENA 7-9-5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:28 /28Days |
LEFLUNOMIDE 10MG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEFLUNOMIDE 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LEFLUNOMIDE TABLETS ![Compare how all Medicare Part D PDP plans in NE cover LEFLUNOMIDE TABLETS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LESSINA 0.1-0.02 TABLET ![Compare how all Medicare Part D PDP plans in NE cover LESSINA 0.1-0.02 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:28 /28Days |
LETAIRIS 10MG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LETAIRIS 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty Tier Drugs |
25% | N/A | P |
LETAIRIS 5MG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LETAIRIS 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty Tier Drugs |
25% | N/A | P |
LEUCOVORIN CALCIUM 100MG VL ![Compare how all Medicare Part D PDP plans in NE cover LEUCOVORIN CALCIUM 100MG VL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable Drugs |
25% | 25% | None |
LEUCOVORIN CALCIUM 10MG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEUCOVORIN CALCIUM 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LEUCOVORIN CALCIUM 15MG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEUCOVORIN CALCIUM 15MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LEUCOVORIN CALCIUM 25MG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEUCOVORIN CALCIUM 25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUCOVORIN CALCIUM 350MG VL ![Compare how all Medicare Part D PDP plans in NE cover LEUCOVORIN CALCIUM 350MG VL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable Drugs |
25% | 25% | None |
LEUCOVORIN CALCIUM 5MG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEUCOVORIN CALCIUM 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LEUKERAN 2MG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEUKERAN 2MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | None |
LEUKINE 250MCG VIAL ![Compare how all Medicare Part D PDP plans in NE cover LEUKINE 250MCG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty Tier Drugs |
25% | N/A | P |
LEUKINE LIQUID INJECTION 500MCG/VIAL 500 MCG X 5 VILMD CRTN ![Compare how all Medicare Part D PDP plans in NE 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 Tier Drugs |
25% | N/A | P |
LEUPROLIDE 11.25 MG/ML PREFILLED SYRINGE [LUPRON] ![Compare how all Medicare Part D PDP plans in NE cover LEUPROLIDE 11.25 MG/ML PREFILLED SYRINGE [LUPRON].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty Tier Drugs |
25% | N/A | P |
LEUPROLIDE 15 MG/ML PREFILLED SYRINGE [LUPRON] ![Compare how all Medicare Part D PDP plans in NE cover LEUPROLIDE 15 MG/ML PREFILLED SYRINGE [LUPRON].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable Drugs |
25% | 25% | P |
LEUPROLIDE 15 MG/ML PREFILLED SYRINGE [LUPRON] ![Compare how all Medicare Part D PDP plans in NE cover LEUPROLIDE 15 MG/ML PREFILLED SYRINGE [LUPRON].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty Tier Drugs |
25% | N/A | P |
LEUPROLIDE 20 MG/ML PREFILLED SYRINGE [LUPRON] ![Compare how all Medicare Part D PDP plans in NE cover LEUPROLIDE 20 MG/ML PREFILLED SYRINGE [LUPRON].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty Tier Drugs |
25% | N/A | P |
LEUPROLIDE 3.75 MG/ML PREFILLED SYRINGE [LUPRON] ![Compare how all Medicare Part D PDP plans in NE cover LEUPROLIDE 3.75 MG/ML PREFILLED SYRINGE [LUPRON].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable Drugs |
25% | 25% | P |
LEUPROLIDE 7.5 MG/ML PREFILLED SYRINGE [LUPRON] ![Compare how all Medicare Part D PDP plans in NE cover LEUPROLIDE 7.5 MG/ML PREFILLED SYRINGE [LUPRON].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable Drugs |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUPROLIDE ACETATE INJECTION ![Compare how all Medicare Part D PDP plans in NE cover LEUPROLIDE ACETATE INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable Drugs |
25% | 25% | P |
LEUPROLIDE7.5 MG/ML PREFILLED SYRINGE [LUPRON] ![Compare how all Medicare Part D PDP plans in NE cover LEUPROLIDE7.5 MG/ML PREFILLED SYRINGE [LUPRON].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable Drugs |
25% | 25% | P |
LEUSTATIN 1MG/ML VIAL ![Compare how all Medicare Part D PDP plans in NE cover LEUSTATIN 1MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty Tier Drugs |
25% | N/A | P |
LEVALBUTEROL 1.25 MG/0.5 ML ![Compare how all Medicare Part D PDP plans in NE cover LEVALBUTEROL 1.25 MG/0.5 ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | P |
LEVAQUIN 750 MG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEVAQUIN 750 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | Q:14 /1Days |
LEVAQUIN INJECTION 25 MG/ML ![Compare how all Medicare Part D PDP plans in NE cover LEVAQUIN INJECTION 25 MG/ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable Drugs |
25% | 25% | None |
LEVAQUIN INJECTION 5 MG/ML ![Compare how all Medicare Part D PDP plans in NE cover LEVAQUIN INJECTION 5 MG/ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable Drugs |
25% | 25% | None |
LEVEMIR 100UNITS/ML VIAL ![Compare how all Medicare Part D PDP plans in NE cover LEVEMIR 100UNITS/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | None |
LEVEMIR FLEXPEN 100UNITS/ML ![Compare how all Medicare Part D PDP plans in NE cover LEVEMIR FLEXPEN 100UNITS/ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | None |
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT ![Compare how all Medicare Part D PDP plans in NE cover LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LEVETIRACETAM 500 MG TABLET 120 BOT ![Compare how all Medicare Part D PDP plans in NE cover LEVETIRACETAM 500 MG TABLET 120 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM INJECTION ![Compare how all Medicare Part D PDP plans in NE cover LEVETIRACETAM INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable Drugs |
25% | 25% | None |
LEVETIRACETAM TABLETS 1000MG 60 BOT ![Compare how all Medicare Part D PDP plans in NE cover LEVETIRACETAM TABLETS 1000MG 60 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LEVETIRACETAM TABLETS 250MG 500 BOT ![Compare how all Medicare Part D PDP plans in NE cover LEVETIRACETAM TABLETS 250MG 500 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LEVETIRACETAM TABLETS 750MG 500 BOT ![Compare how all Medicare Part D PDP plans in NE cover LEVETIRACETAM TABLETS 750MG 500 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LEVOBUNOLOL 0.25% EYE DROPS ![Compare how all Medicare Part D PDP plans in NE cover LEVOBUNOLOL 0.25% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:30 /30Days |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION ![Compare how all Medicare Part D PDP plans in NE cover LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:30 /30Days |
LEVOCARNITINE 100MG/ML SOLUTION ORAL ![Compare how all Medicare Part D PDP plans in NE cover LEVOCARNITINE 100MG/ML SOLUTION ORAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | P |
LEVOCARNITINE 200MG/ML VIAL ![Compare how all Medicare Part D PDP plans in NE cover LEVOCARNITINE 200MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable Drugs |
25% | 25% | P |
LEVOCARNITINE TABLET 330MG 90 BLPK ![Compare how all Medicare Part D PDP plans in NE cover LEVOCARNITINE TABLET 330MG 90 BLPK.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | P |
LEVOFLOXACIN 25 MG/ML ORAL SOLUTION [LEVAQUIN] ![Compare how all Medicare Part D PDP plans in NE cover LEVOFLOXACIN 25 MG/ML ORAL SOLUTION [LEVAQUIN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | None |
LEVOFLOXACIN 250 MG ORAL TABLET [LEVAQUIN] ![Compare how all Medicare Part D PDP plans in NE cover LEVOFLOXACIN 250 MG ORAL TABLET [LEVAQUIN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | Q:14 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOFLOXACIN 500 MG ORAL TABLET [LEVAQUIN] ![Compare how all Medicare Part D PDP plans in NE cover LEVOFLOXACIN 500 MG ORAL TABLET [LEVAQUIN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | Q:14 /1Days |
LEVORA-28 TABLET 0.15/30 ![Compare how all Medicare Part D PDP plans in NE cover LEVORA-28 TABLET 0.15/30.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:28 /28Days |
LEVOTHROID 100MCG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEVOTHROID 100MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOTHROID 112MCG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEVOTHROID 112MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOTHROID 125MCG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEVOTHROID 125MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOTHROID 137MCG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEVOTHROID 137MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOTHROID 150MCG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEVOTHROID 150MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOTHROID 175MCG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEVOTHROID 175MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOTHROID 200MCG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEVOTHROID 200MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOTHROID 25MCG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEVOTHROID 25MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOTHROID 300MCG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEVOTHROID 300MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHROID 50MCG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEVOTHROID 50MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOTHROID 75MCG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEVOTHROID 75MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOTHROID 88MCG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEVOTHROID 88MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in NE cover LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOTHYROXINE SODIUM .150MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in NE cover LEVOTHYROXINE SODIUM .150MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOTHYROXINE SODIUM 100MCG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEVOTHYROXINE SODIUM 100MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOTHYROXINE SODIUM 112MCG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEVOTHYROXINE SODIUM 112MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOTHYROXINE SODIUM 125MCG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEVOTHYROXINE SODIUM 125MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEVOTHYROXINE SODIUM 137MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOTHYROXINE SODIUM 175MCG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEVOTHYROXINE SODIUM 175MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOTHYROXINE SODIUM 200MCG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEVOTHYROXINE SODIUM 200MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE SODIUM 25MCG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEVOTHYROXINE SODIUM 25MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOTHYROXINE SODIUM 300MCG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEVOTHYROXINE SODIUM 300MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOTHYROXINE SODIUM 50MCG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEVOTHYROXINE SODIUM 50MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOTHYROXINE SODIUM 88MCG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEVOTHYROXINE SODIUM 88MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOXYL 100MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in NE cover LEVOXYL 100MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOXYL 112MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in NE cover LEVOXYL 112MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOXYL 125MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in NE cover LEVOXYL 125MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOXYL 137MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in NE cover LEVOXYL 137MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOXYL 150MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in NE cover LEVOXYL 150MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOXYL 175MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in NE cover LEVOXYL 175MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOXYL 200MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in NE cover LEVOXYL 200MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 25MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in NE cover LEVOXYL 25MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOXYL 50MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in NE cover LEVOXYL 50MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOXYL 75MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in NE cover LEVOXYL 75MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEVOXYL 88MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in NE cover LEVOXYL 88MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LEXAPRO 10MG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEXAPRO 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | Q:45 /30Days |
LEXAPRO 20MG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEXAPRO 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | Q:30 /30Days |
LEXAPRO 5MG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LEXAPRO 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | Q:45 /30Days |
LEXAPRO 5MG/5ML SOLUTION ![Compare how all Medicare Part D PDP plans in NE cover LEXAPRO 5MG/5ML SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | Q:600 /30Days |
LEXIVA 50MG/ML SUSPENSION ORAL ![Compare how all Medicare Part D PDP plans in NE cover LEXIVA 50MG/ML SUSPENSION ORAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | None |
LEXIVA TABLETS ![Compare how all Medicare Part D PDP plans in NE cover LEXIVA TABLETS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty Tier Drugs |
25% | N/A | None |
LIDOCAINE 5% OINTMENT ![Compare how all Medicare Part D PDP plans in NE cover LIDOCAINE 5% OINTMENT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIDOCAINE HCL 0.5% VIAL ![Compare how all Medicare Part D PDP plans in NE cover LIDOCAINE HCL 0.5% VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable Drugs |
25% | 25% | None |
LIDOCAINE HCL 1% VIAL ![Compare how all Medicare Part D PDP plans in NE cover LIDOCAINE HCL 1% VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable Drugs |
25% | 25% | None |
LIDOCAINE HCL 2% JELLY ![Compare how all Medicare Part D PDP plans in NE cover LIDOCAINE HCL 2% JELLY.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LIDOCAINE HCL 2% JELLY 30ML TUBE ![Compare how all Medicare Part D PDP plans in NE cover LIDOCAINE HCL 2% JELLY 30ML TUBE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT ![Compare how all Medicare Part D PDP plans in NE cover LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT ![Compare how all Medicare Part D PDP plans in NE 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 Drugs |
$4.00 | $6.00 | None |
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM ![Compare how all Medicare Part D PDP plans in NE cover LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LIDODERM 5% PATCH ![Compare how all Medicare Part D PDP plans in NE cover LIDODERM 5% PATCH.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | None |
LINCOCIN 300MG/ML VIAL ![Compare how all Medicare Part D PDP plans in NE cover LINCOCIN 300MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable Drugs |
25% | 25% | None |
LINDANE SHAMPOO 1MG 2 FLO BOT ![Compare how all Medicare Part D PDP plans in NE cover LINDANE SHAMPOO 1MG 2 FLO BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | None |
LIOTHYRONINE SODIUM INJECTION 10MCG ![Compare how all Medicare Part D PDP plans in NE cover LIOTHYRONINE SODIUM INJECTION 10MCG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty Tier Drugs |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT ![Compare how all Medicare Part D PDP plans in NE cover LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT ![Compare how all Medicare Part D PDP plans in NE cover LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT ![Compare how all Medicare Part D PDP plans in NE cover LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LIPOSYN II 10% IV FAT EMUL ![Compare how all Medicare Part D PDP plans in NE cover LIPOSYN II 10% IV FAT EMUL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable Drugs |
25% | 25% | None |
LIPOSYN III 30% IV FAT EMUL ![Compare how all Medicare Part D PDP plans in NE cover LIPOSYN III 30% IV FAT EMUL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable Drugs |
25% | 25% | None |
LISINOPRIL 10MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in NE cover LISINOPRIL 10MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LISINOPRIL 2.5MG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LISINOPRIL 2.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LISINOPRIL 20MG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LISINOPRIL 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LISINOPRIL 30MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in NE cover LISINOPRIL 30MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LISINOPRIL 40MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in NE cover LISINOPRIL 40MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LISINOPRIL TABLETS 5 MG ![Compare how all Medicare Part D PDP plans in NE cover LISINOPRIL TABLETS 5 MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL-HCTZ 10/12.5 TABLET ![Compare how all Medicare Part D PDP plans in NE cover LISINOPRIL-HCTZ 10/12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in NE cover LISINOPRIL-HCTZ 20-25MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LISINOPRIL-HCTZ 20/12.5 TABLET ![Compare how all Medicare Part D PDP plans in NE cover LISINOPRIL-HCTZ 20/12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LITHIUM CARBONATE 150MG CAPSULE ![Compare how all Medicare Part D PDP plans in NE cover LITHIUM CARBONATE 150MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) ![Compare how all Medicare Part D PDP plans in NE cover LITHIUM CARBONATE 300MG CAPSULE (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LITHIUM CARBONATE 300MG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LITHIUM CARBONATE 300MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LITHIUM CARBONATE CAPSULES ![Compare how all Medicare Part D PDP plans in NE cover LITHIUM CARBONATE CAPSULES.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) ![Compare how all Medicare Part D PDP plans in NE cover LITHIUM CARBONATE ER TABLET 300MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP ![Compare how all Medicare Part D PDP plans in NE cover LITHIUM CIT 8MEQ/5ML SYRUP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LITHIUM ER 450 MG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LITHIUM ER 450 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic Drugs |
$4.00 | $6.00 | None |
LITHOBID 300MG TABLET SA ![Compare how all Medicare Part D PDP plans in NE cover LITHOBID 300MG TABLET SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOPERAMIDE HCL 2MG CAPSULE ![Compare how all Medicare Part D PDP plans in NE cover LOPERAMIDE HCL 2MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LOSARTAN POTASSIUM 100 MG TAB ![Compare how all Medicare Part D PDP plans in NE cover LOSARTAN POTASSIUM 100 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LOSARTAN POTASSIUM 25 MG TAB ![Compare how all Medicare Part D PDP plans in NE cover LOSARTAN POTASSIUM 25 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LOSARTAN POTASSIUM 50 MG TAB ![Compare how all Medicare Part D PDP plans in NE cover LOSARTAN POTASSIUM 50 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LOSARTAN-HCTZ 100-12.5 MG TAB ![Compare how all Medicare Part D PDP plans in NE cover LOSARTAN-HCTZ 100-12.5 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LOSARTAN-HCTZ 100-25 MG TAB ![Compare how all Medicare Part D PDP plans in NE cover LOSARTAN-HCTZ 100-25 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LOSARTAN-HCTZ 50-12.5 MG TAB ![Compare how all Medicare Part D PDP plans in NE cover LOSARTAN-HCTZ 50-12.5 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LOTREL 10/40MG CAPSULE ![Compare how all Medicare Part D PDP plans in NE cover LOTREL 10/40MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | None |
LOTREL 5/40MG CAPSULE ![Compare how all Medicare Part D PDP plans in NE cover LOTREL 5/40MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | None |
LOTRONEX TABLETS .5MG 30 BOTPL ![Compare how all Medicare Part D PDP plans in NE cover LOTRONEX TABLETS .5MG 30 BOTPL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | P Q:60 /30Days |
LOTRONEX TABLETS 1MG 30 BOTPL ![Compare how all Medicare Part D PDP plans in NE cover LOTRONEX TABLETS 1MG 30 BOTPL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOVASTATIN 10MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in NE cover LOVASTATIN 10MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:30 /30Days |
LOVASTATIN 20 MG ORAL TABLET ![Compare how all Medicare Part D PDP plans in NE cover LOVASTATIN 20 MG ORAL TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:30 /30Days |
LOVASTATIN 40 MG ORAL TABLET ![Compare how all Medicare Part D PDP plans in NE cover LOVASTATIN 40 MG ORAL TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:60 /30Days |
LOVAZA CAPSULES 1GM 120 BOT ![Compare how all Medicare Part D PDP plans in NE cover LOVAZA CAPSULES 1GM 120 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | None |
LOVENOX 100MG PREFILLED SYR ![Compare how all Medicare Part D PDP plans in NE cover LOVENOX 100MG PREFILLED SYR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty Tier Drugs |
25% | N/A | None |
LOVENOX 120MG PREFILLED SYR ![Compare how all Medicare Part D PDP plans in NE cover LOVENOX 120MG PREFILLED SYR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty Tier Drugs |
25% | N/A | None |
LOVENOX 150MG PREFILLED SYR ![Compare how all Medicare Part D PDP plans in NE cover LOVENOX 150MG PREFILLED SYR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty Tier Drugs |
25% | N/A | None |
LOVENOX 300MG VIAL ![Compare how all Medicare Part D PDP plans in NE cover LOVENOX 300MG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty Tier Drugs |
25% | N/A | None |
LOVENOX 30MG PREFILLED SYRN ![Compare how all Medicare Part D PDP plans in NE cover LOVENOX 30MG PREFILLED SYRN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable Drugs |
25% | 25% | None |
LOVENOX 40MG PREFILLED SYRN ![Compare how all Medicare Part D PDP plans in NE cover LOVENOX 40MG PREFILLED SYRN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Injectable Drugs |
25% | 25% | None |
LOVENOX 60MG PREFILLED SYRN ![Compare how all Medicare Part D PDP plans in NE cover LOVENOX 60MG PREFILLED SYRN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty Tier Drugs |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOVENOX 80MG PREFILLED SYRN ![Compare how all Medicare Part D PDP plans in NE cover LOVENOX 80MG PREFILLED SYRN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty Tier Drugs |
25% | N/A | None |
LOW-OGESTREL-28 TABLET ![Compare how all Medicare Part D PDP plans in NE cover LOW-OGESTREL-28 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:28 /28Days |
LOXAPINE 25MG CAPSULE (100 CT) ![Compare how all Medicare Part D PDP plans in NE cover LOXAPINE 25MG CAPSULE (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LOXAPINE CAPSULES 10MG 100 BOT ![Compare how all Medicare Part D PDP plans in NE cover LOXAPINE CAPSULES 10MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LOXAPINE CAPSULES 50MG 100 BOT ![Compare how all Medicare Part D PDP plans in NE cover LOXAPINE CAPSULES 50MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LOXAPINE CAPSULES 5MG 100 BOT ![Compare how all Medicare Part D PDP plans in NE cover LOXAPINE CAPSULES 5MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | None |
LUTERA 0.1-0.02 TABLET ![Compare how all Medicare Part D PDP plans in NE cover LUTERA 0.1-0.02 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generic Drugs |
$7.00 | $10.50 | Q:28 /28Days |
LYRICA 100MG CAPSULE ![Compare how all Medicare Part D PDP plans in NE cover LYRICA 100MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | P Q:90 /30Days |
LYRICA 150MG CAPSULE ![Compare how all Medicare Part D PDP plans in NE cover LYRICA 150MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | P Q:90 /30Days |
LYRICA 200MG CAPSULE ![Compare how all Medicare Part D PDP plans in NE cover LYRICA 200MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | P Q:90 /30Days |
LYRICA 225MG CAPSULE ![Compare how all Medicare Part D PDP plans in NE cover LYRICA 225MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYRICA 25MG CAPSULE ![Compare how all Medicare Part D PDP plans in NE cover LYRICA 25MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | P Q:90 /30Days |
LYRICA 300MG CAPSULE ![Compare how all Medicare Part D PDP plans in NE cover LYRICA 300MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | P Q:60 /30Days |
LYRICA 50MG CAPSULE ![Compare how all Medicare Part D PDP plans in NE cover LYRICA 50MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | P Q:90 /30Days |
LYRICA 75MG CAPSULE ![Compare how all Medicare Part D PDP plans in NE cover LYRICA 75MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | P Q:90 /30Days |
LYSODREN 500MG TABLET ![Compare how all Medicare Part D PDP plans in NE cover LYSODREN 500MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand Drugs |
$38.00 | $95.00 | None |