2011 Medicare Part D Plan Formulary Information |
EnvisionRxPlus Gold (PDP) (S7694-038-0)
Benefit Details
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The EnvisionRxPlus Gold (PDP) (S7694-038-0) Formulary Drugs Starting with the Letter L in CMS PDP Region 4 which includes: NJ
|
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 NJ 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 Non-Preferred Brand |
25% | 25% | 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 NJ 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 Non-Preferred Brand |
25% | 25% | None |
LABETALOL HCL 100MG TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LABETALOL HCL 100MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LABETALOL HCL 200MG TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LABETALOL HCL 200MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LABETALOL HCL 300MG TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LABETALOL HCL 300MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LABETALOL HCL 5MG/20ML VIAL ![Compare how all Medicare Part D PDP plans in NJ cover LABETALOL HCL 5MG/20ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LACLOTION 12% LOTION ![Compare how all Medicare Part D PDP plans in NJ cover LACLOTION 12% LOTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LACRISERT OPTHALMIC INSERT 5MG 60 BLPK ![Compare how all Medicare Part D PDP plans in NJ cover LACRISERT OPTHALMIC INSERT 5MG 60 BLPK.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
LACTATED RINGERS IRRIGATION 20-30-600MG 3000ML BAG ![Compare how all Medicare Part D PDP plans in NJ cover LACTATED RINGERS IRRIGATION 20-30-600MG 3000ML BAG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT ![Compare how all Medicare Part D PDP plans in NJ cover LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE 150MG TABLET (60 CT) ![Compare how all Medicare Part D PDP plans in NJ cover LAMOTRIGINE 150MG TABLET (60 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
LAMOTRIGINE 200MG TABLET (60 CT) ![Compare how all Medicare Part D PDP plans in NJ cover LAMOTRIGINE 200MG TABLET (60 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
LAMOTRIGINE 25MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in NJ cover LAMOTRIGINE 25MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE ![Compare how all Medicare Part D PDP plans in NJ cover LAMOTRIGINE 25MG TABLET DISPERSIBLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE ![Compare how all Medicare Part D PDP plans in NJ cover LAMOTRIGINE 5MG TABLET DISPERSIBLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
LAMOTRIGINE TABLET 100MG (100 CT) ![Compare how all Medicare Part D PDP plans in NJ cover LAMOTRIGINE TABLET 100MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
LANREOTIDE 240 MG/ML PREFILLED SYRINGE [SOMATULINE] ![Compare how all Medicare Part D PDP plans in NJ cover LANREOTIDE 240 MG/ML PREFILLED SYRINGE [SOMATULINE].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
LANREOTIDE INJECTION 30MG ![Compare how all Medicare Part D PDP plans in NJ cover LANREOTIDE INJECTION 30MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
LANTUS 100U/ML VIAL ![Compare how all Medicare Part D PDP plans in NJ cover LANTUS 100U/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LANTUS SOLOSTAR INJECTION ![Compare how all Medicare Part D PDP plans in NJ cover LANTUS SOLOSTAR INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEFLUNOMIDE 10MG TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LEFLUNOMIDE 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEFLUNOMIDE TABLETS ![Compare how all Medicare Part D PDP plans in NJ cover LEFLUNOMIDE TABLETS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
LETAIRIS 10MG TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LETAIRIS 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
LETAIRIS 5MG TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LETAIRIS 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
LEUKERAN 2MG TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LEUKERAN 2MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEUKINE 250MCG VIAL ![Compare how all Medicare Part D PDP plans in NJ cover LEUKINE 250MCG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
LEUPROLIDE 11.25 MG/ML PREFILLED SYRINGE [LUPRON] ![Compare how all Medicare Part D PDP plans in NJ cover LEUPROLIDE 11.25 MG/ML PREFILLED SYRINGE [LUPRON].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEUPROLIDE 15 MG/ML PREFILLED SYRINGE [LUPRON] ![Compare how all Medicare Part D PDP plans in NJ cover LEUPROLIDE 15 MG/ML PREFILLED SYRINGE [LUPRON].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEUPROLIDE 15 MG/ML PREFILLED SYRINGE [LUPRON] ![Compare how all Medicare Part D PDP plans in NJ cover LEUPROLIDE 15 MG/ML PREFILLED SYRINGE [LUPRON].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEUPROLIDE 20 MG/ML PREFILLED SYRINGE [LUPRON] ![Compare how all Medicare Part D PDP plans in NJ cover LEUPROLIDE 20 MG/ML PREFILLED SYRINGE [LUPRON].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEUPROLIDE 3.75 MG/ML PREFILLED SYRINGE [LUPRON] ![Compare how all Medicare Part D PDP plans in NJ cover LEUPROLIDE 3.75 MG/ML PREFILLED SYRINGE [LUPRON].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEUPROLIDE 7.5 MG/ML PREFILLED SYRINGE [LUPRON] ![Compare how all Medicare Part D PDP plans in NJ cover LEUPROLIDE 7.5 MG/ML PREFILLED SYRINGE [LUPRON].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
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 NJ cover LEUPROLIDE ACETATE INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
LEUPROLIDE7.5 MG/ML PREFILLED SYRINGE [LUPRON] ![Compare how all Medicare Part D PDP plans in NJ cover LEUPROLIDE7.5 MG/ML PREFILLED SYRINGE [LUPRON].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEVAQUIN 750 MG TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LEVAQUIN 750 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEVAQUIN INJECTION 25 MG/ML ![Compare how all Medicare Part D PDP plans in NJ cover LEVAQUIN INJECTION 25 MG/ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEVAQUIN INJECTION 5 MG/ML ![Compare how all Medicare Part D PDP plans in NJ cover LEVAQUIN INJECTION 5 MG/ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEVEMIR 100UNITS/ML VIAL ![Compare how all Medicare Part D PDP plans in NJ cover LEVEMIR 100UNITS/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEVEMIR FLEXPEN 100UNITS/ML ![Compare how all Medicare Part D PDP plans in NJ cover LEVEMIR FLEXPEN 100UNITS/ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT ![Compare how all Medicare Part D PDP plans in NJ cover LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
LEVETIRACETAM 500 MG TABLET 120 BOT ![Compare how all Medicare Part D PDP plans in NJ cover LEVETIRACETAM 500 MG TABLET 120 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
LEVETIRACETAM INJECTION ![Compare how all Medicare Part D PDP plans in NJ cover LEVETIRACETAM INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
LEVETIRACETAM TABLETS 1000MG 60 BOT ![Compare how all Medicare Part D PDP plans in NJ cover LEVETIRACETAM TABLETS 1000MG 60 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM TABLETS 250MG 500 BOT ![Compare how all Medicare Part D PDP plans in NJ cover LEVETIRACETAM TABLETS 250MG 500 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
LEVETIRACETAM TABLETS 750MG 500 BOT ![Compare how all Medicare Part D PDP plans in NJ cover LEVETIRACETAM TABLETS 750MG 500 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
LEVOBUNOLOL 0.25% EYE DROPS ![Compare how all Medicare Part D PDP plans in NJ cover LEVOBUNOLOL 0.25% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION ![Compare how all Medicare Part D PDP plans in NJ cover LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LEVOCARNITINE 100MG/ML SOLUTION ORAL ![Compare how all Medicare Part D PDP plans in NJ cover LEVOCARNITINE 100MG/ML SOLUTION ORAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LEVOCARNITINE 200MG/ML VIAL ![Compare how all Medicare Part D PDP plans in NJ cover LEVOCARNITINE 200MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LEVOCARNITINE TABLET 330MG 90 BLPK ![Compare how all Medicare Part D PDP plans in NJ cover LEVOCARNITINE TABLET 330MG 90 BLPK.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LEVOFLOXACIN 25 MG/ML ORAL SOLUTION [LEVAQUIN] ![Compare how all Medicare Part D PDP plans in NJ cover LEVOFLOXACIN 25 MG/ML ORAL SOLUTION [LEVAQUIN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEVOFLOXACIN 250 MG ORAL TABLET [LEVAQUIN] ![Compare how all Medicare Part D PDP plans in NJ cover LEVOFLOXACIN 250 MG ORAL TABLET [LEVAQUIN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEVOFLOXACIN 500 MG ORAL TABLET [LEVAQUIN] ![Compare how all Medicare Part D PDP plans in NJ cover LEVOFLOXACIN 500 MG ORAL TABLET [LEVAQUIN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in NJ cover LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE SODIUM .150MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in NJ cover LEVOTHYROXINE SODIUM .150MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LEVOTHYROXINE SODIUM 100MCG TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LEVOTHYROXINE SODIUM 100MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LEVOTHYROXINE SODIUM 112MCG TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LEVOTHYROXINE SODIUM 112MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LEVOTHYROXINE SODIUM 125MCG TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LEVOTHYROXINE SODIUM 125MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LEVOTHYROXINE SODIUM 137MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LEVOTHYROXINE SODIUM 175MCG TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LEVOTHYROXINE SODIUM 175MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LEVOTHYROXINE SODIUM 200MCG TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LEVOTHYROXINE SODIUM 200MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LEVOTHYROXINE SODIUM 25MCG TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LEVOTHYROXINE SODIUM 25MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LEVOTHYROXINE SODIUM 300MCG TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LEVOTHYROXINE SODIUM 300MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LEVOTHYROXINE SODIUM 50MCG TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LEVOTHYROXINE SODIUM 50MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LEVOTHYROXINE SODIUM 88MCG TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LEVOTHYROXINE SODIUM 88MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEXAPRO 10MG TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LEXAPRO 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEXAPRO 20MG TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LEXAPRO 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEXAPRO 5MG TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LEXAPRO 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEXAPRO 5MG/5ML SOLUTION ![Compare how all Medicare Part D PDP plans in NJ cover LEXAPRO 5MG/5ML SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LEXIVA 50MG/ML SUSPENSION ORAL ![Compare how all Medicare Part D PDP plans in NJ cover LEXIVA 50MG/ML SUSPENSION ORAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
LEXIVA TABLETS ![Compare how all Medicare Part D PDP plans in NJ cover LEXIVA TABLETS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty Drugs |
25% | N/A | None |
LIDOCAINE 5% OINTMENT ![Compare how all Medicare Part D PDP plans in NJ cover LIDOCAINE 5% OINTMENT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LIDOCAINE HCL 0.5% VIAL ![Compare how all Medicare Part D PDP plans in NJ cover LIDOCAINE HCL 0.5% VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LIDOCAINE HCL 1% VIAL ![Compare how all Medicare Part D PDP plans in NJ cover LIDOCAINE HCL 1% VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LIDOCAINE HCL 2% JELLY 30ML TUBE ![Compare how all Medicare Part D PDP plans in NJ cover LIDOCAINE HCL 2% JELLY 30ML TUBE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT ![Compare how all Medicare Part D PDP plans in NJ cover LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM ![Compare how all Medicare Part D PDP plans in NJ cover LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LIDODERM 5% PATCH ![Compare how all Medicare Part D PDP plans in NJ cover LIDODERM 5% PATCH.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
LINCOCIN 300MG/ML VIAL ![Compare how all Medicare Part D PDP plans in NJ cover LINCOCIN 300MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
LINDANE 1% LOTION ![Compare how all Medicare Part D PDP plans in NJ cover LINDANE 1% LOTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LINDANE SHAMPOO 1MG 2 FLO BOT ![Compare how all Medicare Part D PDP plans in NJ cover LINDANE SHAMPOO 1MG 2 FLO BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT ![Compare how all Medicare Part D PDP plans in NJ cover LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT ![Compare how all Medicare Part D PDP plans in NJ cover LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT ![Compare how all Medicare Part D PDP plans in NJ cover LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
LIPOFEN CAPSULES ![Compare how all Medicare Part D PDP plans in NJ cover LIPOFEN CAPSULES.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LISINOPRIL 10MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in NJ cover LISINOPRIL 10MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LISINOPRIL 2.5MG TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LISINOPRIL 2.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL 20MG TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LISINOPRIL 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LISINOPRIL 30MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in NJ cover LISINOPRIL 30MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LISINOPRIL 40MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in NJ cover LISINOPRIL 40MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LISINOPRIL TABLETS 5 MG ![Compare how all Medicare Part D PDP plans in NJ cover LISINOPRIL TABLETS 5 MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LISINOPRIL-HCTZ 10/12.5 TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LISINOPRIL-HCTZ 10/12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in NJ cover LISINOPRIL-HCTZ 20-25MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LISINOPRIL-HCTZ 20/12.5 TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LISINOPRIL-HCTZ 20/12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LITHIUM CARBONATE 150MG CAPSULE ![Compare how all Medicare Part D PDP plans in NJ cover LITHIUM CARBONATE 150MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) ![Compare how all Medicare Part D PDP plans in NJ cover LITHIUM CARBONATE 300MG CAPSULE (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LITHIUM CARBONATE 300MG TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LITHIUM CARBONATE 300MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LITHIUM CARBONATE CAPSULES ![Compare how all Medicare Part D PDP plans in NJ cover LITHIUM CARBONATE CAPSULES.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) ![Compare how all Medicare Part D PDP plans in NJ cover LITHIUM CARBONATE ER TABLET 300MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP ![Compare how all Medicare Part D PDP plans in NJ cover LITHIUM CIT 8MEQ/5ML SYRUP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LITHIUM ER 450 MG TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LITHIUM ER 450 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LOKARA 0.05% LOTION ![Compare how all Medicare Part D PDP plans in NJ cover LOKARA 0.05% LOTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LOPERAMIDE HCL 2MG CAPSULE ![Compare how all Medicare Part D PDP plans in NJ cover LOPERAMIDE HCL 2MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generics |
$4.00 | $12.00 | None |
LOSARTAN POTASSIUM 100 MG TAB ![Compare how all Medicare Part D PDP plans in NJ cover LOSARTAN POTASSIUM 100 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
LOSARTAN POTASSIUM 25 MG TAB ![Compare how all Medicare Part D PDP plans in NJ cover LOSARTAN POTASSIUM 25 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
LOSARTAN POTASSIUM 50 MG TAB ![Compare how all Medicare Part D PDP plans in NJ cover LOSARTAN POTASSIUM 50 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
LOSARTAN-HCTZ 100-12.5 MG TAB ![Compare how all Medicare Part D PDP plans in NJ cover LOSARTAN-HCTZ 100-12.5 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
LOSARTAN-HCTZ 100-25 MG TAB ![Compare how all Medicare Part D PDP plans in NJ cover LOSARTAN-HCTZ 100-25 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
LOSARTAN-HCTZ 50-12.5 MG TAB ![Compare how all Medicare Part D PDP plans in NJ cover LOSARTAN-HCTZ 50-12.5 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOTRONEX TABLETS .5MG 30 BOTPL ![Compare how all Medicare Part D PDP plans in NJ cover LOTRONEX TABLETS .5MG 30 BOTPL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LOTRONEX TABLETS 1MG 30 BOTPL ![Compare how all Medicare Part D PDP plans in NJ cover LOTRONEX TABLETS 1MG 30 BOTPL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LOVAZA CAPSULES 1GM 120 BOT ![Compare how all Medicare Part D PDP plans in NJ cover LOVAZA CAPSULES 1GM 120 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LOVENOX 100MG PREFILLED SYR ![Compare how all Medicare Part D PDP plans in NJ cover LOVENOX 100MG PREFILLED SYR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
LOVENOX 120MG PREFILLED SYR ![Compare how all Medicare Part D PDP plans in NJ cover LOVENOX 120MG PREFILLED SYR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
LOVENOX 150MG PREFILLED SYR ![Compare how all Medicare Part D PDP plans in NJ cover LOVENOX 150MG PREFILLED SYR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
LOVENOX 300MG VIAL ![Compare how all Medicare Part D PDP plans in NJ cover LOVENOX 300MG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
LOVENOX 30MG PREFILLED SYRN ![Compare how all Medicare Part D PDP plans in NJ cover LOVENOX 30MG PREFILLED SYRN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
LOVENOX 40MG PREFILLED SYRN ![Compare how all Medicare Part D PDP plans in NJ cover LOVENOX 40MG PREFILLED SYRN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
LOVENOX 60MG PREFILLED SYRN ![Compare how all Medicare Part D PDP plans in NJ cover LOVENOX 60MG PREFILLED SYRN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
LOVENOX 80MG PREFILLED SYRN ![Compare how all Medicare Part D PDP plans in NJ cover LOVENOX 80MG PREFILLED SYRN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | 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 NJ cover LOXAPINE 25MG CAPSULE (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
LOXAPINE CAPSULES 10MG 100 BOT ![Compare how all Medicare Part D PDP plans in NJ cover LOXAPINE CAPSULES 10MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
LOXAPINE CAPSULES 50MG 100 BOT ![Compare how all Medicare Part D PDP plans in NJ cover LOXAPINE CAPSULES 50MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
LOXAPINE CAPSULES 5MG 100 BOT ![Compare how all Medicare Part D PDP plans in NJ cover LOXAPINE CAPSULES 5MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 Non-Preferred Generics |
25% | 25% | None |
LYRICA 100MG CAPSULE ![Compare how all Medicare Part D PDP plans in NJ cover LYRICA 100MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
LYRICA 150MG CAPSULE ![Compare how all Medicare Part D PDP plans in NJ cover LYRICA 150MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
LYRICA 200MG CAPSULE ![Compare how all Medicare Part D PDP plans in NJ cover LYRICA 200MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
LYRICA 225MG CAPSULE ![Compare how all Medicare Part D PDP plans in NJ cover LYRICA 225MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
LYRICA 25MG CAPSULE ![Compare how all Medicare Part D PDP plans in NJ cover LYRICA 25MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
LYRICA 300MG CAPSULE ![Compare how all Medicare Part D PDP plans in NJ cover LYRICA 300MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
LYRICA 50MG CAPSULE ![Compare how all Medicare Part D PDP plans in NJ cover LYRICA 50MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYRICA 75MG CAPSULE ![Compare how all Medicare Part D PDP plans in NJ cover LYRICA 75MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |
LYSODREN 500MG TABLET ![Compare how all Medicare Part D PDP plans in NJ cover LYSODREN 500MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
LYSTEDA TABLETS ![Compare how all Medicare Part D PDP plans in NJ cover LYSTEDA TABLETS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 Non-Preferred Brand |
25% | 25% | None |