2012 Medicare Part D Plan Formulary Information |
WindsorSterling Gold Access Plan (PFFS) (H5006-017-17)
Benefit Details
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The WindsorSterling Gold Access Plan (PFFS) (H5006-017-17) Formulary Drugs Starting with the Letter L in PIKE County, MO: CMS MA Region 15 which includes: MO
|
Drugs Starting with Letter L
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE 16 VACCINE 0.04 MG/ML / L1 PROTEIN, HUMAN PAPILLOMAVIRU ![Compare how all Medicare Part D PDP plans in MO 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 |
$34.00 | $102.00 | 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 MO 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 |
$34.00 | $102.00 | None |
LABETALOL HCL 100MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LABETALOL HCL 100MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LABETALOL HCL 200MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LABETALOL HCL 200MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LABETALOL HCL 300MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LABETALOL HCL 300MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LABETALOL HCL 5MG/20ML VIAL ![Compare how all Medicare Part D PDP plans in MO cover LABETALOL HCL 5MG/20ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LACTATED RINGERS INJECTION ![Compare how all Medicare Part D PDP plans in MO cover LACTATED RINGERS INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | P |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT ![Compare how all Medicare Part D PDP plans in MO cover LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LAMIVUDINE 150 MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LAMIVUDINE 150 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LAMIVUDINE 300 MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LAMIVUDINE 300 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMIVUDINE-ZIDOVUDINE TABLET ![Compare how all Medicare Part D PDP plans in MO cover LAMIVUDINE-ZIDOVUDINE TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LAMOTRIGINE 150MG TABLET (60 CT) ![Compare how all Medicare Part D PDP plans in MO cover LAMOTRIGINE 150MG TABLET (60 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LAMOTRIGINE 200MG TABLET (60 CT) ![Compare how all Medicare Part D PDP plans in MO cover LAMOTRIGINE 200MG TABLET (60 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LAMOTRIGINE 25MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in MO cover LAMOTRIGINE 25MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE ![Compare how all Medicare Part D PDP plans in MO cover LAMOTRIGINE 25MG TABLET DISPERSIBLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE ![Compare how all Medicare Part D PDP plans in MO cover LAMOTRIGINE 5MG TABLET DISPERSIBLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LAMOTRIGINE TABLET 100MG (100 CT) ![Compare how all Medicare Part D PDP plans in MO cover LAMOTRIGINE TABLET 100MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LANOXIN 0.125MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LANOXIN 0.125MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$84.00 | $252.00 | None |
LANOXIN 0.25MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LANOXIN 0.25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$84.00 | $252.00 | None |
LANOXIN PED 0.1MG/ML AMPUL ![Compare how all Medicare Part D PDP plans in MO cover LANOXIN PED 0.1MG/ML AMPUL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$84.00 | $252.00 | P |
LANREOTIDE 240 MG/ML PREFILLED SYRINGE [SOMATULINE] ![Compare how all Medicare Part D PDP plans in MO cover LANREOTIDE 240 MG/ML PREFILLED SYRINGE [SOMATULINE].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 |
30% | 30% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LANTUS 100U/ML VIAL ![Compare how all Medicare Part D PDP plans in MO cover LANTUS 100U/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$34.00 | $102.00 | None |
LANTUS SOLOSTAR INJECTION ![Compare how all Medicare Part D PDP plans in MO cover LANTUS SOLOSTAR INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$34.00 | $102.00 | None |
LATANOPROST OPHTHALMIC SOLUTION .005% ![Compare how all Medicare Part D PDP plans in MO cover LATANOPROST OPHTHALMIC SOLUTION .005%.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LATUDA 20 MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LATUDA 20 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$84.00 | $252.00 | Q:60 /30Days |
Latuda 40mg/1 ![Compare how all Medicare Part D PDP plans in MO cover Latuda 40mg/1.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$84.00 | $252.00 | Q:60 /30Days |
Latuda 80mg/1 ![Compare how all Medicare Part D PDP plans in MO cover Latuda 80mg/1.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$84.00 | $252.00 | Q:60 /30Days |
LEFLUNOMIDE 10MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEFLUNOMIDE 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEFLUNOMIDE TABLETS ![Compare how all Medicare Part D PDP plans in MO cover LEFLUNOMIDE TABLETS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LETAIRIS 10MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LETAIRIS 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 |
30% | 30% | P |
LETAIRIS 5MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LETAIRIS 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 |
30% | 30% | P |
Letrozole 2.5mg/1 500 TABLET, FILM COATED in 1 BOTTLE, PLASTIC ![Compare how all Medicare Part D PDP plans in MO cover Letrozole 2.5mg/1 500 TABLET, FILM COATED in 1 BOTTLE, PLASTIC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUCOVORIN CALCIUM 100MG VL ![Compare how all Medicare Part D PDP plans in MO cover LEUCOVORIN CALCIUM 100MG VL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | P |
LEUCOVORIN CALCIUM 10MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEUCOVORIN CALCIUM 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Leucovorin Calcium 15mg/1 24 TABLET in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in MO cover Leucovorin Calcium 15mg/1 24 TABLET in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEUCOVORIN CALCIUM 25MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEUCOVORIN CALCIUM 25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEUCOVORIN CALCIUM 350MG VL ![Compare how all Medicare Part D PDP plans in MO cover LEUCOVORIN CALCIUM 350MG VL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | P |
LEUCOVORIN CALCIUM 5MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEUCOVORIN CALCIUM 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEUKERAN 2MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEUKERAN 2MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$34.00 | $102.00 | None |
LEUKINE 500 MCG/ML ![Compare how all Medicare Part D PDP plans in MO cover LEUKINE 500 MCG/ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 |
30% | 30% | None |
LEUKINE INJECTION 250 MCG/ML ![Compare how all Medicare Part D PDP plans in MO cover LEUKINE INJECTION 250 MCG/ML .](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 |
30% | 30% | None |
LEUPROLIDE ACETATE INJECTION ![Compare how all Medicare Part D PDP plans in MO cover LEUPROLIDE ACETATE INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | P |
LEVALBUTEROL 1.25 MG/0.5 ML ![Compare how all Medicare Part D PDP plans in MO cover LEVALBUTEROL 1.25 MG/0.5 ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Tier 1 |
$5.00 | $15.00 | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVATOL 20MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVATOL 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$84.00 | $252.00 | None |
LEVEMIR 100UNITS/ML VIAL ![Compare how all Medicare Part D PDP plans in MO cover LEVEMIR 100UNITS/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$34.00 | $102.00 | None |
Levemir 14.2mg/mL 5 SYRINGE, PLASTIC in 1 CARTON / 3 mL in 1 SYRINGE, PLASTIC ![Compare how all Medicare Part D PDP plans in MO cover Levemir 14.2mg/mL 5 SYRINGE, PLASTIC in 1 CARTON / 3 mL in 1 SYRINGE, PLASTIC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$34.00 | $102.00 | None |
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT ![Compare how all Medicare Part D PDP plans in MO cover LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEVETIRACETAM 500 MG TABLET 120 BOT ![Compare how all Medicare Part D PDP plans in MO cover LEVETIRACETAM 500 MG TABLET 120 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEVETIRACETAM ER 500 MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVETIRACETAM ER 500 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$84.00 | $252.00 | Q:180 /30Days |
LEVETIRACETAM ER 750 MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVETIRACETAM ER 750 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$84.00 | $252.00 | Q:120 /30Days |
LEVETIRACETAM INJECTION ![Compare how all Medicare Part D PDP plans in MO cover LEVETIRACETAM INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | P |
LEVETIRACETAM TABLETS 1000MG 60 BOT ![Compare how all Medicare Part D PDP plans in MO cover LEVETIRACETAM TABLETS 1000MG 60 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEVETIRACETAM TABLETS 250MG 500 BOT ![Compare how all Medicare Part D PDP plans in MO cover LEVETIRACETAM TABLETS 250MG 500 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEVETIRACETAM TABLETS 750MG 500 BOT ![Compare how all Medicare Part D PDP plans in MO cover LEVETIRACETAM TABLETS 750MG 500 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOBUNOLOL 0.25% EYE DROPS ![Compare how all Medicare Part D PDP plans in MO cover LEVOBUNOLOL 0.25% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION ![Compare how all Medicare Part D PDP plans in MO cover LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEVOCARNITINE 100MG/ML SOLUTION ORAL ![Compare how all Medicare Part D PDP plans in MO cover LEVOCARNITINE 100MG/ML SOLUTION ORAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Tier 1 |
$5.00 | $15.00 | P |
LEVOCARNITINE TABLET 330MG 90 BLPK ![Compare how all Medicare Part D PDP plans in MO cover LEVOCARNITINE TABLET 330MG 90 BLPK.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Tier 1 |
$5.00 | $15.00 | P |
Levocetirizine dihydrochloride 5mg/1 30 TABLET in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in MO cover Levocetirizine dihydrochloride 5mg/1 30 TABLET in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Levofloxacin 250mg/1 ![Compare how all Medicare Part D PDP plans in MO cover Levofloxacin 250mg/1.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | Q:28 /30Days |
Levofloxacin 25mg/mL 1 VIAL in 1 CARTON / 30 mL in 1 VIAL ![Compare how all Medicare Part D PDP plans in MO cover Levofloxacin 25mg/mL 1 VIAL in 1 CARTON / 30 mL in 1 VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | P |
Levofloxacin 500mg/1 ![Compare how all Medicare Part D PDP plans in MO cover Levofloxacin 500mg/1.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | Q:28 /30Days |
Levofloxacin 5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER ![Compare how all Medicare Part D PDP plans in MO cover Levofloxacin 5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Levofloxacin 750mg/1 ![Compare how all Medicare Part D PDP plans in MO cover Levofloxacin 750mg/1.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | Q:15 /30Days |
Levothroid 100ug/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in MO cover Levothroid 100ug/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levothroid 112ug/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in MO cover Levothroid 112ug/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Levothroid 125ug/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in MO cover Levothroid 125ug/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Levothroid 137ug/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in MO cover Levothroid 137ug/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Levothroid 150ug/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in MO cover Levothroid 150ug/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Levothroid 175ug/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in MO cover Levothroid 175ug/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Levothroid 200ug/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in MO cover Levothroid 200ug/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Levothroid 25ug/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in MO cover Levothroid 25ug/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Levothroid 300ug/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in MO cover Levothroid 300ug/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Levothroid 50ug/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in MO cover Levothroid 50ug/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Levothroid 75ug/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in MO cover Levothroid 75ug/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Levothroid 88ug/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in MO cover Levothroid 88ug/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEVOTHYROXINE SODIUM .150MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHYROXINE SODIUM .150MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEVOTHYROXINE SODIUM 100MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHYROXINE SODIUM 100MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEVOTHYROXINE SODIUM 112MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHYROXINE SODIUM 112MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEVOTHYROXINE SODIUM 125MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHYROXINE SODIUM 125MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHYROXINE SODIUM 137MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEVOTHYROXINE SODIUM 175MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHYROXINE SODIUM 175MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEVOTHYROXINE SODIUM 200MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHYROXINE SODIUM 200MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEVOTHYROXINE SODIUM 25MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHYROXINE SODIUM 25MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEVOTHYROXINE SODIUM 300MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHYROXINE SODIUM 300MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEVOTHYROXINE SODIUM 50MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHYROXINE SODIUM 50MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE SODIUM 88MCG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEVOTHYROXINE SODIUM 88MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEVOXYL 100MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEVOXYL 100MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEVOXYL 112MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEVOXYL 112MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEVOXYL 125MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEVOXYL 125MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEVOXYL 137MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEVOXYL 137MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEVOXYL 150MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEVOXYL 150MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEVOXYL 175MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEVOXYL 175MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEVOXYL 200MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEVOXYL 200MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEVOXYL 25MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEVOXYL 25MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEVOXYL 50MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEVOXYL 50MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEVOXYL 75MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEVOXYL 75MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 88MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in MO cover LEVOXYL 88MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LEXAPRO 10MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEXAPRO 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$84.00 | $252.00 | Q:45 /30Days |
LEXAPRO 20MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEXAPRO 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$84.00 | $252.00 | Q:30 /30Days |
LEXAPRO 5MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LEXAPRO 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$84.00 | $252.00 | Q:45 /30Days |
LEXAPRO 5MG/5ML SOLUTION ![Compare how all Medicare Part D PDP plans in MO cover LEXAPRO 5MG/5ML SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$84.00 | $252.00 | Q:600 /30Days |
LEXIVA 50mg/mL 225 mL in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in MO cover LEXIVA 50mg/mL 225 mL in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$34.00 | $102.00 | None |
LEXIVA TABLETS ![Compare how all Medicare Part D PDP plans in MO cover LEXIVA TABLETS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$34.00 | $102.00 | None |
LIDOCAINE 5% OINTMENT ![Compare how all Medicare Part D PDP plans in MO cover LIDOCAINE 5% OINTMENT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LIDOCAINE HCL 0.5% VIAL ![Compare how all Medicare Part D PDP plans in MO cover LIDOCAINE HCL 0.5% VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | P |
LIDOCAINE HCL 1% VIAL ![Compare how all Medicare Part D PDP plans in MO cover LIDOCAINE HCL 1% VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | P |
lidocaine hcl 2% jelly ![Compare how all Medicare Part D PDP plans in MO cover lidocaine hcl 2% jelly.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIDOCAINE HCL 2% JELLY 30ML TUBE ![Compare how all Medicare Part D PDP plans in MO cover LIDOCAINE HCL 2% JELLY 30ML TUBE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT ![Compare how all Medicare Part D PDP plans in MO cover LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT ![Compare how all Medicare Part D PDP plans in MO cover LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM ![Compare how all Medicare Part D PDP plans in MO cover LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | P |
LIDODERM 5% PATCH ![Compare how all Medicare Part D PDP plans in MO cover LIDODERM 5% PATCH.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$84.00 | $252.00 | P Q:90 /30Days |
LINCOCIN 300MG/ML VIAL ![Compare how all Medicare Part D PDP plans in MO cover LINCOCIN 300MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$34.00 | $102.00 | P |
Lindane 10mg/mL ![Compare how all Medicare Part D PDP plans in MO cover Lindane 10mg/mL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$84.00 | $252.00 | None |
LINDANE SHAMPOO 1MG 2 FLO BOT ![Compare how all Medicare Part D PDP plans in MO cover LINDANE SHAMPOO 1MG 2 FLO BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT ![Compare how all Medicare Part D PDP plans in MO cover LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT ![Compare how all Medicare Part D PDP plans in MO cover LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT ![Compare how all Medicare Part D PDP plans in MO cover LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIPITOR 10MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LIPITOR 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$34.00 | $102.00 | Q:30 /30Days |
LIPITOR 20MG TABLET (5000 CT) ![Compare how all Medicare Part D PDP plans in MO cover LIPITOR 20MG TABLET (5000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$34.00 | $102.00 | Q:30 /30Days |
LIPITOR 40MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in MO cover LIPITOR 40MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$34.00 | $102.00 | Q:30 /30Days |
LIPITOR 80MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LIPITOR 80MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$34.00 | $102.00 | None |
LISINOPRIL 10MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in MO cover LISINOPRIL 10MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Tier 1 |
$5.00 | $15.00 | None |
Lisinopril 2.5mg 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in MO cover Lisinopril 2.5mg 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Tier 1 |
$5.00 | $15.00 | None |
LISINOPRIL 20MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LISINOPRIL 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Tier 1 |
$5.00 | $15.00 | None |
LISINOPRIL 30MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in MO cover LISINOPRIL 30MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Tier 1 |
$5.00 | $15.00 | None |
LISINOPRIL 40MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in MO cover LISINOPRIL 40MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Tier 1 |
$5.00 | $15.00 | None |
Lisinopril 5mg/1 1000 TABLET in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in MO cover Lisinopril 5mg/1 1000 TABLET in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Tier 1 |
$5.00 | $15.00 | None |
LISINOPRIL-HCTZ 10/12.5 TABLET ![Compare how all Medicare Part D PDP plans in MO cover LISINOPRIL-HCTZ 10/12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Tier 1 |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in MO cover LISINOPRIL-HCTZ 20-25MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Tier 1 |
$5.00 | $15.00 | None |
LISINOPRIL-HCTZ 20/12.5 TABLET ![Compare how all Medicare Part D PDP plans in MO cover LISINOPRIL-HCTZ 20/12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Tier 1 |
$5.00 | $15.00 | None |
LITHIUM CARBONATE 150MG CAPSULE ![Compare how all Medicare Part D PDP plans in MO cover LITHIUM CARBONATE 150MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Tier 1 |
$5.00 | $15.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) ![Compare how all Medicare Part D PDP plans in MO cover LITHIUM CARBONATE 300MG CAPSULE (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Tier 1 |
$5.00 | $15.00 | None |
Lithium Carbonate 450mg/1 ![Compare how all Medicare Part D PDP plans in MO cover Lithium Carbonate 450mg/1.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LITHIUM CARBONATE CAPSULES ![Compare how all Medicare Part D PDP plans in MO cover LITHIUM CARBONATE CAPSULES.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) ![Compare how all Medicare Part D PDP plans in MO cover LITHIUM CARBONATE ER TABLET 300MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP ![Compare how all Medicare Part D PDP plans in MO cover LITHIUM CIT 8MEQ/5ML SYRUP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$84.00 | $252.00 | None |
LOPERAMIDE HCL 2MG CAPSULE ![Compare how all Medicare Part D PDP plans in MO cover LOPERAMIDE HCL 2MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LOSARTAN POTASSIUM 100 MG TAB ![Compare how all Medicare Part D PDP plans in MO cover LOSARTAN POTASSIUM 100 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LOSARTAN POTASSIUM 25 MG TAB ![Compare how all Medicare Part D PDP plans in MO cover LOSARTAN POTASSIUM 25 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOSARTAN POTASSIUM 50 MG TAB ![Compare how all Medicare Part D PDP plans in MO cover LOSARTAN POTASSIUM 50 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LOSARTAN-HCTZ 100-12.5 MG TAB ![Compare how all Medicare Part D PDP plans in MO cover LOSARTAN-HCTZ 100-12.5 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LOSARTAN-HCTZ 100-25 MG TAB ![Compare how all Medicare Part D PDP plans in MO cover LOSARTAN-HCTZ 100-25 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LOSARTAN-HCTZ 50-12.5 MG TAB ![Compare how all Medicare Part D PDP plans in MO cover LOSARTAN-HCTZ 50-12.5 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LOTRONEX TABLETS .5MG 30 BOTPL ![Compare how all Medicare Part D PDP plans in MO cover LOTRONEX TABLETS .5MG 30 BOTPL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$34.00 | $102.00 | P |
LOTRONEX TABLETS 1MG 30 BOTPL ![Compare how all Medicare Part D PDP plans in MO cover LOTRONEX TABLETS 1MG 30 BOTPL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 |
30% | 30% | P |
Lovastatin 10mg 60 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in MO cover Lovastatin 10mg 60 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
Lovastatin 20mg 500 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in MO cover Lovastatin 20mg 500 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LOVASTATIN 40 MG ORAL TABLET ![Compare how all Medicare Part D PDP plans in MO cover LOVASTATIN 40 MG ORAL TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LOVAZA 1g/ 120 LIQUID FILLED CAPSULES in BOTTLE ![Compare how all Medicare Part D PDP plans in MO cover LOVAZA 1g/ 120 LIQUID FILLED CAPSULES in BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$84.00 | $252.00 | Q:120 /30Days |
LOW-OGESTREL-28 TABLET ![Compare how all Medicare Part D PDP plans in MO cover LOW-OGESTREL-28 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | Q:28 /28Days |
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 MO cover LOXAPINE 25MG CAPSULE (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LOXAPINE CAPSULES 10MG 100 BOT ![Compare how all Medicare Part D PDP plans in MO cover LOXAPINE CAPSULES 10MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LOXAPINE CAPSULES 50MG 100 BOT ![Compare how all Medicare Part D PDP plans in MO cover LOXAPINE CAPSULES 50MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LOXAPINE CAPSULES 5MG 100 BOT ![Compare how all Medicare Part D PDP plans in MO cover LOXAPINE CAPSULES 5MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Tier 2 |
$15.00 | $45.00 | None |
LUMIGAN 0.03% EYE DROPS ![Compare how all Medicare Part D PDP plans in MO cover LUMIGAN 0.03% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$34.00 | $102.00 | Q:3 /30Days |
LUMIGAN 0.1mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER ![Compare how all Medicare Part D PDP plans in MO cover LUMIGAN 0.1mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 |
$34.00 | $102.00 | Q:3 /30Days |
Lumizyme 5mg/mL ![Compare how all Medicare Part D PDP plans in MO cover Lumizyme 5mg/mL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 |
30% | 30% | P |
LUPRON DEPOT 11.25 MG 3MO KIT ![Compare how all Medicare Part D PDP plans in MO cover LUPRON DEPOT 11.25 MG 3MO KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$84.00 | $252.00 | P |
LUPRON DEPOT 22.5 MG 3MO KIT [LUPRON] ![Compare how all Medicare Part D PDP plans in MO cover LUPRON DEPOT 22.5 MG 3MO KIT [LUPRON].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 |
30% | 30% | P |
LUPRON DEPOT 3.75 MG KIT ![Compare how all Medicare Part D PDP plans in MO cover LUPRON DEPOT 3.75 MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$84.00 | $252.00 | P |
LUPRON DEPOT 7.5 MG KIT ![Compare how all Medicare Part D PDP plans in MO cover LUPRON DEPOT 7.5 MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 |
30% | 30% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUPRON DEPOT-4 MONTH KIT ![Compare how all Medicare Part D PDP plans in MO cover LUPRON DEPOT-4 MONTH KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 |
30% | 30% | P |
LUPRON DEPOT-PED 11.25 MG KIT ![Compare how all Medicare Part D PDP plans in MO cover LUPRON DEPOT-PED 11.25 MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 |
30% | 30% | P |
LUPRON DEPOT-PED 15 MG KIT ![Compare how all Medicare Part D PDP plans in MO cover LUPRON DEPOT-PED 15 MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 |
30% | 30% | P |
LYRICA 100MG CAPSULE ![Compare how all Medicare Part D PDP plans in MO cover LYRICA 100MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$84.00 | $252.00 | P Q:120 /30Days |
LYRICA 150MG CAPSULE ![Compare how all Medicare Part D PDP plans in MO cover LYRICA 150MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$84.00 | $252.00 | P Q:120 /30Days |
LYRICA 200MG CAPSULE ![Compare how all Medicare Part D PDP plans in MO cover LYRICA 200MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$84.00 | $252.00 | P Q:90 /30Days |
LYRICA 225MG CAPSULE ![Compare how all Medicare Part D PDP plans in MO cover LYRICA 225MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$84.00 | $252.00 | P Q:60 /30Days |
LYRICA 25MG CAPSULE ![Compare how all Medicare Part D PDP plans in MO cover LYRICA 25MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$84.00 | $252.00 | P Q:120 /30Days |
LYRICA 300MG CAPSULE ![Compare how all Medicare Part D PDP plans in MO cover LYRICA 300MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$84.00 | $252.00 | P Q:60 /30Days |
LYRICA 50MG CAPSULE ![Compare how all Medicare Part D PDP plans in MO cover LYRICA 50MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$84.00 | $252.00 | P Q:120 /30Days |
LYRICA 75MG CAPSULE ![Compare how all Medicare Part D PDP plans in MO cover LYRICA 75MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 |
$84.00 | $252.00 | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYSODREN 500MG TABLET ![Compare how all Medicare Part D PDP plans in MO cover LYSODREN 500MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 |
30% | 30% | None |