2013 Medicare Part D Plan Formulary Information |
Anthem Medicare Preferred Core (PPO) (H4036-004-0)
Benefit Details
![Email Prescription and/or Health Benefit details for Anthem Medicare Preferred Core (PPO). This function does not email the formulary drug list.](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
The Anthem Medicare Preferred Core (PPO) (H4036-004-0) Formulary Drugs Starting with the Letter L in WASHINGTON County, WI: CMS MA Region 14 which includes: WI
|
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 WI 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 |
Preferred Brand |
$45.00 | $112.50 | None |
LABETALOL HCL 100MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LABETALOL HCL 100MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LABETALOL HCL 200MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LABETALOL HCL 200MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LABETALOL HCL 300MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LABETALOL HCL 300MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LABETALOL HCL 5MG/20ML VIAL ![Compare how all Medicare Part D PDP plans in WI cover LABETALOL HCL 5MG/20ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5* |
Injectable Drugs |
33% | 33% | None |
Lac Hydrin Cream 120mg/g 140 g in 1 TUBE ![Compare how all Medicare Part D PDP plans in WI cover Lac Hydrin Cream 120mg/g 140 g in 1 TUBE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Lac-Hydrin 120mg/g 400 g in 1 BOTTLE, PLASTIC ![Compare how all Medicare Part D PDP plans in WI cover Lac-Hydrin 120mg/g 400 g in 1 BOTTLE, PLASTIC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LACLOTION 12% LOTION ![Compare how all Medicare Part D PDP plans in WI cover LACLOTION 12% LOTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LACRISERT 5 MG EYE INSERT ![Compare how all Medicare Part D PDP plans in WI cover LACRISERT 5 MG EYE INSERT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Lactated Ringers 200; 300; 6; 3.1mg/1000mL; mg/1000mL; g/1000mL; g/1000mL 5000 mL in 1 BAG ![Compare how all Medicare Part D PDP plans in WI cover Lactated Ringers 200; 300; 6; 3.1mg/1000mL; mg/1000mL; g/1000mL; g/1000mL 5000 mL in 1 BAG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5* |
Injectable Drugs |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LACTATED RINGERS INJECTION ![Compare how all Medicare Part D PDP plans in WI cover LACTATED RINGERS INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5* |
Injectable Drugs |
33% | 33% | None |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT ![Compare how all Medicare Part D PDP plans in WI cover LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LAMICTAL 100MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LAMICTAL 100MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LAMICTAL 150MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LAMICTAL 150MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LAMICTAL 200MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LAMICTAL 200MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LAMICTAL 25MG DISPER TABLET CHEW ![Compare how all Medicare Part D PDP plans in WI cover LAMICTAL 25MG DISPER TABLET CHEW.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LAMICTAL 25MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LAMICTAL 25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LAMICTAL 25MG TABLET STARTER KIT ![Compare how all Medicare Part D PDP plans in WI cover LAMICTAL 25MG TABLET STARTER KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LAMICTAL 5MG DISPER TABLET CHEW ![Compare how all Medicare Part D PDP plans in WI cover LAMICTAL 5MG DISPER TABLET CHEW.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LAMICTAL KIT 100;25MG;MG ![Compare how all Medicare Part D PDP plans in WI cover LAMICTAL KIT 100;25MG;MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LAMICTAL TABLET STARTER KIT ![Compare how all Medicare Part D PDP plans in WI cover LAMICTAL TABLET STARTER KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMISIL 125MG GRANULES IN PACKET ![Compare how all Medicare Part D PDP plans in WI cover LAMISIL 125MG GRANULES IN PACKET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LAMISIL 187.5MG GRANULES IN PACKET ![Compare how all Medicare Part D PDP plans in WI cover LAMISIL 187.5MG GRANULES IN PACKET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LAMISIL 250MG TABLET (30 CT) ![Compare how all Medicare Part D PDP plans in WI cover LAMISIL 250MG TABLET (30 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LAMIVUDINE 150 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LAMIVUDINE 150 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LAMIVUDINE 300 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LAMIVUDINE 300 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LAMIVUDINE-ZIDOVUDINE TABLET ![Compare how all Medicare Part D PDP plans in WI cover LAMIVUDINE-ZIDOVUDINE TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
6* |
Specialty Tier |
33% | N/A | None |
LAMOTRIGINE 150MG TABLET (60 CT) ![Compare how all Medicare Part D PDP plans in WI cover LAMOTRIGINE 150MG TABLET (60 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LAMOTRIGINE 200MG TABLET (60 CT) ![Compare how all Medicare Part D PDP plans in WI cover LAMOTRIGINE 200MG TABLET (60 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LAMOTRIGINE 25MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in WI cover LAMOTRIGINE 25MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE ![Compare how all Medicare Part D PDP plans in WI cover LAMOTRIGINE 25MG TABLET DISPERSIBLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE ![Compare how all Medicare Part D PDP plans in WI cover LAMOTRIGINE 5MG TABLET DISPERSIBLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE TABLET 100MG (100 CT) ![Compare how all Medicare Part D PDP plans in WI cover LAMOTRIGINE TABLET 100MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LANOXIN 0.125MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LANOXIN 0.125MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
LANOXIN 0.25MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LANOXIN 0.25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
LANOXIN PED 0.1MG/ML AMPUL ![Compare how all Medicare Part D PDP plans in WI cover LANOXIN PED 0.1MG/ML AMPUL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5* |
Injectable Drugs |
33% | 33% | None |
Lansoprazole 15mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE, PLASTIC ![Compare how all Medicare Part D PDP plans in WI cover Lansoprazole 15mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE, PLASTIC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
Lansoprazole 30mg/1 30 CAPSULE, DELAYED RELEASE in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in WI cover Lansoprazole 30mg/1 30 CAPSULE, DELAYED RELEASE in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days |
LANTUS 100U/ML VIAL ![Compare how all Medicare Part D PDP plans in WI cover LANTUS 100U/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
LANTUS SOLOSTAR INJECTION ![Compare how all Medicare Part D PDP plans in WI cover LANTUS SOLOSTAR INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
LASIX 40MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LASIX 40MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LASIX TABLETS ![Compare how all Medicare Part D PDP plans in WI cover LASIX TABLETS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LASIX TABLETS ![Compare how all Medicare Part D PDP plans in WI cover LASIX TABLETS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LATANOPROST OPHTHALMIC SOLUTION .005% ![Compare how all Medicare Part D PDP plans in WI cover LATANOPROST OPHTHALMIC SOLUTION .005%.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LATUDA 120 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LATUDA 120 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:30 /30Days |
LATUDA 20 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LATUDA 20 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:240 /30Days |
Latuda 40mg/1 ![Compare how all Medicare Part D PDP plans in WI cover Latuda 40mg/1.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:120 /30Days |
Latuda 80mg/1 ![Compare how all Medicare Part D PDP plans in WI cover Latuda 80mg/1.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:60 /30Days |
LEENA 7-9-5 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEENA 7-9-5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
LEFLUNOMIDE 10MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEFLUNOMIDE 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LEFLUNOMIDE TABLETS ![Compare how all Medicare Part D PDP plans in WI cover LEFLUNOMIDE TABLETS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LESCOL 20MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LESCOL 20MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:60 /30Days |
LESCOL 40MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LESCOL 40MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:60 /30Days |
LESCOL XL 80MG TABLET SA ![Compare how all Medicare Part D PDP plans in WI cover LESCOL XL 80MG TABLET SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Lessina 3 POUCH in 1 CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER PACK ![Compare how all Medicare Part D PDP plans in WI cover Lessina 3 POUCH in 1 CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER PACK.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
LETAIRIS 10MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LETAIRIS 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
6* |
Specialty Tier |
33% | N/A | P |
LETAIRIS 5MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LETAIRIS 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
6* |
Specialty Tier |
33% | N/A | P |
Letrozole 2.5mg/1 500 FILM COATED TABLETS in BOTTLE, PLASTIC ![Compare how all Medicare Part D PDP plans in WI cover Letrozole 2.5mg/1 500 FILM COATED TABLETS in BOTTLE, PLASTIC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LEUCOVORIN CALCIUM 100MG VL ![Compare how all Medicare Part D PDP plans in WI cover LEUCOVORIN CALCIUM 100MG VL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5* |
Injectable Drugs |
33% | 33% | None |
LEUCOVORIN CALCIUM 10MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEUCOVORIN CALCIUM 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
Leucovorin Calcium 15mg/1 24 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in WI cover Leucovorin Calcium 15mg/1 24 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LEUCOVORIN CALCIUM 25MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEUCOVORIN CALCIUM 25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LEUCOVORIN CALCIUM 350MG VL ![Compare how all Medicare Part D PDP plans in WI cover LEUCOVORIN CALCIUM 350MG VL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5* |
Injectable Drugs |
33% | 33% | None |
LEUCOVORIN CALCIUM 5MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEUCOVORIN CALCIUM 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LEUKERAN 2MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEUKERAN 2MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUKINE 500 MCG/ML ![Compare how all Medicare Part D PDP plans in WI cover LEUKINE 500 MCG/ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
6* |
Specialty Tier |
33% | N/A | P |
LEUKINE INJECTION 250 MCG/ML ![Compare how all Medicare Part D PDP plans in WI cover LEUKINE INJECTION 250 MCG/ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
6* |
Specialty Tier |
33% | N/A | P |
LEUPROLIDE ACETATE INJECTION ![Compare how all Medicare Part D PDP plans in WI cover LEUPROLIDE ACETATE INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5* |
Injectable Drugs |
33% | 33% | P |
Levalbuterol 0.31 mg/3 ml sol ![Compare how all Medicare Part D PDP plans in WI cover Levalbuterol 0.31 mg/3 ml sol.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:270 /30Days |
Levalbuterol 0.63 mg/3 ml sol ![Compare how all Medicare Part D PDP plans in WI cover Levalbuterol 0.63 mg/3 ml sol.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:270 /30Days |
LEVALBUTEROL 1.25 MG/0.5 ML ![Compare how all Medicare Part D PDP plans in WI cover LEVALBUTEROL 1.25 MG/0.5 ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $112.50 | P Q:45 /30Days |
LEVAQUIN INJECTION 5 MG/ML ![Compare how all Medicare Part D PDP plans in WI cover LEVAQUIN INJECTION 5 MG/ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5* |
Injectable Drugs |
33% | 33% | None |
LEVATOL 20 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVATOL 20 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LEVEMIR 100UNITS/ML VIAL ![Compare how all Medicare Part D PDP plans in WI cover LEVEMIR 100UNITS/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $112.50 | 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 WI 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 |
Preferred Brand |
$45.00 | $112.50 | None |
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT ![Compare how all Medicare Part D PDP plans in WI cover LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM 100MG/ML INJECTION ![Compare how all Medicare Part D PDP plans in WI cover LEVETIRACETAM 100MG/ML INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5* |
Injectable Drugs |
33% | 33% | None |
LEVETIRACETAM 500 MG TABLET 120 BOT ![Compare how all Medicare Part D PDP plans in WI cover LEVETIRACETAM 500 MG TABLET 120 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
Levetiracetam 750mg/1 60 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in WI cover Levetiracetam 750mg/1 60 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | Q:120 /30Days |
Levetiracetam er 500 mg tablet ![Compare how all Medicare Part D PDP plans in WI cover Levetiracetam er 500 mg tablet.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | Q:180 /30Days |
LEVETIRACETAM TABLETS 1000MG 60 BOT ![Compare how all Medicare Part D PDP plans in WI cover LEVETIRACETAM TABLETS 1000MG 60 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LEVETIRACETAM TABLETS 250MG 500 BOT ![Compare how all Medicare Part D PDP plans in WI cover LEVETIRACETAM TABLETS 250MG 500 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LEVETIRACETAM TABLETS 750MG 500 BOT ![Compare how all Medicare Part D PDP plans in WI cover LEVETIRACETAM TABLETS 750MG 500 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION ![Compare how all Medicare Part D PDP plans in WI cover LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LEVOCARNITINE 100MG/ML SOLUTION ORAL ![Compare how all Medicare Part D PDP plans in WI cover LEVOCARNITINE 100MG/ML SOLUTION ORAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | P |
LEVOCARNITINE 200MG/ML VIAL ![Compare how all Medicare Part D PDP plans in WI cover LEVOCARNITINE 200MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5* |
Injectable Drugs |
33% | 33% | P |
LEVOCARNITINE TABLET 330MG 90 BLPK ![Compare how all Medicare Part D PDP plans in WI cover LEVOCARNITINE TABLET 330MG 90 BLPK.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levocetirizine dihydrochloride 5mg/1 30 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in WI cover Levocetirizine dihydrochloride 5mg/1 30 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | Q:30 /30Days |
Levofloxacin 250mg/1 ![Compare how all Medicare Part D PDP plans in WI cover Levofloxacin 250mg/1.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | Q:14 /1Days |
Levofloxacin 25mg/mL 1 BOTTLE in 1 CARTON / 100 mL in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in WI cover Levofloxacin 25mg/mL 1 BOTTLE in 1 CARTON / 100 mL in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Levofloxacin 25mg/mL 1 VIAL in 1 CARTON / 30 mL in 1 VIAL ![Compare how all Medicare Part D PDP plans in WI 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) |
5* |
Injectable Drugs |
33% | 33% | None |
Levofloxacin 500mg/1 ![Compare how all Medicare Part D PDP plans in WI cover Levofloxacin 500mg/1.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | Q:14 /1Days |
Levofloxacin 5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER ![Compare how all Medicare Part D PDP plans in WI 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* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
Levofloxacin 5mg/mL 24 POUCH in 1 CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG ![Compare how all Medicare Part D PDP plans in WI cover Levofloxacin 5mg/mL 24 POUCH in 1 CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5* |
Injectable Drugs |
33% | 33% | None |
Levofloxacin 750mg/1 ![Compare how all Medicare Part D PDP plans in WI cover Levofloxacin 750mg/1.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | Q:14 /1Days |
LEVONEST-28 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVONEST-28 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
levonor-eth estrad 0.15-0.03 ![Compare how all Medicare Part D PDP plans in WI cover levonor-eth estrad 0.15-0.03.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
LEVORA-28 TABLET 0.15/30 ![Compare how all Medicare Part D PDP plans in WI cover LEVORA-28 TABLET 0.15/30.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVORPHANOL TARTRATE 2mg 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in WI cover LEVORPHANOL TARTRATE 2mg 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | Q:180 /30Days |
Levothroid 100ug/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in WI cover Levothroid 100ug/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothroid 112ug/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in WI cover Levothroid 112ug/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothroid 125ug/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in WI cover Levothroid 125ug/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothroid 137ug/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in WI cover Levothroid 137ug/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothroid 150ug/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in WI cover Levothroid 150ug/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothroid 175ug/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in WI cover Levothroid 175ug/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothroid 200ug/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in WI cover Levothroid 200ug/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothroid 25ug/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in WI cover Levothroid 25ug/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothroid 300ug/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in WI cover Levothroid 300ug/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothroid 50ug/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in WI cover Levothroid 50ug/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levothroid 75ug/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in WI cover Levothroid 75ug/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothroid 88ug/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in WI cover Levothroid 88ug/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothyroxine Sodium 100ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA ![Compare how all Medicare Part D PDP plans in WI cover Levothyroxine Sodium 100ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothyroxine Sodium 112ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA ![Compare how all Medicare Part D PDP plans in WI cover Levothyroxine Sodium 112ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothyroxine Sodium 125ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA ![Compare how all Medicare Part D PDP plans in WI cover Levothyroxine Sodium 125ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHYROXINE SODIUM 137MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothyroxine Sodium 150ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA ![Compare how all Medicare Part D PDP plans in WI cover Levothyroxine Sodium 150ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothyroxine Sodium 175ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA ![Compare how all Medicare Part D PDP plans in WI cover Levothyroxine Sodium 175ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothyroxine Sodium 200ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA ![Compare how all Medicare Part D PDP plans in WI cover Levothyroxine Sodium 200ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothyroxine Sodium 25ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS ![Compare how all Medicare Part D PDP plans in WI cover Levothyroxine Sodium 25ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothyroxine Sodium 300ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA ![Compare how all Medicare Part D PDP plans in WI cover Levothyroxine Sodium 300ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levothyroxine Sodium 50ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS ![Compare how all Medicare Part D PDP plans in WI cover Levothyroxine Sodium 50ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothyroxine Sodium 75ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS ![Compare how all Medicare Part D PDP plans in WI cover Levothyroxine Sodium 75ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Levothyroxine Sodium 88ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS ![Compare how all Medicare Part D PDP plans in WI cover Levothyroxine Sodium 88ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLAS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LEVOXYL 100MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LEVOXYL 100MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LEVOXYL 112MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LEVOXYL 112MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LEVOXYL 125MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LEVOXYL 125MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LEVOXYL 137MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LEVOXYL 137MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LEVOXYL 150MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LEVOXYL 150MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LEVOXYL 175MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LEVOXYL 175MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LEVOXYL 200MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LEVOXYL 200MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LEVOXYL 25MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LEVOXYL 25MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 50MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LEVOXYL 50MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LEVOXYL 75MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LEVOXYL 75MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LEVOXYL 88MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in WI cover LEVOXYL 88MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LEXAPRO 10MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEXAPRO 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:60 /30Days |
LEXAPRO 20MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEXAPRO 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:30 /30Days |
LEXAPRO 5MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEXAPRO 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:120 /30Days |
LEXAPRO 5MG/5ML SOLUTION ![Compare how all Medicare Part D PDP plans in WI cover LEXAPRO 5MG/5ML SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:600 /30Days |
LEXIVA 50mg/mL 225 mL in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in WI cover LEXIVA 50mg/mL 225 mL in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LEXIVA TABLETS ![Compare how all Medicare Part D PDP plans in WI cover LEXIVA TABLETS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
6* |
Specialty Tier |
33% | N/A | None |
LIALDA 1.2G TABLET DELAYED RELEASE ![Compare how all Medicare Part D PDP plans in WI cover LIALDA 1.2G TABLET DELAYED RELEASE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
LIDOCAINE 5% OINTMENT ![Compare how all Medicare Part D PDP plans in WI cover LIDOCAINE 5% OINTMENT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
lidocaine hcl 2% jelly ![Compare how all Medicare Part D PDP plans in WI cover lidocaine hcl 2% jelly.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LIDOCAINE HCL 2% JELLY 30ML TUBE ![Compare how all Medicare Part D PDP plans in WI cover LIDOCAINE HCL 2% JELLY 30ML TUBE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT ![Compare how all Medicare Part D PDP plans in WI cover LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT ![Compare how all Medicare Part D PDP plans in WI cover LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM ![Compare how all Medicare Part D PDP plans in WI cover LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LIDODERM 5% PATCH ![Compare how all Medicare Part D PDP plans in WI cover LIDODERM 5% PATCH.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:90 /30Days |
LINCOCIN 300MG/ML VIAL ![Compare how all Medicare Part D PDP plans in WI cover LINCOCIN 300MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5* |
Injectable Drugs |
33% | 33% | None |
Lindane 10mg/mL ![Compare how all Medicare Part D PDP plans in WI cover Lindane 10mg/mL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LINDANE SHAMPOO 1MG 2 FLO BOT ![Compare how all Medicare Part D PDP plans in WI cover LINDANE SHAMPOO 1MG 2 FLO BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
liothyronine sodium 10ug/mL 1 VIAL in 1 CARTON / 1 mL in 1 VIAL ![Compare how all Medicare Part D PDP plans in WI cover liothyronine sodium 10ug/mL 1 VIAL in 1 CARTON / 1 mL in 1 VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
6* |
Specialty Tier |
33% | N/A | None |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT ![Compare how all Medicare Part D PDP plans in WI cover LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT ![Compare how all Medicare Part D PDP plans in WI cover LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT ![Compare how all Medicare Part D PDP plans in WI cover LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Liposyn III 1.2; 2.5; 10g/100mL; g/100mL; g/100mL 12 BOTTLE, GLASS in 1 CASE / 250 mL in 1 BOTTLE, ![Compare how all Medicare Part D PDP plans in WI cover Liposyn III 1.2; 2.5; 10g/100mL; g/100mL; g/100mL 12 BOTTLE, GLASS in 1 CASE / 250 mL in 1 BOTTLE, .](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5* |
Injectable Drugs |
33% | 33% | None |
Liposyn III 1.2; 2.5; 20g/100mL; g/100mL; g/100mL 12 BOTTLE, GLASS in 1 CASE / 250 mL in 1 BOTTLE, ![Compare how all Medicare Part D PDP plans in WI cover Liposyn III 1.2; 2.5; 20g/100mL; g/100mL; g/100mL 12 BOTTLE, GLASS in 1 CASE / 250 mL in 1 BOTTLE, .](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5* |
Injectable Drugs |
33% | 33% | None |
LISINOPRIL 10MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in WI cover LISINOPRIL 10MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LISINOPRIL 2.5 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LISINOPRIL 2.5 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LISINOPRIL 20MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LISINOPRIL 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LISINOPRIL 30MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in WI cover LISINOPRIL 30MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LISINOPRIL 40MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in WI cover LISINOPRIL 40MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Lisinopril 5mg/1 1000 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in WI cover Lisinopril 5mg/1 1000 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LISINOPRIL-HCTZ 10/12.5 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LISINOPRIL-HCTZ 10/12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $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 WI cover LISINOPRIL-HCTZ 20-25MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LISINOPRIL-HCTZ 20/12.5 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LISINOPRIL-HCTZ 20/12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
Lithium Carbonate 150mg/1 100 CAPSULE in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in WI cover Lithium Carbonate 150mg/1 100 CAPSULE in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Lithium Carbonate 300 mg tab ![Compare how all Medicare Part D PDP plans in WI cover Lithium Carbonate 300 mg tab.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) ![Compare how all Medicare Part D PDP plans in WI cover LITHIUM CARBONATE 300MG CAPSULE (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
Lithium Carbonate 450mg/1 ![Compare how all Medicare Part D PDP plans in WI cover Lithium Carbonate 450mg/1.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LITHIUM CARBONATE CAPSULES ![Compare how all Medicare Part D PDP plans in WI cover LITHIUM CARBONATE CAPSULES.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) ![Compare how all Medicare Part D PDP plans in WI cover LITHIUM CARBONATE ER TABLET 300MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$4.00 | $6.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP ![Compare how all Medicare Part D PDP plans in WI cover LITHIUM CIT 8MEQ/5ML SYRUP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LITHOBID 300MG TABLET SA ![Compare how all Medicare Part D PDP plans in WI cover LITHOBID 300MG TABLET SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LIVALO TABLETS 1 MG ![Compare how all Medicare Part D PDP plans in WI cover LIVALO TABLETS 1 MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIVALO TABLETS 2 MG ![Compare how all Medicare Part D PDP plans in WI cover LIVALO TABLETS 2 MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:30 /30Days |
LIVALO TABLETS 4 MG ![Compare how all Medicare Part D PDP plans in WI cover LIVALO TABLETS 4 MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:30 /30Days |
Lo/Ovral-28 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK ![Compare how all Medicare Part D PDP plans in WI cover Lo/Ovral-28 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Locoid Lipocream 1.0mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE ![Compare how all Medicare Part D PDP plans in WI cover Locoid Lipocream 1.0mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOCOID LOTN 0.1 % ![Compare how all Medicare Part D PDP plans in WI cover LOCOID LOTN 0.1 %.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LODOSYN TAB 25MG ![Compare how all Medicare Part D PDP plans in WI cover LODOSYN TAB 25MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S |
LOESTRIN 24 FE TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOESTRIN 24 FE TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOFIBRA 134MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOFIBRA 134MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:30 /30Days |
LOFIBRA 160MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOFIBRA 160MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:30 /30Days |
LOFIBRA 200MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOFIBRA 200MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:30 /30Days |
LOFIBRA 54MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOFIBRA 54MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOFIBRA 67MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOFIBRA 67MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:90 /30Days |
LOKARA 0.05% LOTION ![Compare how all Medicare Part D PDP plans in WI cover LOKARA 0.05% LOTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOPERAMIDE HCL 2MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOPERAMIDE HCL 2MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LOPID 600MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in WI cover LOPID 600MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOPRESSOR 100MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in WI cover LOPRESSOR 100MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOPRESSOR 1MG/ML AMPUL ![Compare how all Medicare Part D PDP plans in WI cover LOPRESSOR 1MG/ML AMPUL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5* |
Injectable Drugs |
33% | 33% | None |
LOPRESSOR 50MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in WI cover LOPRESSOR 50MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOPRESSOR HCT 100/25 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOPRESSOR HCT 100/25 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOPRESSOR HCT 50-25 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOPRESSOR HCT 50-25 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOPROX 1% SHAMPOO ![Compare how all Medicare Part D PDP plans in WI cover LOPROX 1% SHAMPOO.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOPROX GEL TOPICAL ![Compare how all Medicare Part D PDP plans in WI cover LOPROX GEL TOPICAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Loryna (drospirenone and ethinyl estradiol) 3 CARTON in 1 BOX / 1 KIT in 1 CARTON ![Compare how all Medicare Part D PDP plans in WI cover Loryna (drospirenone and ethinyl estradiol) 3 CARTON in 1 BOX / 1 KIT in 1 CARTON.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOSARTAN POTASSIUM 100 MG TAB ![Compare how all Medicare Part D PDP plans in WI cover LOSARTAN POTASSIUM 100 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | Q:30 /30Days |
LOSARTAN POTASSIUM 25 MG TAB ![Compare how all Medicare Part D PDP plans in WI cover LOSARTAN POTASSIUM 25 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | Q:60 /30Days |
LOSARTAN POTASSIUM 50 MG TAB ![Compare how all Medicare Part D PDP plans in WI cover LOSARTAN POTASSIUM 50 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | Q:60 /30Days |
LOSARTAN-HCTZ 100-12.5 MG TAB ![Compare how all Medicare Part D PDP plans in WI cover LOSARTAN-HCTZ 100-12.5 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | Q:30 /30Days |
LOSARTAN-HCTZ 100-25 MG TAB ![Compare how all Medicare Part D PDP plans in WI cover LOSARTAN-HCTZ 100-25 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | Q:30 /30Days |
LOSARTAN-HCTZ 50-12.5 MG TAB ![Compare how all Medicare Part D PDP plans in WI cover LOSARTAN-HCTZ 50-12.5 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | Q:30 /30Days |
LOTEMAX 0.5% EYE DROPS ![Compare how all Medicare Part D PDP plans in WI cover LOTEMAX 0.5% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Lotemax 5mg/g 1 TUBE in 1 CARTON / 3.5 g in 1 TUBE ![Compare how all Medicare Part D PDP plans in WI cover Lotemax 5mg/g 1 TUBE in 1 CARTON / 3.5 g in 1 TUBE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOTREL 10/20MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOTREL 10/20MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOTREL 10/40MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOTREL 10/40MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOTREL 2.5/10MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOTREL 2.5/10MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Lotrel 5; 40mg/1; mg/1 100 CAPSULE in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in WI cover Lotrel 5; 40mg/1; mg/1 100 CAPSULE in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOTREL 5/10MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOTREL 5/10MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOTREL 5/20MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOTREL 5/20MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOTRISONE CREAM ![Compare how all Medicare Part D PDP plans in WI cover LOTRISONE CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOTRONEX TABLETS .5MG 30 BOTPL ![Compare how all Medicare Part D PDP plans in WI cover LOTRONEX TABLETS .5MG 30 BOTPL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $112.50 | P Q:60 /30Days |
LOTRONEX TABLETS 1MG 30 BOTPL ![Compare how all Medicare Part D PDP plans in WI cover LOTRONEX TABLETS 1MG 30 BOTPL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $112.50 | P Q:60 /30Days |
Lovastatin 10mg 60 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in WI cover Lovastatin 10mg 60 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | Q:30 /30Days |
Lovastatin 20mg 500 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in WI cover Lovastatin 20mg 500 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | Q:30 /30Days |
LOVASTATIN 40 MG ORAL TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOVASTATIN 40 MG ORAL TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | Q:60 /30Days |
LOVAZA 1g/ 120 LIQUID FILLED CAPSULES in BOTTLE ![Compare how all Medicare Part D PDP plans in WI cover LOVAZA 1g/ 120 LIQUID FILLED CAPSULES in BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOW-OGESTREL-28 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOW-OGESTREL-28 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
LOXAPINE 25MG CAPSULE (100 CT) ![Compare how all Medicare Part D PDP plans in WI cover LOXAPINE 25MG CAPSULE (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LOXAPINE CAPSULES 10MG 100 BOT ![Compare how all Medicare Part D PDP plans in WI cover LOXAPINE CAPSULES 10MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LOXAPINE CAPSULES 50MG 100 BOT ![Compare how all Medicare Part D PDP plans in WI cover LOXAPINE CAPSULES 50MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LOXAPINE CAPSULES 5MG 100 BOT ![Compare how all Medicare Part D PDP plans in WI cover LOXAPINE CAPSULES 5MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None |
LOXITANE 10MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOXITANE 10MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOXITANE 25MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOXITANE 25MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOXITANE 50MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOXITANE 50MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LOXITANE 5MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOXITANE 5MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LUFYLLIN 200MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LUFYLLIN 200MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LUFYLLIN-400 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LUFYLLIN-400 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUMIGAN 0.03% EYE DROPS ![Compare how all Medicare Part D PDP plans in WI cover LUMIGAN 0.03% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
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 WI 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 |
Preferred Brand |
$45.00 | $112.50 | None |
LUNESTA 2MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LUNESTA 2MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:30 /30Days |
LUNESTA 3MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LUNESTA 3MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:30 /30Days |
LUNESTA TABLETS 1MG 30 BOT ![Compare how all Medicare Part D PDP plans in WI cover LUNESTA TABLETS 1MG 30 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:30 /30Days |
LUPRON DEPOT 3.75 MG KIT ![Compare how all Medicare Part D PDP plans in WI cover LUPRON DEPOT 3.75 MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5* |
Injectable Drugs |
33% | 33% | P |
LUPRON DEPOT 7.5 MG KIT ![Compare how all Medicare Part D PDP plans in WI cover LUPRON DEPOT 7.5 MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5* |
Injectable Drugs |
33% | 33% | P |
LUTERA 0.1-0.02 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LUTERA 0.1-0.02 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
LUXIQ 1.2mg/g 1 CAN in 1 CARTON / 100 g in 1 CAN ![Compare how all Medicare Part D PDP plans in WI cover LUXIQ 1.2mg/g 1 CAN in 1 CARTON / 100 g in 1 CAN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
LYRICA 100MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LYRICA 100MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:180 /30Days |
LYRICA 150MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LYRICA 150MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYRICA 20 MG/ML ORAL SOLUTION ![Compare how all Medicare Part D PDP plans in WI cover LYRICA 20 MG/ML ORAL SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:900 /30Days |
LYRICA 200MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LYRICA 200MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:90 /30Days |
LYRICA 225MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LYRICA 225MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:60 /30Days |
LYRICA 25MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LYRICA 25MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:720 /30Days |
LYRICA 300MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LYRICA 300MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:60 /30Days |
LYRICA 50MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LYRICA 50MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:360 /30Days |
LYRICA 75MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LYRICA 75MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:240 /30Days |
LYSODREN 500MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LYSODREN 500MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $112.50 | None |