2013 Medicare Part D Plan Formulary Information |
Gateway Health Plan Medicare Assured Select (HMO SNP) (H5932-007-0)
Benefit Details
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The Gateway Health Plan Medicare Assured Select (HMO SNP) (H5932-007-0) Formulary Drugs Starting with the Letter L in ARMSTRONG County, PA: CMS MA Region 6 which includes: PA
|
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 PA cover L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE 16 VACCINE 0.04 MG/ML / L1 PROTEIN, HUMAN PAPILLOMAVIRU.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
LABETALOL HCL 100MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LABETALOL HCL 100MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LABETALOL HCL 200MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LABETALOL HCL 200MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LABETALOL HCL 300MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LABETALOL HCL 300MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LACTATED RINGERS INJECTION ![Compare how all Medicare Part D PDP plans in PA cover LACTATED RINGERS INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT ![Compare how all Medicare Part D PDP plans in PA 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 | $30.00 | None |
LAMICTAL 25MG TABLET STARTER KIT ![Compare how all Medicare Part D PDP plans in PA cover LAMICTAL 25MG TABLET STARTER KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LAMICTAL TABLET STARTER KIT ![Compare how all Medicare Part D PDP plans in PA cover LAMICTAL TABLET STARTER KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LAMICTAL XR 250mg/1 30 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in PA cover LAMICTAL XR 250mg/1 30 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
LAMIVUDINE 150 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LAMIVUDINE 150 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMIVUDINE 300 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LAMIVUDINE 300 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LAMOTRIGINE 150MG TABLET (60 CT) ![Compare how all Medicare Part D PDP plans in PA cover LAMOTRIGINE 150MG TABLET (60 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LAMOTRIGINE 200MG TABLET (60 CT) ![Compare how all Medicare Part D PDP plans in PA cover LAMOTRIGINE 200MG TABLET (60 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LAMOTRIGINE 25MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover LAMOTRIGINE 25MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE ![Compare how all Medicare Part D PDP plans in PA cover LAMOTRIGINE 25MG TABLET DISPERSIBLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE ![Compare how all Medicare Part D PDP plans in PA cover LAMOTRIGINE 5MG TABLET DISPERSIBLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LAMOTRIGINE ER 100 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LAMOTRIGINE ER 100 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
lamotrigine er 200 mg tablet ![Compare how all Medicare Part D PDP plans in PA cover lamotrigine er 200 mg tablet.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
lamotrigine er 25 mg tablet ![Compare how all Medicare Part D PDP plans in PA cover lamotrigine er 25 mg tablet.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
lamotrigine er 250 mg tablet ![Compare how all Medicare Part D PDP plans in PA cover lamotrigine er 250 mg tablet.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
lamotrigine er 300 mg tablet ![Compare how all Medicare Part D PDP plans in PA cover lamotrigine er 300 mg tablet.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
lamotrigine er 50 mg tablet ![Compare how all Medicare Part D PDP plans in PA cover lamotrigine er 50 mg tablet.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LAMOTRIGINE TABLET 100MG (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover LAMOTRIGINE TABLET 100MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
Lansoprazole 15mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE, PLASTIC ![Compare how all Medicare Part D PDP plans in PA cover Lansoprazole 15mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE, PLASTIC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:60 /30Days |
Lansoprazole 30mg/1 30 CAPSULE, DELAYED RELEASE in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in PA cover Lansoprazole 30mg/1 30 CAPSULE, DELAYED RELEASE in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:60 /30Days |
LANTUS 100U/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover LANTUS 100U/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LANTUS SOLOSTAR INJECTION ![Compare how all Medicare Part D PDP plans in PA cover LANTUS SOLOSTAR INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LATANOPROST OPHTHALMIC SOLUTION .005% ![Compare how all Medicare Part D PDP plans in PA cover LATANOPROST OPHTHALMIC SOLUTION .005%.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LATUDA 20 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LATUDA 20 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
Latuda 40mg/1 ![Compare how all Medicare Part D PDP plans in PA cover Latuda 40mg/1.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
Latuda 80mg/1 ![Compare how all Medicare Part D PDP plans in PA cover Latuda 80mg/1.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days |
LEFLUNOMIDE 10MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEFLUNOMIDE 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEFLUNOMIDE TABLETS ![Compare how all Medicare Part D PDP plans in PA cover LEFLUNOMIDE TABLETS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LETAIRIS 10MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LETAIRIS 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | 33% | Q:30 /30Days |
LETAIRIS 5MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LETAIRIS 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | 33% | Q:30 /30Days |
Letrozole 2.5mg/1 500 FILM COATED TABLETS in BOTTLE, PLASTIC ![Compare how all Medicare Part D PDP plans in PA 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 | $30.00 | None |
LEUCOVORIN CALCIUM 100MG VL ![Compare how all Medicare Part D PDP plans in PA cover LEUCOVORIN CALCIUM 100MG VL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
LEUCOVORIN CALCIUM 10MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEUCOVORIN CALCIUM 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Leucovorin Calcium 15mg/1 24 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in PA 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 | $30.00 | None |
LEUCOVORIN CALCIUM 25MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEUCOVORIN CALCIUM 25MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEUCOVORIN CALCIUM 350MG VL ![Compare how all Medicare Part D PDP plans in PA cover LEUCOVORIN CALCIUM 350MG VL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
LEUCOVORIN CALCIUM 5MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEUCOVORIN CALCIUM 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEUKERAN 2MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEUKERAN 2MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $135.00 | 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 PA cover LEUKINE 500 MCG/ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | 33% | P |
LEUKINE INJECTION 250 MCG/ML ![Compare how all Medicare Part D PDP plans in PA cover LEUKINE INJECTION 250 MCG/ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | 33% | P |
LEUPROLIDE ACETATE INJECTION ![Compare how all Medicare Part D PDP plans in PA cover LEUPROLIDE ACETATE INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
LEVEMIR 100UNITS/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover LEVEMIR 100UNITS/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | 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 PA 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) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT ![Compare how all Medicare Part D PDP plans in PA 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 | $30.00 | None |
LEVETIRACETAM 100MG/ML INJECTION ![Compare how all Medicare Part D PDP plans in PA cover LEVETIRACETAM 100MG/ML INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEVETIRACETAM 500 MG TABLET 120 BOT ![Compare how all Medicare Part D PDP plans in PA cover LEVETIRACETAM 500 MG TABLET 120 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levetiracetam 750mg/1 60 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in PA 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 | $30.00 | None |
Levetiracetam er 500 mg tablet ![Compare how all Medicare Part D PDP plans in PA cover Levetiracetam er 500 mg tablet.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEVETIRACETAM TABLETS 1000MG 60 BOT ![Compare how all Medicare Part D PDP plans in PA cover LEVETIRACETAM TABLETS 1000MG 60 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM TABLETS 250MG 500 BOT ![Compare how all Medicare Part D PDP plans in PA cover LEVETIRACETAM TABLETS 250MG 500 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEVETIRACETAM TABLETS 750MG 500 BOT ![Compare how all Medicare Part D PDP plans in PA cover LEVETIRACETAM TABLETS 750MG 500 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION ![Compare how all Medicare Part D PDP plans in PA cover LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEVOCARNITINE 100MG/ML SOLUTION ORAL ![Compare how all Medicare Part D PDP plans in PA cover LEVOCARNITINE 100MG/ML SOLUTION ORAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
LEVOCARNITINE TABLET 330MG 90 BLPK ![Compare how all Medicare Part D PDP plans in PA cover LEVOCARNITINE TABLET 330MG 90 BLPK.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
Levocetirizine dihydrochloride 5mg/1 30 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in PA 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 | $30.00 | None |
Levofloxacin 250mg/1 ![Compare how all Medicare Part D PDP plans in PA cover Levofloxacin 250mg/1.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levofloxacin 500mg/1 ![Compare how all Medicare Part D PDP plans in PA cover Levofloxacin 500mg/1.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levofloxacin 750mg/1 ![Compare how all Medicare Part D PDP plans in PA cover Levofloxacin 750mg/1.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEVORA-28 TABLET 0.15/30 ![Compare how all Medicare Part D PDP plans in PA cover LEVORA-28 TABLET 0.15/30.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levothroid 112ug/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in PA cover Levothroid 112ug/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levothroid 300ug/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in PA cover Levothroid 300ug/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Levothroid 75ug/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in PA cover Levothroid 75ug/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | 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 PA 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 | $12.00 | 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 PA 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 | $12.00 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LEVOTHYROXINE SODIUM 137MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | 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 PA 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 | $12.00 | None |
LEVOXYL 150MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in PA cover LEVOXYL 150MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEVOXYL 175MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in PA cover LEVOXYL 175MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEVOXYL 50MCG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in PA cover LEVOXYL 50MCG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LEXIVA 50mg/mL 225 mL in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in PA cover LEXIVA 50mg/mL 225 mL in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
LEXIVA TABLETS ![Compare how all Medicare Part D PDP plans in PA cover LEXIVA TABLETS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIDOCAINE 5% OINTMENT ![Compare how all Medicare Part D PDP plans in PA cover LIDOCAINE 5% OINTMENT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
LIDOCAINE HCL 2% JELLY 30ML TUBE ![Compare how all Medicare Part D PDP plans in PA cover LIDOCAINE HCL 2% JELLY 30ML TUBE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT ![Compare how all Medicare Part D PDP plans in PA cover LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
Lidocaine Hydrochloride 5mg/mL 25 VIAL, SINGLE-DOSE in 1 CONTAINER / 50 mL in 1 VIAL, SINGLE-DOSE ![Compare how all Medicare Part D PDP plans in PA cover Lidocaine Hydrochloride 5mg/mL 25 VIAL, SINGLE-DOSE in 1 CONTAINER / 50 mL in 1 VIAL, SINGLE-DOSE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT ![Compare how all Medicare Part D PDP plans in PA cover LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM ![Compare how all Medicare Part D PDP plans in PA 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 | $30.00 | P |
LIDODERM 5% PATCH ![Compare how all Medicare Part D PDP plans in PA cover LIDODERM 5% PATCH.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:90 /30Days |
Lindane 10mg/mL ![Compare how all Medicare Part D PDP plans in PA cover Lindane 10mg/mL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LINDANE SHAMPOO 1MG 2 FLO BOT ![Compare how all Medicare Part D PDP plans in PA cover LINDANE SHAMPOO 1MG 2 FLO BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LISINOPRIL 10MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover LISINOPRIL 10MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LISINOPRIL 2.5 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LISINOPRIL 2.5 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL 20MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LISINOPRIL 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LISINOPRIL 30MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover LISINOPRIL 30MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LISINOPRIL 40MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in PA cover LISINOPRIL 40MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
Lisinopril 5mg/1 1000 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in PA cover Lisinopril 5mg/1 1000 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LISINOPRIL-HCTZ 10/12.5 TABLET ![Compare how all Medicare Part D PDP plans in PA cover LISINOPRIL-HCTZ 10/12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover LISINOPRIL-HCTZ 20-25MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LISINOPRIL-HCTZ 20/12.5 TABLET ![Compare how all Medicare Part D PDP plans in PA cover LISINOPRIL-HCTZ 20/12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
Lithium Carbonate 150mg/1 100 CAPSULE in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in PA 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 | $12.00 | None |
Lithium Carbonate 300 mg tab ![Compare how all Medicare Part D PDP plans in PA cover Lithium Carbonate 300 mg tab.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LITHIUM CARBONATE 300MG CAPSULE (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover LITHIUM CARBONATE 300MG CAPSULE (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
Lithium Carbonate 450mg/1 ![Compare how all Medicare Part D PDP plans in PA cover Lithium Carbonate 450mg/1.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LITHIUM CARBONATE CAPSULES ![Compare how all Medicare Part D PDP plans in PA cover LITHIUM CARBONATE CAPSULES.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover LITHIUM CARBONATE ER TABLET 300MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP ![Compare how all Medicare Part D PDP plans in PA cover LITHIUM CIT 8MEQ/5ML SYRUP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LOKARA 0.05% LOTION ![Compare how all Medicare Part D PDP plans in PA cover LOKARA 0.05% LOTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LOPERAMIDE HCL 2MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover LOPERAMIDE HCL 2MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Lorazepam 0.5mg/1 500 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in PA cover Lorazepam 0.5mg/1 500 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P Q:120 /30Days |
Lorazepam 1mg/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in PA cover Lorazepam 1mg/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P Q:120 /30Days |
Lorazepam 2mg/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in PA cover Lorazepam 2mg/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P Q:120 /30Days |
Lorazepam 2mg/mL 30 mL in 1 BOTTLE, DROPPER ![Compare how all Medicare Part D PDP plans in PA cover Lorazepam 2mg/mL 30 mL in 1 BOTTLE, DROPPER.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P Q:120 /30Days |
LOSARTAN POTASSIUM 100 MG TAB ![Compare how all Medicare Part D PDP plans in PA cover LOSARTAN POTASSIUM 100 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LOSARTAN POTASSIUM 25 MG TAB ![Compare how all Medicare Part D PDP plans in PA cover LOSARTAN POTASSIUM 25 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | 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 PA cover LOSARTAN POTASSIUM 50 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LOSARTAN-HCTZ 100-12.5 MG TAB ![Compare how all Medicare Part D PDP plans in PA cover LOSARTAN-HCTZ 100-12.5 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LOSARTAN-HCTZ 100-25 MG TAB ![Compare how all Medicare Part D PDP plans in PA cover LOSARTAN-HCTZ 100-25 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LOSARTAN-HCTZ 50-12.5 MG TAB ![Compare how all Medicare Part D PDP plans in PA cover LOSARTAN-HCTZ 50-12.5 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LOTRONEX TABLETS .5MG 30 BOTPL ![Compare how all Medicare Part D PDP plans in PA cover LOTRONEX TABLETS .5MG 30 BOTPL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
LOTRONEX TABLETS 1MG 30 BOTPL ![Compare how all Medicare Part D PDP plans in PA cover LOTRONEX TABLETS 1MG 30 BOTPL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
Lovastatin 10mg 60 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in PA cover Lovastatin 10mg 60 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
Lovastatin 20mg 500 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in PA cover Lovastatin 20mg 500 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LOVASTATIN 40 MG ORAL TABLET ![Compare how all Medicare Part D PDP plans in PA cover LOVASTATIN 40 MG ORAL TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$4.00 | $12.00 | None |
LOVAZA 1g/ 120 LIQUID FILLED CAPSULES in BOTTLE ![Compare how all Medicare Part D PDP plans in PA 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 | $135.00 | P Q:120 /30Days |
LOVENOX 300MG VIAL ![Compare how all Medicare Part D PDP plans in PA cover LOVENOX 300MG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $135.00 | 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 PA cover LOW-OGESTREL-28 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LOXAPINE 25MG CAPSULE (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover LOXAPINE 25MG CAPSULE (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LOXAPINE CAPSULES 10MG 100 BOT ![Compare how all Medicare Part D PDP plans in PA cover LOXAPINE CAPSULES 10MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LOXAPINE CAPSULES 50MG 100 BOT ![Compare how all Medicare Part D PDP plans in PA cover LOXAPINE CAPSULES 50MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LOXAPINE CAPSULES 5MG 100 BOT ![Compare how all Medicare Part D PDP plans in PA cover LOXAPINE CAPSULES 5MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
Lupron Depot 1 KIT in 1 CARTON ![Compare how all Medicare Part D PDP plans in PA cover Lupron Depot 1 KIT in 1 CARTON.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
LUPRON DEPOT 22.5 MG 3MO KIT [LUPRON] ![Compare how all Medicare Part D PDP plans in PA cover LUPRON DEPOT 22.5 MG 3MO KIT [LUPRON].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
LUPRON DEPOT 3.75 MG KIT ![Compare how all Medicare Part D PDP plans in PA cover LUPRON DEPOT 3.75 MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
LUPRON DEPOT 7.5 MG KIT ![Compare how all Medicare Part D PDP plans in PA cover LUPRON DEPOT 7.5 MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
LUPRON DEPOT-4 MONTH KIT ![Compare how all Medicare Part D PDP plans in PA cover LUPRON DEPOT-4 MONTH KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
Lupron Depot-PED 1 KIT in 1 CARTON ![Compare how all Medicare Part D PDP plans in PA cover Lupron Depot-PED 1 KIT in 1 CARTON.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUPRON DEPOT-PED 11.25 MG KIT ![Compare how all Medicare Part D PDP plans in PA cover LUPRON DEPOT-PED 11.25 MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
LUPRON DEPOT-PED 15 MG KIT ![Compare how all Medicare Part D PDP plans in PA cover LUPRON DEPOT-PED 15 MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P |
LUTERA 0.1-0.02 TABLET ![Compare how all Medicare Part D PDP plans in PA cover LUTERA 0.1-0.02 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None |
LYRICA 100MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover LYRICA 100MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:90 /30Days |
LYRICA 150MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover LYRICA 150MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:90 /30Days |
LYRICA 20 MG/ML ORAL SOLUTION ![Compare how all Medicare Part D PDP plans in PA cover LYRICA 20 MG/ML ORAL SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:473 /30Days |
LYRICA 200MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover LYRICA 200MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:90 /30Days |
LYRICA 225MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover LYRICA 225MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
LYRICA 25MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover LYRICA 25MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:90 /30Days |
LYRICA 300MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover LYRICA 300MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days |
LYRICA 50MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover LYRICA 50MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYRICA 75MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover LYRICA 75MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:90 /30Days |
LYSODREN 500MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover LYSODREN 500MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$45.00 | $135.00 | None |