2021 Medicare Part D Plan Formulary Information |
iCare Medicare Plan (HMO D-SNP) (H2237-001-0)
Benefit Details
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The iCare Medicare Plan (HMO D-SNP) (H2237-001-0) Formulary Drugs Starting with the Letter L in Manitowoc County, WI: CMS MA Region 14 which includes: WI Plan Monthly Premium: $40.70 Deductible: $445 |
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 |
LABETALOL HCL 100 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LABETALOL HCL 100 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LABETALOL HCL 200 MG TABLET [Trandate] ![Compare how all Medicare Part D PDP plans in WI cover LABETALOL HCL 200 MG TABLET [Trandate].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LABETALOL HCL 300 MG TABLET [Trandate] ![Compare how all Medicare Part D PDP plans in WI cover LABETALOL HCL 300 MG TABLET [Trandate].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LACTULOSE 10 GM/15 ML SOLUTION [Constulose] ![Compare how all Medicare Part D PDP plans in WI cover LACTULOSE 10 GM/15 ML SOLUTION [Constulose].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LAMIVUDINE 10 MG/ML ORAL SOLUTION [Epivir] ![Compare how all Medicare Part D PDP plans in WI cover LAMIVUDINE 10 MG/ML ORAL SOLUTION [Epivir].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LAMIVUDINE 150 MG TABLET [Epivir] ![Compare how all Medicare Part D PDP plans in WI cover LAMIVUDINE 150 MG TABLET [Epivir].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LAMIVUDINE 300 MG TABLET [Epivir] ![Compare how all Medicare Part D PDP plans in WI cover LAMIVUDINE 300 MG TABLET [Epivir].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LAMIVUDINE HBV 100 MG TABLET [Epivir HBV] ![Compare how all Medicare Part D PDP plans in WI cover LAMIVUDINE HBV 100 MG TABLET [Epivir HBV].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LAMIVUDINE-ZIDOVUDINE TABLET [Combivir] ![Compare how all Medicare Part D PDP plans in WI cover LAMIVUDINE-ZIDOVUDINE TABLET [Combivir].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LAMOTRIGINE 100 MG TABLET [Subvenite] ![Compare how all Medicare Part D PDP plans in WI cover LAMOTRIGINE 100 MG TABLET [Subvenite].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE 150 MG TABLET [Subvenite] ![Compare how all Medicare Part D PDP plans in WI cover LAMOTRIGINE 150 MG TABLET [Subvenite].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LAMOTRIGINE 200 MG TABLET [Subvenite] ![Compare how all Medicare Part D PDP plans in WI cover LAMOTRIGINE 200 MG TABLET [Subvenite].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LAMOTRIGINE 25 MG DISPER TABLET CHW [Lamictal CD] ![Compare how all Medicare Part D PDP plans in WI cover LAMOTRIGINE 25 MG DISPER TABLET CHW [Lamictal CD].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LAMOTRIGINE 25 MG TABLET [Subvenite] ![Compare how all Medicare Part D PDP plans in WI cover LAMOTRIGINE 25 MG TABLET [Subvenite].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LAMOTRIGINE 5 MG DISPER TABLET CHW [Lamictal CD] ![Compare how all Medicare Part D PDP plans in WI cover LAMOTRIGINE 5 MG DISPER TABLET CHW [Lamictal CD].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LANSOPRAZOLE DR 15 MG CAPSULE DR [Prevacid] ![Compare how all Medicare Part D PDP plans in WI cover LANSOPRAZOLE DR 15 MG CAPSULE DR [Prevacid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | Q:30 /30Days |
LANSOPRAZOLE DR 30 MG CAPSULE DR [Prevacid] ![Compare how all Medicare Part D PDP plans in WI cover LANSOPRAZOLE DR 30 MG CAPSULE DR [Prevacid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | Q:60 /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) |
2 |
Brand |
$45.00 | $135.00 | Q:40 /28Days |
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) |
2 |
Brand |
$45.00 | $135.00 | Q:30 /28Days |
LAPATINIB 250 MG TABLET [Tykerb] ![Compare how all Medicare Part D PDP plans in WI cover LAPATINIB 250 MG TABLET [Tykerb].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Specialty Tier |
25% | N/A | P |
LARIN 1.5 MG-30 MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LARIN 1.5 MG-30 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LARIN 21 1-20 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LARIN 21 1-20 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LARIN FE 1-20 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LARIN FE 1-20 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LARIN FE 1.5-30 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LARIN FE 1.5-30 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LARISSIA-28 TABLET [Vienva] ![Compare how all Medicare Part D PDP plans in WI cover LARISSIA-28 TABLET [Vienva].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LATANOPROST 0.005% EYE DROPS ![Compare how all Medicare Part D PDP plans in WI cover LATANOPROST 0.005% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | Q:3 /25Days |
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) |
2 |
Brand |
$45.00 | $135.00 | 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) |
2 |
Brand |
$45.00 | $135.00 | Q:30 /30Days |
LATUDA 40 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LATUDA 40 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Brand |
$45.00 | $135.00 | Q:30 /30Days |
LATUDA 60 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LATUDA 60 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Brand |
$45.00 | $135.00 | Q:30 /30Days |
LATUDA 80 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LATUDA 80 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Brand |
$45.00 | $135.00 | Q:60 /30Days |
LEDIPASVIR-SOFOSBUVIR 90-400MG TABLET [Harvoni] ![Compare how all Medicare Part D PDP plans in WI cover LEDIPASVIR-SOFOSBUVIR 90-400MG TABLET [Harvoni].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEFLUNOMIDE 10 MG TABLET [Arava] ![Compare how all Medicare Part D PDP plans in WI cover LEFLUNOMIDE 10 MG TABLET [Arava].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEFLUNOMIDE 20 MG TABLET [Arava] ![Compare how all Medicare Part D PDP plans in WI cover LEFLUNOMIDE 20 MG TABLET [Arava].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LENVIMA 10 MG DAILY DOSE ![Compare how all Medicare Part D PDP plans in WI cover LENVIMA 10 MG DAILY DOSE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Specialty Tier |
25% | N/A | P |
LENVIMA 12 MG DAILY DOSE CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LENVIMA 12 MG DAILY DOSE CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Specialty Tier |
25% | N/A | P |
LENVIMA 14 MG DAILY DOSE ![Compare how all Medicare Part D PDP plans in WI cover LENVIMA 14 MG DAILY DOSE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Specialty Tier |
25% | N/A | P |
LENVIMA 18 MG DAILY DOSE ![Compare how all Medicare Part D PDP plans in WI cover LENVIMA 18 MG DAILY DOSE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Specialty Tier |
25% | N/A | P |
LENVIMA 20 MG DAILY DOSE ![Compare how all Medicare Part D PDP plans in WI cover LENVIMA 20 MG DAILY DOSE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Specialty Tier |
25% | N/A | P |
LENVIMA 24 MG DAILY DOSE ![Compare how all Medicare Part D PDP plans in WI cover LENVIMA 24 MG DAILY DOSE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Specialty Tier |
25% | N/A | P |
LENVIMA 4 MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LENVIMA 4 MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Specialty Tier |
25% | N/A | P |
LENVIMA 8 MG DAILY DOSE ![Compare how all Medicare Part D PDP plans in WI cover LENVIMA 8 MG DAILY DOSE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Specialty Tier |
25% | N/A | P |
Lessina 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK ![Compare how all Medicare Part D PDP plans in WI cover Lessina 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LETROZOLE 2.5 MG TABLET [Femara] ![Compare how all Medicare Part D PDP plans in WI cover LETROZOLE 2.5 MG TABLET [Femara].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | 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) |
1* |
Generic |
$15.00 | $45.00 | None |
LEUCOVORIN CALCIUM 15MG 24 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in WI cover LEUCOVORIN CALCIUM 15MG 24 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEUCOVORIN CALCIUM 25 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEUCOVORIN CALCIUM 25 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEUCOVORIN CALCIUM 5 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEUCOVORIN CALCIUM 5 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEUKERAN 2 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEUKERAN 2 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Brand |
$45.00 | $135.00 | None |
LEUKINE 250 MCG VIAL ![Compare how all Medicare Part D PDP plans in WI cover LEUKINE 250 MCG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Specialty Tier |
25% | N/A | None |
LEUPROLIDE 2WK 14 MG/2.8 ML KT ![Compare how all Medicare Part D PDP plans in WI cover LEUPROLIDE 2WK 14 MG/2.8 ML KT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Specialty Tier |
25% | N/A | None |
LEVETIRACETAM 1,000 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVETIRACETAM 1,000 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVETIRACETAM 100 MG/ML SOLUTION [Keppra] ![Compare how all Medicare Part D PDP plans in WI cover LEVETIRACETAM 100 MG/ML SOLUTION [Keppra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVETIRACETAM 250 MG TABLET [Keppra] ![Compare how all Medicare Part D PDP plans in WI cover LEVETIRACETAM 250 MG TABLET [Keppra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM 500 MG TABLET [Roweepra] ![Compare how all Medicare Part D PDP plans in WI cover LEVETIRACETAM 500 MG TABLET [Roweepra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVETIRACETAM 750 MG TABLET [Keppra] ![Compare how all Medicare Part D PDP plans in WI cover LEVETIRACETAM 750 MG TABLET [Keppra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVETIRACETAM ER 500 MG TABLET ER 24H [Roweepra] ![Compare how all Medicare Part D PDP plans in WI cover LEVETIRACETAM ER 500 MG TABLET ER 24H [Roweepra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVETIRACETAM ER 750 MG TABLET ER 24H [Roweepra] ![Compare how all Medicare Part D PDP plans in WI cover LEVETIRACETAM ER 750 MG TABLET ER 24H [Roweepra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVOBUNOLOL 0.5% EYE DROPS [Betagan] ![Compare how all Medicare Part D PDP plans in WI cover LEVOBUNOLOL 0.5% EYE DROPS [Betagan].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVOCARNITINE 1 G/10 ML SOLUTION ![Compare how all Medicare Part D PDP plans in WI cover LEVOCARNITINE 1 G/10 ML SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVOCARNITINE 330 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOCARNITINE 330 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVOCETIRIZINE 2.5 MG/5 ML SOLUTION ![Compare how all Medicare Part D PDP plans in WI cover LEVOCETIRIZINE 2.5 MG/5 ML SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVOCETIRIZINE 5 MG TABLET [Xyzal Allergy 24 Hour] ![Compare how all Medicare Part D PDP plans in WI cover LEVOCETIRIZINE 5 MG TABLET [Xyzal Allergy 24 Hour].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVOFLOXACIN 0.5% EYE DROPS [LEVAQUIN] ![Compare how all Medicare Part D PDP plans in WI cover LEVOFLOXACIN 0.5% EYE DROPS [LEVAQUIN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVOFLOXACIN 25 MG/ML SOLUTION [LEVAQUIN] ![Compare how all Medicare Part D PDP plans in WI cover LEVOFLOXACIN 25 MG/ML SOLUTION [LEVAQUIN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOFLOXACIN 250 MG TABLET [LEVAQUIN] ![Compare how all Medicare Part D PDP plans in WI cover LEVOFLOXACIN 250 MG TABLET [LEVAQUIN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVOFLOXACIN 500 MG TABLET [Levaquin] ![Compare how all Medicare Part D PDP plans in WI cover LEVOFLOXACIN 500 MG TABLET [Levaquin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVOFLOXACIN 500 MG/100 ML-D5W PIGGYBACK [Levaquin] ![Compare how all Medicare Part D PDP plans in WI cover LEVOFLOXACIN 500 MG/100 ML-D5W PIGGYBACK [Levaquin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVOFLOXACIN 500 MG/20 ML VIAL [Levaquin] ![Compare how all Medicare Part D PDP plans in WI cover LEVOFLOXACIN 500 MG/20 ML VIAL [Levaquin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVOFLOXACIN 750 MG TABLET [Levaquin Leva-Pak] ![Compare how all Medicare Part D PDP plans in WI cover LEVOFLOXACIN 750 MG TABLET [Levaquin Leva-Pak].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVOFLOXACIN 750 MG/150 ML-D5W PIGGYBACK [Levaquin] ![Compare how all Medicare Part D PDP plans in WI cover LEVOFLOXACIN 750 MG/150 ML-D5W PIGGYBACK [Levaquin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
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) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVONO-E ESTRAD 0.10-0.02-0.01 TBDSPK 3MO [LoSeasonique] ![Compare how all Medicare Part D PDP plans in WI cover LEVONO-E ESTRAD 0.10-0.02-0.01 TBDSPK 3MO [LoSeasonique].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | Q:91 /84Days |
LEVONOR-ETH ESTRAD 0.1-0.02 MG Tablet [Vienva] ![Compare how all Medicare Part D PDP plans in WI cover LEVONOR-ETH ESTRAD 0.1-0.02 MG Tablet [Vienva].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | 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) |
1* |
Generic |
$15.00 | $45.00 | 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) |
1* |
Generic |
$15.00 | $45.00 | Q:91 /84Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Levonor-eth Estrad 0.15-0.03-0.01 ![Compare how all Medicare Part D PDP plans in WI cover Levonor-eth Estrad 0.15-0.03-0.01.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | Q:91 /84Days |
LEVONOR-ETH ESTRAD TRIPHASIC TABLET [Trivora] ![Compare how all Medicare Part D PDP plans in WI cover LEVONOR-ETH ESTRAD TRIPHASIC TABLET [Trivora].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
Levora-28 tablet ![Compare how all Medicare Part D PDP plans in WI cover Levora-28 tablet.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVOTHYROXINE 100 MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHYROXINE 100 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVOTHYROXINE 112 MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHYROXINE 112 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVOTHYROXINE 125 MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHYROXINE 125 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVOTHYROXINE 137 MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHYROXINE 137 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVOTHYROXINE 150 MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHYROXINE 150 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVOTHYROXINE 175 MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHYROXINE 175 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVOTHYROXINE 200 MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHYROXINE 200 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVOTHYROXINE 25 MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHYROXINE 25 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE 300 MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHYROXINE 300 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVOTHYROXINE 50 MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHYROXINE 50 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVOTHYROXINE 75 MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHYROXINE 75 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LEVOTHYROXINE 88 MCG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LEVOTHYROXINE 88 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
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) |
2 |
Brand |
$45.00 | $135.00 | None |
LIDOCAINE 2% VISCOUS SOLUTION ![Compare how all Medicare Part D PDP plans in WI cover LIDOCAINE 2% VISCOUS SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | 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) |
1* |
Generic |
$15.00 | $45.00 | P Q:90 /30Days |
LIDOCAINE 5% PATCH [Lidoderm] ![Compare how all Medicare Part D PDP plans in WI cover LIDOCAINE 5% PATCH [Lidoderm].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | P Q:90 /30Days |
LIDOCAINE HCL IV 4% SOLUTION ![Compare how all Medicare Part D PDP plans in WI cover LIDOCAINE HCL IV 4% SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | P |
LIDOCAINE-PRILOCAINE CREAM (g) [SOLUPICC] ![Compare how all Medicare Part D PDP plans in WI cover LIDOCAINE-PRILOCAINE CREAM (g) [SOLUPICC].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | P Q:30 /30Days |
LINEZOLID 100 MG/5 ML ORAL SUSPENSION [Zyvox] ![Compare how all Medicare Part D PDP plans in WI cover LINEZOLID 100 MG/5 ML ORAL SUSPENSION [Zyvox].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Specialty Tier |
25% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LINEZOLID 600 MG TABLET [Zyvox] ![Compare how all Medicare Part D PDP plans in WI cover LINEZOLID 600 MG TABLET [Zyvox].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LINEZOLID 600 MG/300 ML-D5W PIGGYBACK [Zyvox] ![Compare how all Medicare Part D PDP plans in WI cover LINEZOLID 600 MG/300 ML-D5W PIGGYBACK [Zyvox].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Specialty Tier |
25% | N/A | None |
LINZESS 145 MCG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LINZESS 145 MCG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Brand |
$45.00 | $135.00 | Q:30 /30Days |
LINZESS 290 MCG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LINZESS 290 MCG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Brand |
$45.00 | $135.00 | Q:30 /30Days |
LINZESS 72 MCG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LINZESS 72 MCG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Brand |
$45.00 | $135.00 | Q:30 /30Days |
LIOTHYRONINE SOD 25 MCG TABLET [Cytomel] ![Compare how all Medicare Part D PDP plans in WI cover LIOTHYRONINE SOD 25 MCG TABLET [Cytomel].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LIOTHYRONINE SOD 5 MCG TABLET [Cytomel] ![Compare how all Medicare Part D PDP plans in WI cover LIOTHYRONINE SOD 5 MCG TABLET [Cytomel].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LIOTHYRONINE SOD 50 MCG TABLET [Cytomel] ![Compare how all Medicare Part D PDP plans in WI cover LIOTHYRONINE SOD 50 MCG TABLET [Cytomel].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LISINOPRIL 10 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LISINOPRIL 10 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | 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* |
Generic |
$15.00 | $45.00 | None |
LISINOPRIL 20 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LISINOPRIL 20 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL 30 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LISINOPRIL 30 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LISINOPRIL 40 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LISINOPRIL 40 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LISINOPRIL 5 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LISINOPRIL 5 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LISINOPRIL-HCTZ 10-12.5 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LISINOPRIL-HCTZ 10-12.5 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LISINOPRIL-HCTZ 20-12.5 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LISINOPRIL-HCTZ 20-12.5 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LISINOPRIL-HCTZ 20-25 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LISINOPRIL-HCTZ 20-25 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LITHIUM CARBONATE 150 MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LITHIUM CARBONATE 150 MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LITHIUM CARBONATE 300 MG CAPSULE [Eskalith] ![Compare how all Medicare Part D PDP plans in WI cover LITHIUM CARBONATE 300 MG CAPSULE [Eskalith].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LITHIUM CARBONATE 300 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LITHIUM CARBONATE 300 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LITHIUM CARBONATE 600 MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LITHIUM CARBONATE 600 MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LITHIUM CARBONATE ER 300 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LITHIUM CARBONATE ER 300 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LITHIUM CARBONATE ER 450 MG TABLET [Eskalith CR] ![Compare how all Medicare Part D PDP plans in WI cover LITHIUM CARBONATE ER 450 MG TABLET [Eskalith CR].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LIVALO 1 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LIVALO 1 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Brand |
$45.00 | $135.00 | Q:30 /30Days |
LIVALO 2 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LIVALO 2 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Brand |
$45.00 | $135.00 | Q:30 /30Days |
LIVALO 4 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LIVALO 4 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Brand |
$45.00 | $135.00 | Q:30 /30Days |
LOKELMA 10 GRAM POWDER PACKET ![Compare how all Medicare Part D PDP plans in WI cover LOKELMA 10 GRAM POWDER PACKET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Brand |
$45.00 | $135.00 | Q:90 /30Days |
LOKELMA 5 GRAM POWDER PACKET ![Compare how all Medicare Part D PDP plans in WI cover LOKELMA 5 GRAM POWDER PACKET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Brand |
$45.00 | $135.00 | Q:90 /30Days |
LONSURF 15 MG-6.14 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LONSURF 15 MG-6.14 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Specialty Tier |
25% | N/A | P Q:100 /28Days |
LONSURF 20 MG-8.19 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LONSURF 20 MG-8.19 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Specialty Tier |
25% | N/A | P Q:80 /28Days |
LOPERAMIDE 2 MG CAPSULE ![Compare how all Medicare Part D PDP plans in WI cover LOPERAMIDE 2 MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LOPINAVIR-RITONAVIR 80-20MG/ML Solution [Kaletra] ![Compare how all Medicare Part D PDP plans in WI cover LOPINAVIR-RITONAVIR 80-20MG/ML Solution [Kaletra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | Q:480 /30Days |
LORAZEPAM 0.5 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LORAZEPAM 0.5 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LORAZEPAM 1 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LORAZEPAM 1 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | Q:90 /30Days |
LORAZEPAM 2 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LORAZEPAM 2 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | Q:150 /30Days |
LORBRENA 100 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LORBRENA 100 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
LORBRENA 25 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LORBRENA 25 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
LORYNA 3 MG-0.02 MG TABLET [Yaz] ![Compare how all Medicare Part D PDP plans in WI cover LORYNA 3 MG-0.02 MG TABLET [Yaz].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LOSARTAN POTASSIUM 100 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOSARTAN POTASSIUM 100 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LOSARTAN POTASSIUM 25 MG TABLET [Cozaar] ![Compare how all Medicare Part D PDP plans in WI cover LOSARTAN POTASSIUM 25 MG TABLET [Cozaar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LOSARTAN POTASSIUM 50 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOSARTAN POTASSIUM 50 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LOSARTAN-HCTZ 100-12.5 MG TABLET [Hyzaar] ![Compare how all Medicare Part D PDP plans in WI cover LOSARTAN-HCTZ 100-12.5 MG TABLET [Hyzaar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LOSARTAN-HCTZ 100-25 MG TABLET [Hyzaar] ![Compare how all Medicare Part D PDP plans in WI cover LOSARTAN-HCTZ 100-25 MG TABLET [Hyzaar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LOSARTAN-HCTZ 50-12.5 MG TABLET [Hyzaar] ![Compare how all Medicare Part D PDP plans in WI cover LOSARTAN-HCTZ 50-12.5 MG TABLET [Hyzaar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Lotemax 5mg/g 1 TUBE per CARTON / 3.5 g in 1 TUBE ![Compare how all Medicare Part D PDP plans in WI cover Lotemax 5mg/g 1 TUBE per CARTON / 3.5 g in 1 TUBE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Brand |
$45.00 | $135.00 | None |
LOTEMAX SM 0.38% OPHTH GEL DROPS ![Compare how all Medicare Part D PDP plans in WI cover LOTEMAX SM 0.38% OPHTH GEL DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Brand |
$45.00 | $135.00 | None |
LOTEPREDNOL 0.5% OPHTHALMC GEL DROPS [Lotemax] ![Compare how all Medicare Part D PDP plans in WI cover LOTEPREDNOL 0.5% OPHTHALMC GEL DROPS [Lotemax].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LOVASTATIN 10 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOVASTATIN 10 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LOVASTATIN 20 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOVASTATIN 20 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LOVASTATIN 40 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LOVASTATIN 40 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LOW-OGESTREL-28 TABLET [Low-Ogestrel] ![Compare how all Medicare Part D PDP plans in WI cover LOW-OGESTREL-28 TABLET [Low-Ogestrel].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LOXAPINE 10 MG CAPSULE [Loxitane] ![Compare how all Medicare Part D PDP plans in WI cover LOXAPINE 10 MG CAPSULE [Loxitane].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LOXAPINE 25 MG CAPSULE [Loxitane] ![Compare how all Medicare Part D PDP plans in WI cover LOXAPINE 25 MG CAPSULE [Loxitane].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LOXAPINE 5 MG CAPSULE [Loxitane] ![Compare how all Medicare Part D PDP plans in WI cover LOXAPINE 5 MG CAPSULE [Loxitane].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LOXAPINE 50 MG CAPSULE [Loxitane] ![Compare how all Medicare Part D PDP plans in WI cover LOXAPINE 50 MG CAPSULE [Loxitane].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUBIPROSTONE 24 MCG CAPSULE [Amitiza] ![Compare how all Medicare Part D PDP plans in WI cover LUBIPROSTONE 24 MCG CAPSULE [Amitiza].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Brand |
$45.00 | $135.00 | Q:60 /30Days |
LUBIPROSTONE 8 MCG CAPSULE [Amitiza] ![Compare how all Medicare Part D PDP plans in WI cover LUBIPROSTONE 8 MCG CAPSULE [Amitiza].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Brand |
$45.00 | $135.00 | Q:60 /30Days |
LUCEMYRA 0.18 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LUCEMYRA 0.18 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Specialty Tier |
25% | N/A | Q:228 /14Days |
LUMIGAN 0.01% EYE DROPS ![Compare how all Medicare Part D PDP plans in WI cover LUMIGAN 0.01% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Brand |
$45.00 | $135.00 | Q:3 /25Days |
LUPRON DEPOT 11.25 MG 3MO KIT ![Compare how all Medicare Part D PDP plans in WI cover LUPRON DEPOT 11.25 MG 3MO KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Specialty Tier |
25% | N/A | None |
LUPRON DEPOT 22.5 MG 3MO KIT SYRINGEKIT ![Compare how all Medicare Part D PDP plans in WI cover LUPRON DEPOT 22.5 MG 3MO KIT SYRINGEKIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Specialty Tier |
25% | N/A | None |
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) |
3 |
Specialty Tier |
25% | N/A | None |
LUPRON DEPOT 45 MG 6MO KIT ![Compare how all Medicare Part D PDP plans in WI cover LUPRON DEPOT 45 MG 6MO KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Specialty Tier |
25% | N/A | None |
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) |
3 |
Specialty Tier |
25% | N/A | None |
LUPRON DEPOT-4 MONTH KIT ![Compare how all Medicare Part D PDP plans in WI cover LUPRON DEPOT-4 MONTH KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Specialty Tier |
25% | N/A | None |
LUTERA-28 TABLET ![Compare how all Medicare Part D PDP plans in WI cover LUTERA-28 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYLEQ 0.35 MG TABLET [Sharobel 28-Day] ![Compare how all Medicare Part D PDP plans in WI cover LYLEQ 0.35 MG TABLET [Sharobel 28-Day].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |
LYLLANA 0.025 MG PATCH TDSW [Vivelle-Dot] ![Compare how all Medicare Part D PDP plans in WI cover LYLLANA 0.025 MG PATCH TDSW [Vivelle-Dot].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | P Q:8 /28Days |
LYLLANA 0.0375 MG PATCH TDSW [Vivelle-Dot] ![Compare how all Medicare Part D PDP plans in WI cover LYLLANA 0.0375 MG PATCH TDSW [Vivelle-Dot].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | P Q:8 /28Days |
LYLLANA 0.05 MG PATCH TDSW [Vivelle-Dot] ![Compare how all Medicare Part D PDP plans in WI cover LYLLANA 0.05 MG PATCH TDSW [Vivelle-Dot].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | P Q:8 /28Days |
LYLLANA 0.075 MG PATCH TDSW [Vivelle-Dot] ![Compare how all Medicare Part D PDP plans in WI cover LYLLANA 0.075 MG PATCH TDSW [Vivelle-Dot].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | P Q:8 /28Days |
LYLLANA 0.1 MG PATCH TDSW [Vivelle-Dot] ![Compare how all Medicare Part D PDP plans in WI cover LYLLANA 0.1 MG PATCH TDSW [Vivelle-Dot].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | P Q:8 /28Days |
LYNPARZA 100 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LYNPARZA 100 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
LYNPARZA 150 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LYNPARZA 150 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
LYSODREN 500 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LYSODREN 500 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Specialty Tier |
25% | N/A | None |
LYZA 0.35 MG TABLET ![Compare how all Medicare Part D PDP plans in WI cover LYZA 0.35 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Generic |
$15.00 | $45.00 | None |