2022 Medicare Part D Plan Formulary Information |
Mutual of Omaha Rx Plus (PDP) (S7126-032-0)
Benefit Details
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The Mutual of Omaha Rx Plus (PDP) (S7126-032-0) Formulary Drugs Starting with the Letter L in CMS PDP Region 33 which includes: HI
|
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 HI cover LABETALOL HCL 100 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LABETALOL HCL 200 MG TABLET [Trandate] ![Compare how all Medicare Part D PDP plans in HI cover LABETALOL HCL 200 MG TABLET [Trandate].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LABETALOL HCL 300 MG TABLET [Trandate] ![Compare how all Medicare Part D PDP plans in HI cover LABETALOL HCL 300 MG TABLET [Trandate].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LACOSAMIDE 10 MG/ML SOLUTION [Vimpat] ![Compare how all Medicare Part D PDP plans in HI cover LACOSAMIDE 10 MG/ML SOLUTION [Vimpat].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | Q:1200 /30Days |
LACOSAMIDE 100 MG TABLET [Vimpat] ![Compare how all Medicare Part D PDP plans in HI cover LACOSAMIDE 100 MG TABLET [Vimpat].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | Q:60 /30Days |
LACOSAMIDE 150 MG TABLET [Vimpat] ![Compare how all Medicare Part D PDP plans in HI cover LACOSAMIDE 150 MG TABLET [Vimpat].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | Q:60 /30Days |
LACOSAMIDE 200 MG TABLET [Vimpat] ![Compare how all Medicare Part D PDP plans in HI cover LACOSAMIDE 200 MG TABLET [Vimpat].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | Q:60 /30Days |
LACOSAMIDE 50 MG TABLET [Vimpat] ![Compare how all Medicare Part D PDP plans in HI cover LACOSAMIDE 50 MG TABLET [Vimpat].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | Q:60 /30Days |
LACTULOSE 10 GM/15 ML SOLUTION [Generlac] ![Compare how all Medicare Part D PDP plans in HI cover LACTULOSE 10 GM/15 ML SOLUTION [Generlac].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LAMIVUDINE 10 MG/ML ORAL SOLUTION [Epivir] ![Compare how all Medicare Part D PDP plans in HI cover LAMIVUDINE 10 MG/ML ORAL SOLUTION [Epivir].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | Q:900 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMIVUDINE 150 MG TABLET [Epivir] ![Compare how all Medicare Part D PDP plans in HI cover LAMIVUDINE 150 MG TABLET [Epivir].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | Q:60 /30Days |
LAMIVUDINE 300 MG TABLET [Epivir] ![Compare how all Medicare Part D PDP plans in HI cover LAMIVUDINE 300 MG TABLET [Epivir].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | Q:30 /30Days |
LAMIVUDINE HBV 100 MG TABLET [Epivir HBV] ![Compare how all Medicare Part D PDP plans in HI cover LAMIVUDINE HBV 100 MG TABLET [Epivir HBV].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | Q:30 /30Days |
LAMIVUDINE-ZIDOVUDINE TABLET [Combivir] ![Compare how all Medicare Part D PDP plans in HI cover LAMIVUDINE-ZIDOVUDINE TABLET [Combivir].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | Q:60 /30Days |
LAMOTRIGINE 100 MG TABLET [Subvenite] ![Compare how all Medicare Part D PDP plans in HI cover LAMOTRIGINE 100 MG TABLET [Subvenite].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LAMOTRIGINE 150 MG TABLET [Subvenite] ![Compare how all Medicare Part D PDP plans in HI cover LAMOTRIGINE 150 MG TABLET [Subvenite].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LAMOTRIGINE 200 MG TABLET [Subvenite] ![Compare how all Medicare Part D PDP plans in HI cover LAMOTRIGINE 200 MG TABLET [Subvenite].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LAMOTRIGINE 25 MG DISPER TABLET CHW [Lamictal CD] ![Compare how all Medicare Part D PDP plans in HI cover LAMOTRIGINE 25 MG DISPER TABLET CHW [Lamictal CD].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LAMOTRIGINE 25 MG TABLET [Subvenite] ![Compare how all Medicare Part D PDP plans in HI cover LAMOTRIGINE 25 MG TABLET [Subvenite].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LAMOTRIGINE 5 MG DISPER TABLET CHW [Lamictal CD] ![Compare how all Medicare Part D PDP plans in HI cover LAMOTRIGINE 5 MG DISPER TABLET CHW [Lamictal CD].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LAMOTRIGINE ODT KIT (ORANGE) TB RD DSPK [Lamictal ODT] ![Compare how all Medicare Part D PDP plans in HI cover LAMOTRIGINE ODT KIT (ORANGE) TB RD DSPK [Lamictal ODT].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE START KIT-BLUE TABLET DS PK [Subvenite] ![Compare how all Medicare Part D PDP plans in HI cover LAMOTRIGINE START KIT-BLUE TABLET DS PK [Subvenite].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LAMOTRIGINE START KIT-GREEN TABLET DS PK [Subvenite] ![Compare how all Medicare Part D PDP plans in HI cover LAMOTRIGINE START KIT-GREEN TABLET DS PK [Subvenite].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LAMOTRIGINE START KIT-ORANG TABLET DS PK [Subvenite] ![Compare how all Medicare Part D PDP plans in HI cover LAMOTRIGINE START KIT-ORANG TABLET DS PK [Subvenite].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LANSOPRAZOLE DR 15 MG CAPSULE DR [Prevacid] ![Compare how all Medicare Part D PDP plans in HI cover LANSOPRAZOLE DR 15 MG CAPSULE DR [Prevacid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | Q:30 /30Days |
LANSOPRAZOLE DR 30 MG CAPSULE DR [Prevacid] ![Compare how all Medicare Part D PDP plans in HI cover LANSOPRAZOLE DR 30 MG CAPSULE DR [Prevacid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LANTUS 100U/ML VIAL ![Compare how all Medicare Part D PDP plans in HI cover LANTUS 100U/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LANTUS SOLOSTAR INJECTION ![Compare how all Medicare Part D PDP plans in HI cover LANTUS SOLOSTAR INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LAPATINIB 250 MG TABLET [Tykerb] ![Compare how all Medicare Part D PDP plans in HI cover LAPATINIB 250 MG TABLET [Tykerb].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P Q:180 /30Days |
LARISSIA-28 TABLET [Vienva] ![Compare how all Medicare Part D PDP plans in HI cover LARISSIA-28 TABLET [Vienva].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | None |
LATANOPROST 0.005% EYE DROPS ![Compare how all Medicare Part D PDP plans in HI cover LATANOPROST 0.005% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LATUDA 120 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LATUDA 120 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LATUDA 20 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LATUDA 20 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | Q:30 /30Days |
LATUDA 40 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LATUDA 40 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | Q:30 /30Days |
LATUDA 60 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LATUDA 60 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | Q:30 /30Days |
LATUDA 80 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LATUDA 80 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | Q:60 /30Days |
LEFLUNOMIDE 10 MG TABLET [Arava] ![Compare how all Medicare Part D PDP plans in HI cover LEFLUNOMIDE 10 MG TABLET [Arava].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | Q:30 /30Days |
LEFLUNOMIDE 20 MG TABLET [Arava] ![Compare how all Medicare Part D PDP plans in HI cover LEFLUNOMIDE 20 MG TABLET [Arava].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | Q:30 /30Days |
LENALIDOMIDE 10 MG CAPSULE [Revlimid] ![Compare how all Medicare Part D PDP plans in HI cover LENALIDOMIDE 10 MG CAPSULE [Revlimid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
LENALIDOMIDE 15 MG CAPSULE [Revlimid] ![Compare how all Medicare Part D PDP plans in HI cover LENALIDOMIDE 15 MG CAPSULE [Revlimid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
LENALIDOMIDE 25 MG CAPSULE [Revlimid] ![Compare how all Medicare Part D PDP plans in HI cover LENALIDOMIDE 25 MG CAPSULE [Revlimid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
LENALIDOMIDE 5 MG CAPSULE [Revlimid] ![Compare how all Medicare Part D PDP plans in HI cover LENALIDOMIDE 5 MG CAPSULE [Revlimid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
LENVIMA 10 MG DAILY DOSE ![Compare how all Medicare Part D PDP plans in HI cover LENVIMA 10 MG DAILY DOSE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LENVIMA 12 MG DAILY DOSE CAPSULE ![Compare how all Medicare Part D PDP plans in HI cover LENVIMA 12 MG DAILY DOSE CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
LENVIMA 14 MG DAILY DOSE ![Compare how all Medicare Part D PDP plans in HI cover LENVIMA 14 MG DAILY DOSE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
LENVIMA 18 MG DAILY DOSE ![Compare how all Medicare Part D PDP plans in HI cover LENVIMA 18 MG DAILY DOSE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
LENVIMA 20 MG DAILY DOSE ![Compare how all Medicare Part D PDP plans in HI cover LENVIMA 20 MG DAILY DOSE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
LENVIMA 24 MG DAILY DOSE ![Compare how all Medicare Part D PDP plans in HI cover LENVIMA 24 MG DAILY DOSE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
LENVIMA 4 MG CAPSULE ![Compare how all Medicare Part D PDP plans in HI cover LENVIMA 4 MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
LENVIMA 8 MG DAILY DOSE ![Compare how all Medicare Part D PDP plans in HI cover LENVIMA 8 MG DAILY DOSE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
LETROZOLE 2.5 MG TABLET [Femara] ![Compare how all Medicare Part D PDP plans in HI cover LETROZOLE 2.5 MG TABLET [Femara].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LEUCOVORIN CALCIUM 10MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEUCOVORIN CALCIUM 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LEUCOVORIN CALCIUM 15MG 24 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in HI cover LEUCOVORIN CALCIUM 15MG 24 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LEUCOVORIN CALCIUM 25 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEUCOVORIN CALCIUM 25 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUCOVORIN CALCIUM 5 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEUCOVORIN CALCIUM 5 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LEUKERAN 2 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEUKERAN 2 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | None |
LEUPROLIDE 2WK 14 MG/2.8 ML KT ![Compare how all Medicare Part D PDP plans in HI cover LEUPROLIDE 2WK 14 MG/2.8 ML KT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | P |
LEVETIRACETAM 1,000 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVETIRACETAM 1,000 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LEVETIRACETAM 100 MG/ML SOLUTION [Keppra] ![Compare how all Medicare Part D PDP plans in HI cover LEVETIRACETAM 100 MG/ML SOLUTION [Keppra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LEVETIRACETAM 250 MG TABLET [Keppra] ![Compare how all Medicare Part D PDP plans in HI cover LEVETIRACETAM 250 MG TABLET [Keppra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LEVETIRACETAM 500 MG TABLET [Roweepra] ![Compare how all Medicare Part D PDP plans in HI cover LEVETIRACETAM 500 MG TABLET [Roweepra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LEVETIRACETAM 750 MG TABLET [Keppra] ![Compare how all Medicare Part D PDP plans in HI cover LEVETIRACETAM 750 MG TABLET [Keppra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LEVO-T 100 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVO-T 100 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LEVO-T 112 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVO-T 112 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LEVO-T 125 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVO-T 125 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVO-T 137 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVO-T 137 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LEVO-T 150 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVO-T 150 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LEVO-T 175 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVO-T 175 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LEVO-T 200 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVO-T 200 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LEVO-T 25 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVO-T 25 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LEVO-T 300 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVO-T 300 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LEVO-T 50 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVO-T 50 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LEVO-T 75 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVO-T 75 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LEVO-T 88 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVO-T 88 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LEVOBUNOLOL 0.5% EYE DROPS [Betagan] ![Compare how all Medicare Part D PDP plans in HI cover LEVOBUNOLOL 0.5% EYE DROPS [Betagan].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LEVOCARNITINE 1 G/10 ML SOLUTION ![Compare how all Medicare Part D PDP plans in HI cover LEVOCARNITINE 1 G/10 ML SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOCARNITINE 330 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVOCARNITINE 330 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | None |
LEVOCETIRIZINE 2.5 MG/5 ML SOLUTION ![Compare how all Medicare Part D PDP plans in HI cover LEVOCETIRIZINE 2.5 MG/5 ML SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | None |
LEVOCETIRIZINE 5 MG TABLET [Xyzal Allergy 24 Hour] ![Compare how all Medicare Part D PDP plans in HI cover LEVOCETIRIZINE 5 MG TABLET [Xyzal Allergy 24 Hour].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | Q:30 /30Days |
LEVOFLOXACIN 25 MG/ML SOLUTION [Levaquin] ![Compare how all Medicare Part D PDP plans in HI cover LEVOFLOXACIN 25 MG/ML SOLUTION [Levaquin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | None |
LEVOFLOXACIN 250 MG TABLET [LEVAQUIN] ![Compare how all Medicare Part D PDP plans in HI cover LEVOFLOXACIN 250 MG TABLET [LEVAQUIN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LEVOFLOXACIN 500 MG TABLET [Levaquin] ![Compare how all Medicare Part D PDP plans in HI cover LEVOFLOXACIN 500 MG TABLET [Levaquin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LEVOFLOXACIN 500 MG/100 ML-D5W PIGGYBACK [Levaquin] ![Compare how all Medicare Part D PDP plans in HI cover LEVOFLOXACIN 500 MG/100 ML-D5W PIGGYBACK [Levaquin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | P |
LEVOFLOXACIN 500 MG/20 ML VIAL [Levaquin] ![Compare how all Medicare Part D PDP plans in HI cover LEVOFLOXACIN 500 MG/20 ML VIAL [Levaquin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | P |
LEVOFLOXACIN 750 MG TABLET [Levaquin Leva-Pak] ![Compare how all Medicare Part D PDP plans in HI cover LEVOFLOXACIN 750 MG TABLET [Levaquin Leva-Pak].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LEVOFLOXACIN 750 MG/150 ML-D5W PIGGYBACK [Levaquin] ![Compare how all Medicare Part D PDP plans in HI cover LEVOFLOXACIN 750 MG/150 ML-D5W PIGGYBACK [Levaquin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | P |
LEVONOR-ETH ESTRAD 0.09-0.02 MG ![Compare how all Medicare Part D PDP plans in HI cover LEVONOR-ETH ESTRAD 0.09-0.02 MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVONOR-ETH ESTRAD 0.1-0.02 MG Tablet [Vienva] ![Compare how all Medicare Part D PDP plans in HI cover LEVONOR-ETH ESTRAD 0.1-0.02 MG Tablet [Vienva].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | None |
LEVONOR-ETH ESTRAD 0.15-0.03 ![Compare how all Medicare Part D PDP plans in HI cover LEVONOR-ETH ESTRAD 0.15-0.03.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | None |
Levonor-eth Estrad 0.15-0.03-0.01 ![Compare how all Medicare Part D PDP plans in HI cover Levonor-eth Estrad 0.15-0.03-0.01.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | None |
LEVONOR-ETH ESTRAD TRIPHASIC TABLET [Trivora] ![Compare how all Medicare Part D PDP plans in HI cover LEVONOR-ETH ESTRAD TRIPHASIC TABLET [Trivora].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | None |
LEVONORG 0.15MG-EE 20-25-30MCG ![Compare how all Medicare Part D PDP plans in HI cover LEVONORG 0.15MG-EE 20-25-30MCG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | None |
LEVOTHYROXINE 100 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVOTHYROXINE 100 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
LEVOTHYROXINE 112 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVOTHYROXINE 112 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
LEVOTHYROXINE 125 MCG TABLET [Unithroid] ![Compare how all Medicare Part D PDP plans in HI cover LEVOTHYROXINE 125 MCG TABLET [Unithroid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
LEVOTHYROXINE 137 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVOTHYROXINE 137 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
LEVOTHYROXINE 150 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVOTHYROXINE 150 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
LEVOTHYROXINE 175 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVOTHYROXINE 175 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE 200 MCG TABLET [Unithroid] ![Compare how all Medicare Part D PDP plans in HI cover LEVOTHYROXINE 200 MCG TABLET [Unithroid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
LEVOTHYROXINE 25 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVOTHYROXINE 25 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
LEVOTHYROXINE 300 MCG TABLET [Unithroid] ![Compare how all Medicare Part D PDP plans in HI cover LEVOTHYROXINE 300 MCG TABLET [Unithroid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
LEVOTHYROXINE 50 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVOTHYROXINE 50 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
LEVOTHYROXINE 75 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVOTHYROXINE 75 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
LEVOTHYROXINE 88 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVOTHYROXINE 88 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
LEVOXYL 100 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVOXYL 100 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LEVOXYL 112 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVOXYL 112 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LEVOXYL 125 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVOXYL 125 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LEVOXYL 137 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVOXYL 137 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LEVOXYL 150 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVOXYL 150 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 175 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVOXYL 175 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LEVOXYL 200 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVOXYL 200 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LEVOXYL 25 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVOXYL 25 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LEVOXYL 50 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVOXYL 50 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LEVOXYL 75 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVOXYL 75 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LEVOXYL 88 MCG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LEVOXYL 88 MCG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LEXIVA 50mg/mL 225 mL in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in HI cover LEXIVA 50mg/mL 225 mL in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | Q:1680 /30Days |
LIDOCAINE 2% VISCOUS SOLUTION ![Compare how all Medicare Part D PDP plans in HI cover LIDOCAINE 2% VISCOUS SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LIDOCAINE 5% OINTMENT [SOLUPAK] ![Compare how all Medicare Part D PDP plans in HI cover LIDOCAINE 5% OINTMENT [SOLUPAK].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | Q:50 /30Days |
LIDOCAINE 5% PATCH [Lidoderm] ![Compare how all Medicare Part D PDP plans in HI cover LIDOCAINE 5% PATCH [Lidoderm].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | P |
LIDOCAINE HCL 4% SOLUTION [Xylocaine] ![Compare how all Medicare Part D PDP plans in HI cover LIDOCAINE HCL 4% SOLUTION [Xylocaine].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIDOCAINE-PRILOCAINE CREAM (g) [SOLUPICC] ![Compare how all Medicare Part D PDP plans in HI cover LIDOCAINE-PRILOCAINE CREAM (g) [SOLUPICC].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | Q:30 /30Days |
LINDANE SHAMPOO 1MG 2 FLO BOTTLE ![Compare how all Medicare Part D PDP plans in HI cover LINDANE SHAMPOO 1MG 2 FLO BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | None |
LINEZOLID 100 MG/5 ML ORAL SUSPENSION [Zyvox] ![Compare how all Medicare Part D PDP plans in HI cover LINEZOLID 100 MG/5 ML ORAL SUSPENSION [Zyvox].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | Q:1800 /30Days |
LINEZOLID 600 MG TABLET [Zyvox] ![Compare how all Medicare Part D PDP plans in HI cover LINEZOLID 600 MG TABLET [Zyvox].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | Q:60 /30Days |
LINEZOLID 600 MG/300 ML-D5W PIGGYBACK [Zyvox] ![Compare how all Medicare Part D PDP plans in HI cover LINEZOLID 600 MG/300 ML-D5W PIGGYBACK [Zyvox].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | P |
LIOTHYRONINE SOD 25 MCG TABLET [Cytomel] ![Compare how all Medicare Part D PDP plans in HI cover LIOTHYRONINE SOD 25 MCG TABLET [Cytomel].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LIOTHYRONINE SOD 5 MCG TABLET [Cytomel] ![Compare how all Medicare Part D PDP plans in HI cover LIOTHYRONINE SOD 5 MCG TABLET [Cytomel].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LIOTHYRONINE SOD 50 MCG TABLET [Cytomel] ![Compare how all Medicare Part D PDP plans in HI cover LIOTHYRONINE SOD 50 MCG TABLET [Cytomel].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LISINOPRIL 10 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LISINOPRIL 10 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
LISINOPRIL 2.5 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LISINOPRIL 2.5 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
LISINOPRIL 20 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LISINOPRIL 20 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | 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 HI cover LISINOPRIL 30 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
LISINOPRIL 40 MG TABLET [Zestril] ![Compare how all Medicare Part D PDP plans in HI cover LISINOPRIL 40 MG TABLET [Zestril].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
LISINOPRIL 5 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LISINOPRIL 5 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
LISINOPRIL-HCTZ 10-12.5 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LISINOPRIL-HCTZ 10-12.5 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
LISINOPRIL-HCTZ 20-12.5 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LISINOPRIL-HCTZ 20-12.5 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
LISINOPRIL-HCTZ 20-25 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LISINOPRIL-HCTZ 20-25 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
LITHIUM CARBONATE 150 MG CAPSULE CAPSULE ![Compare how all Medicare Part D PDP plans in HI cover LITHIUM CARBONATE 150 MG CAPSULE CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LITHIUM CARBONATE 300 MG CAPSULE [Eskalith] ![Compare how all Medicare Part D PDP plans in HI cover LITHIUM CARBONATE 300 MG CAPSULE [Eskalith].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LITHIUM CARBONATE 300 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LITHIUM CARBONATE 300 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LITHIUM CARBONATE 600 MG CAPSULE ![Compare how all Medicare Part D PDP plans in HI cover LITHIUM CARBONATE 600 MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LITHIUM CARBONATE ER 300 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LITHIUM CARBONATE ER 300 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | 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 HI cover LITHIUM CARBONATE ER 450 MG TABLET [Eskalith CR].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LONSURF 15 MG-6.14 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LONSURF 15 MG-6.14 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
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 HI cover LONSURF 20 MG-8.19 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P Q:80 /28Days |
LOPERAMIDE 2 MG CAPSULE ![Compare how all Medicare Part D PDP plans in HI cover LOPERAMIDE 2 MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | None |
LOPINAVIR-RITONAVIR 80-20MG/ML Solution [Kaletra] ![Compare how all Medicare Part D PDP plans in HI cover LOPINAVIR-RITONAVIR 80-20MG/ML Solution [Kaletra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | None |
LOPINAVIR-RITONAVR 100-25MG TABLET [Kaletra] ![Compare how all Medicare Part D PDP plans in HI cover LOPINAVIR-RITONAVR 100-25MG TABLET [Kaletra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | Q:300 /30Days |
LOPINAVIR-RITONAVR 200-50MG TABLET [Kaletra] ![Compare how all Medicare Part D PDP plans in HI cover LOPINAVIR-RITONAVR 200-50MG TABLET [Kaletra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | Q:180 /30Days |
LORAZEPAM 0.5 MG TABLET [Ativan] ![Compare how all Medicare Part D PDP plans in HI cover LORAZEPAM 0.5 MG TABLET [Ativan].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | P Q:90 /30Days |
LORAZEPAM 1 MG TABLET [Ativan] ![Compare how all Medicare Part D PDP plans in HI cover LORAZEPAM 1 MG TABLET [Ativan].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | P Q:90 /30Days |
LORAZEPAM 2 MG TABLET [Ativan] ![Compare how all Medicare Part D PDP plans in HI cover LORAZEPAM 2 MG TABLET [Ativan].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$3.00 | $9.00 | P Q:150 /30Days |
LORAZEPAM INTENSOL 2 MG/ML ORAL CONC ![Compare how all Medicare Part D PDP plans in HI cover LORAZEPAM INTENSOL 2 MG/ML ORAL CONC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | P Q:150 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LORBRENA 100 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LORBRENA 100 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
LORBRENA 25 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LORBRENA 25 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
LOSARTAN POTASSIUM 100 MG TABLET [Cozaar] ![Compare how all Medicare Part D PDP plans in HI cover LOSARTAN POTASSIUM 100 MG TABLET [Cozaar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
LOSARTAN POTASSIUM 25 MG TABLET [Cozaar] ![Compare how all Medicare Part D PDP plans in HI cover LOSARTAN POTASSIUM 25 MG TABLET [Cozaar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
LOSARTAN POTASSIUM 50 MG TABLET [Cozaar] ![Compare how all Medicare Part D PDP plans in HI cover LOSARTAN POTASSIUM 50 MG TABLET [Cozaar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
LOSARTAN-HCTZ 100-12.5 MG TABLET [Hyzaar] ![Compare how all Medicare Part D PDP plans in HI cover LOSARTAN-HCTZ 100-12.5 MG TABLET [Hyzaar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
LOSARTAN-HCTZ 100-25 MG TABLET [Hyzaar] ![Compare how all Medicare Part D PDP plans in HI cover LOSARTAN-HCTZ 100-25 MG TABLET [Hyzaar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
LOSARTAN-HCTZ 50-12.5 MG TABLET [Hyzaar] ![Compare how all Medicare Part D PDP plans in HI cover LOSARTAN-HCTZ 50-12.5 MG TABLET [Hyzaar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
LOTEPREDNOL ETABONATE 0.5% DRP EYE DROPPER [Lotemax] ![Compare how all Medicare Part D PDP plans in HI cover LOTEPREDNOL ETABONATE 0.5% DRP EYE DROPPER [Lotemax].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | None |
LOVASTATIN 10 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LOVASTATIN 10 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
LOVASTATIN 20 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LOVASTATIN 20 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOVASTATIN 40 MG TABLET [Mevacor] ![Compare how all Medicare Part D PDP plans in HI cover LOVASTATIN 40 MG TABLET [Mevacor].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:60 /30Days |
LOW-OGESTREL-28 TABLET [Low-Ogestrel] ![Compare how all Medicare Part D PDP plans in HI cover LOW-OGESTREL-28 TABLET [Low-Ogestrel].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | None |
LOXAPINE 10 MG CAPSULE [Loxitane] ![Compare how all Medicare Part D PDP plans in HI cover LOXAPINE 10 MG CAPSULE [Loxitane].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LOXAPINE 25 MG CAPSULE [Loxitane] ![Compare how all Medicare Part D PDP plans in HI cover LOXAPINE 25 MG CAPSULE [Loxitane].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LOXAPINE 5 MG CAPSULE [Loxitane] ![Compare how all Medicare Part D PDP plans in HI cover LOXAPINE 5 MG CAPSULE [Loxitane].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LOXAPINE 50 MG CAPSULE [Loxitane] ![Compare how all Medicare Part D PDP plans in HI cover LOXAPINE 50 MG CAPSULE [Loxitane].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LUBIPROSTONE 24 MCG CAPSULE [Amitiza] ![Compare how all Medicare Part D PDP plans in HI cover LUBIPROSTONE 24 MCG CAPSULE [Amitiza].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | Q:60 /30Days |
LUBIPROSTONE 8 MCG CAPSULE [Amitiza] ![Compare how all Medicare Part D PDP plans in HI cover LUBIPROSTONE 8 MCG CAPSULE [Amitiza].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | Q:60 /30Days |
LUMAKRAS 120 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LUMAKRAS 120 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT 11.25 MG 3MO KIT ![Compare how all Medicare Part D PDP plans in HI cover LUPRON DEPOT 11.25 MG 3MO KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT 22.5 MG 3MO KIT SYRINGEKIT ![Compare how all Medicare Part D PDP plans in HI cover LUPRON DEPOT 22.5 MG 3MO KIT SYRINGEKIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LUPRON DEPOT 3.75 MG KIT ![Compare how all Medicare Part D PDP plans in HI cover LUPRON DEPOT 3.75 MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT 45 MG 6MO KIT ![Compare how all Medicare Part D PDP plans in HI cover LUPRON DEPOT 45 MG 6MO KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT 7.5 MG KIT ![Compare how all Medicare Part D PDP plans in HI cover LUPRON DEPOT 7.5 MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT-4 MONTH KIT ![Compare how all Medicare Part D PDP plans in HI cover LUPRON DEPOT-4 MONTH KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P |
LYBALVI 10-10 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LYBALVI 10-10 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | Q:30 /30Days |
LYBALVI 15-10 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LYBALVI 15-10 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | Q:30 /30Days |
LYBALVI 20-10 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LYBALVI 20-10 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | Q:30 /30Days |
LYBALVI 5-10 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LYBALVI 5-10 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
44% | N/A | Q:30 /30Days |
LYLEQ 0.35 MG TABLET [Sharobel 28-Day] ![Compare how all Medicare Part D PDP plans in HI cover LYLEQ 0.35 MG TABLET [Sharobel 28-Day].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LYNPARZA 100 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LYNPARZA 100 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
LYNPARZA 150 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LYNPARZA 150 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYSODREN 500 MG TABLET ![Compare how all Medicare Part D PDP plans in HI cover LYSODREN 500 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | None |
LYUMJEV 100 UNIT/ML KWIKPEN INSULN PEN ![Compare how all Medicare Part D PDP plans in HI cover LYUMJEV 100 UNIT/ML KWIKPEN INSULN PEN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |
LYUMJEV 100 UNIT/ML VIAL ![Compare how all Medicare Part D PDP plans in HI cover LYUMJEV 100 UNIT/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
18% | 18% | None |