2023 Medicare Part D Plan Formulary Information |
Mutual of Omaha Rx Plus (PDP) (S7126-031-0)
Benefit Details
 Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less. Call drug plan for more details. |
The Mutual of Omaha Rx Plus (PDP) (S7126-031-0) Formulary Drugs Starting with the Letter L in CMS PDP Region 32 which includes: CA
|
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  |
2 |
Generic |
$5.00 | $12.50 | None |
LABETALOL HCL 200 MG TABLET [Trandate] ![Compare how all Medicare Part D PDP plans in CA cover LABETALOL HCL 200 MG TABLET [Trandate].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LABETALOL HCL 300 MG TABLET [Trandate] ![Compare how all Medicare Part D PDP plans in CA cover LABETALOL HCL 300 MG TABLET [Trandate].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LACOSAMIDE 10 MG/ML SOLUTION [Vimpat] ![Compare how all Medicare Part D PDP plans in CA cover LACOSAMIDE 10 MG/ML SOLUTION [Vimpat].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | Q:1200 /30Days |
LACOSAMIDE 100 MG TABLET [Vimpat] ![Compare how all Medicare Part D PDP plans in CA cover LACOSAMIDE 100 MG TABLET [Vimpat].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
36% | N/A | Q:60 /30Days |
LACOSAMIDE 150 MG TABLET [Vimpat] ![Compare how all Medicare Part D PDP plans in CA cover LACOSAMIDE 150 MG TABLET [Vimpat].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
36% | N/A | Q:60 /30Days |
LACOSAMIDE 200 MG TABLET [Vimpat] ![Compare how all Medicare Part D PDP plans in CA cover LACOSAMIDE 200 MG TABLET [Vimpat].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
36% | N/A | Q:60 /30Days |
LACOSAMIDE 50 MG TABLET [Vimpat] ![Compare how all Medicare Part D PDP plans in CA cover LACOSAMIDE 50 MG TABLET [Vimpat].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | Q:120 /30Days |
LACTULOSE 10 GM/15 ML SOLUTION [Generlac] ![Compare how all Medicare Part D PDP plans in CA cover LACTULOSE 10 GM/15 ML SOLUTION [Generlac].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LAMIVUDINE 10 MG/ML ORAL SOLUTION [Epivir] ![Compare how all Medicare Part D PDP plans in CA cover LAMIVUDINE 10 MG/ML ORAL SOLUTION [Epivir].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | None |
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 CA cover LAMIVUDINE 150 MG TABLET [Epivir].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | None |
LAMIVUDINE 300 MG TABLET [Epivir] ![Compare how all Medicare Part D PDP plans in CA cover LAMIVUDINE 300 MG TABLET [Epivir].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | None |
LAMIVUDINE HBV 100 MG TABLET [Epivir HBV] ![Compare how all Medicare Part D PDP plans in CA cover LAMIVUDINE HBV 100 MG TABLET [Epivir HBV].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | None |
LAMIVUDINE-ZIDOVUDINE TABLET [Combivir] ![Compare how all Medicare Part D PDP plans in CA cover LAMIVUDINE-ZIDOVUDINE TABLET [Combivir].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | None |
LAMOTRIGINE 100 MG TABLET [Subvenite] ![Compare how all Medicare Part D PDP plans in CA cover LAMOTRIGINE 100 MG TABLET [Subvenite].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LAMOTRIGINE 150 MG TABLET [Subvenite] ![Compare how all Medicare Part D PDP plans in CA cover LAMOTRIGINE 150 MG TABLET [Subvenite].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LAMOTRIGINE 200 MG TABLET [Subvenite] ![Compare how all Medicare Part D PDP plans in CA cover LAMOTRIGINE 200 MG TABLET [Subvenite].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LAMOTRIGINE 25 MG DISPER TABLET CHEWABLE [Lamictal CD] ![Compare how all Medicare Part D PDP plans in CA cover LAMOTRIGINE 25 MG DISPER TABLET CHEWABLE [Lamictal CD].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LAMOTRIGINE 25 MG TABLET [Subvenite] ![Compare how all Medicare Part D PDP plans in CA cover LAMOTRIGINE 25 MG TABLET [Subvenite].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LAMOTRIGINE 5 MG DISPER TABLET CHEWABLE [Lamictal CD] ![Compare how all Medicare Part D PDP plans in CA cover LAMOTRIGINE 5 MG DISPER TABLET CHEWABLE [Lamictal CD].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LAMOTRIGINE ODT 100 MG TABLET RAPDIS [Lamictal ODT] ![Compare how all Medicare Part D PDP plans in CA cover LAMOTRIGINE ODT 100 MG TABLET RAPDIS [Lamictal ODT].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
36% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMOTRIGINE ODT 200 MG TABLET RAPDIS [Lamictal ODT] ![Compare how all Medicare Part D PDP plans in CA cover LAMOTRIGINE ODT 200 MG TABLET RAPDIS [Lamictal ODT].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
36% | N/A | None |
LAMOTRIGINE ODT 25 MG TABLET  |
4 |
Non-Preferred Drug |
36% | N/A | None |
LAMOTRIGINE ODT 50 MG TABLET RAPDIS [Lamictal ODT] ![Compare how all Medicare Part D PDP plans in CA cover LAMOTRIGINE ODT 50 MG TABLET RAPDIS [Lamictal ODT].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
36% | N/A | None |
LANSOPRAZOLE DR 15 MG CAPSULE DR [Prevacid] ![Compare how all Medicare Part D PDP plans in CA cover LANSOPRAZOLE DR 15 MG CAPSULE DR [Prevacid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | Q:30 /30Days |
LANSOPRAZOLE DR 30 MG CAPSULE DR [Prevacid] ![Compare how all Medicare Part D PDP plans in CA cover LANSOPRAZOLE DR 30 MG CAPSULE DR [Prevacid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | None |
LANTUS 100U/ML VIAL  |
3 |
Preferred Brand |
$35 max* | 20% | None |
LANTUS SOLOSTAR INJECTION  |
3 |
Preferred Brand |
$35 max* | 20% | None |
LAPATINIB 250 MG TABLET [Tykerb] ![Compare how all Medicare Part D PDP plans in CA 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 |
LARIN 1.5 MG-30 MCG TABLET  |
2 |
Generic |
$5.00 | $12.50 | None |
LARIN 21 1-20 TABLET  |
2 |
Generic |
$5.00 | $12.50 | None |
LARIN FE 1-20 TABLET  |
2 |
Generic |
$5.00 | $12.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LARIN FE 1.5-30 TABLET  |
2 |
Generic |
$5.00 | $12.50 | None |
LATANOPROST 0.005% EYE DROPS  |
2 |
Generic |
$5.00 | $12.50 | None |
LATUDA 120 MG TABLET  |
4 |
Non-Preferred Drug |
36% | N/A | Q:30 /30Days |
LATUDA 20 MG TABLET  |
4 |
Non-Preferred Drug |
36% | N/A | Q:30 /30Days |
LATUDA 40 MG TABLET  |
4 |
Non-Preferred Drug |
36% | N/A | Q:30 /30Days |
LATUDA 60 MG TABLET  |
4 |
Non-Preferred Drug |
36% | N/A | Q:30 /30Days |
LATUDA 80 MG TABLET  |
4 |
Non-Preferred Drug |
36% | N/A | Q:60 /30Days |
LEFLUNOMIDE 10 MG TABLET [Arava] ![Compare how all Medicare Part D PDP plans in CA cover LEFLUNOMIDE 10 MG TABLET [Arava].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | Q:30 /30Days |
LEFLUNOMIDE 20 MG TABLET [Arava] ![Compare how all Medicare Part D PDP plans in CA cover LEFLUNOMIDE 20 MG TABLET [Arava].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | Q:30 /30Days |
LENALIDOMIDE 10 MG CAPSULE [Revlimid] ![Compare how all Medicare Part D PDP plans in CA 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 CA 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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LENALIDOMIDE 2.5 MG CAPSULE [Revlimid] ![Compare how all Medicare Part D PDP plans in CA cover LENALIDOMIDE 2.5 MG CAPSULE [Revlimid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
LENALIDOMIDE 20 MG CAPSULE [Revlimid] ![Compare how all Medicare Part D PDP plans in CA cover LENALIDOMIDE 20 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 CA 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 CA 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  |
5 |
Specialty Tier |
25% | N/A | P |
LENVIMA 12 MG DAILY DOSE CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P |
LENVIMA 14 MG DAILY DOSE  |
5 |
Specialty Tier |
25% | N/A | P |
LENVIMA 18 MG DAILY DOSE  |
5 |
Specialty Tier |
25% | N/A | P |
LENVIMA 20 MG DAILY DOSE  |
5 |
Specialty Tier |
25% | N/A | P |
LENVIMA 24 MG DAILY DOSE  |
5 |
Specialty Tier |
25% | N/A | P |
LENVIMA 4 MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LENVIMA 8 MG DAILY DOSE  |
5 |
Specialty Tier |
25% | N/A | P |
Lessina 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK  |
2 |
Generic |
$5.00 | $12.50 | None |
LETROZOLE 2.5 MG TABLET [Femara] ![Compare how all Medicare Part D PDP plans in CA cover LETROZOLE 2.5 MG TABLET [Femara].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LEUCOVORIN CALCIUM 10MG TABLET  |
3 |
Preferred Brand |
20% | 20% | None |
LEUCOVORIN CALCIUM 15MG 24 TABLET BOTTLE  |
3 |
Preferred Brand |
20% | 20% | None |
LEUCOVORIN CALCIUM 25 MG TABLET  |
3 |
Preferred Brand |
20% | 20% | None |
LEUCOVORIN CALCIUM 5 MG TABLET  |
3 |
Preferred Brand |
20% | 20% | None |
LEUKERAN 2 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | None |
LEUPROLIDE 2WK 14 MG/2.8 ML KT  |
5 |
Specialty Tier |
25% | N/A | P |
LEVETIRACETAM 1,000 MG TABLET [Keppra] ![Compare how all Medicare Part D PDP plans in CA cover LEVETIRACETAM 1,000 MG TABLET [Keppra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | None |
LEVETIRACETAM 100 MG/ML SOLUTION [Keppra] ![Compare how all Medicare Part D PDP plans in CA cover LEVETIRACETAM 100 MG/ML SOLUTION [Keppra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM 250 MG TABLET [Keppra] ![Compare how all Medicare Part D PDP plans in CA cover LEVETIRACETAM 250 MG TABLET [Keppra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | None |
LEVETIRACETAM 500 MG TABLET [Roweepra] ![Compare how all Medicare Part D PDP plans in CA cover LEVETIRACETAM 500 MG TABLET [Roweepra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | None |
LEVETIRACETAM 750 MG TABLET [Keppra] ![Compare how all Medicare Part D PDP plans in CA cover LEVETIRACETAM 750 MG TABLET [Keppra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | None |
LEVETIRACETAM ER 500 MG TABLET 24H [Roweepra] ![Compare how all Medicare Part D PDP plans in CA cover LEVETIRACETAM ER 500 MG TABLET 24H [Roweepra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | None |
LEVETIRACETAM ER 750 MG TABLET 24H [Roweepra] ![Compare how all Medicare Part D PDP plans in CA cover LEVETIRACETAM ER 750 MG TABLET 24H [Roweepra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | None |
LEVOBUNOLOL 0.5% EYE DROPS [Betagan] ![Compare how all Medicare Part D PDP plans in CA cover LEVOBUNOLOL 0.5% EYE DROPS [Betagan].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LEVOCARNITINE 1 G/10 ML SOLUTION [Carnitor] ![Compare how all Medicare Part D PDP plans in CA cover LEVOCARNITINE 1 G/10 ML SOLUTION [Carnitor].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
36% | N/A | None |
LEVOCARNITINE 330 MG TABLET [Carnitor] ![Compare how all Medicare Part D PDP plans in CA cover LEVOCARNITINE 330 MG TABLET [Carnitor].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
36% | N/A | None |
LEVOCETIRIZINE 2.5 MG/5 ML SOLUTION [Xyzal Solution] ![Compare how all Medicare Part D PDP plans in CA cover LEVOCETIRIZINE 2.5 MG/5 ML SOLUTION [Xyzal Solution].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
36% | N/A | None |
LEVOCETIRIZINE 5 MG TABLET [Xyzal Allergy 24 Hour] ![Compare how all Medicare Part D PDP plans in CA cover LEVOCETIRIZINE 5 MG TABLET [Xyzal Allergy 24 Hour].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | Q:30 /30Days |
LEVOFLOXACIN 0.5% EYE DROPS 5 ML BOTTLE  |
3 |
Preferred Brand |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOFLOXACIN 25 MG/ML SOLUTION [Levaquin] ![Compare how all Medicare Part D PDP plans in CA cover LEVOFLOXACIN 25 MG/ML SOLUTION [Levaquin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
36% | N/A | None |
LEVOFLOXACIN 250 MG TABLET [LEVAQUIN] ![Compare how all Medicare Part D PDP plans in CA cover LEVOFLOXACIN 250 MG TABLET [LEVAQUIN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LEVOFLOXACIN 500 MG TABLET [Levaquin] ![Compare how all Medicare Part D PDP plans in CA cover LEVOFLOXACIN 500 MG TABLET [Levaquin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LEVOFLOXACIN 500 MG/100 ML-D5W PIGGYBACK [Levaquin] ![Compare how all Medicare Part D PDP plans in CA cover LEVOFLOXACIN 500 MG/100 ML-D5W PIGGYBACK [Levaquin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
36% | N/A | P |
LEVOFLOXACIN 750 MG TABLET [Levaquin Leva-Pak] ![Compare how all Medicare Part D PDP plans in CA cover LEVOFLOXACIN 750 MG TABLET [Levaquin Leva-Pak].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LEVOFLOXACIN 750 MG/150 ML-D5W PIGGYBACK [Levaquin] ![Compare how all Medicare Part D PDP plans in CA cover LEVOFLOXACIN 750 MG/150 ML-D5W PIGGYBACK [Levaquin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
36% | N/A | P |
LEVONEST-28 TABLET  |
2 |
Generic |
$5.00 | $12.50 | None |
LEVONO-E ESTRAD 0.10-0.02-0.01 TBDSPK 3MO [LoSeasonique] ![Compare how all Medicare Part D PDP plans in CA cover LEVONO-E ESTRAD 0.10-0.02-0.01 TBDSPK 3MO [LoSeasonique].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LEVONOR-ETH ESTRAD 0.1-0.02 MG TABLET [Vienva] ![Compare how all Medicare Part D PDP plans in CA cover LEVONOR-ETH ESTRAD 0.1-0.02 MG TABLET [Vienva].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LEVONOR-ETH ESTRAD 0.15-0.03  |
2 |
Generic |
$5.00 | $12.50 | None |
LEVONOR-ETH ESTRAD 0.15-0.03  |
2 |
Generic |
$5.00 | $12.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVONOR-ETH ESTRAD TRIPHASIC TABLET [Trivora] ![Compare how all Medicare Part D PDP plans in CA cover LEVONOR-ETH ESTRAD TRIPHASIC TABLET [Trivora].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LEVORA-28 TABLET  |
2 |
Generic |
$5.00 | $12.50 | None |
LEVOTHYROXINE 100 MCG TABLET  |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
LEVOTHYROXINE 112 MCG TABLET  |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
LEVOTHYROXINE 125 MCG TABLET [Unithroid] ![Compare how all Medicare Part D PDP plans in CA cover LEVOTHYROXINE 125 MCG TABLET [Unithroid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
LEVOTHYROXINE 137 MCG TABLET  |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
LEVOTHYROXINE 150 MCG TABLET  |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
LEVOTHYROXINE 175 MCG TABLET  |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
LEVOTHYROXINE 200 MCG TABLET [Unithroid] ![Compare how all Medicare Part D PDP plans in CA cover LEVOTHYROXINE 200 MCG TABLET [Unithroid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
LEVOTHYROXINE 25 MCG TABLET  |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
LEVOTHYROXINE 300 MCG TABLET [Unithroid] ![Compare how all Medicare Part D PDP plans in CA cover LEVOTHYROXINE 300 MCG TABLET [Unithroid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE 50 MCG TABLET  |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
LEVOTHYROXINE 75 MCG TABLET  |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
LEVOTHYROXINE 88 MCG TABLET  |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
LEVOXYL 100 MCG TABLET  |
3 |
Preferred Brand |
20% | 20% | None |
LEVOXYL 112 MCG TABLET  |
3 |
Preferred Brand |
20% | 20% | None |
LEVOXYL 125 MCG TABLET  |
3 |
Preferred Brand |
20% | 20% | None |
LEVOXYL 137 MCG TABLET  |
3 |
Preferred Brand |
20% | 20% | None |
LEVOXYL 150 MCG TABLET  |
3 |
Preferred Brand |
20% | 20% | None |
LEVOXYL 175 MCG TABLET  |
3 |
Preferred Brand |
20% | 20% | None |
LEVOXYL 200 MCG TABLET  |
3 |
Preferred Brand |
20% | 20% | None |
LEVOXYL 25 MCG TABLET  |
3 |
Preferred Brand |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 50 MCG TABLET  |
3 |
Preferred Brand |
20% | 20% | None |
LEVOXYL 75 MCG TABLET  |
3 |
Preferred Brand |
20% | 20% | None |
LEVOXYL 88 MCG TABLET  |
3 |
Preferred Brand |
20% | 20% | None |
LEXIVA 50mg/mL 225 mL in 1 BOTTLE  |
4 |
Non-Preferred Drug |
36% | N/A | None |
LIDOCAINE 2% VISCOUS SOLUTION [Xylocaine Viscous] ![Compare how all Medicare Part D PDP plans in CA cover LIDOCAINE 2% VISCOUS SOLUTION [Xylocaine Viscous].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LIDOCAINE 5% OINTMENT [SOLUPAK] ![Compare how all Medicare Part D PDP plans in CA cover LIDOCAINE 5% OINTMENT [SOLUPAK].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
36% | N/A | Q:36 /30Days |
LIDOCAINE 5% PATCH [Lidoderm] ![Compare how all Medicare Part D PDP plans in CA cover LIDOCAINE 5% PATCH [Lidoderm].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
36% | N/A | P Q:90 /30Days |
LIDOCAINE HCL 4% SOLUTION [Xylocaine] ![Compare how all Medicare Part D PDP plans in CA cover LIDOCAINE HCL 4% SOLUTION [Xylocaine].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | None |
LIDOCAINE-PRILOCAINE CREAM (G) [SOLUPICC] ![Compare how all Medicare Part D PDP plans in CA cover LIDOCAINE-PRILOCAINE CREAM (G) [SOLUPICC].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | Q:30 /30Days |
LINEZOLID 100 MG/5 ML ORAL SUSPENSION [Zyvox Powder] ![Compare how all Medicare Part D PDP plans in CA cover LINEZOLID 100 MG/5 ML ORAL SUSPENSION [Zyvox Powder].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | None |
LINEZOLID 600 MG TABLET [Zyvox] ![Compare how all Medicare Part D PDP plans in CA cover LINEZOLID 600 MG TABLET [Zyvox].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
36% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LINEZOLID 600 MG/300 ML-D5W PIGGYBACK [Zyvox] ![Compare how all Medicare Part D PDP plans in CA cover LINEZOLID 600 MG/300 ML-D5W PIGGYBACK [Zyvox].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
36% | N/A | P |
LIOTHYRONINE SOD 25 MCG TABLET [Cytomel] ![Compare how all Medicare Part D PDP plans in CA cover LIOTHYRONINE SOD 25 MCG TABLET [Cytomel].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LIOTHYRONINE SOD 5 MCG TABLET [Cytomel] ![Compare how all Medicare Part D PDP plans in CA cover LIOTHYRONINE SOD 5 MCG TABLET [Cytomel].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LIOTHYRONINE SOD 50 MCG TABLET [Cytomel] ![Compare how all Medicare Part D PDP plans in CA cover LIOTHYRONINE SOD 50 MCG TABLET [Cytomel].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LISINOPRIL 10 MG TABLET  |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
LISINOPRIL 2.5 MG TABLET  |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
LISINOPRIL 20 MG TABLET  |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
LISINOPRIL 30 MG TABLET  |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
LISINOPRIL 40 MG TABLET [Zestril] ![Compare how all Medicare Part D PDP plans in CA cover LISINOPRIL 40 MG TABLET [Zestril].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
LISINOPRIL 5 MG TABLET  |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
LISINOPRIL-HCTZ 10-12.5 MG TABLET  |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL-HCTZ 20-12.5 MG TABLET  |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
LISINOPRIL-HCTZ 20-25 MG TABLET  |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
LITHIUM CARBONATE 150 MG CAPSULE CAPSULE  |
2 |
Generic |
$5.00 | $12.50 | None |
LITHIUM CARBONATE 300 MG CAPSULE [Eskalith] ![Compare how all Medicare Part D PDP plans in CA cover LITHIUM CARBONATE 300 MG CAPSULE [Eskalith].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LITHIUM CARBONATE 300 MG TABLET  |
2 |
Generic |
$5.00 | $12.50 | None |
LITHIUM CARBONATE 600 MG CAPSULE  |
2 |
Generic |
$5.00 | $12.50 | None |
LITHIUM CARBONATE ER 300 MG TABLET  |
2 |
Generic |
$5.00 | $12.50 | None |
LITHIUM CARBONATE ER 450 MG TABLET [Eskalith CR] ![Compare how all Medicare Part D PDP plans in CA cover LITHIUM CARBONATE ER 450 MG TABLET [Eskalith CR].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LOKELMA 10 GRAM POWDER PACKET  |
3 |
Preferred Brand |
20% | 20% | None |
LOKELMA 5 GRAM POWDER PACKET  |
3 |
Preferred Brand |
20% | 20% | None |
LONSURF 15 MG-6.14 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LONSURF 20 MG-8.19 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
LOPERAMIDE 2 MG CAPSULE  |
2 |
Generic |
$5.00 | $12.50 | None |
LOPINAVIR-RITONAVIR 80-20MG/ML Solution [Kaletra] ![Compare how all Medicare Part D PDP plans in CA cover LOPINAVIR-RITONAVIR 80-20MG/ML Solution [Kaletra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
36% | N/A | None |
LOPINAVIR-RITONAVR 100-25MG TABLET [Kaletra] ![Compare how all Medicare Part D PDP plans in CA cover LOPINAVIR-RITONAVR 100-25MG TABLET [Kaletra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | None |
LOPINAVIR-RITONAVR 200-50MG TABLET [Kaletra] ![Compare how all Medicare Part D PDP plans in CA cover LOPINAVIR-RITONAVR 200-50MG TABLET [Kaletra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | None |
LORAZEPAM 0.5 MG TABLET [Ativan] ![Compare how all Medicare Part D PDP plans in CA cover LORAZEPAM 0.5 MG TABLET [Ativan].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | P Q:90 /30Days |
LORAZEPAM 1 MG TABLET [Ativan] ![Compare how all Medicare Part D PDP plans in CA cover LORAZEPAM 1 MG TABLET [Ativan].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | P Q:90 /30Days |
LORAZEPAM 2 MG TABLET [Ativan] ![Compare how all Medicare Part D PDP plans in CA cover LORAZEPAM 2 MG TABLET [Ativan].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | P Q:150 /30Days |
LORAZEPAM INTENSOL 2 MG/ML ORAL CONC  |
2 |
Generic |
$5.00 | $12.50 | P Q:150 /30Days |
LORBRENA 100 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
LORBRENA 25 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LORYNA 3 MG-0.02 MG TABLET [Yaz] ![Compare how all Medicare Part D PDP plans in CA cover LORYNA 3 MG-0.02 MG TABLET [Yaz].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LOSARTAN POTASSIUM 100 MG TABLET [Cozaar] ![Compare how all Medicare Part D PDP plans in CA cover LOSARTAN POTASSIUM 100 MG TABLET [Cozaar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
LOSARTAN POTASSIUM 25 MG TABLET [Cozaar] ![Compare how all Medicare Part D PDP plans in CA cover LOSARTAN POTASSIUM 25 MG TABLET [Cozaar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
LOSARTAN POTASSIUM 50 MG TABLET [Cozaar] ![Compare how all Medicare Part D PDP plans in CA cover LOSARTAN POTASSIUM 50 MG TABLET [Cozaar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
LOSARTAN-HCTZ 100-12.5 MG TABLET [Hyzaar] ![Compare how all Medicare Part D PDP plans in CA 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 | $2.50 | None |
LOSARTAN-HCTZ 100-25 MG TABLET [Hyzaar] ![Compare how all Medicare Part D PDP plans in CA cover LOSARTAN-HCTZ 100-25 MG TABLET [Hyzaar].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $2.50 | None |
LOSARTAN-HCTZ 50-12.5 MG TABLET [Hyzaar] ![Compare how all Medicare Part D PDP plans in CA 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 | $2.50 | None |
LOTEPREDNOL 0.5% OPHTHALMC GEL DROPS GEL [Lotemax] ![Compare how all Medicare Part D PDP plans in CA cover LOTEPREDNOL 0.5% OPHTHALMC GEL DROPS GEL [Lotemax].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | None |
LOTEPREDNOL ETABONATE 0.5% EYE DROPPER [Lotemax] ![Compare how all Medicare Part D PDP plans in CA cover LOTEPREDNOL ETABONATE 0.5% EYE DROPPER [Lotemax].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | None |
LOVASTATIN 10 MG TABLET  |
1 |
Preferred Generic |
$1.00 | $2.50 | Q:30 /30Days |
LOVASTATIN 20 MG TABLET  |
1 |
Preferred Generic |
$1.00 | $2.50 | 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 CA cover LOVASTATIN 40 MG TABLET [Mevacor].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$1.00 | $2.50 | Q:60 /30Days |
LOW-OGESTREL-28 TABLET [Low-Ogestrel] ![Compare how all Medicare Part D PDP plans in CA cover LOW-OGESTREL-28 TABLET [Low-Ogestrel].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LOXAPINE 10 MG CAPSULE [Loxitane] ![Compare how all Medicare Part D PDP plans in CA cover LOXAPINE 10 MG CAPSULE [Loxitane].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LOXAPINE 25 MG CAPSULE [Loxitane] ![Compare how all Medicare Part D PDP plans in CA cover LOXAPINE 25 MG CAPSULE [Loxitane].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LOXAPINE 5 MG CAPSULE [Loxitane] ![Compare how all Medicare Part D PDP plans in CA cover LOXAPINE 5 MG CAPSULE [Loxitane].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LOXAPINE 50 MG CAPSULE [Loxitane] ![Compare how all Medicare Part D PDP plans in CA cover LOXAPINE 50 MG CAPSULE [Loxitane].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LUBIPROSTONE 24 MCG CAPSULE [Amitiza] ![Compare how all Medicare Part D PDP plans in CA cover LUBIPROSTONE 24 MCG CAPSULE [Amitiza].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
36% | N/A | Q:60 /30Days |
LUBIPROSTONE 8 MCG CAPSULE [Amitiza] ![Compare how all Medicare Part D PDP plans in CA cover LUBIPROSTONE 8 MCG CAPSULE [Amitiza].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
36% | N/A | Q:60 /30Days |
LUMAKRAS 120 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
LUMAKRAS 320 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT 11.25 MG 3MO KIT  |
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 22.5 MG 3MO KIT SYRINGEKIT  |
5 |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT 3.75 MG KIT  |
5 |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT 45 MG 6MO KIT  |
5 |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT 7.5 MG KIT  |
5 |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT-4 MONTH KIT  |
5 |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT-PED 11.25 MG 3MO SYRINGE KIT  |
5 |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT-PED 45 MG 6MO SYRINGE KIT  |
5 |
Specialty Tier |
25% | N/A | P |
LUPRON DEPOT-PED 7.5 MG KIT  |
5 |
Specialty Tier |
25% | N/A | P |
LURASIDONE HCL 120 MG TABLET [Latuda] ![Compare how all Medicare Part D PDP plans in CA cover LURASIDONE HCL 120 MG TABLET [Latuda].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
36% | N/A | Q:30 /30Days |
LURASIDONE HCL 20 MG TABLET [Latuda] ![Compare how all Medicare Part D PDP plans in CA cover LURASIDONE HCL 20 MG TABLET [Latuda].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
36% | N/A | Q:30 /30Days |
LURASIDONE HCL 40 MG TABLET [Latuda] ![Compare how all Medicare Part D PDP plans in CA cover LURASIDONE HCL 40 MG TABLET [Latuda].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
36% | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LURASIDONE HCL 60 MG TABLET [Latuda] ![Compare how all Medicare Part D PDP plans in CA cover LURASIDONE HCL 60 MG TABLET [Latuda].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
36% | N/A | Q:30 /30Days |
LURASIDONE HCL 80 MG TABLET [Latuda] ![Compare how all Medicare Part D PDP plans in CA cover LURASIDONE HCL 80 MG TABLET [Latuda].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
36% | N/A | Q:60 /30Days |
LUTERA-28 TABLET  |
2 |
Generic |
$5.00 | $12.50 | None |
LYLEQ 0.35 MG TABLET [Sharobel 28-Day] ![Compare how all Medicare Part D PDP plans in CA cover LYLEQ 0.35 MG TABLET [Sharobel 28-Day].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $12.50 | None |
LYLLANA 0.025 MG PATCH TDSW [Vivelle-Dot] ![Compare how all Medicare Part D PDP plans in CA cover LYLLANA 0.025 MG PATCH TDSW [Vivelle-Dot].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | P Q:8 /28Days |
LYLLANA 0.0375 MG PATCH TDSW [Vivelle-Dot] ![Compare how all Medicare Part D PDP plans in CA cover LYLLANA 0.0375 MG PATCH TDSW [Vivelle-Dot].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | P Q:8 /28Days |
LYLLANA 0.05 MG PATCH TDSW [Vivelle-Dot] ![Compare how all Medicare Part D PDP plans in CA cover LYLLANA 0.05 MG PATCH TDSW [Vivelle-Dot].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | P Q:8 /28Days |
LYLLANA 0.075 MG PATCH TDSW [Vivelle-Dot] ![Compare how all Medicare Part D PDP plans in CA cover LYLLANA 0.075 MG PATCH TDSW [Vivelle-Dot].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | P Q:8 /28Days |
LYLLANA 0.1 MG PATCH TDSW [Vivelle-Dot] ![Compare how all Medicare Part D PDP plans in CA cover LYLLANA 0.1 MG PATCH TDSW [Vivelle-Dot].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
20% | 20% | P Q:8 /28Days |
LYNPARZA 100 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
LYNPARZA 150 MG TABLET  |
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  |
5 |
Specialty Tier |
25% | N/A | None |
LYTGOBI 12 MG DOSE (3X 4MG TB) TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
LYTGOBI 16 MG DOSE (4X 4MG TB) TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
LYTGOBI 20 MG DOSE (5X 4MG TB) TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
LYUMJEV 100 UNIT/ML KWIKPEN INSULN PEN  |
3 |
Preferred Brand |
$35 max* | 20% | None |
LYUMJEV 100 UNIT/ML VIAL  |
3 |
Preferred Brand |
$35 max* | 20% | None |
LYUMJEV 200 UNIT/ML KWIKPEN INSULN PEN  |
4 |
Non-Preferred Drug |
$35 max* | N/A | None |
LYZA 0.35 MG TABLET  |
2 |
Generic |
$5.00 | $12.50 | None |