2025 Medicare Part D Plan Formulary Information |
Anthem MediBlue Rx Standard (PDP) (S5596-046-0)
Benefits & Contact Info
 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 Anthem MediBlue Rx Standard (PDP) (S5596-046-0) Formulary Drugs Starting with the Letter L in CMS PDP Region 01 which includes: ME NH
|
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 |
L-GLUTAMINE 5 GRAM POWDER PACKET [Endari] ![Compare how all Medicare Part D PDP plans in ME cover L-GLUTAMINE 5 GRAM POWDER PACKET [Endari].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P |
LABETALOL HCL 100 MG TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
LABETALOL HCL 200 MG TABLET [Trandate] ![Compare how all Medicare Part D PDP plans in ME cover LABETALOL HCL 200 MG TABLET [Trandate].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LABETALOL HCL 300 MG TABLET [Trandate] ![Compare how all Medicare Part D PDP plans in ME cover LABETALOL HCL 300 MG TABLET [Trandate].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LACOSAMIDE 10 MG/ML SOLUTION [Vimpat] ![Compare how all Medicare Part D PDP plans in ME cover LACOSAMIDE 10 MG/ML SOLUTION [Vimpat].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:1200 /30Days |
LACOSAMIDE 100 MG TABLET [Vimpat] ![Compare how all Medicare Part D PDP plans in ME cover LACOSAMIDE 100 MG TABLET [Vimpat].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
LACOSAMIDE 150 MG TABLET [Vimpat] ![Compare how all Medicare Part D PDP plans in ME cover LACOSAMIDE 150 MG TABLET [Vimpat].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
LACOSAMIDE 200 MG TABLET [Vimpat] ![Compare how all Medicare Part D PDP plans in ME cover LACOSAMIDE 200 MG TABLET [Vimpat].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
LACOSAMIDE 50 MG TABLET [Vimpat] ![Compare how all Medicare Part D PDP plans in ME cover LACOSAMIDE 50 MG TABLET [Vimpat].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
LACTULOSE 10 GM/15 ML SOLUTION [Generlac] ![Compare how all Medicare Part D PDP plans in ME cover LACTULOSE 10 GM/15 ML SOLUTION [Generlac].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LAMIVUDINE 10 MG/ML ORAL SOLUTION [Epivir] ![Compare how all Medicare Part D PDP plans in ME cover LAMIVUDINE 10 MG/ML ORAL SOLUTION [Epivir].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:960 /30Days |
LAMIVUDINE 150 MG TABLET [Epivir] ![Compare how all Medicare Part D PDP plans in ME cover LAMIVUDINE 150 MG TABLET [Epivir].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
LAMIVUDINE 300 MG TABLET [Epivir] ![Compare how all Medicare Part D PDP plans in ME cover LAMIVUDINE 300 MG TABLET [Epivir].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
LAMIVUDINE HBV 100 MG TABLET [Epivir HBV] ![Compare how all Medicare Part D PDP plans in ME cover LAMIVUDINE HBV 100 MG TABLET [Epivir HBV].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
17% | 17% | None |
LAMIVUDINE-ZIDOVUDINE TABLET [Combivir] ![Compare how all Medicare Part D PDP plans in ME cover LAMIVUDINE-ZIDOVUDINE TABLET [Combivir].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
LAMOTRIGINE 100 MG TABLET [Subvenite] ![Compare how all Medicare Part D PDP plans in ME cover LAMOTRIGINE 100 MG TABLET [Subvenite].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LAMOTRIGINE 150 MG TABLET [Subvenite] ![Compare how all Medicare Part D PDP plans in ME cover LAMOTRIGINE 150 MG TABLET [Subvenite].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LAMOTRIGINE 200 MG TABLET [Subvenite] ![Compare how all Medicare Part D PDP plans in ME cover LAMOTRIGINE 200 MG TABLET [Subvenite].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LAMOTRIGINE 25 MG DISPER TABLET CHEWABLE [Lamictal CD] ![Compare how all Medicare Part D PDP plans in ME cover LAMOTRIGINE 25 MG DISPER TABLET CHEWABLE [Lamictal CD].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | None |
LAMOTRIGINE 25 MG TABLET [Subvenite] ![Compare how all Medicare Part D PDP plans in ME cover LAMOTRIGINE 25 MG TABLET [Subvenite].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LAMOTRIGINE 5 MG DISPER TABLET CHEWABLE [Lamictal CD] ![Compare how all Medicare Part D PDP plans in ME cover LAMOTRIGINE 5 MG DISPER TABLET CHEWABLE [Lamictal CD].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LANSOPRAZOLE DR 15 MG CAPSULE DR [Prevacid] ![Compare how all Medicare Part D PDP plans in ME cover LANSOPRAZOLE DR 15 MG CAPSULE DR [Prevacid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LANSOPRAZOLE DR 30 MG CAPSULE DR [Prevacid] ![Compare how all Medicare Part D PDP plans in ME cover LANSOPRAZOLE DR 30 MG CAPSULE DR [Prevacid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | Q:30 /30Days |
LANTUS 100U/ML VIAL  |
3 |
Preferred Brand |
17% | 17% | Q:30 /30Days |
LANTUS SOLOSTAR INJECTION  |
3 |
Preferred Brand |
17% | 17% | Q:30 /30Days |
LAPATINIB 250 MG TABLET [Tykerb] ![Compare how all Medicare Part D PDP plans in ME 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  |
3 |
Preferred Brand |
17% | 17% | None |
LARIN 21 1-20 TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
LARIN FE 1-20 TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
LARIN FE 1.5-30 TABLET  |
3 |
Preferred Brand |
17% | 17% | None |
LATANOPROST 0.005% EYE DROPS  |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
LEENA 28 TABLET [Tri-Norinyl] ![Compare how all Medicare Part D PDP plans in ME cover LEENA 28 TABLET [Tri-Norinyl].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
17% | 17% | None |
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 ME cover LEFLUNOMIDE 10 MG TABLET [Arava].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
LEFLUNOMIDE 20 MG TABLET [Arava] ![Compare how all Medicare Part D PDP plans in ME cover LEFLUNOMIDE 20 MG TABLET [Arava].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
LENALIDOMIDE 10 MG CAPSULE [Revlimid] ![Compare how all Medicare Part D PDP plans in ME 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:60 /30Days |
LENALIDOMIDE 15 MG CAPSULE [Revlimid] ![Compare how all Medicare Part D PDP plans in ME 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:30 /30Days |
LENALIDOMIDE 2.5 MG CAPSULE [Revlimid] ![Compare how all Medicare Part D PDP plans in ME 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:30 /30Days |
LENALIDOMIDE 20 MG CAPSULE [Revlimid] ![Compare how all Medicare Part D PDP plans in ME 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:30 /30Days |
LENALIDOMIDE 25 MG CAPSULE [Revlimid] ![Compare how all Medicare Part D PDP plans in ME 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:30 /30Days |
LENALIDOMIDE 5 MG CAPSULE [Revlimid] ![Compare how all Medicare Part D PDP plans in ME 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:150 /30Days |
LENVIMA 10 MG DAILY DOSE  |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
LENVIMA 12 MG DAILY DOSE CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
LENVIMA 14 MG DAILY DOSE  |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LENVIMA 18 MG DAILY DOSE  |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
LENVIMA 20 MG DAILY DOSE  |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
LENVIMA 24 MG DAILY DOSE  |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
LENVIMA 4 MG CAPSULE  |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
LENVIMA 8 MG DAILY DOSE  |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
Lessina 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK  |
2 |
Generic |
$4.00 | $12.00 | None |
LETROZOLE 2.5 MG TABLET [Femara] ![Compare how all Medicare Part D PDP plans in ME cover LETROZOLE 2.5 MG TABLET [Femara].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
LEUCOVORIN CALCIUM 10MG TABLET  |
4 |
Non-Preferred Drug |
50% | 50% | None |
LEUCOVORIN CALCIUM 15MG 24 TABLET BOTTLE  |
4 |
Non-Preferred Drug |
50% | 50% | None |
LEUCOVORIN CALCIUM 25 MG TABLET  |
4 |
Non-Preferred Drug |
50% | 50% | None |
LEUCOVORIN CALCIUM 5 MG TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEUPROLIDE 2WK 14 MG/2.8 ML KT  |
4 |
Non-Preferred Drug |
50% | 50% | P |
LEUPROLIDE DEPOT 22.5 MG VIAL  |
4 |
Non-Preferred Drug |
50% | 50% | P |
LEVALBUTEROL 0.63 MG/3 ML SOL VIAL-NEB [Xopenex] ![Compare how all Medicare Part D PDP plans in ME cover LEVALBUTEROL 0.63 MG/3 ML SOL VIAL-NEB [Xopenex].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | P Q:540 /30Days |
LEVALBUTEROL 1.25 MG/3 ML SOL VIAL-NEB [Xopenex] ![Compare how all Medicare Part D PDP plans in ME cover LEVALBUTEROL 1.25 MG/3 ML SOL VIAL-NEB [Xopenex].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | P Q:270 /30Days |
LEVETIRACETAM 1,000 MG TABLET [Keppra] ![Compare how all Medicare Part D PDP plans in ME cover LEVETIRACETAM 1,000 MG TABLET [Keppra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LEVETIRACETAM 100 MG/ML SOLUTION [Keppra] ![Compare how all Medicare Part D PDP plans in ME cover LEVETIRACETAM 100 MG/ML SOLUTION [Keppra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LEVETIRACETAM 250 MG TABLET [Keppra] ![Compare how all Medicare Part D PDP plans in ME cover LEVETIRACETAM 250 MG TABLET [Keppra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LEVETIRACETAM 500 MG TABLET [Roweepra] ![Compare how all Medicare Part D PDP plans in ME cover LEVETIRACETAM 500 MG TABLET [Roweepra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LEVETIRACETAM 750 MG TABLET [Keppra] ![Compare how all Medicare Part D PDP plans in ME cover LEVETIRACETAM 750 MG TABLET [Keppra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LEVOBUNOLOL 0.5% EYE DROPS [Betagan] ![Compare how all Medicare Part D PDP plans in ME cover LEVOBUNOLOL 0.5% EYE DROPS [Betagan].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LEVOCARNITINE 1 G/10 ML SOLUTION [Carnitor] ![Compare how all Medicare Part D PDP plans in ME cover LEVOCARNITINE 1 G/10 ML SOLUTION [Carnitor].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOCARNITINE 330 MG TABLET [Carnitor] ![Compare how all Medicare Part D PDP plans in ME cover LEVOCARNITINE 330 MG TABLET [Carnitor].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | P |
LEVOCETIRIZINE 5 MG TABLET [Xyzal Allergy 24 Hour] ![Compare how all Medicare Part D PDP plans in ME cover LEVOCETIRIZINE 5 MG TABLET [Xyzal Allergy 24 Hour].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
LEVOFLOXACIN 25 MG/ML SOLUTION [Levaquin] ![Compare how all Medicare Part D PDP plans in ME cover LEVOFLOXACIN 25 MG/ML SOLUTION [Levaquin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | None |
LEVOFLOXACIN 250 MG TABLET [LEVAQUIN] ![Compare how all Medicare Part D PDP plans in ME cover LEVOFLOXACIN 250 MG TABLET [LEVAQUIN].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LEVOFLOXACIN 500 MG TABLET [Levaquin] ![Compare how all Medicare Part D PDP plans in ME cover LEVOFLOXACIN 500 MG TABLET [Levaquin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LEVOFLOXACIN 500 MG/100 ML-D5W PIGGYBACK [Levaquin] ![Compare how all Medicare Part D PDP plans in ME cover LEVOFLOXACIN 500 MG/100 ML-D5W PIGGYBACK [Levaquin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | None |
LEVOFLOXACIN 750 MG TABLET [Levaquin Leva-Pak] ![Compare how all Medicare Part D PDP plans in ME cover LEVOFLOXACIN 750 MG TABLET [Levaquin Leva-Pak].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LEVOFLOXACIN 750 MG/150 ML-D5W PIGGYBACK [Levaquin] ![Compare how all Medicare Part D PDP plans in ME cover LEVOFLOXACIN 750 MG/150 ML-D5W PIGGYBACK [Levaquin].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | None |
LEVONEST-28 TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
LEVONOR-ETH ESTRAD 0.1-0.02 MG TABLET [Vienva] ![Compare how all Medicare Part D PDP plans in ME cover LEVONOR-ETH ESTRAD 0.1-0.02 MG TABLET [Vienva].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LEVONOR-ETH ESTRAD 0.15-0.03  |
2 |
Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVONOR-ETH ESTRAD 0.15-0.03  |
2 |
Generic |
$4.00 | $12.00 | None |
LEVONOR-ETH ESTRAD TRIPHASIC TABLET [Trivora] ![Compare how all Medicare Part D PDP plans in ME cover LEVONOR-ETH ESTRAD TRIPHASIC TABLET [Trivora].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LEVORA-28 TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
LEVOTHYROXINE 100 MCG TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
LEVOTHYROXINE 112 MCG TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
LEVOTHYROXINE 125 MCG TABLET [Unithroid] ![Compare how all Medicare Part D PDP plans in ME cover LEVOTHYROXINE 125 MCG TABLET [Unithroid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LEVOTHYROXINE 137 MCG TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
LEVOTHYROXINE 150 MCG TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
LEVOTHYROXINE 175 MCG TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
LEVOTHYROXINE 200 MCG TABLET [Unithroid] ![Compare how all Medicare Part D PDP plans in ME cover LEVOTHYROXINE 200 MCG TABLET [Unithroid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LEVOTHYROXINE 25 MCG TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOTHYROXINE 300 MCG TABLET [Unithroid] ![Compare how all Medicare Part D PDP plans in ME cover LEVOTHYROXINE 300 MCG TABLET [Unithroid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LEVOTHYROXINE 50 MCG TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
LEVOTHYROXINE 75 MCG TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
LEVOTHYROXINE 88 MCG TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
LEVOXYL 100 MCG TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
LEVOXYL 112 MCG TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
LEVOXYL 125 MCG TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
LEVOXYL 137 MCG TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
LEVOXYL 150 MCG TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
LEVOXYL 175 MCG TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
LEVOXYL 200 MCG TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVOXYL 25 MCG TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
LEVOXYL 50 MCG TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
LEVOXYL 75 MCG TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
LEVOXYL 88 MCG TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
LIBERVANT 10 MG FILM  |
4 |
Non-Preferred Drug |
50% | 50% | Q:10 /30Days |
LIBERVANT 12.5 MG FILM  |
4 |
Non-Preferred Drug |
50% | 50% | Q:10 /30Days |
LIBERVANT 15 MG FILM  |
4 |
Non-Preferred Drug |
50% | 50% | Q:10 /30Days |
LIBERVANT 5 MG FILM  |
4 |
Non-Preferred Drug |
50% | 50% | Q:10 /30Days |
LIBERVANT 7.5 MG FILM  |
4 |
Non-Preferred Drug |
50% | 50% | Q:10 /30Days |
LIDOCAINE 2% VISCOUS SOLUTION [Xylocaine Viscous] ![Compare how all Medicare Part D PDP plans in ME cover LIDOCAINE 2% VISCOUS SOLUTION [Xylocaine Viscous].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LIDOCAINE 5% PATCH [Lidoderm] ![Compare how all Medicare Part D PDP plans in ME cover LIDOCAINE 5% PATCH [Lidoderm].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LIDOCAINE HCL 4% SOLUTION [Xylocaine] ![Compare how all Medicare Part D PDP plans in ME cover LIDOCAINE HCL 4% SOLUTION [Xylocaine].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | P Q:300 /30Days |
LIDOCAINE-PRILOCAINE CREAM (G) [SOLUPICC] ![Compare how all Medicare Part D PDP plans in ME cover LIDOCAINE-PRILOCAINE CREAM (G) [SOLUPICC].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | Q:30 /30Days |
LINEZOLID 100 MG/5 ML ORAL SUSPENSION [Zyvox Powder] ![Compare how all Medicare Part D PDP plans in ME cover LINEZOLID 100 MG/5 ML ORAL SUSPENSION [Zyvox Powder].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | P Q:1800 /30Days |
LINEZOLID 600 MG TABLET [Zyvox] ![Compare how all Medicare Part D PDP plans in ME cover LINEZOLID 600 MG TABLET [Zyvox].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | P Q:56 /28Days |
LINEZOLID 600 MG/300 ML-D5W PIGGYBACK [Zyvox] ![Compare how all Medicare Part D PDP plans in ME cover LINEZOLID 600 MG/300 ML-D5W PIGGYBACK [Zyvox].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | None |
LINZESS 145 MCG CAPSULE  |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
LINZESS 290 MCG CAPSULE  |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
LINZESS 72 MCG CAPSULE  |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
LIOTHYRONINE SOD 25 MCG TABLET [Cytomel] ![Compare how all Medicare Part D PDP plans in ME cover LIOTHYRONINE SOD 25 MCG TABLET [Cytomel].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LIOTHYRONINE SOD 5 MCG TABLET [Cytomel] ![Compare how all Medicare Part D PDP plans in ME cover LIOTHYRONINE SOD 5 MCG TABLET [Cytomel].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LIOTHYRONINE SOD 50 MCG TABLET [Cytomel] ![Compare how all Medicare Part D PDP plans in ME cover LIOTHYRONINE SOD 50 MCG TABLET [Cytomel].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LISINOPRIL 10 MG TABLET  |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
LISINOPRIL 2.5 MG TABLET  |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
LISINOPRIL 20 MG TABLET  |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
LISINOPRIL 30 MG TABLET  |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
LISINOPRIL 40 MG TABLET [Zestril] ![Compare how all Medicare Part D PDP plans in ME 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  |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
LISINOPRIL-HCTZ 10-12.5 MG TABLET  |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:30 /30Days |
LISINOPRIL-HCTZ 20-12.5 MG TABLET  |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:120 /30Days |
LISINOPRIL-HCTZ 20-25 MG TABLET  |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:60 /30Days |
LITHIUM 8 MEQ/5 ML SOLUTION  |
4 |
Non-Preferred Drug |
50% | 50% | None |
LITHIUM CARBONATE 150 MG CAPSULE CAPSULE  |
2 |
Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LITHIUM CARBONATE 300 MG CAPSULE [Eskalith] ![Compare how all Medicare Part D PDP plans in ME cover LITHIUM CARBONATE 300 MG CAPSULE [Eskalith].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LITHIUM CARBONATE 300 MG TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
LITHIUM CARBONATE 600 MG CAPSULE  |
2 |
Generic |
$4.00 | $12.00 | None |
LITHIUM CARBONATE ER 300 MG TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
LITHIUM CARBONATE ER 450 MG TABLET [Eskalith CR] ![Compare how all Medicare Part D PDP plans in ME cover LITHIUM CARBONATE ER 450 MG TABLET [Eskalith CR].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LIVTENCITY 200 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P |
LOESTRIN 21 1.5/30 TABLET  |
3 |
Preferred Brand |
17% | 17% | None |
LOESTRIN 21 1/20 TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
LOESTRIN FE 1.5/30 TABLET  |
3 |
Preferred Brand |
17% | 17% | None |
LOESTRIN FE 1/20 TABLET  |
2 |
Generic |
$4.00 | $12.00 | 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 |
$4.00 | $12.00 | None |
LOPINAVIR-RITONAVIR 80-20MG/ML Solution [Kaletra] ![Compare how all Medicare Part D PDP plans in ME cover LOPINAVIR-RITONAVIR 80-20MG/ML Solution [Kaletra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:480 /30Days |
LOPINAVIR-RITONAVR 100-25MG TABLET [Kaletra] ![Compare how all Medicare Part D PDP plans in ME cover LOPINAVIR-RITONAVR 100-25MG TABLET [Kaletra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:300 /30Days |
LOPINAVIR-RITONAVR 200-50MG TABLET [Kaletra] ![Compare how all Medicare Part D PDP plans in ME cover LOPINAVIR-RITONAVR 200-50MG TABLET [Kaletra].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:120 /30Days |
LORAZEPAM 0.5 MG TABLET [Ativan] ![Compare how all Medicare Part D PDP plans in ME cover LORAZEPAM 0.5 MG TABLET [Ativan].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | Q:90 /30Days |
LORAZEPAM 1 MG TABLET [Ativan] ![Compare how all Medicare Part D PDP plans in ME cover LORAZEPAM 1 MG TABLET [Ativan].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | Q:90 /30Days |
LORAZEPAM 2 MG TABLET [Ativan] ![Compare how all Medicare Part D PDP plans in ME cover LORAZEPAM 2 MG TABLET [Ativan].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | Q:150 /30Days |
LORAZEPAM INTENSOL 2 MG/ML ORAL CONC  |
4 |
Non-Preferred Drug |
50% | 50% | 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 ME cover LORYNA 3 MG-0.02 MG TABLET [Yaz].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LOSARTAN POTASSIUM 100 MG TABLET [Cozaar] ![Compare how all Medicare Part D PDP plans in ME 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 ME 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:60 /30Days |
LOSARTAN POTASSIUM 50 MG TABLET [Cozaar] ![Compare how all Medicare Part D PDP plans in ME 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:60 /30Days |
LOSARTAN-HCTZ 100-12.5 MG TABLET [Hyzaar] ![Compare how all Medicare Part D PDP plans in ME 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 ME 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 ME 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 |
LOVASTATIN 10 MG TABLET  |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:60 /30Days |
LOVASTATIN 20 MG TABLET  |
1 |
Preferred Generic |
$1.00 | $3.00 | Q:60 /30Days |
LOVASTATIN 40 MG TABLET [Mevacor] ![Compare how all Medicare Part D PDP plans in ME 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 ME cover LOW-OGESTREL-28 TABLET [Low-Ogestrel].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LOXAPINE 10 MG CAPSULE [Loxitane] ![Compare how all Medicare Part D PDP plans in ME cover LOXAPINE 10 MG CAPSULE [Loxitane].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LOXAPINE 25 MG CAPSULE [Loxitane] ![Compare how all Medicare Part D PDP plans in ME cover LOXAPINE 25 MG CAPSULE [Loxitane].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LOXAPINE 5 MG CAPSULE [Loxitane] ![Compare how all Medicare Part D PDP plans in ME cover LOXAPINE 5 MG CAPSULE [Loxitane].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LOXAPINE 50 MG CAPSULE [Loxitane] ![Compare how all Medicare Part D PDP plans in ME cover LOXAPINE 50 MG CAPSULE [Loxitane].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LUMAKRAS 120 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P Q:240 /30Days |
LUMAKRAS 320 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
LUMIGAN 0.01% EYE DROPS  |
3 |
Preferred Brand |
17% | 17% | None |
LUPRON DEPOT 3.75 MG KIT  |
5 |
Specialty Tier |
25% | N/A | P Q:1 /28Days |
LURASIDONE HCL 120 MG TABLET [Latuda] ![Compare how all Medicare Part D PDP plans in ME cover LURASIDONE HCL 120 MG TABLET [Latuda].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
LURASIDONE HCL 20 MG TABLET [Latuda] ![Compare how all Medicare Part D PDP plans in ME cover LURASIDONE HCL 20 MG TABLET [Latuda].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
LURASIDONE HCL 40 MG TABLET [Latuda] ![Compare how all Medicare Part D PDP plans in ME cover LURASIDONE HCL 40 MG TABLET [Latuda].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | 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 ME cover LURASIDONE HCL 60 MG TABLET [Latuda].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days |
LURASIDONE HCL 80 MG TABLET [Latuda] ![Compare how all Medicare Part D PDP plans in ME cover LURASIDONE HCL 80 MG TABLET [Latuda].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days |
LUTERA-28 TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |
LYLEQ 0.35 MG TABLET [Sharobel 28-Day] ![Compare how all Medicare Part D PDP plans in ME cover LYLEQ 0.35 MG TABLET [Sharobel 28-Day].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$4.00 | $12.00 | None |
LYLLANA 0.025 MG PATCH TDSW [Vivelle-Dot] ![Compare how all Medicare Part D PDP plans in ME cover LYLLANA 0.025 MG PATCH TDSW [Vivelle-Dot].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | P Q:8 /28Days |
LYLLANA 0.0375 MG PATCH TDSW [Vivelle-Dot] ![Compare how all Medicare Part D PDP plans in ME cover LYLLANA 0.0375 MG PATCH TDSW [Vivelle-Dot].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | P Q:8 /28Days |
LYLLANA 0.05 MG PATCH TDSW [Vivelle-Dot] ![Compare how all Medicare Part D PDP plans in ME cover LYLLANA 0.05 MG PATCH TDSW [Vivelle-Dot].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | P Q:8 /28Days |
LYLLANA 0.075 MG PATCH TDSW [Vivelle-Dot] ![Compare how all Medicare Part D PDP plans in ME cover LYLLANA 0.075 MG PATCH TDSW [Vivelle-Dot].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | P Q:8 /28Days |
LYLLANA 0.1 MG PATCH TDSW [Vivelle-Dot] ![Compare how all Medicare Part D PDP plans in ME cover LYLLANA 0.1 MG PATCH TDSW [Vivelle-Dot].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
50% | 50% | 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 |
17% | 17% | None |
LYUMJEV 100 UNIT/ML VIAL  |
3 |
Preferred Brand |
17% | 17% | None |
LYUMJEV 200 UNIT/ML KWIKPEN INSULN PEN  |
3 |
Preferred Brand |
17% | 17% | None |
LYZA 0.35 MG TABLET  |
2 |
Generic |
$4.00 | $12.00 | None |