LILETTA 52 mg Intrauterine Device
Also known as Levonorgestrel. Coverage in Connecticut, Massachusetts, Rhode Island and Vermont (CMS PDP Region 02).
8 of 11 stand-alone Part D plans in Connecticut, Massachusetts, Rhode Island and Vermont cover this drug on tier 3.
Lowest 30-day cost $30.00 at a preferred pharmacy. No plan applies a prior authorization, step therapy or quantity limit.
136 Medicare Advantage plans in CT, MA, RI do cover it
Medicare Advantage plans carry their own formularies, separate from stand-alone Part D. A patient on an MA-PD plan may have coverage even where no PDP lists the drug. CT: 32 plans · MA: 84 plans · RI: 20 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $1173.9900 | — | None |
| Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $935.3686 | — | None |
| Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $1173.9900 | — | None |
| SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible | 3Preferred Brand | 19% | 19% | $986.1432 | — | None |
| AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $980.2735 | — | None |
| HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible | 3Preferred Brand | 21% | 21% | $864.8957 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible | 3Preferred Brand | 15% | 15% | $980.2735 | — | None |
| Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible | 3Preferred Brand | $30.00 | $60.00 | $935.3686 | — | None |
Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity.