LILETTA 52 mg Intrauterine Device
Also known as Levonorgestrel. Coverage in Delaware, DC and Maryland (CMS PDP Region 05).
7 of 10 stand-alone Part D plans in Delaware, DC and Maryland cover this drug on tier 3.
No plan applies a prior authorization, step therapy or quantity limit.
69 Medicare Advantage plans in DE, DC, MD 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. DE: 26 plans · DC: 10 plans · MD: 33 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)$5.60/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $1173.9900 | — | None |
| Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $1173.9900 | — | None |
| HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible | 3Preferred Brand | 22% | 22% | $932.4067 | — | None |
| AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $1017.8409 | — | None |
| HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $932.2809 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible | 3Preferred Brand | 17% | 17% | $1017.8409 | — | None |
| SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $986.1432 | — | 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.