LILETTA 52 mg Intrauterine Device
Also known as Levonorgestrel. Coverage in Indiana and Kentucky (CMS PDP Region 15).
7 of 10 stand-alone Part D plans in Indiana and Kentucky cover this drug on tier 3.
No plan applies a prior authorization, step therapy or quantity limit.
124 Medicare Advantage plans in IN, KY 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. IN: 71 plans · KY: 53 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)$8.60/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $1173.9900 | — | None |
| Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $1173.9900 | — | None |
| SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible | 3Preferred Brand | 19% | 19% | $986.1432 | — | None |
| HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $932.2809 | — | None |
| AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $1001.4051 | — | None |
| HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible | 3Preferred Brand | 20% | 20% | $932.4067 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible | 3Preferred Brand | 18% | 18% | $1001.4051 | — | 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.