FillMapDevoted C-SNP Premium 016 Pa (HMO C-SNP)

Does Devoted C-SNP Premium 016 Pa (HMO C-SNP) cover levothyroxine?

Devoted C-SNP Premium 016 Pa (HMO C-SNP)
H6852-016-0 · MA_LOCAL · Medicare Part D
levothyroxine
Do you get help with your Medicare drug costs?None of these

Optional. Some plans charge less at a preferred pharmacy. Enter your ZIP to see which pharmacies near you take this plan — pick yours and the price above is re-worked for it. Until you do, we show what a standard pharmacy costs. Nothing here is saved.

levothyroxineunder Devoted C-SNP Premium 016 Pa (HMO C-SNP)
Covered — just walk in
Nothing to clear first — take the prescription to an in-network pharmacy.
What you'd pay
$18per 30-day fill

Part D caps what you pay out of pocket at $2,100 for 2026. Before that, you pay the full price until you have paid $615 this year.

This plan charges the same at every pharmacy in its network — where you fill it will not change this figure.

Tier
Tier 1
Approval first
Not needed
Try another first
No
Amount limit
None
Talk to your pharmacist or doctor before acting on anything here. They can see your full history and this page cannot. Never start, stop, or switch a medication based on it. Coverage rules change and plans make exceptions — your pharmacy can check your exact benefit in seconds.As of Sep 16, 2026 · CMS Part D monthly PUF. Reference information, not medical advice and not a price.

Covered forms and strengths (47)

  • levothyroxine sodium 0.025 MG Oral TabletTier 1
  • levothyroxine sodium 0.025 MG Oral Tablet [Levoxyl]Tier 1
  • levothyroxine sodium 0.025 MG Oral Tablet [Synthroid]Tier 2
  • levothyroxine sodium 0.025 MG Oral Tablet [Unithroid]Tier 1
  • levothyroxine sodium 0.05 MG Oral TabletTier 1
  • levothyroxine sodium 0.05 MG Oral Tablet [Levoxyl]Tier 1
  • levothyroxine sodium 0.05 MG Oral Tablet [Synthroid]Tier 2
  • levothyroxine sodium 0.05 MG Oral Tablet [Unithroid]Tier 1
  • levothyroxine sodium 0.075 MG Oral TabletTier 1
  • levothyroxine sodium 0.075 MG Oral Tablet [Levoxyl]Tier 1
  • levothyroxine sodium 0.075 MG Oral Tablet [Synthroid]Tier 2
  • levothyroxine sodium 0.075 MG Oral Tablet [Unithroid]Tier 1
  • levothyroxine sodium 0.088 MG Oral TabletTier 1
  • levothyroxine sodium 0.088 MG Oral Tablet [Levoxyl]Tier 1
  • levothyroxine sodium 0.088 MG Oral Tablet [Synthroid]Tier 2
  • levothyroxine sodium 0.088 MG Oral Tablet [Unithroid]Tier 1
  • levothyroxine sodium 0.1 MG Oral TabletTier 1
  • levothyroxine sodium 0.1 MG Oral Tablet [Levoxyl]Tier 1
  • levothyroxine sodium 0.1 MG Oral Tablet [Synthroid]Tier 2
  • levothyroxine sodium 0.1 MG Oral Tablet [Unithroid]Tier 1
  • levothyroxine sodium 0.112 MG Oral TabletTier 1
  • levothyroxine sodium 0.112 MG Oral Tablet [Levoxyl]Tier 1
  • levothyroxine sodium 0.112 MG Oral Tablet [Synthroid]Tier 2
  • levothyroxine sodium 0.112 MG Oral Tablet [Unithroid]Tier 1
  • levothyroxine sodium 0.125 MG Oral TabletTier 1
  • levothyroxine sodium 0.125 MG Oral Tablet [Levoxyl]Tier 1
  • levothyroxine sodium 0.125 MG Oral Tablet [Synthroid]Tier 2
  • levothyroxine sodium 0.125 MG Oral Tablet [Unithroid]Tier 1
  • levothyroxine sodium 0.137 MG Oral TabletTier 1
  • levothyroxine sodium 0.137 MG Oral Tablet [Levoxyl]Tier 1
  • levothyroxine sodium 0.137 MG Oral Tablet [Synthroid]Tier 2
  • levothyroxine sodium 0.137 MG Oral Tablet [Unithroid]Tier 1
  • levothyroxine sodium 0.15 MG Oral TabletTier 1
  • levothyroxine sodium 0.15 MG Oral Tablet [Levoxyl]Tier 1
  • levothyroxine sodium 0.15 MG Oral Tablet [Synthroid]Tier 2
  • levothyroxine sodium 0.15 MG Oral Tablet [Unithroid]Tier 1
  • levothyroxine sodium 0.175 MG Oral TabletTier 1
  • levothyroxine sodium 0.175 MG Oral Tablet [Levoxyl]Tier 1
  • levothyroxine sodium 0.175 MG Oral Tablet [Synthroid]Tier 2
  • levothyroxine sodium 0.175 MG Oral Tablet [Unithroid]Tier 1

← All coverage for levothyroxine