PREVYMIS 240 mg Tablet, Film Coated

Also known as Letermovir. Coverage in California (CMS PDP Region 32).

12 of 12 stand-alone Part D plans in California cover this drug on tier 5.

12 of 12 plans apply a prior authorization, step therapy or quantity limit.

385 Medicare Advantage plans in CA 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. CA: 385 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$253.9879	$761.963 units	Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$249.7557	$7,492.6730 units	Prior authorization Quantity limit 28 per 28 days
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$249.7557	$7,492.6730 units	Prior authorization Quantity limit 28 per 28 days
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$254.0114	$762.033 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$276.7500	$8,302.5030 units	Prior authorization Quantity limit 28 per 28 days
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$266.7705	$8,003.1230 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$279.0778	$8,372.3330 units	Prior authorization Quantity limit 28 per 28 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$266.7705	$8,003.1230 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$279.0778	$8,372.3330 units	Prior authorization Quantity limit 28 per 28 days
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$266.7705	$8,003.1230 units	Prior authorization Quantity limit 28 per 28 days
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$274.8773	$43.980.16 units	Quantity limit 2 per 365 days
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$274.8773	$43.980.16 units	Quantity limit 2 per 365 days

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.

See coverage in all 39 regions →