DELSTRIGO 100/300/300 mg Tablet, Film Coated

Also known as Doravirine, Lamivudine, And Tenofovir Disoproxil Fumarate. Coverage in Kansas (CMS PDP Region 24).

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

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

77 Medicare Advantage plans in KS 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. KS: 77 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$97.3027	$291.913 units	Quantity limit 3 per 30 days
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$96.7825	$290.353 units	Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$89.6495	—	None
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$88.6736	—	None
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$88.6736	—	None
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$91.1659	$273.503 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$91.1659	$273.503 units	Quantity limit 3 per 30 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$96.7825	$290.353 units	Quantity limit 3 per 30 days
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$93.0010	—	None
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$99.5516	$298.653 units	Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$91.1659	$273.503 units	Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$99.5516	$298.653 units	Quantity limit 3 per 30 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 →