RESTASIS MULTIDOSE .5 mg/mL Emulsion

Also known as Cyclosporine. Coverage in Michigan (CMS PDP Region 13).

5 of 12 stand-alone Part D plans in Michigan cover this drug on tier 3.

5 of 5 plans apply a prior authorization, step therapy or quantity limit.

128 Medicare Advantage plans in MI 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. MI: 128 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$106.1572	$743.107 units	Quantity limit 5.5 per 25 days
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$115.5119	$693.076 units	Quantity limit 5.5 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$106.1572	$743.107 units	Quantity limit 5.5 per 25 days
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$112.7814	$676.696 units	Quantity limit 18 per 90 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	3Preferred Brand	24%	24%	$112.7814	$676.696 units	Quantity limit 18 per 90 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 →