UBRELVY 100 mg Tablet

Also known as Ubrogepant. Coverage in Pennsylvania and West Virginia (CMS PDP Region 06).

7 of 12 stand-alone Part D plans in Pennsylvania and West Virginia cover this drug on tier 3–5.

Lowest 30-day cost $45.00 at a preferred pharmacy. 7 of 7 plans apply a prior authorization, step therapy or quantity limit.

343 Medicare Advantage plans in PA, WV 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. PA: 285 plans · WV: 58 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$6.60/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$108.9096	$1,742.5516 units	Prior authorization Quantity limit 16 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$108.9096	$1,742.5516 units	Prior authorization Quantity limit 16 per 30 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$114.8346	$1,837.3516 units	Prior authorization Quantity limit 16 per 30 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$108.9096	$1,742.5516 units	Prior authorization Quantity limit 16 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	4Non-Preferred Drug	33%	—	$115.2820	$1,844.5116 units	Prior authorization Quantity limit 16 per 30 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	5Specialty Tier	25%	—	$106.8479	$1,923.2618 units	Prior authorization Quantity limit 17 per 28 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$106.3854	$1,914.9418 units	Prior authorization Quantity limit 17 per 28 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 →