RESTASIS .5 mg/mL Emulsion
Also known as Cyclosporine. Coverage in California (CMS PDP Region 32).
5 of 12 stand-alone Part D plans in California cover this drug on tier 3.
5 of 5 plans apply a prior authorization, step therapy or quantity limit.
197 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: 197 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $10.5885 | $63.536 units |
|
| AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $10.4493 | $62.706 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible | 3Preferred Brand | 15% | 15% | $10.4493 | $62.706 units |
|
| Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible | 3Preferred Brand | 19% | 19% | $10.4746 | $62.856 units |
|
| Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible | 3Preferred Brand | 19% | 19% | $10.4746 | $62.856 units |
|
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.