ICOSAPENT ETHYL 1 g Capsule
Coverage in Pennsylvania and West Virginia (CMS PDP Region 06).
6 of 12 stand-alone Part D plans in Pennsylvania and West Virginia cover this drug on tier 4.
2 of 6 plans apply a prior authorization, step therapy or quantity limit.
204 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: 180 plans · WV: 24 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible | 4Non-Preferred Drug | 40% | 40% | $1.4069 | — | None |
| Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 28% | 28% | $1.4328 | — | None |
| HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $0.8900 | — | None |
| HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $0.7433 | — | None |
| Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible | 4Non-Preferred Drug | 25% | 25% | $0.8604 | $103.25120 units |
|
| Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible | 4Non-Preferred Drug | 25% | 25% | $0.8604 | $103.25120 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.