LEUCOVORIN CALCIUM 5 mg Tablet
Coverage in Arizona (CMS PDP Region 28).
10 of 10 stand-alone Part D plans in Arizona cover this drug on tier 3–4.
No plan applies a prior authorization, step therapy or quantity limit.
125 Medicare Advantage plans in AZ 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. AZ: 125 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $0.6936 | — | None |
| AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $0.6596 | — | None |
| HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $1.1383 | — | None |
| SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $0.4826 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible | 3Preferred Brand | 18% | 18% | $0.6596 | — | None |
| Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 32% | 32% | $1.6700 | — | None |
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 40% | 40% | $1.6795 | — | None |
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | — | $0.8110 | — | None |
| Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible | 4Non-Preferred Drug | 34% | — | $0.8233 | — | None |
| Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.8042 | — | None |
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.