PROMACTA 75 mg Tablet, Film Coated
Also known as Eltrombopag Olamine. Package: 30 TABLET, FILM COATED in 1 BOTTLE (0078-0687-15). NDC 00078068715.
- Plans covering it
- 102
- across 39 regions checked
- Lowest tier
- 5
- lower tiers cost less
- Plans with restrictions
- 102
- prior auth, step therapy or quantity limit
Coverage by region
Covered by at least one plan in 34 of 39 CMS regions; no plan covers it in 5.
| Region | Plans covering | Tiers | Lowest 30-day cost | Restrictions |
|---|---|---|---|---|
| Maine and New Hampshire | 3 of 9 | 5 | — | 3 of 3 plans |
| Connecticut, Massachusetts, Rhode Island and Vermont | 3 of 11 | 5 | — | 3 of 3 plans |
| New York | 3 of 10 | 5 | — | 3 of 3 plans |
| New Jersey | 3 of 12 | 5 | — | 3 of 3 plans |
| Delaware, DC and Maryland | 3 of 10 | 5 | — | 3 of 3 plans |
| Pennsylvania and West Virginia | 3 of 12 | 5 | — | 3 of 3 plans |
| Virginia | 3 of 9 | 5 | — | 3 of 3 plans |
| North Carolina | 3 of 12 | 5 | — | 3 of 3 plans |
| South Carolina | 3 of 11 | 5 | — | 3 of 3 plans |
| Georgia | 3 of 10 | 5 | — | 3 of 3 plans |
| Florida | 3 of 10 | 5 | — | 3 of 3 plans |
| Alabama and Tennessee | 3 of 12 | 5 | — | 3 of 3 plans |
| Michigan | 3 of 12 | 5 | — | 3 of 3 plans |
| Ohio | 3 of 10 | 5 | — | 3 of 3 plans |
| Indiana and Kentucky | 3 of 10 | 5 | — | 3 of 3 plans |
| Wisconsin | 3 of 10 | 5 | — | 3 of 3 plans |
| Illinois | 3 of 12 | 5 | — | 3 of 3 plans |
| Missouri | 3 of 10 | 5 | — | 3 of 3 plans |
| Arkansas | 3 of 12 | 5 | — | 3 of 3 plans |
| Mississippi | 3 of 10 | 5 | — | 3 of 3 plans |
| Louisiana | 3 of 10 | 5 | — | 3 of 3 plans |
| Texas | 3 of 12 | 5 | — | 3 of 3 plans |
| Oklahoma | 3 of 11 | 5 | — | 3 of 3 plans |
| Kansas | 3 of 12 | 5 | — | 3 of 3 plans |
| Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming | 3 of 11 | 5 | — | 3 of 3 plans |
| New Mexico | 3 of 11 | 5 | — | 3 of 3 plans |
| Colorado | 3 of 10 | 5 | — | 3 of 3 plans |
| Arizona | 3 of 10 | 5 | — | 3 of 3 plans |
| Nevada | 3 of 10 | 5 | — | 3 of 3 plans |
| Oregon and Washington | 3 of 10 | 5 | — | 3 of 3 plans |
| Idaho and Utah | 3 of 10 | 5 | — | 3 of 3 plans |
| California | 3 of 12 | 5 | — | 3 of 3 plans |
| Hawaii | 3 of 8 | 5 | — | 3 of 3 plans |
| Alaska | 3 of 9 | 5 | — | 3 of 3 plans |
| American Samoa | no PDP | — | — | — |
| Guam | no PDP | — | — | — |
| Northern Mariana Islands | no PDP | — | — | — |
| Puerto Rico | no PDP | — | — | — |
| U.S. Virgin Islands | no PDP | — | — | — |
Plan-by-plan detail
Open a region to see every plan that covers this drug, with tier, cost-sharing and restrictions.
Maine and New Hampshire — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $675.0062 | $4,050.046 units |
|
| Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $675.0062 | $4,050.046 units |
|
| Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $675.0062 | $4,050.046 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 — elsewhere it depends on what is prescribed.
Connecticut, Massachusetts, Rhode Island and Vermont — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$8.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $671.8132 | $4,030.886 units |
|
| Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $671.8132 | $4,030.886 units |
|
| Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $671.8132 | $4,030.886 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 — elsewhere it depends on what is prescribed.
New York — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $672.6690 | $4,036.016 units |
|
| Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $672.6690 | $4,036.016 units |
|
| Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $672.6690 | $4,036.016 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 — elsewhere it depends on what is prescribed.
New Jersey — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$4.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $667.8895 | $4,007.346 units |
|
| Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $667.8895 | $4,007.346 units |
|
| Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $667.8895 | $4,007.346 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 — elsewhere it depends on what is prescribed.
Delaware, DC and Maryland — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $672.6215 | $4,035.736 units |
|
| Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $672.6215 | $4,035.736 units |
|
| Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $672.6215 | $4,035.736 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 — elsewhere it depends on what is prescribed.
Pennsylvania and West Virginia — 3 plans, 3 with restrictions
| 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 | 5Specialty Tier | 25% | — | $675.4737 | $4,052.846 units |
|
| Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $675.4737 | $4,052.846 units |
|
| Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $675.4737 | $4,052.846 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 — elsewhere it depends on what is prescribed.
Virginia — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $665.6735 | $3,994.046 units |
|
| Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $665.6735 | $3,994.046 units |
|
| Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $665.6735 | $3,994.046 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 — elsewhere it depends on what is prescribed.
North Carolina — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $676.6756 | $4,060.056 units |
|
| Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $676.6756 | $4,060.056 units |
|
| Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $676.6756 | $4,060.056 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 — elsewhere it depends on what is prescribed.
South Carolina — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $672.8167 | $4,036.906 units |
|
| Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $672.8167 | $4,036.906 units |
|
| Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $672.8167 | $4,036.906 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 — elsewhere it depends on what is prescribed.
Georgia — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $666.8322 | $4,000.996 units |
|
| Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $666.8322 | $4,000.996 units |
|
| Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $666.8322 | $4,000.996 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 — elsewhere it depends on what is prescribed.
Florida — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $679.3908 | $4,076.346 units |
|
| Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $679.3908 | $4,076.346 units |
|
| Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $679.3908 | $4,076.346 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 — elsewhere it depends on what is prescribed.
Alabama and Tennessee — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $670.8751 | $4,025.256 units |
|
| Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $670.8751 | $4,025.256 units |
|
| Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $670.8751 | $4,025.256 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 — elsewhere it depends on what is prescribed.
Michigan — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $673.1092 | $4,038.666 units |
|
| Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $673.1092 | $4,038.666 units |
|
| Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $673.1092 | $4,038.666 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 — elsewhere it depends on what is prescribed.
Ohio — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $670.4393 | $4,022.646 units |
|
| Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $670.4393 | $4,022.646 units |
|
| Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $670.4393 | $4,022.646 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 — elsewhere it depends on what is prescribed.
Indiana and Kentucky — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $676.3705 | $4,058.226 units |
|
| Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $676.3705 | $4,058.226 units |
|
| Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $676.3705 | $4,058.226 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 — elsewhere it depends on what is prescribed.
Wisconsin — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $673.0820 | $4,038.496 units |
|
| Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $673.0820 | $4,038.496 units |
|
| Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $673.0820 | $4,038.496 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 — elsewhere it depends on what is prescribed.
Illinois — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $670.1925 | $4,021.156 units |
|
| Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $670.1925 | $4,021.156 units |
|
| Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $670.1925 | $4,021.156 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 — elsewhere it depends on what is prescribed.
Missouri — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $685.4241 | $4,112.546 units |
|
| Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $685.4241 | $4,112.546 units |
|
| Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $685.4241 | $4,112.546 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 — elsewhere it depends on what is prescribed.
Arkansas — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $665.6735 | $3,994.046 units |
|
| Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $665.6735 | $3,994.046 units |
|
| Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $665.6735 | $3,994.046 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 — elsewhere it depends on what is prescribed.
Mississippi — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $669.1577 | $4,014.956 units |
|
| Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $669.1577 | $4,014.956 units |
|
| Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $669.1577 | $4,014.956 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 — elsewhere it depends on what is prescribed.
Louisiana — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $670.0314 | $4,020.196 units |
|
| Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $670.0314 | $4,020.196 units |
|
| Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $670.0314 | $4,020.196 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 — elsewhere it depends on what is prescribed.
Texas — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $673.2440 | $4,039.466 units |
|
| Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $673.2440 | $4,039.466 units |
|
| Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $673.2440 | $4,039.466 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 — elsewhere it depends on what is prescribed.
Oklahoma — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $668.1091 | $4,008.656 units |
|
| Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $668.1091 | $4,008.656 units |
|
| Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $668.1091 | $4,008.656 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 — elsewhere it depends on what is prescribed.
Kansas — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $668.5890 | $4,011.536 units |
|
| Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $668.5890 | $4,011.536 units |
|
| Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $668.5890 | $4,011.536 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 — elsewhere it depends on what is prescribed.
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$4.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $668.0917 | $4,008.556 units |
|
| Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $668.0917 | $4,008.556 units |
|
| Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $668.0917 | $4,008.556 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 — elsewhere it depends on what is prescribed.
New Mexico — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $665.6735 | $3,994.046 units |
|
| Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $665.6735 | $3,994.046 units |
|
| Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $665.6735 | $3,994.046 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 — elsewhere it depends on what is prescribed.
Colorado — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $683.5148 | $4,101.096 units |
|
| Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $683.5148 | $4,101.096 units |
|
| Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $683.5148 | $4,101.096 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 — elsewhere it depends on what is prescribed.
Arizona — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $674.3684 | $4,046.216 units |
|
| Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $674.3684 | $4,046.216 units |
|
| Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $674.3684 | $4,046.216 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 — elsewhere it depends on what is prescribed.
Nevada — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $694.0000 | $4,164.006 units |
|
| Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $694.0000 | $4,164.006 units |
|
| Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $694.0000 | $4,164.006 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 — elsewhere it depends on what is prescribed.
Oregon and Washington — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $666.4496 | $3,998.706 units |
|
| Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $666.4496 | $3,998.706 units |
|
| Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $666.4496 | $3,998.706 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 — elsewhere it depends on what is prescribed.
Idaho and Utah — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $666.1981 | $3,997.196 units |
|
| Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $666.1981 | $3,997.196 units |
|
| Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $666.1981 | $3,997.196 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 — elsewhere it depends on what is prescribed.
California — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $676.9086 | $4,061.456 units |
|
| Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $676.9086 | $4,061.456 units |
|
| Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $676.9086 | $4,061.456 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 — elsewhere it depends on what is prescribed.
Hawaii — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $685.3789 | $4,112.276 units |
|
| Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $685.3789 | $4,112.276 units |
|
| Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $685.3789 | $4,112.276 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 — elsewhere it depends on what is prescribed.
Alaska — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $736.4898 | $4,418.946 units |
|
| Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $736.4898 | $4,418.946 units |
|
| Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $736.4898 | $4,418.946 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 — elsewhere it depends on what is prescribed.
No stand-alone Part D plan in American Samoa
None of the 1 stand-alone Part D plans in CMS PDP Region 35 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Guam
None of the 1 stand-alone Part D plans in CMS PDP Region 36 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Northern Mariana Islands
None of the 1 stand-alone Part D plans in CMS PDP Region 37 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Puerto Rico
None of the 3 stand-alone Part D plans in CMS PDP Region 38 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in U.S. Virgin Islands
None of the 1 stand-alone Part D plans in CMS PDP Region 39 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.