CLINISOL 1.18/1.04/1.04/960/894/749/749/749/250/2.17/1.47/1.04/894/749/592/434/39 g/100mL/mg/100mL Injection, Solution
Also known as Lysine, Leucine, Phenylalanine, Valine, Histidine, Isoleucine, Methionine, Threonine, Tryptophan, Alanine, Arginine, Glycine, Proline, Glutamic Acid, Serine, Aspartic Acid, Tyrosine. Coverage in Pennsylvania and West Virginia (CMS PDP Region 06).
4 of 12 stand-alone Part D plans in Pennsylvania and West Virginia cover this drug on tier 4.
4 of 4 plans apply a prior authorization, step therapy or quantity limit.
195 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: 160 plans · WV: 35 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 35% | 35% | $0.0621 | — |
|
| HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $0.0730 | — |
|
| HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $0.0730 | — |
|
| Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0656 | — |
|
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.