CLINIMIX 365/280/290/200/300/290/240/210/90/1035/515/575/340/250/20/20 mg/100mL/g/100mL Injection
Also known as Leucine, Phenylalanine, Lysine, Methionine, Isoleucine, Valine, Histidine, Threonine, Tryptophan, Alanine, Glycine, Arginine, Proline, Serine, Tyrosine, Dextrose. Coverage in Connecticut, Massachusetts, Rhode Island and Vermont (CMS PDP Region 02).
7 of 11 stand-alone Part D plans in Connecticut, Massachusetts, Rhode Island and Vermont cover this drug on tier 4.
7 of 7 plans apply a prior authorization, step therapy or quantity limit.
73 Medicare Advantage plans in CT, MA, RI, VT 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. CT: 27 plans · MA: 39 plans · RI: 5 plans · VT: 2 plans.
Every plan that covers it
| 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 | 4Non-Preferred Drug | 32% | — | $0.0449 | — |
|
| Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 32% | 32% | $0.0457 | — |
|
| SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 35% | 35% | $0.0467 | — |
|
| Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible | 4Non-Preferred Drug | 31% | — | $0.0449 | — |
|
| Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0449 | — |
|
| HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $0.0525 | — |
|
| Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible | 4Non-Preferred Drug | 35% | 35% | $0.0457 | — |
|
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.