CLINIMIX E 311/238/247/170/255/247/204/179/77/880/438/489/289/213/17/297/261/51/77/33/5 mg/100mL/g/100mL Injection
Also known as Leucine, Phenylalanine, Lysine, Methionine, Isoleucine, Valine, Histidine, Threonine, Tryptophan, Alanine, Glycine, Arginine, Proline, Serine, Tyrosine, Sodium Acetate, Dibasic Potassium Phosphate, Magnesium Chloride, Sodium Chloride, Calcium Chloride, Dextrose. Package: 1000 mL in 1 BAG (0338-1144-03). NDC 00338114403.
- Plans covering it
- 104
- across 39 regions checked
- Lowest tier
- 4
- lower tiers cost less
- Plans with restrictions
- 104
- 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 |
|---|---|---|---|---|
| Pennsylvania and West Virginia | 5 of 12 | 4 | — | 5 of 5 plans |
| Maine and New Hampshire | 3 of 9 | 4 | — | 3 of 3 plans |
| Connecticut, Massachusetts, Rhode Island and Vermont | 3 of 11 | 4 | — | 3 of 3 plans |
| New York | 3 of 10 | 4 | — | 3 of 3 plans |
| New Jersey | 3 of 12 | 4 | — | 3 of 3 plans |
| Delaware, DC and Maryland | 3 of 10 | 4 | — | 3 of 3 plans |
| Virginia | 3 of 9 | 4 | — | 3 of 3 plans |
| North Carolina | 3 of 12 | 4 | — | 3 of 3 plans |
| South Carolina | 3 of 11 | 4 | — | 3 of 3 plans |
| Georgia | 3 of 10 | 4 | — | 3 of 3 plans |
| Florida | 3 of 10 | 4 | — | 3 of 3 plans |
| Alabama and Tennessee | 3 of 12 | 4 | — | 3 of 3 plans |
| Michigan | 3 of 12 | 4 | — | 3 of 3 plans |
| Ohio | 3 of 10 | 4 | — | 3 of 3 plans |
| Indiana and Kentucky | 3 of 10 | 4 | — | 3 of 3 plans |
| Wisconsin | 3 of 10 | 4 | — | 3 of 3 plans |
| Illinois | 3 of 12 | 4 | — | 3 of 3 plans |
| Missouri | 3 of 10 | 4 | — | 3 of 3 plans |
| Arkansas | 3 of 12 | 4 | — | 3 of 3 plans |
| Mississippi | 3 of 10 | 4 | — | 3 of 3 plans |
| Louisiana | 3 of 10 | 4 | — | 3 of 3 plans |
| Texas | 3 of 12 | 4 | — | 3 of 3 plans |
| Oklahoma | 3 of 11 | 4 | — | 3 of 3 plans |
| Kansas | 3 of 12 | 4 | — | 3 of 3 plans |
| Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming | 3 of 11 | 4 | — | 3 of 3 plans |
| New Mexico | 3 of 11 | 4 | — | 3 of 3 plans |
| Colorado | 3 of 10 | 4 | — | 3 of 3 plans |
| Arizona | 3 of 10 | 4 | — | 3 of 3 plans |
| Nevada | 3 of 10 | 4 | — | 3 of 3 plans |
| Oregon and Washington | 3 of 10 | 4 | — | 3 of 3 plans |
| Idaho and Utah | 3 of 10 | 4 | — | 3 of 3 plans |
| California | 3 of 12 | 4 | — | 3 of 3 plans |
| Hawaii | 3 of 8 | 4 | — | 3 of 3 plans |
| Alaska | 3 of 9 | 4 | — | 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.
Pennsylvania and West Virginia — 5 plans, 5 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 | 4Non-Preferred Drug | 33% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible | 4Non-Preferred Drug | 33% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
| Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible | 4Non-Preferred Drug | 25% | 25% | $0.0508 | — |
|
| Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible | 4Non-Preferred Drug | 25% | 25% | $0.0509 | — |
|
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.
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 | 4Non-Preferred Drug | 33% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible | 4Non-Preferred Drug | 31% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 32% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible | 4Non-Preferred Drug | 31% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 30% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible | 4Non-Preferred Drug | 31% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 32% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible | 4Non-Preferred Drug | 32% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 33% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible | 4Non-Preferred Drug | 33% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 33% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible | 4Non-Preferred Drug | 32% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 32% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible | 4Non-Preferred Drug | 34% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 30% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible | 4Non-Preferred Drug | 34% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 34% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible | 4Non-Preferred Drug | 34% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 33% | — | $0.0431 | — |
|
| Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 36% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 34% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible | 4Non-Preferred Drug | 33% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 33% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible | 4Non-Preferred Drug | 33% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 31% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible | 4Non-Preferred Drug | 34% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 33% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible | 4Non-Preferred Drug | 34% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 32% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible | 4Non-Preferred Drug | 35% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 34% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible | 4Non-Preferred Drug | 35% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 35% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible | 4Non-Preferred Drug | 34% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 34% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible | 4Non-Preferred Drug | 33% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 35% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible | 4Non-Preferred Drug | 35% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 32% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible | 4Non-Preferred Drug | 35% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 34% | — | $0.0431 | — |
|
| Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 34% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 29% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible | 4Non-Preferred Drug | 35% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 35% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible | 4Non-Preferred Drug | 32% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 34% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible | 4Non-Preferred Drug | 34% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 32% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible | 4Non-Preferred Drug | 30% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 31% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible | 4Non-Preferred Drug | 34% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 30% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible | 4Non-Preferred Drug | 34% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 32% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible | 4Non-Preferred Drug | 34% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 33% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible | 4Non-Preferred Drug | 33% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 33% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible | 4Non-Preferred Drug | 32% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 32% | — | $0.0431 | — |
|
| Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible | 4Non-Preferred Drug | 32% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 28% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible | 4Non-Preferred Drug | 30% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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 | 4Non-Preferred Drug | 28% | — | $0.0431 | — |
|
| Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible | 4Non-Preferred Drug | 33% | — | $0.0431 | — |
|
| Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.0431 | — |
|
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.