TELMISARTAN AND AMLODIPINE 80/5 mg Tablet
Package: 30 TABLET in 1 BOTTLE, PLASTIC (0378-1077-93). NDC 00378107793.
- Plans covering it
- 109
- across 39 regions checked
- Lowest tier
- 1
- lower tiers cost less
- Plans with restrictions
- 79
- prior auth, step therapy or quantity limit
Coverage by region
Covered by at least one plan in 35 of 39 CMS regions; no plan covers it in 4.
| Region | Plans covering | Tiers | Lowest 30-day cost | Restrictions |
|---|---|---|---|---|
| Pennsylvania and West Virginia | 5 of 12 | 1–4 | $0.00 | 2 of 5 plans |
| Michigan | 5 of 12 | 1–4 | $0.00 | 4 of 5 plans |
| New Jersey | 4 of 12 | 1–4 | $0.00 | 3 of 4 plans |
| North Carolina | 4 of 12 | 1–4 | $0.00 | 3 of 4 plans |
| Alabama and Tennessee | 4 of 12 | 1–4 | $0.00 | 3 of 4 plans |
| Illinois | 4 of 12 | 1–4 | $0.00 | 3 of 4 plans |
| Texas | 4 of 12 | 1–4 | $0.00 | 3 of 4 plans |
| Kansas | 4 of 12 | 1–4 | $0.00 | 4 of 4 plans |
| California | 4 of 12 | 1–4 | $0.00 | 2 of 4 plans |
| New York | 3 of 10 | 1–4 | $0.00 | 2 of 3 plans |
| Delaware, DC and Maryland | 3 of 10 | 1–4 | $0.00 | 2 of 3 plans |
| South Carolina | 3 of 11 | 1–4 | $0.00 | 2 of 3 plans |
| Georgia | 3 of 10 | 1–4 | $0.00 | 2 of 3 plans |
| Florida | 3 of 10 | 1–4 | $0.00 | 3 of 3 plans |
| Ohio | 3 of 10 | 1–4 | $0.00 | 2 of 3 plans |
| Indiana and Kentucky | 3 of 10 | 1–4 | $0.00 | 2 of 3 plans |
| Wisconsin | 3 of 10 | 1–4 | $0.00 | 2 of 3 plans |
| Missouri | 3 of 10 | 1–4 | $0.00 | 2 of 3 plans |
| Arkansas | 3 of 12 | 1–4 | $0.00 | 2 of 3 plans |
| Mississippi | 3 of 10 | 1–4 | $0.00 | 2 of 3 plans |
| Louisiana | 3 of 10 | 1–4 | $0.00 | 2 of 3 plans |
| Oklahoma | 3 of 11 | 1–4 | $0.00 | 2 of 3 plans |
| Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming | 3 of 11 | 1–4 | $0.00 | 2 of 3 plans |
| New Mexico | 3 of 11 | 1–4 | $0.00 | 3 of 3 plans |
| Colorado | 3 of 10 | 1–4 | $0.00 | 2 of 3 plans |
| Arizona | 3 of 10 | 1–4 | $0.00 | 2 of 3 plans |
| Nevada | 3 of 10 | 1–4 | $0.00 | 2 of 3 plans |
| Oregon and Washington | 3 of 10 | 1–4 | $0.00 | 2 of 3 plans |
| Idaho and Utah | 3 of 10 | 1–4 | $0.00 | 2 of 3 plans |
| Maine and New Hampshire | 2 of 9 | 1–4 | $0.00 | 2 of 2 plans |
| Connecticut, Massachusetts, Rhode Island and Vermont | 2 of 11 | 1 | $0.00 | 2 of 2 plans |
| Virginia | 2 of 9 | 1–4 | $0.00 | 2 of 2 plans |
| Hawaii | 2 of 8 | 1 | $0.00 | 2 of 2 plans |
| Alaska | 2 of 9 | 1–4 | $0.00 | 2 of 2 plans |
| Puerto Rico | 1 of 3 | 4 | — | none |
| American Samoa | no PDP | — | — | — |
| Guam | no PDP | — | — | — |
| Northern Mariana Islands | 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, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.9485 | $2.853 units |
|
| SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible | 1Preferred Generic | $2.00 | $6.00 | $4.2004 | $12.603 units |
|
| Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible | 2Generic | $5.00 | $12.50 | $3.1980 | — | None |
| Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible | 2Generic | 25% | 25% | $3.2004 | — | None |
| HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $3.5231 | — | 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 — elsewhere it depends on what is prescribed.
Michigan — 5 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $1.0069 | $3.023 units |
|
| Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible | 2Generic | $5.00 | $15.00 | $3.7359 | $11.213 units |
|
| Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible | 2Generic | $5.00 | $10.00 | $3.7359 | $11.213 units |
|
| HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible | 4Non-Preferred Drug | 32% | 32% | $3.3810 | — | None |
| SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $4.2724 | $12.823 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 — 4 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.8801 | $2.643 units |
|
| HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $3.4891 | — | None |
| SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $4.2810 | $12.843 units |
|
| Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible | 4Non-Preferred Drug | 45% | 45% | $4.7759 | $14.333 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 — 4 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.3921 | $1.183 units |
|
| HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $4.0058 | — | None |
| SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $4.2739 | $12.823 units |
|
| Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible | 4Non-Preferred Drug | 40% | 40% | $4.9346 | $14.803 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 — 4 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.7204 | $2.163 units |
|
| HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $3.8960 | — | None |
| SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $4.2543 | $12.763 units |
|
| BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible | 4Non-Preferred Drug | 42% | 42% | $4.9080 | $14.723 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 — 4 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.3956 | $1.193 units |
|
| HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $3.9955 | — | None |
| SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $4.2810 | $12.843 units |
|
| Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 32% | 32% | $4.7560 | $14.273 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 — 4 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.7141 | $2.143 units |
|
| HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $3.8112 | — | None |
| SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $4.2742 | $12.823 units |
|
| Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible | 4Non-Preferred Drug | 32% | 32% | $4.7901 | $14.373 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 — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.1460 | $0.443 units |
|
| Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $4.9098 | $14.733 units |
|
| Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible | 4Non-Preferred Drug | 40% | 40% | $4.9098 | $14.733 units |
|
| SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $4.2810 | $12.843 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 — 4 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.6012 | $1.803 units |
|
| HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $3.6832 | — | None |
| SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $4.2317 | $12.703 units |
|
| Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible | 4Non-Preferred Drug | 37% | 37% | $4.3961 | — | 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 — elsewhere it depends on what is prescribed.
New York — 3 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.9997 | $3.003 units |
|
| HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 29% | 29% | $3.4386 | — | None |
| SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $4.1503 | $12.453 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, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.6310 | $1.893 units |
|
| HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 32% | 32% | $3.5880 | — | None |
| SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $4.2810 | $12.843 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, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$4.80/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.6696 | $2.013 units |
|
| HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $3.7584 | — | None |
| SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $4.2177 | $12.653 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, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.5604 | $1.683 units |
|
| HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $3.9621 | — | None |
| SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $4.2705 | $12.813 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 |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.7845 | $2.353 units |
|
| SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $4.2105 | $12.633 units |
|
| BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 29% | 29% | $4.9428 | $14.833 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, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.8615 | $2.583 units |
|
| HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $3.7754 | — | None |
| SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $4.2409 | $12.723 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, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.7967 | $2.393 units |
|
| SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible | 1Preferred Generic | $2.00 | $6.00 | $4.2203 | $12.663 units |
|
| HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $3.7299 | — | 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 — elsewhere it depends on what is prescribed.
Wisconsin — 3 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.7489 | $2.253 units |
|
| SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible | 1Preferred Generic | $2.00 | $6.00 | $4.2810 | $12.843 units |
|
| HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $3.5589 | — | 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 — elsewhere it depends on what is prescribed.
Missouri — 3 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.6206 | $1.863 units |
|
| HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $3.6946 | — | None |
| SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $4.2360 | $12.713 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, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $1.3863 | $4.163 units |
|
| HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $3.4896 | — | None |
| SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $4.2810 | $12.843 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, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.8013 | $2.403 units |
|
| HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $4.1040 | — | None |
| SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $4.2810 | $12.843 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, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.6817 | $2.053 units |
|
| SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible | 1Preferred Generic | $2.00 | $6.00 | $4.2810 | $12.843 units |
|
| HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $4.3033 | — | 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 — elsewhere it depends on what is prescribed.
Oklahoma — 3 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.8109 | $2.433 units |
|
| HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $3.4990 | — | None |
| Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 32% | 32% | $4.6814 | $14.043 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, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.8752 | $2.633 units |
|
| SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible | 1Preferred Generic | $2.00 | $6.00 | $4.2810 | $12.843 units |
|
| HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $3.6478 | — | 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 — 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 |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $1.4740 | $4.423 units |
|
| SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $4.0955 | $12.293 units |
|
| Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $4.8667 | $14.603 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, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.4322 | $1.303 units |
|
| HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $4.4214 | — | None |
| SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $4.2810 | $12.843 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, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.7075 | $2.123 units |
|
| HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $4.0117 | — | None |
| SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $4.2810 | $12.843 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, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $1.1535 | $3.463 units |
|
| HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $3.5899 | — | None |
| SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $4.1762 | $12.533 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, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.7649 | $2.293 units |
|
| HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $3.9239 | — | None |
| SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $4.2810 | $12.843 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, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $1.1888 | $3.573 units |
|
| SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible | 1Preferred Generic | $2.00 | $6.00 | $4.1560 | $12.473 units |
|
| HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $3.6268 | — | 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 — elsewhere it depends on what is prescribed.
Maine and New Hampshire — 2 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.7043 | $2.113 units |
|
| SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $4.2810 | $12.843 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 — 2 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.4708 | $1.413 units |
|
| SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible | 1Preferred Generic | $2.00 | $6.00 | $4.2810 | $12.843 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 — 2 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.4384 | $1.323 units |
|
| SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $4.2810 | $12.843 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 — 2 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible | 1Preferred Generic | $2.00 | $6.00 | $4.2810 | $12.843 units |
|
| Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.2275 | $0.683 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 — 2 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $0.6476 | $1.943 units |
|
| SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $4.2810 | $12.843 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.
Puerto Rico — 1 plan
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $3.1476 | — | 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 — 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 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.