GLATIRAMER ACETATE 40 mg/mL Injection, Solution

Also known as Glatiramer. Coverage in Arizona (CMS PDP Region 28).

10 of 10 stand-alone Part D plans in Arizona cover this drug on tier 4–5.

10 of 10 plans apply a prior authorization, step therapy or quantity limit.

125 Medicare Advantage plans in AZ 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. AZ: 125 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$125.2301	$1,627.9913 units	Quantity limit 12 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$125.2544	$1,628.3113 units	Quantity limit 12 per 28 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$207.7222	$2,700.3913 units	Prior authorization Quantity limit 12 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$207.7222	$2,700.3913 units	Prior authorization Quantity limit 12 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$208.3306	$2,708.3013 units	Prior authorization Quantity limit 12 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$224.0000	$2,912.0013 units	Prior authorization Quantity limit 12 per 28 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$224.0000	$2,912.0013 units	Prior authorization Quantity limit 12 per 28 days
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$208.3306	$2,708.3013 units	Prior authorization Quantity limit 12 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$161.5522	$2,100.1813 units	Prior authorization Quantity limit 12 per 28 days
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$224.0000	$2,912.0013 units	Prior authorization Quantity limit 12 per 28 days

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.

See coverage in all 39 regions →