GLATIRAMER ACETATE 40 mg/mL Injection, Solution

Also known as Glatiramer. Coverage in Connecticut, Massachusetts, Rhode Island and Vermont (CMS PDP Region 02).

11 of 11 stand-alone Part D plans in Connecticut, Massachusetts, Rhode Island and Vermont cover this drug on tier 4–5.

11 of 11 plans apply a prior authorization, step therapy or quantity limit.

148 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: 42 plans · MA: 84 plans · RI: 20 plans · VT: 2 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	35%	—	$136.8741	$1,779.3613 units	Quantity limit 12 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	4Non-Preferred Drug	30%	—	$136.8757	$1,779.3813 units	Quantity limit 12 per 28 days
Humana Basic Rx Plan (PDP)$8.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$224.0000	$2,912.0013 units	Prior authorization Quantity limit 12 per 28 days
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$217.2168	$2,823.8213 units	Prior authorization Quantity limit 12 per 28 days
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$136.6842	$1,776.8913 units	Prior authorization Quantity limit 12 per 28 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$219.0016	$2,847.0213 units	Prior authorization Quantity limit 12 per 28 days
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$163.9322	$2,131.1213 units	Prior authorization Quantity limit 12 per 28 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$224.0000	$2,912.0013 units	Prior authorization Quantity limit 12 per 28 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$224.0000	$2,912.0013 units	Prior authorization Quantity limit 12 per 28 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$206.6440	$2,686.3713 units	Prior authorization Quantity limit 12 per 28 days
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$136.6842	$1,776.8913 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 →