GLATIRAMER ACETATE 40 mg/mL Injection, Solution

Also known as Glatiramer. Coverage in Oregon and Washington (CMS PDP Region 30).

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

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

171 Medicare Advantage plans in OR, WA 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. OR: 75 plans · WA: 96 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)$38.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$120.1495	$1,561.9413 units	Quantity limit 12 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	4Non-Preferred Drug	37%	—	$120.1908	$1,562.4813 units	Quantity limit 12 per 28 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$222.0795	$2,887.0313 units	Prior authorization Quantity limit 12 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$222.0795	$2,887.0313 units	Prior authorization Quantity limit 12 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$208.0861	$2,705.1213 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)$22.10/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)$50.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$210.9745	$2,742.6713 units	Prior authorization Quantity limit 12 per 28 days
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$161.9365	$2,105.1713 units	Prior authorization Quantity limit 12 per 28 days
Humana Premier Rx Plan (PDP)$108.60/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 →