GLATIRAMER ACETATE 40 mg/mL Injection, Solution

Also known as Glatiramer. Coverage in Virginia (CMS PDP Region 07).

9 of 9 stand-alone Part D plans in Virginia cover this drug on tier 4–5.

9 of 9 plans apply a prior authorization, step therapy or quantity limit.

122 Medicare Advantage plans in VA 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. VA: 122 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)$39.60/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$120.2243	$1,562.9213 units	Quantity limit 12 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$120.2633	$1,563.4213 units	Quantity limit 12 per 28 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$207.6830	$2,699.8813 units	Prior authorization Quantity limit 12 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$207.6830	$2,699.8813 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)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$224.0000	$2,912.0013 units	Prior authorization Quantity limit 12 per 28 days
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$182.9331	$2,378.1313 units	Prior authorization Quantity limit 12 per 28 days
Humana Premier Rx Plan (PDP)$87.60/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)$133.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$209.7300	$2,726.4913 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 →