GLATOPA 40 mg/mL Injection, Solution

Also known as Glatiramer Acetate. Coverage in New Jersey (CMS PDP Region 04).

12 of 12 stand-alone Part D plans in New Jersey cover this drug on tier 4–5.

12 of 12 plans apply a prior authorization, step therapy or quantity limit.

72 Medicare Advantage plans in NJ 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. NJ: 72 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)$77.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$134.3062	$1,745.9813 units	Quantity limit 12 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	4Non-Preferred Drug	33%	—	$134.3459	$1,746.5013 units	Quantity limit 12 per 28 days
Humana Basic Rx Plan (PDP)$4.40/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)$22.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$220.2816	$2,863.6613 units	Prior authorization Quantity limit 12 per 28 days
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$234.4410	$3,047.7313 units	Prior authorization Quantity limit 12 per 28 days
Humana Value Rx Plan (PDP)$35.60/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)$59.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$209.6292	$2,725.1813 units	Prior authorization Quantity limit 12 per 28 days
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$146.4647	$1,904.0413 units	Prior authorization Quantity limit 12 per 28 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$200.8860	$2,611.5213 units	Prior authorization Quantity limit 12 per 28 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$209.6292	$2,725.1813 units	Prior authorization Quantity limit 12 per 28 days
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$224.0000	$2,912.0013 units	Prior authorization Quantity limit 12 per 28 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	5Specialty Tier	30%	—	$146.4647	$1,904.0413 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.

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