CLORAZEPATE DIPOTASSIUM 7.5 mg Tablet
Coverage in Maine and New Hampshire (CMS PDP Region 01).
9 of 9 stand-alone Part D plans in Maine and New Hampshire cover this drug on tier 4.
6 of 9 plans apply a prior authorization, step therapy or quantity limit.
61 Medicare Advantage plans in ME, NH 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. ME: 45 plans · NH: 16 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 27% | 27% | $1.6973 | $61.1036 units |
|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 40% | 40% | $1.7320 | $62.3536 units |
|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $1.2091 | $43.5336 units |
|
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | — | $1.9522 | — | None |
| Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible | 4Non-Preferred Drug | 31% | — | $1.9852 | — | None |
| AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible | 4Non-Preferred Drug | 36% | — | $1.4484 | $52.1436 units |
|
| SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $1.5804 | $14.229 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible | 4Non-Preferred Drug | 30% | — | $1.4318 | $51.5436 units |
|
| Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $1.9336 | — | None |
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.