DIMETHYL FUMARATE 120 mg Capsule, Delayed Release

Coverage in Pennsylvania and West Virginia (CMS PDP Region 06).

9 of 12 stand-alone Part D plans in Pennsylvania and West Virginia cover this drug on tier 4.

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

292 Medicare Advantage plans in PA, WV 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. PA: 241 plans · WV: 51 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$4.1289	$247.7360 units	Prior authorization Quantity limit 56 per 28 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$4.1289	$247.7360 units	Prior authorization Quantity limit 56 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	—	$1.6558	$99.3560 units	Quantity limit 56 per 28 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$59.5900	$834.2614 units	Prior authorization Quantity limit 14 per 30 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$59.5889	$834.2414 units	Prior authorization Quantity limit 14 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	4Non-Preferred Drug	33%	—	$1.6718	$100.3160 units	Quantity limit 56 per 28 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$4.6550	$65.1714 units	Prior authorization Quantity limit 14 per 30 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	4Non-Preferred Drug	25%	25%	$4.9700	$298.2060 units	Prior authorization Quantity limit 62 per 31 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$4.9700	$298.2060 units	Prior authorization Quantity limit 62 per 31 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 →