VANCOMYCIN HYDROCHLORIDE 250 mg Capsule

Coverage in Arkansas (CMS PDP Region 19).

12 of 12 stand-alone Part D plans in Arkansas cover this drug on tier 4.

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

77 Medicare Advantage plans in AR 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. AR: 77 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	26%	26%	$3.0161	$72.3924 units	Quantity limit 8 per 10 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$3.0161	$72.3924 units	Quantity limit 8 per 10 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$2.9881	$71.7124 units	Prior authorization Quantity limit 8 per 10 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$2.3777	$57.0624 units	Quantity limit 24 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$2.4306	$58.3324 units	Quantity limit 24 per 30 days
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	34%	$1.0566	$3.173 units	Quantity limit 16 per 180 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$2.9811	$71.5524 units	Prior authorization Quantity limit 8 per 10 days
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$2.0752	$49.8024 units	Quantity limit 24 per 30 days
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.3422	$104.2124 units	Quantity limit 24 per 30 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$2.3480	$56.3524 units	Quantity limit 24 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	4Non-Preferred Drug	29%	—	$2.0752	$49.8024 units	Quantity limit 24 per 30 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	4Non-Preferred Drug	34%	34%	$1.0566	$3.173 units	Quantity limit 16 per 180 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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