VANCOMYCIN HYDROCHLORIDE 250 mg Capsule

Coverage in Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming (CMS PDP Region 25).

11 of 11 stand-alone Part D plans in Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming cover this drug on tier 4.

11 of 11 plans apply a prior authorization, step therapy or quantity limit.

241 Medicare Advantage plans in IA, MN, MT, NE, ND, SD, WY 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. IA: 54 plans · MN: 69 plans · MT: 25 plans · NE: 44 plans · ND: 22 plans · SD: 19 plans · WY: 8 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$4.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$2.5919	$62.2124 units	Quantity limit 24 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$2.1534	$51.6824 units	Quantity limit 24 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$4.0708	$97.7024 units	Quantity limit 8 per 10 days
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$4.0708	$97.7024 units	Quantity limit 8 per 10 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$2.6187	$62.8524 units	Quantity limit 24 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$4.4600	$107.0424 units	Quantity limit 24 per 30 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$3.2752	$78.6024 units	Prior authorization Quantity limit 8 per 10 days
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	42%	$6.8849	$165.2424 units	Quantity limit 24 per 30 days
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$2.5768	$61.8424 units	Quantity limit 24 per 30 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.5211	$84.5124 units	Prior authorization Quantity limit 8 per 10 days
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$2.1534	$51.6824 units	Quantity limit 24 per 30 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 →