VANCOMYCIN HYDROCHLORIDE 250 mg Capsule

Coverage in Oklahoma (CMS PDP Region 23).

11 of 11 stand-alone Part D plans in Oklahoma cover this drug on tier 4.

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

71 Medicare Advantage plans in OK 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. OK: 71 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue Cross MedicareRx Basic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$7.1784	$172.2824 units	Quantity limit 24 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	—	$2.6783	$64.2824 units	Quantity limit 24 per 30 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$4.1644	$99.9524 units	Quantity limit 8 per 10 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$4.1644	$99.9524 units	Quantity limit 8 per 10 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	4Non-Preferred Drug	35%	—	$2.7391	$65.7424 units	Quantity limit 24 per 30 days
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.8061	$91.3524 units	Prior authorization Quantity limit 8 per 10 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	—	$2.0898	$50.1624 units	Quantity limit 24 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$2.6440	$63.4624 units	Quantity limit 24 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	4Non-Preferred Drug	40%	—	$2.0898	$50.1624 units	Quantity limit 24 per 30 days
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$4.0716	$97.7224 units	Prior authorization Quantity limit 8 per 10 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$7.1985	$172.7624 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.

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