VANCOMYCIN HYDROCHLORIDE 250 mg Capsule

Coverage in South Carolina (CMS PDP Region 09).

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

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

80 Medicare Advantage plans in SC 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. SC: 80 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)$4.80/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$4.2917	$103.0024 units	Quantity limit 8 per 10 days
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$4.2917	$103.0024 units	Quantity limit 8 per 10 days
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$2.7737	$66.5724 units	Quantity limit 24 per 30 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$2.8013	$67.2324 units	Quantity limit 24 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$3.5283	$84.6824 units	Prior authorization Quantity limit 8 per 10 days
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$4.4658	$107.1824 units	Quantity limit 24 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$2.1120	$50.6924 units	Quantity limit 24 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$2.1120	$50.6924 units	Quantity limit 24 per 30 days
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	4Non-Preferred Drug	50%	50%	$2.8184	$67.6424 units	Quantity limit 24 per 30 days
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$2.7581	$66.1924 units	Quantity limit 24 per 30 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$4.2023	$100.8624 units	Prior authorization Quantity limit 8 per 10 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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