TIVICAY PD 5 mg Tablet, For Suspension
Also known as Dolutegravir Sodium. 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 4–5.
8 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 |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $7.6171 | $137.1118 units |
|
| HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $7.6182 | $137.1318 units |
|
| Humana Basic Rx Plan (PDP)$4.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $7.9890 | $143.8018 units |
|
| AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $8.3061 | $149.5118 units |
|
| Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $7.6867 | — | None |
| Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $7.6867 | — | None |
| Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $7.9890 | $143.8018 units |
|
| SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $8.3045 | — | None |
| MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $8.3445 | $300.4036 units |
|
| Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $7.9890 | $143.8018 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible | 5Specialty Tier | 31% | — | $8.3061 | $149.5118 units |
|
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.