ROZLYTREK 100 mg Capsule

Also known as Entrectinib. Coverage in Georgia (CMS PDP Region 10).

10 of 10 stand-alone Part D plans in Georgia cover this drug on tier 5.

10 of 10 plans apply a prior authorization, step therapy or quantity limit.

142 Medicare Advantage plans in GA 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. GA: 142 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	5Specialty Tier	25%	—	$236.1259	$3,541.8915 units	Prior authorization Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$236.1259	$3,541.8915 units	Prior authorization Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$230.7947	$3,461.9215 units	Prior authorization Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$230.7947	$3,461.9215 units	Prior authorization Quantity limit 15 per 30 days
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$233.9801	$3,509.7015 units	Prior authorization Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$246.0176	$3,690.2615 units	Prior authorization Quantity limit 15 per 30 days
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$247.4906	$4,454.8318 units	Prior authorization Quantity limit 18 per 30 days
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$230.7947	$3,461.9215 units	Prior authorization Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$246.0176	$3,690.2615 units	Prior authorization Quantity limit 15 per 30 days
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$234.0118	$3,510.1815 units	Prior authorization Quantity limit 15 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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