ROZLYTREK 200 mg Capsule

Also known as Entrectinib. Coverage in Pennsylvania and West Virginia (CMS PDP Region 06).

12 of 12 stand-alone Part D plans in Pennsylvania and West Virginia cover this drug on tier 5.

12 of 12 plans apply a prior authorization, step therapy or quantity limit.

365 Medicare Advantage plans in PA, WV 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. PA: 306 plans · WV: 59 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)$6.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$232.7618	$2,094.869 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$227.0181	$2,043.169 units	Prior authorization Quantity limit 9 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$227.0181	$2,043.169 units	Prior authorization Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$232.7618	$2,094.869 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$247.4909	$2,227.429 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$246.0179	$2,214.169 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$226.7938	$2,041.149 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$226.7938	$2,041.149 units	Prior authorization Quantity limit 9 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$246.0179	$2,214.169 units	Prior authorization Quantity limit 9 per 30 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$232.7618	$2,094.869 units	Prior authorization Quantity limit 9 per 30 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	5Specialty Tier	25%	—	$226.7938	$20,411.4490 units	Prior authorization Quantity limit 93 per 31 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$227.0181	$20,431.6390 units	Prior authorization Quantity limit 93 per 31 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 →