XOLAIR PFS 150 mg/mL Injection, Solution

Also known as Omalizumab. Coverage in Indiana and Kentucky (CMS PDP Region 15).

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

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

219 Medicare Advantage plans in IN, KY 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. IN: 116 plans · KY: 103 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)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1484.2334	$13,358.109 units	Prior authorization Quantity limit 8 per 28 days
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1678.0700	$15,102.639 units	Prior authorization Quantity limit 8 per 28 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1678.0700	$15,102.639 units	Prior authorization Quantity limit 8 per 28 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$1484.2334	$13,358.109 units	Prior authorization Quantity limit 8 per 28 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1528.8982	—	Prior authorization
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1464.5800	$13,181.229 units	Prior authorization Quantity limit 8 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1586.3875	—	Prior authorization
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1463.0900	$13,167.819 units	Prior authorization Quantity limit 8 per 28 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1484.2334	$13,358.109 units	Prior authorization Quantity limit 8 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$1586.3875	—	Prior authorization

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 →