ROZLYTREK 50 mg/201 Pellet

Also known as Entrectinib. Coverage in Idaho and Utah (CMS PDP Region 31).

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

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

88 Medicare Advantage plans in ID, UT 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. ID: 40 plans · UT: 48 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%	—	$123.1867	$4,434.7236 units	Prior authorization Quantity limit 36 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$118.0598	$42,501.53360 units	Prior authorization Quantity limit 336 per 28 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$123.1867	$4,434.7236 units	Prior authorization Quantity limit 36 per 30 days
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$118.0598	$42,501.53360 units	Prior authorization Quantity limit 336 per 28 days
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$129.0020	$46,440.72360 units	Prior authorization Quantity limit 336 per 28 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$116.9872	$4,211.5436 units	Prior authorization Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$127.7140	$4,597.7036 units	Prior authorization Quantity limit 36 per 30 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$123.1867	$4,434.7236 units	Prior authorization Quantity limit 36 per 30 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$117.0029	$4,212.1036 units	Prior authorization Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$127.7140	$4,597.7036 units	Prior authorization Quantity limit 36 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.

See coverage in all 39 regions →