ELMIRON 100 mg Capsule, Gelatin Coated
Also known as Pentosan Polysulfate Sodium. Coverage in Connecticut, Massachusetts, Rhode Island and Vermont (CMS PDP Region 02).
6 of 11 stand-alone Part D plans in Connecticut, Massachusetts, Rhode Island and Vermont cover this drug on tier 4.
3 of 6 plans apply a prior authorization, step therapy or quantity limit.
70 Medicare Advantage plans in CT, MA, VT 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. CT: 20 plans · MA: 48 plans · VT: 2 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)$8.40/mo premium · $615.00 deductible | 4Non-Preferred Drug | 32% | — | $12.1672 | $109.509 units |
|
| Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible | 4Non-Preferred Drug | 40% | 40% | $11.5459 | — | None |
| Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 29% | 29% | $11.5459 | — | None |
| Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible | 4Non-Preferred Drug | 31% | — | $12.1672 | $109.509 units |
|
| Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $12.1672 | $109.509 units |
|
| HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $11.9636 | — | None |
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.