DOLISHALE 90/20 ug Tablet
Also known as Levonorgestrel And Ethinyl Estradiol. Coverage in Virginia (CMS PDP Region 07).
5 of 9 stand-alone Part D plans in Virginia cover this drug on tier 3–4.
No plan applies a prior authorization, step therapy or quantity limit.
106 Medicare Advantage plans in VA 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. VA: 106 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $1.3791 | — | None |
| SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $0.9540 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible | 3Preferred Brand | 17% | 17% | $1.3791 | — | None |
| Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $1.3368 | — | None |
| HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $1.6000 | — | 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.