DICLOFENAC SODIUM 16.05 mg/mL Solution

Coverage in Maine and New Hampshire (CMS PDP Region 01).

9 of 9 stand-alone Part D plans in Maine and New Hampshire cover this drug on tier 2–4.

Lowest 30-day cost $3.00 at a preferred pharmacy. 9 of 9 plans apply a prior authorization, step therapy or quantity limit.

61 Medicare Advantage plans in ME, NH 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. ME: 45 plans · NH: 16 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.1219	$0.373 units	Quantity limit 3 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$3.00	$9.00	$0.0910	$0.273 units	Quantity limit 3 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$1.1494	$3.453 units	Quantity limit 3 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.1886	—	Prior authorization
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$0.3657	$1.103 units	Prior authorization Quantity limit 3 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$0.2336	$0.703 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	4Non-Preferred Drug	31%	—	$0.2367	$0.713 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.1886	—	Prior authorization
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$0.2319	$0.703 units	Prior authorization Quantity limit 3 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 →