DIFICID 200 mg/5mL Granule, For Suspension
Also known as Fidaxomicin. Package: 1 POUCH in 1 CARTON (52015-700-22) / 1 BOTTLE, GLASS in 1 POUCH (52015-700-23) / 150 mL in 1 BOTTLE, GLASS (52015-700-21). NDC 52015070022.
- Plans covering it
- 121
- across 39 regions checked
- Lowest tier
- 5
- lower tiers cost less
- Plans with restrictions
- 84
- prior auth, step therapy or quantity limit
Coverage by region
Covered by at least one plan in 35 of 39 CMS regions; no plan covers it in 4.
| Region | Plans covering | Tiers | Lowest 30-day cost | Restrictions |
|---|---|---|---|---|
| New Jersey | 5 of 12 | 5 | — | 4 of 5 plans |
| Pennsylvania and West Virginia | 5 of 12 | 5 | — | 4 of 5 plans |
| North Carolina | 5 of 12 | 5 | — | 4 of 5 plans |
| Alabama and Tennessee | 5 of 12 | 5 | — | 4 of 5 plans |
| Illinois | 5 of 12 | 5 | — | 4 of 5 plans |
| Arkansas | 5 of 12 | 5 | — | 2 of 5 plans |
| Texas | 5 of 12 | 5 | — | 4 of 5 plans |
| Kansas | 5 of 12 | 5 | — | 4 of 5 plans |
| California | 5 of 12 | 5 | — | 4 of 5 plans |
| Connecticut, Massachusetts, Rhode Island and Vermont | 4 of 11 | 5 | — | 1 of 4 plans |
| Oklahoma | 4 of 11 | 5 | — | 4 of 4 plans |
| Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming | 4 of 11 | 5 | — | 3 of 4 plans |
| New Mexico | 4 of 11 | 5 | — | 3 of 4 plans |
| New York | 3 of 10 | 5 | — | 2 of 3 plans |
| Delaware, DC and Maryland | 3 of 10 | 5 | — | 2 of 3 plans |
| South Carolina | 3 of 11 | 5 | — | 2 of 3 plans |
| Georgia | 3 of 10 | 5 | — | 2 of 3 plans |
| Florida | 3 of 10 | 5 | — | 2 of 3 plans |
| Michigan | 3 of 12 | 5 | — | 2 of 3 plans |
| Ohio | 3 of 10 | 5 | — | 2 of 3 plans |
| Indiana and Kentucky | 3 of 10 | 5 | — | 2 of 3 plans |
| Wisconsin | 3 of 10 | 5 | — | 2 of 3 plans |
| Missouri | 3 of 10 | 5 | — | 2 of 3 plans |
| Mississippi | 3 of 10 | 5 | — | 2 of 3 plans |
| Louisiana | 3 of 10 | 5 | — | 2 of 3 plans |
| Colorado | 3 of 10 | 5 | — | 2 of 3 plans |
| Arizona | 3 of 10 | 5 | — | 2 of 3 plans |
| Nevada | 3 of 10 | 5 | — | 2 of 3 plans |
| Oregon and Washington | 3 of 10 | 5 | — | 2 of 3 plans |
| Idaho and Utah | 3 of 10 | 5 | — | 2 of 3 plans |
| Maine and New Hampshire | 2 of 9 | 5 | — | 1 of 2 plans |
| Virginia | 2 of 9 | 5 | — | 1 of 2 plans |
| Alaska | 2 of 9 | 5 | — | 1 of 2 plans |
| Puerto Rico | 2 of 3 | 5 | — | 2 of 2 plans |
| Hawaii | 1 of 8 | 5 | — | none |
| American Samoa | no PDP | — | — | — |
| Guam | no PDP | — | — | — |
| Northern Mariana Islands | no PDP | — | — | — |
| U.S. Virgin Islands | no PDP | — | — | — |
Plan-by-plan detail
Open a region to see every plan that covers this drug, with tier, cost-sharing and restrictions.
New Jersey — 5 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $33.7700 | $13,778.16408 units |
|
| Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $40.7531 | $16,627.26408 units |
|
| SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $37.6598 | — | None |
| HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $33.7700 | $13,778.16408 units |
|
| Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible | 5Specialty Tier | 30% | — | $40.7531 | $16,627.26408 units |
|
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 — elsewhere it depends on what is prescribed.
Pennsylvania and West Virginia — 5 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $37.6598 | — | None |
| HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $35.0100 | $14,284.08408 units |
|
| HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $35.0100 | $14,284.08408 units |
|
| Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible | 5Specialty Tier | 25% | — | $35.0100 | $11,903.40340 units |
|
| Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible | 5Specialty Tier | 25% | 25% | $35.0100 | $11,903.40340 units |
|
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 — elsewhere it depends on what is prescribed.
North Carolina — 5 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.6100 | $14,936.88408 units |
|
| Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $39.7740 | $16,227.79408 units |
|
| SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $37.6598 | — | None |
| HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.5900 | $14,928.72408 units |
|
| Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $39.7740 | $16,227.79408 units |
|
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 — elsewhere it depends on what is prescribed.
Alabama and Tennessee — 5 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible | 5Specialty Tier | 25% | 25% | $39.9886 | $16,315.35408 units |
|
| HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.4808 | $14,884.17408 units |
|
| HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.4858 | $14,886.21408 units |
|
| SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $39.8117 | — | None |
| BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible | 5Specialty Tier | 31% | 31% | $39.9886 | $16,315.35408 units |
|
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 — elsewhere it depends on what is prescribed.
Illinois — 5 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.0900 | $14,724.72408 units |
|
| Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $40.7978 | $16,645.50408 units |
|
| SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $37.6598 | — | None |
| HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.0500 | $14,708.40408 units |
|
| Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $40.5195 | $16,531.96408 units |
|
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 — elsewhere it depends on what is prescribed.
Arkansas — 5 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.4858 | $14,886.21408 units |
|
| BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $39.2555 | — | None |
| HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.4808 | $14,884.17408 units |
|
| SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $39.8117 | — | None |
| BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $39.2555 | — | 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 — elsewhere it depends on what is prescribed.
Texas — 5 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $35.0013 | $14,280.53408 units |
|
| SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $37.6598 | — | None |
| Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $37.2360 | $15,192.29408 units |
|
| HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $34.9663 | $14,266.25408 units |
|
| Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $37.0770 | $15,127.42408 units |
|
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 — elsewhere it depends on what is prescribed.
Kansas — 5 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $40.0996 | $16,360.64408 units |
|
| Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $40.1474 | $16,380.14408 units |
|
| HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.4858 | $14,886.21408 units |
|
| Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $40.1474 | $16,380.14408 units |
|
| SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $39.8117 | — | 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 — elsewhere it depends on what is prescribed.
California — 5 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.3200 | $14,818.56408 units |
|
| HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.3500 | $14,830.80408 units |
|
| SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $37.6598 | — | None |
| Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $37.3193 | $15,226.27408 units |
|
| Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $37.3193 | $15,226.27408 units |
|
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 — elsewhere it depends on what is prescribed.
Connecticut, Massachusetts, Rhode Island and Vermont — 4 plans, 1 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.5346 | — | None |
| SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $37.6598 | — | None |
| HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $34.6700 | $14,145.36408 units |
|
| Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $36.5346 | — | 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 — elsewhere it depends on what is prescribed.
Oklahoma — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Blue Cross MedicareRx Basic (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $39.9249 | $16,289.36408 units |
|
| HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.4808 | $14,884.17408 units |
|
| HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.4858 | $14,886.21408 units |
|
| Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $39.5095 | $16,119.88408 units |
|
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 — elsewhere it depends on what is prescribed.
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming — 4 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $37.6598 | — | None |
| HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $33.7700 | $13,778.16408 units |
|
| MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $39.1860 | $15,987.89408 units |
|
| HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $33.7700 | $13,778.16408 units |
|
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 — elsewhere it depends on what is prescribed.
New Mexico — 4 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.4858 | $14,886.21408 units |
|
| SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $39.8117 | — | None |
| Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $39.5036 | $16,117.47408 units |
|
| Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $39.9045 | $16,281.04408 units |
|
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 — elsewhere it depends on what is prescribed.
New York — 3 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$35.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $33.8300 | $13,802.64408 units |
|
| HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $33.8300 | $13,802.64408 units |
|
| SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $37.6598 | — | 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 — elsewhere it depends on what is prescribed.
Delaware, DC and Maryland — 3 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $35.7900 | $14,602.32408 units |
|
| HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $35.7900 | $14,602.32408 units |
|
| SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $37.6598 | — | 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 — elsewhere it depends on what is prescribed.
South Carolina — 3 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.4808 | $14,884.17408 units |
|
| SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $39.8117 | — | None |
| HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.4858 | $14,886.21408 units |
|
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 — elsewhere it depends on what is prescribed.
Georgia — 3 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.0900 | $14,724.72408 units |
|
| SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $37.6598 | — | None |
| HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.0500 | $14,708.40408 units |
|
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 — elsewhere it depends on what is prescribed.
Florida — 3 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $37.6598 | — | None |
| BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $41.1670 | $16,796.14408 units |
|
| BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $41.1670 | $16,796.14408 units |
|
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 — elsewhere it depends on what is prescribed.
Michigan — 3 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $35.6100 | $14,528.88408 units |
|
| HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $35.6100 | $14,528.88408 units |
|
| SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $37.6598 | — | 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 — elsewhere it depends on what is prescribed.
Ohio — 3 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $35.6600 | $14,549.28408 units |
|
| SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $37.6598 | — | None |
| HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $35.6000 | $14,524.80408 units |
|
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 — elsewhere it depends on what is prescribed.
Indiana and Kentucky — 3 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $37.6598 | — | None |
| HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $37.1300 | $15,149.04408 units |
|
| HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $37.1300 | $15,149.04408 units |
|
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 — elsewhere it depends on what is prescribed.
Wisconsin — 3 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $34.2567 | $13,976.73408 units |
|
| SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $37.6598 | — | None |
| HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $34.2567 | $13,976.73408 units |
|
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 — elsewhere it depends on what is prescribed.
Missouri — 3 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.4808 | $14,884.17408 units |
|
| HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.4858 | $14,886.21408 units |
|
| SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $39.8117 | — | 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 — elsewhere it depends on what is prescribed.
Mississippi — 3 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.4858 | $14,886.21408 units |
|
| HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.4808 | $14,884.17408 units |
|
| SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $39.8117 | — | 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 — elsewhere it depends on what is prescribed.
Louisiana — 3 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $37.6598 | — | None |
| HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.4858 | $14,886.21408 units |
|
| HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.4808 | $14,884.17408 units |
|
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 — elsewhere it depends on what is prescribed.
Colorado — 3 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.0500 | $14,708.40408 units |
|
| HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.0900 | $14,724.72408 units |
|
| SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $37.6598 | — | 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 — elsewhere it depends on what is prescribed.
Arizona — 3 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.0500 | $14,708.40408 units |
|
| HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.0900 | $14,724.72408 units |
|
| SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $37.6598 | — | 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 — elsewhere it depends on what is prescribed.
Nevada — 3 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.4808 | $14,884.17408 units |
|
| HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.4858 | $14,886.21408 units |
|
| SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $39.8117 | — | 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 — elsewhere it depends on what is prescribed.
Oregon and Washington — 3 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.0500 | $14,708.40408 units |
|
| HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.0900 | $14,724.72408 units |
|
| SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $37.6598 | — | 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 — elsewhere it depends on what is prescribed.
Idaho and Utah — 3 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $39.8117 | — | None |
| HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.4808 | $14,884.17408 units |
|
| HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.4858 | $14,886.21408 units |
|
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 — elsewhere it depends on what is prescribed.
Maine and New Hampshire — 2 plans, 1 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.4858 | $14,886.21408 units |
|
| SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $39.8117 | — | 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 — elsewhere it depends on what is prescribed.
Virginia — 2 plans, 1 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $37.6598 | — | None |
| HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.1100 | $14,732.88408 units |
|
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 — elsewhere it depends on what is prescribed.
Alaska — 2 plans, 1 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.4858 | $14,886.21408 units |
|
| SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $39.8117 | — | 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 — elsewhere it depends on what is prescribed.
Puerto Rico — 2 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.4808 | $14,884.17408 units |
|
| HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $36.4858 | $14,886.21408 units |
|
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 — elsewhere it depends on what is prescribed.
Hawaii — 1 plan
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $39.8117 | — | 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 — elsewhere it depends on what is prescribed.
No stand-alone Part D plan in American Samoa
None of the 1 stand-alone Part D plans in CMS PDP Region 35 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Guam
None of the 1 stand-alone Part D plans in CMS PDP Region 36 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Northern Mariana Islands
None of the 1 stand-alone Part D plans in CMS PDP Region 37 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in U.S. Virgin Islands
None of the 1 stand-alone Part D plans in CMS PDP Region 39 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.