TRAMADOL HYDROCHLORIDE AND ACETAMINOPHEN 37.5/325 mg Tablet
Package: 100 TABLET in 1 BOTTLE (53746-617-01). NDC 53746061701.
- Plans covering it
- 156
- across 39 regions checked
- Lowest tier
- 2
- lower tiers cost less
- Plans with restrictions
- 155
- 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 | 6 of 12 | 2–4 | $2.00 | 6 of 6 plans |
| Pennsylvania and West Virginia | 6 of 12 | 2 | $2.00 | 6 of 6 plans |
| North Carolina | 6 of 12 | 2–4 | $2.00 | 6 of 6 plans |
| Alabama and Tennessee | 6 of 12 | 2–4 | $2.00 | 6 of 6 plans |
| Michigan | 6 of 12 | 2–4 | $3.00 | 6 of 6 plans |
| Illinois | 6 of 12 | 2–4 | $1.00 | 6 of 6 plans |
| Texas | 6 of 12 | 2–4 | $1.00 | 6 of 6 plans |
| Kansas | 6 of 12 | 2–4 | $0.00 | 6 of 6 plans |
| California | 6 of 12 | 2–4 | $3.00 | 6 of 6 plans |
| South Carolina | 5 of 11 | 2–4 | $2.00 | 4 of 5 plans |
| Arkansas | 5 of 12 | 2–4 | $3.00 | 5 of 5 plans |
| Oklahoma | 5 of 11 | 2–4 | $1.00 | 5 of 5 plans |
| Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming | 5 of 11 | 2–4 | $2.00 | 5 of 5 plans |
| New Mexico | 5 of 11 | 2–4 | $3.00 | 5 of 5 plans |
| Connecticut, Massachusetts, Rhode Island and Vermont | 4 of 11 | 2 | $2.00 | 4 of 4 plans |
| New York | 4 of 10 | 2–4 | $3.00 | 4 of 4 plans |
| Delaware, DC and Maryland | 4 of 10 | 2–4 | $2.00 | 4 of 4 plans |
| Georgia | 4 of 10 | 2–4 | $2.00 | 4 of 4 plans |
| Florida | 4 of 10 | 2–4 | $3.00 | 4 of 4 plans |
| Ohio | 4 of 10 | 2–4 | $2.00 | 4 of 4 plans |
| Indiana and Kentucky | 4 of 10 | 2 | $2.00 | 4 of 4 plans |
| Wisconsin | 4 of 10 | 2 | $3.00 | 4 of 4 plans |
| Missouri | 4 of 10 | 2–4 | $2.00 | 4 of 4 plans |
| Mississippi | 4 of 10 | 2–4 | $2.00 | 4 of 4 plans |
| Louisiana | 4 of 10 | 2 | $2.00 | 4 of 4 plans |
| Colorado | 4 of 10 | 2–4 | $2.00 | 4 of 4 plans |
| Arizona | 4 of 10 | 2–4 | $3.00 | 4 of 4 plans |
| Nevada | 4 of 10 | 2–4 | $2.00 | 4 of 4 plans |
| Oregon and Washington | 4 of 10 | 2–4 | $3.00 | 4 of 4 plans |
| Idaho and Utah | 4 of 10 | 2 | $2.00 | 4 of 4 plans |
| Maine and New Hampshire | 3 of 9 | 2–4 | $3.00 | 3 of 3 plans |
| Virginia | 3 of 9 | 2–4 | $2.00 | 3 of 3 plans |
| Alaska | 3 of 9 | 2–4 | $3.00 | 3 of 3 plans |
| Hawaii | 2 of 8 | 2 | $3.00 | 2 of 2 plans |
| Puerto Rico | 2 of 3 | 2 | $2.00 | 2 of 2 plans |
| 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 — 6 plans, 6 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.0825 | $1.9824 units |
|
| HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible | 2Generic | $5.00 | $3.00 | $0.1200 | $2.8824 units |
|
| HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible | 2Generic | $2.00 | $2.00 | $0.2198 | $5.2824 units |
|
| Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible | 2Generic | $6.00 | $9.00 | $0.2331 | $5.5924 units |
|
| Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 45% | 45% | $0.2331 | $5.5924 units |
|
| SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $0.3528 | $8.4724 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 — 6 plans, 6 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.0912 | $2.1924 units |
|
| SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible | 2Generic | $10.00 | $30.00 | $0.1298 | $3.1224 units |
|
| HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible | 2Generic | $5.00 | $3.00 | $0.1375 | $3.3024 units |
|
| HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible | 2Generic | $2.00 | $2.00 | $0.2407 | $5.7824 units |
|
| Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible | 2Generic | $5.00 | $12.50 | $0.1410 | $50.76360 units |
|
| Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible | 2Generic | 25% | 25% | $0.1410 | $50.76360 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 — 6 plans, 6 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.1022 | $2.4524 units |
|
| HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible | 2Generic | $5.00 | $3.00 | $0.1530 | $3.6724 units |
|
| HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible | 2Generic | $2.00 | $2.00 | $0.2543 | $6.1024 units |
|
| Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible | 2Generic | $6.00 | $18.00 | $0.2865 | $6.8824 units |
|
| Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible | 4Non-Preferred Drug | 32% | 32% | $0.2865 | $6.8824 units |
|
| SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $0.3539 | $8.4924 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 — 6 plans, 6 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.1076 | $2.5824 units |
|
| HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible | 2Generic | $5.00 | $3.00 | $0.1613 | $3.8724 units |
|
| HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible | 2Generic | $2.00 | $2.00 | $0.2453 | $5.8924 units |
|
| BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible | 3Preferred Brand | $47.00 | $94.00 | $0.2927 | $7.0224 units |
|
| BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible | 4Non-Preferred Drug | 41% | 41% | $0.2927 | $7.0224 units |
|
| SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $0.3387 | $8.1324 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 — 6 plans, 6 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.0881 | $2.1124 units |
|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 2Generic | 10% | 10% | $0.2152 | $5.1624 units |
|
| HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible | 2Generic | $5.00 | $3.00 | $0.1384 | $3.3224 units |
|
| Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible | 2Generic | $5.00 | $15.00 | $0.1351 | $48.64360 units |
|
| Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible | 2Generic | $5.00 | $10.00 | $0.1351 | $48.64360 units |
|
| SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $0.3565 | $8.5624 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 — 6 plans, 6 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.0705 | $1.6924 units |
|
| HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible | 2Generic | $5.00 | $3.00 | $0.1276 | $3.0624 units |
|
| HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible | 2Generic | $2.00 | $2.00 | $0.2499 | $6.0024 units |
|
| Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible | 2Generic | $1.00 | $3.00 | $0.2412 | $5.7924 units |
|
| Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 43% | 43% | $0.2321 | $5.5724 units |
|
| SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $0.4075 | $9.7824 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.
Texas — 6 plans, 6 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.0928 | $2.2324 units |
|
| HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible | 2Generic | $5.00 | $3.00 | $0.1478 | $3.5524 units |
|
| HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible | 2Generic | $2.00 | $2.00 | $0.2358 | $5.6624 units |
|
| Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible | 2Generic | $1.00 | $3.00 | $0.3055 | $7.3324 units |
|
| SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $0.3971 | $9.5324 units |
|
| Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 42% | 42% | $0.2503 | $6.0124 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 — 6 plans, 6 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible | 2Generic | 10% | 10% | $0.2405 | $5.7724 units |
|
| Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.0966 | $2.3224 units |
|
| Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible | 2Generic | $0.00 | $0.00 | $0.3004 | $7.2124 units |
|
| Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible | 3Preferred Brand | 20% | 20% | $0.2876 | $6.9024 units |
|
| Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 40% | 40% | $0.3004 | $7.2124 units |
|
| SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $0.3791 | $9.1024 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.
California — 6 plans, 6 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 | 2Generic | 10% | 10% | $0.2277 | $5.4624 units |
|
| Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.0815 | $1.9624 units |
|
| HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible | 2Generic | $5.00 | $3.00 | $0.1155 | $2.7724 units |
|
| Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible | 2Generic | $7.00 | $14.00 | $0.5059 | $56.66112 units |
|
| Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible | 3Preferred Brand | 19% | 19% | $0.5059 | $56.66112 units |
|
| SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $0.3518 | $8.4424 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.
South Carolina — 5 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$4.80/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.0949 | $2.2824 units |
|
| HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible | 2Generic | $5.00 | $3.00 | $0.1498 | $3.6024 units |
|
| BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible | 2Generic | $17.00 | $42.50 | $0.1433 | — | None |
| HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible | 2Generic | $2.00 | $2.00 | $0.2539 | $6.0924 units |
|
| SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $0.3955 | $9.4924 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, 5 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.1330 | $3.1924 units |
|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 2Generic | 10% | 10% | $0.2815 | $6.7624 units |
|
| HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible | 2Generic | $5.00 | $3.00 | $0.1937 | $4.6524 units |
|
| BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible | 2Generic | $5.00 | $15.00 | $0.2554 | $6.1324 units |
|
| SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $0.3870 | $9.2924 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.
Oklahoma — 5 plans, 5 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.1246 | $2.9924 units |
|
| HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible | 2Generic | $5.00 | $3.00 | $0.1782 | $4.2824 units |
|
| HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible | 2Generic | $2.00 | $2.00 | $0.2727 | $6.5424 units |
|
| Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible | 2Generic | $1.00 | $3.00 | $0.3487 | $8.3724 units |
|
| Blue Cross MedicareRx Basic (PDP)$0.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 40% | 40% | $0.2850 | $6.8424 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 — 5 plans, 5 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.1131 | $2.7124 units |
|
| SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible | 2Generic | $10.00 | $30.00 | $0.1351 | $3.2424 units |
|
| HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible | 2Generic | $5.00 | $3.00 | $0.1591 | $3.8224 units |
|
| HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible | 2Generic | $2.00 | $2.00 | $0.2333 | $5.6024 units |
|
| MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 42% | 42% | $0.3038 | $7.2924 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 — 5 plans, 5 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.1513 | $3.6324 units |
|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 2Generic | 10% | 10% | $0.3301 | $7.9224 units |
|
| Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible | 3Preferred Brand | 14% | 14% | $0.3685 | $8.8424 units |
|
| SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $0.4222 | $10.1324 units |
|
| Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible | 4Non-Preferred Drug | 40% | 40% | $0.3131 | $7.5124 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, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.0747 | $1.7924 units |
|
| SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible | 2Generic | $10.00 | $30.00 | $0.1365 | $3.2824 units |
|
| HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible | 2Generic | $2.00 | $2.00 | $0.2321 | $5.5724 units |
|
| Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible | 2Generic | $7.00 | $14.00 | $0.2296 | $5.5124 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 — 4 plans, 4 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 | 2Generic | 10% | 10% | $0.2077 | $4.9824 units |
|
| Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.0892 | $2.1424 units |
|
| HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible | 2Generic | $5.00 | $3.00 | $0.1233 | $2.9624 units |
|
| SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $0.3519 | $8.4524 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.
Delaware, DC and Maryland — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.0714 | $1.7124 units |
|
| HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible | 2Generic | $2.00 | $2.00 | $0.2214 | $5.3124 units |
|
| HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible | 2Generic | $5.00 | $3.00 | $0.1190 | $2.8624 units |
|
| SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $0.4003 | $9.6124 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 — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.1026 | $2.4624 units |
|
| HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible | 2Generic | $5.00 | $3.00 | $0.1513 | $3.6324 units |
|
| HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible | 2Generic | $2.00 | $2.00 | $0.2342 | $5.6224 units |
|
| SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $0.3297 | $7.9124 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 — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.0762 | $1.8324 units |
|
| BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $0.2339 | $5.6124 units |
|
| SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $0.3558 | $8.5424 units |
|
| BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 40% | 40% | $0.2339 | $5.6124 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.
Ohio — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.0897 | $2.1524 units |
|
| HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible | 2Generic | $5.00 | $3.00 | $0.1437 | $3.4524 units |
|
| HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible | 2Generic | $2.00 | $2.00 | $0.2485 | $5.9624 units |
|
| SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $0.3907 | $9.3824 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 — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.0905 | $2.1724 units |
|
| SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible | 2Generic | $10.00 | $30.00 | $0.1372 | $3.2924 units |
|
| HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible | 2Generic | $5.00 | $3.00 | $0.1441 | $3.4624 units |
|
| HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible | 2Generic | $2.00 | $2.00 | $0.2502 | $6.0024 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 — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.0990 | $2.3824 units |
|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 2Generic | 10% | 10% | $0.2575 | $6.1824 units |
|
| SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible | 2Generic | $10.00 | $30.00 | $0.1371 | $3.2924 units |
|
| HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible | 2Generic | $5.00 | $3.00 | $0.1598 | $3.8424 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 — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.1132 | $2.7224 units |
|
| HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible | 2Generic | $5.00 | $3.00 | $0.1652 | $3.9624 units |
|
| HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible | 2Generic | $2.00 | $2.00 | $0.2701 | $6.4824 units |
|
| SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $0.4117 | $9.8824 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.
Mississippi — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.1322 | $3.1724 units |
|
| HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible | 2Generic | $2.00 | $2.00 | $0.2481 | $5.9524 units |
|
| HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible | 2Generic | $5.00 | $3.00 | $0.1737 | $4.1724 units |
|
| SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $0.3209 | $7.7024 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.
Louisiana — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.1161 | $2.7924 units |
|
| SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible | 2Generic | $10.00 | $30.00 | $0.1290 | $3.1024 units |
|
| HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible | 2Generic | $2.00 | $2.00 | $0.2575 | $6.1824 units |
|
| HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible | 2Generic | $5.00 | $3.00 | $0.1671 | $4.0124 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 — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.0893 | $2.1424 units |
|
| HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible | 2Generic | $2.00 | $2.00 | $0.2637 | $6.3324 units |
|
| HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible | 2Generic | $5.00 | $3.00 | $0.1617 | $3.8824 units |
|
| SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $0.3979 | $9.5524 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.
Arizona — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.0735 | $1.7624 units |
|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 2Generic | 10% | 10% | $0.2707 | $6.5024 units |
|
| HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible | 2Generic | $5.00 | $3.00 | $0.1471 | $3.5324 units |
|
| SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $0.4628 | $11.1124 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.
Nevada — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.0729 | $1.7524 units |
|
| HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible | 2Generic | $5.00 | $3.00 | $0.1372 | $3.2924 units |
|
| HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible | 2Generic | $2.00 | $2.00 | $0.2650 | $6.3624 units |
|
| SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $0.4526 | $10.8624 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.
Oregon and Washington — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.0789 | $1.8924 units |
|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 2Generic | 10% | 10% | $0.2345 | $5.6324 units |
|
| HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible | 2Generic | $5.00 | $3.00 | $0.1330 | $3.1924 units |
|
| SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $0.3410 | $8.1824 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.
Idaho and Utah — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.0956 | $2.2924 units |
|
| SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible | 2Generic | $10.00 | $30.00 | $0.1336 | $3.2124 units |
|
| HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible | 2Generic | $5.00 | $3.00 | $0.1521 | $3.6524 units |
|
| HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible | 2Generic | $2.00 | $2.00 | $0.2377 | $5.7024 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 — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.1079 | $2.5924 units |
|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 2Generic | 10% | 10% | $0.2424 | $5.8224 units |
|
| SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $0.4863 | $11.6724 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.
Virginia — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.0922 | $2.2124 units |
|
| HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible | 2Generic | $2.00 | $2.00 | $0.2484 | $5.9624 units |
|
| SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $0.4133 | $9.9224 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 — 3 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 | 2Generic | 10% | 10% | $0.2350 | $5.6424 units |
|
| Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.1010 | $2.4224 units |
|
| SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $0.3314 | $7.9524 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 — 2 plans, 2 with restrictions
| 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 | 2Generic | $10.00 | $30.00 | $0.1304 | $3.1324 units |
|
| Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.0783 | $1.8824 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.
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 | 2Generic | $5.00 | $3.00 | $0.1441 | $3.4624 units |
|
| HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible | 2Generic | $2.00 | $2.00 | $0.2045 | $4.9124 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.
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.