TALICIA 10/250/12.5 mg Capsule, Delayed Release
Also known as Omeprazole Magnesium, Amoxicillin And Rifabutin. Coverage in Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming (CMS PDP Region 25).
5 of 11 stand-alone Part D plans in Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming cover this drug on tier 4.
2 of 5 plans apply a prior authorization, step therapy or quantity limit.
35 Medicare Advantage plans in IA, MN, MT, NE, WY 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. IA: 8 plans · MN: 5 plans · MT: 14 plans · NE: 6 plans · WY: 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)$4.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 34% | — | $4.9143 | — | None |
| Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible | 4Non-Preferred Drug | 34% | — | $4.9143 | — | None |
| HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $5.0700 | $141.9628 units |
|
| Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $4.9143 | — | None |
| HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $5.0740 | $142.0728 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.