PEDIARIX 25/10/25/25/8/10/40/8/32 [iU]/.5mL/ug/.5mL Injection, Suspension
Also known as Diphtheria And Tetanus Toxoids And Acellular Pertussis Adsorbed, Hepatitis B (Recombinant) And Inactivated Poliovirus Vaccine Combined. Coverage in Wisconsin (CMS PDP Region 16).
10 of 10 stand-alone Part D plans in Wisconsin cover this drug on tier 1–3.
Lowest 30-day cost $0.00 at a preferred pharmacy. 2 of 10 plans apply a prior authorization, step therapy or quantity limit.
88 Medicare Advantage plans in WI 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. WI: 88 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)$0.00/mo premium · $615.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $202.0248 | — | None |
| Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $202.0248 | — | None |
| SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible | 1Preferred Generic | $2.00 | $6.00 | $207.0152 | — | None |
| Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible | 1Preferred Generic | $0.00 | $0.00 | $202.0248 | — | None |
| Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $193.6686 | — | None |
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $193.6686 | — | None |
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $193.7190 | — | None |
| AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $221.6125 | $3,324.1915 units |
|
| HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $193.7190 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible | 3Preferred Brand | 15% | 15% | $221.6125 | $3,324.1915 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.