DABIGATRAN ETEXILATE 110 mg Capsule
Coverage in Wisconsin (CMS PDP Region 16).
8 of 10 stand-alone Part D plans in Wisconsin cover this drug on tier 4.
8 of 8 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 |
|---|---|---|---|---|---|---|
| Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 26% | 26% | $1.6068 | $9.646 units |
|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 40% | 40% | $1.6068 | $9.646 units |
|
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 32% | — | $2.8710 | $17.236 units |
|
| Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible | 4Non-Preferred Drug | 35% | — | $2.8710 | $17.236 units |
|
| AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | — | $2.2891 | $13.736 units |
|
| SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 35% | 35% | $2.5590 | $30.7112 units |
|
| Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $2.8710 | $17.236 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible | 4Non-Preferred Drug | 36% | — | $2.3350 | $14.016 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.