LYTGOBI 4 mg Tablet

Also known as Futibatinib. Coverage in Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming (CMS PDP Region 25).

11 of 11 stand-alone Part D plans in Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming cover this drug on tier 5.

11 of 11 plans apply a prior authorization, step therapy or quantity limit.

241 Medicare Advantage plans in IA, MN, MT, NE, ND, SD, 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: 54 plans · MN: 69 plans · MT: 25 plans · NE: 44 plans · ND: 22 plans · SD: 19 plans · WY: 8 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	5Specialty Tier	25%	—	$231.2700	$3,469.0515 units	Prior authorization Quantity limit 14 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$239.7694	$28,772.33120 units	Prior authorization Quantity limit 112 per 28 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$276.5600	$33,187.20120 units	Prior authorization Quantity limit 112 per 28 days
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$276.5600	$33,187.20120 units	Prior authorization Quantity limit 112 per 28 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$231.2700	$3,469.0515 units	Prior authorization Quantity limit 14 per 28 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$242.1875	$29,062.50120 units	Prior authorization Quantity limit 112 per 28 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$219.6221	$2,635.4712 units	Prior authorization Quantity limit 12 per 30 days
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$234.2999	$28,115.99120 units	Prior authorization Quantity limit 112 per 28 days
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$231.2700	$3,469.0515 units	Prior authorization Quantity limit 14 per 28 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$219.6519	$2,635.8212 units	Prior authorization Quantity limit 12 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$239.7694	$28,772.33120 units	Prior authorization Quantity limit 112 per 28 days

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.

See coverage in all 39 regions →