VIVITROL Kit
Also known as Naltrexone. Coverage in Oklahoma (CMS PDP Region 23).
8 of 11 stand-alone Part D plans in Oklahoma cover this drug on tier 5.
3 of 8 plans apply a prior authorization, step therapy or quantity limit.
61 Medicare Advantage plans in OK 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. OK: 61 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 | 5Specialty Tier | 25% | — | $1710.2040 | $1,710.201 unit |
|
| Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $1710.2040 | $1,710.201 unit |
|
| HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $1761.3836 | — | None |
| AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $1843.0245 | — | None |
| Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $1710.2040 | $1,710.201 unit |
|
| AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible | 5Specialty Tier | 31% | — | $1843.0245 | — | None |
| HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $1761.0924 | — | None |
| Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $1761.6043 | — | None |
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.