VIVITROL Kit
Also known as Naltrexone. Coverage in Wisconsin (CMS PDP Region 16).
8 of 10 stand-alone Part D plans in Wisconsin cover this drug on tier 5.
3 of 8 plans apply a prior authorization, step therapy or quantity limit.
77 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: 77 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $1656.6990 | — | None |
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $1693.5043 | $1,693.501 unit |
|
| Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $1693.5043 | $1,693.501 unit |
|
| AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $1829.4413 | — | None |
| SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $1763.8340 | — | None |
| HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $1656.2499 | — | None |
| Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $1693.5043 | $1,693.501 unit |
|
| AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible | 5Specialty Tier | 31% | — | $1829.4413 | — | 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.