UPTRAVI TITRATION PACK Kit

Also known as Selexipag. Coverage in Hawaii (CMS PDP Region 33).

6 of 8 stand-alone Part D plans in Hawaii cover this drug on tier 5.

6 of 6 plans apply a prior authorization, step therapy or quantity limit.

31 Medicare Advantage plans in HI 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. HI: 31 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)$0.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$182.3880	$364.782 units	Prior authorization Quantity limit 2 per 30 days
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$189.0593	$378.122 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$218.1100	$71.980.33 units	Prior authorization Quantity limit 2 per 180 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$218.1100	$71.980.33 units	Prior authorization Quantity limit 2 per 180 days
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$182.3880	$364.782 units	Prior authorization Quantity limit 2 per 30 days
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$182.3880	$364.782 units	Prior authorization Quantity limit 2 per 30 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 →