DALFAMPRIDINE 10 mg Tablet, Film Coated, Extended Release

Coverage in Texas (CMS PDP Region 22).

9 of 12 stand-alone Part D plans in Texas cover this drug on tier 3.

9 of 9 plans apply a prior authorization, step therapy or quantity limit.

325 Medicare Advantage plans in TX 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. TX: 325 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	3Preferred Brand	25%	25%	$5.0789	$30.476 units	Prior authorization Quantity limit 6 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$5.0789	$30.476 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$18.9296	$113.586 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$89.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.7813	$4.696 units	Quantity limit 6 per 30 days
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$5.2737	—	Prior authorization
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$1.9494	—	Prior authorization
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$18.7943	$112.776 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.7813	$4.696 units	Quantity limit 6 per 30 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$2.0274	—	Prior authorization

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 →