SIVEXTRO 200 mg/4mL Injection, Powder, Lyophilized, For Solution
Also known as Tedizolid Phosphate. Coverage in Wisconsin (CMS PDP Region 16).
3 of 10 stand-alone Part D plans in Wisconsin cover this drug on tier 5.
2 of 3 plans apply a prior authorization, step therapy or quantity limit.
13 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: 13 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% | — | $374.2869 | $2,245.726 units |
|
| SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $408.5075 | — | None |
| HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $374.2364 | $2,245.426 units |
|
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.