SIVEXTRO 200 mg Tablet, Film Coated
Also known as Tedizolid Phosphate. Package: 30 TABLET, FILM COATED in 1 BOTTLE (67919-041-04). NDC 67919004104.
- Plans covering it
- 103
- across 39 regions checked
- Lowest tier
- 5
- lower tiers cost less
- Plans with restrictions
- 70
- prior auth, step therapy or quantity limit
Medicare Advantage plans in your county
Medicare Advantage drug plans in 49 states list this drug on their own formularies. Enter a ZIP code or choose a state to see every plan in a county, with its tier, cost-sharing and restrictions.
Coverage by region
Covered by at least one plan in 35 of 39 CMS regions; no plan covers it in 4.
| Region | Plans covering | Tiers | Lowest 30-day cost | Restrictions |
|---|---|---|---|---|
| New Jersey | 4 of 12 | 5 | — | 3 of 4 plans |
| North Carolina | 4 of 12 | 5 | — | 3 of 4 plans |
| Alabama and Tennessee | 4 of 12 | 5 | — | 3 of 4 plans |
| Illinois | 4 of 12 | 5 | — | 3 of 4 plans |
| Texas | 4 of 12 | 5 | — | 3 of 4 plans |
| Kansas | 4 of 12 | 5 | — | 3 of 4 plans |
| New York | 3 of 10 | 5 | — | 2 of 3 plans |
| Delaware, DC and Maryland | 3 of 10 | 5 | — | 2 of 3 plans |
| Pennsylvania and West Virginia | 3 of 12 | 5 | — | 2 of 3 plans |
| South Carolina | 3 of 11 | 5 | — | 2 of 3 plans |
| Georgia | 3 of 10 | 5 | — | 2 of 3 plans |
| Michigan | 3 of 12 | 5 | — | 2 of 3 plans |
| Ohio | 3 of 10 | 5 | — | 2 of 3 plans |
| Indiana and Kentucky | 3 of 10 | 5 | — | 2 of 3 plans |
| Wisconsin | 3 of 10 | 5 | — | 2 of 3 plans |
| Missouri | 3 of 10 | 5 | — | 2 of 3 plans |
| Arkansas | 3 of 12 | 5 | — | 2 of 3 plans |
| Mississippi | 3 of 10 | 5 | — | 2 of 3 plans |
| Louisiana | 3 of 10 | 5 | — | 2 of 3 plans |
| Oklahoma | 3 of 11 | 5 | — | 3 of 3 plans |
| Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming | 3 of 11 | 5 | — | 2 of 3 plans |
| New Mexico | 3 of 11 | 5 | — | 2 of 3 plans |
| Colorado | 3 of 10 | 5 | — | 2 of 3 plans |
| Arizona | 3 of 10 | 5 | — | 2 of 3 plans |
| Nevada | 3 of 10 | 5 | — | 2 of 3 plans |
| Oregon and Washington | 3 of 10 | 5 | — | 2 of 3 plans |
| Idaho and Utah | 3 of 10 | 5 | — | 2 of 3 plans |
| California | 3 of 12 | 5 | — | 2 of 3 plans |
| Maine and New Hampshire | 2 of 9 | 5 | — | 1 of 2 plans |
| Connecticut, Massachusetts, Rhode Island and Vermont | 2 of 11 | 5 | — | 1 of 2 plans |
| Virginia | 2 of 9 | 5 | — | 1 of 2 plans |
| Florida | 2 of 10 | 5 | — | 1 of 2 plans |
| Alaska | 2 of 9 | 5 | — | 1 of 2 plans |
| Puerto Rico | 2 of 3 | 5 | — | 2 of 2 plans |
| Hawaii | 1 of 8 | 5 | — | none |
| American Samoa | no PDP | — | — | — |
| Guam | no PDP | — | — | — |
| Northern Mariana Islands | no PDP | — | — | — |
| U.S. Virgin Islands | no PDP | — | — | — |
Plan-by-plan detail
Open a region to see every plan that covers this drug, with tier, cost-sharing and restrictions.
New Jersey — 4 plans, 3 with restrictions
Showing 4 of 4 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $441.2075 | $2,647.246 units |
|
| SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $485.1038 | — | None |
| HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $441.1971 | $2,647.186 units |
|
| Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible | 5Specialty Tier | 30% | — | $483.5840 | — |
|
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 — elsewhere it depends on what is prescribed.
North Carolina — 4 plans, 3 with restrictions
Showing 4 of 4 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $462.5811 | $2,775.496 units |
|
| SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $485.1038 | — | None |
| HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $462.5045 | $2,775.036 units |
|
| Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $483.5304 | — |
|
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 — elsewhere it depends on what is prescribed.
Alabama and Tennessee — 4 plans, 3 with restrictions
Showing 4 of 4 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $468.4130 | $2,810.486 units |
|
| HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $468.1946 | $2,809.176 units |
|
| SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $485.1038 | — | None |
| BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible | 5Specialty Tier | 31% | 31% | $495.9967 | — |
|
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 — elsewhere it depends on what is prescribed.
Illinois — 4 plans, 3 with restrictions
Showing 4 of 4 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $457.0814 | $2,742.496 units |
|
| SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $485.1038 | — | None |
| HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $457.5592 | $2,745.366 units |
|
| Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $468.1239 | — |
|
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 — elsewhere it depends on what is prescribed.
Texas — 4 plans, 3 with restrictions
Showing 4 of 4 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $460.7267 | $2,764.366 units |
|
| SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $485.1038 | — | None |
| HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $460.2172 | $2,761.306 units |
|
| Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $465.8583 | — |
|
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 — elsewhere it depends on what is prescribed.
Kansas — 4 plans, 3 with restrictions
Showing 4 of 4 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help | 5Specialty Tier | 25% | — | $509.3350 | — |
|
| HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible · $0 with full Extra Help | 5Specialty Tier | 25% | — | $482.9800 | $2,897.886 units |
|
| Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $509.3350 | — |
|
| SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $485.1038 | — | 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 — elsewhere it depends on what is prescribed.
New York — 3 plans, 2 with restrictions
Showing 3 of 3 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$35.70/mo premium · $615.00 deductible · $0 with full Extra Help | 5Specialty Tier | 25% | — | $445.7739 | $2,674.646 units |
|
| HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $446.1497 | $2,676.906 units |
|
| SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $485.1038 | — | 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 — elsewhere it depends on what is prescribed.
Delaware, DC and Maryland — 3 plans, 2 with restrictions
Showing 3 of 3 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $432.3311 | $2,593.996 units |
|
| HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $432.3311 | $2,593.996 units |
|
| SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $485.1038 | — | 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 — elsewhere it depends on what is prescribed.
Pennsylvania and West Virginia — 3 plans, 2 with restrictions
Showing 3 of 3 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible · $0 with full Extra Help | 5Specialty Tier | 25% | — | $485.1038 | — | None |
| HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $439.0963 | $2,634.586 units |
|
| HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $439.1338 | $2,634.806 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 — elsewhere it depends on what is prescribed.
South Carolina — 3 plans, 2 with restrictions
Showing 3 of 3 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $464.0600 | $2,784.366 units |
|
| SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $485.1038 | — | None |
| HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $463.6683 | $2,782.016 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 — elsewhere it depends on what is prescribed.
Georgia — 3 plans, 2 with restrictions
Showing 3 of 3 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $459.7959 | $2,758.786 units |
|
| SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $485.1038 | — | None |
| HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $461.4809 | $2,768.896 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 — elsewhere it depends on what is prescribed.
Michigan — 3 plans, 2 with restrictions
Showing 3 of 3 plans
| 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 · $0 with full Extra Help | 5Specialty Tier | 25% | — | $439.5060 | $2,637.046 units |
|
| HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $440.7140 | $2,644.286 units |
|
| SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $485.1038 | — | 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 — elsewhere it depends on what is prescribed.
Ohio — 3 plans, 2 with restrictions
Showing 3 of 3 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $456.3945 | $2,738.376 units |
|
| SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $485.1038 | — | None |
| HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $456.2352 | $2,737.416 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 — elsewhere it depends on what is prescribed.
Indiana and Kentucky — 3 plans, 2 with restrictions
Showing 3 of 3 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible · $0 with full Extra Help | 5Specialty Tier | 25% | — | $485.1038 | — | None |
| HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $437.3040 | $2,623.826 units |
|
| HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $437.3035 | $2,623.826 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 — elsewhere it depends on what is prescribed.
Wisconsin — 3 plans, 2 with restrictions
Showing 3 of 3 plans
| 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 · $0 with full Extra Help | 5Specialty Tier | 25% | — | $446.4202 | $2,678.526 units |
|
| SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $485.1038 | — | None |
| HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $446.5181 | $2,679.116 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 — elsewhere it depends on what is prescribed.
Missouri — 3 plans, 2 with restrictions
Showing 3 of 3 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $455.6716 | $2,734.036 units |
|
| HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $455.6682 | $2,734.016 units |
|
| SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $485.1038 | — | 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 — elsewhere it depends on what is prescribed.
Arkansas — 3 plans, 2 with restrictions
Showing 3 of 3 plans
| 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 · $0 with full Extra Help | 5Specialty Tier | 25% | — | $482.9800 | $2,897.886 units |
|
| HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $474.7000 | $2,848.206 units |
|
| SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $485.1038 | — | 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 — elsewhere it depends on what is prescribed.
Mississippi — 3 plans, 2 with restrictions
Showing 3 of 3 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $469.8606 | $2,819.166 units |
|
| HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $469.7971 | $2,818.786 units |
|
| SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $485.1038 | — | 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 — elsewhere it depends on what is prescribed.
Louisiana — 3 plans, 2 with restrictions
Showing 3 of 3 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $485.1038 | — | None |
| HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $461.9446 | $2,771.676 units |
|
| HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $462.1238 | $2,772.746 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 — elsewhere it depends on what is prescribed.
Oklahoma — 3 plans, 3 with restrictions
Showing 3 of 3 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $438.3691 | $2,630.216 units |
|
| HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $438.3549 | $2,630.136 units |
|
| Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $444.2776 | — |
|
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 — elsewhere it depends on what is prescribed.
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming — 3 plans, 2 with restrictions
Showing 3 of 3 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible · $0 with full Extra Help | 5Specialty Tier | 25% | — | $485.1038 | — | None |
| HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $461.3559 | $2,768.146 units |
|
| HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $461.0875 | $2,766.526 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 — elsewhere it depends on what is prescribed.
New Mexico — 3 plans, 2 with restrictions
Showing 3 of 3 plans
| 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 · $0 with full Extra Help | 5Specialty Tier | 25% | — | $464.2300 | $2,785.386 units |
|
| SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $485.1038 | — | None |
| Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $486.8305 | — |
|
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 — elsewhere it depends on what is prescribed.
Colorado — 3 plans, 2 with restrictions
Showing 3 of 3 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $439.0341 | $2,634.206 units |
|
| HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $439.0911 | $2,634.556 units |
|
| SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $485.1038 | — | 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 — elsewhere it depends on what is prescribed.
Arizona — 3 plans, 2 with restrictions
Showing 3 of 3 plans
| 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 · $0 with full Extra Help | 5Specialty Tier | 25% | — | $478.1300 | $2,868.786 units |
|
| HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $478.1300 | $2,868.786 units |
|
| SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $485.1038 | — | 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 — elsewhere it depends on what is prescribed.
Nevada — 3 plans, 2 with restrictions
Showing 3 of 3 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $478.1300 | $2,868.786 units |
|
| HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $478.1300 | $2,868.786 units |
|
| SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $485.1038 | — | 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 — elsewhere it depends on what is prescribed.
Oregon and Washington — 3 plans, 2 with restrictions
Showing 3 of 3 plans
| 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 · $0 with full Extra Help | 5Specialty Tier | 25% | — | $469.2752 | $2,815.656 units |
|
| HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $469.6305 | $2,817.786 units |
|
| SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $507.2884 | — | 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 — elsewhere it depends on what is prescribed.
Idaho and Utah — 3 plans, 2 with restrictions
Showing 3 of 3 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible · $0 with full Extra Help | 5Specialty Tier | 25% | — | $512.8231 | — | None |
| HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $469.7971 | $2,818.786 units |
|
| HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $469.8606 | $2,819.166 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 — elsewhere it depends on what is prescribed.
California — 3 plans, 2 with restrictions
Showing 3 of 3 plans
| 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 · $0 with full Extra Help | 5Specialty Tier | 25% | — | $456.6908 | $2,740.146 units |
|
| HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $457.0099 | $2,742.066 units |
|
| SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $485.1038 | — | 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 — elsewhere it depends on what is prescribed.
Maine and New Hampshire — 2 plans, 1 with restrictions
Showing 2 of 2 plans
| 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 · $0 with full Extra Help | 5Specialty Tier | 25% | — | $469.8606 | $2,819.166 units |
|
| SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $485.1038 | — | 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 — elsewhere it depends on what is prescribed.
Connecticut, Massachusetts, Rhode Island and Vermont — 2 plans, 1 with restrictions
Showing 2 of 2 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible · $0 with full Extra Help | 5Specialty Tier | 25% | — | $485.1038 | — | None |
| HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $451.3259 | $2,707.966 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 — elsewhere it depends on what is prescribed.
Virginia — 2 plans, 1 with restrictions
Showing 2 of 2 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $485.1038 | — | None |
| HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $456.9483 | $2,741.696 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 — elsewhere it depends on what is prescribed.
Florida — 2 plans, 1 with restrictions
Showing 2 of 2 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $485.1038 | — | None |
| BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $489.5891 | — |
|
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 — elsewhere it depends on what is prescribed.
Alaska — 2 plans, 1 with restrictions
Showing 2 of 2 plans
| 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 · $0 with full Extra Help | 5Specialty Tier | 25% | — | $469.8606 | $2,819.166 units |
|
| SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $512.8231 | — | 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 — elsewhere it depends on what is prescribed.
Puerto Rico — 2 plans, 2 with restrictions
Showing 2 of 2 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $469.7971 | $2,818.786 units |
|
| HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $469.8606 | $2,819.166 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 — elsewhere it depends on what is prescribed.
Hawaii — 1 plan
Showing 1 of 1 plan
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible · $0 with full Extra Help | 5Specialty Tier | 25% | — | $512.8231 | — | 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 — elsewhere it depends on what is prescribed.
No stand-alone Part D plan in American Samoa
None of the 1 stand-alone Part D plans in CMS PDP Region 35 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Guam
None of the 1 stand-alone Part D plans in CMS PDP Region 36 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Northern Mariana Islands
None of the 1 stand-alone Part D plans in CMS PDP Region 37 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in U.S. Virgin Islands
None of the 1 stand-alone Part D plans in CMS PDP Region 39 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.