MODEYSO 125 mg Capsule

Also known as Dordaviprone. Coverage in Illinois (CMS PDP Region 17).

12 of 12 stand-alone Part D plans in Illinois cover this drug on tier 5.

12 of 12 plans apply a prior authorization, step therapy or quantity limit.

137 Medicare Advantage plans in IL 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. IL: 137 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	5Specialty Tier	25%	—	$3840.0100	$7,680.022 units	Prior authorization Quantity limit 2 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3840.0100	$7,680.022 units	Prior authorization Quantity limit 2 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3211.2667	$6,422.532 units	Prior authorization Quantity limit 2 per 28 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$3211.2667	$6,422.532 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3329.2802	$6,658.562 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3049.3980	$6,098.802 units	Prior authorization Quantity limit 2 per 28 days
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3185.2497	$6,370.502 units	Prior authorization Quantity limit 2 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3328.7253	$6,657.452 units	Prior authorization Quantity limit 2 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$3329.2802	$6,658.562 units	Prior authorization Quantity limit 2 per 28 days
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3049.8097	$6,099.622 units	Prior authorization Quantity limit 2 per 28 days
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$3211.2667	$6,422.532 units	Prior authorization Quantity limit 2 per 28 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3151.4029	$6,302.812 units	Prior authorization Quantity limit 2 per 28 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 →