DIHYDROERGOTAMINE MESYLATE NASAL 4 mg/mL Spray, Metered

Coverage in Alaska (CMS PDP Region 34).

9 of 9 stand-alone Part D plans in Alaska cover this drug on tier 4–5.

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

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$97.5728	$1,658.7417 units	Quantity limit 16 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$98.2009	$1,669.4217 units	Quantity limit 16 per 28 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$105.0754	$945.689 units	Quantity limit 8 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$60.2432	$542.199 units	Quantity limit 8 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$55.5857	$444.698 units	Prior authorization Quantity limit 8 per 30 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$55.7143	$445.718 units	Prior authorization Quantity limit 8 per 30 days
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$105.0128	$945.129 units	Quantity limit 8 per 28 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$256.6927	$2,053.548 units	Prior authorization Quantity limit 8 per 30 days
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$55.5133	$444.118 units	Prior authorization Quantity limit 8 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.

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