DIHYDROERGOTAMINE MESYLATE NASAL 4 mg/mL Spray, Metered

Coverage in Colorado (CMS PDP Region 27).

10 of 10 stand-alone Part D plans in Colorado cover this drug on tier 4–5.

10 of 10 plans apply a prior authorization, step therapy or quantity limit.

96 Medicare Advantage plans in CO 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. CO: 96 plans.

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)$125.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$61.3905	$1,043.6417 units	Quantity limit 16 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	4Non-Preferred Drug	37%	—	$65.4002	$1,111.8017 units	Quantity limit 16 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$96.7194	$870.479 units	Quantity limit 8 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$74.4779	$595.828 units	Prior authorization Quantity limit 8 per 30 days
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$99.2729	$893.469 units	Quantity limit 8 per 28 days
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$74.4779	$595.828 units	Prior authorization Quantity limit 8 per 30 days
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$129.8335	$1,168.509 units	Quantity limit 8 per 28 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$160.4729	$1,444.269 units	Quantity limit 8 per 28 days
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$88.7004	$709.608 units	Prior authorization Quantity limit 8 per 30 days
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$74.4779	$595.828 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.

See coverage in all 39 regions →