DIHYDROERGOTAMINE MESYLATE NASAL 4 mg/mL Spray, Metered

Coverage in Indiana and Kentucky (CMS PDP Region 15).

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

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

219 Medicare Advantage plans in IN, KY 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. IN: 116 plans · KY: 103 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)$90.30/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	—	$79.5675	$1,352.6517 units	Quantity limit 16 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	4Non-Preferred Drug	34%	—	$84.0100	$1,428.1717 units	Quantity limit 16 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$62.6245	$501.008 units	Prior authorization Quantity limit 8 per 30 days
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$94.5706	$851.149 units	Quantity limit 8 per 28 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$96.1600	$865.449 units	Quantity limit 8 per 28 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$63.6577	$509.268 units	Prior authorization Quantity limit 8 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$86.8248	$694.608 units	Prior authorization Quantity limit 8 per 30 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$139.9079	$1,259.179 units	Quantity limit 8 per 28 days
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$135.1553	$1,216.409 units	Quantity limit 8 per 28 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$62.0433	$496.358 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 →