DIHYDROERGOTAMINE MESYLATE NASAL 4 mg/mL Spray, Metered

Coverage in Louisiana (CMS PDP Region 21).

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

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

103 Medicare Advantage plans in LA 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. LA: 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)$37.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	—	$62.4358	$1,061.4117 units	Quantity limit 16 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$63.9433	$1,087.0417 units	Quantity limit 16 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$69.1239	$552.998 units	Prior authorization Quantity limit 8 per 30 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$90.0614	$810.559 units	Quantity limit 8 per 28 days
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$90.0614	$810.559 units	Quantity limit 8 per 28 days
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$69.8295	$558.648 units	Prior authorization Quantity limit 8 per 30 days
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$88.7004	$709.608 units	Prior authorization Quantity limit 8 per 30 days
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$120.2438	$1,082.199 units	Quantity limit 8 per 28 days
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$130.9966	$1,178.979 units	Quantity limit 8 per 28 days
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$68.7270	$549.828 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 →