DIHYDROERGOTAMINE MESYLATE NASAL 4 mg/mL Spray, Metered

Coverage in Michigan (CMS PDP Region 13).

12 of 12 stand-alone Part D plans in Michigan cover this drug on tier 4–5.

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

177 Medicare Advantage plans in MI 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. MI: 177 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)$14.10/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$55.0711	$936.2117 units	Quantity limit 16 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	4Non-Preferred Drug	32%	—	$55.2393	$939.0717 units	Quantity limit 16 per 28 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$100.3707	$903.349 units	Quantity limit 8 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$100.3018	$902.729 units	Quantity limit 8 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$61.4085	$552.689 units	Quantity limit 8 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$58.5072	$468.068 units	Prior authorization Quantity limit 8 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$58.5320	$468.268 units	Prior authorization Quantity limit 8 per 30 days
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$65.3612	$588.259 units	Quantity limit 8 per 28 days
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$88.5726	$708.588 units	Prior authorization Quantity limit 8 per 30 days
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$115.1110	$920.898 units	Prior authorization Quantity limit 24 per 90 days
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$58.4933	$467.958 units	Prior authorization Quantity limit 8 per 30 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$115.1110	$920.898 units	Prior authorization Quantity limit 24 per 90 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 →