SAJAZIR 30 mg/3mL Injection
Also known as Icatibant. Coverage in Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming (CMS PDP Region 25).
7 of 11 stand-alone Part D plans in Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming cover this drug on tier 5.
7 of 7 plans apply a prior authorization, step therapy or quantity limit.
Every plan that covers it
Showing 7 of 7 plans
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$4.70/mo premium · $615.00 deductible · $0 with full Extra Help | 5Specialty Tier | 25% | — | $1238.6380 | $22,295.4818 units |
|
| Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $1238.6380 | $22,295.4818 units |
|
| SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible · $0 with full Extra Help | 5Specialty Tier | 25% | — | $2476.2047 | $66,857.5327 units |
|
| HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $1725.3586 | $31,056.4518 units |
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| MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $613.6940 | $11,046.4918 units |
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| Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $1238.6380 | $22,295.4818 units |
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| HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $1717.6868 | $30,918.3618 units |
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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.
Medicare Advantage plans
Medicare Advantage plans carry their own formularies, separate from stand-alone Part D, and are sold county by county. Pick a county to see every Medicare Advantage drug plan there that covers this drug.
144 Medicare Advantage plans in IA, MN, MT, ND, NE, SD, WY do cover it
A patient on an MA-PD plan may have coverage even where no PDP lists the drug. IA: 30 plans · MN: 42 plans · MT: 20 plans · ND: 10 plans · NE: 27 plans · SD: 13 plans · WY: 2 plans.