XERMELO 250 mg Tablet

Also known as Telotristat Ethyl. Coverage in Kansas (CMS PDP Region 24).

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

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

77 Medicare Advantage plans in KS 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. KS: 77 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$135.0800	$1,215.729 units	Prior authorization Quantity limit 9 per 30 days
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$134.7560	$1,212.809 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$122.1123	$10,990.1190 units	Prior authorization Quantity limit 84 per 28 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$173.4100	$15,606.9090 units	Prior authorization Quantity limit 84 per 28 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$173.4100	$15,606.9090 units	Prior authorization Quantity limit 84 per 28 days
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$135.8318	$12,224.8690 units	Prior authorization Quantity limit 84 per 28 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$135.8318	$12,224.8690 units	Prior authorization Quantity limit 84 per 28 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$134.7560	$1,212.809 units	Prior authorization Quantity limit 9 per 30 days
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$147.3920	$13,265.2890 units	Prior authorization Quantity limit 84 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$136.3878	$12,274.9090 units	Prior authorization Quantity limit 84 per 28 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$135.8318	$12,224.8690 units	Prior authorization Quantity limit 84 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$136.3878	$12,274.9090 units	Prior authorization Quantity limit 84 per 28 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 →