DALBAVANCIN 500 mg/25mL Injection, Powder, Lyophilized, For Solution
Coverage in Pennsylvania and West Virginia (CMS PDP Region 06).
2 of 12 stand-alone Part D plans in Pennsylvania and West Virginia cover this drug on tier 5.
No plan applies a prior authorization, step therapy or quantity limit.
42 Medicare Advantage plans in PA 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. PA: 42 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible | 5Specialty Tier | 25% | — | $962.7617 | — | None |
| Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible | 5Specialty Tier | 25% | 25% | $976.0625 | — | None |
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.