OXERVATE 20 ug/mL Solution/ Drops
Also known as Cenegermin-Bkbj. Package: 7 VIAL, MULTI-DOSE in 1 CARTON (71981-020-07) / 1 mL in 1 VIAL, MULTI-DOSE. NDC 71981002007.
- Plans covering it
- 128
- across 39 regions checked
- Lowest tier
- 5
- lower tiers cost less
- Plans with restrictions
- 128
- prior auth, step therapy or quantity limit
Coverage by region
Covered by at least one plan in 35 of 39 CMS regions; no plan covers it in 4.
| Region | Plans covering | Tiers | Lowest 30-day cost | Restrictions |
|---|---|---|---|---|
| New York | 4 of 10 | 5 | — | 4 of 4 plans |
| New Jersey | 4 of 12 | 5 | — | 4 of 4 plans |
| Delaware, DC and Maryland | 4 of 10 | 5 | — | 4 of 4 plans |
| Pennsylvania and West Virginia | 4 of 12 | 5 | — | 4 of 4 plans |
| North Carolina | 4 of 12 | 5 | — | 4 of 4 plans |
| South Carolina | 4 of 11 | 5 | — | 4 of 4 plans |
| Georgia | 4 of 10 | 5 | — | 4 of 4 plans |
| Alabama and Tennessee | 4 of 12 | 5 | — | 4 of 4 plans |
| Michigan | 4 of 12 | 5 | — | 4 of 4 plans |
| Ohio | 4 of 10 | 5 | — | 4 of 4 plans |
| Indiana and Kentucky | 4 of 10 | 5 | — | 4 of 4 plans |
| Wisconsin | 4 of 10 | 5 | — | 4 of 4 plans |
| Illinois | 4 of 12 | 5 | — | 4 of 4 plans |
| Missouri | 4 of 10 | 5 | — | 4 of 4 plans |
| Arkansas | 4 of 12 | 5 | — | 4 of 4 plans |
| Mississippi | 4 of 10 | 5 | — | 4 of 4 plans |
| Louisiana | 4 of 10 | 5 | — | 4 of 4 plans |
| Texas | 4 of 12 | 5 | — | 4 of 4 plans |
| Oklahoma | 4 of 11 | 5 | — | 4 of 4 plans |
| Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming | 4 of 11 | 5 | — | 4 of 4 plans |
| Colorado | 4 of 10 | 5 | — | 4 of 4 plans |
| Arizona | 4 of 10 | 5 | — | 4 of 4 plans |
| Nevada | 4 of 10 | 5 | — | 4 of 4 plans |
| Oregon and Washington | 4 of 10 | 5 | — | 4 of 4 plans |
| Idaho and Utah | 4 of 10 | 5 | — | 4 of 4 plans |
| California | 4 of 12 | 5 | — | 4 of 4 plans |
| Maine and New Hampshire | 3 of 9 | 5 | — | 3 of 3 plans |
| Connecticut, Massachusetts, Rhode Island and Vermont | 3 of 11 | 5 | — | 3 of 3 plans |
| Virginia | 3 of 9 | 5 | — | 3 of 3 plans |
| Kansas | 3 of 12 | 5 | — | 3 of 3 plans |
| New Mexico | 3 of 11 | 5 | — | 3 of 3 plans |
| Alaska | 3 of 9 | 5 | — | 3 of 3 plans |
| Florida | 2 of 10 | 5 | — | 2 of 2 plans |
| Hawaii | 2 of 8 | 5 | — | 2 of 2 plans |
| Puerto Rico | 2 of 3 | 5 | — | 2 of 2 plans |
| American Samoa | no PDP | — | — | — |
| Guam | no PDP | — | — | — |
| Northern Mariana Islands | no PDP | — | — | — |
| U.S. Virgin Islands | no PDP | — | — | — |
Plan-by-plan detail
Open a region to see every plan that covers this drug, with tier, cost-sharing and restrictions.
New York — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$35.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
| Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.1036 | $122,406.2260 units |
|
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 — elsewhere it depends on what is prescribed.
New Jersey — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.1036 | $122,406.2260 units |
|
| HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
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 — elsewhere it depends on what is prescribed.
Delaware, DC and Maryland — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
| HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.1036 | $122,406.2260 units |
|
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 — elsewhere it depends on what is prescribed.
Pennsylvania and West Virginia — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.1036 | $122,406.2260 units |
|
| HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
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 — elsewhere it depends on what is prescribed.
North Carolina — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.1036 | $122,406.2260 units |
|
| HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
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 — elsewhere it depends on what is prescribed.
South Carolina — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$4.80/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.1036 | $122,406.2260 units |
|
| HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
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 — elsewhere it depends on what is prescribed.
Georgia — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.1036 | $122,406.2260 units |
|
| HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
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 — elsewhere it depends on what is prescribed.
Alabama and Tennessee — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.1036 | $122,406.2260 units |
|
| HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
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 — elsewhere it depends on what is prescribed.
Michigan — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
| HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.1036 | $122,406.2260 units |
|
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 — elsewhere it depends on what is prescribed.
Ohio — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.1036 | $122,406.2260 units |
|
| HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
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 — elsewhere it depends on what is prescribed.
Indiana and Kentucky — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.1036 | $122,406.2260 units |
|
| HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
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 — elsewhere it depends on what is prescribed.
Wisconsin — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
| HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.1036 | $122,406.2260 units |
|
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 — elsewhere it depends on what is prescribed.
Illinois — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.1036 | $122,406.2260 units |
|
| HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
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 — elsewhere it depends on what is prescribed.
Missouri — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.1036 | $122,406.2260 units |
|
| HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
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 — elsewhere it depends on what is prescribed.
Arkansas — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
| HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.1036 | $122,406.2260 units |
|
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 — elsewhere it depends on what is prescribed.
Mississippi — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
| HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.1036 | $122,406.2260 units |
|
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 — elsewhere it depends on what is prescribed.
Louisiana — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
| HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.1036 | $122,406.2260 units |
|
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 — elsewhere it depends on what is prescribed.
Texas — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.1036 | $122,406.2260 units |
|
| HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
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 — elsewhere it depends on what is prescribed.
Oklahoma — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.1036 | $122,406.2260 units |
|
| HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
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 — elsewhere it depends on what is prescribed.
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.1036 | $122,406.2260 units |
|
| HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
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 — elsewhere it depends on what is prescribed.
Colorado — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
| HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.1036 | $122,406.2260 units |
|
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 — elsewhere it depends on what is prescribed.
Arizona — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
| HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.1036 | $122,406.2260 units |
|
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 — elsewhere it depends on what is prescribed.
Nevada — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.1036 | $122,406.2260 units |
|
| HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
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 — elsewhere it depends on what is prescribed.
Oregon and Washington — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
| HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.1036 | $122,406.2260 units |
|
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 — elsewhere it depends on what is prescribed.
Idaho and Utah — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.1036 | $122,406.2260 units |
|
| HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
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 — elsewhere it depends on what is prescribed.
California — 4 plans, 4 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
| Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.1036 | $122,406.2260 units |
|
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 — elsewhere it depends on what is prescribed.
Maine and New Hampshire — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
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 — elsewhere it depends on what is prescribed.
Connecticut, Massachusetts, Rhode Island and Vermont — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
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 — elsewhere it depends on what is prescribed.
Virginia — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
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 — elsewhere it depends on what is prescribed.
Kansas — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
| Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
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 — elsewhere it depends on what is prescribed.
New Mexico — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
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 — elsewhere it depends on what is prescribed.
Alaska — 3 plans, 3 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
| Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
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 — elsewhere it depends on what is prescribed.
Florida — 2 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
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 — elsewhere it depends on what is prescribed.
Hawaii — 2 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
| Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2569.0400 | — |
|
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 — elsewhere it depends on what is prescribed.
Puerto Rico — 2 plans, 2 with restrictions
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.1036 | $122,406.2260 units |
|
| HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $2040.3792 | $122,422.7560 units |
|
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 — elsewhere it depends on what is prescribed.
No stand-alone Part D plan in American Samoa
None of the 1 stand-alone Part D plans in CMS PDP Region 35 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Guam
None of the 1 stand-alone Part D plans in CMS PDP Region 36 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in Northern Mariana Islands
None of the 1 stand-alone Part D plans in CMS PDP Region 37 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.
No stand-alone Part D plan in U.S. Virgin Islands
None of the 1 stand-alone Part D plans in CMS PDP Region 39 list this drug on their formulary. The patient would pay the full retail price, or you would need a formulary exception. It is on a Part D formulary elsewhere in the country.