ROFLUMILAST 250 ug Tablet

Coverage in Wisconsin (CMS PDP Region 16).

10 of 10 stand-alone Part D plans in Wisconsin cover this drug on tier 3–4.

Lowest 30-day cost $45.00 at a preferred pharmacy. 9 of 10 plans apply a prior authorization, step therapy or quantity limit.

88 Medicare Advantage plans in WI 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. WI: 88 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$4.7538	$9.512 units	Quantity limit 28 per 365 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$4.8093	$9.622 units	Quantity limit 28 per 365 days
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$4.7226	$9.452 units	Quantity limit 28 per 365 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$5.5999	$16.803 units	Quantity limit 3 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$5.5999	$16.803 units	Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$1.8507	$5.553 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$3.4171	$102.5130 units	Prior authorization Quantity limit 28 per 28 days
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$2.5218	—	None
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$3.5444	$10.633 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$3.4171	$102.5130 units	Prior authorization Quantity limit 28 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 →