GOMEKLI 1 mg Capsule

Also known as Mirdametinib. Coverage in New Mexico (CMS PDP Region 26).

11 of 11 stand-alone Part D plans in New Mexico cover this drug on tier 5.

11 of 11 plans apply a prior authorization, step therapy or quantity limit.

67 Medicare Advantage plans in NM 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. NM: 67 plans.

Every plan that covers it

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%	—	$267.3100	$36,086.85135 units	Prior authorization Quantity limit 126 per 28 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$267.3100	$36,086.85135 units	Prior authorization Quantity limit 126 per 28 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$212.3045	$28,661.11135 units	Prior authorization Quantity limit 126 per 28 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$222.9101	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$231.7493	$31,286.16135 units	Prior authorization Quantity limit 126 per 28 days
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$222.9101	—	Prior authorization
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$222.9101	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$231.7493	$31,286.16135 units	Prior authorization Quantity limit 126 per 28 days
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$235.2745	$31,762.06135 units	Prior authorization Quantity limit 126 per 28 days
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$224.0025	$40,320.45180 units	Prior authorization Quantity limit 168 per 28 days
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$226.2086	$40,717.55180 units	Prior authorization Quantity limit 168 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.

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