FULPHILA 6 mg/.6mL Injection (Pegfilgrastim-Jmdb) — Medicare Part D coverage and cost

Region	Plans covering	Tiers	Lowest 30-day cost	Restrictions
Connecticut, Massachusetts, Rhode Island and Vermont	4 of 11	5	—	4 of 4 plans
Michigan	4 of 12	5	—	4 of 4 plans
Arkansas	4 of 12	5	—	4 of 4 plans
California	4 of 12	5	—	4 of 4 plans
New Jersey	3 of 12	5	—	3 of 3 plans
North Carolina	3 of 12	5	—	3 of 3 plans
Illinois	3 of 12	5	—	3 of 3 plans
Texas	3 of 12	5	—	3 of 3 plans
Oklahoma	3 of 11	5	—	3 of 3 plans
Kansas	3 of 12	5	—	3 of 3 plans
Maine and New Hampshire	2 of 9	5	—	2 of 2 plans
New York	2 of 10	5	—	2 of 2 plans
Delaware, DC and Maryland	2 of 10	5	—	2 of 2 plans
Pennsylvania and West Virginia	2 of 12	5	—	2 of 2 plans
Virginia	2 of 9	5	—	2 of 2 plans
South Carolina	2 of 11	5	—	2 of 2 plans
Georgia	2 of 10	5	—	2 of 2 plans
Florida	2 of 10	5	—	2 of 2 plans
Alabama and Tennessee	2 of 12	5	—	2 of 2 plans
Ohio	2 of 10	5	—	2 of 2 plans
Indiana and Kentucky	2 of 10	5	—	2 of 2 plans
Wisconsin	2 of 10	5	—	2 of 2 plans
Missouri	2 of 10	5	—	2 of 2 plans
Mississippi	2 of 10	5	—	2 of 2 plans
Louisiana	2 of 10	5	—	2 of 2 plans
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming	2 of 11	5	—	2 of 2 plans
New Mexico	2 of 11	5	—	2 of 2 plans
Colorado	2 of 10	5	—	2 of 2 plans
Arizona	2 of 10	5	—	2 of 2 plans
Nevada	2 of 10	5	—	2 of 2 plans
Oregon and Washington	2 of 10	5	—	2 of 2 plans
Idaho and Utah	2 of 10	5	—	2 of 2 plans
Hawaii	2 of 8	5	—	2 of 2 plans
Alaska	2 of 9	5	—	2 of 2 plans
American Samoa	no PDP	—	—	—
Guam	no PDP	—	—	—
Northern Mariana Islands	no PDP	—	—	—
Puerto Rico	no PDP	—	—	—
U.S. Virgin Islands	no PDP	—	—	—

Connecticut, Massachusetts, Rhode Island and Vermont — 4 plans, 4 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%	—	$3071.9800	—	Prior authorization
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3327.5642	$3,327.561 unit	Prior authorization Quantity limit 1.2 per 28 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3071.9800	—	Prior authorization
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$3327.5642	$3,327.561 unit	Prior authorization Quantity limit 1.2 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 — 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%	—	$3058.6659	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3058.6659	—	Prior authorization
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3327.3104	—	Prior authorization
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$3327.3104	—	Prior authorization

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%	—	$3256.5100	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3256.5100	—	Prior authorization
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3377.5750	$3,377.571 unit	Prior authorization Quantity limit 1.2 per 28 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$3377.5750	$3,377.571 unit	Prior authorization Quantity limit 1.2 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 — 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
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3224.6853	—	Prior authorization
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3224.6853	—	Prior authorization
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3332.3636	—	Prior authorization
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$3332.3636	—	Prior authorization

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 — 3 plans, 3 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%	—	$3107.4079	—	Prior authorization
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3107.4079	—	Prior authorization
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	5Specialty Tier	30%	—	$3078.2090	—	Prior authorization

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 — 3 plans, 3 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%	—	$3100.3408	—	Prior authorization
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3100.3408	—	Prior authorization
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$2519.7300	—	Prior authorization

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 — 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%	—	$3138.8545	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3138.8545	—	Prior authorization
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1829.2041	—	Prior authorization

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 — 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%	—	$3141.8514	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3141.8514	—	Prior authorization
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$2811.1608	—	Prior authorization

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 — 3 plans, 3 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%	—	$3076.7274	—	Prior authorization
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3076.7274	—	Prior authorization
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$1861.1590	—	Prior authorization

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
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3325.3530	—	Prior authorization
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3325.3530	—	Prior authorization
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$1269.1900	—	Prior authorization

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 — 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%	—	$3135.4400	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3135.4400	—	Prior authorization

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 York — 2 plans, 2 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3183.3426	—	Prior authorization
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3183.3426	—	Prior authorization

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 — 2 plans, 2 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%	—	$3141.9619	—	Prior authorization
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3141.9619	—	Prior authorization

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 — 2 plans, 2 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%	—	$3091.2797	—	Prior authorization
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3091.2797	—	Prior authorization

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 — 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%	—	$3034.4000	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3034.4000	—	Prior authorization

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 — 2 plans, 2 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%	—	$3289.3114	—	Prior authorization
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3289.3114	—	Prior authorization

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 — 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%	—	$3093.6900	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3093.6900	—	Prior authorization

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%	—	$3149.1118	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3149.1118	—	Prior authorization

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 — 2 plans, 2 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%	—	$3106.8540	—	Prior authorization
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3106.8540	—	Prior authorization

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 — 2 plans, 2 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%	—	$3325.3530	—	Prior authorization
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3325.3530	—	Prior authorization

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 — 2 plans, 2 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%	—	$3082.5567	—	Prior authorization
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3082.5567	—	Prior authorization

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 — 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%	—	$3127.8756	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3127.8756	—	Prior authorization

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 — 2 plans, 2 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%	—	$3109.9233	—	Prior authorization
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3109.9233	—	Prior authorization

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 — 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%	—	$3325.3530	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3325.3530	—	Prior authorization

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 — 2 plans, 2 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%	—	$3092.3716	—	Prior authorization
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3092.3716	—	Prior authorization

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 — 2 plans, 2 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%	—	$3239.8129	—	Prior authorization
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3239.8129	—	Prior authorization

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 — 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%	—	$3325.3530	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3325.3530	—	Prior authorization

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 — 2 plans, 2 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%	—	$3089.5150	—	Prior authorization
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3089.5150	—	Prior authorization

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 — 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%	—	$3325.3530	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3325.3530	—	Prior authorization

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 — 2 plans, 2 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%	—	$3325.3530	—	Prior authorization
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3325.3530	—	Prior authorization

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 — 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%	—	$3157.3550	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3157.3550	—	Prior authorization

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 — 2 plans, 2 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%	—	$3218.9360	—	Prior authorization
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3218.9360	—	Prior authorization

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%	—	$3093.6900	—	Prior authorization
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$3093.6900	—	Prior authorization

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 — 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%	—	$4119.9000	—	Prior authorization
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$4119.9000	—	Prior authorization

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.

FULPHILA 6 mg/.6mL Injection

Coverage by region

Plan-by-plan detail

No stand-alone Part D plan in American Samoa

No stand-alone Part D plan in Guam

No stand-alone Part D plan in Northern Mariana Islands

No stand-alone Part D plan in Puerto Rico

No stand-alone Part D plan in U.S. Virgin Islands