Medicare Advantage Drug Cost for Orkambi
There are 74 Medicare Advantage Plans with additional prescription drug coverage for Orkambi available to residents in Ohio. The average retail unit cost (e.g. per pill) for a 30-day supply at in-area retail pharmacies is $414.27 ($12,428.16). Orkambi is typically listed as a Tier 5 drug on the formulary and does not require prior authorization.
Below is the average retail cost and your co-pay for Orkambi in Ohio. You can also see if each plan requires prior authorization, step therapy or has drug quantity limits. Please check the formulary for different brand and generic drug names. Every Medicare Advantage Plan will vary in coverage, co-pays, costs and premiums. This chart can help you sort through different plan details to find a Medicare Advantage Plan in Cuyahoga with the best coverage and the cheapest prices for your medications in Ohio.
| Proprietary Name: | Orkambi |
|---|---|
| Generic Name: | Lumacaftor And Ivacaftor |
| Drug Package: | 56 Packet In 1 Carton > 1 Granule In 1 Packet |
| Drug Strength: | 125; 100mg/1; mg/1 |
| Substance: | Ivacaftor; Lumacaftor |
| Dosage Form: | Granule |
| Route: | Oral |
| Labeler: | Vertex Pharmaceuticals Incorporated |
| Pen Name: | Human Prescription Drug |
| NDC# | 51167090001 |
| RX# | 2053512 |
| Days Supply: | 30 |
| Coverage Phase: | Initial Coverage |
| Plan Year: | 2023 |
| County: | Cuyahoga |
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Medicare Advantage Coverage for Orkambi in Ohio
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| Plan Name ⇅ |
Tier Level |
Your Cost Preferred |
Cost Non Preferred |
Cost |
Limit Amt/ Days |
Prior Auth Y/N |
Step Therapy Y/N |
Avg Unit Cost (x30) |
|---|---|---|---|---|---|---|---|---|
| AARP Medicare Advantage Choice |
5 | NA | 33% | 33% | / | Y | N | $418.15 ($12,544.44) |
| AARP Medicare Advantage Flex Plan 8 |
5 | NA | 33% | 33% | / | Y | N | $419.57 ($12,587.22) |
| AARP Medicare Advantage Plan 1 |
5 | NA | 33% | 33% | / | Y | N | $419.57 ($12,587.22) |
| AARP Medicare Advantage Plan 3 |
5 | NA | 33% | 33% | / | Y | N | $419.57 ($12,587.22) |
| AARP Medicare Advantage Plan 7 |
5 | NA | 33% | 33% | / | Y | N | $419.57 ($12,587.22) |
| Aetna Medicare Advantra Silver |
5 | 33% | 33% | 33% | / | Y | N | $432.89 ($12,986.60) |
| Aetna Medicare Premier |
5 | 33% | 33% | 33% | / | Y | N | $432.89 ($12,986.60) |
| Aetna Medicare Premier 1 |
5 | 33% | 33% | 33% | / | Y | N | $432.89 ($12,986.60) |
| Aetna Medicare Premier 2 |
5 | 33% | 33% | 33% | / | Y | N | $432.89 ($12,986.60) |
| Aetna Medicare Premier Plus 1 |
5 | 33% | 33% | 33% | / | Y | N | $432.89 ($12,986.60) |
| Aetna Medicare Premier Plus 2 |
5 | 25% | 25% | 25% | / | Y | N | $432.89 ($12,986.60) |
| Aetna Medicare Value Plan |
5 | 33% | 33% | 33% | / | Y | N | $432.89 ($12,986.60) |
| Aetna Medicare Value Plan |
5 | 33% | 33% | 33% | / | Y | N | $432.89 ($12,986.60) |
| Cigna Preferred Medicare |
5 | 33% | 33% | 33% | / | Y | N | $415.83 ($12,475.00) |
| Cigna True Choice Medicare |
5 | 33% | 33% | 33% | / | Y | N | $415.83 ($12,475.00) |
| Devoted CORE Ohio |
5 | NA | 33% | NA | / | Y | N | $420.74 ($12,622.07) |
| Devoted GIVEBACK Ohio |
5 | NA | 27% | NA | / | Y | N | $420.74 ($12,622.07) |
| Devoted PRIME Ohio |
5 | NA | 33% | NA | / | Y | N | $420.74 ($12,622.07) |
| Humana Cleveland Clinic Preferred |
5 | NA | 33% | 33% | / | Y | N | $406.47 ($12,194.01) |
| Humana Gold Plus H6622-019 |
5 | NA | 31% | 31% | / | Y | N | $406.47 ($12,194.01) |
| Humana Gold Plus H6622-022 |
5 | NA | 33% | 33% | / | Y | N | $406.47 ($12,194.01) |
| Humana Value Plus H5525-041 |
5 | NA | 29% | 29% | / | Y | N | $406.47 ($12,194.01) |
| HumanaChoice H5216-024 |
5 | NA | 31% | 31% | / | Y | N | $406.47 ($12,194.01) |
| HumanaChoice H5216-106 |
5 | NA | 33% | 33% | / | Y | N | $406.47 ($12,194.01) |
| HumanaChoice H5216-285 |
5 | NA | 29% | 29% | / | Y | N | $406.47 ($12,194.01) |
| HumanaChoice H5525-030 |
5 | NA | 31% | 31% | / | Y | N | $406.47 ($12,194.01) |
| HumanaChoice H5525-042 |
5 | NA | 29% | 29% | / | Y | N | $406.47 ($12,194.01) |
| HumanaChoice R5495-002 |
5 | NA | 25% | 25% | / | Y | N | $406.47 ($12,194.01) |
| MedMutual Advantage Access |
5 | 33% | 33% | 33% | / | Y | N | $392.59 ($11,777.79) |
| MedMutual Advantage Choice |
5 | 32% | 32% | 32% | / | Y | N | $392.59 ($11,777.79) |
| MedMutual Advantage Classic |
5 | 31% | 31% | 31% | / | Y | N | $392.59 ($11,777.79) |
| MedMutual Advantage Plus |
5 | 32% | 32% | 32% | / | Y | N | $392.59 ($11,777.79) |
| MedMutual Advantage Preferred |
5 | 32% | 32% | 32% | / | Y | N | $392.59 ($11,777.79) |
| MedMutual Advantage Premium |
5 | 32% | 32% | 32% | / | Y | N | $392.59 ($11,777.79) |
| MedMutual Advantage Secure |
5 | 31% | 31% | 31% | / | Y | N | $392.59 ($11,777.79) |
| MedMutual Advantage Select |
5 | 31% | 31% | 31% | / | Y | N | $392.59 ($11,777.79) |
| MedMutual Advantage Signature |
5 | 33% | 33% | 33% | / | Y | N | $392.59 ($11,777.79) |
| Molina Medicare Choice Care |
5 | NA | 31% | NA | / | Y | N | $415.82 ($12,474.48) |
| SummaCare Medicare Emerald |
5 | NA | 33% | NA | / | Y | N | $395.31 ($11,859.31) |
| SummaCare Medicare Garnet |
5 | NA | 33% | NA | / | Y | N | $395.31 ($11,859.31) |
| SummaCare Medicare Ruby |
5 | NA | 33% | NA | / | Y | N | $395.31 ($11,859.31) |
| SummaCare Medicare Sapphire |
5 | NA | 33% | NA | / | Y | N | $395.31 ($11,859.31) |
| SummaCare Medicare Topaz |
5 | NA | 33% | NA | / | Y | N | $395.31 ($11,859.31) |
| The Health Plan SecureCare - Option II |
5 | 31% | 31% | 31% | / | Y | N | $392.65 ($11,779.53) |
| The Health Plan SecureChoice - Option II |
5 | 31% | 31% | 31% | / | Y | N | $392.65 ($11,779.53) |
| Wellcare Assist |
5 | 25% | 25% | 25% | / | Y | N | $433.54 ($13,006.34) |
| Wellcare Assist Complement |
5 | 25% | 25% | 25% | / | Y | N | $433.54 ($13,006.34) |
| Wellcare Dividend Giveback |
5 | 25% | 25% | 25% | / | Y | N | $438.77 ($13,163.07) |
| Wellcare Giveback |
5 | 25% | 25% | 25% | / | Y | N | $437.61 ($13,128.23) |
| Wellcare Giveback Boost |
5 | 30% | 30% | 30% | / | Y | N | $437.61 ($13,128.23) |
| Wellcare No Premium |
5 | 31% | 31% | 31% | / | Y | N | $437.61 ($13,128.23) |
| Wellcare No Premium Essential |
5 | 33% | 33% | 33% | / | Y | N | $438.77 ($13,163.07) |
| Wellcare No Premium Medicare |
5 | 31% | 31% | 31% | / | Y | N | $437.61 ($13,128.23) |
| Wellcare No Premium Open |
5 | 30% | 30% | 30% | / | Y | N | $437.61 ($13,128.23) |
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SNP Prescription Drug Cost for Orkambi
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| Plan Name ⇅ |
Tier Level |
Cost Preferred |
Cost Non Preferred |
Cost Amt |
Limit Days/ Amt |
Prior Auth Y/N |
Step Therapy Y/N |
Avg Unit Cost (x30) |
|---|---|---|---|---|---|---|---|---|
| Aetna Medicare Assure 1 |
5 | NA | $0 | NA | / | Y | N | $432.89 ($12,986.60) |
| CareSource Dual Advantage |
5 | NA | 25% | NA | / | Y | N | $391.70 ($11,750.88) |
| CommuniCare Advantage CSNP |
5 | NA | 25% | NA | / | Y | N | $400.89 ($12,026.73) |
| CommuniCare Advantage ISNP |
1 | NA | 25% | NA | / | Y | N | $400.89 ($12,026.73) |
| Humana Gold Plus - Diabetes and Heart |
5 | NA | 29% | 29% | / | Y | N | $406.47 ($12,194.01) |
| Humana Gold Plus SNP-DE H6622-015 |
5 | NA | $0 | NA | / | Y | N | $406.47 ($12,194.01) |
| Molina Medicare Complete Care |
5 | NA | 25% | NA | / | Y | N | $415.82 ($12,474.48) |
| Perennial Advantage Concierge |
5 | NA | 25% | NA | / | Y | N | $438.96 ($13,168.94) |
| Perennial Advantage Strive |
1 | NA | 25% | NA | / | Y | N | $438.82 ($13,164.61) |
| The Health Plan SecureCare SNP |
1 | NA | 15% | NA | / | Y | N | $392.66 ($11,779.94) |
| UnitedHealthcare Assisted Living Plan |
5 | NA | 33% | 33% | / | Y | N | $419.57 ($12,587.22) |
| UnitedHealthcare Dual Complete LP |
5 | NA | 15% | NA | / | Y | N | $419.57 ($12,587.22) |
| UnitedHealthcare Nursing Home Plan 1 |
5 | NA | 25% | NA | / | Y | N | $419.57 ($12,587.22) |
| UnitedHealthcare Nursing Home Plan 2 |
5 | NA | 25% | NA | / | Y | N | $419.57 ($12,587.22) |
| Valor Health Plan |
1 | NA | 25% | NA | / | Y | N | $400.89 ($12,026.73) |
| Wellcare Dual Access |
1 | NA | $0 | NA | / | Y | N | $433.54 ($13,006.34) |
| Wellcare Dual Access Extra |
1 | NA | $0 | NA | / | Y | N | $433.54 ($13,006.34) |
Do any Medicare Advantage Plans Cover Orkambi? Yes, 74 Medicare Advantage Plans cover this drug in Ohio.
How much does Orkambi Cost? $414.27, the average retail cost in Ohio is $414.27 per unit or $12,428.16 for a 30-day supply at in-area pharmacies.
What Tier is Orkambi? Tier 5, most Advantage Plans list Orkambi on Tier 5 on their formulary. Usually, the higher the tier, the more you have to pay for the medication.
Do I need Prior Authorization for Orkambi? Yes, the majority of Medicare Prescription Plans do require prior authorization from your doctor for Orkambi.
Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible. Some plans offer select Pre-deductible drug Coverage
2.Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit.
3.Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $7550 in 2022.
4.Catastrophic: Anything over $7550 you will receive a significant increase in coverage.
Formulary Definitions:
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Cost Preferred: Your Cost for the Drug at the Providers In Network Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non Preferred: Your Cost for the Prescription Drug at a Non-Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization in order to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Avg Unit Cost: Average unit cost (e.g. per pill) for specified days supply at in-area retail pharmacies. A pharmacy is considered in-area when it is geographically located in the service area.
What if a drug I need is not listed?
Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plans formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.
Last updated on
Source:CMS Formulary Data Q4 2022
Source:NDC Directory by FDA.gov
**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.