Medicare Part D coverage · 20 · RxCUI 2557391
20 ML pegcetacoplan 54 MG/ML Injection [Empaveli]
Per the CMS 2026 Part D formulary file, 20 ML pegcetacoplan 54 MG/ML Injection [Empaveli] is covered by 141 Medicare Part D plans (2.8% of enrollable products), averaging Tier 4.4, with prior authorization required on 100% of covering formularies.
- 2.8%
- Plan coverage
- 141
- Plans covering
- T4.4
- Avg tier
- 100%
- Prior auth required
What the CMS Formulary Data Shows for 20 ML pegcetacoplan 54 MG/ML Injection [Empaveli]
Per the CMS 2026 Part D formulary file, 20 ML pegcetacoplan 54 MG/ML Injection [Empaveli] (RxNorm concept RXCUI 2557391, generic name 20) appears on 27 distinct formulary files spanning 141 Medicare Part D plan offerings - 2.8% of enrollable Part D products, selective placement; verify formulary inclusion before enrolling. Tier placement ranges from Tier 1 to Tier 5, with a cross-plan average of Tier 4.4.
Real-world access to 20 ML pegcetacoplan 54 MG/ML Injection [Empaveli] depends on utilization management as much as tier placement: 100% of covering formularies require prior authorization. 0% require step therapy. 22.2% apply quantity limits.
Historical spending context from the CMS Medicare Part D Drug Spending Dashboard shows 68 Part D beneficiaries filled 20 ML pegcetacoplan 54 MG/ML Injection [Empaveli] in 2023, with total plan-and-beneficiary spending of $25,176,818 and an average per-beneficiary annual cost of $370,247.32. The plan-by-plan detail below lists exactly which PDP and MA-PD contracts carry 20 ML pegcetacoplan 54 MG/ML Injection [Empaveli] today.
Coverage Details
- Formularies covering
- 27
- Plans covering
- 141
- Coverage rate
- 2.8%
- Tier range
- Tier 1 – Tier 5
- Average tier
- Tier 4, Non-Preferred
Restrictions
- Prior authorization required
- 100% of formularies
- Step therapy required
- 0% of formularies
- Quantity limits
- 22.2% of formularies
2023 Medicare Spending
- Beneficiaries
- 68
- Total spending
- $25,176,818
- Avg per beneficiary
- $370,247.32
Tier Distribution Across Plans
Medicare Advantage Plans (MA-PD) Covering 20 ML pegcetacoplan 54 MG/ML Injection [Empaveli]
100 Medicare Advantage plans with Part D drug coverage include this drug.
| Plan | Insurer | Tier | PA | Premium | States |
|---|---|---|---|---|---|
| NaviCare (HMO D-SNP) | Fallon Community Health Plan | T1 | Yes | $0 | MA |
| Provider Partners Pennsylvania Community Plan (HMO I-SNP) | Provider Partners Health Plan OF Pennsylvania, Inc | T1 | Yes | $0 | PA |
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Provider Partners Health Plan OF North Carolina | T1 | Yes | $0 | NC |
| Provider Partners Indiana Community Plan (HMO I-SNP) | Provider Partners Health Plan OF Indiana | T1 | Yes | $0 | IN |
| Provider Partners Missouri Community Plan (HMO I-SNP) | Provider Partners Health Plan OF Missouri, Inc. | T1 | Yes | $0 | MO |
| Tufts Health One Care (HMO D-SNP) | Tufts Health Public Plans, Inc. | T1 | Yes | $0 | MA |
| Tufts Health One Care CW (HMO D-SNP) | Tufts Health Public Plans, Inc. | T1 | Yes | $0 | MA |
| Tufts Health Plan Senior Care Options (HMO D-SNP) | Tufts Associated Health Maintenance Organization | T1 | Yes | $0 | MA |
| Tufts Health Plan Senior Care Options CW (HMO D-SNP) | Tufts Associated Health Maintenance Organization | T1 | Yes | $0 | MA |
| Provider Partners Texas Advantage Plan (HMO I-SNP) | Provider Partners Health Plan OF Texas, Inc. | T1 | Yes | $4.80 | TX |
| Provider Partners Illinois Advantage Plan (HMO I-SNP) | Provider Partners Health Plan OF Illinois | T1 | Yes | $15.20 | IL |
| Provider Partners Pennsylvania Advantage Plan (HMO I-SNP) | Provider Partners Health Plan OF Pennsylvania, Inc | T1 | Yes | $32.70 | PA |
| Provider Partners Pennsylvania Essential Plan (HMO I-SNP) | Provider Partners Health Plan OF Pennsylvania, Inc | T1 | Yes | $32.70 | PA |
| Provider Partners North Carolina Advantage Plan (HMO I-SNP) | Provider Partners Health Plan OF North Carolina | T1 | Yes | $36.20 | NC |
| Provider Partners North Carolina Essential Plan (HMO I-SNP) | Provider Partners Health Plan OF North Carolina | T1 | Yes | $36.20 | NC |
| Provider Partners Indiana Advantage Plan (HMO I-SNP) | Provider Partners Health Plan OF Indiana | T1 | Yes | $38.40 | IN |
| Provider Partners Indiana Essential Plan (HMO I-SNP) | Provider Partners Health Plan OF Indiana | T1 | Yes | $38.40 | IN |
| Provider Partners Kentucky Advantage Plan (HMO I-SNP) | Provider Partners Health Plan OF Kentucky | T1 | Yes | $38.40 | KY |
| Provider Partners Missouri Advantage Plan (HMO I-SNP) | Provider Partners Health Plan OF Missouri, Inc. | T1 | Yes | $43.00 | MO |
| Provider Partners Missouri Essential Plan (HMO I-SNP) | Provider Partners Health Plan OF Missouri, Inc. | T1 | Yes | $43.00 | MO |
Show the next 30 plans
| CalOptima Health OneCare Complete (HMO D-SNP) | Orange County Health Authority | T2 | Yes | $0 | CA |
| eternalHealth Forever (HMO) | Eternalhealth, Inc. | T5 | Yes | $0 | MA |
| eternalHealth Freedom (PPO) | Eternalhealth, Inc. | T5 | Yes | $0 | MA |
| eternalHealth Give Back (PPO) | Eternalhealth, Inc. | T5 | Yes | $0 | MA |
| eternalHealth Horizon (HMO) | Eternalhealth OF Arizona Inc | T5 | Yes | $0 | AZ |
| eternalHealth Grand Give Back (HMO) | Eternalhealth OF Arizona Inc | T5 | Yes | $0 | AZ |
| eternalHealth + Fry's Medicare Advantage (HMO) | Eternalhealth OF Arizona Inc | T5 | Yes | $0 | AZ |
| Senior Care Plus Essential plan (HMO) | Hometown Health Plan, Inc. | T5 | Yes | $0 | NV |
| Senior Care Plus Complete Plan (HMO) | Hometown Health Plan, Inc. | T5 | Yes | $0 | NV |
| Renown Preferred Plan by Senior Care Plus (HMO) | Hometown Health Plan, Inc. | T5 | Yes | $0 | NV |
| Senior Care Plus Extensive Duals Plan (HMO D-SNP) | Hometown Health Plan, Inc. | T5 | Yes | $0 | NV |
| Senior Care Plus Enriched Duals Plan (HMO D-SNP) | Hometown Health Plan, Inc. | T5 | Yes | $0 | NV |
| MyAdvocate Medicare Advantage SILVER (HMO-POS) | Beshp, Inc. | T5 | Yes | $0 | NE |
| Great Plain Medicare Advantage Gold (HMO I-SNP) | Sanford Health Plan | T5 | Yes | $0 | IA, SD |
| Align ChoicePlus (PPO) | Sanford Health Plan OF Minnesota | T5 | Yes | $0 | MN |
| Great Plains Medicare Advantage Gold (HMO I-SNP) | Good Samaritan Insurance Plan OF Nebraska, Inc. | T5 | Yes | $0 | NE |
| Align ChoicePlus (PPO) | Sanford Health Plan | T5 | Yes | $0 | IA, SD |
| Align ChoicePlus (PPO) | Sanford Health Plan | T5 | Yes | $0 | ND |
| Great Plains Medicare Advantage Gold (HMO I-SNP) | Sanford Health Plan | T5 | Yes | $0 | ND |
| Align Dual Partnership (HMO D-SNP) | Sanford Health Plan | T5 | Yes | $0 | ND |
| Ally Rx (HMO D-SNP) | Security Health Plan OF Wisconsin, Inc. | T5 | Yes | $0 | WI |
| Esteem Rx (HMO-POS) | Security Health Plan OF Wisconsin, Inc. | T5 | Yes | $0 | WI |
| BlueCross Total Value (PPO) | Bluecross AND Blueshield OF South Carolina | T5 | Yes | $0 | SC |
| BlueCross Total Value (PPO) | Bluecross AND Blueshield OF South Carolina | T5 | Yes | $0 | SC |
| BlueCross Total Value (PPO) | Bluecross AND Blueshield OF South Carolina | T5 | Yes | $0 | SC |
| Blue Best Life Classic (HMO) | Medisun, Inc. | T5 | Yes | $0 | AZ |
| Blue Best Life Classic (HMO) | Medisun, Inc. | T5 | Yes | $0 | AZ |
| Geisinger Gold Preferred Complete Rx (PPO) | Geisinger Indemnity Insurance Company | T5 | Yes | $0 | PA |
| Geisinger Gold Secure Rx (HMO D-SNP) | Geisinger Health Plan | T5 | Yes | $0 | PA |
| Geisinger Gold Classic 360 Rx (HMO) | Geisinger Health Plan | T5 | Yes | $0 | PA |
Showing top 50 of 100 plans.
Frequently Asked Questions
Is 20 ML pegcetacoplan 54 MG/ML Injection [Empaveli] covered by Medicare Part D?
Yes, 20 ML pegcetacoplan 54 MG/ML Injection [Empaveli] is covered by 141 Medicare Part D plans (2.8% of all Part D formularies).
What tier is 20 ML pegcetacoplan 54 MG/ML Injection [Empaveli] on Medicare Part D plans?
20 ML pegcetacoplan 54 MG/ML Injection [Empaveli] averages Tier 4.4 across Part D plans, ranging from Tier 1 to Tier 5.
Does 20 ML pegcetacoplan 54 MG/ML Injection [Empaveli] require prior authorization?
100% of Part D formularies require prior authorization for 20 ML pegcetacoplan 54 MG/ML Injection [Empaveli]. Step therapy: 0%. Quantity limits: 22.2%.
How much does Medicare spend on 20 ML pegcetacoplan 54 MG/ML Injection [Empaveli]?
In 2023, total Medicare Part D spending on 20 ML pegcetacoplan 54 MG/ML Injection [Empaveli] was $25,176,818, covering 68 beneficiaries. The average spend per beneficiary was $370,247.32.
Read our methodology - how this data is sourced, computed, and verified.
Nationwide similar Part D drugs
Data-derived peers across the CMS Part D formulary extract: nearest average tier placement and nearest prior-authorization rate. Not therapeutic alternatives or same-generic strengths.
Closest average formulary tier
- lofexidine 0.18 MG Oral Tablet T4.4
- fostamatinib 100 MG Oral Tablet [Tavalisse] T4.5
- 0.5 ML filgrastim-sndz 0.6 MG/ML Prefilled Syringe [Zarxio] T4.4
- 0.8 ML filgrastim-sndz 0.6 MG/ML Prefilled Syringe [Zarxio] T4.4
- 168 HR granisetron 0.129 MG/HR Transdermal System [Sancuso] T4.4
- chenodeoxycholate 250 MG Oral Tablet [Ctexli] T4.4
Similar prior-authorization rate
- azathioprine 50 MG Oral Tablet 100% PA
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- 0.5 ML hepatitis B surface antigen vaccine 0.02 MG/ML Prefilled Syringe [Engerix-B] 100% PA
- 1 ML hepatitis B surface antigen vaccine 0.02 MG/ML Prefilled Syringe [Engerix-B] 100% PA
- sotagliflozin 200 MG Oral Tablet [Inpefa] 100% PA
- mycophenolate mofetil 250 MG Oral Capsule 100% PA