acetohydroxamic acid 250 MG Oral Tablet [Lithostat]
acetohydroxamic acid
RxCUI: 213557
What the CMS Formulary Data Shows for acetohydroxamic acid 250 MG Oral Tablet [Lithostat]
Per the CMS 2026 Part D formulary file, acetohydroxamic acid 250 MG Oral Tablet [Lithostat] (RxNorm concept RXCUI 213557, generic name acetohydroxamic acid) appears on 14 distinct formulary files spanning 249 Medicare Part D plan offerings - 4.9% of enrollable Part D products, selective placement; verify formulary inclusion before enrolling. Tier placement ranges from Tier 1 to Tier 4, with a cross-plan average of Tier 3.6.
Real-world access to acetohydroxamic acid 250 MG Oral Tablet [Lithostat] depends on utilization management as much as tier placement: 7.1% of covering formularies require prior authorization. 0% require step therapy. 0% apply quantity limits.
Historical spending context from the CMS Medicare Part D Drug Spending Dashboard shows 203 Part D beneficiaries filled acetohydroxamic acid 250 MG Oral Tablet [Lithostat] in 2023, with total plan-and-beneficiary spending of $572,333 and an average per-beneficiary annual cost of $2,819.38. The plan-by-plan detail below lists exactly which PDP and MA-PD contracts carry acetohydroxamic acid 250 MG Oral Tablet [Lithostat] today.
Coverage Details
- Formularies covering
- 14
- Plans covering
- 249
- Coverage rate
- 4.9%
- Tier range
- Tier 1 – Tier 4
- Average tier
- Tier 4, Non-Preferred
Restrictions
- Prior authorization required
- 7.1% of formularies
- Step therapy required
- 0% of formularies
- Quantity limits
- 0% of formularies
2023 Medicare Spending
- Beneficiaries
- 203
- Total spending
- $572,333
- Avg per beneficiary
- $2,819.38
Tier Distribution Across Plans
Medicare Advantage Plans (MA-PD) Covering acetohydroxamic acid 250 MG Oral Tablet [Lithostat]
100 Medicare Advantage plans with Part D drug coverage include this drug.
| Plan | Insurer | Tier | PA | Premium | States |
|---|---|---|---|---|---|
| Platino Blindao (HMO D-SNP) | TRIPLE S ADVANTAGE, INC. | T1 | No | $0 | PR |
| Platino Enlace (HMO D-SNP) | TRIPLE S ADVANTAGE, INC. | T1 | No | $0 | PR |
| PLATINO ADVANCE (HMO D-SNP) | TRIPLE S ADVANTAGE, INC. | T1 | No | $0 | PR |
| PLATINO PLUS (HMO D-SNP) | TRIPLE S ADVANTAGE, INC. | T1 | No | $0 | PR |
| CalOptima Health OneCare Complete (HMO D-SNP) | ORANGE COUNTY HEALTH AUTHORITY | T2 | Yes | $0 | CA |
| HealthSun HealthAdvantage Plan (HMO) | HEALTHSUN HEALTH PLANS, INC. | T4 | No | $0 | FL |
| HealthSun MediMax (HMO) | HEALTHSUN HEALTH PLANS, INC. | T4 | No | $0 | FL |
| HealthSun HealthAdvantage Plan (HMO) | HEALTHSUN HEALTH PLANS, INC. | T4 | No | $0 | FL |
| HealthSun HealthAdvantage Plan (HMO) | HEALTHSUN HEALTH PLANS, INC. | T4 | No | $0 | FL |
| HealthSun MediSun Plus (HMO D-SNP) | HEALTHSUN HEALTH PLANS, INC. | T4 | No | $0 | FL |
| HealthSun HealthAdvantage Plus (HMO) | HEALTHSUN HEALTH PLANS, INC. | T4 | No | $0 | FL |
| HealthSun HealthAdvantage Plus (HMO) | HEALTHSUN HEALTH PLANS, INC. | T4 | No | $0 | FL |
| HealthSun MediSun Extra (HMO D-SNP) | HEALTHSUN HEALTH PLANS, INC. | T4 | No | $0 | FL |
| HealthSun HealthAdvantage Plus (HMO) | HEALTHSUN HEALTH PLANS, INC. | T4 | No | $0 | FL |
| HealthSun VitalCare (HMO C-SNP) | HEALTHSUN HEALTH PLANS, INC. | T4 | No | $0 | FL |
| HealthSun VitalCare (HMO C-SNP) | HEALTHSUN HEALTH PLANS, INC. | T4 | No | $0 | FL |
| HealthSun MediSun Full Dual Plus (HMO D-SNP) | HEALTHSUN HEALTH PLANS, INC. | T4 | No | $0 | FL |
| HealthSun MediSun Full Dual Extra (HMO D-SNP) | HEALTHSUN HEALTH PLANS, INC. | T4 | No | $0 | FL |
| Simply Complete (HMO D-SNP) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply More (HMO) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply Complete (HMO D-SNP) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply Level (HMO C-SNP) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply Level (HMO C-SNP) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply More (HMO) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply Level (HMO C-SNP) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply More (HMO) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply Level (HMO C-SNP) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply Complete (HMO D-SNP) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply More (HMO) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply More (HMO) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply Level (HMO C-SNP) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply Complete (HMO D-SNP) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply More (HMO) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply Extra (HMO) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply Extra Platinum (HMO) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply More Platinum (HMO) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply Complete Platinum (HMO D-SNP) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply Level Platinum (HMO C-SNP) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply Extra Platinum (HMO) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply Level Platinum (HMO C-SNP) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply Extra Platinum (HMO) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply Level Platinum (HMO C-SNP) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply Extra Platinum (HMO) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply More Platinum (HMO) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply Complete Platinum (HMO D-SNP) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply Level Platinum (HMO C-SNP) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply Integrated (HMO D-SNP) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply Integrated (HMO D-SNP) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply Integrated (HMO D-SNP) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
| Simply Integrated (HMO D-SNP) | SIMPLY HEALTHCARE PLANS, INC. | T4 | No | $0 | FL |
Frequently Asked Questions
Is acetohydroxamic acid 250 MG Oral Tablet [Lithostat] covered by Medicare Part D?
Yes, acetohydroxamic acid 250 MG Oral Tablet [Lithostat] is covered by 249 Medicare Part D plans (4.9% of all Part D formularies).
What tier is acetohydroxamic acid 250 MG Oral Tablet [Lithostat] on Medicare Part D plans?
acetohydroxamic acid 250 MG Oral Tablet [Lithostat] averages Tier 3.6 across Part D plans, ranging from Tier 1 to Tier 4.
Does acetohydroxamic acid 250 MG Oral Tablet [Lithostat] require prior authorization?
7.1% of Part D formularies require prior authorization for acetohydroxamic acid 250 MG Oral Tablet [Lithostat]. Step therapy: 0%. Quantity limits: 0%.
How much does Medicare spend on acetohydroxamic acid 250 MG Oral Tablet [Lithostat]?
In 2023, total Medicare Part D spending on acetohydroxamic acid 250 MG Oral Tablet [Lithostat] was $572,333, covering 203 beneficiaries. The average spend per beneficiary was $2,819.38.
Read our methodology - how this data is sourced, computed, and verified.