dichlorphenamide 50 MG Oral Tablet [Ormalvi]
dichlorphenamide
RxCUI: 2677447
What the CMS Formulary Data Shows for dichlorphenamide 50 MG Oral Tablet [Ormalvi]
Per the CMS 2026 Part D formulary file, dichlorphenamide 50 MG Oral Tablet [Ormalvi] (RxNorm concept RXCUI 2677447, generic name dichlorphenamide) appears on 13 distinct formulary files spanning 49 Medicare Part D plan offerings - 1% 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 4.1.
Real-world access to dichlorphenamide 50 MG Oral Tablet [Ormalvi] depends on utilization management as much as tier placement: 100% of covering formularies require prior authorization. 0% require step therapy. 30.8% apply quantity limits.
Historical spending context from the CMS Medicare Part D Drug Spending Dashboard shows 98 Part D beneficiaries filled dichlorphenamide 50 MG Oral Tablet [Ormalvi] in 2023, with total plan-and-beneficiary spending of $20,667,743 and an average per-beneficiary annual cost of $210,895.34. The plan-by-plan detail below lists exactly which PDP and MA-PD contracts carry dichlorphenamide 50 MG Oral Tablet [Ormalvi] today.
Coverage Details
- Formularies covering
- 13
- Plans covering
- 49
- Coverage rate
- 1%
- 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
- 30.8% of formularies
2023 Medicare Spending
- Beneficiaries
- 98
- Total spending
- $20,667,743
- Avg per beneficiary
- $210,895.34
Tier Distribution Across Plans
Medicare Advantage Plans (MA-PD) Covering dichlorphenamide 50 MG Oral Tablet [Ormalvi]
49 Medicare Advantage plans with Part D drug coverage include this drug.
| Plan | Insurer | Tier | PA | Premium | States |
|---|---|---|---|---|---|
| CalOptima Health OneCare Complete (HMO D-SNP) | ORANGE COUNTY HEALTH AUTHORITY | T1 | Yes | $0 | CA |
| Mass General Brigham SCO (HMO D-SNP) | MASS GENERAL BRIGHAM HEALTH PLAN, INC | T1 | Yes | $0 | MA |
| Mass General Brigham One Care (HMO D-SNP) | MASS GENERAL BRIGHAM HEALTH PLAN, INC | T1 | Yes | $0 | MA |
| Medicare BlueEssential (PPO) | EXCELLUS HEALTH PLAN, INC. | T5 | Yes | $0 | NY |
| Medicare BlueActive (PPO) | EXCELLUS HEALTH PLAN, INC. | T5 | Yes | $0 | NY |
| Medicare BlueVital (PPO) | EXCELLUS HEALTH PLAN, INC. | T5 | Yes | $0 | NY |
| Univera SeniorChoice Basic (HMO) | EXCELLUS HEALTH PLAN, INC. | T5 | Yes | $0 | NY |
| Univera SeniorChoice Extra (HMO) | EXCELLUS HEALTH PLAN, INC. | T5 | Yes | $0 | NY |
| Medicare Blue Choice Core (HMO) | EXCELLUS HEALTH PLAN, INC. | T5 | Yes | $0 | NY |
| Univera Medicare Dual (HMO D-SNP) | EXCELLUS HEALTH PLAN COMMUNITY CARE LLC | T5 | Yes | $0 | NY |
| Medicare Blue Dual (HMO D-SNP) | EXCELLUS HEALTH PLAN COMMUNITY CARE LLC | T5 | Yes | $0 | NY |
| Personal Choice 65 Achieve Rx (PPO) | QCC INSURANCE COMPANY | T5 | Yes | $0 | PA |
| Keystone 65 Focus Rx (HMO-POS) | KEYSTONE HEALTH PLAN EAST, INC. | T5 | Yes | $0 | PA |
| Keystone 65 Focus Rx (HMO-POS) | KEYSTONE HEALTH PLAN EAST, INC. | T5 | Yes | $0 | PA |
| Keystone 65 Basic Rx (HMO) | KEYSTONE HEALTH PLAN EAST, INC. | T5 | Yes | $0 | PA |
| AmeriHealth Medicare Core (PPO) | AMERIHEALTH INSURANCE COMPANY OF NEW JERSEY | T5 | Yes | $0 | NJ |
| AmeriHealth Medicare Ultimate (PPO) | AMERIHEALTH INSURANCE COMPANY OF NEW JERSEY | T5 | Yes | $0 | NJ |
| CDPHP $0 Medicare Rx (HMO) | CAPITAL DISTRICT PHYSICIANS' HEALTH PLAN, INC. | T5 | Yes | $0 | NY |
| Mass General Brigham Advantage (PPO) | Mass General Brigham Health Plan, Inc. | T5 | Yes | $0 | MA |
| Keystone 65 Essential Rx (HMO-POS) | KEYSTONE HEALTH PLAN EAST, INC. | T5 | Yes | $31.00 | PA |
| Univera SeniorChoice Core (PPO) | EXCELLUS HEALTH PLAN, INC. | T5 | Yes | $33.00 | NY |
| AmeriHealth Medicare Enhanced (PPO) | AMERIHEALTH INSURANCE COMPANY OF NEW JERSEY | T5 | Yes | $36.00 | NJ |
| Univera SeniorChoice Advanced (HMO-POS) | EXCELLUS HEALTH PLAN, INC. | T5 | Yes | $36.90 | NY |
| Independent Health's Encompass 65 RED 042 (HMO) | INDEPENDENT HEALTH ASSOCIATION, INC. | T5 | Yes | $40.00 | NY |
| Independent Health's Assure Advantage (HMO C-SNP) | INDEPENDENT HEALTH ASSOCIATION, INC. | T5 | Yes | $46.50 | NY |
| Keystone 65 Select Rx (HMO) | KEYSTONE HEALTH PLAN EAST, INC. | T5 | Yes | $47.00 | PA |
| Medicare BlueClassic (PPO) | EXCELLUS HEALTH PLAN, INC. | T5 | Yes | $51.00 | NY |
| Univera SeniorChoice Secure (HMO-POS) | EXCELLUS HEALTH PLAN, INC. | T5 | Yes | $54.90 | NY |
| Medicare BlueBalanced (PPO) | EXCELLUS HEALTH PLAN, INC. | T5 | Yes | $55.00 | NY |
| Medicare Blue Choice Prime (HMO) | EXCELLUS HEALTH PLAN, INC. | T5 | Yes | $55.00 | NY |
| Univera SeniorChoice Value Plus (HMO-POS) | EXCELLUS HEALTH PLAN, INC. | T5 | Yes | $58.60 | NY |
| Independent Health's Medicare Family Choice (HMO I-SNP) | INDEPENDENT HEALTH ASSOCIATION, INC. | T5 | Yes | $58.80 | NY |
| Independent Health's Medicare Passport Connect (PPO) | INDEPENDENT HEALTH BENEFITS CORPORATION | T5 | Yes | $58.80 | NY |
| Keystone 65 Preferred Rx (HMO) | KEYSTONE HEALTH PLAN EAST, INC. | T5 | Yes | $59.70 | PA |
| Mass General Brigham Advantage Secure (HMO-POS) | Mass General Brigham Health Plan, Inc. | T5 | Yes | $62.00 | MA |
| Keystone 65 Select Rx (HMO) | KEYSTONE HEALTH PLAN EAST, INC. | T5 | Yes | $63.50 | PA |
| Medicare BlueEnhanced (PPO) | EXCELLUS HEALTH PLAN, INC. | T5 | Yes | $70.30 | NY |
| Keystone 65 Preferred Rx (HMO) | KEYSTONE HEALTH PLAN EAST, INC. | T5 | Yes | $79.70 | PA |
| Mass General Brigham Advantage Premier (PPO) | Mass General Brigham Health Plan, Inc. | T5 | Yes | $79.70 | MA |
| Personal Choice 65 Plus Rx (PPO) | QCC INSURANCE COMPANY | T5 | Yes | $81.20 | PA |
| Medicare BluePlus (PPO) | EXCELLUS HEALTH PLAN, INC. | T5 | Yes | $86.40 | NY |
| Independent Health's Encompass 65 RED 044 (HMO) | INDEPENDENT HEALTH ASSOCIATION, INC. | T5 | Yes | $95.00 | NY |
| CDPHP Clear Rx (HMO) | CAPITAL DISTRICT PHYSICIANS' HEALTH PLAN, INC. | T5 | Yes | $100.00 | NY |
| Personal Choice 65 Rx (PPO) | QCC INSURANCE COMPANY | T5 | Yes | $102.20 | PA |
| Personal Choice 65 Rx (PPO) | QCC INSURANCE COMPANY | T5 | Yes | $112.70 | PA |
| CDPHP Choice Rx (HMO) | CAPITAL DISTRICT PHYSICIANS' HEALTH PLAN, INC. | T5 | Yes | $135.00 | NY |
| Medicare Blue Choice Optimum (HMO-POS) | EXCELLUS HEALTH PLAN, INC. | T5 | Yes | $146.00 | NY |
| Mass General Brigham Advantage Signature (PPO) | Mass General Brigham Health Plan, Inc. | T5 | Yes | $147.20 | MA |
| Independent Health's Encompass 65 RED 043 (HMO) | INDEPENDENT HEALTH ASSOCIATION, INC. | T5 | Yes | $190.00 | NY |
Frequently Asked Questions
Is dichlorphenamide 50 MG Oral Tablet [Ormalvi] covered by Medicare Part D?
Yes, dichlorphenamide 50 MG Oral Tablet [Ormalvi] is covered by 49 Medicare Part D plans (1% of all Part D formularies).
What tier is dichlorphenamide 50 MG Oral Tablet [Ormalvi] on Medicare Part D plans?
dichlorphenamide 50 MG Oral Tablet [Ormalvi] averages Tier 4.1 across Part D plans, ranging from Tier 1 to Tier 5.
Does dichlorphenamide 50 MG Oral Tablet [Ormalvi] require prior authorization?
100% of Part D formularies require prior authorization for dichlorphenamide 50 MG Oral Tablet [Ormalvi]. Step therapy: 0%. Quantity limits: 30.8%.
How much does Medicare spend on dichlorphenamide 50 MG Oral Tablet [Ormalvi]?
In 2023, total Medicare Part D spending on dichlorphenamide 50 MG Oral Tablet [Ormalvi] was $20,667,743, covering 98 beneficiaries. The average spend per beneficiary was $210,895.34.
Read our methodology - how this data is sourced, computed, and verified.