Medicare Part D coverage · fingolimod · RxCUI 2045493
fingolimod 0.25 MG Oral Capsule [Gilenya]
Per the CMS 2026 Part D formulary file, fingolimod 0.25 MG Oral Capsule [Gilenya] is covered by 21 Medicare Part D plans (0.4% of enrollable products), averaging Tier 4.2, with prior authorization required on 60% of covering formularies.
- 0.4%
- Plan coverage
- 21
- Plans covering
- T4.2
- Avg tier
- 60%
- Prior auth required
What the CMS Formulary Data Shows for fingolimod 0.25 MG Oral Capsule [Gilenya]
Per the CMS 2026 Part D formulary file, fingolimod 0.25 MG Oral Capsule [Gilenya] (RxNorm concept RXCUI 2045493, generic name fingolimod) appears on 5 distinct formulary files spanning 21 Medicare Part D plan offerings - 0.4% of enrollable Part D products, selective placement; verify formulary inclusion before enrolling. Tier placement ranges from Tier 2 to Tier 5, with a cross-plan average of Tier 4.2.
Real-world access to fingolimod 0.25 MG Oral Capsule [Gilenya] depends on utilization management as much as tier placement: 60% of covering formularies require prior authorization. 0% require step therapy. 100% apply quantity limits.
Historical spending context from the CMS Medicare Part D Drug Spending Dashboard shows 2,875 Part D beneficiaries filled fingolimod 0.25 MG Oral Capsule [Gilenya] in 2023, with total plan-and-beneficiary spending of $108,657,034 and an average per-beneficiary annual cost of $37,793.75. The plan-by-plan detail below lists exactly which PDP and MA-PD contracts carry fingolimod 0.25 MG Oral Capsule [Gilenya] today.
Coverage Details
- Formularies covering
- 5
- Plans covering
- 21
- Coverage rate
- 0.4%
- Tier range
- Tier 2 – Tier 5
- Average tier
- Tier 4, Non-Preferred
Restrictions
- Prior authorization required
- 60% of formularies
- Step therapy required
- 0% of formularies
- Quantity limits
- 100% of formularies
2023 Medicare Spending
- Beneficiaries
- 2,875
- Total spending
- $108,657,034
- Avg per beneficiary
- $37,793.75
Tier Distribution Across Plans
Medicare Advantage Plans (MA-PD) Covering fingolimod 0.25 MG Oral Capsule [Gilenya]
21 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 | T2 | Yes | $0 | CA |
| Leon MediExtra (HMO) | Leon Health, Inc. | T4 | Yes | $0 | FL |
| Leon MediDual (HMO D-SNP) | Leon Health, Inc. | T4 | Yes | $0 | FL |
| Leon MediMore (HMO) | Leon Health, Inc. | T4 | Yes | $0 | FL |
| Leon MediMax (HMO D-SNP) | Leon Health, Inc. | T4 | Yes | $0 | FL |
| Personal Choice 65 Achieve Rx (PPO) | QCC Insurance Company | T5 | No | $0 | PA |
| Keystone 65 Focus Rx (HMO-POS) | Keystone Health Plan East, Inc. | T5 | No | $0 | PA |
| Keystone 65 Focus Rx (HMO-POS) | Keystone Health Plan East, Inc. | T5 | No | $0 | PA |
| Keystone 65 Basic Rx (HMO) | Keystone Health Plan East, Inc. | T5 | No | $0 | PA |
| AmeriHealth Medicare Core (PPO) | Amerihealth Insurance Company OF NEW Jersey | T5 | No | $0 | NJ |
| AmeriHealth Medicare Ultimate (PPO) | Amerihealth Insurance Company OF NEW Jersey | T5 | No | $0 | NJ |
| Samaritan Dual Advantage (HMO D-SNP) | Samaritan Health Plans, Inc. | T5 | Yes | $10.50 | OR |
| Keystone 65 Essential Rx (HMO-POS) | Keystone Health Plan East, Inc. | T5 | No | $31.00 | PA |
| AmeriHealth Medicare Enhanced (PPO) | Amerihealth Insurance Company OF NEW Jersey | T5 | No | $36.00 | NJ |
| Keystone 65 Select Rx (HMO) | Keystone Health Plan East, Inc. | T5 | No | $47.00 | PA |
| Keystone 65 Preferred Rx (HMO) | Keystone Health Plan East, Inc. | T5 | No | $59.70 | PA |
| Keystone 65 Select Rx (HMO) | Keystone Health Plan East, Inc. | T5 | No | $63.50 | PA |
| Keystone 65 Preferred Rx (HMO) | Keystone Health Plan East, Inc. | T5 | No | $79.70 | PA |
| Personal Choice 65 Plus Rx (PPO) | QCC Insurance Company | T5 | No | $81.20 | PA |
| Personal Choice 65 Rx (PPO) | QCC Insurance Company | T5 | No | $102.20 | PA |
Show the next 1 plans
| Personal Choice 65 Rx (PPO) | QCC Insurance Company | T5 | No | $112.70 | PA |
Frequently Asked Questions
Is fingolimod 0.25 MG Oral Capsule [Gilenya] covered by Medicare Part D?
Yes, fingolimod 0.25 MG Oral Capsule [Gilenya] is covered by 21 Medicare Part D plans (0.4% of all Part D formularies).
What tier is fingolimod 0.25 MG Oral Capsule [Gilenya] on Medicare Part D plans?
fingolimod 0.25 MG Oral Capsule [Gilenya] averages Tier 4.2 across Part D plans, ranging from Tier 2 to Tier 5.
Does fingolimod 0.25 MG Oral Capsule [Gilenya] require prior authorization?
60% of Part D formularies require prior authorization for fingolimod 0.25 MG Oral Capsule [Gilenya]. Step therapy: 0%. Quantity limits: 100%.
How much does Medicare spend on fingolimod 0.25 MG Oral Capsule [Gilenya]?
In 2023, total Medicare Part D spending on fingolimod 0.25 MG Oral Capsule [Gilenya] was $108,657,034, covering 2,875 beneficiaries. The average spend per beneficiary was $37,793.75.
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
- dasatinib 20 MG Oral Tablet T4.2
- rilpivirine 2.5 MG Tablet for Oral Suspension [Edurant] T4.2
- tenofovir disoproxil fumarate 250 MG Oral Tablet [Viread] T4.2
- sodium oxybate 500 MG/ML Oral Solution T4.2
- sapropterin dihydrochloride 100 MG Oral Tablet T4.2
- ivacaftor 125 MG / lumacaftor 200 MG Oral Tablet [ORKAMBI] T4.2
Similar prior-authorization rate
- sebetralstat 300 MG Oral Tablet [Ekterly] 60% PA
- ivermectin 6 MG Oral Tablet 60.2% PA
- cyproheptadine hydrochloride 0.4 MG/ML Oral Solution 60.7% PA
- aspirin 325 MG / butalbital 50 MG / caffeine 40 MG / codeine phosphate 30 MG Oral Capsule 60.7% PA
- {2 (iloperidone 1 MG Oral Tablet [Fanapt]) / 2 (iloperidone 2 MG Oral Tablet [Fanapt]) / 2 (iloperidone 4 MG Oral Tablet [Fanapt]) / 2 (iloperidone 6 MG Oral Tablet [Fanapt]) } Pack [Fanapt Titration Pack] 60.7% PA
- 24 HR budesonide 9 MG Extended Release Oral Tablet 60.7% PA