fingolimod 0.5 MG Oral Capsule [Gilenya]
fingolimod
RxCUI: 1012899
What the CMS Formulary Data Shows for fingolimod 0.5 MG Oral Capsule [Gilenya]
Per the CMS 2026 Part D formulary file, fingolimod 0.5 MG Oral Capsule [Gilenya] (RxNorm concept RXCUI 1012899, generic name fingolimod) appears on 3 distinct formulary files spanning 17 Medicare Part D plan offerings - 0.3% 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 3.7.
Real-world access to fingolimod 0.5 MG Oral Capsule [Gilenya] depends on utilization management as much as tier placement: 33.3% 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 0.5 MG Oral Capsule [Gilenya] in 2023, with total plan-and-beneficiary spending of $109,017,450 and an average per-beneficiary annual cost of $37,919.11. The plan-by-plan detail below lists exactly which PDP and MA-PD contracts carry fingolimod 0.5 MG Oral Capsule [Gilenya] today.
Coverage Details
- Formularies covering
- 3
- Plans covering
- 17
- Coverage rate
- 0.3%
- Tier range
- Tier 1 – Tier 5
- Average tier
- Tier 4, Non-Preferred
Restrictions
- Prior authorization required
- 33.3% of formularies
- Step therapy required
- 0% of formularies
- Quantity limits
- 100% of formularies
2023 Medicare Spending
- Beneficiaries
- 2,875
- Total spending
- $109,017,450
- Avg per beneficiary
- $37,919.11
Tier Distribution Across Plans
Medicare Advantage Plans (MA-PD) Covering fingolimod 0.5 MG Oral Capsule [Gilenya]
17 Medicare Advantage plans with Part D drug coverage include this drug.
| Plan | Insurer | Tier | PA | Premium | States |
|---|---|---|---|---|---|
| Hamaspik Medicare Choice (HMO D-SNP) | HAMASPIK, INC. | T1 | Yes | $0 | NY |
| Hamaspik Medicare Select (HMO D-SNP) | HAMASPIK, INC. | T1 | Yes | $34.50 | NY |
| 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 |
| 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 |
| Personal Choice 65 Rx (PPO) | QCC INSURANCE COMPANY | T5 | No | $112.70 | PA |
Frequently Asked Questions
Is fingolimod 0.5 MG Oral Capsule [Gilenya] covered by Medicare Part D?
Yes, fingolimod 0.5 MG Oral Capsule [Gilenya] is covered by 17 Medicare Part D plans (0.3% of all Part D formularies).
What tier is fingolimod 0.5 MG Oral Capsule [Gilenya] on Medicare Part D plans?
fingolimod 0.5 MG Oral Capsule [Gilenya] averages Tier 3.7 across Part D plans, ranging from Tier 1 to Tier 5.
Does fingolimod 0.5 MG Oral Capsule [Gilenya] require prior authorization?
33.3% of Part D formularies require prior authorization for fingolimod 0.5 MG Oral Capsule [Gilenya]. Step therapy: 0%. Quantity limits: 100%.
How much does Medicare spend on fingolimod 0.5 MG Oral Capsule [Gilenya]?
In 2023, total Medicare Part D spending on fingolimod 0.5 MG Oral Capsule [Gilenya] was $109,017,450, covering 2,875 beneficiaries. The average spend per beneficiary was $37,919.11.
Read our methodology - how this data is sourced, computed, and verified.