Medicare Part D coverage · pentosan polysulfate · RxCUI 211140
pentosan polysulfate 100 MG Oral Capsule [Elmiron]
Per the CMS 2026 Part D formulary file, pentosan polysulfate 100 MG Oral Capsule [Elmiron] is covered by 2,436 Medicare Part D plans (48.2% of enrollable products), averaging Tier 3.4, with prior authorization required on 2.7% of covering formularies.
- 48.2%
- Plan coverage
- 2,436
- Plans covering
- T3.4
- Avg tier
- 2.7%
- Prior auth required
What the CMS Formulary Data Shows for pentosan polysulfate 100 MG Oral Capsule [Elmiron]
Per the CMS 2026 Part D formulary file, pentosan polysulfate 100 MG Oral Capsule [Elmiron] (RxNorm concept RXCUI 211140, generic name pentosan polysulfate) appears on 148 distinct formulary files spanning 2,436 Medicare Part D plan offerings - 48.2% 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 3.4.
Real-world access to pentosan polysulfate 100 MG Oral Capsule [Elmiron] depends on utilization management as much as tier placement: 2.7% of covering formularies require prior authorization. 0% require step therapy. 14.9% apply quantity limits.
Historical spending context from the CMS Medicare Part D Drug Spending Dashboard shows 593,832 Part D beneficiaries filled pentosan polysulfate 100 MG Oral Capsule [Elmiron] in 2023, with total plan-and-beneficiary spending of $127,016,041 and an average per-beneficiary annual cost of $213.89. The plan-by-plan detail below lists exactly which PDP and MA-PD contracts carry pentosan polysulfate 100 MG Oral Capsule [Elmiron] today.
Coverage Details
- Formularies covering
- 148
- Plans covering
- 2,436
- Coverage rate
- 48.2%
- Tier range
- Tier 1 – Tier 5
- Average tier
- Tier 3, Preferred Brand
Restrictions
- Prior authorization required
- 2.7% of formularies
- Step therapy required
- 0% of formularies
- Quantity limits
- 14.9% of formularies
2023 Medicare Spending
- Beneficiaries
- 593,832
- Total spending
- $127,016,041
- Avg per beneficiary
- $213.89
Tier Distribution Across Plans
Medicare Advantage Plans (MA-PD) Covering pentosan polysulfate 100 MG Oral Capsule [Elmiron]
100 Medicare Advantage plans with Part D drug coverage include this drug.
| Plan | Insurer | Tier | PA | Premium | States |
|---|---|---|---|---|---|
| Sentara Community Complete Select (HMO D-SNP) | Sentara Health Plans | T1 | No | $0 | VA |
| Sentara Community Complete (HMO D-SNP) | Sentara Health Plans | T1 | No | $0 | VA |
| ElderServe MAP (HMO D-SNP) | Elderserve Health, Inc. | T1 | No | $0 | NY |
| Cooperative Advantage (HMO D-SNP) | Group Health Cooperative OF EAU Claire | T1 | No | $0 | WI |
| Longevity Health Plan (PPO I-SNP) | Longevity Health Plan OF NEW Jersey Insurance Comp | T1 | No | $0 | NJ |
| Upper Peninsula Health Plan MI Coordinated Health (HMO D-SNP) | Upper Peninsula Health Plan, LLC | T1 | No | $0 | MI |
| CareSource Dual Advantage (HMO D-SNP) | Caresource Georgia Co. | T1 | No | $0 | GA |
| HAP CareSource MI Coordinated Health (HMO D-SNP) | HAP Caresource | T1 | No | $0 | MI |
| NaviCare (HMO D-SNP) | Fallon Community Health Plan | T1 | No | $0 | MA |
| SeniorCare Complete (HMO D-SNP) | South Country Health Alliance | T1 | No | $0 | MN |
| AbilityCare (HMO D-SNP) | South Country Health Alliance | T1 | No | $0 | MN |
| Alameda Alliance Wellness (HMO D-SNP) | Alameda Alliance FOR Health | T1 | No | $0 | CA |
| Provider Partners Pennsylvania Community Plan (HMO I-SNP) | Provider Partners Health Plan OF Pennsylvania, Inc | T1 | No | $0 | PA |
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Provider Partners Health Plan OF North Carolina | T1 | No | $0 | NC |
| Provider Partners Indiana Community Plan (HMO I-SNP) | Provider Partners Health Plan OF Indiana | T1 | No | $0 | IN |
| Provider Partners Missouri Community Plan (HMO I-SNP) | Provider Partners Health Plan OF Missouri, Inc. | T1 | No | $0 | MO |
| Abilis Health Community (HMO I-SNP) | Signature Advantage, LLC | T1 | No | $0 | KY, TN |
| Arkansas Integrated Providers (AIP) Dual Advantage (HMO D-SNP) | Arkansas Superior Select, Inc. | T1 | No | $0 | AR |
| Community Care's Partnership Program (HMO D-SNP) | Community Care Health Plan, Inc. | T1 | No | $0 | WI |
| Platino Blindao (HMO D-SNP) | Triple S Advantage, Inc. | T1 | No | $0 | PR |
Show the next 30 plans
| 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 |
| Mass General Brigham SCO (HMO D-SNP) | Mass General Brigham Health Plan, Inc | T1 | No | $0 | MA |
| Mass General Brigham One Care (HMO D-SNP) | Mass General Brigham Health Plan, Inc | T1 | No | $0 | MA |
| Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) | Gateway Health Plan, Inc. | T1 | No | $0 | PA |
| Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) | Gateway Health Plan, Inc. | T1 | No | $0 | PA |
| Highmark Health Options Duals (HMO D-SNP) | Highmark Health Options West Virginia Inc. | T1 | No | $0 | WV |
| Highmark Health Options Duals (HMO D-SNP) | Highmark Bcbsd, Inc. | T1 | No | $0 | DE |
| Tufts Health One Care (HMO D-SNP) | Tufts Health Public Plans, Inc. | T1 | No | $0 | MA |
| Tufts Health One Care CW (HMO D-SNP) | Tufts Health Public Plans, Inc. | T1 | No | $0 | MA |
| Tufts Health Plan Senior Care Options (HMO D-SNP) | Tufts Associated Health Maintenance Organization | T1 | No | $0 | MA |
| Tufts Health Plan Senior Care Options CW (HMO D-SNP) | Tufts Associated Health Maintenance Organization | T1 | No | $0 | MA |
| Longevity Health Plan (HMO I-SNP) | Longevity Health Plan OF Florida, Inc. | T1 | No | $4.80 | FL |
| American Health Advantage of Florida (HMO I-SNP) | American Health Plan OF FL, Inc. | T1 | No | $4.80 | FL |
| Gold Dialysis & Kidney Complete (HMO-POS C-SNP) | Gold Kidney OF Florida Inc | T1 | No | $4.80 | FL |
| Provider Partners Texas Advantage Plan (HMO I-SNP) | Provider Partners Health Plan OF Texas, Inc. | T1 | No | $4.80 | TX |
| Texas Independence Health Plan, Inc. (HMO I-SNP) | Texas Independence Health Plan, Inc. | T1 | No | $4.80 | TX |
| Texas Independence Community Plan (HMO I-SNP) | Texas Independence Health Plan, Inc. | T1 | No | $4.80 | TX |
| Longevity Health Plan (HMO I-SNP) | Longevity Health Plan OF Michigan, Inc. | T1 | No | $8.80 | MI |
| Tribute Select (HMO-POS I-SNP) | Arkansas Superior Select, Inc. | T1 | No | $8.90 | AR |
| Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) | Gateway Health Plan, Inc. | T1 | No | $13.10 | PA |
| Longevity Health Plan (HMO I-SNP) | Longevity Health Plan OF Illinois, Inc. | T1 | No | $15.20 | IL |
| Provider Partners Illinois Advantage Plan (HMO I-SNP) | Provider Partners Health Plan OF Illinois | T1 | No | $15.20 | IL |
| Gold Dialysis & Kidney Complete (HMO-POS C-SNP) | Gold Kidney OF Arizona | T1 | No | $17.00 | AZ |
| Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) | Gateway Health Plan, Inc. | T1 | No | $17.60 | PA |
| WellSense Added Value (HMO) | Boston Medical Center Health Plan, Inc. | T1 | No | $21.70 | NH |
| American Health Advantage of Mississippi (HMO I-SNP) | American Health Plan OF MS, Inc. | T1 | No | $23.80 | MS |
| Georgia Health Advantage (HMO I-SNP) | Georgia Assurance, Inc. | T1 | No | $25.40 | GA |
| Georgia Health Advantage Choice (HMO I-SNP) | Georgia Assurance, Inc. | T1 | No | $25.40 | GA |
Showing top 50 of 100 plans.
Frequently Asked Questions
Is pentosan polysulfate 100 MG Oral Capsule [Elmiron] covered by Medicare Part D?
Yes, pentosan polysulfate 100 MG Oral Capsule [Elmiron] is covered by 2,436 Medicare Part D plans (48.2% of all Part D formularies).
What tier is pentosan polysulfate 100 MG Oral Capsule [Elmiron] on Medicare Part D plans?
pentosan polysulfate 100 MG Oral Capsule [Elmiron] averages Tier 3.4 across Part D plans, ranging from Tier 1 to Tier 5.
Does pentosan polysulfate 100 MG Oral Capsule [Elmiron] require prior authorization?
2.7% of Part D formularies require prior authorization for pentosan polysulfate 100 MG Oral Capsule [Elmiron]. Step therapy: 0%. Quantity limits: 14.9%.
How much does Medicare spend on pentosan polysulfate 100 MG Oral Capsule [Elmiron]?
In 2023, total Medicare Part D spending on pentosan polysulfate 100 MG Oral Capsule [Elmiron] was $127,016,041, covering 593,832 beneficiaries. The average spend per beneficiary was $213.89.
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
- ganciclovir 0.0015 MG/MG Ophthalmic Gel [Zirgan] T3.4
- erythromycin lactobionate 500 MG Injection [Erythrocin] T3.4
- mafenide 85 MG/ML Topical Cream [Sulfamylon] T3.4
- 1 ML darbepoetin alfa 0.06 MG/ML Injection [Aranesp] T3.4
- 1 ML denosumab-dssb 60 MG/ML Prefilled Syringe [Ospomyv] T3.4
- {5 (dienogest 2 MG / estradiol valerate 2 MG Oral Tablet) / 17 (dienogest 3 MG / estradiol valerate 2 MG Oral Tablet) / 2 (estradiol valerate 1 MG Oral Tablet) / 2 (estradiol valerate 3 MG Oral Tablet) / 2 (inert ingredients 1 MG Oral Tablet) } Pack [Natazia 28 Day] T3.4
Similar prior-authorization rate
- ceftaroline fosamil 400 MG Injection 2.7% PA
- ceftaroline fosamil 600 MG Injection 2.7% PA
- entecavir 0.05 MG/ML Oral Solution [Baraclude] 2.7% PA
- hydroxyurea 200 MG Oral Capsule [Droxia] 2.8% PA
- betaxolol 2.5 MG/ML Ophthalmic Suspension [Betoptic S] 2.8% PA
- varenicline 0.03 MG/ACTUAT Nasal Spray [Tyrvaya] 2.6% PA