Medicare Part D coverage · sapropterin dihydrochloride · RxCUI 2712691
sapropterin dihydrochloride 500 MG Powder for Oral Solution [Zelvysia]
Per the CMS 2026 Part D formulary file, sapropterin dihydrochloride 500 MG Powder for Oral Solution [Zelvysia] is covered by 2,622 Medicare Part D plans (51.9% of enrollable products), averaging Tier 4.4, with prior authorization required on 96.1% of covering formularies.
- 51.9%
- Plan coverage
- 2,622
- Plans covering
- T4.4
- Avg tier
- 96.1%
- Prior auth required
What the CMS Formulary Data Shows for sapropterin dihydrochloride 500 MG Powder for Oral Solution [Zelvysia]
Per the CMS 2026 Part D formulary file, sapropterin dihydrochloride 500 MG Powder for Oral Solution [Zelvysia] (RxNorm concept RXCUI 2712691, generic name sapropterin dihydrochloride) appears on 154 distinct formulary files spanning 2,622 Medicare Part D plan offerings - 51.9% of enrollable Part D products, mid-range placement; shopping across contracts changes access. Tier placement ranges from Tier 1 to Tier 5, with a cross-plan average of Tier 4.4.
Real-world access to sapropterin dihydrochloride 500 MG Powder for Oral Solution [Zelvysia] depends on utilization management as much as tier placement: 96.1% 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 137 Part D beneficiaries filled sapropterin dihydrochloride 500 MG Powder for Oral Solution [Zelvysia] in 2023, with total plan-and-beneficiary spending of $14,682,881 and an average per-beneficiary annual cost of $107,174.32. The plan-by-plan detail below lists exactly which PDP and MA-PD contracts carry sapropterin dihydrochloride 500 MG Powder for Oral Solution [Zelvysia] today.
Coverage Details
- Formularies covering
- 154
- Plans covering
- 2,622
- Coverage rate
- 51.9%
- Tier range
- Tier 1 – Tier 5
- Average tier
- Tier 4, Non-Preferred
Restrictions
- Prior authorization required
- 96.1% of formularies
- Step therapy required
- 0% of formularies
- Quantity limits
- 0% of formularies
2023 Medicare Spending
- Beneficiaries
- 137
- Total spending
- $14,682,881
- Avg per beneficiary
- $107,174.32
Tier Distribution Across Plans
Standalone Drug Plans (PDP) Covering sapropterin dihydrochloride 500 MG Powder for Oral Solution [Zelvysia]
5 standalone prescription drug plans include this drug.
| Plan | Insurer | Tier | PA | ST | Premium | States |
|---|---|---|---|---|---|---|
| AARP Medicare Rx Preferred from UHC (PDP) | Unitedhealthcare INS. Co. & UHC INS. Co. OF NY | T5 | No | No | $0 | - |
| AARP Medicare Rx Preferred from UHC (PDP) | Unitedhealthcare INS. Co. & UHC INS. Co. OF NY | T5 | No | No | $0 | - |
| AARP Medicare Rx Saver from UHC (PDP) | Unitedhealthcare INS. Co. & UHC INS. Co. OF NY | T5 | No | No | $0 | - |
| AARP Medicare Rx Saver from UHC (PDP) | Unitedhealthcare INS. Co. & UHC INS. Co. OF NY | T5 | No | No | $0 | - |
| AARP Medicare Rx Saver from UHC (PDP) | Unitedhealthcare INS. Co. & UHC INS. Co. OF NY | T5 | No | No | $0 | - |
Medicare Advantage Plans (MA-PD) Covering sapropterin dihydrochloride 500 MG Powder for Oral Solution [Zelvysia]
95 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 | Yes | $0 | VA |
| Sentara Community Complete (HMO D-SNP) | Sentara Health Plans | T1 | Yes | $0 | VA |
| Florida Complete Care-Duals VIP (HMO-POS D-SNP) | Hpmp OF Florida, Inc. | T1 | Yes | $0 | FL |
| Mercy Care Advantage (HMO D-SNP) | Mercy Care | T1 | Yes | $0 | AZ |
| Mercy Care Advantage (HMO D-SNP) | Mercy Care | T1 | Yes | $0 | AZ |
| Mercy Care Advantage (HMO D-SNP) | Mercy Care | T1 | Yes | $0 | AZ |
| Elderplan Plus Long-Term Care (HMO-POS D-SNP) | Elderplan, Inc. | T1 | Yes | $0 | NY |
| Health Choice Pathway (HMO D-SNP) | Health Choice Arizona, Inc. | T1 | Yes | $0 | AZ |
| Healthfirst CompleteCare (HMO D-SNP) | Healthfirst Health Plan, Inc. | T1 | Yes | $0 | NY |
| IMCare Classic (HMO D-SNP) | Itasca Medical Care | T1 | Yes | $0 | MN |
| Johns Hopkins Advantage MD D-SNP (HMO D-SNP) | Hopkins Health Advantage, Inc. | T1 | Yes | $0 | MD |
| MetroPlus UltraCare (HMO D-SNP) | Metroplus Health Plan, Inc. | T1 | Yes | $0 | NY |
| Senior Whole Health SCO (HMO D-SNP) | Senior Whole Health, LLC | T1 | Yes | $0 | MA |
| Senior Whole Health SCO NHC (HMO D-SNP) | Senior Whole Health, LLC | T1 | Yes | $0 | MA |
| Molina One Care (HMO D-SNP) | Senior Whole Health, LLC | T1 | Yes | $0 | MA |
| Gold Coast Health Plan Total Care Advantage (HMO D-SNP) | Ventura County Medi-Cal Managed Care Commission | T1 | Yes | $0 | CA |
| Blue Cross Medicare Advantage Dual Care Plus (HMO D-SNP) | Health Care Service Corporation | T1 | Yes | $0 | NM |
| Blue Cross MA Dual Care Plus Preferred (PPO D-SNP) | Health Care Service Corporation | T1 | Yes | $0 | NM |
| Horizon NJ TotalCare (HMO D-SNP) | Horizon Healthcare OF NEW Jersey, Inc. | T1 | Yes | $0 | NJ |
| SecureBlue (HMO D-SNP) | HMO Minnesota | T1 | Yes | $0 | MN |
Show the next 30 plans
| NaviCare (HMO D-SNP) | Fallon Community Health Plan | T1 | Yes | $0 | MA |
| Hamaspik Medicare Choice (HMO D-SNP) | Hamaspik, Inc. | T1 | Yes | $0 | NY |
| CCA One Care (HMO D-SNP) | Commonwealth Care Alliance, Inc. | T1 | Yes | $0 | MA |
| CCA Senior Care Options (HMO D-SNP) | Commonwealth Care Alliance, Inc. | T1 | Yes | $0 | MA |
| Provider Partners Pennsylvania Community Plan (HMO I-SNP) | Provider Partners Health Plan OF Pennsylvania, Inc | T1 | Yes | $0 | PA |
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Provider Partners Health Plan OF North Carolina | T1 | Yes | $0 | NC |
| Provider Partners Indiana Community Plan (HMO I-SNP) | Provider Partners Health Plan OF Indiana | T1 | Yes | $0 | IN |
| Provider Partners Missouri Community Plan (HMO I-SNP) | Provider Partners Health Plan OF Missouri, Inc. | T1 | Yes | $0 | MO |
| 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 |
| Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) | Gateway Health Plan, Inc. | T1 | Yes | $0 | PA |
| Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) | Gateway Health Plan, Inc. | T1 | Yes | $0 | PA |
| Highmark Health Options Duals (HMO D-SNP) | Highmark Health Options West Virginia Inc. | T1 | Yes | $0 | WV |
| Highmark Health Options Duals (HMO D-SNP) | Highmark Bcbsd, Inc. | T1 | Yes | $0 | DE |
| Tufts Health One Care (HMO D-SNP) | Tufts Health Public Plans, Inc. | T1 | Yes | $0 | MA |
| Tufts Health One Care CW (HMO D-SNP) | Tufts Health Public Plans, Inc. | T1 | Yes | $0 | MA |
| Tufts Health Plan Senior Care Options (HMO D-SNP) | Tufts Associated Health Maintenance Organization | T1 | Yes | $0 | MA |
| Tufts Health Plan Senior Care Options CW (HMO D-SNP) | Tufts Associated Health Maintenance Organization | T1 | Yes | $0 | MA |
| Florida Complete Care (HMO I-SNP) | Hpmp OF Florida, Inc. | T1 | Yes | $4.80 | FL |
| Florida Complete Care- In The Community (HMO-POS I-SNP) | Hpmp OF Florida, Inc. | T1 | Yes | $4.80 | FL |
| Blue Cross Medicare Advantage Dual Care Plus (HMO D-SNP) | Hcsc Insurance Services Company | T1 | Yes | $4.80 | TX |
| Provider Partners Texas Advantage Plan (HMO I-SNP) | Provider Partners Health Plan OF Texas, Inc. | T1 | Yes | $4.80 | TX |
| Blue Cross Medicare Advantage Dual Care Plus (HMO D-SNP) | GHS Insurance Company | T1 | Yes | $5.00 | OK |
| Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) | Gateway Health Plan, Inc. | T1 | Yes | $13.10 | PA |
| Provider Partners Illinois Advantage Plan (HMO I-SNP) | Provider Partners Health Plan OF Illinois | T1 | Yes | $15.20 | IL |
| Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) | Gateway Health Plan, Inc. | T1 | Yes | $17.60 | PA |
| Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP) | Elderplan, Inc. | T1 | Yes | $22.70 | NY |
| VIVA Medicare Extra Value (HMO D-SNP) | Viva Health, Inc. | T1 | Yes | $27.70 | AL |
| VIVA Medicare Extra Care (HMO D-SNP) | Viva Health, Inc. | T1 | Yes | $27.70 | AL |
| Highmark Health Options Duals Select (HMO D-SNP) | Highmark Bcbsd, Inc. | T1 | Yes | $31.20 | DE |
Showing top 50 of 95 plans.
Frequently Asked Questions
Is sapropterin dihydrochloride 500 MG Powder for Oral Solution [Zelvysia] covered by Medicare Part D?
Yes, sapropterin dihydrochloride 500 MG Powder for Oral Solution [Zelvysia] is covered by 2,622 Medicare Part D plans (51.9% of all Part D formularies).
What tier is sapropterin dihydrochloride 500 MG Powder for Oral Solution [Zelvysia] on Medicare Part D plans?
sapropterin dihydrochloride 500 MG Powder for Oral Solution [Zelvysia] averages Tier 4.4 across Part D plans, ranging from Tier 1 to Tier 5.
Does sapropterin dihydrochloride 500 MG Powder for Oral Solution [Zelvysia] require prior authorization?
96.1% of Part D formularies require prior authorization for sapropterin dihydrochloride 500 MG Powder for Oral Solution [Zelvysia]. Step therapy: 0%. Quantity limits: 0%.
How much does Medicare spend on sapropterin dihydrochloride 500 MG Powder for Oral Solution [Zelvysia]?
In 2023, total Medicare Part D spending on sapropterin dihydrochloride 500 MG Powder for Oral Solution [Zelvysia] was $14,682,881, covering 137 beneficiaries. The average spend per beneficiary was $107,174.32.
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
- cysteamine 4.4 MG/ML Ophthalmic Solution [Cystaran] T4.4
- ceftaroline fosamil 600 MG Injection [Teflaro] T4.4
- eliglustat 84 MG Oral Capsule [Cerdelga] T4.4
- {28 (alpelisib 50 MG Oral Granules [Vijoice]) } Pack [Vijoice 50 MG Granules 28 Day] T4.4
- sofosbuvir 200 MG Oral Tablet [Sovaldi] T4.4
- sinecatechins 0.15 MG/MG Topical Ointment [Veregen] T4.4
Similar prior-authorization rate
- voriconazole 200 MG Injection 96% PA
- mechlorethamine 0.00016 MG/MG Topical Gel [Valchlor] 96% PA
- solriamfetol 75 MG Oral Tablet [Sunosi] 96.2% PA
- droxidopa 100 MG Oral Capsule 96.2% PA
- droxidopa 300 MG Oral Capsule 96.2% PA
- dasatinib 100 MG Oral Tablet [Phyrago] 96.2% PA