theophylline 400 MG Extended Release Oral Capsule [Theo-24]
theophylline
RxCUI: 844829
What the CMS Formulary Data Shows for theophylline 400 MG Extended Release Oral Capsule [Theo-24]
Per the CMS 2026 Part D formulary file, theophylline 400 MG Extended Release Oral Capsule [Theo-24] (RxNorm concept RXCUI 844829, generic name theophylline) appears on 25 distinct formulary files spanning 578 Medicare Part D plan offerings - 11.4% of enrollable Part D products, selective placement; verify formulary inclusion before enrolling. Tier placement ranges from Tier 1 to Tier 4, with a cross-plan average of Tier 3.6.
Real-world access to theophylline 400 MG Extended Release Oral Capsule [Theo-24] depends on utilization management as much as tier placement: 0% 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 39,063 Part D beneficiaries filled theophylline 400 MG Extended Release Oral Capsule [Theo-24] in 2023, with total plan-and-beneficiary spending of $24,909,786 and an average per-beneficiary annual cost of $637.68. The plan-by-plan detail below lists exactly which PDP and MA-PD contracts carry theophylline 400 MG Extended Release Oral Capsule [Theo-24] today.
Coverage Details
- Formularies covering
- 25
- Plans covering
- 578
- Coverage rate
- 11.4%
- Tier range
- Tier 1 – Tier 4
- Average tier
- Tier 4, Non-Preferred
Restrictions
- Prior authorization required
- 0% of formularies
- Step therapy required
- 0% of formularies
- Quantity limits
- 0% of formularies
2023 Medicare Spending
- Beneficiaries
- 39,063
- Total spending
- $24,909,786
- Avg per beneficiary
- $637.68
Tier Distribution Across Plans
Standalone Drug Plans (PDP) Covering theophylline 400 MG Extended Release Oral Capsule [Theo-24]
2 standalone prescription drug plans include this drug.
| Plan | Insurer | Tier | PA | ST | Premium | States |
|---|---|---|---|---|---|---|
| Blue Rx PDP Complete (PDP) | HM HEALTH INSURANCE COMPANY | T3 | No | No | $164.80 | - |
| Blue Rx PDP Plus (PDP) | HM HEALTH INSURANCE COMPANY | T3 | No | No | $193.20 | - |
Medicare Advantage Plans (MA-PD) Covering theophylline 400 MG Extended Release Oral Capsule [Theo-24]
98 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 | No | $0 | NY |
| Community Care's Partnership Program (HMO D-SNP) | COMMUNITY CARE HEALTH PLAN, INC. | T1 | No | $0 | WI |
| Hamaspik Medicare Select (HMO D-SNP) | HAMASPIK, INC. | T1 | No | $34.50 | NY |
| MMM Supremo (HMO C-SNP) | MMM HEALTHCARE, LLC | T2 | No | $0 | PR |
| MMM Diamante Platino (HMO D-SNP) | MMM HEALTHCARE, LLC | T2 | No | $0 | PR |
| MMM Unico (HMO-POS) | MMM HEALTHCARE, LLC | T2 | No | $0 | PR |
| MMM Elite (HMO-POS) | MMM HEALTHCARE, LLC | T2 | No | $0 | PR |
| MMM Deluxe (HMO-POS) | MMM HEALTHCARE, LLC | T2 | No | $0 | PR |
| MMM Dorado Platino (HMO D-SNP) | MMM HEALTHCARE, LLC | T2 | No | $0 | PR |
| PMC Premier Platino (HMO D-SNP) | MMM HEALTHCARE, LLC | T2 | No | $0 | PR |
| PMC Max (HMO-POS) | MMM HEALTHCARE, LLC | T2 | No | $0 | PR |
| MMM Plenitud (HMO-POS) | MMM HEALTHCARE, LLC | T2 | No | $0 | PR |
| MMM Valioso (HMO-POS) | MMM HEALTHCARE, LLC | T2 | No | $0 | PR |
| MMM Combo Platino (HMO D-SNP) | MMM HEALTHCARE, LLC | T2 | No | $0 | PR |
| MMM Flexi Platino (HMO D-SNP) | MMM HEALTHCARE, LLC | T2 | No | $0 | PR |
| MMM Grandioso (HMO-POS) | MMM HEALTHCARE, LLC | T2 | No | $0 | PR |
| MMM Mega Flex (HMO-POS) | MMM HEALTHCARE, LLC | T2 | No | $0 | PR |
| MMM Relax Platino (HMO D-SNP) | MMM HEALTHCARE, LLC | T2 | No | $0 | PR |
| MMM Balance (HMO-POS) | MMM HEALTHCARE, LLC | T2 | No | $0 | PR |
| Community Blue Medicare HMO Signature (HMO) | Highmark Western and Northeastern New York Inc. | T3 | No | $0 | NY |
| Community Blue Medicare HMO Merit (HMO) | Highmark Western and Northeastern New York Inc. | T3 | No | $0 | NY |
| Community Blue Medicare PPO Signature (PPO) | HIGHMARK SENIOR HEALTH COMPANY | T3 | No | $0 | PA |
| Complete Blue PPO Signature (PPO) | HIGHMARK SENIOR HEALTH COMPANY | T3 | No | $0 | PA |
| Community Blue Medicare Plus PPO Signature (PPO) | HIGHMARK SENIOR HEALTH COMPANY | T3 | No | $0 | PA |
| Complete Blue PPO Signature (PPO) | HIGHMARK SENIOR HEALTH COMPANY | T3 | No | $0 | PA |
| Complete Blue PPO Merit (PPO) | HIGHMARK SENIOR HEALTH COMPANY | T3 | No | $0 | PA |
| Complete Blue PPO Signature (PPO) | HIGHMARK SENIOR HEALTH COMPANY | T3 | No | $0 | PA |
| Complete Blue PPO Distinct (PPO) | HIGHMARK SENIOR HEALTH COMPANY | T3 | No | $0 | PA |
| Community Blue Medicare Plus PPO Signature (PPO) | HIGHMARK SENIOR HEALTH COMPANY | T3 | No | $0 | PA |
| Complete Blue Plus PPO Merit (PPO) | HIGHMARK SENIOR HEALTH COMPANY | T3 | No | $0 | PA |
| Community Blue Medicare PPO Signature (PPO) | HIGHMARK SENIOR HEALTH COMPANY | T3 | No | $0 | PA |
| Complete Blue PPO Merit (PPO) | HIGHMARK SENIOR HEALTH COMPANY | T3 | No | $0 | PA |
| Community Blue Medicare HMO Signature (HMO) | HIGHMARK CHOICE COMPANY | T3 | No | $0 | PA |
| Security Blue HMO-POS ValueRx (HMO-POS) | HIGHMARK CHOICE COMPANY | T3 | No | $0 | PA |
| Community Blue Medicare HMO Signature (HMO) | HIGHMARK CHOICE COMPANY | T3 | No | $0 | PA |
| Together Blue Medicare HMO Signature (HMO) | HIGHMARK CHOICE COMPANY | T3 | No | $0 | PA |
| Community Blue Medicare HMO Distinct (HMO) | HIGHMARK CHOICE COMPANY | T3 | No | $0 | PA |
| Complete Blue HMO Distinct (HMO) | HIGHMARK CHOICE COMPANY | T3 | No | $0 | PA |
| Complete Blue PPO Distinct (PPO) | HIGHMARK SENIOR SOLUTIONS COMPANY | T3 | No | $0 | WV |
| Complete Blue PPO Signature (PPO) | HIGHMARK SENIOR SOLUTIONS COMPANY | T3 | No | $0 | WV |
| Complete Blue PPO Signature (PPO) | HIGHMARK SENIOR SOLUTIONS COMPANY | T3 | No | $0 | WV |
| Complete Blue PPO Merit (PPO) | HIGHMARK SENIOR SOLUTIONS COMPANY | T3 | No | $0 | WV |
| Complete Blue PPO Signature (PPO) | HIGHMARK BCBSD INC. | T3 | No | $0 | DE |
| Senior Blue 652 (HMO) | Highmark Western and Northeastern New York Inc. | T3 | No | $0.40 | NY |
| Complete Blue PPO Distinct (PPO) | HIGHMARK SENIOR HEALTH COMPANY | T3 | No | $1.00 | PA |
| Complete Blue PPO Distinct (PPO) | HIGHMARK SENIOR HEALTH COMPANY | T3 | No | $6.00 | PA |
| Community Blue Medicare HMO Distinct (HMO) | Highmark Western and Northeastern New York Inc. | T3 | No | $6.80 | NY |
| Security Blue HMO-POS ValueRx (HMO-POS) | HIGHMARK CHOICE COMPANY | T3 | No | $10.00 | PA |
| Complete Blue PPO Distinct (PPO) | HIGHMARK SENIOR HEALTH COMPANY | T3 | No | $11.00 | PA |
| Complete Blue Plus PPO Distinct (PPO) | HIGHMARK SENIOR HEALTH COMPANY | T3 | No | $11.00 | PA |
Frequently Asked Questions
Is theophylline 400 MG Extended Release Oral Capsule [Theo-24] covered by Medicare Part D?
Yes, theophylline 400 MG Extended Release Oral Capsule [Theo-24] is covered by 578 Medicare Part D plans (11.4% of all Part D formularies).
What tier is theophylline 400 MG Extended Release Oral Capsule [Theo-24] on Medicare Part D plans?
theophylline 400 MG Extended Release Oral Capsule [Theo-24] averages Tier 3.6 across Part D plans, ranging from Tier 1 to Tier 4.
Does theophylline 400 MG Extended Release Oral Capsule [Theo-24] require prior authorization?
0% of Part D formularies require prior authorization for theophylline 400 MG Extended Release Oral Capsule [Theo-24]. Step therapy: 0%. Quantity limits: 0%.
How much does Medicare spend on theophylline 400 MG Extended Release Oral Capsule [Theo-24]?
In 2023, total Medicare Part D spending on theophylline 400 MG Extended Release Oral Capsule [Theo-24] was $24,909,786, covering 39,063 beneficiaries. The average spend per beneficiary was $637.68.
Read our methodology - how this data is sourced, computed, and verified.