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Gocovri - Amantadine capsule, Coated Pellets
The Health Plan (of the Upper Ohio Valley)
The Health Plan (of the Upper Ohio Valley) Coverage for Gocovri - Amantadine capsule, Coated Pellets
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All
5
Commercial
3
Managed Medicaid
1
Medicare
1
Commercial
Commercial - HMO
PA Required
No Step Therapy
No Quantity Limit
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Commercial - PPO
PA Required
No Step Therapy
No Quantity Limit
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Commercial - Point of Service
PA Required
No Step Therapy
No Quantity Limit
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Managed Medicaid
Managed Medicaid - HMO - Medicaid
PA Required
Step Therapy
No Quantity Limit
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Medicare
Medicare - Medicare Advantage Part D
No PA
No Step Therapy
No Quantity Limit
See Details
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