Varies by plan

Does Optimum Healthcare, INC. require prior authorization for Koselugo?

Prior authorization for Koselugo differs across Optimum Healthcare, INC.'s Medicare Part D plans and product strengths — 3 of 4 Koselugo products in the corpus appear on their formularies, and the requirement is not uniform. Check the member's specific plan.

Some plans require authorization and others do not. The member's specific plan decides.

This drug does not appear on any of this payer's Medicare Part D formularies. That means it is NOT COVERED under those plans — which is a different and generally worse outcome than requiring prior authorization. An exception or formulary-exception request may still be possible.

By product strength

RxNorm product	Plans covering	Require prior auth	Status
selumetinib 10 MG Oral Capsule [Koselugo]2289424	15 / 15	15	Prior authorization required
selumetinib 25 MG Oral Capsule [Koselugo]2289428	15 / 15	15	Prior authorization required
selumetinib 5 MG Oral Granules [Koselugo]2723657	15 / 15	15	Prior authorization required
selumetinib 7.5 MG Oral Granules [Koselugo]2723661	0 / 15	0	Not on formulary

Product names come from RxNorm (U.S. National Library of Medicine).

Plan-by-plan detail — selumetinib 10 MG Oral Capsule [Koselugo]

Koselugo has 4 products in the corpus; this table is for selumetinib 10 MG Oral Capsule [Koselugo], the one carried on the most plans. The product table above covers every strength.

Plan	Contract	Tier	Prior auth	Step therapy	Qty limit
Optimum Diamond (HMO C-SNP)	H5594-036	4	Yes	No	No
Optimum Diamond Rewards (HMO C-SNP)	H5594-028	4	Yes	No	No
Optimum Diamond Rewards (HMO C-SNP)	H5594-034	4	Yes	No	No
Optimum Diamond Rewards COPD (HMO C-SNP)	H5594-029	4	Yes	No	No
Optimum Diamond Rewards COPD (HMO C-SNP)	H5594-035	4	Yes	No	No
Optimum Diamond Savings (HMO C-SNP)	H5594-030	4	Yes	No	No
Optimum Diamond Savings COPD (HMO C-SNP)	H5594-031	4	Yes	No	No
Optimum Emerald Full (HMO D-SNP)	H5594-017	4	Yes	No	No
Optimum Emerald Partial (HMO D-SNP)	H5594-016	4	Yes	No	No
Optimum Gold Plan (HMO)	H5594-019	4	Yes	No	No
Optimum Gold Plus Plan (HMO)	H5594-032	4	Yes	No	No
Optimum Gold Rewards Plan (HMO)	H5594-001	4	Yes	No	No
Optimum Gold Rewards Plan (HMO)	H5594-022	4	Yes	No	No
Optimum Gold Rewards Plan (HMO)	H5594-026	4	Yes	No	No
Optimum Platinum Plan (HMO)	H5594-002	4	Yes	No	No

Source

Monthly Prescription Drug Plan Formulary and Pharmacy Network Information — Basic Drugs Formulary File

Effective: 2026-06-30
Retrieved: 2026-07-19
SHA-256: e626e6bcda1aa6a0071e6f0df6bafe686ae41842cdf0a9feffdc649b6d3ff3ae

We publish the hash of the exact file we ingested so any answer can be audited against the bytes CMS served that day.

Koselugo at other payers

Or see Koselugo across every payer at once.

Administrative information only. Benefily reports what a payer has published in its own prior-authorization policy as of the effective date shown. It is not medical advice, not a coverage or payment guarantee, and not an authorization. Requirements vary by plan, place of service and member benefits — always verify with the payer before rendering service.