ABILIFY MAINTENA ER 400 MG SUSER VIAL (1 unit ) (NDC: 59148001971)
2021 Medicare Prescription Drug Plan (MAPD) Information
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Plan Name |
Monthly Prem. |
De- duct- ible |
Does Plan Offer Additional Gap Coverage |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Plan’s Avg. Retail Drug Price 30-Day |
Tier Nbr. |
Tier Desc. |
30-Day Prfrd. Pharm |
90-Day Mail Order |
Aetna Medicare Advantra Credit Value (PPO)
|
$0.00 |
$250 |
No |
5 |
Specialty Tier |
28% | n/a | Q:1 /28Days | $2,519.41 |
Browse Plan Formulary |
Aetna Medicare Advantra Gold (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,522.22 |
Browse Plan Formulary |
Aetna Medicare Advantra Silver (PPO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,509.83 |
Browse Plan Formulary |
Aetna Medicare Value (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,519.75 |
Browse Plan Formulary |
Allwell Medicare (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,522.45 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Allwell Medicare (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,528.30 |
Browse Plan Formulary |
Allwell Medicare Boost (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,523.01 |
Browse Plan Formulary |
BlueJourney Essential (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,408.13 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,511.09 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,423.32 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,511.33 |
Browse Plan Formulary |
|
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,573.95 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,573.95 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,506.61 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,422.94 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,493.35 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,293.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,293.33 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,286.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,276.76 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,290.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,278.63 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,278.63 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,293.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,293.33 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,286.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,276.76 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,290.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5525-038 (PPO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,507.59 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Vibra Essential Advocate (PPO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,340.65 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Vibra Essential Advocate (PPO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,411.66 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
UPMC for Life HMO Deductible with Rx (HMO)
|
$22.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,388.73 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Premier (HMO)
|
$25.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,509.83 |
Browse Plan Formulary |
Vibra Health Plan Enhanced Complete (PPO)
|
$26.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,399.27 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Humana Value Plus H5525-039 (PPO)
|
$27.20 |
$400 |
No |
5 |
Specialty Tier |
25% | n/a | Q:1 /28Days | $2,509.16 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Allwell Medicare Complement (HMO)
|
$29.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | Q:1 /28Days | $2,526.37 |
Browse Plan Formulary |
HumanaChoice SNP-DE H5216-227 (PPO D-SNP)
|
$29.50 |
$425 |
No |
5 |
Specialty Tier |
25% | n/a | Q:1 /28Days | $2,504.91 |
Browse Plan Formulary |
HumanaChoice R0923-002 (Regional PPO)
|
$29.60 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,508.06 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$30.10 |
$445 |
No |
5 |
Tier 5 |
$0.00 | $0.00 | None | $2,534.16 |
Browse Plan Formulary |
Allwell Dual Medicare (HMO D-SNP)
|
$34.20 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | Q:1 /28Days | $2,522.38 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,573.95 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,506.61 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,422.94 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,493.35 |
Browse Plan Formulary |
UPMC for Life PPO High Deductible with Rx (PPO)
|
$35.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,395.69 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AmeriHealth Caritas VIP Care (HMO D-SNP)
|
$37.40 |
$445 |
No |
2 |
Brand |
25% | 25% | P Q:1 /28Days | $2,349.62 |
Browse Plan Formulary |
Geisinger Gold Secure Rx (HMO D-SNP)
|
$37.50 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | P Q:1 /28Days | $2,278.82 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
UPMC for Life Complete Care (HMO D-SNP)
|
$37.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | Q:1 /28Days | $2,393.62 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,276.76 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,290.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,278.63 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,293.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,293.33 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,286.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UPMC for Life HMO Rx Choice (HMO)
|
$40.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,388.73 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,278.81 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,279.62 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BlueJourney Classic (PPO)
|
$49.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,408.13 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
BlueJourney Value (HMO)
|
$51.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,408.13 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HumanaChoice H5525-007 (PPO)
|
$54.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,512.74 |
Browse Plan Formulary |
Aetna Medicare Silver (HMO)
|
$69.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,519.52 |
Browse Plan Formulary |
Freedom Blue PPO ValueRx (PPO)
|
$70.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,507.84 |
Browse Plan Formulary |
UPMC for Life HMO Rx (HMO)
|
$81.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,388.73 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BlueJourney Premier (HMO)
|
$106.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,408.13 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$115.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,293.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$115.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,293.33 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$115.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,286.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$115.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,276.76 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$115.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,290.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$115.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,278.63 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UPMC for Life PPO Rx Enhanced (PPO)
|
$136.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,395.69 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Geisinger Gold Classic Advantage Rx (HMO)
|
$166.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,293.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$166.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,293.33 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$166.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,286.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$166.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,276.76 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$166.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,290.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$166.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $2,278.63 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Aetna Medicare Gold Plan (PPO)
|
$169.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,519.52 |
Browse Plan Formulary |
BlueJourney Prime (PPO)
|
$171.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,408.13 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Freedom Blue PPO Standard (PPO)
|
$175.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,507.84 |
Browse Plan Formulary |
Freedom Blue PPO Deluxe (PPO)
|
$289.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,507.84 |
Browse Plan Formulary |
UPMC for Life HMO Rx Enhanced (HMO)
|
$302.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $2,393.78 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |