EMGALITY 300 MG (100 MG X3SYR) SYRINGE (3 mls ) (NDC: 00002311509)
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 |
AARP Medicare Advantage Choice Plan 3 (PPO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:3 /30Days | $1,675.68 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BlueJourney Essential (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:3 /30Days | $1,515.09 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
BlueJourney Select (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:3 /30Days | $1,515.09 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $120.00 | P Q:3 /28Days | $1,569.18 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $120.00 | P Q:3 /28Days | $1,527.30 |
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 |
3 |
Preferred Brand |
$47.00 | $120.00 | P Q:3 /28Days | $1,569.18 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $120.00 | P Q:3 /28Days | $1,541.10 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $120.00 | P Q:3 /28Days | $1,569.06 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $120.00 | P Q:3 /28Days | $1,541.10 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $120.00 | P Q:3 /28Days | $1,569.06 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $120.00 | P Q:3 /28Days | $1,527.30 |
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 |
Geisinger Gold Classic 360 Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,503.72 |
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. |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,512.33 |
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. |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,506.24 |
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. |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,506.24 |
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. |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,512.33 |
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. |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,503.72 |
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. |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,512.33 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred 360 Rx (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,512.33 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred 360 Rx (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,512.33 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,512.33 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,503.72 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,512.33 |
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 Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,512.33 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,506.24 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,506.24 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Health Partners Medicare Complete (HMO-POS)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | P Q:3 /28Days | $1,526.01 |
Browse Plan Formulary |
Vibra Essential Advocate (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:3 /30Days | $1,510.62 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Vibra Essential Advocate (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:3 /30Days | $1,541.07 |
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 |
UPMC for Life HMO Deductible with Rx (HMO)
|
$22.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:3 /30Days | $1,528.59 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage (HMO)
|
$23.50 |
$130 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:3 /30Days | $1,675.68 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice Plan 1 (PPO)
|
$25.00 |
$95 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:3 /30Days | $1,675.68 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Vibra Health Plan Enhanced Complete (PPO)
|
$26.00 |
$0 |
No |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:3 /30Days | $1,516.17 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$30.10 |
$445 |
No |
4 |
Tier 4 |
$0.00 | $0.00 | P Q:3 /30Days | $1,675.62 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $120.00 | P Q:3 /28Days | $1,569.06 |
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 |
3 |
Preferred Brand |
$47.00 | $120.00 | P Q:3 /28Days | $1,527.30 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $120.00 | P Q:3 /28Days | $1,569.06 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $120.00 | P Q:3 /28Days | $1,541.10 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
|
$37.20 |
$445 |
No |
4 |
Tier 4 |
25% | 25% | P Q:3 /30Days | $1,675.59 |
Browse Plan Formulary |
AmeriHealth Caritas VIP Care (HMO D-SNP)
|
$37.40 |
$445 |
No |
2 |
Brand |
25% | 25% | P | $1,545.24 |
Browse Plan Formulary |
Geisinger Gold Secure Rx (HMO D-SNP)
|
$37.50 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | P Q:3 /30Days | $1,504.50 |
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 |
Health Partners Medicare Prime (HMO-POS)
|
$37.50 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | P Q:3 /28Days | $1,526.01 |
Browse Plan Formulary |
Health Partners Medicare Special (HMO D-SNP)
|
$37.50 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:3 /28Days | $1,526.01 |
Browse Plan Formulary |
UPMC for Life Complete Care (HMO D-SNP)
|
$37.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:3 /30Days | $1,537.32 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,512.33 |
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. |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,503.72 |
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. |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,512.33 |
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. |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,512.33 |
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. |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,506.24 |
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. |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,506.24 |
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 | P Q:3 /30Days | $1,528.59 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,506.24 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,503.72 |
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 |
BlueJourney Classic (PPO)
|
$49.00 |
$0 |
No |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:3 /30Days | $1,515.09 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
BlueJourney Value (HMO)
|
$51.00 |
$0 |
No |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:3 /30Days | $1,515.09 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
AARP Medicare Advantage Choice Plan 2 (PPO)
|
$58.00 |
$150 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:3 /30Days | $1,675.68 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UPMC for Life PPO Rx Enhanced (PPO)
|
$60.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:3 /30Days | $1,569.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Freedom Blue PPO ValueRx (PPO)
|
$70.00 |
$0 |
No |
3 |
Preferred Brand |
$45.00 | $115.00 | P Q:3 /28Days | $1,537.32 |
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 | P Q:3 /30Days | $1,528.59 |
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)
|
$85.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,512.33 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$85.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,506.24 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$85.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,506.24 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$85.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,512.33 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$85.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,503.72 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$85.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,512.33 |
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 |
BlueJourney Premier (HMO)
|
$106.00 |
$0 |
No |
3 |
Preferred Brand |
$40.00 | $80.00 | P Q:3 /30Days | $1,515.09 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$136.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,512.33 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$136.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,506.24 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$136.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,506.24 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$136.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,512.33 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$136.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,503.72 |
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)
|
$136.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | P Q:3 /30Days | $1,512.33 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BlueJourney Prime (PPO)
|
$171.00 |
$0 |
No |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:3 /30Days | $1,515.09 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Freedom Blue PPO Standard (PPO)
|
$175.00 |
$0 |
No |
3 |
Preferred Brand |
$45.00 | $115.00 | P Q:3 /28Days | $1,537.32 |
Browse Plan Formulary |
Freedom Blue PPO Deluxe (PPO)
|
$289.00 |
$0 |
No |
3 |
Preferred Brand |
$45.00 | $115.00 | P Q:3 /28Days | $1,537.32 |
Browse Plan Formulary |
UPMC for Life HMO Rx Enhanced (HMO)
|
$302.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:3 /30Days | $1,525.11 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |