EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H (30 PATCHES CRTN) (NDC: 49502090030)
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 Plan 1 (HMO-POS)
|
$0.00 |
$195 |
No |
5 |
Specialty Tier |
29% | n/a | Q:30 /30Days | $1,966.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Plan 2 (HMO)
|
$0.00 |
$195 |
No |
5 |
Specialty Tier |
29% | n/a | Q:30 /30Days | $1,966.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Premier Plan (HMO)
|
$0.00 |
$250 |
No |
5 |
Specialty Tier |
28% | n/a | P Q:30 /30Days | $1,947.90 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$250 |
No |
5 |
Specialty Tier |
28% | n/a | P Q:30 /30Days | $1,947.90 |
Browse Plan Formulary |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$195 |
No |
5 |
Specialty Tier |
29% | n/a | P Q:30 /30Days | $1,947.90 |
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 |
Amerigroup Medicare-Medicaid Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | P Q:30 /30Days | $1,794.00 |
Browse Plan Formulary |
Amerivantage Care To You (HMO I-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,794.00 |
Browse Plan Formulary |
Amerivantage Care To You Plus (HMO I-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,794.00 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,928.70 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $2,007.00 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $2,007.00 |
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 |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,947.90 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,895.40 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,922.40 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,928.70 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $2,007.00 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $2,007.00 |
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 |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,947.90 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,895.40 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,922.40 |
Browse Plan Formulary |
Amerivantage Diabetes Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,941.90 |
Browse Plan Formulary |
Amerivantage Diabetes Care Plus (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,941.90 |
Browse Plan Formulary |
Amerivantage Heart Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,941.90 |
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 |
Amerivantage Heart Care Plus (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,941.90 |
Browse Plan Formulary |
Amerivantage Lung Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,941.90 |
Browse Plan Formulary |
Amerivantage Lung Care Plus (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,941.90 |
Browse Plan Formulary |
Amerivantage Select (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,923.60 |
Browse Plan Formulary |
Amerivantage Select Plus (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,923.60 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Basic (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | 33% | None | $1,805.40 |
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 |
Blue Cross Medicare Advantage Choice Plus (PPO)
|
$0.00 |
$445 |
No |
5 |
Specialty Tier |
25% | 25% | None | $1,806.30 |
Browse Plan Formulary |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$190 |
No |
5 |
Specialty Tier |
29% | n/a | Q:30 /30Days | $1,923.90 |
Browse Plan Formulary |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$190 |
No |
5 |
Specialty Tier |
29% | n/a | Q:30 /30Days | $1,943.70 |
Browse Plan Formulary |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$190 |
No |
5 |
Specialty Tier |
29% | n/a | Q:30 /30Days | $1,893.90 |
Browse Plan Formulary |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$190 |
No |
5 |
Specialty Tier |
29% | n/a | Q:30 /30Days | $1,892.10 |
Browse Plan Formulary |
Devoted Health Core Greater Houston (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,809.60 |
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 |
Erickson Advantage Liberty with Drugs (HMO-POS)
|
$0.00 |
$400 |
No |
5 |
Specialty Tier |
25% | n/a | Q:30 /30Days | $1,966.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H0028-042 (HMO)
|
$0.00 |
$195 |
No |
5 |
Specialty Tier |
29% | n/a | Q:30 /30Days | $1,950.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Imperial Insurance Company Traditional (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | S Q:30 /30Days | $1,870.20 |
Browse Plan Formulary |
Imperial Insurance Value (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | S Q:30 /30Days | $1,870.20 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
KelseyCare Advantage Rx (HMO)
|
$0.00 |
$100 |
No |
5 |
Specialty Tier |
31% | n/a | P Q:30 /30Days | $1,787.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Memorial Hermann Advantage (HMO)
|
$0.00 |
$300 |
No |
4 |
Non-Preferred Drug |
$92.00 | $184.00 | None | $1,829.10 |
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 |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | P Q:30 /30Days | $1,794.00 |
Browse Plan Formulary |
Oscar Easy Care (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,794.00 |
Browse Plan Formulary |
UnitedHealthcare Connected (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | Q:30 /30Days | $1,964.70 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice (Regional PPO D-SNP)
|
$0.00 |
$445 |
No |
5 |
Tier 5 |
$0.00 | $0.00 | Q:30 /30Days | $1,967.70 |
Browse Plan Formulary |
WellCare Dividend Prime (HMO)
|
$0.00 |
$300 |
No |
5 |
Specialty Tier |
27% | n/a | P Q:30 /30Days | $1,949.10 |
Browse Plan Formulary |
WellCare Guardian (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,947.90 |
Browse Plan Formulary select insulin pay $10 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 |
WellCare Premier (PPO)
|
$0.00 |
$200 |
No |
5 |
Specialty Tier |
29% | n/a | P Q:30 /30Days | $1,947.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
WellCare Rx Plus (PPO)
|
$0.00 |
$300 |
No |
5 |
Specialty Tier |
27% | n/a | P Q:30 /30Days | $1,948.80 |
Browse Plan Formulary |
WellCare TexanPlus Choice (HMO-POS)
|
$0.00 |
$250 |
No |
5 |
Specialty Tier |
28% | n/a | P Q:30 /30Days | $1,947.90 |
Browse Plan Formulary |
WellCare TexanPlus Classic (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,947.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
WellCare Value (HMO-POS)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,949.10 |
Browse Plan Formulary |
WellCare Value (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,947.90 |
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 |
UnitedHealthcare Medicare Silver (Regional PPO C-SNP)
|
$4.90 |
$445 |
No |
5 |
Tier 5 |
25% | 25% | Q:30 /30Days | $1,967.70 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$7.00 |
$445 |
No |
5 |
Tier 5 |
15% | 15% | Q:30 /30Days | $1,923.90 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$7.00 |
$445 |
No |
5 |
Tier 5 |
15% | 15% | Q:30 /30Days | $1,943.70 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$7.00 |
$445 |
No |
5 |
Tier 5 |
15% | 15% | Q:30 /30Days | $1,893.90 |
Browse Plan Formulary |
HumanaChoice H5216-043 (PPO)
|
$10.00 |
$295 |
No |
5 |
Specialty Tier |
27% | n/a | Q:30 /30Days | $1,936.80 |
Browse Plan Formulary |
HumanaChoice H5216-043 (PPO)
|
$10.00 |
$295 |
No |
5 |
Specialty Tier |
27% | n/a | Q:30 /30Days | $1,947.00 |
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 |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP)
|
$11.70 |
$295 |
No |
5 |
Specialty Tier |
27% | n/a | Q:30 /30Days | $1,967.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice (PPO)
|
$15.00 |
$245 |
No |
5 |
Specialty Tier |
28% | n/a | Q:30 /30Days | $1,966.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Amerivantage Choice (PPO)
|
$15.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,922.40 |
Browse Plan Formulary |
WellCare Compass (HMO)
|
$16.20 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,949.10 |
Browse Plan Formulary |
WellCare Access (HMO D-SNP)
|
$17.70 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,949.10 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$19.00 |
$300 |
No |
5 |
Specialty Tier |
27% | n/a | P Q:30 /30Days | $1,947.90 |
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 |
WellCare Liberty (HMO D-SNP)
|
$20.30 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,949.10 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$20.60 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,928.70 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$20.60 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $2,007.00 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$20.60 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $2,007.00 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$20.60 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,947.90 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$20.60 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,895.40 |
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 |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$20.60 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,922.40 |
Browse Plan Formulary |
Amerivantage Dual Secure (HMO D-SNP)
|
$21.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,922.40 |
Browse Plan Formulary |
Aetna Medicare Dual Complete Plan (HMO D-SNP)
|
$22.50 |
$220 |
No |
5 |
Specialty Tier |
29% | n/a | P Q:30 /30Days | $1,947.90 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,928.70 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $2,007.00 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $2,007.00 |
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 |
Amerivantage Dual Coordination (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,947.90 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,895.40 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,922.40 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,928.70 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $2,007.00 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $2,007.00 |
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 |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,947.90 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,895.40 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,922.40 |
Browse Plan Formulary |
Community Health Choice (HMO D-SNP)
|
$22.50 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | None | $1,840.50 |
Browse Plan Formulary |
Devoted Health Prime Greater Houston (HMO)
|
$22.50 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,809.60 |
Browse Plan Formulary select insulin pay $30 copay but not this drug |
Humana Gold Plus SNP-DE H0028-031 (HMO D-SNP)
|
$22.50 |
$425 |
No |
5 |
Specialty Tier |
25% | n/a | Q:30 /30Days | $1,946.40 |
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 |
Humana Gold Plus SNP-DE H0028-033 (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | Q:30 /30Days | $1,950.30 |
Browse Plan Formulary |
Imperial Insurance Company Dual (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | S Q:30 /30Days | $1,868.40 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,794.00 |
Browse Plan Formulary |
ProCare Advantage (HMO I-SNP)
|
$22.50 |
$445 |
No |
1 |
Tier 1 |
25% | n/a | None | $1,839.90 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Tier 5 |
$0.00 | $0.00 | Q:30 /30Days | $1,958.10 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Tier 5 |
$0.00 | $0.00 | Q:30 /30Days | $1,968.30 |
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 |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Tier 5 |
$0.00 | $0.00 | Q:30 /30Days | $1,966.50 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$22.50 |
$445 |
No |
5 |
Tier 5 |
25% | 25% | Q:30 /30Days | $1,967.40 |
Browse Plan Formulary |
WellCare Imperial (PPO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,948.80 |
Browse Plan Formulary |
Erickson Advantage Guardian (HMO-POS I-SNP)
|
$28.80 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:30 /30Days | $1,966.50 |
Browse Plan Formulary select insulin pay $28 copay but not this drug |
HumanaChoice R4182-004 (Regional PPO)
|
$37.10 |
$175 |
No |
5 |
Specialty Tier |
30% | n/a | Q:30 /30Days | $1,945.20 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice (Regional PPO)
|
$38.80 |
$395 |
No |
5 |
Specialty Tier |
25% | n/a | Q:30 /30Days | $1,967.70 |
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 |
HumanaChoice R4182-003 (Regional PPO)
|
$41.00 |
$175 |
No |
5 |
Specialty Tier |
30% | n/a | Q:30 /30Days | $1,945.20 |
Browse Plan Formulary |
Memorial Hermann Advantage Plus (HMO)
|
$50.00 |
$300 |
No |
4 |
Non-Preferred Drug |
$92.00 | $184.00 | None | $1,829.10 |
Browse Plan Formulary |
Erickson Advantage Freedom (HMO-POS)
|
$70.00 |
$200 |
No |
5 |
Specialty Tier |
29% | n/a | Q:30 /30Days | $1,966.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
KelseyCare Advantage Rx+Choice (HMO-POS)
|
$77.00 |
$100 |
No |
5 |
Specialty Tier |
31% | n/a | P Q:30 /30Days | $1,787.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Blue Cross Medicare Advantage Choice Premier (PPO)
|
$90.00 |
$295 |
No |
5 |
Specialty Tier |
27% | 27% | None | $1,806.30 |
Browse Plan Formulary |
HumanaChoice H5216-042 (PPO)
|
$93.00 |
$175 |
No |
5 |
Specialty Tier |
30% | n/a | Q:30 /30Days | $1,949.10 |
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 |
Humana Gold Choice H8145-084 (PFFS)
|
$96.00 |
$250 |
No |
5 |
Specialty Tier |
28% | n/a | Q:30 /30Days | $1,937.40 |
Browse Plan Formulary |
Erickson Advantage Champion (HMO-POS C-SNP)
|
$199.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:30 /30Days | $1,966.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Erickson Advantage Signature with Drugs (HMO-POS)
|
$199.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:30 /30Days | $1,966.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |