ICLUSIG 45 MG TABLET (tablets ) (NDC: 63020053430)
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 (HMO-POS)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $19,014.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice (PPO)
|
$0.00 |
$345 |
No |
5 |
Specialty Tier |
26% | n/a | P Q:30 /30Days | $19,014.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons Plan 1 (HMO-POS)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $19,014.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Choice Plan (PPO)
|
$0.00 |
$300 |
No |
5 |
Specialty Tier |
27% | n/a | P | $19,196.40 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$250 |
No |
5 |
Specialty Tier |
28% | n/a | P | $19,196.40 |
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 |
Allwell Medicare (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $19,157.10 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $19,392.60 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $19,392.60 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $19,392.60 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $19,392.60 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $19,392.60 |
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 | $18,271.20 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $19,392.60 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $19,392.60 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $18,271.20 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $19,392.60 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $19,392.60 |
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 | $19,392.60 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Choice Plus (PPO)
|
$0.00 |
$445 |
No |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days | $17,652.00 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Value (HMO)
|
$0.00 |
$200 |
No |
5 |
Specialty Tier |
29% | 29% | P Q:30 /30Days | $17,652.00 |
Browse Plan Formulary |
BSW SeniorCare Advantage Select Rx (HMO)
|
$0.00 |
$300 |
No |
5 |
Specialty Tier |
27% | n/a | P | $18,579.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Care N' Care Choice (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days | $18,678.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Care N' Care Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days | $18,678.60 |
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 |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$190 |
No |
5 |
Specialty Tier |
29% | n/a | P Q:30 /30Days | $18,681.60 |
Browse Plan Formulary |
Cigna Preferred Medicare (PPO)
|
$0.00 |
$190 |
No |
5 |
Specialty Tier |
29% | n/a | P Q:30 /30Days | $18,681.60 |
Browse Plan Formulary |
Erickson Advantage Liberty with Drugs (HMO-POS)
|
$0.00 |
$400 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $19,131.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H0028-043 (HMO)
|
$0.00 |
$200 |
No |
5 |
Specialty Tier |
29% | n/a | P Q:30 /30Days | $18,383.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H0028-043 (HMO)
|
$0.00 |
$200 |
No |
5 |
Specialty Tier |
29% | n/a | P Q:30 /30Days | $18,383.10 |
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 | P Q:30 /30Days | $18,066.60 |
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 |
Imperial Insurance Value (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $18,066.60 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
UnitedHealthcare Dual Complete Choice (Regional PPO D-SNP)
|
$0.00 |
$445 |
No |
5 |
Tier 5 |
$0.00 | $0.00 | P Q:30 /30Days | $19,131.00 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Ally (HMO-POS C-SNP)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $19,014.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
WellCare Premier (PPO)
|
$0.00 |
$200 |
No |
5 |
Specialty Tier |
29% | n/a | P Q:30 /30Days | $19,198.50 |
Browse Plan Formulary |
WellCare Rx Plus (PPO)
|
$0.00 |
$300 |
No |
5 |
Specialty Tier |
27% | n/a | P Q:30 /30Days | $18,271.20 |
Browse Plan Formulary |
WellCare TexanPlus Classic (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $19,152.90 |
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% | P Q:30 /30Days | $19,131.00 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$9.40 |
$445 |
No |
5 |
Tier 5 |
15% | 15% | P Q:30 /30Days | $18,681.60 |
Browse Plan Formulary |
HumanaChoice H5216-043 (PPO)
|
$10.00 |
$295 |
No |
5 |
Specialty Tier |
27% | n/a | P Q:30 /30Days | $18,383.10 |
Browse Plan Formulary |
HumanaChoice H5216-043 (PPO)
|
$10.00 |
$295 |
No |
5 |
Specialty Tier |
27% | n/a | P Q:30 /30Days | $18,383.10 |
Browse Plan Formulary |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP)
|
$11.70 |
$295 |
No |
5 |
Specialty Tier |
27% | n/a | P Q:30 /30Days | $19,131.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Allwell Medicare Complement (HMO)
|
$14.10 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $19,198.50 |
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 |
Aetna Medicare Choice II Plan (PPO)
|
$15.00 |
$300 |
No |
5 |
Specialty Tier |
27% | n/a | P | $19,196.40 |
Browse Plan Formulary |
Amerivantage Dual Secure (HMO D-SNP)
|
$16.40 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $19,392.60 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$19.40 |
$445 |
No |
5 |
Tier 5 |
15% | 15% | P Q:30 /30Days | $19,014.60 |
Browse Plan Formulary |
Allwell Dual Medicare Harmony (HMO D-SNP)
|
$20.30 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $19,198.50 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$20.60 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $19,392.60 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$20.60 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $19,392.60 |
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 | $19,392.60 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$20.60 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $19,392.60 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$20.60 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $19,392.60 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$20.60 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $18,271.20 |
Browse Plan Formulary |
Aetna Medicare Dual Complete Plan (HMO D-SNP)
|
$21.30 |
$220 |
No |
5 |
Specialty Tier |
29% | n/a | P | $19,196.40 |
Browse Plan Formulary |
Allwell Medicare Nurture (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $19,198.50 |
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 |
American Health Advantage of Texas (HMO I-SNP)
|
$22.50 |
$445 |
No |
1 |
Tier 1 |
25% | n/a | P Q:30 /30Days | $18,518.10 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $19,392.60 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $19,392.60 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $19,392.60 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $19,392.60 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $19,392.60 |
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 | $18,271.20 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $19,392.60 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $19,392.60 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $19,392.60 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $19,392.60 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $19,392.60 |
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 | $18,271.20 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H0028-031 (HMO D-SNP)
|
$22.50 |
$425 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $18,383.10 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H0028-032 (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $18,383.10 |
Browse Plan Formulary |
Imperial Insurance Company Dual (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $18,066.60 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $17,422.20 |
Browse Plan Formulary |
ProCare Advantage (HMO I-SNP)
|
$22.50 |
$445 |
No |
1 |
Tier 1 |
25% | n/a | P Q:30 /30Days | $17,803.50 |
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 |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$22.50 |
$445 |
No |
5 |
Tier 5 |
25% | 25% | P Q:30 /30Days | $19,131.00 |
Browse Plan Formulary |
WellCare Imperial (PPO D-SNP)
|
$22.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $18,271.20 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Dual Care Plus (HMO D-SNP)
|
$23.30 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:30 /30Days | $17,691.30 |
Browse Plan Formulary |
Erickson Advantage Guardian (HMO-POS I-SNP)
|
$28.80 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $19,131.00 |
Browse Plan Formulary select insulin pay $28 copay but not this drug |
BSW SeniorCare Advantage (PPO)
|
$37.00 |
$300 |
No |
5 |
Specialty Tier |
27% | n/a | P | $18,579.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice R4182-004 (Regional PPO)
|
$37.10 |
$175 |
No |
5 |
Specialty Tier |
30% | n/a | P Q:30 /30Days | $18,383.10 |
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 |
UnitedHealthcare Medicare Advantage Choice (Regional PPO)
|
$38.80 |
$395 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $19,131.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice R4182-003 (Regional PPO)
|
$41.00 |
$175 |
No |
5 |
Specialty Tier |
30% | n/a | P Q:30 /30Days | $18,383.10 |
Browse Plan Formulary |
Care N' Care Choice Plus (PPO)
|
$55.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days | $18,678.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Blue Cross Medicare Advantage Choice Premier (PPO)
|
$62.00 |
$295 |
No |
5 |
Specialty Tier |
27% | 27% | P Q:30 /30Days | $17,652.00 |
Browse Plan Formulary |
Erickson Advantage Freedom (HMO-POS)
|
$70.00 |
$200 |
No |
5 |
Specialty Tier |
29% | n/a | P Q:30 /30Days | $19,131.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons Plan 2 (HMO-POS)
|
$73.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $19,014.60 |
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 |
HumanaChoice H5216-042 (PPO)
|
$93.00 |
$175 |
No |
5 |
Specialty Tier |
30% | n/a | P Q:30 /30Days | $18,383.10 |
Browse Plan Formulary |
Humana Gold Choice H8145-084 (PFFS)
|
$96.00 |
$250 |
No |
5 |
Specialty Tier |
28% | n/a | P Q:30 /30Days | $18,383.10 |
Browse Plan Formulary |
Erickson Advantage Champion (HMO-POS C-SNP)
|
$199.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $19,131.00 |
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 | P Q:30 /30Days | $19,131.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Care N' Care Choice Premium (PPO)
|
$200.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days | $18,678.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |