INTELENCE 25 MG TABLET (120 EA ) (NDC: 59676057201)
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 Value (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $1,134.00 |
Browse Plan Formulary |
Align Connect (HMO C-SNP)
|
$0.00 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | None | $1,083.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage Prime Value (HMO-POS)
|
$0.00 |
$50 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,062.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage Prime Value (HMO-POS)
|
$0.00 |
$50 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,062.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage Prime Value (HMO-POS)
|
$0.00 |
$50 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,062.00 |
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 |
BCN Advantage Prime Value (HMO-POS)
|
$0.00 |
$50 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,062.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage Prime Value (HMO-POS)
|
$0.00 |
$50 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,062.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HAP Choice Medicare - West Michigan Option 1 (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
48% | 48% | None | $1,062.00 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$100 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,062.00 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$100 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,062.00 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$100 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,062.00 |
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 |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$100 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,062.00 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$100 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,062.00 |
Browse Plan Formulary |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $95.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $95.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $95.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$100 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:120 /30Days | $1,058.40 |
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 |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$100 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$100 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$100 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$100 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:120 /30Days | $1,058.40 |
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 |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$445 |
No |
4 |
Non-Preferred Drug |
50% | 50% | None | $1,152.00 |
Browse Plan Formulary |
WellCare Essential (HMO-POS)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $1,152.00 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$13.00 |
$75 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$13.00 |
$75 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$13.00 |
$75 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary select insulin pay $15-$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 |
PriorityMedicare Value (HMO-POS)
|
$13.00 |
$75 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$13.00 |
$75 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
Aetna Medicare Premier (PPO)
|
$15.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $1,134.00 |
Browse Plan Formulary |
HumanaChoice H8087-001 (PPO)
|
$20.00 |
$75 |
No |
5 |
Specialty Tier |
31% | n/a | Q:120 /30Days | $1,087.20 |
Browse Plan Formulary |
Humana Value Plus H8087-002 (PPO)
|
$22.50 |
$260 |
No |
5 |
Specialty Tier |
28% | n/a | Q:120 /30Days | $1,087.20 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$23.00 |
$125 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:120 /30Days | $1,058.40 |
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 |
PriorityMedicare Ideal (PPO)
|
$23.00 |
$125 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$23.00 |
$125 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$23.00 |
$125 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$23.00 |
$125 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
HumanaChoice SNP-DE H8087-003 (PPO D-SNP)
|
$28.70 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | Q:120 /30Days | $1,087.20 |
Browse Plan Formulary |
HAP Choice Medicare - West Michigan Option 2 (HMO)
|
$30.00 |
$0 |
No |
4 |
Non-Preferred Drug |
48% | 48% | None | $1,062.00 |
Browse Plan Formulary select insulin pay $15-$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 |
Align Thrive (HMO I-SNP)
|
$30.10 |
$445 |
No |
1 |
Tier 1 |
25% | n/a | None | $1,083.60 |
Browse Plan Formulary |
Longevity Health Plan (HMO I-SNP)
|
$30.10 |
$445 |
No |
1 |
Tier 1 |
25% | n/a | None | $1,083.60 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$30.10 |
$445 |
No |
4 |
Non-Preferred Drug |
33% | 33% | None | $1,126.80 |
Browse Plan Formulary |
PriorityMedicare D-SNP (HMO D-SNP)
|
$30.10 |
$445 |
No |
3 |
Tier 3 |
$0.00 | $0.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$30.10 |
$445 |
No |
4 |
Tier 4 |
$0.00 | $0.00 | Q:120 /30Days | $1,123.20 |
Browse Plan Formulary |
WellCare Extra Plus (HMO-POS D-SNP)
|
$30.10 |
$445 |
No |
4 |
Non-Preferred Drug |
48% | 48% | None | $1,152.00 |
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 |
HumanaChoice R3887-002 (Regional PPO)
|
$32.40 |
$380 |
No |
5 |
Specialty Tier |
26% | n/a | Q:120 /30Days | $1,087.20 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$100 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,062.00 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$100 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,062.00 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$100 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,062.00 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$100 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,062.00 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$100 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,062.00 |
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 |
PriorityMedicare Merit (PPO)
|
$55.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$55.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$55.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$55.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$55.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
HumanaChoice H5216-009 (PPO)
|
$70.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,087.20 |
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 |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$80.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $114.00 | None | $1,062.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$80.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $114.00 | None | $1,062.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$80.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $114.00 | None | $1,062.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$80.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $114.00 | None | $1,062.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$80.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $114.00 | None | $1,062.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Choice H8145-006 (PFFS)
|
$81.00 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | Q:120 /30Days | $1,087.20 |
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 |
PriorityMedicare (HMO-POS)
|
$86.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $95.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$86.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $95.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$86.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $95.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$86.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $95.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$86.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $95.00 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$97.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,062.00 |
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 |
Medicare Plus Blue PPO Signature (PPO)
|
$97.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,062.00 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$97.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,062.00 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$97.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,062.00 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$97.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,062.00 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$149.00 |
$0 |
No |
3 |
Preferred Brand |
$37.00 | $92.50 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$149.00 |
$0 |
No |
3 |
Preferred Brand |
$37.00 | $92.50 | Q:120 /30Days | $1,058.40 |
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 |
PriorityMedicare Select (PPO)
|
$149.00 |
$0 |
No |
3 |
Preferred Brand |
$37.00 | $92.50 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$149.00 |
$0 |
No |
3 |
Preferred Brand |
$37.00 | $92.50 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$149.00 |
$0 |
No |
3 |
Preferred Brand |
$37.00 | $92.50 | Q:120 /30Days | $1,058.40 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$178.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $114.00 | None | $1,062.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$178.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $114.00 | None | $1,062.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$178.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $114.00 | None | $1,062.00 |
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 |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$178.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $114.00 | None | $1,062.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$178.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $114.00 | None | $1,062.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Medicare Plus Blue PPO Assure (PPO)
|
$200.00 |
$0 |
No |
3 |
Preferred Brand |
$37.00 | $111.00 | None | $1,062.00 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$200.00 |
$0 |
No |
3 |
Preferred Brand |
$37.00 | $111.00 | None | $1,062.00 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$200.00 |
$0 |
No |
3 |
Preferred Brand |
$37.00 | $111.00 | None | $1,062.00 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$200.00 |
$0 |
No |
3 |
Preferred Brand |
$37.00 | $111.00 | None | $1,062.00 |
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 |
Medicare Plus Blue PPO Assure (PPO)
|
$200.00 |
$0 |
No |
3 |
Preferred Brand |
$37.00 | $111.00 | None | $1,062.00 |
Browse Plan Formulary |