OXYCODONE HCL 5 MG/5 ML SOLUTION [Roxicodone] (500 ML ) (NDC: 00054039063)
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)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:3900 /30Days | $90.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Credit Value (PPO)
|
$0.00 |
$250 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:900 /30Days | $50.00 |
Browse Plan Formulary |
Aetna Medicare Advantra Gold (HMO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:900 /30Days | $50.00 |
Browse Plan Formulary |
Aetna Medicare Advantra Silver (PPO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:900 /30Days | $50.00 |
Browse Plan Formulary |
Aetna Medicare Value (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:900 /30Days | $50.00 |
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 |
Allwell Medicare (HMO)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:900 /30Days | $105.00 |
Browse Plan Formulary |
Allwell Medicare Boost (HMO)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:900 /30Days | $105.00 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 | No | 2 |
Generic |
$5.00 | $12.00 | P Q:4133 /31Days | $95.00 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 | No | 2 |
Generic |
$5.00 | $12.00 | P Q:4133 /31Days | $95.00 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:1300 /30Days | $35.00 |
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. | 2 |
Generic |
$20.00 | $30.00 | Q:1300 /30Days | $35.00 |
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 |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:1300 /30Days | $35.00 |
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. | 2 |
Generic |
$20.00 | $30.00 | Q:1300 /30Days | $35.00 |
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. | 2 |
Generic |
$20.00 | $30.00 | Q:1300 /30Days | $35.00 |
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. | 2 |
Generic |
$20.00 | $30.00 | Q:1300 /30Days | $35.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | No | 2 |
Generic |
$20.00 | $30.00 | Q:1300 /30Days | $35.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | No | 2 |
Generic |
$20.00 | $30.00 | Q:1300 /30Days | $35.00 |
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 |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | No | 2 |
Generic |
$20.00 | $30.00 | Q:1300 /30Days | $35.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | No | 2 |
Generic |
$20.00 | $30.00 | Q:1300 /30Days | $35.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | No | 2 |
Generic |
$20.00 | $30.00 | Q:1300 /30Days | $35.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | No | 2 |
Generic |
$20.00 | $30.00 | Q:1300 /30Days | $35.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5525-038 (PPO)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:5400 /30Days | $100.00 |
Browse Plan Formulary |
UPMC for Life HMO Premier Rx (HMO)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:900 /30Days | $85.00 |
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 |
UPMC for Life HMO Deductible with Rx (HMO)
|
$22.00 |
$0 | No | 2 |
Generic |
$10.00 | $20.00 | Q:900 /30Days | $85.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Premier (HMO)
|
$25.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:900 /30Days | $50.00 |
Browse Plan Formulary |
Humana Value Plus H5525-039 (PPO)
|
$27.20 |
$400 | No | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:5400 /30Days | $100.00 |
Browse Plan Formulary |
Aetna Medicare Advantra Cares (HMO D-SNP)
|
$27.30 |
$220 | No | 3 |
Preferred Brand |
25% | 25% | Q:900 /30Days | $50.00 |
Browse Plan Formulary |
HumanaChoice H5525-006 (PPO)
|
$28.00 |
$0 | No | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:5400 /30Days | $100.00 |
Browse Plan Formulary |
Allwell Medicare Complement (HMO)
|
$29.50 |
$445 | No | 4 |
Non-Preferred Drug |
50% | 50% | Q:900 /30Days | $105.00 |
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 SNP-DE H5216-227 (PPO D-SNP)
|
$29.50 |
$425 | No | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:5400 /30Days | $100.00 |
Browse Plan Formulary |
HumanaChoice R0923-002 (Regional PPO)
|
$29.60 |
$0 | No | 4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:5400 /30Days | $100.00 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$30.10 |
$445 | No | 4 |
Tier 4 |
$0.00 | $0.00 | Q:3900 /30Days | $90.00 |
Browse Plan Formulary |
AARP Medicare Advantage Choice (PPO)
|
$35.00 |
$0 | No | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:3900 /30Days | $90.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Plan 2 (HMO)
|
$35.00 |
$0 | No | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:3900 /30Days | $90.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Complete Blue PPO Distinct (PPO)
|
$35.00 |
$0 | No | 2 |
Generic |
$9.00 | $27.00 | P Q:4133 /31Days | $95.00 |
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 |
Complete Blue PPO Distinct (PPO)
|
$35.00 |
$0 | No | 2 |
Generic |
$9.00 | $27.00 | P Q:4133 /31Days | $95.00 |
Browse Plan Formulary |
UPMC for Life PPO High Deductible with Rx (PPO)
|
$35.00 |
$0 | No | 2 |
Generic |
$10.00 | $20.00 | Q:900 /30Days | $85.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
|
$37.20 |
$445 | No | 4 |
Tier 4 |
25% | 25% | Q:3900 /30Days | $90.00 |
Browse Plan Formulary |
AmeriHealth Caritas VIP Care (HMO D-SNP)
|
$37.40 |
$445 | No | 1 |
Generic |
$5.00 | $15.00 | Q:5400 /30Days | $65.00 |
Browse Plan Formulary |
Allwell Dual Medicare (HMO D-SNP)
|
$37.50 |
$445 | No | 4 |
Non-Preferred Drug |
42% | 42% | Q:900 /30Days | $105.00 |
Browse Plan Formulary |
Gateway Health Medicare Assured Diamond (HMO D-SNP)
|
$37.50 |
$445 | No | 4 |
Non-Preferred Drug |
49% | 49% | Q:3600 /30Days | $105.00 |
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 |
Gateway Health Medicare Assured Ruby (HMO D-SNP)
|
$37.50 |
$445 | No | 4 |
Non-Preferred Drug |
50% | 50% | Q:3600 /30Days | $105.00 |
Browse Plan Formulary |
Geisinger Gold Secure Rx (HMO D-SNP)
|
$37.50 |
$445 | No | 1 |
Tier 1 |
15% | 15% | Q:1300 /30Days | $35.00 |
Browse Plan Formulary |
UPMC for Life Complete Care (HMO D-SNP)
|
$37.50 |
$445 | No | 4 |
Non-Preferred Drug |
49% | 49% | Q:900 /30Days | $85.00 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:1300 /30Days | $35.00 |
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. | 2 |
Generic |
$20.00 | $30.00 | Q:1300 /30Days | $35.00 |
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. | 2 |
Generic |
$20.00 | $30.00 | Q:1300 /30Days | $35.00 |
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 |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:1300 /30Days | $35.00 |
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. | 2 |
Generic |
$20.00 | $30.00 | Q:1300 /30Days | $35.00 |
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. | 2 |
Generic |
$20.00 | $30.00 | Q:1300 /30Days | $35.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UPMC for Life HMO Rx Choice (HMO)
|
$40.00 |
$0 | No | 2 |
Generic |
$10.00 | $20.00 | Q:900 /30Days | $85.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 | No | 2 |
Generic |
$5.00 | $0.00 | Q:1300 /30Days | $35.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 | No | 2 |
Generic |
$5.00 | $0.00 | Q:1300 /30Days | $35.00 |
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 |
Aetna Medicare Advantra Premier Plus (PPO)
|
$47.00 |
$0 | No | 3 |
Preferred Brand |
$37.00 | $111.00 | Q:900 /30Days | $50.00 |
Browse Plan Formulary |
Security Blue HMO-POS ValueRx (HMO-POS)
|
$58.00 |
$0 | No | 2 |
Generic |
$13.00 | $27.00 | P Q:4133 /31Days | $95.00 |
Browse Plan Formulary |
Security Blue HMO-POS ValueRx (HMO-POS)
|
$58.00 |
$0 | No | 2 |
Generic |
$13.00 | $27.00 | P Q:4133 /31Days | $80.00 |
Browse Plan Formulary |
Aetna Medicare Silver (HMO)
|
$69.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:900 /30Days | $50.00 |
Browse Plan Formulary |
Freedom Blue PPO ValueRx (PPO)
|
$72.00 |
$0 | No | 2 |
Generic |
$13.00 | $27.00 | P Q:4133 /31Days | $95.00 |
Browse Plan Formulary |
UPMC for Life HMO Rx (HMO)
|
$81.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $20.00 | Q:900 /30Days | $85.00 |
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 |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$110.00 |
$0 | No | 2 |
Generic |
$20.00 | $30.00 | Q:1300 /30Days | $35.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$110.00 |
$0 | No | 2 |
Generic |
$20.00 | $30.00 | Q:1300 /30Days | $35.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$110.00 |
$0 | No | 2 |
Generic |
$20.00 | $30.00 | Q:1300 /30Days | $35.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$110.00 |
$0 | No | 2 |
Generic |
$20.00 | $30.00 | Q:1300 /30Days | $35.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$110.00 |
$0 | No | 2 |
Generic |
$20.00 | $30.00 | Q:1300 /30Days | $35.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$110.00 |
$0 | No | 2 |
Generic |
$20.00 | $30.00 | Q:1300 /30Days | $35.00 |
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 |
Freedom Blue PPO Select (PPO)
|
$131.00 |
$0 | No | 2 |
Generic |
$13.00 | $27.00 | P Q:4133 /31Days | $95.00 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$136.00 |
$0 | No | 2 |
Generic |
$10.00 | $20.00 | Q:900 /30Days | $85.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$159.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | Q:1300 /30Days | $35.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$159.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | Q:1300 /30Days | $35.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$159.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | Q:1300 /30Days | $35.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$159.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | Q:1300 /30Days | $35.00 |
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 |
Geisinger Gold Classic Advantage Rx (HMO)
|
$159.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | Q:1300 /30Days | $35.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$159.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | Q:1300 /30Days | $35.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Security Blue HMO-POS Standard (HMO-POS)
|
$165.00 |
$0 | No | 2 |
Generic |
$13.00 | $32.50 | P Q:4133 /31Days | $65.00 |
Browse Plan Formulary |
Security Blue HMO-POS Standard (HMO-POS)
|
$165.00 |
$0 | No | 2 |
Generic |
$13.00 | $32.50 | P Q:4133 /31Days | $85.00 |
Browse Plan Formulary |
Security Blue HMO-POS Standard (HMO-POS)
|
$165.00 |
$0 | No | 2 |
Generic |
$13.00 | $32.50 | P Q:4133 /31Days | $70.00 |
Browse Plan Formulary |
Aetna Medicare Gold Plan (PPO)
|
$169.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:900 /30Days | $50.00 |
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 |
Security Blue HMO-POS Deluxe (HMO-POS)
|
$225.00 |
$0 | No | 2 |
Generic |
$13.00 | $32.50 | P Q:4133 /31Days | $85.00 |
Browse Plan Formulary |
Security Blue HMO-POS Deluxe (HMO-POS)
|
$225.00 |
$0 | No | 2 |
Generic |
$13.00 | $32.50 | P Q:4133 /31Days | $70.00 |
Browse Plan Formulary |
Security Blue HMO-POS Deluxe (HMO-POS)
|
$225.00 |
$0 | No | 2 |
Generic |
$13.00 | $32.50 | P Q:4133 /31Days | $65.00 |
Browse Plan Formulary |
Freedom Blue PPO Classic (PPO)
|
$254.00 |
$0 | No | 2 |
Generic |
$13.00 | $27.00 | P Q:4133 /31Days | $95.00 |
Browse Plan Formulary |
UPMC for Life HMO Rx Enhanced (HMO)
|
$302.00 |
$0 | No | 2 |
Generic |
$10.00 | $20.00 | Q:900 /30Days | $85.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |