VELTASSA 8.4 GM POWDER PACKET (30.000 EA ) (NDC: 53436008430)
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 2 (PPO)
|
$0.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | Q:30 /30Days | $1,341.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Credit Value (PPO)
|
$0.00 |
$250 | No | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:90 /30Days | $1,037.10 |
Browse Plan Formulary |
Aetna Medicare Advantra Value (HMO)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:90 /30Days | $1,037.40 |
Browse Plan Formulary |
Aetna Medicare Elite (HMO)
|
$0.00 |
$150 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:90 /30Days | $1,037.40 |
Browse Plan Formulary |
Aetna Medicare Value (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:90 /30Days | $1,036.80 |
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 | P | $1,036.50 |
Browse Plan Formulary |
Allwell Medicare (HMO)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $1,036.50 |
Browse Plan Formulary |
Allwell Medicare Boost (HMO)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $1,036.50 |
Browse Plan Formulary |
Cigna Achieve Medicare (HMO C-SNP)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,327.80 |
Browse Plan Formulary |
Cigna Alliance Medicare (HMO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,327.80 |
Browse Plan Formulary |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,327.80 |
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 |
Clover Health Choice (PPO)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Drug |
$95.00 | $275.00 | P | $927.90 |
Browse Plan Formulary |
Erickson Advantage Liberty with Drugs (HMO-POS)
|
$0.00 |
$400 | No | 5 |
Specialty Tier |
25% | n/a | Q:30 /30Days | $1,316.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic 360 Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $904.20 |
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. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $905.70 |
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. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $906.60 |
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. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $905.70 |
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 |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $903.60 |
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. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $901.20 |
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. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $904.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $904.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $905.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $901.20 |
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 | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $903.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $905.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $906.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Health Partners Medicare Complete (HMO-POS)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $916.50 |
Browse Plan Formulary |
Keystone 65 Basic Rx (HMO)
|
$0.00 |
$0 | No | 5 |
Specialty Tier |
33% | 33% | None | $1,249.80 |
Browse Plan Formulary |
Keystone 65 Focus Rx (HMO-POS)
|
$0.00 |
$0 | No | 5 |
Specialty Tier |
33% | 33% | None | $1,249.80 |
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 |
Personal Choice 65 Prime Rx (PPO)
|
$0.00 |
$0 | No | 5 |
Specialty Tier |
33% | 33% | None | $1,249.80 |
Browse Plan Formulary |
Cigna Traditions Medicare (HMO I-SNP)
|
$24.50 |
$445 | No | 3 |
Tier 3 |
25% | n/a | None | $1,327.80 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$25.50 |
$445 | No | 3 |
Tier 3 |
15% | 15% | None | $1,327.80 |
Browse Plan Formulary |
Erickson Advantage Guardian (HMO-POS I-SNP)
|
$28.80 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | Q:30 /30Days | $1,316.40 |
Browse Plan Formulary select insulin pay $28 copay but not this drug |
AARP Medicare Advantage (HMO)
|
$29.00 |
$200 | No | 5 |
Specialty Tier |
29% | n/a | Q:30 /30Days | $1,341.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Cigna Preferred Medicare (HMO)
|
$29.00 |
$0 | No | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,327.80 |
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 Complement (HMO)
|
$29.50 |
$445 | No | 4 |
Non-Preferred Drug |
50% | 50% | P | $1,036.50 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$30.10 |
$445 | No | 5 |
Tier 5 |
$0.00 | $0.00 | Q:30 /30Days | $1,337.40 |
Browse Plan Formulary |
Aetna Medicare Advantra Cares (HMO D-SNP)
|
$30.90 |
$130 | No | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:90 /30Days | $1,037.40 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
|
$37.20 |
$445 | No | 5 |
Tier 5 |
25% | 25% | Q:30 /30Days | $1,338.30 |
Browse Plan Formulary |
Allwell Dual Medicare (HMO D-SNP)
|
$37.50 |
$445 | No | 4 |
Non-Preferred Drug |
45% | 45% | P | $1,036.50 |
Browse Plan Formulary |
Clover Health Choice Value (PPO)
|
$37.50 |
$445 | No | 4 |
Non-Preferred Drug |
25% | 25% | P | $927.90 |
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 |
Gateway Health Medicare Assured Diamond (HMO D-SNP)
|
$37.50 |
$445 | No | 3 |
Preferred Brand |
$38.00 | $114.00 | Q:30 /30Days | $893.70 |
Browse Plan Formulary |
Gateway Health Medicare Assured Ruby (HMO D-SNP)
|
$37.50 |
$445 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $893.70 |
Browse Plan Formulary |
Geisinger Gold Secure Rx (HMO D-SNP)
|
$37.50 |
$445 | No | 1 |
Tier 1 |
15% | 15% | P Q:30 /30Days | $904.20 |
Browse Plan Formulary |
Health Partners Medicare Prime (HMO-POS)
|
$37.50 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $916.50 |
Browse Plan Formulary |
Health Partners Medicare Special (HMO D-SNP)
|
$37.50 |
$445 | No | 1 |
Tier 1 |
$0.00 | $0.00 | None | $916.50 |
Browse Plan Formulary |
UPMC for Life Complete Care (HMO D-SNP)
|
$37.50 |
$445 | No | 4 |
Non-Preferred Drug |
49% | 49% | Q:30 /30Days | $1,241.70 |
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 Complete Rx (HMO)
|
$38.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $904.50 |
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. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $905.70 |
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. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $901.20 |
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. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $906.60 |
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. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $905.70 |
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. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $903.60 |
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 |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $905.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $903.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Premier (HMO)
|
$49.00 |
$150 | No | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:90 /30Days | $1,037.40 |
Browse Plan Formulary |
Aetna Medicare Advantra Premier Plus (PPO)
|
$49.00 |
$0 | No | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:90 /30Days | $1,037.40 |
Browse Plan Formulary |
Keystone 65 Select Rx (HMO)
|
$56.50 |
$0 | No | 5 |
Specialty Tier |
33% | 33% | None | $1,249.80 |
Browse Plan Formulary |
AARP Medicare Advantage Choice Plan 1 (PPO)
|
$58.00 |
$295 | No | 5 |
Specialty Tier |
27% | n/a | Q:30 /30Days | $1,341.30 |
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 True Choice Plus Medicare (PPO)
|
$59.00 |
$0 | No | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,327.80 |
Browse Plan Formulary |
Aetna Medicare Silver (HMO)
|
$69.00 |
$0 | No | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:90 /30Days | $1,037.10 |
Browse Plan Formulary |
Erickson Advantage Freedom (HMO-POS)
|
$70.00 |
$200 | No | 5 |
Specialty Tier |
29% | n/a | Q:30 /30Days | $1,316.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$85.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $901.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$85.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $905.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$85.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $904.50 |
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 | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $903.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$85.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $905.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$85.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $906.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Premier (HMO)
|
$100.00 |
$0 | No | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:90 /30Days | $1,037.40 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$136.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $901.20 |
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. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $903.60 |
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 |
Geisinger Gold Classic Advantage Rx (HMO)
|
$136.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $905.70 |
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. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $906.60 |
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. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $905.70 |
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. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $904.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Cigna Preferred Plus Medicare (HMO)
|
$139.00 |
$0 | No | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,327.80 |
Browse Plan Formulary |
Aetna Medicare Gold Plan (PPO)
|
$169.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:90 /30Days | $1,037.10 |
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 |
Aetna Medicare Premier Plus (HMO)
|
$185.00 |
$0 | No | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:90 /30Days | $1,037.40 |
Browse Plan Formulary |
Erickson Advantage Champion (HMO-POS C-SNP)
|
$199.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | Q:30 /30Days | $1,316.70 |
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 | $1,316.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Keystone 65 Preferred Rx (HMO)
|
$230.00 |
$0 | No | 5 |
Specialty Tier |
33% | 33% | None | $1,249.80 |
Browse Plan Formulary |
Personal Choice 65 Rx (PPO)
|
$290.00 |
$0 | No | 5 |
Specialty Tier |
33% | 33% | None | $1,249.80 |
Browse Plan Formulary |