XATMEP 2.5 MG/ML ORAL SOLUTION (120 ML ) (NDC: 52652200101)
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 |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P | $2,178.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice (PPO)
|
$0.00 |
$150 |
No |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P | $2,178.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice Plan 2 (Regional PPO)
|
$0.00 |
$395 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $2,190.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Choice (HMO-POS)
|
$0.00 |
$195 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $2,062.80 |
Browse Plan Formulary |
Aetna Medicare Premier (PPO)
|
$0.00 |
$300 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $2,062.80 |
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 |
Aetna Medicare Premier Plus (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $2,094.00 |
Browse Plan Formulary |
Aetna Medicare Select (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $2,094.00 |
Browse Plan Formulary select insulin pay $20 copay but not this drug |
Align Connect (HMO C-SNP)
|
$0.00 |
$445 |
No |
4 |
Non-Preferred Brand |
$95.00 | n/a | P | $1,996.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Align Thrive (HMO I-SNP)
|
$0.00 |
$445 |
No |
4 |
Non-Preferred Brand |
$95.00 | n/a | P | $1,996.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BlueMedicare Classic (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | P | $1,957.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BlueMedicare Premier (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | P | $1,957.20 |
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 |
BlueMedicare Saver (HMO)
|
$0.00 |
$50 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $1,958.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BlueMedicare Value (PPO)
|
$0.00 |
$150 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $1,958.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Bright Advantage Choice (PPO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | P | $2,121.60 |
Browse Plan Formulary |
Bright Advantage Health Dollars (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | P | $2,121.60 |
Browse Plan Formulary |
Bright Advantage Part B Savings (PPO)
|
$0.00 |
$400 |
No |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | P | $2,121.60 |
Browse Plan Formulary |
CareComplete (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $245.00 | P | $2,128.80 |
Browse Plan Formulary select insulin pay $20-$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 |
CareFree (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$85.00 | $245.00 | P | $2,128.80 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
CareOne PLATINUM (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $245.00 | P | $2,128.80 |
Browse Plan Formulary select insulin pay $0-$30 copay but not this drug |
CareOne PLUS (HMO-POS)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$85.00 | $245.00 | P | $2,128.80 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $2,037.60 |
Browse Plan Formulary |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $2,037.60 |
Browse Plan Formulary |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $2,037.60 |
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 |
Devoted Health Core Greater Orlando (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | P | $2,085.60 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Devoted Health Essentials Greater Orlando (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $2,085.60 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Freedom Platinum Plan Rx (HMO)
|
$0.00 |
$0 |
No |
3 |
Non-Preferred Drug |
$70.00 | $140.00 | None | $2,071.20 |
Browse Plan Formulary |
Freedom Platinum Rewards Plan Rx (HMO)
|
$0.00 |
$0 |
No |
3 |
Non-Preferred Drug |
$85.00 | $170.00 | None | $2,071.20 |
Browse Plan Formulary |
Freedom VIP Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Non-Preferred Drug |
$60.00 | $120.00 | None | $1,899.60 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Freedom VIP Savings (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Non-Preferred Drug |
$80.00 | $160.00 | None | $1,899.60 |
Browse Plan Formulary select insulin pay $0-$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 |
Freedom VIP Savings COPD (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Non-Preferred Drug |
$60.00 | $120.00 | None | $1,899.60 |
Browse Plan Formulary |
Humana Gold Plus H1036-146 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $245.00 | P | $2,004.00 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
Humana Gold Plus H1036-269 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P | $2,128.80 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
HumanaChoice Florida H5216-072 (PPO)
|
$0.00 |
$150 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $2,004.00 |
Browse Plan Formulary |
HumanaChoice R5826-074 (Regional PPO)
|
$0.00 |
$395 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $2,082.00 |
Browse Plan Formulary |
Optimum Diamond Rewards (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Non-Preferred Drug |
$80.00 | $160.00 | None | $1,899.60 |
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 |
Optimum Diamond Rewards COPD (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Non-Preferred Drug |
$80.00 | $160.00 | None | $1,899.60 |
Browse Plan Formulary |
Optimum Gold Rewards Plan (HMO)
|
$0.00 |
$0 |
No |
3 |
Non-Preferred Drug |
$85.00 | $170.00 | None | $2,071.20 |
Browse Plan Formulary |
Simply Care (HMO I-SNP)
|
$0.00 |
$445 |
No |
4 |
Non-Preferred Brand |
25% | n/a | None | $2,073.60 |
Browse Plan Formulary |
Simply Comfort (HMO I-SNP)
|
$0.00 |
$445 |
No |
4 |
Non-Preferred Brand |
25% | n/a | None | $2,073.60 |
Browse Plan Formulary |
Simply Level (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$75.00 | n/a | None | $2,073.60 |
Browse Plan Formulary |
Simply More (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Brand |
$75.00 | n/a | None | $2,073.60 |
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 |
SOLIS SPF 005 (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Brand |
$85.00 | n/a | P | $1,996.80 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $2,172.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $2,172.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $2,191.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $2,172.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
WellCare Champion (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$80.00 | $160.00 | P | $2,122.80 |
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 Dividend Prime (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P | $2,122.80 |
Browse Plan Formulary |
WellCare Elite (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $150.00 | P | $2,122.80 |
Browse Plan Formulary |
WellCare Guardian (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $150.00 | P | $2,122.80 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
WellCare Premier (PPO)
|
$0.00 |
$100 |
No |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | P | $2,122.80 |
Browse Plan Formulary |
CareNeeds PLUS (HMO D-SNP)
|
$14.00 |
$445 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $2,128.80 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$18.50 |
$445 |
No |
4 |
Non-Preferred Drug |
44% | 44% | P | $2,037.60 |
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 |
Cigna Primary Medicare (HMO)
|
$18.90 |
$445 |
No |
4 |
Non-Preferred Drug |
39% | 39% | P | $2,037.60 |
Browse Plan Formulary |
Humana Fully Integrated H1036-283 (HMO D-SNP)
|
$19.50 |
$445 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $2,128.80 |
Browse Plan Formulary |
Aetna Medicare Assure (HMO D-SNP)
|
$22.20 |
$250 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $2,096.40 |
Browse Plan Formulary |
Allwell Dual Medicare (HMO D-SNP)
|
$25.00 |
$445 |
No |
4 |
Non-Preferred Drug |
47% | 47% | P | $2,122.80 |
Browse Plan Formulary |
Aetna Medicare Assure Plus (HMO D-SNP)
|
$28.00 |
$250 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $2,096.40 |
Browse Plan Formulary |
WellCare Access (HMO D-SNP)
|
$28.10 |
$445 |
No |
4 |
Non-Preferred Drug |
50% | 50% | P | $2,062.80 |
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 |
WellCare Reserve (HMO D-SNP)
|
$29.20 |
$445 |
No |
4 |
Non-Preferred Drug |
49% | 49% | P | $2,122.80 |
Browse Plan Formulary |
WellCare Select (HMO D-SNP)
|
$29.40 |
$445 |
No |
4 |
Non-Preferred Drug |
45% | 45% | P | $2,122.80 |
Browse Plan Formulary |
WellCare Select (HMO D-SNP)
|
$29.40 |
$445 |
No |
4 |
Non-Preferred Drug |
45% | 45% | P | $2,122.80 |
Browse Plan Formulary |
WellCare Select (HMO D-SNP)
|
$29.40 |
$445 |
No |
4 |
Non-Preferred Drug |
45% | 45% | P | $2,122.80 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-213 (HMO D-SNP)
|
$29.60 |
$445 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $2,128.80 |
Browse Plan Formulary |
Simply Complete (HMO D-SNP)
|
$29.80 |
$445 |
No |
4 |
Non-Preferred Brand |
$95.00 | n/a | None | $2,086.80 |
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 |
WellCare Liberty (HMO D-SNP)
|
$30.50 |
$445 |
No |
4 |
Non-Preferred Drug |
50% | 50% | P | $2,062.80 |
Browse Plan Formulary |
Devoted Health Dual Greater Orlando (HMO D-SNP)
|
$30.70 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | P | $2,085.60 |
Browse Plan Formulary |
Allwell Medicare Nurture (HMO D-SNP)
|
$30.80 |
$445 |
No |
4 |
Non-Preferred Drug |
49% | 49% | P | $2,062.80 |
Browse Plan Formulary |
BlueMedicare Complete (HMO D-SNP)
|
$30.80 |
$445 |
No |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | P | $1,954.80 |
Browse Plan Formulary |
Devoted Health Prime Greater Orlando (HMO)
|
$30.80 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | P | $2,085.60 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Freedom Medi-Medi Full (HMO D-SNP)
|
$30.80 |
$445 |
No |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,899.60 |
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 |
Freedom Medi-Medi Partial (HMO D-SNP)
|
$30.80 |
$445 |
No |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,899.60 |
Browse Plan Formulary |
Longevity Health Plan (HMO I-SNP)
|
$30.80 |
$445 |
No |
1 |
Tier 1 |
25% | n/a | P | $1,996.80 |
Browse Plan Formulary |
Optimum Emerald Full (HMO D-SNP)
|
$30.80 |
$445 |
No |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,899.60 |
Browse Plan Formulary |
Optimum Emerald Partial (HMO D-SNP)
|
$30.80 |
$445 |
No |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,899.60 |
Browse Plan Formulary |
Simply Select (HMO)
|
$30.80 |
$445 |
No |
4 |
Non-Preferred Brand |
25% | n/a | None | $2,073.60 |
Browse Plan Formulary |
SOLIS SPF 006 (HMO D-SNP)
|
$30.80 |
$0 |
No |
4 |
Non-Preferred Brand |
25% | n/a | P | $1,996.80 |
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 |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$30.80 |
$200 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $2,188.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$30.80 |
$445 |
No |
4 |
Tier 4 |
15% | 15% | P | $2,178.00 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$30.80 |
$445 |
No |
4 |
Tier 4 |
15% | 15% | P | $2,190.00 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP (HMO D-SNP)
|
$30.80 |
$445 |
No |
4 |
Tier 4 |
15% | 15% | P | $2,188.80 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO D-SNP)
|
$30.80 |
$445 |
No |
4 |
Tier 4 |
15% | 15% | P | $2,190.00 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$30.80 |
$445 |
No |
4 |
Tier 4 |
25% | 25% | P | $2,190.00 |
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 R5826-005 (Regional PPO)
|
$42.90 |
$100 |
No |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P | $2,082.00 |
Browse Plan Formulary |
BlueMedicare Choice (Regional PPO)
|
$47.90 |
$250 |
No |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | P | $1,929.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
WellCare Prime (PPO)
|
$75.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | P | $2,122.80 |
Browse Plan Formulary |
Humana Gold Choice H8145-061 (PFFS)
|
$101.00 |
$200 |
No |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | P | $2,128.80 |
Browse Plan Formulary |
BlueMedicare Select (PPO)
|
$146.80 |
$305 |
No |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | P | $1,929.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |