HYDROMORPHONE 4 MG TABLET [Dilaudid] (100.000 EA ) (NDC: 00406324401)
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 Advantra Credit Value (PPO)
|
$0.00 |
$250 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days | $72.00 |
Browse Plan Formulary |
Aetna Medicare Advantra Gold (HMO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days | $64.80 |
Browse Plan Formulary |
Aetna Medicare Advantra Silver (PPO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days | $63.00 |
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:180 /30Days | $73.80 |
Browse Plan Formulary |
Allwell Medicare (HMO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days | $19.80 |
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 | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days | $19.80 |
Browse Plan Formulary |
Allwell Medicare Boost (HMO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days | $19.80 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 | No | 2 |
Generic |
$5.00 | $12.00 | P Q:186 /31Days | $32.40 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 | No | 2 |
Generic |
$5.00 | $12.00 | P Q:186 /31Days | $32.40 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 | No | 2 |
Generic |
$5.00 | $12.00 | P Q:186 /31Days | $28.80 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 | No | 2 |
Generic |
$5.00 | $12.00 | P Q:186 /31Days | $28.80 |
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 |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 | No | 2 |
Generic |
$5.00 | $12.00 | P Q:186 /31Days | $32.40 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 | No | 2 |
Generic |
$5.00 | $12.00 | P Q:186 /31Days | $32.40 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 | No | 2 |
Generic |
$5.00 | $12.00 | P Q:186 /31Days | $30.60 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 | No | 2 |
Generic |
$5.00 | $12.00 | P Q:186 /31Days | $28.80 |
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:180 /30Days | $10.80 |
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:180 /30Days | $10.80 |
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:180 /30Days | $10.80 |
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:180 /30Days | $10.80 |
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:180 /30Days | $10.80 |
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:180 /30Days | $10.80 |
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:180 /30Days | $10.80 |
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:180 /30Days | $10.80 |
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:180 /30Days | $10.80 |
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:180 /30Days | $10.80 |
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:180 /30Days | $10.80 |
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:180 /30Days | $10.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H6622-052 (HMO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $18.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5525-038 (PPO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $18.00 |
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 |
Vibra Essential Advocate (PPO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$40.00 | $120.00 | Q:180 /30Days | $27.00 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Vibra Essential Advocate (PPO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$40.00 | $120.00 | Q:180 /30Days | $27.00 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Humana Gold Choice H8145-052 (PFFS)
|
$8.00 |
$360 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $18.00 |
Browse Plan Formulary |
Aetna Medicare Advantra Silver Plus (PPO)
|
$19.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days | $63.00 |
Browse Plan Formulary |
UPMC for Life HMO Deductible with Rx (HMO)
|
$22.00 |
$0 | No | 2 |
Generic |
$10.00 | $20.00 | Q:180 /30Days | $28.80 |
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:180 /30Days | $63.00 |
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 |
Vibra Health Plan Enhanced Complete (PPO)
|
$26.00 |
$0 | No | 3 |
Preferred Brand |
$40.00 | $120.00 | Q:180 /30Days | $27.00 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Humana Gold Plus SNP-DE H6622-038 (HMO D-SNP)
|
$26.10 |
$445 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $18.00 |
Browse Plan Formulary |
Humana Value Plus H5216-117 (PPO)
|
$26.90 |
$420 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $18.00 |
Browse Plan Formulary |
Allwell Medicare Complement (HMO)
|
$29.50 |
$445 | No | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /30Days | $19.80 |
Browse Plan Formulary |
HumanaChoice R0923-002 (Regional PPO)
|
$29.60 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $18.00 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$30.10 |
$445 | No | 2 |
Tier 2 |
$0.00 | $0.00 | Q:240 /30Days | $68.40 |
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 Dual Medicare (HMO D-SNP)
|
$34.20 |
$445 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days | $19.80 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 | No | 2 |
Generic |
$5.00 | $12.00 | P Q:186 /31Days | $28.80 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 | No | 2 |
Generic |
$5.00 | $12.00 | P Q:186 /31Days | $32.40 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 | No | 2 |
Generic |
$5.00 | $12.00 | P Q:186 /31Days | $32.40 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 | No | 2 |
Generic |
$5.00 | $12.00 | P Q:186 /31Days | $30.60 |
Browse Plan Formulary |
AmeriHealth Caritas VIP Care (HMO D-SNP)
|
$37.40 |
$445 | No | 1 |
Generic |
$5.00 | $15.00 | Q:120 /30Days | $19.80 |
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 |
Geisinger Gold Secure Rx (HMO D-SNP)
|
$37.50 |
$445 | No | 1 |
Tier 1 |
15% | 15% | Q:180 /30Days | $10.80 |
Browse Plan Formulary |
UPMC for Life Complete Care (HMO D-SNP)
|
$37.50 |
$445 | No | 3 |
Preferred Brand |
$18.00 | $45.00 | Q:180 /30Days | $28.80 |
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:180 /30Days | $10.80 |
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:180 /30Days | $10.80 |
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:180 /30Days | $10.80 |
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:180 /30Days | $10.80 |
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:180 /30Days | $10.80 |
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:180 /30Days | $10.80 |
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:180 /30Days | $28.80 |
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:180 /30Days | $10.80 |
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:180 /30Days | $10.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Premier Plus (PPO)
|
$47.00 |
$0 | No | 3 |
Preferred Brand |
$37.00 | $111.00 | Q:180 /30Days | $63.00 |
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 H5525-007 (PPO)
|
$54.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $18.00 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$60.00 |
$0 | No | 2 |
Generic |
$10.00 | $20.00 | Q:180 /30Days | $28.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Silver (HMO)
|
$69.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days | $63.00 |
Browse Plan Formulary |
Freedom Blue PPO ValueRx (PPO)
|
$70.00 |
$0 | No | 2 |
Generic |
$13.00 | $27.00 | P Q:186 /31Days | $32.40 |
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:180 /30Days | $28.80 |
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:180 /30Days | $10.80 |
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:180 /30Days | $10.80 |
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:180 /30Days | $10.80 |
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:180 /30Days | $10.80 |
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:180 /30Days | $10.80 |
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:180 /30Days | $10.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$121.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | Q:180 /30Days | $10.80 |
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)
|
$121.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | Q:180 /30Days | $10.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$121.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | Q:180 /30Days | $10.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$121.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | Q:180 /30Days | $10.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$121.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | Q:180 /30Days | $10.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$121.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | Q:180 /30Days | $10.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-120 (PPO)
|
$127.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $18.00 |
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 |
Aetna Medicare Gold Plan (PPO)
|
$169.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days | $72.00 |
Browse Plan Formulary |
Freedom Blue PPO Standard (PPO)
|
$175.00 |
$0 | No | 2 |
Generic |
$13.00 | $27.00 | P Q:186 /31Days | $32.40 |
Browse Plan Formulary |
Freedom Blue PPO Deluxe (PPO)
|
$289.00 |
$0 | No | 2 |
Generic |
$13.00 | $27.00 | P Q:186 /31Days | $32.40 |
Browse Plan Formulary |
UPMC for Life HMO Rx Enhanced (HMO)
|
$302.00 |
$0 | No | 2 |
Generic |
$10.00 | $20.00 | Q:180 /30Days | $28.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |