AIMOVIG 70 MG/ML AUTOINJECTOR (1 ml ) (NDC: 55513084101)
2022 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-POS)
|
$0.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:2 /30Days | $742.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Plan 2 (HMO)
|
$0.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:2 /30Days | $742.71 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Choice Plan (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:1 /30Days | $783.84 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$0.00 |
$200* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $141.00 | P Q:1 /30Days | $783.69 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:2 /28Days | $807.42 |
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 |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:2 /28Days | $807.42 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:2 /28Days | $807.42 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:2 /28Days | $807.42 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:2 /28Days | $807.42 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:2 /28Days | $807.42 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:2 /28Days | $807.42 |
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 |
Amerivantage ESRD Care Plus (HMO C-SNP)
|
$0.00 |
$0 |
Few Generics |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:2 /28Days | $807.42 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Basic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $94.00 | P Q:2 /30Days | $696.67 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Choice Plus (PPO)
|
$0.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $94.00 | P Q:2 /30Days | $696.43 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Classic (PPO)
|
$0.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $94.00 | P Q:2 /30Days | $695.71 |
Browse Plan Formulary |
Cigna Alliance Medicare (HMO)
|
$0.00 |
$190* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$42.00 | $126.00 | P Q:1 /28Days | $758.68 |
Browse Plan Formulary |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$190* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$42.00 | $126.00 | P Q:1 /28Days | $761.42 |
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 Preferred Medicare (HMO)
|
$0.00 |
$190* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$42.00 | $126.00 | P Q:1 /28Days | $762.42 |
Browse Plan Formulary |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$190* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$42.00 | $126.00 | P Q:1 /28Days | $759.61 |
Browse Plan Formulary |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$190* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$42.00 | $126.00 | P Q:1 /28Days | $759.61 |
Browse Plan Formulary |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$190* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$42.00 | $126.00 | P Q:1 /28Days | $758.69 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Devoted Health Core Greater Houston (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:1 /30Days | $662.02 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H0028-042 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:2 /30Days | $751.50 |
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 |
Memorial Hermann Advantage (HMO)
|
$0.00 |
$300* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$39.00 | $78.00 | P | $745.84 |
Browse Plan Formulary |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | P Q:1 /30Days | $677.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Molina Medicare Choice Care Select (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | P Q:1 /30Days | $677.60 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice (Regional PPO D-SNP)
|
$0.00 |
$480 |
No |
4 |
Tier 4 |
$0.00 | $0.00 | P Q:2 /30Days | $742.74 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$20.00 | $40.00 | P Q:1 /30Days | $807.42 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$20.00 | $40.00 | P Q:1 /30Days | $807.42 |
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 Giveback (HMO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$20.00 | $40.00 | P Q:1 /30Days | $807.42 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$20.00 | $40.00 | P Q:1 /30Days | $807.42 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$20.00 | $40.00 | P Q:1 /30Days | $807.42 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$20.00 | $40.00 | P Q:1 /30Days | $807.42 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$20.00 | $40.00 | P Q:1 /30Days | $807.42 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$20.00 | $40.00 | P Q:1 /30Days | $807.42 |
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 No Premium (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$20.00 | $40.00 | P Q:1 /30Days | $807.42 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$20.00 | $40.00 | P Q:1 /30Days | $807.42 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$20.00 | $40.00 | P Q:1 /30Days | $807.42 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$25.00 | $50.00 | P Q:1 /30Days | $807.42 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare No Premium Rx Plus Open (PPO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35.00 | $70.00 | P Q:1 /30Days | $807.42 |
Browse Plan Formulary |
Wellcare Specialty No Premium (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
3 |
Preferred Brand |
$0.00 | $0.00 | P Q:1 /30Days | $807.42 |
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 TexanPlus Classic No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$25.00 | $50.00 | P Q:1 /30Days | $807.42 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare TexanPlus No Premium (HMO-POS)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | $60.00 | P Q:1 /30Days | $807.42 |
Browse Plan Formulary |
UnitedHealthcare Medicare Silver (Regional PPO C-SNP)
|
$3.70 |
$480 |
No |
4 |
Tier 4 |
25% | 25% | P Q:2 /30Days | $742.74 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$5.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | P Q:1 /28Days | $778.14 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$5.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | P Q:1 /28Days | $779.14 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$5.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | P Q:1 /28Days | $775.65 |
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 |
AARP Medicare Advantage Choice (PPO)
|
$10.00 |
$245 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:2 /30Days | $742.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-043 (PPO)
|
$10.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:2 /30Days | $750.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-043 (PPO)
|
$10.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:2 /30Days | $750.83 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP)
|
$10.80 |
$295 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:2 /30Days | $742.74 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Choice II Plan (PPO)
|
$15.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:1 /30Days | $783.84 |
Browse Plan Formulary |
KelseyCare Advantage Gold Community (HMO-POS)
|
$15.00 |
$100 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:1 /30Days | $676.93 |
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)
|
$19.00 |
$190* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$42.00 | $126.00 | P Q:1 /28Days | $758.69 |
Browse Plan Formulary |
Wellcare Assist (HMO)
|
$20.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | P Q:1 /30Days | $790.11 |
Browse Plan Formulary |
Aetna Medicare Dual Complete Plan (HMO D-SNP)
|
$24.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:1 /30Days | $783.68 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:2 /28Days | $807.42 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:2 /28Days | $807.42 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:2 /28Days | $807.42 |
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 |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:2 /28Days | $807.42 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:2 /28Days | $807.42 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:2 /28Days | $807.42 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:2 /28Days | $807.42 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:2 /28Days | $807.42 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:2 /28Days | $807.42 |
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 |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:2 /28Days | $807.42 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:2 /28Days | $807.42 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:2 /28Days | $807.42 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:2 /28Days | $807.42 |
Browse Plan Formulary |
Community Health Choice (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P | $779.92 |
Browse Plan Formulary |
Devoted Health Prime Greater Houston (HMO)
|
$25.10 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:1 /30Days | $662.02 |
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 |
Humana Gold Plus SNP-DE H0028-033 (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:2 /30Days | $751.71 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$25.10 |
$480 |
Some Generics |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:1 /30Days | $677.60 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | P Q:2 /30Days | $742.65 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | P Q:2 /30Days | $742.71 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | P Q:2 /30Days | $743.84 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | P Q:1 /30Days | $790.11 |
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 Dual Access Open (PPO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | P Q:1 /30Days | $790.11 |
Browse Plan Formulary |
Wellcare Dual Liberty (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | P Q:1 /30Days | $790.11 |
Browse Plan Formulary |
HumanaChoice R4182-004 (Regional PPO)
|
$43.60 |
$175 |
No |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:2 /30Days | $750.53 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice (Regional PPO)
|
$49.00 |
$395 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:2 /30Days | $742.74 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Memorial Hermann Advantage Plus (HMO)
|
$50.00 |
$300* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$39.00 | $78.00 | P | $745.84 |
Browse Plan Formulary |
HumanaChoice R4182-003 (Regional PPO)
|
$51.00 |
$175 |
No |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:2 /30Days | $750.53 |
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 |
Blue Cross Medicare Advantage Choice Premier (PPO)
|
$90.00 |
$295 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $94.00 | P Q:2 /30Days | $696.43 |
Browse Plan Formulary |
HumanaChoice H5216-042 (PPO)
|
$94.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:2 /30Days | $750.80 |
Browse Plan Formulary |