ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6 (6 ) (NDC: 00555904758)
2022 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
See your cost using a drug discount card: Compare prices at pharmacies near you |
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 7 (HMO)
|
$0.00 |
$175 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $19.88 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Walgreens (PPO)
|
$0.00 |
$225 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $21.28 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Silver (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $10.00 | None | $6.44 |
Browse Plan Formulary |
Aetna Medicare Premier (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $4.76 |
Browse Plan Formulary |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$150* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $5.60 |
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 |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $8.68 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $8.40 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $10.64 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $11.20 |
Browse Plan Formulary |
CareSource Advantage Zero Premium (HMO)
|
$0.00 |
$175* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | $30.00 | None | $14.28 |
Browse Plan Formulary |
CareSource MyCare Ohio (Medicare-Medicaid Plan)
|
$0.00 |
$0 | All Generics, All Brands | 1 |
Tier 1 |
0% | 0% | None | $14.28 |
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 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $13.72 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Devoted Health Saver (HMO)
|
$0.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $25.00 | None | $13.72 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H6622-014 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $18.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-285 (PPO)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $18.48 |
Browse Plan Formulary |
HumanaChoice H5525-042 (PPO)
|
$0.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $18.48 |
Browse Plan Formulary |
MedMutual Advantage Access (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$8.00 | $15.00 | None | $15.68 |
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 |
MedMutual Advantage Access (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$8.00 | $15.00 | None | $15.40 |
Browse Plan Formulary |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $15.12 |
Browse Plan Formulary |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $15.40 |
Browse Plan Formulary |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $15.68 |
Browse Plan Formulary |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$8.00 | $15.00 | None | $15.40 |
Browse Plan Formulary |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$8.00 | $15.00 | None | $15.68 |
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 |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$8.00 | $15.00 | None | $15.40 |
Browse Plan Formulary |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$12.00 | $24.00 | None | $16.24 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
PrimeTime Health Plan Aultimate (HMO-POS)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $17.92 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SummaCare Medicare Topaz (HMO)
|
$0.00 |
$150* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$10.00 | $25.00 | None | $13.44 |
Browse Plan Formulary |
The Health Plan SecureCare - Option II (HMO)
|
$0.00 |
$100* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $0.00 | None | $14.56 |
Browse Plan Formulary |
UnitedHealthcare Connected for MyCareOhio (Medicare-Medicaid Plan)
|
$0.00 |
$0 | All Generics, All Brands | 1 |
Tier 1 |
0% | 0% | None | $21.28 |
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 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $0.00 | None | $10.08 |
Browse Plan Formulary |
Wellcare Giveback Boost (HMO)
|
$0.00 |
$75* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$9.00 | $0.00 | None | $10.08 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$75* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$9.00 | $0.00 | None | $10.08 |
Browse Plan Formulary |
Wellcare No Premium Medicare (HMO)
|
$0.00 |
$75* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$9.00 | $0.00 | None | $10.08 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$160* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$7.00 | $0.00 | None | $10.08 |
Browse Plan Formulary |
HumanaChoice H5216-106 (PPO)
|
$15.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $18.48 |
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 - Diabetes and Heart (HMO C-SNP)
|
$16.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $18.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Assist (HMO)
|
$16.80 |
$480 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | None | $19.32 |
Browse Plan Formulary |
Wellcare Assist Complement (HMO)
|
$17.60 |
$480 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | None | $19.32 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 1 (HMO)
|
$19.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $19.88 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Anthem MediBlue Preferred Plus (HMO)
|
$19.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $10.36 |
Browse Plan Formulary |
Humana Gold Plus H6622-070 (HMO)
|
$21.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $18.48 |
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 |
Anthem MediBlue Extra (HMO)
|
$22.00 |
$480 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $10.08 |
Browse Plan Formulary |
MedMutual Advantage Secure (HMO)
|
$22.00 |
$95* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $15.40 |
Browse Plan Formulary |
MedMutual Advantage Secure (HMO)
|
$22.00 |
$95* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $15.68 |
Browse Plan Formulary |
Aetna Medicare Assure 1 (HMO D-SNP)
|
$23.20 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$5.00 | $15.00 | None | $6.16 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 8 (HMO)
|
$25.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $19.88 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus SNP-DE H6622-015 (HMO D-SNP)
|
$27.60 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $18.48 |
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 |
Perennial Advantage Strive (HMO I-SNP)
|
$28.20 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $20.44 |
Browse Plan Formulary |
SummaCare Medicare Garnet (HMO)
|
$29.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$8.00 | $20.00 | None | $14.28 |
Browse Plan Formulary |
SummaCare Medicare Garnet (HMO)
|
$29.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$8.00 | $20.00 | None | $13.44 |
Browse Plan Formulary |
CareSource Advantage (HMO)
|
$30.00 |
$100* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $20.00 | None | $14.28 |
Browse Plan Formulary |
Devoted Health Prime (HMO)
|
$31.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $13.72 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Perennial Advantage Concierge (HMO C-SNP)
|
$31.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $45.00 | None | $20.44 |
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 (HMO D-SNP)
|
$32.00 |
$480 | Some Generics | 2 |
Generic |
$9.00 | $0.00 | None | $19.32 |
Browse Plan Formulary |
Aetna Medicare Premier Plus 2 (Regional PPO)
|
$33.40 |
$260* | No | 2* |
Generic |
$10.00 | $25.00 | None | $9.24 |
Browse Plan Formulary |
Anthem MediBlue Dual Advantage (HMO D-SNP)
|
$33.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $10.08 |
Browse Plan Formulary |
CareSource Dual Advantage (HMO D-SNP)
|
$33.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
25% | 25% | None | $14.28 |
Browse Plan Formulary |
CommuniCare Advantage ISNP (HMO I-SNP)
|
$33.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $18.20 |
Browse Plan Formulary |
CommuniCare Advantage ISNP (HMO I-SNP)
|
$33.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $21.28 |
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 |
CommuniCare Advantage ISNP (HMO I-SNP)
|
$33.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $16.80 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$33.50 |
$480* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$4.00 | $12.00 | None | $16.24 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP (HMO D-SNP)
|
$33.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $19.88 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
|
$33.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $19.60 |
Browse Plan Formulary |
Valor Health Plan (HMO I-SNP)
|
$33.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $18.48 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP)
|
$33.90 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $19.32 |
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 |
PrimeTime Health Plan Classic (HMO-POS)
|
$39.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $17.92 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $15.40 |
Browse Plan Formulary |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $15.12 |
Browse Plan Formulary |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $15.68 |
Browse Plan Formulary |
The Health Plan SecureCare SNP (HMO D-SNP)
|
$40.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $14.56 |
Browse Plan Formulary |
Anthem MediBlue Access Basic (Regional PPO)
|
$41.50 |
$200 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $10.08 |
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 |
SummaCare Medicare Ruby (HMO)
|
$43.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$8.00 | $20.00 | None | $13.44 |
Browse Plan Formulary |
HumanaChoice H5216-051 (PPO)
|
$44.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $18.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MedMutual Advantage Select (PPO)
|
$44.00 |
$95* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $15.40 |
Browse Plan Formulary |
MedMutual Advantage Select (PPO)
|
$44.00 |
$95* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $15.12 |
Browse Plan Formulary |
MedMutual Advantage Select (PPO)
|
$44.00 |
$95* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $15.68 |
Browse Plan Formulary |
Aetna Medicare Premier Plus 1 (Regional PPO)
|
$44.50 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $4.20 |
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 R5495-002 (Regional PPO)
|
$47.80 |
$480 | No | 4 |
Non-Preferred Drug |
20% | 20% | None | $18.48 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$55.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$37.00 | $74.00 | None | $11.76 |
Browse Plan Formulary |
Anthem MediBlue Access (PPO)
|
$56.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $10.08 |
Browse Plan Formulary |
SummaCare Medicare Sapphire (HMO-POS)
|
$76.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$8.00 | $20.00 | None | $13.44 |
Browse Plan Formulary |
MedMutual Advantage Preferred (PPO)
|
$80.00 |
$55* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $15.40 |
Browse Plan Formulary |
MedMutual Advantage Preferred (PPO)
|
$80.00 |
$55* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $15.12 |
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 |
MedMutual Advantage Preferred (PPO)
|
$80.00 |
$55* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $15.68 |
Browse Plan Formulary |
Humana Gold Choice H8145-032 (PFFS)
|
$83.00 |
$225 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $18.48 |
Browse Plan Formulary |
Anthem MediBlue Access Plus (PPO)
|
$89.00 |
$40 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $8.96 |
Browse Plan Formulary |
PrimeTime Health Plan Plus (HMO-POS)
|
$89.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $17.92 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H6622-019 (HMO)
|
$91.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$97.00 | $281.00 | None | $18.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MedMutual Advantage Plus (HMO)
|
$97.00 |
$55* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $15.68 |
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 |
MedMutual Advantage Plus (HMO)
|
$97.00 |
$55* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $15.12 |
Browse Plan Formulary |
MedMutual Advantage Plus (HMO)
|
$97.00 |
$55* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $15.40 |
Browse Plan Formulary |
The Health Plan SecureChoice - Option II (PPO)
|
$100.00 |
$100* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $0.00 | None | $14.56 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 3 (HMO)
|
$111.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $19.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Premier 2 (PPO)
|
$118.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $10.00 | None | $5.88 |
Browse Plan Formulary |
MedMutual Advantage Premium (PPO)
|
$134.00 |
$55* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $15.40 |
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 |
MedMutual Advantage Premium (PPO)
|
$134.00 |
$55* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $15.12 |
Browse Plan Formulary |
MedMutual Advantage Premium (PPO)
|
$134.00 |
$55* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $15.68 |
Browse Plan Formulary |
Aetna Medicare Premier 1 (PPO)
|
$149.00 |
$150* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $5.88 |
Browse Plan Formulary |
HumanaChoice H5525-030 (PPO)
|
$151.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$97.00 | $281.00 | None | $18.48 |
Browse Plan Formulary |
SummaCare Medicare Emerald (HMO-POS)
|
$180.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$8.00 | $20.00 | None | $13.44 |
Browse Plan Formulary |