ACITRETIN 25 MG CAPSULE [Soriatane] (30 CAPSULES ) (NDC: 42794008308)
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)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $372.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Plan 2 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $372.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Plan 4 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $372.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Walgreens Plan 1 (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $397.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Walgreens Plan 2 (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $397.80 |
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 |
Aetna Medicare Freedom Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $52.80 |
Browse Plan Formulary |
Aetna Medicare Platinum Plan (HMO-POS)
|
$0.00 |
$100 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $53.70 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $52.20 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$100 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $52.20 |
Browse Plan Formulary |
Aetna Medicare Prime Plus Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $74.40 |
Browse Plan Formulary |
Alignment Health Plan Heart & Diabetes (HMO C-SNP)
|
$0.00 |
$0 |
Few Generics |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $750.00 |
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 |
Alignment Health Plan the ONE (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $750.60 |
Browse Plan Formulary |
Amerivantage Comfort (HMO I-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | None | $707.40 |
Browse Plan Formulary |
Amerivantage Comfort Plus (HMO I-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | None | $707.40 |
Browse Plan Formulary |
Amerivantage Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | None | $398.10 |
Browse Plan Formulary |
AVA (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $750.00 |
Browse Plan Formulary |
Banner Medicare Advantage Prime (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $423.90 |
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 |
Blue Medicare Advantage Classic (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$9.00 | $9.00 | None | $278.70 |
Browse Plan Formulary |
BluePathway Plan 1 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $7.00 | None | $278.70 |
Browse Plan Formulary |
BluePathway Plan 2 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $7.00 | None | $278.70 |
Browse Plan Formulary |
Bright Advantage Classic Care Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $10.00 | None | $278.70 |
Browse Plan Formulary |
Bright Advantage Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics |
2 |
Generic |
$9.00 | $18.00 | None | $278.70 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Cigna Achieve Medicare (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $346.20 |
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 |
Cigna Alliance Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $346.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $346.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Devoted Health Advance (HMO C-SNP)
|
$0.00 |
$0 |
Few Generics |
2 |
Generic |
$0.00 | $0.00 | P | $759.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Devoted Health Core (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $0.00 | P | $759.00 |
Browse Plan Formulary |
Devoted Health Essence (HMO C-SNP)
|
$0.00 |
$0 |
Few Generics |
2 |
Generic |
$0.00 | $0.00 | P | $759.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Global Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | P | $865.20 |
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 |
Global Special Care (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | P | $865.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Global Special Care Savings (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | P | $865.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H0028-027 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $468.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H0028-028 (HMO)
|
$0.00 |
$225 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $468.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H0028-052 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $468.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-137 (PPO)
|
$0.00 |
$445 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P | $474.00 |
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 |
HumanaChoice H5216-265 (PPO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $469.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Imperial Insurance Company Traditional (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | P | $610.20 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Imperial Insurance Traditional Plus (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | P | $610.20 |
Browse Plan Formulary |
Imperial Insurance Value (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | P | $610.20 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
SCAN Balance (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
4 |
Non-Preferred Drug |
$95.00 | $265.00 | P | $571.20 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
SCAN Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $265.00 | P | $571.20 |
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 |
SCAN Heart First (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
4 |
Non-Preferred Drug |
$95.00 | $265.00 | P | $571.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Venture (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $265.00 | P | $571.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Chronic Complete (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $372.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Giveback (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | P | $503.70 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | P | $503.70 |
Browse Plan Formulary |
Wellcare No Premium Essentials (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | P | $486.00 |
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 |
Wellcare No Premium Open (PPO)
|
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | P | $527.70 |
Browse Plan Formulary |
Wellcare No Premium Rx Plus Open (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
43% | 43% | P | $527.70 |
Browse Plan Formulary |
Wellcare Specialty No Premium (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
2 |
Generic |
$5.00 | $0.00 | P | $498.90 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
HumanaChoice H5216-224 (PPO)
|
$17.00 |
$195 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $470.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Walgreens Plan 3 (PPO)
|
$25.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $397.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Banner Medicare Advantage Plus (PPO)
|
$25.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $423.90 |
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 |
Banner Medicare Advantage Dual (HMO D-SNP)
|
$26.30 |
$480 |
Few Generics |
4 |
Non-Preferred Drug |
25% | 25% | None | $423.90 |
Browse Plan Formulary |
Humana Value Plus H5216-197 (PPO)
|
$29.60 |
$450 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $469.80 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 3 (HMO)
|
$30.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $372.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BluePathway Plan 3 (HMO)
|
$32.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $7.00 | None | $278.70 |
Browse Plan Formulary |
Wellcare Assist (HMO)
|
$35.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
44% | 44% | P | $615.00 |
Browse Plan Formulary |
Banner Medicare Advantage Dual (HMO D-SNP)
|
$37.30 |
$480 |
Few Generics |
4 |
Non-Preferred Drug |
25% | 25% | None | $423.90 |
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 |
Bright Advantage Classic Choice Plan (HMO)
|
$39.20 |
$480 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | 25% | None | $278.70 |
Browse Plan Formulary |
Devoted Health Select (HMO)
|
$39.70 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$0.00 | $0.00 | P | $759.00 |
Browse Plan Formulary |
Bright Advantage Embrace Assist Plan (HMO C-SNP)
|
$40.00 |
$480 |
Some Generics |
2 |
Generic |
25% | 25% | None | $278.70 |
Browse Plan Formulary |
Bright Advantage Embrace Choice Plan (HMO C-SNP)
|
$40.00 |
$480 |
Some Generics |
2 |
Generic |
25% | 25% | None | $278.70 |
Browse Plan Formulary |
Bright Advantage Harmony Choice Plan (HMO C-SNP)
|
$40.00 |
$480 |
Some Generics |
2 |
Generic |
25% | 25% | None | $278.70 |
Browse Plan Formulary |
Health Choice Pathway (HMO D-SNP)
|
$40.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $589.50 |
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 |
Mercy Care Advantage (HMO D-SNP)
|
$40.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P | $447.90 |
Browse Plan Formulary |
Mercy Care Advantage (HMO D-SNP)
|
$40.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P | $447.90 |
Browse Plan Formulary |
Mercy Care Advantage (HMO D-SNP)
|
$40.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P | $447.90 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$40.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P | $865.20 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP (HMO D-SNP)
|
$40.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $378.90 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete ONE (HMO D-SNP)
|
$40.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $378.00 |
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 |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$40.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $374.70 |
Browse Plan Formulary |
Wellcare Dual Liberty (HMO D-SNP)
|
$40.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P | $609.90 |
Browse Plan Formulary |
Devoted Health Flex (HMO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $0.00 | P | $759.00 |
Browse Plan Formulary |
HumanaChoice R7220-002 (Regional PPO)
|
$47.20 |
$440 |
No |
4 |
Non-Preferred Drug |
24% | 24% | P | $469.80 |
Browse Plan Formulary |
Blue Medicare Advantage Plus (HMO)
|
$48.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$9.00 | $9.00 | None | $278.70 |
Browse Plan Formulary |
Humana Gold Plus H0028-023 (HMO)
|
$50.00 |
$225 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $468.30 |
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 |
BlueJourney (PPO)
|
$59.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$9.00 | $9.00 | None | $278.70 |
Browse Plan Formulary |
Aetna Medicare Platinum Plan (PPO)
|
$85.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $72.30 |
Browse Plan Formulary |
HumanaChoice H5216-034 (PPO)
|
$119.00 |
$225 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $470.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |