ACYCLOVIR 200 MG CAPSULE [Zovirax] (60 CAPSULES ) (NDC: 60505004206)
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 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $0.00 | None | $43.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice (PPO)
|
$0.00 |
$150* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$10.00 | $0.00 | None | $43.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice Plan 2 (Regional PPO)
|
$0.00 |
$395* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$14.00 | $28.00 | None | $45.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Choice (HMO-POS)
|
$0.00 |
$195* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$0.00 | $0.00 | None | $21.00 |
Browse Plan Formulary |
Aetna Medicare Premier (PPO)
|
$0.00 |
$300* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$0.00 | $0.00 | None | $21.00 |
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 Premier Plus (PPO)
|
$0.00 |
$150* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$0.00 | $0.00 | None | $21.00 |
Browse Plan Formulary |
Aetna Medicare Select (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $21.00 |
Browse Plan Formulary select insulin pay $20 copay but not this drug |
BlueMedicare Classic (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $46.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BlueMedicare Premier (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $46.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BlueMedicare Saver (HMO)
|
$0.00 |
$50* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$12.00 | $36.00 | None | $49.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BlueMedicare Value (PPO)
|
$0.00 |
$150* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$8.00 | $24.00 | None | $51.00 |
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 |
Bright Advantage Health Dollars Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $25.50 |
Browse Plan Formulary |
Bright Advantage Health Dollars Plan (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $25.50 |
Browse Plan Formulary |
Bright Advantage Part B Savings Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$15.00 | $30.00 | None | $25.50 |
Browse Plan Formulary |
Bright Advantage Part B Savings Plan (PPO)
|
$0.00 |
$110 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $25.50 |
Browse Plan Formulary |
CareBreeze (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $16.50 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
CareComplete (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $16.50 |
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 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $16.50 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
CareFree (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $18.00 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
CareOne PLATINUM (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $16.50 |
Browse Plan Formulary select insulin pay $0-$30 copay but not this drug |
CareOne PLUS (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $16.50 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | None | $57.00 |
Browse Plan Formulary |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$4.00 | $0.00 | None | $57.00 |
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 |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$4.00 | $0.00 | None | $57.00 |
Browse Plan Formulary |
Devoted Health Core Greater Orlando (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $15.00 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Devoted Health Essentials Greater Orlando (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $15.00 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Devoted Health Latitude Greater Orlando (PPO)
|
$0.00 |
$150* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $15.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Freedom Platinum Plan Rx (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $13.50 |
Browse Plan Formulary |
Freedom Platinum Rewards Plan Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $13.50 |
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 |
Freedom VIP Care (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Some Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $13.50 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Freedom VIP Savings (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Some Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $13.50 |
Browse Plan Formulary select insulin pay $0-$10 copay but not this drug |
Freedom VIP Savings COPD (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $13.50 |
Browse Plan Formulary |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $16.50 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
Humana Gold Plus H1036-146 (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $16.50 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
Humana Gold Plus H1036-269 (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $16.50 |
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 |
HumanaChoice Florida H5216-072 (PPO)
|
$0.00 |
$150* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $0.00 | None | $16.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$3.00 | $6.00 | None | $25.50 |
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 | 1 |
Preferred Generic |
$15.00 | $30.00 | None | $25.50 |
Browse Plan Formulary |
Molina Medicare Connect Care (HMO C-SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$8.00 | $24.00 | None | $25.50 |
Browse Plan Formulary |
Optimum Diamond Rewards (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $13.50 |
Browse Plan Formulary |
Optimum Diamond Rewards COPD (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $13.50 |
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 |
Optimum Gold Rewards Plan (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $13.50 |
Browse Plan Formulary |
Simply Care (HMO I-SNP)
|
$0.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$4.00 | n/a | None | $13.50 |
Browse Plan Formulary |
Simply Comfort (HMO I-SNP)
|
$0.00 |
$480* | Some Generics, Few Brands | 1* |
Preferred Generic |
$0.00 | n/a | None | $13.50 |
Browse Plan Formulary |
Simply Extra (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $13.50 |
Browse Plan Formulary |
Simply Level (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $13.50 |
Browse Plan Formulary |
Simply More (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $13.50 |
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 |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150* | Some Generics | 2* |
Generic |
$0.00 | $0.00 | None | $43.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150* | Some Generics | 2* |
Generic |
$0.00 | $0.00 | None | $43.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150* | Some Generics | 2* |
Generic |
$0.00 | $0.00 | None | $43.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150* | Some Generics | 2* |
Generic |
$0.00 | $0.00 | None | $45.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Giveback (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $19.50 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $19.50 |
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 |
Wellcare No Premium Open (PPO)
|
$0.00 |
$100* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $18.00 |
Browse Plan Formulary |
Wellcare Specialty Giveback (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $18.00 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
Wellcare Specialty No Premium (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $19.50 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
HumanaChoice R5826-074 (Regional PPO)
|
$0.50 |
$395* | No | 2* |
Generic |
$20.00 | $0.00 | None | $16.50 |
Browse Plan Formulary |
CareNeeds PLUS (HMO D-SNP)
|
$14.10 |
$480* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $16.50 |
Browse Plan Formulary |
Humana Fully Integrated H1036-283 (HMO D-SNP)
|
$15.60 |
$480* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $16.50 |
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 |
Cigna TotalCare Plus (HMO D-SNP)
|
$20.80 |
$480* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$13.00 | $0.00 | None | $57.00 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-213 (HMO D-SNP)
|
$22.70 |
$480* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $16.50 |
Browse Plan Formulary |
Cigna Primary Medicare (HMO)
|
$23.60 |
$480* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$12.00 | $0.00 | None | $57.00 |
Browse Plan Formulary |
Aetna Medicare Assure (HMO D-SNP)
|
$25.20 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$5.00 | $15.00 | None | $21.00 |
Browse Plan Formulary |
Aetna Medicare Assure Plus (HMO D-SNP)
|
$30.80 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$5.00 | $15.00 | None | $21.00 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO D-SNP)
|
$31.50 |
$480 | No | 2 |
Tier 2 |
15% | 15% | None | $45.00 |
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 Dual Access (HMO D-SNP)
|
$32.30 |
$480* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$0.00 | $0.00 | None | $55.50 |
Browse Plan Formulary |
Wellcare Dual Medicare (HMO D-SNP)
|
$33.70 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$8.00 | $0.00 | None | $55.50 |
Browse Plan Formulary |
BlueMedicare Complete (HMO D-SNP)
|
$34.30 |
$480* | Some Generics, Few Brands | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $43.50 |
Browse Plan Formulary |
Devoted Health Dual Greater Orlando (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
25% | 25% | None | $15.00 |
Browse Plan Formulary |
Devoted Health Prime (HMO)
|
$34.30 |
$480* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $15.00 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Devoted Health Prime (HMO)
|
$34.30 |
$480* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $15.00 |
Browse Plan Formulary select insulin pay $0 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 |
Florida Complete Care (HMO I-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $21.00 |
Browse Plan Formulary |
Florida Complete Care- In The Community (HMO I-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $21.00 |
Browse Plan Formulary |
Freedom Medi-Medi Full (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$10.00 | $30.00 | None | $13.50 |
Browse Plan Formulary |
Freedom Medi-Medi Partial (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$10.00 | $30.00 | None | $13.50 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$34.30 |
$480* | Some Generics, Few Brands | 2* |
Generic |
$0.00 | $0.00 | None | $25.50 |
Browse Plan Formulary |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$34.30 |
$480* | Some Generics, Few Brands | 2* |
Generic |
$0.00 | $0.00 | None | $25.50 |
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 |
Optimum Emerald Full (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$10.00 | $30.00 | None | $13.50 |
Browse Plan Formulary |
Optimum Emerald Partial (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$10.00 | $30.00 | None | $13.50 |
Browse Plan Formulary |
Simply Complete (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$10.00 | $30.00 | None | $16.50 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $45.00 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $43.50 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $43.50 |
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 |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $45.00 |
Browse Plan Formulary |
Wellcare Dual Liberty (HMO D-SNP)
|
$34.30 |
$480* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$0.00 | $0.00 | None | $55.50 |
Browse Plan Formulary |
Wellcare Dual Nurture (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $0.00 | None | $55.50 |
Browse Plan Formulary |
Wellcare Dual Reserve (HMO D-SNP)
|
$34.30 |
$480* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$0.00 | $0.00 | None | $54.00 |
Browse Plan Formulary |
BlueMedicare Choice (Regional PPO)
|
$47.90 |
$250* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $48.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice R5826-005 (Regional PPO)
|
$55.00 |
$100* | No | 2* |
Generic |
$15.00 | $0.00 | None | $16.50 |
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 |
Wellcare Premium Enhanced Open (PPO)
|
$85.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $18.00 |
Browse Plan Formulary |
Humana Gold Choice H8145-061 (PFFS)
|
$102.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$17.00 | $0.00 | None | $16.50 |
Browse Plan Formulary |
BlueMedicare Select (PPO)
|
$147.90 |
$305 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$3.00 | $9.00 | None | $48.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |