ALYACEN 1-35-28 TABLET (28.000 EA ) (NDC: 68462039429)
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 7 (HMO)
![Email Prescription and/or Health Benefit details for AARP Medicare Advantage Plan 7 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$175 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $14.84 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Walgreens (PPO)
![Email Prescription and/or Health Benefit details for AARP Medicare Advantage Walgreens (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$225 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $16.24 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Silver (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Advantra Silver (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $10.00 | None | $7.56 |
Browse Plan Formulary |
Aetna Medicare Premier (HMO-POS)
![Email Prescription and/or Health Benefit details for Aetna Medicare Premier (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $7.00 |
Browse Plan Formulary |
Aetna Medicare Value Plan (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Value Plan (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$150* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $8.96 |
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)
![Email Prescription and/or Health Benefit details for Anthem MediBlue Preferred (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $20.16 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
![Email Prescription and/or Health Benefit details for Anthem MediBlue Preferred (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $18.20 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
![Email Prescription and/or Health Benefit details for Anthem MediBlue Preferred (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $18.48 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
![Email Prescription and/or Health Benefit details for Anthem MediBlue Preferred (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $18.76 |
Browse Plan Formulary |
CareSource Advantage Zero Premium (HMO)
![Email Prescription and/or Health Benefit details for CareSource Advantage Zero Premium (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$175* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | $30.00 | None | $16.80 |
Browse Plan Formulary |
CareSource MyCare Ohio (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for CareSource MyCare Ohio (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
All Generics, All Brands |
1 |
Tier 1 |
0% | 0% | None | $17.08 |
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 |
Devoted Health Core (HMO)
![Email Prescription and/or Health Benefit details for Devoted Health Core (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | None | $14.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Devoted Health Saver (HMO)
![Email Prescription and/or Health Benefit details for Devoted Health Saver (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $25.00 | None | $14.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-285 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H5216-285 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $17.64 |
Browse Plan Formulary |
HumanaChoice H5525-042 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H5525-042 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $17.64 |
Browse Plan Formulary |
MedMutual Advantage Access (PPO)
![Email Prescription and/or Health Benefit details for MedMutual Advantage Access (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$8.00 | $15.00 | None | $17.36 |
Browse Plan Formulary |
MedMutual Advantage Access (PPO)
![Email Prescription and/or Health Benefit details for MedMutual Advantage Access (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$8.00 | $15.00 | None | $17.64 |
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 Classic (HMO)
![Email Prescription and/or Health Benefit details for MedMutual Advantage Classic (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $17.36 |
Browse Plan Formulary |
MedMutual Advantage Classic (HMO)
![Email Prescription and/or Health Benefit details for MedMutual Advantage Classic (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $16.52 |
Browse Plan Formulary |
MedMutual Advantage Classic (HMO)
![Email Prescription and/or Health Benefit details for MedMutual Advantage Classic (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $17.64 |
Browse Plan Formulary |
MedMutual Advantage Signature (HMO)
![Email Prescription and/or Health Benefit details for MedMutual Advantage Signature (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$8.00 | $15.00 | None | $17.36 |
Browse Plan Formulary |
MedMutual Advantage Signature (HMO)
![Email Prescription and/or Health Benefit details for MedMutual Advantage Signature (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$8.00 | $15.00 | None | $17.64 |
Browse Plan Formulary |
MedMutual Advantage Signature (HMO)
![Email Prescription and/or Health Benefit details for MedMutual Advantage Signature (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$8.00 | $15.00 | None | $17.36 |
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 |
Molina Medicare Choice Care (HMO)
![Email Prescription and/or Health Benefit details for Molina Medicare Choice Care (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$12.00 | $24.00 | None | $13.16 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
PrimeTime Health Plan Aultimate (HMO-POS)
![Email Prescription and/or Health Benefit details for PrimeTime Health Plan Aultimate (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $15.68 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SummaCare Medicare Topaz (HMO)
![Email Prescription and/or Health Benefit details for SummaCare Medicare Topaz (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$10.00 | $25.00 | None | $9.80 |
Browse Plan Formulary |
The Health Plan SecureCare - Option II (HMO)
![Email Prescription and/or Health Benefit details for The Health Plan SecureCare - Option II (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$100* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | None | $16.52 |
Browse Plan Formulary |
UnitedHealthcare Connected for MyCareOhio (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Connected for MyCareOhio (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
All Generics, All Brands |
1 |
Tier 1 |
0% | 0% | None | $16.24 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
![Email Prescription and/or Health Benefit details for Wellcare Giveback (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $0.00 | 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 |
Wellcare Giveback Boost (HMO)
![Email Prescription and/or Health Benefit details for Wellcare Giveback Boost (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$75* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$9.00 | $0.00 | None | $10.36 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
![Email Prescription and/or Health Benefit details for Wellcare No Premium (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$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)
![Email Prescription and/or Health Benefit details for Wellcare No Premium Medicare (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$75* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$9.00 | $0.00 | None | $10.36 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
![Email Prescription and/or Health Benefit details for Wellcare No Premium Open (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$160* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$7.00 | $0.00 | None | $10.36 |
Browse Plan Formulary |
HumanaChoice H5216-106 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H5216-106 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$15.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $17.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Assist (HMO)
![Email Prescription and/or Health Benefit details for Wellcare Assist (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$16.80 |
$480 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | None | $8.68 |
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 |
Wellcare Assist Complement (HMO)
![Email Prescription and/or Health Benefit details for Wellcare Assist Complement (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$17.60 |
$480 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | None | $9.24 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 1 (HMO)
![Email Prescription and/or Health Benefit details for AARP Medicare Advantage Plan 1 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$19.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $14.84 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Anthem MediBlue Preferred Plus (HMO)
![Email Prescription and/or Health Benefit details for Anthem MediBlue Preferred Plus (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$19.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $19.32 |
Browse Plan Formulary |
Humana Value Plus H5525-041 (PPO)
![Email Prescription and/or Health Benefit details for Humana Value Plus H5525-041 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$21.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | None | $17.64 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
![Email Prescription and/or Health Benefit details for Anthem MediBlue Extra (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$22.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $19.32 |
Browse Plan Formulary |
MedMutual Advantage Secure (HMO)
![Email Prescription and/or Health Benefit details for MedMutual Advantage Secure (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$22.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $17.36 |
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 Secure (HMO)
![Email Prescription and/or Health Benefit details for MedMutual Advantage Secure (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$22.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $17.64 |
Browse Plan Formulary |
Aetna Medicare Assure 1 (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Aetna Medicare Assure 1 (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$23.20 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$5.00 | $15.00 | None | $7.56 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 8 (HMO)
![Email Prescription and/or Health Benefit details for AARP Medicare Advantage Plan 8 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$25.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $14.84 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice SNP-DE H5525-046 (PPO D-SNP)
![Email Prescription and/or Health Benefit details for HumanaChoice SNP-DE H5525-046 (PPO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$27.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $17.64 |
Browse Plan Formulary |
CareSource Advantage (HMO)
![Email Prescription and/or Health Benefit details for CareSource Advantage (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$30.00 |
$100* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $20.00 | None | $16.80 |
Browse Plan Formulary |
Devoted Health Prime (HMO)
![Email Prescription and/or Health Benefit details for Devoted Health Prime (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$31.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | None | $14.00 |
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 |
Wellcare Dual Access (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Wellcare Dual Access (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$32.00 |
$480 |
Some Generics |
2 |
Generic |
$9.00 | $0.00 | None | $8.68 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO-POS D-SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Dual Complete (HMO-POS D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$33.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $15.96 |
Browse Plan Formulary |
Aetna Medicare Premier Plus 2 (Regional PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Premier Plus 2 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$33.40 |
$260* |
No |
2* |
Generic |
$10.00 | $25.00 | None | $10.92 |
Browse Plan Formulary |
Anthem MediBlue Dual Advantage (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Anthem MediBlue Dual Advantage (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $19.32 |
Browse Plan Formulary |
CareSource Dual Advantage (HMO D-SNP)
![Email Prescription and/or Health Benefit details for CareSource Dual Advantage (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | None | $16.80 |
Browse Plan Formulary |
CommuniCare Advantage ISNP (HMO I-SNP)
![Email Prescription and/or Health Benefit details for CommuniCare Advantage ISNP (HMO I-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | 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 |
CommuniCare Advantage ISNP (HMO I-SNP)
![Email Prescription and/or Health Benefit details for CommuniCare Advantage ISNP (HMO I-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $19.04 |
Browse Plan Formulary |
CommuniCare Advantage ISNP (HMO I-SNP)
![Email Prescription and/or Health Benefit details for CommuniCare Advantage ISNP (HMO I-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $19.60 |
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Molina Medicare Complete Care (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Molina Medicare Complete Care (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$33.50 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$4.00 | $12.00 | None | $13.16 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP1 (HMO D-SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Dual Complete LP1 (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $15.96 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $17.36 |
Browse Plan Formulary |
Valor Health Plan (HMO I-SNP)
![Email Prescription and/or Health Benefit details for Valor Health Plan (HMO I-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $19.04 |
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)
![Email Prescription and/or Health Benefit details for PrimeTime Health Plan Classic (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$39.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $15.68 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MedMutual Advantage Choice (HMO)
![Email Prescription and/or Health Benefit details for MedMutual Advantage Choice (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$40.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $17.36 |
Browse Plan Formulary |
MedMutual Advantage Choice (HMO)
![Email Prescription and/or Health Benefit details for MedMutual Advantage Choice (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$40.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $16.52 |
Browse Plan Formulary |
MedMutual Advantage Choice (HMO)
![Email Prescription and/or Health Benefit details for MedMutual Advantage Choice (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$40.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $17.64 |
Browse Plan Formulary |
The Health Plan SecureCare SNP (HMO D-SNP)
![Email Prescription and/or Health Benefit details for The Health Plan SecureCare SNP (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$40.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $16.52 |
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Anthem MediBlue Access Basic (Regional PPO)
![Email Prescription and/or Health Benefit details for Anthem MediBlue Access Basic (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$41.50 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
41% | 41% | 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 |
SummaCare Medicare Ruby (HMO)
![Email Prescription and/or Health Benefit details for SummaCare Medicare Ruby (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$43.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$8.00 | $20.00 | None | $9.80 |
Browse Plan Formulary |
HumanaChoice H5216-051 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H5216-051 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$44.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $17.36 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MedMutual Advantage Select (PPO)
![Email Prescription and/or Health Benefit details for MedMutual Advantage Select (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$44.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $17.64 |
Browse Plan Formulary |
MedMutual Advantage Select (PPO)
![Email Prescription and/or Health Benefit details for MedMutual Advantage Select (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$44.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $17.36 |
Browse Plan Formulary |
MedMutual Advantage Select (PPO)
![Email Prescription and/or Health Benefit details for MedMutual Advantage Select (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$44.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $16.52 |
Browse Plan Formulary |
Aetna Medicare Premier Plus 1 (Regional PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Premier Plus 1 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$44.50 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $7.00 |
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 R5495-002 (Regional PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice R5495-002 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$47.80 |
$480 |
No |
4 |
Non-Preferred Drug |
20% | 20% | None | $17.64 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
![Email Prescription and/or Health Benefit details for Anthem MediBlue Plus (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$55.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $21.00 |
Browse Plan Formulary |
Anthem MediBlue Access (PPO)
![Email Prescription and/or Health Benefit details for Anthem MediBlue Access (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$56.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $19.32 |
Browse Plan Formulary |
SummaCare Medicare Sapphire (HMO-POS)
![Email Prescription and/or Health Benefit details for SummaCare Medicare Sapphire (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$76.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$8.00 | $20.00 | None | $9.80 |
Browse Plan Formulary |
MedMutual Advantage Preferred (PPO)
![Email Prescription and/or Health Benefit details for MedMutual Advantage Preferred (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$80.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $17.36 |
Browse Plan Formulary |
MedMutual Advantage Preferred (PPO)
![Email Prescription and/or Health Benefit details for MedMutual Advantage Preferred (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$80.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $16.52 |
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)
![Email Prescription and/or Health Benefit details for MedMutual Advantage Preferred (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$80.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $17.64 |
Browse Plan Formulary |
Humana Gold Choice H8145-032 (PFFS)
![Email Prescription and/or Health Benefit details for Humana Gold Choice H8145-032 (PFFS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$83.00 |
$225 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $17.64 |
Browse Plan Formulary |
Anthem MediBlue Access Plus (PPO)
![Email Prescription and/or Health Benefit details for Anthem MediBlue Access Plus (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$89.00 |
$40 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $19.32 |
Browse Plan Formulary |
PrimeTime Health Plan Plus (HMO-POS)
![Email Prescription and/or Health Benefit details for PrimeTime Health Plan Plus (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$89.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $15.68 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MedMutual Advantage Plus (HMO)
![Email Prescription and/or Health Benefit details for MedMutual Advantage Plus (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$97.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $16.52 |
Browse Plan Formulary |
MedMutual Advantage Plus (HMO)
![Email Prescription and/or Health Benefit details for MedMutual Advantage Plus (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$97.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $17.64 |
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)
![Email Prescription and/or Health Benefit details for MedMutual Advantage Plus (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$97.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $17.36 |
Browse Plan Formulary |
The Health Plan SecureChoice - Option II (PPO)
![Email Prescription and/or Health Benefit details for The Health Plan SecureChoice - Option II (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$100.00 |
$100* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | None | $16.52 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 3 (HMO)
![Email Prescription and/or Health Benefit details for AARP Medicare Advantage Plan 3 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$111.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $16.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Premier 2 (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Premier 2 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$118.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $10.00 | None | $7.84 |
Browse Plan Formulary |
MedMutual Advantage Premium (PPO)
![Email Prescription and/or Health Benefit details for MedMutual Advantage Premium (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$134.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $17.36 |
Browse Plan Formulary |
MedMutual Advantage Premium (PPO)
![Email Prescription and/or Health Benefit details for MedMutual Advantage Premium (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$134.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $16.52 |
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)
![Email Prescription and/or Health Benefit details for MedMutual Advantage Premium (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$134.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $17.64 |
Browse Plan Formulary |
Aetna Medicare Premier 1 (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Premier 1 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$149.00 |
$150* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $7.84 |
Browse Plan Formulary |
HumanaChoice H5525-030 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H5525-030 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$151.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | None | $17.64 |
Browse Plan Formulary |
SummaCare Medicare Emerald (HMO-POS)
![Email Prescription and/or Health Benefit details for SummaCare Medicare Emerald (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$180.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$8.00 | $20.00 | None | $9.80 |
Browse Plan Formulary |