BETASERON 0.3 MG KIT (1.000 EA ) (NDC: 50419052435)
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)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:15 /30Days | $8,990.38 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice Plan 3 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:15 /30Days | $8,990.38 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Credit Value (PPO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | P Q:14 /28Days | $9,374.40 |
Browse Plan Formulary |
Aetna Medicare Advantra Silver (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:14 /28Days | $9,374.40 |
Browse Plan Formulary |
Aetna Medicare Value (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:14 /28Days | $9,374.40 |
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 |
BlueJourney Essential (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:15 /30Days | $8,675.10 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
BlueJourney Select (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:15 /30Days | $8,675.10 |
Browse Plan Formulary select insulin pay $15 copay but not this drug |
Capital Blue Cross WellSpan Health Advantage (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:15 /30Days | $8,356.74 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Capital Blue Cross WellSpan Health Inspire (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:15 /30Days | $8,356.74 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:14 /28Days | $9,485.14 |
Browse Plan Formulary |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:14 /28Days | $9,485.14 |
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 |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:14 /28Days | $8,411.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:14 /28Days | $8,249.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:14 /28Days | $8,431.92 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:14 /28Days | $8,957.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:14 /28Days | $8,411.90 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:14 /28Days | $8,557.36 |
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 |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:14 /28Days | $8,268.96 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:14 /28Days | $8,957.90 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:14 /28Days | $8,319.78 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:14 /28Days | $8,319.78 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Health Partners Medicare Complete (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $8,416.10 |
Browse Plan Formulary |
Humana Gold Plus H6622-035 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:15 /30Days | $8,983.80 |
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 |
HumanaChoice H5525-051 (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:15 /30Days | $8,393.56 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5525-051 (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:15 /30Days | $9,245.46 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UPMC for Life HMO Premier Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:14 /28Days | $8,411.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UPMC for Life PPO Flex Rx (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:14 /28Days | $8,411.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Vibra Essential Advocate (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:15 /30Days | $8,624.70 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Vibra Essential Advocate (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:15 /30Days | $8,356.74 |
Browse Plan Formulary select insulin pay $5 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 Giveback (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:14 /28Days | $9,225.30 |
Browse Plan Formulary |
Wellcare Giveback Open (PPO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
27% | n/a | P Q:14 /28Days | $9,227.12 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:14 /28Days | $9,306.50 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:14 /28Days | $9,227.12 |
Browse Plan Formulary |
Humana Gold Choice H8145-052 (PFFS)
|
$7.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | P Q:15 /30Days | $9,263.66 |
Browse Plan Formulary |
Aetna Medicare Advantra Premier (HMO-POS)
|
$17.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:14 /28Days | $9,374.40 |
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 |
Capital Blue Cross WellSpan Health AdvantagePlus (PPO)
|
$19.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:15 /30Days | $8,356.74 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Aetna Medicare Advantra Silver Plus (PPO)
|
$20.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:14 /28Days | $9,374.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice Plan 1 (PPO)
|
$21.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:15 /30Days | $8,990.38 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UPMC for Life HMO Deductible Rx (HMO)
|
$22.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:14 /28Days | $8,509.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Cares (HMO D-SNP)
|
$22.10 |
$375 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
26% | n/a | P Q:14 /28Days | $9,374.40 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H6622-078 (HMO D-SNP)
|
$23.70 |
$450 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:15 /30Days | $8,393.56 |
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 |
Humana Gold Plus SNP-DE H6622-078 (HMO D-SNP)
|
$23.70 |
$450 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:15 /30Days | $9,227.40 |
Browse Plan Formulary |
Wellcare Assist Open (PPO)
|
$24.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:14 /28Days | $9,169.16 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$25.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:14 /28Days | $8,411.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Community Blue Medicare PPO Distinct (PPO)
|
$25.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:14 /28Days | $8,323.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Community Blue Medicare PPO Distinct (PPO)
|
$25.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:14 /28Days | $8,431.92 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Community Blue Medicare PPO Distinct (PPO)
|
$25.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:14 /28Days | $8,957.90 |
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 |
Vibra Health Plan Enhanced Complete (PPO)
|
$27.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:15 /30Days | $8,580.32 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
HumanaChoice H5525-006 (PPO)
|
$29.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:15 /30Days | $9,026.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UPMC for Life PPO Rx Choice (PPO)
|
$29.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:14 /28Days | $8,411.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Low Premium Open (PPO)
|
$29.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | P Q:14 /28Days | $9,227.12 |
Browse Plan Formulary |
Cigna TotalCare Plus (HMO D-SNP)
|
$29.80 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P Q:14 /28Days | $9,653.98 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$29.90 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | P Q:14 /28Days | $9,693.46 |
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 Plus Medicare (PPO)
|
$30.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:14 /28Days | $9,485.14 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$33.90 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | Q:15 /30Days | $9,257.50 |
Browse Plan Formulary |
HumanaChoice R0923-002 (Regional PPO)
|
$34.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:15 /30Days | $8,819.86 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Assist (HMO)
|
$36.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:14 /28Days | $9,169.16 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:14 /28Days | $8,332.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:14 /28Days | $8,309.14 |
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 |
UPMC for Life HMO Rx Choice (HMO)
|
$38.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:14 /28Days | $8,509.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
|
$40.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | Q:15 /30Days | $9,257.36 |
Browse Plan Formulary |
AmeriHealth Caritas VIP Care (HMO D-SNP)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Brand |
25% | 25% | P | $8,469.86 |
Browse Plan Formulary |
Geisinger Gold Secure Rx (HMO D-SNP)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:14 /28Days | $8,319.78 |
Browse Plan Formulary |
Health Partners Medicare Prime (HMO-POS)
|
$40.70 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $8,416.10 |
Browse Plan Formulary |
Health Partners Medicare Special (HMO D-SNP)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $8,416.10 |
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 |
Highmark Wholecare Medicare Assured Diamond (HMO D-SNP)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:14 /28Days | $8,228.92 |
Browse Plan Formulary |
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:14 /28Days | $8,228.92 |
Browse Plan Formulary |
Provider Partners Pennsylvania Advantage Plan (HMO I-SNP)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P | $8,804.32 |
Browse Plan Formulary |
Provider Partners Pennsylvania Community Plan (HMO I-SNP)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P | $8,804.32 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Select (HMO D-SNP)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | Q:15 /30Days | $9,257.50 |
Browse Plan Formulary |
UPMC for Life Complete Care (HMO D-SNP)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:14 /28Days | $8,511.72 |
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)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:14 /28Days | $9,168.88 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:14 /28Days | $8,320.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:14 /28Days | $8,316.56 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:14 /28Days | $8,316.42 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice Plan 2 (PPO)
|
$46.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:15 /30Days | $8,990.38 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Premier Plus (PPO)
|
$48.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:14 /28Days | $9,374.40 |
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 Classic (PPO)
|
$50.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:15 /30Days | $8,675.10 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
BlueJourney Value (HMO)
|
$60.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:15 /30Days | $8,675.10 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
UPMC for Life PPO Rx Enhanced (PPO)
|
$60.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:14 /28Days | $8,334.34 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Silver (HMO)
|
$65.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:14 /28Days | $9,374.40 |
Browse Plan Formulary |
Freedom Blue PPO ValueRx (PPO)
|
$69.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:14 /28Days | $8,341.48 |
Browse Plan Formulary |
UPMC for Life HMO Rx (HMO)
|
$81.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:14 /28Days | $8,509.48 |
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 |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$86.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:14 /28Days | $8,298.78 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$86.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:14 /28Days | $8,325.38 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BlueJourney Premier (HMO)
|
$116.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:15 /30Days | $8,675.10 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
HumanaChoice H5216-120 (PPO)
|
$128.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:15 /30Days | $8,776.74 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$151.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:14 /28Days | $8,301.16 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$151.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:14 /28Days | $8,323.00 |
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 |
Geisinger Gold Classic Advantage Rx (HMO)
|
$151.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:14 /28Days | $8,332.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Gold Plan (PPO)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:14 /28Days | $9,374.40 |
Browse Plan Formulary |
BlueJourney Prime (PPO)
|
$172.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:15 /30Days | $8,675.10 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Freedom Blue PPO Standard (PPO)
|
$174.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:14 /28Days | $8,341.48 |
Browse Plan Formulary |
Freedom Blue PPO Deluxe (PPO)
|
$288.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:14 /28Days | $8,341.48 |
Browse Plan Formulary |
UPMC for Life HMO Rx Enhanced (HMO)
|
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:14 /28Days | $8,509.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |