BICILLIN LA PFS 1200MU 2ML (TEN 2ML CTG) (NDC: 60793070110)
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 |
Aetna Medicare Credit Plan (PPO)
|
$0.00 |
$350 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $2,248.60 |
Browse Plan Formulary |
Aetna Medicare Elite Plan (PPO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $2,249.80 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO-POS)
|
$0.00 |
$300 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $2,249.80 |
Browse Plan Formulary |
CDPHP $0 Medicare Rx (HMO)
|
$0.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $250.00 | None | $2,026.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
CDPHP Vital Rx (PPO)
|
$0.00 |
$350 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $250.00 | None | $2,026.00 |
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 |
EmblemHealth VIP Rx Saver (HMO)
|
$0.00 |
$395 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $2,042.40 |
Browse Plan Formulary |
EmblemHealth VIP Rx Saver (HMO)
|
$0.00 |
$395 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $2,027.80 |
Browse Plan Formulary |
Highmark Blue Shield Freedom Basic (PPO)
|
$0.00 |
$350 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$94.00 | $235.00 | P | $2,004.40 |
Browse Plan Formulary |
Highmark Blue Shield Freedom Nation (PPO)
|
$0.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$94.00 | $235.00 | P | $2,004.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Highmark Blue Shield Freedom Value (HMO)
|
$0.00 |
$295 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$94.00 | $235.00 | P | $2,004.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H3533-006 (HMO)
|
$0.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $2,268.60 |
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 H5970-015 (PPO)
|
$0.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $2,292.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5970-018 (PPO)
|
$0.00 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $2,292.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MediGold Essential Care (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $2,019.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MVP Medicare WellSelect with Part D (PPO)
|
$0.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | 25% | None | $2,026.00 |
Browse Plan Formulary |
Wellcare Fidelis No Premium (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
42% | 42% | None | $2,213.60 |
Browse Plan Formulary |
Wellcare Giveback Open (PPO)
|
$0.00 |
$325 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
48% | 48% | None | $2,207.40 |
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 |
Wellcare No Premium (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
48% | 48% | None | $2,209.60 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
42% | 42% | None | $2,207.40 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO)
|
$16.00 |
$300 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $2,224.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Fidelis Assist (HMO-POS)
|
$17.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
37% | 37% | None | $2,200.60 |
Browse Plan Formulary |
HumanaChoice SNP-DE H5970-020 (PPO D-SNP)
|
$19.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $2,281.80 |
Browse Plan Formulary |
Wellcare Fidelis Dual Access (HMO D-SNP)
|
$20.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
33% | 33% | None | $2,200.60 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Wellcare Fidelis Dual Plus (HMO D-SNP)
|
$23.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
33% | 33% | None | $2,199.80 |
Browse Plan Formulary |
Aetna Medicare Assure Plan (HMO D-SNP)
|
$23.80 |
$425 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | 25% | None | $2,248.60 |
Browse Plan Formulary |
HumanaChoice H5970-019 (PPO)
|
$24.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$99.00 | $287.00 | None | $2,312.20 |
Browse Plan Formulary |
Humana Gold Plus H3533-013 (HMO)
|
$26.00 |
$275 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $2,312.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MediGold True Advantage (HMO)
|
$29.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $2,019.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus SNP-DE H3533-002 (HMO D-SNP)
|
$30.10 |
$460 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $2,281.80 |
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 Open (PPO)
|
$30.70 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
44% | 44% | None | $2,200.40 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$30.80 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | None | $2,200.00 |
Browse Plan Formulary |
CDPHP Basic RX (HMO)
|
$31.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$97.00 | $242.50 | None | $2,026.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Advantage Choice Plan 3 (Regional PPO)
|
$34.20 |
$250 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $2,224.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Empire MediBlue Dual Advantage (HMO D-SNP)
|
$36.90 |
$480 | Some Generics | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $2,237.20 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage (HMO D-SNP)
|
$36.90 |
$480 | Some Generics | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $2,237.20 |
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 |
Wellcare Dual Access Open (PPO D-SNP)
|
$37.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
49% | 49% | None | $2,200.60 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Plan 2 (HMO D-SNP)
|
$37.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | None | $2,224.80 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Plan 2 (HMO D-SNP)
|
$37.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | None | $2,223.60 |
Browse Plan Formulary |
MVP Medicare Secure with Part D (HMO-POS)
|
$40.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | 25% | None | $2,026.00 |
Browse Plan Formulary |
CDPHP Flex Rx (PPO)
|
$42.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $237.50 | None | $2,026.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Empire MediBlue Plus (HMO)
|
$42.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $2,237.20 |
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 |
Empire MediBlue Plus (HMO)
|
$42.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $2,272.80 |
Browse Plan Formulary |
MVP DualAccess (HMO D-SNP)
|
$42.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | None | $2,026.00 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | None | $2,040.40 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | None | $2,015.40 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | None | $2,028.40 |
Browse Plan Formulary |
EmblemHealth VIP Solutions (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $2,023.40 |
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 |
Hamaspik Medicare Select (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $2,046.00 |
Browse Plan Formulary |
Nascentia Dual Advantage (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $2,085.60 |
Browse Plan Formulary |
Nascentia Skilled Nursing Facility (HMO I-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $2,085.60 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | None | $2,223.60 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | None | $2,224.80 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $2,224.80 |
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 1 (PPO I-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $2,224.80 |
Browse Plan Formulary |
MVP Medicare Patriot Plan with Part D (PPO)
|
$45.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | 25% | None | $2,026.60 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$50.00 |
$250 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $2,249.80 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice Plan 4 (Regional PPO)
|
$51.50 |
$150 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $2,224.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Premium Enhanced (PFFS)
|
$55.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
48% | 48% | None | $2,208.00 |
Browse Plan Formulary |
Highmark Blue Shield Freedom Plus (HMO)
|
$57.00 |
$275 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$94.00 | $235.00 | P | $2,004.40 |
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 |
CDPHP Value Rx (HMO)
|
$60.80 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$93.00 | $232.50 | None | $2,026.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Empire MediBlue Access (PPO)
|
$90.00 |
$310 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$88.00 | $264.00 | None | $2,237.20 |
Browse Plan Formulary |
Empire MediBlue Access (PPO)
|
$90.00 |
$310 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$88.00 | $264.00 | None | $2,272.80 |
Browse Plan Formulary |
MVP Medicare Secure Plus with Part D (HMO-POS)
|
$90.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
27% | 27% | None | $2,026.00 |
Browse Plan Formulary |
Wellcare Premium Ultra Open (PPO)
|
$121.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
43% | 43% | None | $2,209.40 |
Browse Plan Formulary |
Highmark Blue Shield Senior Blue 652 (HMO)
|
$124.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$94.00 | $235.00 | P | $2,004.40 |
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 |
MVP Medicare WellSelect Plus with Part D (PPO)
|
$125.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
26% | 26% | None | $2,026.00 |
Browse Plan Formulary |
CDPHP Choice Rx (HMO)
|
$131.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$90.00 | $225.00 | None | $2,026.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MVP Medicare Preferred Gold with Part D (HMO-POS)
|
$140.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
27% | 27% | None | $2,026.00 |
Browse Plan Formulary |
Wellcare Premium Ultra (PFFS)
|
$156.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
42% | 42% | None | $2,208.00 |
Browse Plan Formulary |
Highmark Blue Shield Forever Blue 770 (PPO)
|
$201.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$94.00 | $235.00 | P | $2,004.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |