ELETRIPTAN HBR 20 MG TABLET [Relpax] (6 TABLETS ) (NDC: 59762232101)
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 Premier (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:12 /30Days | $31.20 |
Browse Plan Formulary |
Aetna Medicare Value (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:12 /30Days | $29.16 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:36 /90Days | $61.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:36 /90Days | $58.08 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:36 /90Days | $67.68 |
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 |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:36 /90Days | $69.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:36 /90Days | $57.24 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | Q:12 /30Days | $87.84 |
Browse Plan Formulary |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | Q:12 /30Days | $87.42 |
Browse Plan Formulary |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | Q:12 /30Days | $88.98 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:12 /30Days | $87.42 |
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 |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:12 /30Days | $88.98 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:12 /30Days | $87.84 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:12 /30Days | $88.32 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:12 /30Days | $89.52 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:12 /30Days | $88.98 |
Browse Plan Formulary |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:12 /30Days | $87.84 |
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 |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:12 /30Days | $87.42 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$10.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:36 /90Days | $32.28 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$10.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:36 /90Days | $23.94 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$10.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:36 /90Days | $45.66 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$10.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:36 /90Days | $52.98 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$10.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:36 /90Days | $22.86 |
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 |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:12 /30Days | $87.84 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:12 /30Days | $88.32 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:12 /30Days | $89.52 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:12 /30Days | $87.42 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:12 /30Days | $88.98 |
Browse Plan Formulary |
PriorityMedicare D-SNP (HMO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:12 /30Days | $82.44 |
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 |
PriorityMedicare Value (HMO-POS)
|
$50.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:12 /30Days | $87.84 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$50.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:12 /30Days | $88.32 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$50.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:12 /30Days | $89.52 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$50.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:12 /30Days | $87.42 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$50.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:12 /30Days | $88.98 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
BCN Advantage HMO ConnectedCare (HMO)
|
$58.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | Q:36 /90Days | $60.84 |
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 |
Medicare Plus Blue PPO Vitality (PPO)
|
$85.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:36 /90Days | $32.28 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$85.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:36 /90Days | $23.94 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$85.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:36 /90Days | $45.66 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$85.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:36 /90Days | $52.98 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$85.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:36 /90Days | $22.86 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$98.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:12 /30Days | $87.84 |
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 |
PriorityMedicare Merit (PPO)
|
$98.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:12 /30Days | $88.32 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$98.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:12 /30Days | $89.52 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$98.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:12 /30Days | $87.42 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$98.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:12 /30Days | $88.98 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:36 /90Days | $61.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:36 /90Days | $58.08 |
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 |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:36 /90Days | $67.68 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:36 /90Days | $69.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:36 /90Days | $57.24 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
PriorityMedicare (HMO-POS)
|
$127.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:12 /30Days | $87.84 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$127.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:12 /30Days | $88.32 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$127.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:12 /30Days | $89.52 |
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 |
PriorityMedicare (HMO-POS)
|
$127.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:12 /30Days | $87.42 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$127.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:12 /30Days | $88.98 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$152.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | Q:36 /90Days | $32.28 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$152.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | Q:36 /90Days | $23.94 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$152.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | Q:36 /90Days | $45.66 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$152.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | Q:36 /90Days | $52.98 |
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 |
Medicare Plus Blue PPO Signature (PPO)
|
$152.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | Q:36 /90Days | $22.86 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:12 /30Days | $87.84 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:12 /30Days | $88.32 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:12 /30Days | $89.52 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:12 /30Days | $87.42 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:12 /30Days | $88.98 |
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 |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$238.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:36 /90Days | $58.08 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$238.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:36 /90Days | $67.68 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$238.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:36 /90Days | $69.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$238.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:36 /90Days | $57.24 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$238.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:36 /90Days | $61.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Medicare Plus Blue PPO Assure (PPO)
|
$301.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:36 /90Days | $45.66 |
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 |
Medicare Plus Blue PPO Assure (PPO)
|
$301.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:36 /90Days | $52.98 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$301.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:36 /90Days | $22.86 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$301.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:36 /90Days | $32.28 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$301.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:36 /90Days | $23.94 |
Browse Plan Formulary |