GLYXAMBI 25 MG-5 MG TABLET (NDC: 00597016430)
2022 Medicare Prescription Drug Plan (MAPD) Information
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Plan Name |
Monthly Prem. |
De- duct- ible | Does Plan Offer Additional Gap Coverage | Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Plan’s Avg. Retail Drug Price 30-Day |
Tier Nbr. |
Tier Desc. |
30-Day Prfrd. Pharm |
90-Day Mail Order |
AARP Medicare Advantage (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days | $608.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice (PPO)
|
$0.00 |
$150 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days | $608.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice Plan 2 (Regional PPO)
|
$0.00 |
$395 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $607.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Focus (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days | $608.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Credit (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $615.90 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Aetna Medicare Premier (PPO)
|
$0.00 |
$300 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $616.20 |
Browse Plan Formulary |
Aetna Medicare Premier Plus (PPO)
|
$0.00 |
$150 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $615.90 |
Browse Plan Formulary |
Aetna Medicare Select (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $105.00 | Q:30 /30Days | $615.90 |
Browse Plan Formulary select insulin pay $20 copay but not this drug |
BayCarePlus Complete (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$35.00 | $95.00 | Q:30 /30Days | $553.80 |
Browse Plan Formulary select insulin pay $4-$35 copay but not this drug |
BayCarePlus Rewards (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $125.00 | Q:30 /30Days | $553.80 |
Browse Plan Formulary |
BlueMedicare Classic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$93.00 | $279.00 | Q:30 /30Days | $571.80 |
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 |
BlueMedicare Premier (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$90.00 | $270.00 | Q:30 /30Days | $573.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BlueMedicare Value (PPO)
|
$0.00 |
$150 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $586.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Bright Advantage Health Dollars Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$20.00 | $40.00 | Q:30 /30Days | $553.80 |
Browse Plan Formulary |
Bright Advantage Health Dollars Plan (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:30 /30Days | $553.80 |
Browse Plan Formulary |
Bright Advantage Part B Savings Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:30 /30Days | $553.80 |
Browse Plan Formulary |
Bright Advantage Part B Savings Plan (PPO)
|
$0.00 |
$110 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:30 /30Days | $553.80 |
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 |
CareBreeze (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 3 |
Preferred Brand |
$35.00 | $95.00 | Q:30 /30Days | $614.10 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
CareComplete (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 3 |
Preferred Brand |
$35.00 | $95.00 | Q:30 /30Days | $614.10 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
CareFree (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $95.00 | Q:30 /30Days | $614.40 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
CareFree (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $95.00 | Q:30 /30Days | $612.00 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
CareOne PLATINUM (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$10.00 | $20.00 | Q:30 /30Days | $614.40 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
CareOne PLUS (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$5.00 | $5.00 | Q:30 /30Days | $614.40 |
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 |
CareOne PLUS (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$5.00 | $5.00 | Q:30 /30Days | $612.00 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$35.00 | $105.00 | Q:30 /30Days | $623.40 |
Browse Plan Formulary |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:30 /30Days | $623.40 |
Browse Plan Formulary |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days | $623.40 |
Browse Plan Formulary |
Devoted Health Core Greater Tampa Bay (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$8.00 | $0.00 | Q:30 /30Days | $540.90 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Devoted Health Core Greater Tampa Bay (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$8.00 | $0.00 | Q:30 /30Days | $540.90 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Devoted Health Essentials Greater Tampa Bay (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $117.50 | Q:30 /30Days | $540.90 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Devoted Health Latitude Greater Tampa Bay (PPO)
|
$0.00 |
$150 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $117.50 | Q:30 /30Days | $540.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 3 |
Preferred Brand |
$5.00 | $5.00 | Q:30 /30Days | $614.40 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
Humana Gold Plus H1036-025 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$5.00 | $5.00 | Q:30 /30Days | $614.10 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
Humana Gold Plus H1036-265 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days | $616.50 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
Humana Gold Plus H1036-265 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days | $614.10 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HumanaChoice Florida H5216-072 (PPO)
|
$0.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $614.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:30 /30Days | $554.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Molina Medicare Choice Care Select (HMO)
|
$0.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:30 /30Days | $554.70 |
Browse Plan Formulary |
Molina Medicare Connect Care (HMO C-SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $554.70 |
Browse Plan Formulary |
Simply Care (HMO I-SNP)
|
$0.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | n/a | Q:30 /30Days | $547.80 |
Browse Plan Formulary |
Simply Comfort (HMO I-SNP)
|
$0.00 |
$480 | Some Generics, Few Brands | 3 |
Preferred Brand |
25% | n/a | Q:30 /30Days | $547.80 |
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 |
Simply Extra (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $547.80 |
Browse Plan Formulary |
Simply Level (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 3 |
Preferred Brand |
$30.00 | $90.00 | Q:30 /30Days | $547.80 |
Browse Plan Formulary |
Simply More (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $105.00 | Q:30 /30Days | $547.80 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150* | Some Generics | 3* |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $592.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150* | Some Generics | 3* |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $593.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150* | Some Generics | 3* |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $592.20 |
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 |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150* | Some Generics | 3* |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $591.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Giveback (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$25.00 | $50.00 | Q:30 /30Days | $603.00 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$0.00 | $0.00 | Q:30 /30Days | $603.00 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$100 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$37.00 | $74.00 | Q:30 /30Days | $603.30 |
Browse Plan Formulary |
Wellcare Specialty Giveback (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 3 |
Preferred Brand |
$0.00 | $0.00 | Q:30 /30Days | $603.00 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Wellcare Specialty No Premium (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 3 |
Preferred Brand |
$0.00 | $0.00 | Q:30 /30Days | $603.00 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HumanaChoice R5826-074 (Regional PPO)
|
$0.50 |
$395 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $615.30 |
Browse Plan Formulary |
CareNeeds PLUS (HMO D-SNP)
|
$14.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $614.10 |
Browse Plan Formulary |
Humana Fully Integrated H1036-283 (HMO D-SNP)
|
$15.60 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $614.40 |
Browse Plan Formulary |
Cigna TotalCare Plus (HMO D-SNP)
|
$21.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
18% | 18% | Q:30 /30Days | $623.40 |
Browse Plan Formulary |
Cigna Primary Medicare (HMO)
|
$22.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
18% | 18% | Q:30 /30Days | $623.40 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-102 (HMO D-SNP)
|
$24.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $614.10 |
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 |
Aetna Medicare Assure (HMO D-SNP)
|
$28.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $615.90 |
Browse Plan Formulary |
Aetna Medicare Assure Plus (HMO D-SNP)
|
$30.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $615.90 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO D-SNP)
|
$31.50 |
$480 | No | 3 |
Tier 3 |
15% | 15% | Q:30 /30Days | $607.80 |
Browse Plan Formulary |
Wellcare Dual Reserve (HMO D-SNP)
|
$31.60 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $80.00 | Q:30 /30Days | $602.70 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$32.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:30 /30Days | $602.70 |
Browse Plan Formulary |
Wellcare Dual Medicare (HMO D-SNP)
|
$33.70 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days | $602.70 |
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 |
BayCarePlus Premier (HMO)
|
$34.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$35.00 | $95.00 | Q:30 /30Days | $553.80 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
BlueMedicare Complete (HMO D-SNP)
|
$34.30 |
$480 | Some Generics, Few Brands | 4 |
Non-Preferred Drug |
$92.00 | $276.00 | Q:30 /30Days | $570.90 |
Browse Plan Formulary |
Devoted Health Dual Greater Tampa Bay (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | 25% | Q:30 /30Days | $540.90 |
Browse Plan Formulary |
Devoted Health Prime (HMO)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | 25% | Q:30 /30Days | $541.20 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Devoted Health Prime (HMO)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | 25% | Q:30 /30Days | $540.90 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Florida Complete Care (HMO I-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $563.10 |
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 |
Florida Complete Care- In The Community (HMO I-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $563.10 |
Browse Plan Formulary |
Longevity Health Plan (HMO I-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | Q:30 /30Days | $547.80 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$34.30 |
$480 | Some Generics, Few Brands | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $554.70 |
Browse Plan Formulary |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$34.30 |
$480 | Some Generics, Few Brands | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $554.70 |
Browse Plan Formulary |
Simply Complete (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $567.00 |
Browse Plan Formulary |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$34.30 |
$200* | No additional gap coverage, only the Donut Hole Discount | 3* |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $608.10 |
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 |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | Q:30 /30Days | $607.50 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | Q:30 /30Days | $608.10 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | Q:30 /30Days | $607.50 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | Q:30 /30Days | $608.10 |
Browse Plan Formulary |
Wellcare Dual Liberty (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:30 /30Days | $602.70 |
Browse Plan Formulary |
Wellcare Dual Nurture (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:30 /30Days | $602.70 |
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 |
BlueMedicare Choice (Regional PPO)
|
$47.90 |
$250 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$93.00 | $279.00 | Q:30 /30Days | $573.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice R5826-005 (Regional PPO)
|
$55.00 |
$100 | No | 3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days | $615.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Premium Enhanced Open (PPO)
|
$85.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$37.00 | $74.00 | Q:30 /30Days | $603.30 |
Browse Plan Formulary |
Humana Gold Choice H8145-061 (PFFS)
|
$102.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 3* |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $615.00 |
Browse Plan Formulary |