MESALAMINE DR 400 MG CAPSULE (DRTAB) [Delzicol] (180 UNITS ) (NDC: 59762011701)
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 Choice (HMO-POS)
|
$0.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $205.20 |
Browse Plan Formulary |
Aetna Medicare Credit (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $212.40 |
Browse Plan Formulary |
Aetna Medicare Premier (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $198.00 |
Browse Plan Formulary |
Aetna Medicare Premier Plus (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $187.20 |
Browse Plan Formulary |
Aetna Medicare Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | None | $216.00 |
Browse Plan Formulary select insulin pay $20 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 |
AvMed Medicare Access (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $187.50 | Q:180 /30Days | $448.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AvMed Medicare Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $187.50 | Q:180 /30Days | $448.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AvMed Medicare Circle (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $187.50 | Q:180 /30Days | $448.20 |
Browse Plan Formulary select insulin pay $30-$35 copay but not this drug |
AvMed Medicare Premium Saver (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$80.00 | $200.00 | Q:180 /30Days | $448.20 |
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:180 /30Days | $505.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BlueMedicare Premier (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | Q:180 /30Days | $496.80 |
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 |
Bright Advantage Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $383.40 |
Browse Plan Formulary select insulin pay $0-$25 copay but not this drug |
Bright Advantage Health Dollars Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $383.40 |
Browse Plan Formulary |
Bright Advantage Part B Savings Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $383.40 |
Browse Plan Formulary |
Bright Advantage Part B Savings Plan (PPO)
|
$0.00 |
$110 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $383.40 |
Browse Plan Formulary |
Devoted Health Core Broward (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $477.00 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Devoted Health Essentials Broward (HMO)
|
$0.00 |
$100* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $477.00 |
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 |
Devoted Health Latitude South Florida (PPO)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $477.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
DrMax-B (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:180 /30Days | $383.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
DrValue-B (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:180 /30Days | $383.40 |
Browse Plan Formulary |
Freedom VIP Savings (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
3 |
Non-Preferred Drug |
$85.00 | $170.00 | None | $509.40 |
Browse Plan Formulary |
Freedom VIP Savings COPD (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
3 |
Non-Preferred Drug |
$80.00 | $160.00 | None | $509.40 |
Browse Plan Formulary |
HealthSun HealthAdvantage Plan (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $565.20 |
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 |
HealthSun HealthAdvantage Plus (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $565.20 |
Browse Plan Formulary |
MMM ELITE (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $487.80 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
MMM EXTRA (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $45.00 | Q:180 /30Days | $487.80 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$12.00 | $24.00 | Q:180 /30Days | $511.20 |
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 |
2 |
Generic |
$20.00 | $40.00 | Q:180 /30Days | $511.20 |
Browse Plan Formulary |
Molina Medicare Connect Care (HMO C-SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:180 /30Days | $511.20 |
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 |
Optimum Gold Rewards Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Drug |
$70.00 | $140.00 | None | $471.60 |
Browse Plan Formulary |
Optimum Platinum Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Drug |
$50.00 | $100.00 | None | $471.60 |
Browse Plan Formulary |
Oscar + Holy Cross + Memorial - with $1500 O-Card (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $462.60 |
Browse Plan Formulary |
Oscar + Holy Cross + Memorial - with Refund Bonus (HMO)
|
$0.00 |
$200* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $462.60 |
Browse Plan Formulary |
Oscar + Holy Cross + Memorial (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $462.60 |
Browse Plan Formulary |
PHP (HMO C-SNP)
|
$0.00 |
$480 |
Few Generics |
1 |
Generic |
15% | n/a | None | $390.60 |
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 |
SOLIS SPF 007 (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $612.00 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $367.20 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $367.20 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$100* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $347.40 |
Browse Plan Formulary |
Wellcare Specialty Giveback (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
2 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $358.20 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
Wellcare Specialty No Premium (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
2 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $358.20 |
Browse Plan Formulary select insulin pay $10 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 |
DrPlus-B (HMO-POS D-SNP)
|
$26.50 |
$0 |
Many Generics, Some Brands |
4 |
Non-Preferred Drug |
$35.00 | $105.00 | Q:180 /30Days | $383.40 |
Browse Plan Formulary |
Aetna Medicare Assure Plus (HMO D-SNP)
|
$27.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | None | $331.20 |
Browse Plan Formulary |
Wellcare Dual Reserve (HMO D-SNP)
|
$30.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
39% | 39% | Q:180 /30Days | $457.20 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$32.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:180 /30Days | $457.20 |
Browse Plan Formulary |
Aetna Medicare Assure (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | None | $331.20 |
Browse Plan Formulary |
BlueMedicare Complete (HMO D-SNP)
|
$34.30 |
$480 |
Some Generics, Few Brands |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | Q:180 /30Days | $487.80 |
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 |
Bright Advantage Embrace Assist Plan (HMO C-SNP)
|
$34.30 |
$480 |
Some Generics |
4 |
Non-Preferred Drug |
25% | 25% | None | $383.40 |
Browse Plan Formulary |
Bright Advantage Embrace Choice Plan (HMO C-SNP)
|
$34.30 |
$480 |
Some Generics |
4 |
Non-Preferred Drug |
25% | 25% | None | $383.40 |
Browse Plan Formulary |
Devoted Health Dual Broward (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | Q:180 /30Days | $477.00 |
Browse Plan Formulary |
Devoted Health Prime South Florida (HMO)
|
$34.30 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $477.00 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Devoted Health Prime South Florida (HMO)
|
$34.30 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $477.00 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Devoted Health Prime South Florida (HMO)
|
$34.30 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $477.00 |
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 |
Florida Complete Care (HMO I-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:180 /30Days | $543.60 |
Browse Plan Formulary |
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:180 /30Days | $543.60 |
Browse Plan Formulary |
Freedom Medi-Medi Full (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $495.00 |
Browse Plan Formulary |
Freedom Medi-Medi Partial (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $495.00 |
Browse Plan Formulary |
HealthSun MediMax (HMO)
|
$34.30 |
$430 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | None | $509.40 |
Browse Plan Formulary |
HealthSun MediSun Extra (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | None | $509.40 |
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 |
HealthSun MediSun Plus (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | None | $509.40 |
Browse Plan Formulary |
MMM PLATINUM (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | Q:180 /30Days | $487.80 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$34.30 |
$480 |
Some Generics, Few Brands |
4 |
Non-Preferred Drug |
34% | 34% | Q:180 /30Days | $511.20 |
Browse Plan Formulary |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$34.30 |
$480 |
Some Generics, Few Brands |
4 |
Non-Preferred Drug |
31% | 31% | Q:180 /30Days | $511.20 |
Browse Plan Formulary |
Optimum Emerald Full (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $495.00 |
Browse Plan Formulary |
Optimum Emerald Partial (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $495.00 |
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 |
SOLIS SPF 012 (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | None | $612.00 |
Browse Plan Formulary |
Wellcare Dual Liberty (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:180 /30Days | $457.20 |
Browse Plan Formulary |
Wellcare Dual Medicare (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
49% | 49% | Q:180 /30Days | $325.80 |
Browse Plan Formulary |
Wellcare Dual Nurture (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
44% | 44% | Q:180 /30Days | $313.20 |
Browse Plan Formulary |
BlueMedicare Choice (Regional PPO)
|
$47.90 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | Q:180 /30Days | $502.20 |
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. |
2 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $347.40 |
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 |
BlueMedicare Select (PPO)
|
$147.90 |
$305 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | Q:180 /30Days | $502.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |