Menactra 4; 4; 4; 4ug/0.5mL; ug/0.5mL; ug/0.5mL; ug/0.5mL 5 VIAL, SINGLE-DOSE in 1 PACKAGE / 0.5 mL (5 VIAL, SINGLE-DOSE ) (NDC: 49281058905)
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 Plan 1 (HMO-POS)
|
$0.00 |
$195* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:1 /1Days | $301.94 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Choice Plan (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $305.80 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$0.00 |
$200* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $141.00 | None | $305.80 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | None | $304.82 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $305.41 |
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 |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $307.50 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $305.07 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $305.78 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $304.53 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $304.73 |
Browse Plan Formulary |
Amerivantage ESRD Care Plus (HMO C-SNP)
|
$0.00 |
$0 |
Few Generics |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $304.62 |
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 |
Blue Cross Medicare Advantage Choice Plus (PPO)
|
$0.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $290.27 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Classic (PPO)
|
$0.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $290.17 |
Browse Plan Formulary |
Cigna Alliance Medicare (HMO)
|
$0.00 |
$190* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$42.00 | $126.00 | None | $154.77 |
Browse Plan Formulary |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$190* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$42.00 | $126.00 | None | $154.67 |
Browse Plan Formulary |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$190* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$42.00 | $126.00 | None | $154.93 |
Browse Plan Formulary |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$190* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$42.00 | $126.00 | None | $154.82 |
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 Preferred Savings Medicare (HMO)
|
$0.00 |
$190* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$42.00 | $126.00 | None | $154.82 |
Browse Plan Formulary |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$190* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$42.00 | $126.00 | None | $154.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Devoted Health Core Greater Houston (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | None | $268.52 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H0028-042 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $305.47 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H0473-005 (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $304.97 |
Browse Plan Formulary |
KelseyCare Advantage Gold (HMO)
|
$0.00 |
$100 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | None | $274.39 |
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 |
KelseyCare Advantage Gold Freedom (HMO-POS)
|
$0.00 |
$100 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | None | $274.39 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
KelseyCare Advantage Platinum (HMO)
|
$0.00 |
$100 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | None | $274.39 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Memorial Hermann Advantage (HMO)
|
$0.00 |
$300* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$39.00 | $78.00 | None | $302.95 |
Browse Plan Formulary |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $275.39 |
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 | None | $275.39 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice (Regional PPO D-SNP)
|
$0.00 |
$480 |
No |
3 |
Tier 3 |
$0.00 | $0.00 | Q:1 /1Days | $302.06 |
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 Giveback (HMO)
|
$0.00 |
$300* |
No additional gap coverage, only the Donut Hole Discount |
6* |
Select Care Drugs |
$0.00 | $0.00 | None | $299.49 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300* |
No additional gap coverage, only the Donut Hole Discount |
6* |
Select Care Drugs |
$0.00 | $0.00 | None | $300.56 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300* |
No additional gap coverage, only the Donut Hole Discount |
6* |
Select Care Drugs |
$0.00 | $0.00 | None | $299.43 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300* |
No additional gap coverage, only the Donut Hole Discount |
6* |
Select Care Drugs |
$0.00 | $0.00 | None | $299.24 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300* |
No additional gap coverage, only the Donut Hole Discount |
6* |
Select Care Drugs |
$0.00 | $0.00 | None | $299.80 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
6 |
Select Care Drugs |
$0.00 | $0.00 | None | $299.49 |
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-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
6 |
Select Care Drugs |
$0.00 | $0.00 | None | $300.56 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
6 |
Select Care Drugs |
$0.00 | $0.00 | None | $299.43 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
6 |
Select Care Drugs |
$0.00 | $0.00 | None | $299.24 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
6 |
Select Care Drugs |
$0.00 | $0.00 | None | $299.80 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
6 |
Select Care Drugs |
$0.00 | $0.00 | None | $299.41 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$200* |
Yes, but No Gap Coverage for this drug. |
6* |
Select Care Drugs |
$0.00 | $0.00 | None | $299.46 |
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 |
Wellcare No Premium Rx Plus Open (PPO)
|
$0.00 |
$300* |
No additional gap coverage, only the Donut Hole Discount |
6* |
Select Care Drugs |
$0.00 | $0.00 | None | $299.43 |
Browse Plan Formulary |
Wellcare Specialty No Premium (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $299.67 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
Wellcare TexanPlus Classic No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
6 |
Select Care Drugs |
$0.00 | $0.00 | None | $299.46 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare TexanPlus No Premium (HMO-POS)
|
$0.00 |
$250* |
Yes, but No Gap Coverage for this drug. |
6* |
Select Care Drugs |
$0.00 | $0.00 | None | $299.46 |
Browse Plan Formulary |
Wellcare TexanPlus No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
6 |
Select Care Drugs |
$0.00 | $0.00 | None | $305.06 |
Browse Plan Formulary |
Wellcare TexanPlus No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
6 |
Select Care Drugs |
$0.00 | $0.00 | None | $299.64 |
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 TexanPlus No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
6 |
Select Care Drugs |
$0.00 | $0.00 | None | $299.49 |
Browse Plan Formulary |
Wellcare TexanPlus No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
6 |
Select Care Drugs |
$0.00 | $0.00 | None | $300.56 |
Browse Plan Formulary |
UnitedHealthcare Medicare Silver (Regional PPO C-SNP)
|
$3.70 |
$480 |
No |
3 |
Tier 3 |
25% | 25% | Q:1 /1Days | $302.06 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$5.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $158.07 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$5.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $158.32 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$5.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $158.22 |
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 |
AARP Medicare Advantage Choice (PPO)
|
$10.00 |
$245 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:1 /1Days | $301.94 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-043 (PPO)
|
$10.00 |
$250* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $131.00 | None | $304.05 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-043 (PPO)
|
$10.00 |
$250* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $131.00 | None | $305.32 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP)
|
$10.80 |
$295* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:1 /1Days | $302.06 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Choice II Plan (PPO)
|
$15.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $305.80 |
Browse Plan Formulary |
Amerivantage Choice (PPO)
|
$15.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $111.00 | None | $304.71 |
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)
|
$19.00 |
$190* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$42.00 | $126.00 | None | $154.80 |
Browse Plan Formulary |
Wellcare Assist (HMO)
|
$20.60 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
6* |
Select Care Drugs |
$0.00 | $0.00 | None | $299.14 |
Browse Plan Formulary |
Aetna Medicare Dual Complete Plan (HMO D-SNP)
|
$24.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $305.80 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $304.82 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $305.78 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $304.53 |
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 |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $304.73 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $305.41 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $307.50 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $305.07 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $305.41 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $307.50 |
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 |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $305.07 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $305.78 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $304.53 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $304.73 |
Browse Plan Formulary |
Community Health Choice (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $316.78 |
Browse Plan Formulary |
Devoted Health Prime Greater Houston (HMO)
|
$25.10 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | None | $268.52 |
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 |
Molina Medicare Complete Care (HMO D-SNP)
|
$25.10 |
$480 |
Some Generics |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $275.39 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:1 /1Days | $302.32 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:1 /1Days | $302.25 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:1 /1Days | $301.93 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:1 /1Days | $302.03 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$25.10 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
6* |
Select Care Drugs |
$0.00 | $0.00 | None | $299.14 |
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 |
Wellcare Dual Access Open (PPO D-SNP)
|
$25.10 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
6* |
Select Care Drugs |
$0.00 | $0.00 | None | $299.14 |
Browse Plan Formulary |
Wellcare Dual Liberty (HMO D-SNP)
|
$25.10 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
6* |
Select Care Drugs |
$0.00 | $0.00 | None | $299.14 |
Browse Plan Formulary |
HumanaChoice R4182-004 (Regional PPO)
|
$43.60 |
$175 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $305.39 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice (Regional PPO)
|
$49.00 |
$395 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:1 /1Days | $302.06 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Memorial Hermann Advantage Plus (HMO)
|
$50.00 |
$300* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$39.00 | $78.00 | None | $302.95 |
Browse Plan Formulary |
HumanaChoice R4182-003 (Regional PPO)
|
$51.00 |
$175 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $305.39 |
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 |
Blue Cross Medicare Advantage Choice Premier (PPO)
|
$90.00 |
$295 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $290.27 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Flex (PPO)
|
$215.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$44.00 | $132.00 | None | $287.68 |
Browse Plan Formulary |