OLMSRTN-AMLDPN-HCTZ 20-5-12.5 TABLET [Tribenzor] (90 TABLETS ) (NDC: 00093500556)
2022 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
See your cost using a drug discount card: Compare prices at pharmacies near you |
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, this drug has Gap Coverage. |
1 |
Preferred Generic |
$3.00 | $0.00 | Q:30 /30Days | $192.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice (PPO)
|
$0.00 |
$150* |
Yes, this drug has Gap Coverage. |
1* |
Preferred Generic |
$3.00 | $0.00 | Q:30 /30Days | $195.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice Plan 2 (Regional PPO)
|
$0.00 |
$395* |
Yes, this drug has Gap Coverage. |
1* |
Preferred Generic |
$3.00 | $0.00 | Q:30 /30Days | $193.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Focus (HMO-POS)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $195.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Advantage Care by Ultimate (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
1 |
Generic |
$0.00 | $0.00 | None | $309.60 |
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 |
Advantage Care by Ultimate (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
1 |
Generic |
$0.00 | $0.00 | None | $309.60 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
Advantage Care CHF by Ultimate (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
1 |
Generic |
$0.00 | $0.00 | None | $309.60 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
Advantage Care COPD by Ultimate (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
1 |
Generic |
$0.00 | $0.00 | None | $309.60 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
Aetna Medicare Credit (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $24.30 |
Browse Plan Formulary |
Aetna Medicare Premier (PPO)
|
$0.00 |
$300* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $29.70 |
Browse Plan Formulary |
Aetna Medicare Premier Plus (PPO)
|
$0.00 |
$150* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $30.60 |
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 |
Aetna Medicare Select (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $20.70 |
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 |
2 |
Generic |
$4.00 | $0.00 | None | $134.10 |
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 |
2 |
Generic |
$10.00 | $0.00 | None | $134.10 |
Browse Plan Formulary |
BlueMedicare Classic (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
6 |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $314.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BlueMedicare Premier (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $339.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
CareBreeze (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
4 |
Non-Preferred Drug |
$85.00 | $245.00 | Q:30 /30Days | $249.30 |
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 |
CareComplete (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
4 |
Non-Preferred Drug |
$85.00 | $245.00 | Q:30 /30Days | $249.30 |
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. |
4 |
Non-Preferred Drug |
$60.00 | $170.00 | Q:30 /30Days | $249.30 |
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. |
4 |
Non-Preferred Drug |
$60.00 | $170.00 | Q:30 /30Days | $250.20 |
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. |
4 |
Non-Preferred Drug |
$55.00 | $155.00 | Q:30 /30Days | $249.30 |
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. |
4 |
Non-Preferred Drug |
$45.00 | $125.00 | Q:30 /30Days | $249.30 |
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. |
4 |
Non-Preferred Drug |
$45.00 | $125.00 | Q:30 /30Days | $250.20 |
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 |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $115.20 |
Browse Plan Formulary |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $115.20 |
Browse Plan Formulary |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$2.00 | $0.00 | None | $115.20 |
Browse Plan Formulary |
Devoted Health Core Greater Tampa Bay (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $276.30 |
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. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $276.30 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Devoted Health Essentials Greater Tampa Bay (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $276.30 |
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 Greater Tampa Bay (PPO)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $276.30 |
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 |
6 |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $249.30 |
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. |
4 |
Non-Preferred Drug |
$55.00 | $155.00 | Q:30 /30Days | $249.30 |
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. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:30 /30Days | $249.30 |
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. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:30 /30Days | $249.30 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
HumanaChoice Florida H5216-072 (PPO)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $249.30 |
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 Choice Care (HMO)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$3.00 | $6.00 | Q:30 /30Days | $241.20 |
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 |
1 |
Preferred Generic |
$15.00 | $30.00 | Q:30 /30Days | $241.20 |
Browse Plan Formulary |
Molina Medicare Connect Care (HMO C-SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$2.00 | $6.00 | Q:30 /30Days | $241.20 |
Browse Plan Formulary |
Premier by Ultimate (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Generic |
$0.00 | $0.00 | None | $309.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Premier by Ultimate (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Generic |
$0.00 | $0.00 | None | $309.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Premier Plus by Ultimate (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Generic |
$0.00 | $0.00 | None | $309.60 |
Browse Plan Formulary select insulin pay $25 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 |
Premier Plus by Ultimate (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Generic |
$0.00 | $0.00 | None | $309.60 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
Simply Care (HMO I-SNP)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$5.00 | n/a | None | $343.80 |
Browse Plan Formulary |
Simply Comfort (HMO I-SNP)
|
$0.00 |
$480 |
Some Generics, Few Brands |
2 |
Generic |
$5.00 | n/a | None | $343.80 |
Browse Plan Formulary |
Simply Extra (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$10.00 | $0.00 | None | $343.80 |
Browse Plan Formulary |
Simply Level (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
2 |
Generic |
$0.00 | $0.00 | None | $343.80 |
Browse Plan Formulary |
Simply More (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $343.80 |
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 Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150* |
Some Generics |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $188.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150* |
Some Generics |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $180.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150* |
Some Generics |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $180.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150* |
Some Generics |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $177.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Giveback (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
6 |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $31.50 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
6 |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $31.50 |
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 |
Wellcare No Premium Open (PPO)
|
$0.00 |
$100* |
Yes, this drug has Gap Coverage. |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $27.90 |
Browse Plan Formulary |
Wellcare Specialty Giveback (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $31.50 |
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 |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $31.50 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
HumanaChoice R5826-074 (Regional PPO)
|
$0.50 |
$395 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $249.30 |
Browse Plan Formulary |
CareNeeds PLUS (HMO D-SNP)
|
$14.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $249.30 |
Browse Plan Formulary |
Humana Fully Integrated H1036-283 (HMO D-SNP)
|
$15.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $249.30 |
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 TotalCare Plus (HMO D-SNP)
|
$21.30 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$1.00 | $0.00 | None | $115.20 |
Browse Plan Formulary |
Cigna Primary Medicare (HMO)
|
$22.40 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$1.00 | $0.00 | None | $115.20 |
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 |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $249.30 |
Browse Plan Formulary |
Aetna Medicare Assure (HMO D-SNP)
|
$28.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$5.00 | $15.00 | Q:30 /30Days | $21.60 |
Browse Plan Formulary |
Aetna Medicare Assure Plus (HMO D-SNP)
|
$30.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$5.00 | $15.00 | Q:30 /30Days | $16.20 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO D-SNP)
|
$31.50 |
$480 |
No |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $193.50 |
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 |
Wellcare Dual Reserve (HMO D-SNP)
|
$31.60 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $135.00 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$32.30 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $135.90 |
Browse Plan Formulary |
Wellcare Dual Medicare (HMO D-SNP)
|
$33.70 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $83.70 |
Browse Plan Formulary |
BayCarePlus Premier (HMO)
|
$34.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | None | $134.10 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Advantage Plus by Ultimate (Full) (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $309.60 |
Browse Plan Formulary |
Advantage Plus by Ultimate (Partial) (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $309.60 |
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 |
BlueMedicare Complete (HMO D-SNP)
|
$34.30 |
$480* |
Some Generics, Few Brands |
2* |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $325.80 |
Browse Plan Formulary |
Devoted Health Dual Greater Tampa Bay (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
25% | 25% | Q:30 /30Days | $276.30 |
Browse Plan Formulary |
Devoted Health Prime (HMO)
|
$34.30 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $276.30 |
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 |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $276.30 |
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 | $357.30 |
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:30 /30Days | $357.30 |
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 |
Longevity Health Plan (HMO I-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $116.10 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$34.30 |
$480* |
Some Generics, Few Brands |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $241.20 |
Browse Plan Formulary |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$34.30 |
$480* |
Some Generics, Few Brands |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $241.20 |
Browse Plan Formulary |
Simply Complete (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $60.00 | None | $404.10 |
Browse Plan Formulary |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$34.30 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days | $192.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $192.60 |
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 |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $194.40 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $193.50 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $192.60 |
Browse Plan Formulary |
Wellcare Dual Liberty (HMO D-SNP)
|
$34.30 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $135.90 |
Browse Plan Formulary |
Wellcare Dual Nurture (HMO D-SNP)
|
$34.30 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $86.40 |
Browse Plan Formulary |
BlueMedicare Choice (Regional PPO)
|
$47.90 |
$250* |
Yes, this drug has Gap Coverage. |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $330.30 |
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 R5826-005 (Regional PPO)
|
$55.00 |
$100 |
No |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:30 /30Days | $249.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Premium Enhanced Open (PPO)
|
$85.00 |
$0 |
Yes, this drug has Gap Coverage. |
6 |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $27.90 |
Browse Plan Formulary |
Humana Gold Choice H8145-061 (PFFS)
|
$102.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:30 /30Days | $249.30 |
Browse Plan Formulary |