OLMSRTN-AMLDPN-HCTZ 40-10-25MG TABLET [Tribenzor] (30 TABLETS ) (NDC: 57664080083)
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 Plan (PPO)
|
$0.00 |
$300* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $12.60 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$0.00 |
$200* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $11.10 |
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 | $99.90 |
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 | $101.10 |
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 | $100.20 |
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 |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $99.00 |
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 | $100.50 |
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 | $99.60 |
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 | $94.80 |
Browse Plan Formulary |
Amerivantage ESRD Care Plus (HMO C-SNP)
|
$0.00 |
$0 |
Few Generics |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $100.50 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Classic (PPO)
|
$0.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:30 /30Days | $110.70 |
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 |
Blue Cross Medicare Advantage Value (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:30 /30Days | $114.00 |
Browse Plan Formulary |
Cigna Alliance Medicare (HMO)
|
$0.00 |
$190* |
Yes, this drug has Gap Coverage. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $45.00 |
Browse Plan Formulary |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$190* |
Yes, this drug has Gap Coverage. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $37.20 |
Browse Plan Formulary |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$190* |
Yes, this drug has Gap Coverage. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $54.90 |
Browse Plan Formulary |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$190* |
Yes, this drug has Gap Coverage. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $47.40 |
Browse Plan Formulary |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$190* |
Yes, this drug has Gap Coverage. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $47.40 |
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 |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$190* |
Yes, this drug has Gap Coverage. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $46.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Devoted Health Core Greater Houston (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $112.80 |
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 |
1 |
Preferred Generic |
$3.00 | $6.00 | Q:30 /30Days | $95.70 |
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 |
1 |
Preferred Generic |
$15.00 | $30.00 | Q:30 /30Days | $95.70 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice (Regional PPO D-SNP)
|
$0.00 |
$480 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $77.40 |
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 | Q:30 /30Days | $15.90 |
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 |
Wellcare Giveback (HMO)
|
$0.00 |
$300* |
No additional gap coverage, only the Donut Hole Discount |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $19.50 |
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 | Q:30 /30Days | $14.70 |
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 | Q:30 /30Days | $13.50 |
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 | Q:30 /30Days | $17.70 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
6 |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $15.90 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
6 |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $19.50 |
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 (HMO-POS)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
6 |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $14.70 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
6 |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $13.50 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
6 |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $17.70 |
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 | $14.70 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$200* |
Yes, this drug has Gap Coverage. |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $14.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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 | Q:30 /30Days | $15.30 |
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 |
Wellcare Specialty No Premium (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $14.70 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
Wellcare TexanPlus Classic No Premium (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
6 |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $14.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare TexanPlus No Premium (HMO-POS)
|
$0.00 |
$250* |
Yes, this drug has Gap Coverage. |
6* |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $14.40 |
Browse Plan Formulary |
UnitedHealthcare Medicare Silver (Regional PPO C-SNP)
|
$3.70 |
$480 |
No |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $77.40 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$5.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $37.20 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$5.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $54.90 |
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 |
Cigna TotalCare (HMO D-SNP)
|
$5.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $47.40 |
Browse Plan Formulary |
HumanaChoice H5216-043 (PPO)
|
$10.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days | $123.30 |
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. |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days | $123.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP)
|
$10.80 |
$295* |
Yes, this drug has Gap Coverage. |
1* |
Preferred Generic |
$4.00 | $0.00 | Q:30 /30Days | $77.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Choice II Plan (PPO)
|
$15.00 |
$195* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $12.60 |
Browse Plan Formulary |
KelseyCare Advantage Gold Community (HMO-POS)
|
$15.00 |
$100* |
Yes, this drug has Gap Coverage. |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $125.70 |
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 |
Cigna True Choice Plus Medicare (PPO)
|
$19.00 |
$190* |
Yes, this drug has Gap Coverage. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $46.20 |
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 | Q:30 /30Days | $32.10 |
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 | $99.90 |
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 | $99.00 |
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 | $100.50 |
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 | $99.60 |
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 |
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 | $94.80 |
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 | $101.10 |
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 | $100.20 |
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 | $99.00 |
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 | $100.50 |
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 | $99.60 |
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 |
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 | $94.80 |
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 | $101.10 |
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 | $100.20 |
Browse Plan Formulary |
Devoted Health Prime Greater Houston (HMO)
|
$25.10 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $112.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Molina Medicare Complete Care (HMO D-SNP)
|
$25.10 |
$480* |
Some Generics |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $95.70 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $71.70 |
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 |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $77.10 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $76.50 |
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 | Q:30 /30Days | $32.10 |
Browse Plan Formulary |
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 | Q:30 /30Days | $32.40 |
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 | Q:30 /30Days | $32.10 |
Browse Plan Formulary |
HumanaChoice R4182-004 (Regional PPO)
|
$43.60 |
$175 |
No |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days | $123.60 |
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 Medicare Advantage Choice (Regional PPO)
|
$49.00 |
$395* |
Yes, this drug has Gap Coverage. |
1* |
Preferred Generic |
$4.00 | $0.00 | Q:30 /30Days | $77.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice R4182-003 (Regional PPO)
|
$51.00 |
$175 |
No |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days | $123.60 |
Browse Plan Formulary |
HumanaChoice H5216-042 (PPO)
|
$94.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days | $123.60 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Flex (PPO)
|
$215.40 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$5.00 | $15.00 | Q:30 /30Days | $116.10 |
Browse Plan Formulary |