OLMSRTN-AMLDPN-HCTZ 40-5-25 MG TABLET [Tribenzor] (90 TABLETS ) (NDC: 00093500456)
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, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $238.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice (PPO)
|
$0.00 |
$260* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$3.00 | $0.00 | Q:30 /30Days | $238.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons Plan 1 (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days | $238.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Choice Plan (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 Prime Plan (HMO)
|
$0.00 |
$250* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$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 |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$150* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $31.50 |
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 | $270.00 |
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 | $262.80 |
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 | $248.40 |
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 | $270.00 |
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 | $270.90 |
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 |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $271.80 |
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 | $273.60 |
Browse Plan Formulary |
Amerivantage ESRD Care Plus (HMO C-SNP)
|
$0.00 |
$0 | Few Generics | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $270.90 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Choice Plus (PPO)
|
$0.00 |
$480 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:30 /30Days | $306.00 |
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 | $303.30 |
Browse Plan Formulary |
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 | $305.10 |
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 |
Care N' Care Choice (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$14.00 | $28.00 | None | $287.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Care N' Care Classic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.00 | $24.00 | None | $287.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$190* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $142.20 |
Browse Plan Formulary |
Cigna Preferred Medicare (PPO)
|
$0.00 |
$190* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $146.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$190* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $150.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Erickson Advantage Liberty with Drugs (HMO-POS)
|
$0.00 |
$400* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$5.00 | $0.00 | Q:30 /30Days | $234.90 |
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 |
Global Classic (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$5.00 | $10.00 | Q:30 /30Days | $557.10 |
Browse Plan Formulary |
Humana Gold Plus H0028-043 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days | $312.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H0028-043 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days | $309.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Imperial Insurance Company Traditional (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $10.00 | Q:30 /30Days | $241.20 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Imperial Insurance Traditional Plus (HMO)
|
$0.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | Q:30 /30Days | $241.20 |
Browse Plan Formulary |
Imperial Insurance Value (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 6 |
Select Care Drugs |
$3.00 | $0.00 | Q:30 /30Days | $241.20 |
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 |
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 | $293.40 |
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 | $293.40 |
Browse Plan Formulary |
Southwestern Health Select (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $0.00 | None | $287.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Dual Complete Choice (Regional PPO D-SNP)
|
$0.00 |
$480 | No | 1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $238.50 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Ally (HMO-POS C-SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $238.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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 | $54.00 |
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 |
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 | $52.20 |
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 | $43.20 |
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 | $33.30 |
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 | $38.70 |
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 | $54.00 |
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 | $38.70 |
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 |
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 | $33.30 |
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 | $43.20 |
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 | $52.20 |
Browse Plan Formulary |
Wellcare No Premium Medicare (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 6 |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $61.20 |
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 | $43.20 |
Browse Plan Formulary |
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 | $42.30 |
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 TexanPlus No Premium (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $43.20 |
Browse Plan Formulary |
UnitedHealthcare Medicare Silver (Regional PPO C-SNP)
|
$3.70 |
$480 | No | 1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $238.50 |
Browse Plan Formulary |
Aetna Medicare Choice II Plan (PPO)
|
$10.00 |
$200* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $31.50 |
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 | $311.40 |
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 | $311.40 |
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 | $238.50 |
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 Complement Assist (HMO)
|
$14.90 |
$480* | No additional gap coverage, only the Donut Hole Discount | 6* |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $117.00 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$17.90 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $142.20 |
Browse Plan Formulary |
Aetna Medicare Dual Complete Plan (HMO D-SNP)
|
$18.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$5.00 | $15.00 | Q:30 /30Days | $24.30 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Dual Care Plus (HMO D-SNP)
|
$18.80 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $279.00 |
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 | $90.90 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H0028-031 (HMO D-SNP)
|
$24.40 |
$475 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $311.40 |
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 |
American Health Advantage of Texas (HMO I-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $261.00 |
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 | $270.00 |
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 | $262.80 |
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 | $248.40 |
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 | $270.00 |
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 | $270.90 |
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 |
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 | $271.80 |
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 | $273.60 |
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 | $273.60 |
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 | $262.80 |
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 | $248.40 |
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 | $270.00 |
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 |
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 | $270.90 |
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 | $271.80 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H0028-032 (HMO D-SNP)
|
$25.10 |
$460 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $311.40 |
Browse Plan Formulary |
Imperial Insurance Company Dual (HMO D-SNP)
|
$25.10 |
$480 | Many Generics, Some Brands | 2 |
Generic |
25% | 25% | Q:30 /30Days | $239.40 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$25.10 |
$480* | Some Generics | 1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $293.40 |
Browse Plan Formulary |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$25.10 |
$200* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days | $236.70 |
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 |
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 | $237.60 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $236.70 |
Browse Plan Formulary |
Wellcare Dual Access Harmony (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 | $119.70 |
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 | $90.90 |
Browse Plan Formulary |
Wellcare Dual Liberty Nurture (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 | $118.80 |
Browse Plan Formulary |
Erickson Advantage Guardian (HMO-POS I-SNP)
|
$32.30 |
$0 | Some Generics | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $234.90 |
Browse Plan Formulary select insulin pay $28 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 R4182-004 (Regional PPO)
|
$43.60 |
$175 | No | 4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days | $311.40 |
Browse Plan Formulary |
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 | $238.50 |
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 | $311.40 |
Browse Plan Formulary |
Care N' Care Choice Plus (PPO)
|
$55.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.00 | $24.00 | None | $287.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Blue Cross Medicare Advantage Choice Premier (PPO)
|
$62.00 |
$295 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:30 /30Days | $306.00 |
Browse Plan Formulary |
Erickson Advantage Freedom (HMO-POS)
|
$70.00 |
$200* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$5.00 | $0.00 | Q:30 /30Days | $234.90 |
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 |
AARP Medicare Advantage SecureHorizons Plan 2 (HMO-POS)
|
$73.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $238.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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 | $311.40 |
Browse Plan Formulary |
Humana Gold Choice H8145-084 (PFFS)
|
$97.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days | $311.40 |
Browse Plan Formulary |
Erickson Advantage Champion (HMO-POS C-SNP)
|
$199.00 |
$0 | Some Generics | 1 |
Preferred Generic |
$5.00 | $0.00 | Q:30 /30Days | $234.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Erickson Advantage Signature with Drugs (HMO-POS)
|
$199.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$5.00 | $0.00 | Q:30 /30Days | $234.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Care N' Care Choice Premium (PPO)
|
$200.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $20.00 | None | $287.10 |
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 |
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 | $288.00 |
Browse Plan Formulary |