OXYCODONE-ACETAMINOPHEN 10-325 TABLET [Percocet] (120 TABLETS ) (NDC: 00406052301)
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, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:360 /30Days | $63.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:360 /30Days | $63.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice Plan 2 (Regional PPO)
|
$0.00 |
$395 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $63.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Plan 2 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:360 /30Days | $63.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Choice (HMO-POS)
|
$0.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /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 |
Aetna Medicare Premier (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days | $54.00 |
Browse Plan Formulary |
Aetna Medicare Premier Plus (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days | $54.00 |
Browse Plan Formulary |
Aetna Medicare Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $105.00 | Q:180 /30Days | $52.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Value (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $105.00 | Q:180 /30Days | $52.80 |
Browse Plan Formulary |
BlueMedicare Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:180 /30Days | $122.40 |
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. |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:180 /30Days | $126.00 |
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 |
BlueMedicare Value (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days | $145.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Bright Advantage Health Dollars Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $30.00 |
Browse Plan Formulary |
Bright Advantage Health Dollars Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $30.00 |
Browse Plan Formulary |
Bright Advantage Part B Savings Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$15.00 | $30.00 | Q:180 /30Days | $30.00 |
Browse Plan Formulary |
Bright Advantage Part B Savings Plan (PPO)
|
$0.00 |
$110 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $30.00 |
Browse Plan Formulary |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35.00 | $105.00 | Q:360 /30Days | $50.40 |
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 Preferred Savings Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:360 /30Days | $50.40 |
Browse Plan Formulary |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:360 /30Days | $50.40 |
Browse Plan Formulary |
Freedom Medicare Plan Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Preferred Brand |
$35.00 | $70.00 | Q:180 /30Days | $58.80 |
Browse Plan Formulary |
Freedom Platinum Plan Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Preferred Brand |
$30.00 | $60.00 | Q:180 /30Days | $58.80 |
Browse Plan Formulary |
Freedom Platinum Rewards Plan Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$35.00 | $70.00 | Q:180 /30Days | $58.80 |
Browse Plan Formulary |
Freedom VIP Care (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Some Brands |
2 |
Preferred Brand |
$20.00 | $40.00 | Q:180 /30Days | $58.80 |
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 |
Freedom VIP Savings (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Some Brands |
2 |
Preferred Brand |
$25.00 | $50.00 | Q:180 /30Days | $58.80 |
Browse Plan Formulary select insulin pay $0-$10 copay but not this drug |
Freedom VIP Savings COPD (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
2 |
Preferred Brand |
$20.00 | $40.00 | Q:180 /30Days | $58.80 |
Browse Plan Formulary |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
3 |
Preferred Brand |
$5.00 | $5.00 | Q:360 /30Days | $38.40 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
Humana Gold Plus H1036-074 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$10.00 | $20.00 | Q:360 /30Days | $38.40 |
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. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:360 /30Days | $38.40 |
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. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:360 /30Days | $38.40 |
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 |
HumanaChoice Florida H5216-072 (PPO)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $38.40 |
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 |
2 |
Generic |
$12.00 | $24.00 | Q:180 /30Days | $96.00 |
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 | $96.00 |
Browse Plan Formulary |
Molina Medicare Connect Care (HMO C-SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:180 /30Days | $96.00 |
Browse Plan Formulary |
Optimum Diamond Rewards (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
2 |
Preferred Brand |
$30.00 | $60.00 | Q:180 /30Days | $58.80 |
Browse Plan Formulary |
Optimum Platinum Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Preferred Brand |
$35.00 | $70.00 | Q:180 /30Days | $58.80 |
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 |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $63.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150* |
Some Generics |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $63.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150* |
Some Generics |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $63.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150* |
Some Generics |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $63.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Giveback (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $78.00 |
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 | $78.00 |
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 No Premium Open (PPO)
|
$0.00 |
$100* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $72.00 |
Browse Plan Formulary |
HumanaChoice R5826-074 (Regional PPO)
|
$0.50 |
$395 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $38.40 |
Browse Plan Formulary |
Humana Fully Integrated H1036-283 (HMO D-SNP)
|
$15.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $38.40 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-262 (HMO D-SNP)
|
$15.80 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $38.40 |
Browse Plan Formulary |
Cigna TotalCare Plus (HMO D-SNP)
|
$21.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
18% | 18% | Q:360 /30Days | $50.40 |
Browse Plan Formulary |
Cigna Primary Medicare (HMO)
|
$22.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
18% | 18% | Q:360 /30Days | $50.40 |
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 |
Humana Gold Plus SNP-DE H1036-261 (HMO D-SNP)
|
$24.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $38.40 |
Browse Plan Formulary |
Aetna Medicare Assure (HMO D-SNP)
|
$25.80 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days | $60.00 |
Browse Plan Formulary |
Aetna Medicare Assure Plus (HMO D-SNP)
|
$30.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days | $60.00 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO D-SNP)
|
$31.50 |
$480 |
No |
3 |
Tier 3 |
15% | 15% | Q:360 /30Days | $63.60 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$32.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:180 /30Days | $82.80 |
Browse Plan Formulary |
BlueMedicare Complete (HMO D-SNP)
|
$34.30 |
$480 |
Some Generics, Few Brands |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:180 /30Days | $112.80 |
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 |
Freedom Medi-Medi Full (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:180 /30Days | $58.80 |
Browse Plan Formulary |
Freedom Medi-Medi Partial (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:180 /30Days | $58.80 |
Browse Plan Formulary |
Longevity Health Plan (HMO I-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | Q:360 /30Days | $25.20 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$34.30 |
$480 |
Some Generics, Few Brands |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days | $96.00 |
Browse Plan Formulary |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$34.30 |
$480 |
Some Generics, Few Brands |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days | $96.00 |
Browse Plan Formulary |
Optimum Emerald Full (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:180 /30Days | $58.80 |
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 |
Optimum Emerald Partial (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:180 /30Days | $58.80 |
Browse Plan Formulary |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$34.30 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $63.60 |
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 |
3 |
Tier 3 |
15% | 15% | Q:360 /30Days | $63.60 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:360 /30Days | $63.60 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:360 /30Days | $63.60 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:360 /30Days | $63.60 |
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 |
Wellcare Dual Liberty (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:180 /30Days | $82.80 |
Browse Plan Formulary |
Wellcare Dual Select (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:180 /30Days | $79.20 |
Browse Plan Formulary |
BlueMedicare Choice (Regional PPO)
|
$47.90 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:180 /30Days | $122.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice R5826-005 (Regional PPO)
|
$55.00 |
$100 |
No |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:360 /30Days | $38.40 |
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 | $72.00 |
Browse Plan Formulary |
Humana Gold Choice H8145-061 (PFFS)
|
$102.00 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $38.40 |
Browse Plan Formulary |