OZEMPIC 0.25-0.5 MG DOSE PEN (1.5 ) (NDC: 00169413212)
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 Choice Plan 2 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,266.74 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Central Value (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $1,284.56 |
Browse Plan Formulary |
Aetna Medicare Advantra Central Value (PPO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $1,284.56 |
Browse Plan Formulary |
Aetna Medicare Advantra Credit Value (PPO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $1,284.50 |
Browse Plan Formulary |
Aetna Medicare Advantra Silver (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:2 /28Days | $1,284.54 |
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 PennHighlands Prime (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:2 /28Days | $1,284.56 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Value (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $1,284.54 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $120.00 | Q:3 /28Days | $1,179.28 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $120.00 | Q:3 /28Days | $1,170.68 |
Browse Plan Formulary |
Complete Blue PPO Signature (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $120.00 | Q:3 /28Days | $1,161.58 |
Browse Plan Formulary |
Complete Blue PPO Signature (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $120.00 | Q:3 /28Days | $1,173.58 |
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 |
Geisinger Gold Classic 360 Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | Q:2 /28Days | $1,140.74 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | Q:2 /28Days | $1,140.68 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | Q:2 /28Days | $1,140.68 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | Q:2 /28Days | $1,141.12 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | Q:2 /28Days | $1,140.52 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | Q:2 /28Days | $1,140.56 |
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 H5525-051 (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,286.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5525-051 (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,284.28 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Giveback (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$37.00 | $74.00 | Q:2 /28Days | $1,260.38 |
Browse Plan Formulary |
Wellcare Giveback Open (PPO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $74.00 | Q:2 /28Days | $1,260.36 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$37.00 | $74.00 | Q:2 /28Days | $1,260.80 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$37.00 | $74.00 | Q:2 /28Days | $1,260.36 |
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 Advantra Silver (PPO)
|
$14.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $1,284.54 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UPMC for Life HMO Deductible Rx (HMO)
|
$22.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $20.00 | Q:2 /28Days | $1,161.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Cares (HMO D-SNP)
|
$22.10 |
$375 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $1,284.52 |
Browse Plan Formulary |
Wellcare Assist Open (PPO)
|
$24.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$43.00 | $86.00 | Q:2 /28Days | $1,256.96 |
Browse Plan Formulary |
Complete Blue PPO Distinct (PPO)
|
$25.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $120.00 | Q:3 /28Days | $1,171.28 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Complete Blue PPO Distinct (PPO)
|
$25.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $120.00 | Q:3 /28Days | $1,161.58 |
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 |
Complete Blue PPO Distinct (PPO)
|
$25.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $120.00 | Q:3 /28Days | $1,173.58 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Gold (HMO)
|
$27.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:2 /28Days | $1,284.54 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Low Premium Open (PPO)
|
$29.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$37.00 | $74.00 | Q:2 /28Days | $1,260.36 |
Browse Plan Formulary |
Humana Value Plus H5525-039 (PPO)
|
$31.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,282.12 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$33.90 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:2 /28Days | $1,268.30 |
Browse Plan Formulary |
HumanaChoice R0923-002 (Regional PPO)
|
$34.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,284.30 |
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 |
AARP Medicare Advantage Choice Plan 1 (PPO)
|
$35.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,266.74 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UPMC for Life PPO High Deductible Rx (PPO)
|
$35.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $20.00 | Q:2 /28Days | $1,161.58 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Assist (HMO)
|
$36.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:2 /28Days | $1,257.10 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | Q:2 /28Days | $1,140.72 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | Q:2 /28Days | $1,140.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UPMC for Life HMO Rx Choice (HMO)
|
$38.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $20.00 | Q:2 /28Days | $1,161.20 |
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 Nursing Home Plan 2 (PPO I-SNP)
|
$40.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:2 /28Days | $1,268.10 |
Browse Plan Formulary |
AmeriHealth Caritas VIP Care (HMO D-SNP)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Brand |
25% | 25% | Q:3 /28Days | $1,168.24 |
Browse Plan Formulary |
Geisinger Gold Secure Rx (HMO D-SNP)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:2 /28Days | $1,140.68 |
Browse Plan Formulary |
Highmark Wholecare Medicare Assured Diamond (HMO D-SNP)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:2 /28Days | $1,129.18 |
Browse Plan Formulary |
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $1,129.18 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Select (HMO D-SNP)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:2 /28Days | $1,268.30 |
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 |
UPMC for Life Complete Care (HMO D-SNP)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$25.00 | $40.00 | Q:2 /28Days | $1,161.12 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$37.00 | $74.00 | Q:2 /28Days | $1,257.62 |
Browse Plan Formulary |
Security Blue HMO-POS ValueRx (HMO-POS)
|
$57.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $115.00 | Q:3 /28Days | $1,148.66 |
Browse Plan Formulary |
Security Blue HMO-POS ValueRx (HMO-POS)
|
$57.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $115.00 | Q:3 /28Days | $1,170.76 |
Browse Plan Formulary |
Aetna Medicare Silver (HMO)
|
$65.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $1,284.50 |
Browse Plan Formulary |
Freedom Blue PPO ValueRx (PPO)
|
$71.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $115.00 | Q:3 /28Days | $1,164.90 |
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 |
UPMC for Life HMO Rx (HMO)
|
$81.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $20.00 | Q:2 /28Days | $1,161.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$111.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | Q:2 /28Days | $1,140.66 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$111.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | Q:2 /28Days | $1,140.72 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Freedom Blue PPO Select (PPO)
|
$130.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $115.00 | Q:3 /28Days | $1,164.90 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$136.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $20.00 | Q:2 /28Days | $1,161.58 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$151.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | Q:2 /28Days | $1,140.62 |
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 |
Geisinger Gold Classic Advantage Rx (HMO)
|
$151.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | Q:2 /28Days | $1,140.78 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$151.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | Q:2 /28Days | $1,140.72 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Security Blue HMO-POS Standard (HMO-POS)
|
$164.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$44.00 | $110.00 | Q:3 /28Days | $1,171.18 |
Browse Plan Formulary |
Security Blue HMO-POS Standard (HMO-POS)
|
$164.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$44.00 | $110.00 | Q:3 /28Days | $1,179.30 |
Browse Plan Formulary |
Aetna Medicare Gold Plan (PPO)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $1,284.50 |
Browse Plan Formulary |
Security Blue HMO-POS Deluxe (HMO-POS)
|
$224.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:3 /28Days | $1,171.18 |
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 |
Security Blue HMO-POS Deluxe (HMO-POS)
|
$224.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:3 /28Days | $1,179.30 |
Browse Plan Formulary |
Freedom Blue PPO Classic (PPO)
|
$253.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $115.00 | Q:3 /28Days | $1,164.90 |
Browse Plan Formulary |
UPMC for Life HMO Rx Enhanced (HMO)
|
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $20.00 | Q:2 /28Days | $1,161.18 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |