OZEMPIC 0.25-0.5 MG DOSE PEN (1.5 ) (NDC: 00169413212)
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 |
$47.00 | $131.00 | Q:2 /28Days | $1,266.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice (PPO)
|
$0.00 |
$260 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,266.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons Plan 1 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,266.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Choice Plan (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $1,283.76 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $1,284.06 |
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, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $1,284.06 |
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 | $1,282.94 |
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 | $1,282.40 |
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 | $1,281.78 |
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 | $1,285.92 |
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 | $1,282.68 |
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 | $1,282.38 |
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 | $1,283.36 |
Browse Plan Formulary |
Amerivantage Diabetes Care Plus (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
3 |
Preferred Brand |
$35.00 | $70.00 | None | $1,282.56 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Amerivantage ESRD Care Plus (HMO C-SNP)
|
$0.00 |
$0 |
Few Generics |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,282.84 |
Browse Plan Formulary |
Amerivantage Heart Care Plus (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
3 |
Preferred Brand |
$40.00 | $80.00 | None | $1,282.56 |
Browse Plan Formulary |
Amerivantage Lung Care Plus (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
3 |
Preferred Brand |
$40.00 | $80.00 | None | $1,282.56 |
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 Choice Plus (PPO)
|
$0.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $94.00 | S Q:2 /28Days | $1,211.82 |
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 | S Q:2 /28Days | $1,213.28 |
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 | S Q:2 /28Days | $1,212.62 |
Browse Plan Formulary |
BSW SeniorCare Advantage (PPO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:2 /28Days | $1,158.18 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BSW SeniorCare Advantage Select Rx (HMO)
|
$0.00 |
$300* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $94.00 | Q:2 /28Days | $1,157.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Care N' Care Choice (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $1,258.46 |
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 |
Care N' Care Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $1,258.46 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$190* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$42.00 | $126.00 | Q:2 /28Days | $1,300.00 |
Browse Plan Formulary |
Cigna Preferred Medicare (PPO)
|
$0.00 |
$190* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$42.00 | $126.00 | Q:2 /28Days | $1,300.28 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$190* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$42.00 | $126.00 | Q:2 /28Days | $1,299.92 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Erickson Advantage Liberty with Drugs (HMO-POS)
|
$0.00 |
$400 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:2 /28Days | $1,267.18 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Global Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:2 /28Days | $1,149.80 |
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 |
Humana Gold Plus H0028-043 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,283.66 |
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. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,286.42 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Imperial Insurance Company Traditional (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $1,208.08 |
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 |
3 |
Tier 3 |
25% | 25% | None | $1,208.08 |
Browse Plan Formulary |
Imperial Insurance Value (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $1,208.08 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:2 /28Days | $1,156.82 |
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 Select (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:2 /28Days | $1,156.82 |
Browse Plan Formulary |
Southwestern Health Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $80.00 | None | $1,258.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Dual Complete Choice (Regional PPO D-SNP)
|
$0.00 |
$480 |
No |
3 |
Tier 3 |
$0.00 | $0.00 | Q:2 /28Days | $1,267.72 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Ally (HMO-POS C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
3 |
Preferred Brand |
$47.00 | $75.00 | Q:2 /28Days | $1,266.10 |
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 |
3 |
Preferred Brand |
$20.00 | $40.00 | Q:2 /28Days | $1,257.26 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$20.00 | $40.00 | Q:2 /28Days | $1,258.10 |
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 |
Wellcare Giveback (HMO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$20.00 | $40.00 | Q:2 /28Days | $1,256.86 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$20.00 | $40.00 | Q:2 /28Days | $1,260.28 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$20.00 | $40.00 | Q:2 /28Days | $1,256.76 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$20.00 | $40.00 | Q:2 /28Days | $1,260.28 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$20.00 | $40.00 | Q:2 /28Days | $1,256.76 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$20.00 | $40.00 | Q:2 /28Days | $1,257.26 |
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, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$20.00 | $40.00 | Q:2 /28Days | $1,258.10 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$20.00 | $40.00 | Q:2 /28Days | $1,256.86 |
Browse Plan Formulary |
Wellcare No Premium Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$37.00 | $74.00 | Q:2 /28Days | $1,257.78 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:2 /28Days | $1,258.02 |
Browse Plan Formulary |
Wellcare No Premium Rx Plus Open (PPO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:2 /28Days | $1,258.02 |
Browse Plan Formulary |
Wellcare TexanPlus No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$20.00 | $40.00 | Q:2 /28Days | $1,258.02 |
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 Silver (Regional PPO C-SNP)
|
$3.70 |
$480 |
No |
3 |
Tier 3 |
25% | 25% | Q:2 /28Days | $1,267.72 |
Browse Plan Formulary |
Aetna Medicare Choice II Plan (PPO)
|
$10.00 |
$200* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $1,284.06 |
Browse Plan Formulary |
HumanaChoice H5216-043 (PPO)
|
$10.00 |
$250* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,281.92 |
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. |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,286.24 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP)
|
$10.80 |
$295* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,267.72 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Complement Assist (HMO)
|
$14.90 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:2 /28Days | $1,256.56 |
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)
|
$17.90 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:2 /28Days | $1,328.00 |
Browse Plan Formulary |
Aetna Medicare Dual Complete Plan (HMO D-SNP)
|
$18.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $1,284.12 |
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 | S Q:2 /28Days | $1,254.52 |
Browse Plan Formulary |
Wellcare Assist (HMO)
|
$20.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:2 /28Days | $1,256.38 |
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 |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,285.90 |
Browse Plan Formulary |
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 | $1,210.12 |
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 (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $1,282.94 |
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 | $1,282.40 |
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 | $1,281.78 |
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 | $1,285.92 |
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 | $1,282.68 |
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 | $1,282.38 |
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 | $1,283.36 |
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 | $1,282.40 |
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 | $1,281.78 |
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 | $1,285.92 |
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 | $1,282.68 |
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 | $1,282.38 |
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 | $1,283.36 |
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 |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,285.76 |
Browse Plan Formulary |
Imperial Insurance Company Dual (HMO D-SNP)
|
$25.10 |
$480 |
Many Generics, Some Brands |
3 |
Preferred Brand |
25% | 25% | None | $1,208.12 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$25.10 |
$480 |
Some Generics |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:2 /28Days | $1,156.82 |
Browse Plan Formulary |
ProCare Advantage (HMO I-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | Q:2 /28Days | $1,446.60 |
Browse Plan Formulary |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$25.10 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,266.88 |
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 |
3 |
Tier 3 |
15% | 15% | Q:2 /28Days | $1,266.08 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:2 /28Days | $1,266.54 |
Browse Plan Formulary |
Wellcare Dual Access Harmony (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:2 /28Days | $1,256.58 |
Browse Plan Formulary |
Wellcare Dual Access Open (PPO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:2 /28Days | $1,256.42 |
Browse Plan Formulary |
Wellcare Dual Liberty Nurture (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:2 /28Days | $1,256.60 |
Browse Plan Formulary |
Erickson Advantage Guardian (HMO-POS I-SNP)
|
$32.30 |
$0 |
Some Generics |
3 |
Preferred Brand |
$28.00 | $74.00 | Q:2 /28Days | $1,267.18 |
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 |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,285.64 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice (Regional PPO)
|
$49.00 |
$395 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,267.72 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice R4182-003 (Regional PPO)
|
$51.00 |
$175 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,285.64 |
Browse Plan Formulary |
Care N' Care Choice Plus (PPO)
|
$55.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $1,258.46 |
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 | S Q:2 /28Days | $1,211.82 |
Browse Plan Formulary |
Erickson Advantage Freedom (HMO-POS)
|
$70.00 |
$200* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:2 /28Days | $1,267.18 |
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, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,266.50 |
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 |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,286.80 |
Browse Plan Formulary |
Humana Gold Choice H8145-084 (PFFS)
|
$97.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,286.14 |
Browse Plan Formulary |
Erickson Advantage Champion (HMO-POS C-SNP)
|
$199.00 |
$0 |
Some Generics |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:2 /28Days | $1,267.18 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Erickson Advantage Signature with Drugs (HMO-POS)
|
$199.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:2 /28Days | $1,267.18 |
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. |
3 |
Preferred Brand |
$40.00 | $80.00 | None | $1,258.46 |
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 |
3 |
Preferred Brand |
$44.00 | $132.00 | S Q:2 /28Days | $1,205.70 |
Browse Plan Formulary |