ZYDELIG 100 MG TABLET (60 EA ) (NDC: 61958170101)
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)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $13,308.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice (PPO)
|
$0.00 |
$270 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
28% | n/a | P Q:60 /30Days | $13,308.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $13,308.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Plus Plan (PPO)
|
$0.00 |
$300 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
28% | n/a | P Q:60 /30Days | $13,757.40 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
28% | n/a | P Q:60 /30Days | $13,983.60 |
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 |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
28% | n/a | P Q:60 /30Days | $13,757.40 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$150 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $13,757.40 |
Browse Plan Formulary |
Amerigroup Medicare-Medicaid Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | All Generics, All Brands | 2 |
Tier 2 |
0% | 0% | P Q:60 /30Days | $11,934.00 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $14,061.00 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $13,827.60 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $14,061.00 |
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 Classic Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $13,827.60 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $14,061.00 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $13,827.60 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $14,061.00 |
Browse Plan Formulary |
Amerivantage Comfort Plus (HMO I-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $11,932.80 |
Browse Plan Formulary |
Amerivantage Diabetes Care Plus (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $14,061.00 |
Browse Plan Formulary select insulin pay $0-$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 |
Amerivantage Heart Care Plus (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $14,061.00 |
Browse Plan Formulary |
Amerivantage Lung Care Plus (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $14,061.00 |
Browse Plan Formulary |
Amerivantage Select Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $13,827.60 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Choice Plus (PPO)
|
$0.00 |
$350 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
27% | n/a | P Q:60 /30Days | $12,640.20 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Classic (PPO)
|
$0.00 |
$295 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
28% | n/a | P Q:60 /30Days | $12,640.20 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Value (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $12,384.60 |
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 |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$190 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
29% | n/a | P Q:60 /30Days | $13,611.00 |
Browse Plan Formulary |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$190 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
29% | n/a | P Q:60 /30Days | $13,324.80 |
Browse Plan Formulary |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$190 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
29% | n/a | P Q:60 /30Days | $13,611.00 |
Browse Plan Formulary |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$190 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
29% | n/a | P Q:60 /30Days | $13,611.00 |
Browse Plan Formulary |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$190 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
29% | n/a | P Q:60 /30Days | $13,324.80 |
Browse Plan Formulary |
Clover Health Choice (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | 33% | P | $13,776.60 |
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 |
Clover Health Classic (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | 33% | P | $13,776.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Community First Medicare Advantage Alamo Plan (HMO)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
29% | n/a | P Q:60 /30Days | $13,648.80 |
Browse Plan Formulary select insulin pay $30 copay but not this drug |
Devoted Health BeWell San Antonio (HMO C-SNP)
|
$0.00 |
$0 | Few Generics | 5 |
Specialty Tier |
33% | n/a | P | $13,308.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Devoted Health Core San Antonio (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $13,308.00 |
Browse Plan Formulary |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $13,300.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H0028-030 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $12,918.00 |
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 |
Imperial Insurance Company Traditional (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $12,487.20 |
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 | 5 |
Tier 5 |
25% | 25% | P Q:60 /30Days | $12,487.20 |
Browse Plan Formulary |
Imperial Insurance Value (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $12,487.20 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
0% | 0% | P | $12,089.40 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
0% | 0% | P | $12,459.60 |
Browse Plan Formulary |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
31% | n/a | P | $12,089.40 |
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 | 5 |
Specialty Tier |
25% | n/a | P | $12,089.40 |
Browse Plan Formulary |
Superior HealthPlan STAR+PLUS Medicare-Medicaid (Medicare-Medicaid Plan)
|
$0.00 |
$0 | All Generics, All Brands | 2 |
Tier 2 |
0% | 0% | P | $12,089.40 |
Browse Plan Formulary |
UnitedHealthcare Chronic Complete (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $13,308.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Dual Complete Choice (Regional PPO D-SNP)
|
$0.00 |
$480 | No | 5 |
Tier 5 |
$0.00 | $0.00 | P Q:60 /30Days | $13,275.00 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
28% | n/a | P | $14,061.00 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
28% | n/a | P | $14,061.00 |
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 | 5 |
Specialty Tier |
28% | n/a | P | $13,863.60 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
28% | n/a | P | $13,863.60 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
28% | n/a | P | $14,061.00 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $14,061.00 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $14,061.00 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $13,863.60 |
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 No Premium (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $13,863.60 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $14,061.00 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $13,833.00 |
Browse Plan Formulary |
Wellcare No Premium Medicare (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $14,061.00 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
28% | n/a | P | $14,061.00 |
Browse Plan Formulary |
Wellcare No Premium Rx Plus Open (PPO)
|
$0.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
28% | n/a | P | $14,061.00 |
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 Specialty No Premium (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 5 |
Specialty Tier |
33% | n/a | P | $14,061.00 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
Wellcare TexanPlus No Premium (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $13,863.60 |
Browse Plan Formulary |
Wellcare TexanPlus No Premium (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $14,061.00 |
Browse Plan Formulary |
Wellcare TexanPlus No Premium (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $13,863.60 |
Browse Plan Formulary |
Wellcare TexanPlus No Premium (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $13,863.60 |
Browse Plan Formulary |
UnitedHealthcare Medicare Silver (Regional PPO C-SNP)
|
$3.70 |
$480 | No | 5 |
Tier 5 |
25% | 25% | P Q:60 /30Days | $13,275.00 |
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 |
Cigna TotalCare (HMO D-SNP)
|
$5.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
15% | 15% | P Q:60 /30Days | $13,450.80 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$5.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
15% | 15% | P Q:60 /30Days | $13,909.80 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$5.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
15% | 15% | P Q:60 /30Days | $13,909.80 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$10.00 |
$300 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
28% | n/a | P Q:60 /30Days | $13,757.40 |
Browse Plan Formulary |
HumanaChoice H5216-043 (PPO)
|
$10.00 |
$250 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
28% | n/a | P Q:60 /30Days | $13,300.20 |
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. | 5 |
Specialty Tier |
28% | n/a | P Q:60 /30Days | $13,300.20 |
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 Medicare Gold (Regional PPO C-SNP)
|
$10.80 |
$295 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
28% | n/a | P Q:60 /30Days | $13,275.00 |
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 | 5 |
Specialty Tier |
25% | n/a | P | $13,752.60 |
Browse Plan Formulary |
Amerivantage Choice (PPO)
|
$15.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $13,827.60 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$17.90 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
15% | 15% | P Q:60 /30Days | $13,909.80 |
Browse Plan Formulary |
Aetna Medicare Dual Complete Plan (HMO D-SNP)
|
$18.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $13,983.60 |
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 | P Q:60 /30Days | $12,671.40 |
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 H0028-036 (HMO D-SNP)
|
$18.80 |
$450 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $13,300.20 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$18.80 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
15% | 15% | P Q:60 /30Days | $13,308.60 |
Browse Plan Formulary |
Wellcare Assist (HMO)
|
$20.60 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P | $13,752.60 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $14,061.00 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $13,827.60 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $14,061.00 |
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 Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $13,827.60 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $14,061.00 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $13,827.60 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $14,061.00 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $13,827.60 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $14,061.00 |
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 | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $13,827.60 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $14,061.00 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $13,827.60 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $14,061.00 |
Browse Plan Formulary |
Amerivantage ESRD Care (HMO-POS C-SNP)
|
$25.10 |
$100 | Few Generics | 5 |
Specialty Tier |
31% | n/a | P Q:60 /30Days | $14,061.00 |
Browse Plan Formulary |
Community First Medicare Advantage D-SNP (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $13,656.00 |
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 |
Devoted Health Prime San Antonio (HMO)
|
$25.10 |
$480 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | P | $13,308.00 |
Browse Plan Formulary |
Imperial Insurance Company Dual (HMO D-SNP)
|
$25.10 |
$480 | Many Generics, Some Brands | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $12,520.80 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$25.10 |
$480 | Some Generics | 5 |
Specialty Tier |
25% | n/a | P | $12,089.40 |
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 | P Q:60 /30Days | $15,522.00 |
Browse Plan Formulary |
Provider Partners Texas Advantage Plan (HMO I-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | P Q:60 /30Days | $12,520.80 |
Browse Plan Formulary |
Provider Partners Texas Community Plan (HMO I-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | P Q:60 /30Days | $12,520.80 |
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 |
Texas Independence Health Plan, Inc. (HMO I-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | P Q:60 /30Days | $12,505.80 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | P Q:60 /30Days | $13,275.00 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P | $13,752.60 |
Browse Plan Formulary |
Wellcare Dual Access Harmony (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P | $13,752.60 |
Browse Plan Formulary |
Wellcare Dual Access Open (PPO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P | $13,752.60 |
Browse Plan Formulary |
Wellcare Dual Liberty (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P | $13,752.60 |
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 Nurture (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P | $13,752.60 |
Browse Plan Formulary |
HumanaChoice R4182-004 (Regional PPO)
|
$43.60 |
$175 | No | 5 |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $13,300.20 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice (Regional PPO)
|
$49.00 |
$395 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
26% | n/a | P Q:60 /30Days | $13,275.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice R4182-003 (Regional PPO)
|
$51.00 |
$175 | No | 5 |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $13,300.20 |
Browse Plan Formulary |
HumanaChoice H5216-042 (PPO)
|
$94.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
29% | n/a | P Q:60 /30Days | $13,300.20 |
Browse Plan Formulary |
Humana Gold Choice H8145-084 (PFFS)
|
$97.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
28% | n/a | P Q:60 /30Days | $13,300.20 |
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 |
Blue Cross Medicare Advantage Flex (PPO)
|
$215.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $12,266.40 |
Browse Plan Formulary |