XULTOPHY 100 UNIT-3.6MG/ML PEN (3 ML ) (NDC: 00169291115)
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 |
Aetna Medicare Choice (HMO-POS)
|
$0.00 |
$195 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:15 /30Days | $1,273.80 |
Browse Plan Formulary |
Aetna Medicare Credit (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:15 /30Days | $1,274.10 |
Browse Plan Formulary |
Aetna Medicare Premier (PPO)
|
$0.00 |
$300 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:15 /30Days | $1,273.80 |
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:15 /30Days | $1,274.10 |
Browse Plan Formulary |
Aetna Medicare Select (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$20.00 | $0.00 | Q:15 /30Days | $1,274.10 |
Browse Plan Formulary select insulin pay $20 copay |
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 |
AvMed Medicare Access (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $75.00 | Q:15 /30Days | $1,142.70 |
Browse Plan Formulary select insulin pay $35 copay |
AvMed Medicare Choice (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $75.00 | Q:15 /30Days | $1,142.70 |
Browse Plan Formulary select insulin pay $35 copay |
AvMed Medicare Circle (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$30.00 | $25.00 | Q:15 /30Days | $1,142.70 |
Browse Plan Formulary select insulin pay $30-$35 copay |
AvMed Medicare Premium Saver (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | Q:15 /30Days | $1,142.70 |
Browse Plan Formulary |
Bright Advantage Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 | Some Generics | 3 |
Preferred Brand |
$25.00 | $50.00 | Q:15 /28Days | $1,145.25 |
Browse Plan Formulary select insulin pay $0-$25 copay but not this drug |
Bright Advantage Health Dollars Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$20.00 | $40.00 | Q:15 /28Days | $1,145.25 |
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 |
Bright Advantage Part B Savings Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:15 /28Days | $1,145.25 |
Browse Plan Formulary |
Bright Advantage Part B Savings Plan (PPO)
|
$0.00 |
$110 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:15 /28Days | $1,145.25 |
Browse Plan Formulary |
CareBreeze (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 3 |
Preferred Brand |
$35.00 | $131.00 | Q:15 /30Days | $1,273.80 |
Browse Plan Formulary select insulin pay $12-$35 copay |
CareComplete (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 3 |
Preferred Brand |
$35.00 | $131.00 | Q:15 /30Days | $1,273.80 |
Browse Plan Formulary select insulin pay $12-$35 copay |
CareFree (HMO)
|
$0.00 |
$100* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$35.00 | $131.00 | Q:15 /30Days | $1,273.80 |
Browse Plan Formulary select insulin pay $35 copay |
CareOne (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $5.00 | Q:15 /30Days | $1,274.25 |
Browse Plan Formulary select insulin pay $10-$35 copay |
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 Core Broward (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$0.00 | $12.50 | Q:15 /30Days | $1,118.55 |
Browse Plan Formulary select insulin pay $0 copay |
Devoted Health Essentials Broward (HMO)
|
$0.00 |
$100* | No additional gap coverage, only the Donut Hole Discount | 3* |
Preferred Brand |
$0.00 | $112.50 | Q:15 /30Days | $1,118.55 |
Browse Plan Formulary select insulin pay $0 copay |
Devoted Health Latitude South Florida (PPO)
|
$0.00 |
$150 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $117.50 | Q:15 /30Days | $1,118.55 |
Browse Plan Formulary select insulin pay $35 copay |
HealthSun HealthAdvantage Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$0.00 | n/a | None | $1,179.30 |
Browse Plan Formulary |
HealthSun HealthAdvantage Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | n/a | None | $1,179.30 |
Browse Plan Formulary |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 3 |
Preferred Brand |
$35.00 | $110.00 | Q:15 /30Days | $1,272.75 |
Browse Plan Formulary select insulin pay $10-$35 copay |
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 H1036-065C (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $5.00 | Q:15 /30Days | $1,274.25 |
Browse Plan Formulary select insulin pay $10-$35 copay |
Humana Gold Plus H1036-237 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$35.00 | $110.00 | Q:15 /30Days | $1,271.10 |
Browse Plan Formulary select insulin pay $20-$35 copay |
Humana Gold Plus H1036-237 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$35.00 | $110.00 | Q:15 /30Days | $1,274.25 |
Browse Plan Formulary select insulin pay $20-$35 copay |
HumanaChoice Florida H5216-068 (PPO)
|
$0.00 |
$150* | No additional gap coverage, only the Donut Hole Discount | 3* |
Preferred Brand |
$47.00 | $131.00 | Q:15 /30Days | $1,272.75 |
Browse Plan Formulary |
HumanaChoice Florida H7284-008 (PPO)
|
$0.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:15 /30Days | $1,272.75 |
Browse Plan Formulary |
MMM ELITE (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$0.00 | $15.00 | Q:15 /30Days | $1,147.35 |
Browse Plan Formulary select insulin pay $0 copay |
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 |
MMM EXTRA (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$0.00 | $141.00 | Q:15 /30Days | $1,147.35 |
Browse Plan Formulary select insulin pay $0 copay |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$35.00 | $94.00 | Q:15 /30Days | $1,147.35 |
Browse Plan Formulary select insulin pay $35 copay |
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:15 /30Days | $1,147.35 |
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:15 /30Days | $1,147.35 |
Browse Plan Formulary |
Oscar + Holy Cross + Memorial - with $1500 O-Card (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$25.00 | $75.00 | Q:15 /30Days | $1,147.35 |
Browse Plan Formulary |
Oscar + Holy Cross + Memorial - with Refund Bonus (HMO)
|
$0.00 |
$200 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$25.00 | $75.00 | Q:15 /30Days | $1,147.35 |
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 |
Oscar + Holy Cross + Memorial (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$25.00 | $75.00 | Q:15 /30Days | $1,147.35 |
Browse Plan Formulary |
PHP (HMO C-SNP)
|
$0.00 |
$480 | Few Generics | 2 |
Preferred Brand |
15% | n/a | Q:15 /28Days | $1,143.15 |
Browse Plan Formulary |
SOLIS SPF 007 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$15.00 | n/a | P Q:15 /30Days | $1,319.70 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$30.00 | $60.00 | Q:15 /30Days | $1,246.80 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$25.00 | $50.00 | Q:15 /30Days | $1,246.80 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$100 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$37.00 | $74.00 | Q:15 /30Days | $1,246.50 |
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 |
Wellcare Specialty Giveback (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 6 |
Select Diabetic Drugs |
$10.00 | $20.00 | Q:15 /30Days | $1,246.95 |
Browse Plan Formulary select insulin pay $10 copay |
Wellcare Specialty No Premium (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 6 |
Select Diabetic Drugs |
$10.00 | $20.00 | Q:15 /30Days | $1,246.65 |
Browse Plan Formulary select insulin pay $10 copay |
HumanaChoice R5826-074 (Regional PPO)
|
$0.50 |
$395 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:15 /30Days | $1,275.60 |
Browse Plan Formulary |
HumanaChoice Florida H7284-007 (PPO)
|
$11.00 |
$150* | No additional gap coverage, only the Donut Hole Discount | 3* |
Preferred Brand |
$30.00 | $80.00 | Q:15 /30Days | $1,273.20 |
Browse Plan Formulary |
CareNeeds PLUS (HMO D-SNP)
|
$13.20 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:15 /30Days | $1,272.75 |
Browse Plan Formulary |
Humana Fully Integrated H1036-280 (HMO D-SNP)
|
$19.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:15 /30Days | $1,272.75 |
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 Assure Plus (HMO D-SNP)
|
$27.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$5.00 | $15.00 | Q:15 /30Days | $1,274.10 |
Browse Plan Formulary |
Wellcare Dual Reserve (HMO D-SNP)
|
$30.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:15 /30Days | $1,246.20 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-103A (HMO D-SNP)
|
$31.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:15 /30Days | $1,274.25 |
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:15 /30Days | $1,246.05 |
Browse Plan Formulary |
Aetna Medicare Assure (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$5.00 | $15.00 | Q:15 /30Days | $1,274.10 |
Browse Plan Formulary |
Bright Advantage Embrace Assist Plan (HMO C-SNP)
|
$34.30 |
$480 | Some Generics | 3 |
Preferred Brand |
25% | 25% | Q:15 /28Days | $1,143.00 |
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 |
Bright Advantage Embrace Choice Plan (HMO C-SNP)
|
$34.30 |
$480 | Some Generics | 3 |
Preferred Brand |
25% | 25% | Q:15 /28Days | $1,143.00 |
Browse Plan Formulary |
Devoted Health Dual Broward (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | 25% | Q:15 /30Days | $1,118.55 |
Browse Plan Formulary |
Devoted Health Prime South Florida (HMO)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$0.00 | 25% | Q:15 /30Days | $1,118.40 |
Browse Plan Formulary select insulin pay $0 copay |
Devoted Health Prime South Florida (HMO)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$0.00 | 25% | Q:15 /30Days | $1,118.55 |
Browse Plan Formulary select insulin pay $0 copay |
Devoted Health Prime South Florida (HMO)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$0.00 | 25% | Q:15 /30Days | $1,118.55 |
Browse Plan Formulary select insulin pay $0 copay |
Florida Complete Care (HMO I-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | Q:15 /30Days | $1,164.00 |
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 |
Florida Complete Care- In The Community (HMO I-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | Q:15 /30Days | $1,164.00 |
Browse Plan Formulary |
HealthSun MediMax (HMO)
|
$34.30 |
$430 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | n/a | None | $1,132.50 |
Browse Plan Formulary |
HealthSun MediSun Extra (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | n/a | None | $1,132.50 |
Browse Plan Formulary |
HealthSun MediSun Plus (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | n/a | None | $1,132.50 |
Browse Plan Formulary |
MMM PLATINUM (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | 25% | Q:15 /30Days | $1,147.35 |
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:15 /30Days | $1,147.35 |
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 |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$34.30 |
$480 | Some Generics, Few Brands | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:15 /30Days | $1,147.35 |
Browse Plan Formulary |
SOLIS SPF 012 (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | n/a | P Q:15 /30Days | $1,319.70 |
Browse Plan Formulary |
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:15 /30Days | $1,246.05 |
Browse Plan Formulary |
Wellcare Dual Medicare (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:15 /30Days | $1,246.20 |
Browse Plan Formulary |
Wellcare Dual Nurture (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:15 /30Days | $1,246.20 |
Browse Plan Formulary |
HumanaChoice H5216-065 (PPO)
|
$53.00 |
$350* | No additional gap coverage, only the Donut Hole Discount | 3* |
Preferred Brand |
$47.00 | $131.00 | Q:15 /30Days | $1,272.75 |
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 |
HumanaChoice R5826-005 (Regional PPO)
|
$55.00 |
$100 | No | 3 |
Preferred Brand |
$35.00 | $125.00 | Q:15 /30Days | $1,275.60 |
Browse Plan Formulary select insulin pay $35 copay |
Wellcare Premium Enhanced Open (PPO)
|
$85.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$37.00 | $74.00 | Q:15 /30Days | $1,246.50 |
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:15 /30Days | $1,275.30 |
Browse Plan Formulary |