Xulane Patch (NDC: 00378334053)
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 Plan 7 (HMO)
|
$0.00 |
$175 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $106.95 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Walgreens (PPO)
|
$0.00 |
$225 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $106.98 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $79.26 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $79.47 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $78.24 |
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 |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $76.80 |
Browse Plan Formulary |
CareSource Advantage Zero Premium (HMO)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $118.59 |
Browse Plan Formulary |
Humana Gold Plus H6622-014 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:3 /28Days | $109.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-285 (PPO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:3 /28Days | $109.83 |
Browse Plan Formulary |
HumanaChoice H5525-042 (PPO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:3 /28Days | $109.83 |
Browse Plan Formulary |
MedMutual Advantage Access (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $118.47 |
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 |
MedMutual Advantage Access (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $119.10 |
Browse Plan Formulary |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $118.47 |
Browse Plan Formulary |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $113.04 |
Browse Plan Formulary |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $119.10 |
Browse Plan Formulary |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $119.34 |
Browse Plan Formulary |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $118.47 |
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 |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $120.21 |
Browse Plan Formulary |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$12.00 | $24.00 | None | $114.51 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SummaCare Medicare Topaz (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:3 /28Days | $106.89 |
Browse Plan Formulary |
The Health Plan SecureCare - Option II (HMO)
|
$0.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $120.06 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $104.94 |
Browse Plan Formulary |
Wellcare Giveback Boost (HMO)
|
$0.00 |
$75 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $104.16 |
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)
|
$0.00 |
$75 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $104.94 |
Browse Plan Formulary |
Wellcare No Premium Medicare (HMO)
|
$0.00 |
$75 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $104.16 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
43% | 43% | None | $104.16 |
Browse Plan Formulary |
HumanaChoice H5216-106 (PPO)
|
$15.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:3 /28Days | $109.83 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$16.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:3 /28Days | $109.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Assist (HMO)
|
$16.80 |
$480 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
42% | 42% | None | $82.53 |
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 Assist Complement (HMO)
|
$17.60 |
$480 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
42% | 42% | None | $83.82 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 1 (HMO)
|
$19.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $106.95 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Anthem MediBlue Preferred Plus (HMO)
|
$19.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $78.48 |
Browse Plan Formulary |
Humana Gold Plus H6622-070 (HMO)
|
$21.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:3 /28Days | $109.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Anthem MediBlue Extra (HMO)
|
$22.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $78.39 |
Browse Plan Formulary |
MedMutual Advantage Secure (HMO)
|
$22.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $118.47 |
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 |
MedMutual Advantage Secure (HMO)
|
$22.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $119.10 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 8 (HMO)
|
$25.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $106.95 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
CareSource Advantage (HMO)
|
$25.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $118.59 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H6622-015 (HMO D-SNP)
|
$27.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:3 /28Days | $109.83 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$32.00 |
$480 |
Some Generics |
4 |
Non-Preferred Drug |
50% | 50% | None | $82.53 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO-POS D-SNP)
|
$33.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $106.89 |
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 |
Anthem MediBlue Dual Advantage (HMO D-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $78.39 |
Browse Plan Formulary |
CareSource Dual Advantage (HMO D-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | None | $118.59 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
33% | 33% | None | $114.51 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP1 (HMO D-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $106.89 |
Browse Plan Formulary |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $118.47 |
Browse Plan Formulary |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $113.04 |
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 |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $119.10 |
Browse Plan Formulary |
The Health Plan SecureCare SNP (HMO D-SNP)
|
$40.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $120.33 |
Browse Plan Formulary |
Anthem MediBlue Access Basic (Regional PPO)
|
$41.50 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
41% | 41% | None | $78.39 |
Browse Plan Formulary |
SummaCare Medicare Ruby (HMO)
|
$43.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:3 /28Days | $106.89 |
Browse Plan Formulary |
HumanaChoice H5216-051 (PPO)
|
$44.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:3 /28Days | $109.86 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MedMutual Advantage Select (PPO)
|
$44.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $113.04 |
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 |
MedMutual Advantage Select (PPO)
|
$44.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $119.10 |
Browse Plan Formulary |
MedMutual Advantage Select (PPO)
|
$44.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $118.47 |
Browse Plan Formulary |
HumanaChoice R5495-002 (Regional PPO)
|
$47.80 |
$480 |
No |
4 |
Non-Preferred Drug |
20% | 20% | Q:3 /28Days | $109.83 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$55.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $77.43 |
Browse Plan Formulary |
Anthem MediBlue Access (PPO)
|
$56.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $78.30 |
Browse Plan Formulary |
SummaCare Medicare Sapphire (HMO-POS)
|
$76.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:3 /28Days | $106.89 |
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 |
MedMutual Advantage Preferred (PPO)
|
$80.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $118.47 |
Browse Plan Formulary |
MedMutual Advantage Preferred (PPO)
|
$80.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $113.04 |
Browse Plan Formulary |
MedMutual Advantage Preferred (PPO)
|
$80.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $119.10 |
Browse Plan Formulary |
Anthem MediBlue Access Plus (PPO)
|
$89.00 |
$40 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $78.15 |
Browse Plan Formulary |
Humana Gold Plus H6622-019 (HMO)
|
$91.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:3 /28Days | $109.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MedMutual Advantage Plus (HMO)
|
$97.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $118.47 |
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 |
MedMutual Advantage Plus (HMO)
|
$97.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $113.04 |
Browse Plan Formulary |
MedMutual Advantage Plus (HMO)
|
$97.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $119.10 |
Browse Plan Formulary |
The Health Plan SecureChoice - Option II (PPO)
|
$100.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $120.06 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 3 (HMO)
|
$111.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $106.92 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MedMutual Advantage Premium (PPO)
|
$134.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $118.47 |
Browse Plan Formulary |
MedMutual Advantage Premium (PPO)
|
$134.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $113.04 |
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 |
MedMutual Advantage Premium (PPO)
|
$134.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $119.10 |
Browse Plan Formulary |
HumanaChoice H5525-030 (PPO)
|
$151.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:3 /28Days | $109.83 |
Browse Plan Formulary |
SummaCare Medicare Emerald (HMO-POS)
|
$180.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:3 /28Days | $106.89 |
Browse Plan Formulary |