SCOPOLAMINE 1 MG/3 DAY PATCH TD 3 [Transderm Scop] (4 UNITS ) (NDC: 45802058046)
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 | $60.80 |
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 | $61.24 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Silver (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:10 /30Days | $61.72 |
Browse Plan Formulary |
Aetna Medicare Premier (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:10 /30Days | $58.04 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO-POS)
|
$0.00 |
$150 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:10 /30Days | $60.20 |
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 |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$150 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:10 /30Days | $66.12 |
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 | Q:10 /28Days | $55.52 |
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 | Q:10 /28Days | $54.72 |
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 | Q:10 /28Days | $54.32 |
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 | Q:10 /28Days | $55.52 |
Browse Plan Formulary |
Anthem MediBlue Prime Select (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:10 /28Days | $54.72 |
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 |
Buckeye Health Plan - MyCare Ohio (Medicare-Medicaid Plan)
|
$0.00 |
$0 | All Generics, All Brands | 2 |
Tier 2 |
0% | 0% | P Q:10 /30Days | $50.40 |
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 | $64.00 |
Browse Plan Formulary |
CareSource MyCare Ohio (Medicare-Medicaid Plan)
|
$0.00 |
$0 | All Generics, All Brands | 1 |
Tier 1 |
0% | 0% | None | $64.36 |
Browse Plan Formulary |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:10 /30Days | $66.28 |
Browse Plan Formulary |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:10 /30Days | $66.28 |
Browse Plan Formulary |
Devoted Health Core (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:10 /30Days | $47.80 |
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 |
Devoted Health Saver (HMO)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:10 /30Days | $47.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Cleveland Clinic Preferred (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:10 /30Days | $53.88 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H6622-022 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:10 /30Days | $54.64 |
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 | 3* |
Preferred Brand |
$47.00 | $131.00 | Q:10 /30Days | $54.40 |
Browse Plan Formulary |
HumanaChoice H5525-042 (PPO)
|
$0.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:10 /30Days | $54.40 |
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 | $64.40 |
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 |
MedMutual Advantage Access (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | None | $64.16 |
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 | $64.40 |
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 | $62.24 |
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 | $64.16 |
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 | $63.88 |
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 | $64.16 |
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 |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | None | $64.48 |
Browse Plan Formulary |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:10 /30Days | $53.28 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Paramount Elite Standard (HMO)
|
$0.00 |
$50 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | P Q:10 /30Days | $68.96 |
Browse Plan Formulary |
SummaCare Medicare Topaz (HMO)
|
$0.00 |
$150* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$10.00 | $25.00 | P Q:10 /30Days | $49.12 |
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 | $63.40 |
Browse Plan Formulary |
UnitedHealthcare Connected for MyCareOhio (Medicare-Medicaid Plan)
|
$0.00 |
$0 | All Generics, All Brands | 1 |
Tier 1 |
0% | 0% | None | $61.28 |
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 Dividend Giveback (HMO)
|
$0.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
48% | 48% | P Q:10 /30Days | $41.64 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
48% | 48% | P Q:10 /30Days | $43.52 |
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 | P Q:10 /30Days | $43.72 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$75 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$90.00 | $180.00 | P Q:10 /30Days | $43.52 |
Browse Plan Formulary |
Wellcare No Premium Essential (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$90.00 | $180.00 | P Q:10 /30Days | $43.08 |
Browse Plan Formulary |
Wellcare No Premium Exclusive (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$90.00 | $180.00 | P Q:10 /30Days | $41.12 |
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 |
Wellcare No Premium Medicare (HMO)
|
$0.00 |
$75 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$90.00 | $180.00 | P Q:10 /30Days | $43.72 |
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% | P Q:10 /30Days | $43.72 |
Browse Plan Formulary |
HumanaChoice H5216-106 (PPO)
|
$15.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:10 /30Days | $54.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
CommuniCare Advantage CSNP (HMO C-SNP)
|
$16.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$92.00 | $270.00 | None | $53.24 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
CommuniCare Advantage CSNP (HMO C-SNP)
|
$16.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$92.00 | $270.00 | None | $52.12 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
CommuniCare Advantage CSNP (HMO C-SNP)
|
$16.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$92.00 | $270.00 | None | $53.28 |
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 |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$16.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:10 /30Days | $54.16 |
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% | P Q:10 /30Days | $42.04 |
Browse Plan Formulary |
Wellcare Assist Complement (HMO)
|
$17.60 |
$480 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
42% | 42% | P Q:10 /30Days | $42.40 |
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 | $60.80 |
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 | Q:10 /28Days | $54.44 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$22.00 |
$480 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:10 /28Days | $54.88 |
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 | $64.40 |
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 | $64.16 |
Browse Plan Formulary |
Aetna Medicare Assure 1 (HMO D-SNP)
|
$23.20 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | 25% | P Q:10 /30Days | $63.44 |
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 | $60.80 |
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 | $64.00 |
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 | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:10 /30Days | $54.16 |
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 |
Paramount Elite Prime (HMO)
|
$28.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | P Q:10 /30Days | $68.96 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Perennial Advantage Strive (HMO I-SNP)
|
$28.20 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $66.52 |
Browse Plan Formulary |
SummaCare Medicare Garnet (HMO)
|
$29.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$8.00 | $20.00 | P Q:10 /30Days | $49.72 |
Browse Plan Formulary |
SummaCare Medicare Garnet (HMO)
|
$29.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$8.00 | $20.00 | P Q:10 /30Days | $48.76 |
Browse Plan Formulary |
Wellcare Dual Access Extra (HMO-POS D-SNP)
|
$29.60 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | 45% | P Q:10 /30Days | $67.60 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)
|
$29.80 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $62.92 |
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 (HMO)
|
$31.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:10 /30Days | $47.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Perennial Advantage Concierge (HMO C-SNP)
|
$31.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $45.00 | None | $66.52 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$32.00 |
$480 | Some Generics | 4 |
Non-Preferred Drug |
50% | 50% | P Q:10 /30Days | $42.04 |
Browse Plan Formulary |
Aetna Medicare Premier Plus 2 (Regional PPO)
|
$33.40 |
$260 | No | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:10 /30Days | $52.84 |
Browse Plan Formulary |
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 | Q:10 /28Days | $54.88 |
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 | $64.00 |
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 |
CommuniCare Advantage ISNP (HMO I-SNP)
|
$33.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $54.52 |
Browse Plan Formulary |
CommuniCare Advantage ISNP (HMO I-SNP)
|
$33.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $53.16 |
Browse Plan Formulary |
CommuniCare Advantage ISNP (HMO I-SNP)
|
$33.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $52.96 |
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% | P Q:10 /30Days | $53.28 |
Browse Plan Formulary |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$33.50 |
$200 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $62.84 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Dual Complete LP (HMO D-SNP)
|
$33.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $62.76 |
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 Nursing Home Plan 2 (PPO I-SNP)
|
$33.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $62.28 |
Browse Plan Formulary |
Valor Health Plan (HMO I-SNP)
|
$33.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $52.24 |
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 | $64.40 |
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 | $62.24 |
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 | $64.16 |
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 | $63.00 |
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 |
Anthem MediBlue Access Basic (Regional PPO)
|
$41.50 |
$200 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
41% | 41% | Q:10 /28Days | $54.88 |
Browse Plan Formulary |
SummaCare Medicare Ruby (HMO)
|
$43.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$8.00 | $20.00 | P Q:10 /30Days | $49.40 |
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 | $64.40 |
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 | $62.24 |
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 | $64.16 |
Browse Plan Formulary |
Aetna Medicare Premier Plus 1 (Regional PPO)
|
$44.50 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$99.00 | $297.00 | P Q:10 /30Days | $56.32 |
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 H6622-011 (HMO)
|
$47.00 |
$195 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:10 /30Days | $53.44 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice R5495-002 (Regional PPO)
|
$47.80 |
$480 | No | 3 |
Preferred Brand |
17% | 17% | Q:10 /30Days | $54.40 |
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 | Q:10 /28Days | $54.84 |
Browse Plan Formulary |
Paramount Elite Enhanced (HMO)
|
$68.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | P Q:10 /30Days | $68.96 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-024 (PPO)
|
$76.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:10 /30Days | $53.44 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SummaCare Medicare Sapphire (HMO-POS)
|
$76.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$8.00 | $20.00 | P Q:10 /30Days | $49.44 |
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 | $64.40 |
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 | $62.24 |
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 | $64.16 |
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 | Q:10 /28Days | $55.12 |
Browse Plan Formulary |
Humana Gold Plus H6622-019 (HMO)
|
$91.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:10 /30Days | $54.16 |
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 | $64.40 |
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 |
MedMutual Advantage Plus (HMO)
|
$97.00 |
$55 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | None | $62.24 |
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 | $64.16 |
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 | $63.40 |
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 | $61.88 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Premier 2 (PPO)
|
$118.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:10 /30Days | $63.20 |
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 | $64.40 |
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 |
MedMutual Advantage Premium (PPO)
|
$134.00 |
$55 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | None | $62.24 |
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 | $64.16 |
Browse Plan Formulary |
Aetna Medicare Premier 1 (PPO)
|
$149.00 |
$150 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:10 /30Days | $64.48 |
Browse Plan Formulary |
HumanaChoice H5525-030 (PPO)
|
$151.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:10 /30Days | $54.40 |
Browse Plan Formulary |
SummaCare Medicare Emerald (HMO-POS)
|
$180.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$8.00 | $20.00 | P Q:10 /30Days | $49.16 |
Browse Plan Formulary |