ACETAZOLAMIDE ER 500 MG CAPSULE ER [Diamox Sequels] (60 CAPSULES ) (NDC: 50742023301)
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 Choice (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $51.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Credit Value (PPO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $94.80 |
Browse Plan Formulary |
Aetna Medicare Advantra Gold (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $98.40 |
Browse Plan Formulary |
Aetna Medicare Advantra Silver (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $91.80 |
Browse Plan Formulary |
Aetna Medicare The Valley Plan (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $107.40 |
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 |
Aetna Medicare Value (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $94.20 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $120.00 | None | $69.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $120.00 | None | $69.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $120.00 | None | $74.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $120.00 | None | $69.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $120.00 | None | $74.40 |
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 |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $120.00 | None | $69.60 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $120.00 | None | $69.60 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $120.00 | None | $69.60 |
Browse Plan Formulary |
Geisinger Gold Classic 360 Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | None | $28.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | None | $28.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | None | $28.80 |
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 |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $0.00 | None | $28.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $0.00 | None | $28.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $0.00 | None | $28.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H6622-036 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $27.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5525-051 (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $27.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5525-051 (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $27.00 |
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 |
Vibra Essential Advocate (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | None | $67.80 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Vibra Essential Advocate (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | None | $68.40 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Wellcare Giveback (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
48% | 48% | None | $111.60 |
Browse Plan Formulary |
Wellcare Giveback Open (PPO)
|
$0.00 |
$350 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
48% | 48% | None | $110.40 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | 45% | None | $114.00 |
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 | $110.40 |
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 |
Aetna Medicare Advantra Premier (HMO-POS)
|
$17.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $91.20 |
Browse Plan Formulary |
Aetna Medicare Advantra Silver Plus (PPO)
|
$20.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $91.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Cares (HMO D-SNP)
|
$22.10 |
$375 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | 25% | None | $104.40 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H6622-078 (HMO D-SNP)
|
$23.70 |
$450 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $27.00 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H6622-078 (HMO D-SNP)
|
$23.70 |
$450 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $27.00 |
Browse Plan Formulary |
Wellcare Assist Open (PPO)
|
$24.70 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
43% | 43% | None | $117.60 |
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 |
Community Blue Medicare PPO Distinct (PPO)
|
$25.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $120.00 | None | $69.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Community Blue Medicare PPO Distinct (PPO)
|
$25.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $120.00 | None | $74.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Community Blue Medicare PPO Distinct (PPO)
|
$25.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $120.00 | None | $69.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Community Blue Medicare PPO Distinct (PPO)
|
$25.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $120.00 | None | $69.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Vibra Health Plan Enhanced Complete (PPO)
|
$27.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | None | $68.40 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Wellcare Low Premium Open (PPO)
|
$29.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
43% | 43% | None | $110.40 |
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 |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$33.90 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | None | $55.80 |
Browse Plan Formulary |
HumanaChoice R0923-002 (Regional PPO)
|
$34.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $27.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Assist (HMO)
|
$36.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
42% | 42% | None | $118.80 |
Browse Plan Formulary |
Humana Value Plus H5216-117 (PPO)
|
$36.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $27.00 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | None | $28.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | None | $28.80 |
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 |
UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
|
$40.60 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $56.40 |
Browse Plan Formulary |
AmeriHealth Caritas VIP Care (HMO D-SNP)
|
$40.70 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$6.50 | $19.50 | None | $27.00 |
Browse Plan Formulary |
Geisinger Gold Secure Rx (HMO D-SNP)
|
$40.70 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $28.80 |
Browse Plan Formulary |
Highmark Wholecare Medicare Assured Diamond (HMO D-SNP)
|
$40.70 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $60.00 | None | $18.00 |
Browse Plan Formulary |
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP)
|
$40.70 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $60.00 | None | $18.00 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Select (HMO D-SNP)
|
$40.70 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $55.80 |
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 |
UPMC for Life Complete Care (HMO D-SNP)
|
$40.70 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$25.00 | $40.00 | None | $79.20 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$40.70 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | None | $119.40 |
Browse Plan Formulary |
Aetna Medicare Advantra Premier Plus (PPO)
|
$48.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$99.00 | $297.00 | None | $91.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5525-007 (PPO)
|
$55.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $27.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Silver (HMO)
|
$65.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $104.40 |
Browse Plan Formulary |
Freedom Blue PPO ValueRx (PPO)
|
$69.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $115.00 | None | $70.80 |
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 |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$86.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | None | $28.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$86.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | None | $29.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$122.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | None | $30.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$122.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | None | $27.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$122.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | None | $28.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-120 (PPO)
|
$128.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $27.00 |
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 |
Aetna Medicare Gold Plan (PPO)
|
$170.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $94.80 |
Browse Plan Formulary |
Freedom Blue PPO Standard (PPO)
|
$174.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$13.00 | $27.00 | None | $70.80 |
Browse Plan Formulary |
Freedom Blue PPO Deluxe (PPO)
|
$288.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$13.00 | $27.00 | None | $70.80 |
Browse Plan Formulary |