SUMATRIPTAN 6 MG/0.5 ML VIAL [Sumavel DosePro System] (2.5 MLS ) (NDC: 55150017301)
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 Open Plan 1 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:6 /30Days | $64.38 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Premier (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:4 /30Days | $119.67 |
Browse Plan Formulary |
Aetna Medicare Value (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:4 /30Days | $209.58 |
Browse Plan Formulary |
Ascension Complete Michigan Access (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:6 /30Days | $321.51 |
Browse Plan Formulary |
Ascension Complete Michigan Access Plus (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:6 /30Days | $321.51 |
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 |
Ascension Complete Michigan Reward (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:6 /30Days | $321.51 |
Browse Plan Formulary |
Ascension Complete Michigan Secure (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:6 /30Days | $321.51 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:18 /90Days | $99.63 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:18 /90Days | $113.01 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:18 /90Days | $108.87 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:18 /90Days | $93.75 |
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 |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:18 /90Days | $96.99 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HAP Senior Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | Q:9 /30Days | $127.53 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
HAP Senior Plus Option 1 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | Q:9 /30Days | $127.80 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
Humana Gold Plus H8908-004 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:6 /30Days | $134.79 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H8087-004 (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:6 /30Days | $134.82 |
Browse Plan Formulary |
McLaren Medicare Inspire (HMO)
|
$0.00 |
$100* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$12.50 | $28.13 | Q:4 /28Days | $113.88 |
Browse Plan Formulary select insulin pay $10-$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 |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:18 /90Days | $102.45 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:18 /90Days | $98.88 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:18 /90Days | $108.06 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:18 /90Days | $110.64 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:18 /90Days | $108.21 |
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 | Q:6 /30Days | $350.31 |
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 |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | Q:4 /30Days | $148.80 |
Browse Plan Formulary |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | Q:4 /30Days | $150.09 |
Browse Plan Formulary |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | Q:4 /30Days | $149.64 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:4 /30Days | $146.55 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:4 /30Days | $150.09 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:4 /30Days | $149.64 |
Browse Plan Formulary select insulin pay $20-$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 |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:4 /30Days | $148.80 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:4 /30Days | $149.34 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:4 /30Days | $150.09 |
Browse Plan Formulary |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:4 /30Days | $149.64 |
Browse Plan Formulary |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:4 /30Days | $148.80 |
Browse Plan Formulary |
Reliance Principle Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:5 /30Days | $68.37 |
Browse Plan Formulary select insulin pay $10 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 |
Wellcare Giveback (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | Q:6 /30Days | $177.09 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$5.00 | $0.00 | Q:6 /30Days | $206.67 |
Browse Plan Formulary |
Wellcare No Premium Exclusive (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$5.00 | $0.00 | Q:6 /30Days | $191.10 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
43% | 43% | Q:6 /30Days | $177.09 |
Browse Plan Formulary |
Zing Choice MI (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$8.00 | $8.00 | Q:5 /30Days | $85.56 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Zing Essential Wellness MI (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
2 |
Generic |
$8.00 | $8.00 | Q:5 /30Days | $85.56 |
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 |
Wellcare Low Premium (HMO-POS)
|
$15.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$5.00 | $0.00 | Q:6 /30Days | $205.68 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H8908-005 (HMO D-SNP)
|
$18.20 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:6 /30Days | $134.79 |
Browse Plan Formulary |
BCN Advantage HMO-POS Community Value (HMO-POS)
|
$20.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:18 /90Days | $99.63 |
Browse Plan Formulary |
BCN Advantage HMO-POS Community Value (HMO-POS)
|
$20.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:18 /90Days | $105.42 |
Browse Plan Formulary |
HumanaChoice H8087-001 (PPO)
|
$20.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:6 /30Days | $134.76 |
Browse Plan Formulary |
Humana Value Plus H8087-002 (PPO)
|
$20.60 |
$260 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:6 /30Days | $134.82 |
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 (HMO)
|
$20.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
41% | 41% | Q:6 /30Days | $352.23 |
Browse Plan Formulary |
Aetna Medicare Assure Premier (HMO D-SNP)
|
$23.50 |
$425 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | Q:4 /30Days | $216.78 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:4 /30Days | $148.80 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:4 /30Days | $149.34 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:4 /30Days | $146.55 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:4 /30Days | $150.09 |
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 |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:4 /30Days | $149.64 |
Browse Plan Formulary |
McLaren Medicare Inspire Plus (HMO)
|
$25.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$12.50 | $28.13 | Q:4 /28Days | $113.88 |
Browse Plan Formulary select insulin pay $10-$35 copay but not this drug |
Zing Open Access MI (HMO-POS)
|
$25.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$8.00 | $8.00 | Q:5 /30Days | $85.56 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Open Plan 2 (PPO)
|
$28.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:6 /30Days | $64.38 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Premier Plus (PPO)
|
$29.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:4 /30Days | $119.67 |
Browse Plan Formulary |
Wellcare Dual Access (HMO-POS D-SNP)
|
$30.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
42% | 42% | Q:6 /30Days | $352.23 |
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 Access Open (PPO D-SNP)
|
$30.80 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
49% | 49% | Q:6 /30Days | $352.23 |
Browse Plan Formulary |
Ascension Complete Michigan DSNP (HMO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
46% | 46% | Q:6 /30Days | $326.04 |
Browse Plan Formulary |
HAP Empowered Duals (HMO D-SNP)
|
$31.50 |
$445 |
Few Brands |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | Q:9 /30Days | $128.01 |
Browse Plan Formulary |
Longevity Health Plan (HMO I-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | Q:8 /28Days | $104.97 |
Browse Plan Formulary |
McLaren Medicare Inspire Duals (HMO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:4 /28Days | $113.88 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
33% | 33% | Q:6 /30Days | $350.31 |
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)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
33% | 33% | Q:6 /30Days | $350.31 |
Browse Plan Formulary |
PriorityMedicare D-SNP (HMO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:4 /30Days | $137.67 |
Browse Plan Formulary |
Reliance Dual Care Plus (HMO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:5 /30Days | $68.37 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:6 /30Days | $68.94 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:6 /30Days | $68.94 |
Browse Plan Formulary |
Wellcare Community Assist (PPO)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
43% | 43% | Q:6 /30Days | $286.86 |
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 |
Zing Complete Plus MI (HMO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | Q:5 /30Days | $85.56 |
Browse Plan Formulary |
HumanaChoice R3887-002 (Regional PPO)
|
$34.10 |
$480 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:6 /30Days | $134.79 |
Browse Plan Formulary |
Reliance Cardinal Plan (HMO)
|
$40.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:5 /30Days | $68.37 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
Humana Gold Plus H8908-001 (HMO)
|
$46.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:6 /30Days | $134.79 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
McLaren Medicare Inspire Flex (HMO-POS)
|
$49.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$12.50 | $28.13 | Q:4 /28Days | $113.88 |
Browse Plan Formulary select insulin pay $10-$35 copay but not this drug |
McLaren Medicare Inspire Flex (HMO-POS)
|
$49.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$12.50 | $28.13 | Q:4 /28Days | $113.88 |
Browse Plan Formulary select insulin pay $10-$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 |
PriorityMedicare Value (HMO-POS)
|
$50.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:4 /30Days | $148.80 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$50.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:4 /30Days | $149.34 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$50.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:4 /30Days | $146.55 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$50.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:4 /30Days | $150.09 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$50.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:4 /30Days | $149.64 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
BCN Advantage HMO ConnectedCare (HMO)
|
$58.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | Q:18 /90Days | $99.78 |
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 |
HAP Senior Plus Option 2 (PPO)
|
$65.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | Q:9 /30Days | $127.80 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
Medicare Plus Blue PPO Vitality (PPO)
|
$80.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:18 /90Days | $102.45 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$80.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:18 /90Days | $98.88 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$80.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:18 /90Days | $108.06 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$80.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:18 /90Days | $110.64 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$80.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:18 /90Days | $108.21 |
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 |
HAP Senior Plus Option 1 (HMO-POS)
|
$90.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | Q:9 /30Days | $127.80 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
PriorityMedicare Merit (PPO)
|
$98.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:4 /30Days | $149.64 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$98.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:4 /30Days | $148.80 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$98.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:4 /30Days | $149.34 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$98.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:4 /30Days | $146.55 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$98.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:4 /30Days | $150.09 |
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 |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$104.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:18 /90Days | $99.63 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$104.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:18 /90Days | $113.01 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$104.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:18 /90Days | $108.87 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$104.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:18 /90Days | $93.75 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$104.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:18 /90Days | $96.99 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Medicare Plus Blue PPO Signature (PPO)
|
$122.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | Q:18 /90Days | $102.45 |
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 |
Medicare Plus Blue PPO Signature (PPO)
|
$122.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | Q:18 /90Days | $98.88 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$122.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | Q:18 /90Days | $108.06 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$122.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | Q:18 /90Days | $110.64 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$122.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | Q:18 /90Days | $108.21 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$127.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:4 /30Days | $148.80 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$127.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:4 /30Days | $149.34 |
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 |
PriorityMedicare (HMO-POS)
|
$127.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:4 /30Days | $146.55 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$127.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:4 /30Days | $150.09 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$127.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:4 /30Days | $149.64 |
Browse Plan Formulary |
HAP Senior Plus Option 3 (PPO)
|
$165.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | Q:9 /30Days | $127.80 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
HAP Senior Plus Option 2 (HMO-POS)
|
$190.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | Q:9 /30Days | $127.80 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
HAP Senior Plus Option 4 (PPO)
|
$200.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | Q:9 /30Days | $127.80 |
Browse Plan Formulary select insulin pay $25 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 |
PriorityMedicare Select (PPO)
|
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:4 /30Days | $148.80 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:4 /30Days | $149.34 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:4 /30Days | $146.55 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:4 /30Days | $150.09 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:4 /30Days | $149.64 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$228.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:18 /90Days | $93.75 |
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 |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$228.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:18 /90Days | $96.99 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$228.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:18 /90Days | $99.63 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$228.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:18 /90Days | $113.01 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$228.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:18 /90Days | $108.87 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Medicare Plus Blue PPO Assure (PPO)
|
$261.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:18 /90Days | $108.06 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$261.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:18 /90Days | $110.64 |
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 |
Medicare Plus Blue PPO Assure (PPO)
|
$261.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:18 /90Days | $108.21 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$261.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:18 /90Days | $102.45 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$261.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | Q:18 /90Days | $98.88 |
Browse Plan Formulary |