OTEZLA 28 DAY STARTER PACK TAB DS PK (UNITS ) (NDC: 55513036955)
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 |
$150 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
30% | n/a | P Q:110 /365Days | $4,616.15 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice Plan 2 (Regional PPO)
|
$0.00 |
$395 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
26% | n/a | P Q:110 /365Days | $4,605.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Choice (HMO-POS)
|
$0.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
29% | n/a | P Q:55 /365Days | $4,683.25 |
Browse Plan Formulary |
Aetna Medicare Credit (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:55 /365Days | $4,639.80 |
Browse Plan Formulary |
Aetna Medicare Premier (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | P Q:55 /365Days | $4,683.25 |
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 |
Aetna Medicare Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:55 /365Days | $4,725.60 |
Browse Plan Formulary select insulin pay $20 copay but not this drug |
Align Connect (HMO C-SNP)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:55 /28Days | $5,316.85 |
Browse Plan Formulary |
AvMed Medicare Access (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:110 /365Days | $4,594.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AvMed Medicare Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:110 /365Days | $4,594.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AvMed Medicare Circle (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:110 /365Days | $4,594.70 |
Browse Plan Formulary select insulin pay $25-$35 copay but not this drug |
BlueMedicare Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $4,285.05 |
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 |
BlueMedicare Premier (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $4,285.05 |
Browse Plan Formulary select insulin pay $12 copay but not this drug |
CareBreeze (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | P Q:55 /28Days | $4,514.95 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
CareComplete (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | P Q:55 /28Days | $4,514.95 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
CareFree PLUS (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:55 /28Days | $4,514.95 |
Browse Plan Formulary select insulin pay $10-$35 copay but not this drug |
CareOne PLUS (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:55 /28Days | $4,514.95 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Devoted Health Core Miami-Dade (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:110 /365Days | $4,651.35 |
Browse Plan Formulary select insulin pay $0 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 Essentials Miami-Dade (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:110 /365Days | $4,651.35 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
DrExtraCare (HMO-POS C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
5 |
Specialty Tier |
33% | n/a | P | $4,363.70 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
DrMax (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $4,363.70 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
DrValue (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $4,363.70 |
Browse Plan Formulary |
HealthSun HealthAdvantage Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $4,604.05 |
Browse Plan Formulary |
HealthSun HealthAdvantage Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $4,604.05 |
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 - Diabetes and Heart (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | P Q:55 /28Days | $4,691.50 |
Browse Plan Formulary select insulin pay $10-$35 copay but not this drug |
Humana Gold Plus H1036-054C (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:55 /28Days | $4,514.95 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Humana Gold Plus H1036-237 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:55 /28Days | $4,514.95 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
Humana Gold Plus H1036-237 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:55 /28Days | $4,691.50 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
HumanaChoice Florida H5216-068 (PPO)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:55 /28Days | $4,691.50 |
Browse Plan Formulary |
HumanaChoice Florida H7284-008 (PPO)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:55 /28Days | $4,691.50 |
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 |
Leon MediExtra (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Specialty Tier |
33% | n/a | P | $4,363.70 |
Browse Plan Formulary |
Leon MediMore (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Specialty Tier |
33% | n/a | P | $4,363.70 |
Browse Plan Formulary |
MedicareMax (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:110 /365Days | $4,651.35 |
Browse Plan Formulary select insulin pay $20 copay but not this drug |
MMM ELITE (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:110 /365Days | $4,225.10 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
MMM EXTRA (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:110 /365Days | $4,225.10 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | P Q:110 /365Days | $4,225.65 |
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 |
Molina Medicare Choice Care Select (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:110 /365Days | $4,225.65 |
Browse Plan Formulary |
Molina Medicare Connect Care (HMO C-SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:110 /365Days | $4,225.65 |
Browse Plan Formulary |
Preferred Choice Dade (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:110 /365Days | $4,651.35 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Preferred Special Care Miami-Dade (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Some Brands |
5 |
Specialty Tier |
33% | n/a | P Q:110 /365Days | $4,651.35 |
Browse Plan Formulary select insulin pay $15 copay but not this drug |
SOLIS SPF 001 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:55 /28Days | $4,991.25 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:110 /365Days | $4,680.50 |
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 No Premium Open (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:110 /365Days | $4,680.50 |
Browse Plan Formulary |
Wellcare Specialty Giveback (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
5 |
Specialty Tier |
33% | n/a | P Q:110 /365Days | $4,680.50 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
HumanaChoice R5826-074 (Regional PPO)
|
$0.50 |
$395 |
No |
5 |
Specialty Tier |
26% | n/a | P Q:55 /28Days | $4,668.95 |
Browse Plan Formulary |
HumanaChoice Florida H7284-007 (PPO)
|
$11.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:55 /28Days | $4,674.45 |
Browse Plan Formulary |
CareNeeds PLUS (HMO D-SNP)
|
$13.20 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:55 /28Days | $4,691.50 |
Browse Plan Formulary |
CareExtra (HMO)
|
$19.20 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P Q:55 /28Days | $4,514.95 |
Browse Plan Formulary select insulin pay $0-$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 Fully Integrated H1036-280 (HMO D-SNP)
|
$19.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:55 /28Days | $4,691.50 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-077A (HMO D-SNP)
|
$21.80 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:55 /28Days | $4,514.95 |
Browse Plan Formulary |
Align Thrive (HMO I-SNP)
|
$22.90 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:55 /28Days | $5,316.85 |
Browse Plan Formulary |
DrPlus (HMO-POS D-SNP)
|
$26.40 |
$0 |
Many Generics, Some Brands |
5 |
Specialty Tier |
33% | n/a | P | $4,363.70 |
Browse Plan Formulary |
Aetna Medicare Assure Plus (HMO D-SNP)
|
$27.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:55 /365Days | $4,639.80 |
Browse Plan Formulary |
Wellcare Dual Reserve (HMO D-SNP)
|
$29.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:110 /365Days | $4,691.50 |
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 |
DrFirst (HMO-POS)
|
$29.50 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $4,363.70 |
Browse Plan Formulary |
MedicareMax Plus 2 (HMO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P Q:110 /365Days | $4,616.15 |
Browse Plan Formulary |
Preferred Medicare Assist Plan 2 (HMO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P Q:110 /365Days | $4,616.15 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO D-SNP)
|
$31.50 |
$480 |
No |
5 |
Tier 5 |
15% | 15% | P Q:110 /365Days | $4,605.70 |
Browse Plan Formulary |
Wellcare Dual Medicare (HMO D-SNP)
|
$31.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:110 /365Days | $4,691.50 |
Browse Plan Formulary |
DrChoice (HMO-POS)
|
$33.40 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $4,363.70 |
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 |
Preferred Medicare Assist Plan 1 (HMO D-SNP)
|
$34.00 |
$480 |
Some Generics, Few Brands |
5 |
Specialty Tier |
25% | n/a | P Q:110 /365Days | $4,616.15 |
Browse Plan Formulary |
Aetna Medicare Assure (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:55 /365Days | $4,639.80 |
Browse Plan Formulary |
BlueMedicare Complete (HMO D-SNP)
|
$34.30 |
$480 |
Some Generics, Few Brands |
5 |
Specialty Tier |
25% | n/a | P | $4,285.05 |
Browse Plan Formulary |
Devoted Health Dual Miami-Dade (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:110 /365Days | $4,651.35 |
Browse Plan Formulary |
Devoted Health Prime South Florida (HMO)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:110 /365Days | $4,651.35 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Devoted Health Prime South Florida (HMO)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:110 /365Days | $4,651.35 |
Browse Plan Formulary select insulin pay $0 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 Prime South Florida (HMO)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:110 /365Days | $4,118.40 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Florida Complete Care (HMO I-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P Q:110 /365Days | $4,287.25 |
Browse Plan Formulary |
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% | P Q:110 /365Days | $4,287.25 |
Browse Plan Formulary |
HealthSun MediMax (HMO)
|
$34.30 |
$430 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $4,170.65 |
Browse Plan Formulary |
HealthSun MediSun Extra (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $4,170.65 |
Browse Plan Formulary |
HealthSun MediSun Plus (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $4,170.65 |
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 |
Leon MediDual (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
25% | n/a | P | $4,363.70 |
Browse Plan Formulary |
Longevity Health Plan (HMO I-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | P Q:55 /28Days | $4,447.85 |
Browse Plan Formulary |
MedicareMax Plus 1 (HMO D-SNP)
|
$34.30 |
$480 |
Some Generics, Few Brands |
5 |
Specialty Tier |
25% | n/a | P Q:110 /365Days | $4,616.15 |
Browse Plan Formulary |
MMM PLATINUM (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:110 /365Days | $4,225.10 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$34.30 |
$480 |
Some Generics, Few Brands |
5 |
Specialty Tier |
25% | n/a | P Q:110 /365Days | $4,225.65 |
Browse Plan Formulary |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$34.30 |
$480 |
Some Generics, Few Brands |
5 |
Specialty Tier |
25% | n/a | P Q:110 /365Days | $4,225.65 |
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 |
SOLIS SPF 002 (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:55 /28Days | $4,988.50 |
Browse Plan Formulary |
SOLIS SPF 011 (HMO C-SNP)
|
$34.30 |
$0 |
Many Generics, Some Brands |
5 |
Specialty Tier |
25% | n/a | P Q:55 /28Days | $4,990.70 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | P Q:110 /365Days | $4,585.90 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | P Q:110 /365Days | $4,610.65 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:110 /365Days | $4,602.95 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:110 /365Days | $4,691.50 |
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 Dual Liberty (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:110 /365Days | $4,691.50 |
Browse Plan Formulary |
Wellcare Dual Nurture (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:110 /365Days | $4,691.50 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP)
|
$36.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:110 /365Days | $4,626.60 |
Browse Plan Formulary |
BlueMedicare Choice (Regional PPO)
|
$47.90 |
$250 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | P | $4,207.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-065 (PPO)
|
$53.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | P Q:55 /28Days | $4,691.50 |
Browse Plan Formulary |
HumanaChoice R5826-005 (Regional PPO)
|
$55.00 |
$100 |
No |
5 |
Specialty Tier |
31% | n/a | P Q:55 /28Days | $4,668.95 |
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 Choice H8145-061 (PFFS)
|
$102.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | P Q:55 /28Days | $4,671.15 |
Browse Plan Formulary |