LEVOXYL 125 MCG TABLET (100 EA ) (NDC: 60793085601)
2022 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
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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 |
Aetna Medicare Premier (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $8.10 |
Browse Plan Formulary |
Aetna Medicare Value (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $1.80 |
Browse Plan Formulary |
Ascension Complete Michigan Access (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $9.90 |
Browse Plan Formulary |
Ascension Complete Michigan Access Plus (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $9.90 |
Browse Plan Formulary |
Ascension Complete Michigan Reward (HMO)
|
$0.00 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $9.90 |
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 Secure (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $9.90 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$50* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $28.20 |
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. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $26.70 |
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. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $24.90 |
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. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $25.50 |
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. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $23.10 |
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 |
Covenant Advantage (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $24.60 |
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. |
2 |
Generic |
$10.00 | $0.00 | None | $27.00 |
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. |
2 |
Generic |
$10.00 | $0.00 | None | $27.60 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
HumanaChoice H8087-004 (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $35.40 |
Browse Plan Formulary |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$12.00 | $24.00 | None | $16.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | None | $27.90 |
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 Edge (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | None | $24.90 |
Browse Plan Formulary |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | None | $26.10 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $0.00 | None | $27.90 |
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 |
2 |
Generic |
$15.00 | $0.00 | None | $24.00 |
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 |
2 |
Generic |
$15.00 | $0.00 | None | $28.50 |
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 |
2 |
Generic |
$15.00 | $0.00 | None | $24.90 |
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 |
2 |
Generic |
$15.00 | $0.00 | None | $26.10 |
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 |
2* |
Generic |
$10.00 | $0.00 | None | $27.90 |
Browse Plan Formulary |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | None | $24.90 |
Browse Plan Formulary |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | None | $26.10 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $5.10 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $4.80 |
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 |
Wellcare No Premium Open (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $5.10 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$10.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $28.20 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$10.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $26.40 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$10.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $24.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$10.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $25.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$10.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $22.80 |
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 |
Wellcare Low Premium (HMO-POS)
|
$15.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $4.80 |
Browse Plan Formulary |
HumanaChoice H8087-001 (PPO)
|
$20.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $35.40 |
Browse Plan Formulary |
Humana Value Plus H8087-002 (PPO)
|
$20.60 |
$260 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $35.40 |
Browse Plan Formulary |
Wellcare Assist (HMO)
|
$20.60 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.60 |
Browse Plan Formulary |
HumanaChoice SNP-DE H8087-003 (PPO D-SNP)
|
$21.80 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $35.40 |
Browse Plan Formulary |
Aetna Medicare Assure Premier (HMO D-SNP)
|
$23.50 |
$425 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $3.60 |
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 |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$13.00 | $0.00 | None | $27.90 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$13.00 | $0.00 | None | $24.00 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$13.00 | $0.00 | None | $28.50 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$13.00 | $0.00 | None | $24.90 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$13.00 | $0.00 | None | $26.10 |
Browse Plan Formulary |
Covenant Advantage Plus (HMO-POS)
|
$25.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $24.60 |
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 Dual Access (HMO-POS D-SNP)
|
$30.60 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.60 |
Browse Plan Formulary |
Wellcare Dual Access Open (PPO D-SNP)
|
$30.80 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.60 |
Browse Plan Formulary |
Ascension Complete Michigan DSNP (HMO D-SNP)
|
$31.50 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $11.40 |
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 | None | $26.70 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$31.50 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $16.50 |
Browse Plan Formulary |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$31.50 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $16.50 |
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 |
PriorityMedicare D-SNP (HMO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | $39.00 | None | $27.30 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | None | $12.30 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | None | $12.30 |
Browse Plan Formulary |
Wellcare Community Assist (PPO)
|
$31.50 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.60 |
Browse Plan Formulary |
HumanaChoice R3887-002 (Regional PPO)
|
$34.10 |
$480 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $35.40 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$50.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | None | $27.90 |
Browse Plan Formulary select insulin pay $15-$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 |
2* |
Generic |
$10.00 | $0.00 | None | $24.00 |
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 |
2* |
Generic |
$10.00 | $0.00 | None | $28.50 |
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 |
2* |
Generic |
$10.00 | $0.00 | None | $24.90 |
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 |
2* |
Generic |
$10.00 | $0.00 | None | $26.10 |
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. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $27.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HAP Senior Plus Option 2 (PPO)
|
$65.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | None | $27.60 |
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 |
HumanaChoice H5216-009 (PPO)
|
$71.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $35.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Medicare Plus Blue PPO Vitality (PPO)
|
$85.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $28.20 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$85.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $26.40 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$85.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $24.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$85.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $25.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$85.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $22.80 |
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 |
HAP Senior Plus Option 1 (HMO-POS)
|
$90.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | None | $27.60 |
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 |
2 |
Generic |
$10.00 | $0.00 | None | $24.90 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$98.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | None | $26.10 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$98.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | None | $27.90 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$98.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | None | $24.00 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$98.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | None | $28.50 |
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 |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $28.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $26.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $24.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $25.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $23.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
PriorityMedicare (HMO-POS)
|
$127.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | None | $27.90 |
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 |
2 |
Generic |
$8.00 | $0.00 | None | $24.00 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$127.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | None | $28.50 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$127.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | None | $24.90 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$127.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | None | $26.10 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$152.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $28.20 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$152.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $26.40 |
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 |
Medicare Plus Blue PPO Signature (PPO)
|
$152.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $24.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$152.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $25.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$152.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $22.80 |
Browse Plan Formulary |
HAP Senior Plus Option 3 (PPO)
|
$165.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | None | $27.60 |
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. |
2 |
Generic |
$10.00 | $0.00 | None | $27.60 |
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. |
2 |
Generic |
$10.00 | $0.00 | None | $27.60 |
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 |
2 |
Generic |
$7.00 | $0.00 | None | $26.10 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $0.00 | None | $27.90 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $0.00 | None | $24.00 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $0.00 | None | $28.50 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $0.00 | None | $24.90 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$238.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $28.20 |
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)
|
$238.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $26.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$238.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $24.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$238.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $25.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$238.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $23.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Medicare Plus Blue PPO Assure (PPO)
|
$301.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $26.40 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$301.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $24.60 |
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 |
Medicare Plus Blue PPO Assure (PPO)
|
$301.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $25.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$301.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $22.80 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$301.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $28.20 |
Browse Plan Formulary |