TRINTELLIX 5 MG TABLET (30 EA ) (NDC: 64764072030)
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 Plan 1 (PPO)
|
$0.00 |
$225 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:30 /30Days | $472.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Plan 2 (HMO)
|
$0.00 |
$275 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $472.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Walgreens (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $462.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Elite Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:120 /30Days | $479.40 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:120 /30Days | $479.40 |
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 Plus Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:120 /30Days | $479.40 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $481.20 |
Browse Plan Formulary |
Amerivantage ESRD Care (HMO C-SNP)
|
$0.00 |
$0 |
Few Generics |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $481.20 |
Browse Plan Formulary |
Community Health Plan of WA MA Plan 1 (HMO)
|
$0.00 |
$230* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$42.00 | $125.00 | Q:30 /30Days | $437.70 |
Browse Plan Formulary |
Humana Gold Plus H2486-006 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $475.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H5619-063 (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $475.80 |
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 |
HumanaChoice H5216-247 (PPO)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $476.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Kaiser Permanente Medicare Advantage Key (HMO)
|
$0.00 |
$100 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$99.00 | $198.00 | None | $463.80 |
Browse Plan Formulary |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:120 /30Days | $432.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Premera Blue Cross Medicare Advantage (HMO)
|
$0.00 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $451.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Premera Blue Cross Medicare Advantage Peak + Rx (HMO)
|
$0.00 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $450.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Providence Medicare Harbor + RX (HMO)
|
$0.00 |
$270 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $240.00 | S | $433.20 |
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 |
Regence BlueAdvantage HMO (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days | $453.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Regence MedAdvantage + Rx Core (PPO)
|
$0.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days | $454.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Giveback (HMO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:120 /30Days | $470.40 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:120 /30Days | $470.40 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:120 /30Days | $470.10 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)
|
$21.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $475.80 |
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 |
Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)
|
$21.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $476.70 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)
|
$21.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $475.80 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)
|
$21.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $475.50 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO D-SNP)
|
$24.50 |
$360 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $481.20 |
Browse Plan Formulary |
Humana Value Plus H5619-134 (HMO)
|
$26.00 |
$440 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | S Q:30 /30Days | $475.80 |
Browse Plan Formulary |
Kaiser Permanente Medicare Advantage Vital (HMO)
|
$29.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$99.00 | $198.00 | None | $462.60 |
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 |
Regence MedAdvantage + Rx Primary (PPO)
|
$29.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days | $452.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Assist (HMO)
|
$29.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
43% | 43% | Q:120 /30Days | $469.20 |
Browse Plan Formulary |
Wellcare Dual Access Open (PPO D-SNP)
|
$33.20 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | Q:120 /30Days | $469.20 |
Browse Plan Formulary |
Humana Gold Plus H5619-059 (HMO)
|
$34.00 |
$50 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $475.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Premera Blue Cross Medicare Advantage Sound + Rx (HMO)
|
$35.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $450.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice Plan 2 (PPO)
|
$36.00 |
$225 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:30 /30Days | $472.80 |
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 Assisted Living Plan (PPO I-SNP)
|
$36.80 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $470.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Dual Liberty (HMO D-SNP)
|
$38.90 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | Q:120 /30Days | $469.20 |
Browse Plan Formulary |
Community Health Plan of WA Dual Plan (HMO D-SNP)
|
$40.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $437.40 |
Browse Plan Formulary |
Community Health Plan of WA MA Plan 2 (HMO)
|
$40.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $125.00 | Q:30 /30Days | $437.40 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$40.50 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
41% | 41% | Q:120 /30Days | $432.00 |
Browse Plan Formulary |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$40.50 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
41% | 41% | Q:120 /30Days | $432.00 |
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 |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$40.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | Q:30 /30Days | $470.70 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Select (HMO D-SNP)
|
$40.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | Q:30 /30Days | $470.70 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP)
|
$40.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | Q:30 /30Days | $470.40 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$40.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | Q:30 /30Days | $470.40 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$40.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
49% | 49% | Q:120 /30Days | $469.20 |
Browse Plan Formulary |
Aetna Medicare Platinum Plus Plan (HMO-POS)
|
$43.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:120 /30Days | $479.40 |
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 |
AARP Medicare Advantage Plan 3 (HMO)
|
$45.00 |
$225 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:30 /30Days | $471.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Regence BlueAdvantage HMO Plus (HMO)
|
$48.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days | $453.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Choice Plan (PPO)
|
$49.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:120 /30Days | $479.10 |
Browse Plan Formulary |
Premera Blue Cross Medicare Advantage Classic (HMO)
|
$55.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $450.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Providence Medicare Summit + RX (HMO-POS)
|
$59.00 |
$240 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $240.00 | S | $433.20 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
Wellcare Premium Enhanced Open (PPO)
|
$65.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:120 /30Days | $470.10 |
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 Health Plan of WA MA Plan 3 (HMO)
|
$68.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $125.00 | Q:30 /30Days | $438.00 |
Browse Plan Formulary |
Regence MedAdvantage + Rx Classic (PPO)
|
$78.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days | $452.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Plan 1 (HMO)
|
$88.00 |
$185 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:30 /30Days | $471.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Select Plan (PPO)
|
$99.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:120 /30Days | $479.40 |
Browse Plan Formulary |
Kaiser Permanente Medicare Advantage Essential (HMO)
|
$99.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$99.00 | $198.00 | None | $462.60 |
Browse Plan Formulary |
HumanaChoice H5216-047 (PPO)
|
$100.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $476.10 |
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 |
Premera Blue Cross Medicare Advantage Charter + Rx (HMO)
|
$110.00 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $450.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Regence MedAdvantage + Rx Enhanced (PPO)
|
$158.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days | $452.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Premera Blue Cross Medicare Advantage Classic Plus (HMO)
|
$170.00 |
$180 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $450.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Kaiser Permanente Medicare Advantage Optimal (HMO)
|
$296.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$99.00 | $198.00 | None | $462.60 |
Browse Plan Formulary |