PANTOPRAZOLE SOD DR 40 MG TABLET DR [Protonix] (30 UNITS ) (NDC: 65862056090)
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 Plan 6 (HMO)
|
$0.00 |
$195* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days | $10.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Walgreens (PPO)
|
$0.00 |
$250* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days | $10.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Premier (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days | $4.80 |
Browse Plan Formulary |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$150* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days | $2.40 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$4.00 | $0.00 | None | $6.60 |
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 |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$4.00 | $0.00 | None | $5.10 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$4.00 | $0.00 | None | $4.50 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$4.00 | $0.00 | None | $5.10 |
Browse Plan Formulary |
CareSource Advantage Zero Premium (HMO)
|
$0.00 |
$175* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$5.00 | $0.00 | None | $3.90 |
Browse Plan Formulary |
Humana Gold Plus H6622-021 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days | $2.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H6622-021 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days | $2.70 |
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 H5216-285 (PPO)
|
$0.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days | $2.70 |
Browse Plan Formulary |
HumanaChoice H5525-042 (PPO)
|
$0.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$7.00 | $0.00 | Q:60 /30Days | $2.70 |
Browse Plan Formulary |
MediGold Prime Choice (PPO)
|
$0.00 |
$150* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$2.00 | $0.00 | None | $3.90 |
Browse Plan Formulary |
MediGold Southwest OH Essential Care (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$2.00 | $0.00 | None | $3.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MedMutual Advantage Access (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$4.00 | $7.00 | None | $6.60 |
Browse Plan Formulary |
MedMutual Advantage Access (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$4.00 | $7.00 | None | $6.90 |
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 |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.60 |
Browse Plan Formulary |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.60 |
Browse Plan Formulary |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.90 |
Browse Plan Formulary |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$4.00 | $7.00 | None | $6.60 |
Browse Plan Formulary |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$4.00 | $7.00 | None | $6.90 |
Browse Plan Formulary |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$4.00 | $7.00 | None | $6.60 |
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 |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$3.00 | $6.00 | None | $3.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Giveback (HMO)
|
$0.00 |
$480* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $3.60 |
Browse Plan Formulary |
Wellcare Giveback Boost (HMO)
|
$0.00 |
$75* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $3.60 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$75* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $3.60 |
Browse Plan Formulary |
Wellcare No Premium Medicare (HMO)
|
$0.00 |
$75* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $3.60 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$160* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | 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 |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$16.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$7.00 | $0.00 | Q:60 /30Days | $2.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Assist (HMO)
|
$16.80 |
$480* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $5.40 |
Browse Plan Formulary |
Wellcare Assist Complement (HMO)
|
$17.60 |
$480* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $5.40 |
Browse Plan Formulary |
Anthem MediBlue Preferred Plus (HMO)
|
$19.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$4.00 | $0.00 | None | $5.70 |
Browse Plan Formulary |
HumanaChoice H5216-109 (PPO)
|
$19.00 |
$150* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days | $2.70 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 2 (HMO)
|
$20.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days | $8.10 |
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 |
AARP Medicare Advantage Plan 2 (HMO)
|
$20.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days | $10.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H6622-055 (HMO)
|
$20.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days | $2.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Value Plus H5525-041 (PPO)
|
$21.30 |
$260* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days | $3.00 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$22.00 |
$480* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $5.40 |
Browse Plan Formulary |
Aetna Medicare Assure 1 (HMO D-SNP)
|
$23.20 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days | $2.40 |
Browse Plan Formulary |
HumanaChoice SNP-DE H5525-046 (PPO D-SNP)
|
$27.40 |
$480* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$1.00 | $0.00 | Q:60 /30Days | $3.00 |
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 |
Humana Gold Plus SNP-DE H6622-015 (HMO D-SNP)
|
$27.60 |
$480* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$2.00 | $0.00 | Q:60 /30Days | $2.70 |
Browse Plan Formulary |
CareSource Advantage (HMO)
|
$30.00 |
$100* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$4.00 | $8.00 | None | $3.90 |
Browse Plan Formulary |
MedMutual Advantage Secure (HMO)
|
$30.00 |
$95* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.90 |
Browse Plan Formulary |
MedMutual Advantage Secure (HMO)
|
$30.00 |
$95* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.60 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$32.00 |
$480* | Some Generics | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $5.40 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO-POS D-SNP)
|
$33.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | Q:60 /30Days | $8.40 |
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 Premier Plus 2 (Regional PPO)
|
$33.40 |
$260* | No | 1* |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days | $5.10 |
Browse Plan Formulary |
Anthem MediBlue Dual Advantage (HMO D-SNP)
|
$33.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$10.00 | $30.00 | None | $5.40 |
Browse Plan Formulary |
CareSource Dual Advantage (HMO D-SNP)
|
$33.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
25% | 25% | None | $3.90 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$33.50 |
$480* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $3.00 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP1 (HMO D-SNP)
|
$33.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | Q:60 /30Days | $8.40 |
Browse Plan Formulary |
Valor Health Plan (HMO I-SNP)
|
$33.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $5.70 |
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 |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.60 |
Browse Plan Formulary |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.60 |
Browse Plan Formulary |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.90 |
Browse Plan Formulary |
Anthem MediBlue Access Basic (Regional PPO)
|
$41.50 |
$200* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$6.00 | $0.00 | None | $5.40 |
Browse Plan Formulary |
Aetna Medicare Premier Plus 1 (Regional PPO)
|
$44.50 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days | $5.10 |
Browse Plan Formulary |
HumanaChoice R5495-002 (Regional PPO)
|
$47.80 |
$480* | No | 1* |
Preferred Generic |
$16.00 | $0.00 | Q:60 /30Days | $2.70 |
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 |
MediGold True Advantage (HMO)
|
$49.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $3.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MedMutual Advantage Select (PPO)
|
$50.00 |
$95* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.90 |
Browse Plan Formulary |
MedMutual Advantage Select (PPO)
|
$50.00 |
$95* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.60 |
Browse Plan Formulary |
MedMutual Advantage Select (PPO)
|
$50.00 |
$95* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.60 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$55.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$2.00 | $0.00 | None | $5.70 |
Browse Plan Formulary |
Anthem MediBlue Access (PPO)
|
$56.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$4.00 | $0.00 | None | $5.40 |
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 |
MediGold Flexible Choice (PPO)
|
$57.00 |
$150* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$2.00 | $4.00 | None | $3.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-023 (PPO)
|
$58.00 |
$100* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$7.00 | $0.00 | Q:60 /30Days | $2.70 |
Browse Plan Formulary |
MedMutual Advantage Preferred (PPO)
|
$80.00 |
$55* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.90 |
Browse Plan Formulary |
MedMutual Advantage Preferred (PPO)
|
$80.00 |
$55* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.60 |
Browse Plan Formulary |
MedMutual Advantage Preferred (PPO)
|
$80.00 |
$55* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.60 |
Browse Plan Formulary |
Humana Gold Plus H6622-019 (HMO)
|
$91.00 |
$125* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$1.00 | $0.00 | Q:60 /30Days | $2.70 |
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 |
MedMutual Advantage Plus (HMO)
|
$97.00 |
$55* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.60 |
Browse Plan Formulary |
MedMutual Advantage Plus (HMO)
|
$97.00 |
$55* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.60 |
Browse Plan Formulary |
MedMutual Advantage Plus (HMO)
|
$97.00 |
$55* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.90 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 3 (HMO)
|
$111.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days | $9.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Premier 2 (PPO)
|
$118.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days | $2.40 |
Browse Plan Formulary |
MediGold Southwest OH Classic Preferred (HMO)
|
$120.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $3.90 |
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 |
MedMutual Advantage Premium (PPO)
|
$136.00 |
$55* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.60 |
Browse Plan Formulary |
MedMutual Advantage Premium (PPO)
|
$136.00 |
$55* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.60 |
Browse Plan Formulary |
MedMutual Advantage Premium (PPO)
|
$136.00 |
$55* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.90 |
Browse Plan Formulary |
Aetna Medicare Premier 1 (PPO)
|
$149.00 |
$150* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days | $2.70 |
Browse Plan Formulary |
HumanaChoice H5525-030 (PPO)
|
$151.00 |
$100* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$1.00 | $0.00 | Q:60 /30Days | $2.70 |
Browse Plan Formulary |