RETACRIT 40,000 UNIT/ML VIAL (4 mls ) (NDC: 00069130904)
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 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P | $1,870.12 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P | $1,864.04 |
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. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $1,865.44 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Focus (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P | $1,863.92 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Advantage Care by Ultimate (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
4 |
Specialty Tier |
33% | n/a | P | $1,764.48 |
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 |
Advantage Care COPD by Ultimate (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
4 |
Specialty Tier |
33% | n/a | P | $1,764.48 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
Align Connect (HMO C-SNP)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | P | $2,173.76 |
Browse Plan Formulary |
BayCarePlus Complete (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35.00 | $95.00 | P Q:4 /28Days | $1,713.28 |
Browse Plan Formulary select insulin pay $4-$35 copay but not this drug |
BayCarePlus Rewards (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $125.00 | P Q:4 /28Days | $1,713.28 |
Browse Plan Formulary |
BlueMedicare Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | P | $1,811.44 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BlueMedicare Premier (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$80.00 | $240.00 | P | $1,816.24 |
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 Saver (HMO)
|
$0.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $1,830.24 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BlueMedicare Value (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $1,825.88 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
CareBreeze (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
4 |
Non-Preferred Drug |
$85.00 | $245.00 | P Q:14 /30Days | $1,894.40 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
CareComplete (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
4 |
Non-Preferred Drug |
$85.00 | $245.00 | P Q:14 /30Days | $1,894.40 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
CareFree (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$60.00 | $170.00 | P Q:14 /30Days | $1,902.12 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
CareFree (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$60.00 | $170.00 | P Q:14 /30Days | $1,892.16 |
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 |
CareOne PLATINUM (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$55.00 | $155.00 | P Q:14 /30Days | $1,892.16 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
CareOne PLUS (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$45.00 | $125.00 | P Q:14 /30Days | $1,892.16 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
CareOne PLUS (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$45.00 | $125.00 | P Q:14 /30Days | $1,902.12 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35.00 | $105.00 | P | $1,919.56 |
Browse Plan Formulary |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | P | $1,919.56 |
Browse Plan Formulary |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | P | $1,919.56 |
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 |
Freedom Medicare Plan Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Preferred Brand |
$35.00 | $70.00 | P Q:12 /28Days | $1,694.48 |
Browse Plan Formulary |
Freedom VIP Care (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Some Brands |
2 |
Preferred Brand |
$20.00 | $40.00 | P Q:12 /28Days | $1,695.04 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Freedom VIP Savings (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Some Brands |
2 |
Preferred Brand |
$25.00 | $50.00 | P Q:12 /28Days | $1,695.04 |
Browse Plan Formulary select insulin pay $0-$10 copay but not this drug |
Freedom VIP Savings COPD (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
2 |
Preferred Brand |
$20.00 | $40.00 | P Q:12 /28Days | $1,695.04 |
Browse Plan Formulary |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
4 |
Non-Preferred Drug |
$35.00 | $95.00 | P Q:14 /30Days | $1,892.60 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
Humana Gold Plus H1036-025 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$55.00 | $155.00 | P Q:14 /30Days | $1,892.72 |
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 |
Humana Gold Plus H1036-265 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P Q:14 /30Days | $1,888.32 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
Humana Gold Plus H1036-265 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P Q:14 /30Days | $1,892.72 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
HumanaChoice Florida H5216-072 (PPO)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:14 /30Days | $1,893.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Optimum Diamond Rewards (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Some Brands |
2 |
Preferred Brand |
$15.00 | $30.00 | P Q:12 /28Days | $1,694.60 |
Browse Plan Formulary select insulin pay $0-$10 copay but not this drug |
Optimum Diamond Rewards COPD (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
2 |
Preferred Brand |
$15.00 | $30.00 | P Q:12 /28Days | $1,694.60 |
Browse Plan Formulary |
Optimum Gold Rewards Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Preferred Brand |
$30.00 | $60.00 | P Q:12 /28Days | $1,694.48 |
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 |
Optimum Platinum Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Preferred Brand |
$5.00 | $10.00 | P Q:12 /28Days | $1,694.48 |
Browse Plan Formulary |
Premier by Ultimate (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Specialty Tier |
33% | n/a | P | $1,764.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SOLIS SPF 009 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$15.00 | n/a | P | $1,973.84 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150 |
Some Generics |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $1,883.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150 |
Some Generics |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $1,810.52 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150 |
Some Generics |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $1,879.12 |
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 Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150 |
Some Generics |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $1,761.92 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice R5826-074 (Regional PPO)
|
$0.50 |
$395 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:14 /30Days | $1,894.96 |
Browse Plan Formulary |
CareNeeds PLUS (HMO D-SNP)
|
$14.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:14 /30Days | $1,894.40 |
Browse Plan Formulary |
Humana Fully Integrated H1036-283 (HMO D-SNP)
|
$15.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:14 /30Days | $1,894.96 |
Browse Plan Formulary |
Cigna TotalCare Plus (HMO D-SNP)
|
$21.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
18% | 18% | P | $1,919.56 |
Browse Plan Formulary |
Cigna Primary Medicare (HMO)
|
$22.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
18% | 18% | P | $1,919.56 |
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 |
Align Thrive (HMO I-SNP)
|
$22.90 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | P | $2,173.76 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-102 (HMO D-SNP)
|
$24.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:14 /30Days | $1,892.72 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO D-SNP)
|
$31.50 |
$480 |
No |
4 |
Tier 4 |
15% | 15% | P | $1,865.44 |
Browse Plan Formulary |
BayCarePlus Premier (HMO)
|
$34.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35.00 | $95.00 | P Q:4 /28Days | $1,713.28 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Advantage Plus by Ultimate (Full) (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $1,764.48 |
Browse Plan Formulary |
Advantage Plus by Ultimate (Partial) (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $1,764.48 |
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 |
BlueMedicare Complete (HMO D-SNP)
|
$34.30 |
$480 |
Some Generics, Few Brands |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | P | $1,813.64 |
Browse Plan Formulary |
Freedom Medi-Medi Full (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$45.00 | $135.00 | P Q:12 /28Days | $1,694.92 |
Browse Plan Formulary |
Freedom Medi-Medi Partial (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$45.00 | $135.00 | P Q:12 /28Days | $1,694.92 |
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 | $1,690.76 |
Browse Plan Formulary |
Optimum Emerald Full (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$45.00 | $135.00 | P Q:12 /28Days | $1,694.92 |
Browse Plan Formulary |
Optimum Emerald Partial (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$45.00 | $135.00 | P Q:12 /28Days | $1,694.92 |
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 010 (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | n/a | P | $1,973.84 |
Browse Plan Formulary |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$34.30 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $1,857.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | P | $1,881.92 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | P | $1,847.12 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | P | $1,854.12 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | P | $1,765.60 |
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 |
BlueMedicare Choice (Regional PPO)
|
$47.90 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | P | $1,783.76 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice R5826-005 (Regional PPO)
|
$55.00 |
$100 |
No |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P Q:14 /30Days | $1,894.96 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BlueMedicare Select (PPO)
|
$147.90 |
$305 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | P | $1,814.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |