AMPHETAMINE SALT COMBO 12.5MG TABLET (100 TABLETS BOT) (NDC: 00555077602)
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 Ally (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $40.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Plan 1 (HMO-POS)
|
$0.00 |
$195* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $43.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Plan 2 (HMO)
|
$0.00 |
$195* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $41.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Premier Plan (HMO)
|
$0.00 |
$200* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $46.80 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $46.80 |
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 |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $46.80 |
Browse Plan Formulary |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $46.80 |
Browse Plan Formulary |
Amerigroup Medicare-Medicaid Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
2 |
Tier 2 |
0% | 0% | P Q:90 /30Days | $29.40 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:90 /30Days | $58.20 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:90 /30Days | $57.60 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:90 /30Days | $55.20 |
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 |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:90 /30Days | $61.80 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:90 /30Days | $67.80 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:90 /30Days | $51.00 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:90 /30Days | $56.40 |
Browse Plan Formulary |
Amerivantage Comfort (HMO I-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
2 |
Generic |
$7.50 | $0.00 | P Q:90 /30Days | $59.40 |
Browse Plan Formulary |
Amerivantage Comfort Plus (HMO I-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
2 |
Generic |
$7.50 | $0.00 | P Q:90 /30Days | $59.40 |
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 |
Amerivantage Diabetes Care (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
2 |
Generic |
$7.50 | $0.00 | P Q:90 /30Days | $55.20 |
Browse Plan Formulary |
Amerivantage Diabetes Care Plus (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
2 |
Generic |
$7.50 | $0.00 | P Q:90 /30Days | $55.20 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Amerivantage ESRD Care Plus (HMO C-SNP)
|
$0.00 |
$0 |
Few Generics |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:90 /30Days | $58.20 |
Browse Plan Formulary |
Amerivantage Heart Care (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
2 |
Generic |
$7.50 | $0.00 | P Q:90 /30Days | $55.20 |
Browse Plan Formulary |
Amerivantage Heart Care Plus (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
2 |
Generic |
$7.50 | $0.00 | P Q:90 /30Days | $55.20 |
Browse Plan Formulary |
Amerivantage Lung Care (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
2 |
Generic |
$7.50 | $0.00 | P Q:90 /30Days | $55.20 |
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 |
Amerivantage Lung Care Plus (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
2 |
Generic |
$7.50 | $0.00 | P Q:90 /30Days | $55.20 |
Browse Plan Formulary |
Amerivantage Select Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:90 /30Days | $52.80 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Basic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:60 /30Days | $72.60 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Choice Plus (PPO)
|
$0.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:60 /30Days | $69.00 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Classic (PPO)
|
$0.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:60 /30Days | $72.60 |
Browse Plan Formulary |
Cigna Alliance Medicare (HMO)
|
$0.00 |
$190* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$42.00 | $126.00 | Q:60 /30Days | $55.20 |
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 |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$190* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$42.00 | $126.00 | Q:60 /30Days | $64.80 |
Browse Plan Formulary |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$190* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$42.00 | $126.00 | Q:60 /30Days | $58.80 |
Browse Plan Formulary |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$190* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$42.00 | $126.00 | Q:60 /30Days | $59.40 |
Browse Plan Formulary |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$190* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$42.00 | $126.00 | Q:60 /30Days | $59.40 |
Browse Plan Formulary |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$190* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$42.00 | $126.00 | Q:60 /30Days | $65.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Devoted Health Core Greater Houston (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | P Q:60 /30Days | $57.60 |
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 |
Erickson Advantage Liberty with Drugs (HMO-POS)
|
$0.00 |
$400 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:60 /30Days | $42.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H0028-042 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:90 /30Days | $46.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Imperial Insurance Company Traditional (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $10.00 | Q:90 /30Days | $76.20 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Imperial Insurance Traditional Plus (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | Q:90 /30Days | $76.20 |
Browse Plan Formulary |
Imperial Insurance Value (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
2 |
Generic |
$5.00 | $10.00 | Q:90 /30Days | $76.20 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
KelseyCare Advantage Gold (HMO)
|
$0.00 |
$100* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$0.00 | $0.00 | P Q:60 /30Days | $49.20 |
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 |
KelseyCare Advantage Gold Freedom (HMO-POS)
|
$0.00 |
$100* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$0.00 | $0.00 | P Q:60 /30Days | $49.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
KelseyCare Advantage Platinum (HMO)
|
$0.00 |
$100* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$0.00 | $0.00 | P Q:60 /30Days | $49.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Memorial Hermann Advantage (HMO)
|
$0.00 |
$300* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$5.00 | $10.00 | None | $52.20 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | P Q:60 /30Days | $77.40 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | P Q:60 /30Days | $77.40 |
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 | P Q:60 /30Days | $77.40 |
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 |
2 |
Generic |
$20.00 | $40.00 | P Q:60 /30Days | $77.40 |
Browse Plan Formulary |
Oscar Easy Care (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | P Q:60 /30Days | $55.80 |
Browse Plan Formulary |
Oscar Signature with $1000 O-Card (HMO)
|
$0.00 |
$200* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$10.00 | $30.00 | P Q:60 /30Days | $55.80 |
Browse Plan Formulary |
UnitedHealthcare Chronic Complete Ally (HMO-POS C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
3 |
Preferred Brand |
$47.00 | $75.00 | Q:60 /30Days | $40.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Connected (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
1 |
Tier 1 |
0% | 0% | Q:60 /30Days | $40.80 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice (Regional PPO D-SNP)
|
$0.00 |
$480 |
No |
3 |
Tier 3 |
$0.00 | $0.00 | Q:60 /30Days | $43.80 |
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 Giveback (HMO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$20.00 | $40.00 | P Q:60 /30Days | $63.60 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$20.00 | $40.00 | P Q:60 /30Days | $64.20 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$20.00 | $40.00 | P Q:60 /30Days | $39.00 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$20.00 | $40.00 | P Q:60 /30Days | $58.80 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$20.00 | $40.00 | P Q:60 /30Days | $70.80 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$20.00 | $40.00 | P Q:60 /30Days | $63.60 |
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 |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$20.00 | $40.00 | P Q:60 /30Days | $64.20 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$20.00 | $40.00 | P Q:60 /30Days | $39.00 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$20.00 | $40.00 | P Q:60 /30Days | $58.80 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$20.00 | $40.00 | P Q:60 /30Days | $70.80 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | P Q:60 /30Days | $39.60 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$200* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$3.00 | $0.00 | P Q:60 /30Days | $39.60 |
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 No Premium Rx Plus Open (PPO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35.00 | $70.00 | P Q:60 /30Days | $54.60 |
Browse Plan Formulary |
Wellcare Specialty No Premium (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
2 |
Generic |
$0.00 | $0.00 | P Q:60 /30Days | $43.20 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
Wellcare TexanPlus Classic No Premium (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | P Q:60 /30Days | $39.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare TexanPlus No Premium (HMO-POS)
|
$0.00 |
$250* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$0.00 | $0.00 | P Q:60 /30Days | $39.60 |
Browse Plan Formulary |
UnitedHealthcare Medicare Silver (Regional PPO C-SNP)
|
$3.70 |
$480 |
No |
3 |
Tier 3 |
25% | 25% | Q:60 /30Days | $43.80 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$5.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:60 /30Days | $58.80 |
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 |
Cigna TotalCare (HMO D-SNP)
|
$5.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:60 /30Days | $59.40 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$5.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:60 /30Days | $64.80 |
Browse Plan Formulary |
AARP Medicare Advantage Choice (PPO)
|
$10.00 |
$245 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $43.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-043 (PPO)
|
$10.00 |
$250* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:90 /30Days | $49.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-043 (PPO)
|
$10.00 |
$250* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:90 /30Days | $46.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP)
|
$10.80 |
$295* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $43.80 |
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 |
Amerivantage Choice (PPO)
|
$15.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $111.00 | P Q:90 /30Days | $53.40 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$19.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $46.80 |
Browse Plan Formulary |
Cigna True Choice Plus Medicare (PPO)
|
$19.00 |
$190* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$42.00 | $126.00 | Q:60 /30Days | $65.40 |
Browse Plan Formulary |
Wellcare Assist (HMO)
|
$20.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | P Q:60 /30Days | $75.00 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H0028-031 (HMO D-SNP)
|
$24.40 |
$475 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:90 /30Days | $46.80 |
Browse Plan Formulary |
Aetna Medicare Dual Complete Plan (HMO D-SNP)
|
$24.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $41.40 |
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 |
Amerivantage Dual Coordination (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:90 /30Days | $58.20 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:90 /30Days | $61.80 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:90 /30Days | $67.80 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:90 /30Days | $51.00 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:90 /30Days | $56.40 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:90 /30Days | $57.60 |
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 |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:90 /30Days | $55.20 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:90 /30Days | $67.80 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:90 /30Days | $51.00 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:90 /30Days | $56.40 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:90 /30Days | $57.60 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:90 /30Days | $55.20 |
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 |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:90 /30Days | $61.80 |
Browse Plan Formulary |
Community Health Choice (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $54.00 |
Browse Plan Formulary |
Devoted Health Prime Greater Houston (HMO)
|
$25.10 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | P Q:60 /30Days | $57.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus SNP-DE H0028-033 (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:90 /30Days | $46.80 |
Browse Plan Formulary |
Imperial Insurance Company Dual (HMO D-SNP)
|
$25.10 |
$480 |
Many Generics, Some Brands |
2 |
Generic |
25% | 25% | Q:90 /30Days | $78.00 |
Browse Plan Formulary |
Memorial Hermann Dual Advantage (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $50.40 |
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 |
Molina Medicare Complete Care (HMO D-SNP)
|
$25.10 |
$480 |
Some Generics |
3 |
Preferred Brand |
$42.00 | $126.00 | P Q:60 /30Days | $77.40 |
Browse Plan Formulary |
ProCare Advantage (HMO I-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $64.20 |
Browse Plan Formulary |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$25.10 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $43.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:60 /30Days | $46.80 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:60 /30Days | $46.80 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:60 /30Days | $41.40 |
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 |
UnitedHealthcare Dual Complete Ally (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:60 /30Days | $40.80 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:60 /30Days | $43.20 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | P Q:60 /30Days | $74.40 |
Browse Plan Formulary |
Wellcare Dual Access Open (PPO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | P Q:60 /30Days | $72.60 |
Browse Plan Formulary |
Wellcare Dual Liberty (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | P Q:60 /30Days | $74.40 |
Browse Plan Formulary |
Erickson Advantage Guardian (HMO-POS I-SNP)
|
$32.30 |
$0 |
Some Generics |
3 |
Preferred Brand |
$28.00 | $74.00 | Q:60 /30Days | $42.00 |
Browse Plan Formulary select insulin pay $28 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 R4182-004 (Regional PPO)
|
$43.60 |
$175 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:90 /30Days | $46.80 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice (Regional PPO)
|
$49.00 |
$395 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $43.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Memorial Hermann Advantage Plus (HMO)
|
$50.00 |
$300* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$5.00 | $10.00 | None | $52.20 |
Browse Plan Formulary |
HumanaChoice R4182-003 (Regional PPO)
|
$51.00 |
$175 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:90 /30Days | $46.80 |
Browse Plan Formulary |
Erickson Advantage Freedom (HMO-POS)
|
$70.00 |
$200* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:60 /30Days | $42.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Blue Cross Medicare Advantage Choice Premier (PPO)
|
$90.00 |
$295 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:60 /30Days | $69.00 |
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 |
HumanaChoice H5216-042 (PPO)
|
$94.00 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:90 /30Days | $46.80 |
Browse Plan Formulary |
Humana Gold Choice H8145-084 (PFFS)
|
$97.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:90 /30Days | $46.80 |
Browse Plan Formulary |
Erickson Advantage Champion (HMO-POS C-SNP)
|
$199.00 |
$0 |
Some Generics |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:60 /30Days | $42.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Erickson Advantage Signature with Drugs (HMO-POS)
|
$199.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:60 /30Days | $42.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Blue Cross Medicare Advantage Flex (PPO)
|
$215.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$44.00 | $132.00 | Q:60 /30Days | $66.00 |
Browse Plan Formulary |