LEVETIRACETAM 500 MG TABLET [Roweepra] (60 TABLETS ) (NDC: 31722053705)
2023 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 2 (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$10.00 | $0.00 | None | $12.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Flex Plan 1 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | None | $12.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Butler Prime (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $11.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Central Value (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $10.00 | None | $11.24 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Credit Value (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $10.00 | None | $10.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 Advantra Silver (HMO-POS)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $10.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $10.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | None | $21.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | None | $21.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Savings Medicare (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | None | $21.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | None | $18.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
|
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 Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | None | $16.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | None | $16.24 |
Browse Plan Formulary all covered insulin pay $35 or less |
Complete Blue PPO Signature (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | None | $15.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
Complete Blue PPO Signature (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | None | $17.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H6622-054 (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $10.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana USAA Honor with Rx (PPO)
|
$0.00 |
$250* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $0.00 | None | $9.63 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 H5525-051 (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $0.00 | None | $9.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-051 (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $0.00 | None | $9.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-058 (PPO)
|
$0.00 |
$505* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $0.00 | None | $9.63 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-060 (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $9.63 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Premier Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $117.50 | None | $10.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life PPO Premier Rx (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $117.50 | None | $11.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$37.00 | $74.00 | None | $40.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback Open (PPO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $74.00 | None | $40.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $74.00 | None | $40.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$37.00 | $74.00 | None | $40.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
|
$13.50 |
$445 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $49.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist Open (PPO)
|
$14.20 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $49.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 Advantra Silver (PPO)
|
$17.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $10.94 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-017 (PPO)
|
$18.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $9.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Deductible Rx (HMO)
|
$22.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $20.00 | None | $11.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life PPO Rx Choice (PPO)
|
$23.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $20.00 | None | $11.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$24.20 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $65.27 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Cares (HMO D-SNP)
|
$24.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $17.06 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 Plus (HMO D-SNP)
|
$24.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $24.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
Complete Blue PPO Distinct (PPO)
|
$25.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | None | $16.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
Complete Blue PPO Distinct (PPO)
|
$25.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | None | $15.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
Complete Blue PPO Distinct (PPO)
|
$25.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | None | $17.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Plus Medicare (HMO)
|
$26.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | None | $21.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Plus Medicare (PPO)
|
$27.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | None | $21.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 Open (PPO)
|
$29.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$37.00 | $74.00 | None | $40.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$31.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $65.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice SNP-DE H5216-227 (PPO D-SNP)
|
$32.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $9.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Flex Plan 2 (HMO-POS)
|
$33.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$10.00 | $0.00 | None | $12.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life PPO High Deductible Rx (PPO)
|
$33.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $20.00 | None | $11.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete (HMO-POS D-SNP)
|
$33.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $11.77 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 Choice Plan 1 (PPO)
|
$35.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $0.00 | None | $12.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Gold (HMO)
|
$35.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $10.94 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx Choice (HMO)
|
$36.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $20.00 | None | $11.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Select (HMO-POS D-SNP)
|
$38.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $11.77 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
|
$41.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $11.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Caritas VIP Care (HMO D-SNP)
|
$41.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$8.00 | $24.00 | None | $8.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
Geisinger Gold Secure Rx (HMO D-SNP)
|
$41.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $7.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Highmark Wholecare Medicare Assured Diamond (HMO D-SNP)
|
$41.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | None | $26.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP)
|
$41.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | $39.00 | None | $26.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$41.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $11.77 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life Complete Care (HMO D-SNP)
|
$41.10 |
$505 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | $60.00 | None | $11.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Silver (HMO)
|
$47.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $10.00 | None | $10.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
Security Blue HMO-POS ValueRx (HMO-POS)
|
$54.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | $27.00 | None | $16.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Security Blue HMO-POS ValueRx (HMO-POS)
|
$54.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | $27.00 | None | $15.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
Freedom Blue PPO ValueRx (PPO)
|
$68.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | $27.00 | None | $16.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R0923-002 (Regional PPO)
|
$71.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $0.00 | None | $9.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx (HMO)
|
$81.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$10.00 | $20.00 | None | $11.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-120 (PPO)
|
$123.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $0.00 | None | $9.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 Blue PPO Select (PPO)
|
$127.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | $27.00 | None | $16.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life PPO Rx Enhanced (PPO)
|
$134.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $20.00 | None | $11.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Security Blue HMO-POS Standard (HMO-POS)
|
$159.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | $32.50 | None | $15.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Security Blue HMO-POS Standard (HMO-POS)
|
$159.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | $32.50 | None | $17.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Gold Plan (PPO)
|
$176.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $10.00 | None | $10.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
Security Blue HMO-POS Deluxe (HMO-POS)
|
$220.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$13.00 | $32.50 | None | $15.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
Security Blue HMO-POS Deluxe (HMO-POS)
|
$220.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$13.00 | $32.50 | None | $17.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Freedom Blue PPO Classic (PPO)
|
$250.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$13.00 | $27.00 | None | $16.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx Enhanced (HMO)
|
$295.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $20.00 | None | $11.69 |
Browse Plan Formulary all covered insulin pay $35 or less |