AMLOD-VALSA-HCTZ 10-320-25 MG TABLET [Exforge HCT] (30 TABLETS ) (NDC: 64380020101)
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 (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $166.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 7 (HMO-POS)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $169.95 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier (HMO-POS)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $328.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $326.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $328.85 |
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 |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
6 |
Select Care Drugs |
$0.00 | $0.00 | None | $125.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
6 |
Select Care Drugs |
$0.00 | $0.00 | None | $127.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
6 |
Select Care Drugs |
$0.00 | $0.00 | None | $139.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
6 |
Select Care Drugs |
$0.00 | $0.00 | None | $131.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Prime Select (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
6 |
Select Care Drugs |
$0.00 | $0.00 | None | $122.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
CareSource MyCare Ohio (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Tier 1 |
0% | 0% | None | $312.96 |
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 Preferred Medicare (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $270.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $270.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $270.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Access (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$8.00 | $0.00 | None | $306.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Access (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$8.00 | $0.00 | None | $278.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $0.00 | None | $306.69 |
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 |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $0.00 | None | $319.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $0.00 | None | $278.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$8.00 | $0.00 | None | $280.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$8.00 | $0.00 | None | $306.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$8.00 | $0.00 | None | $270.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
SummaCare Medicare Topaz (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$9.00 | $22.50 | None | $289.46 |
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 |
The Health Plan SecureCare - Option II (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | None | $315.29 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Connected for MyCareOhio (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Tier 1 |
0% | 0% | Q:30 /30Days | $176.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Extra (HMO)
|
$10.40 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
6 |
Select Care Drugs |
$10.00 | $30.00 | None | $129.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Assure 1 (HMO D-SNP)
|
$14.20 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $329.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 1 (HMO-POS)
|
$19.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $169.95 |
Browse Plan Formulary all covered insulin pay $35 or less |
SummaCare Medicare Jade with Bene-FlexTM (HMO)
|
$19.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$8.00 | $20.00 | None | $289.46 |
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 |
SummaCare Medicare Jade with Bene-FlexTM (HMO)
|
$19.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$8.00 | $20.00 | None | $289.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Secure (HMO)
|
$22.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $306.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Secure (HMO)
|
$22.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $278.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Plus Medicare (HMO)
|
$23.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $270.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Flex Plan 8 (HMO-POS)
|
$25.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $169.95 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Preferred Plus (HMO)
|
$25.00 |
$0 |
Yes, this drug has Gap Coverage. |
6 |
Select Care Drugs |
$0.00 | $0.00 | None | $129.91 |
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 (HMO D-SNP)
|
$28.50 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $270.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Dual Advantage (HMO D-SNP)
|
$28.90 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
6 |
Select Care Drugs |
$10.00 | $30.00 | None | $129.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
SummaCare Medicare Garnet (HMO)
|
$29.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$8.00 | $20.00 | None | $289.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
SummaCare Medicare Garnet (HMO)
|
$29.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$8.00 | $20.00 | None | $289.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)
|
$29.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $198.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
CareSource Dual Advantage (HMO D-SNP)
|
$34.70 |
$505 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | 25% | None | $308.09 |
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 |
Perennial Advantage Concierge (HMO C-SNP)
|
$34.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $45.00 | None | $458.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
Perennial Advantage Strive (HMO I-SNP)
|
$34.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $458.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$34.70 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days | $198.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$34.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $185.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete LP (HMO-POS D-SNP)
|
$34.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $191.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Select (HMO-POS D-SNP)
|
$34.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $191.57 |
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 |
UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
|
$34.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $188.94 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Plus (HMO)
|
$37.00 |
$0 |
Yes, this drug has Gap Coverage. |
6 |
Select Care Drugs |
$0.00 | $0.00 | None | $133.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $319.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $278.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $306.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
The Health Plan SecureCare SNP (HMO D-SNP)
|
$40.80 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $319.44 |
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 |
SummaCare Medicare Ruby (HMO)
|
$43.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$8.00 | $20.00 | None | $289.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Select (PPO)
|
$44.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $306.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Select (PPO)
|
$44.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $319.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Select (PPO)
|
$44.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $278.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Access (PPO)
|
$56.00 |
$0 |
Yes, this drug has Gap Coverage. |
6 |
Select Care Drugs |
$0.00 | $0.00 | None | $128.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
The Health Plan SecureChoice - Option II (PPO)
|
$58.00 |
$100* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | None | $315.29 |
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 |
SummaCare Medicare Sapphire (HMO-POS)
|
$76.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$8.00 | $20.00 | None | $289.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Access Basic (Regional PPO)
|
$78.00 |
$50* |
Yes, this drug has Gap Coverage. |
6* |
Select Care Drugs |
$0.00 | $0.00 | None | $129.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Preferred (PPO)
|
$80.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $306.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Preferred (PPO)
|
$80.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $319.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Preferred (PPO)
|
$80.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $278.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Access Plus (PPO)
|
$87.00 |
$40* |
Yes, this drug has Gap Coverage. |
6* |
Select Care Drugs |
$0.00 | $0.00 | None | $126.89 |
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 |
MedMutual Advantage Plus (HMO)
|
$97.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $306.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Plus (HMO)
|
$97.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $319.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Plus (HMO)
|
$97.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $278.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier 2 (PPO)
|
$101.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $329.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 3 (HMO-POS)
|
$109.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $188.37 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier 1 (PPO)
|
$120.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $329.68 |
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 |
MedMutual Advantage Premium (PPO)
|
$134.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $306.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Premium (PPO)
|
$134.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $319.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Premium (PPO)
|
$134.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $278.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plus 2 (Regional PPO)
|
$137.00 |
$505* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $329.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
SummaCare Medicare Emerald (HMO-POS)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$8.00 | $20.00 | None | $289.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plus 1 (Regional PPO)
|
$198.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $329.88 |
Browse Plan Formulary all covered insulin pay $35 or less |