AMMONIUM LACTATE 12% LOTION (400 GM BOTPL) (NDC: 45802041926)
2023 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
See your cost using a drug discount card: Compare prices at pharmacies near you |
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, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $36.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 | None | $36.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Plan (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $10.00 | None | $17.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (HMO-POS)
|
$0.00 |
$175* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$10.00 | $20.00 | None | $25.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
CCA Medicare Preferred (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | None | $35.72 |
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 |
CCA One Care (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Tier 2 |
0% | 0% | None | $31.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
Erickson Advantage Guardian (HMO-POS I-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$28.00 | $74.00 | None | $39.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Erickson Advantage Liberty with Drugs (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $39.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Orange HMO (HMO)
|
$0.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$7.00 | $14.00 | None | $6.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Mass General Brigham Advantage (PPO)
|
$0.00 |
$275 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $74.00 | None | $25.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue SaverRx (HMO)
|
$0.00 |
$300* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$8.00 | $16.00 | None | $25.52 |
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 |
Medicare PPO Blue SaverRx (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | $20.00 | None | $25.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Whole Health Medicare Choice Care (HMO)
|
$0.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$12.00 | $24.00 | None | $26.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Whole Health Medicare Choice Care Select (HMO)
|
$0.00 |
$375 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $40.00 | None | $26.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Health Unify (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Tier 2 |
0% | 0% | None | $13.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred Access (PPO)
|
$0.00 |
$150* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$4.00 | $8.00 | None | $10.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Saver Rx (HMO)
|
$0.00 |
$250* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$4.00 | $8.00 | None | $10.56 |
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 |
Tufts Medicare Preferred HMO Smart Saver Rx (HMO)
|
$0.00 |
$100* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$2.00 | $4.00 | None | $10.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Connected(r) for One Care (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Tier 1 |
0% | 0% | None | $37.60 |
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 | $35.24 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$35.00 | $70.00 | None | $35.24 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $74.00 | None | $35.24 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Senior Care Options NHC (HMO D-SNP)
|
$17.80 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
$0.00 | $0.00 | None | $37.60 |
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 |
CCA Medicare Value (PPO)
|
$20.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | None | $35.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Senior Care Options (HMO D-SNP)
|
$20.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
$0.00 | $0.00 | None | $37.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue ValueRx (HMO)
|
$35.00 |
$320* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$6.00 | $12.00 | None | $25.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue ValueRx (HMO)
|
$35.00 |
$320* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$6.00 | $12.00 | None | $25.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Longevity Health Plan (HMO I-SNP)
|
$36.20 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $35.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
CCA Senior Care Options (HMO D-SNP)
|
$36.30 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
25% | 25% | None | $35.72 |
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 |
NaviCare (HMO D-SNP)
|
$36.30 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $6.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Whole Health (HMO D-SNP)
|
$36.30 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $26.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Whole Health NHC (HMO D-SNP)
|
$36.30 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $26.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Health Plan Senior Care Options (HMO D-SNP)
|
$36.30 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $13.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Health Plan Senior Care Options CW (HMO D-SNP)
|
$36.30 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $13.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
WellSense Senior Care Options (HMO D-SNP)
|
$36.30 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $35.24 |
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 Plan 2 (HMO-POS)
|
$47.00 |
$175 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $36.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Super Saver HMO (HMO)
|
$52.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$9.00 | $18.00 | None | $6.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Mass General Brigham Advantage Secure (HMO-POS)
|
$52.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $74.00 | None | $25.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Choice (Regional PPO)
|
$53.00 |
$295 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $38.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$59.00 |
$225* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$4.00 | $8.00 | None | $10.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$59.00 |
$225* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$4.00 | $8.00 | None | $10.92 |
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 |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$59.00 |
$225* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$4.00 | $8.00 | None | $10.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Premium Enhanced Open (PPO)
|
$60.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$35.00 | $70.00 | None | $35.24 |
Browse Plan Formulary all covered insulin pay $35 or less |
Erickson Advantage Freedom (HMO-POS)
|
$68.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $39.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare PPO Blue ValueRx (PPO)
|
$75.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$6.00 | $12.00 | None | $25.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare PPO Blue ValueRx (PPO)
|
$75.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$6.00 | $12.00 | None | $25.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Green HMO (HMO)
|
$88.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$7.00 | $14.00 | None | $6.04 |
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 |
Fallon Medicare Plus Green HMO (HMO)
|
$88.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$7.00 | $14.00 | None | $6.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Green HMO (HMO)
|
$88.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$7.00 | $14.00 | None | $6.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue FlexRx (HMO-POS)
|
$95.00 |
$260* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$5.00 | $10.00 | None | $25.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue FlexRx (HMO-POS)
|
$95.00 |
$260* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$5.00 | $10.00 | None | $25.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Mass General Brigham Advantage Premier (PPO)
|
$140.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $74.00 | None | $25.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$167.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$4.00 | $8.00 | None | $10.20 |
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 |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$167.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$4.00 | $8.00 | None | $10.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$167.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$4.00 | $8.00 | None | $10.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Blue HMO (HMO)
|
$179.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | $14.00 | None | $6.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Blue HMO (HMO)
|
$179.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | $14.00 | None | $6.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Blue HMO (HMO)
|
$179.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | $14.00 | None | $6.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$194.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$8.00 | $16.00 | None | $13.08 |
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 |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$194.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$8.00 | $16.00 | None | $13.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$194.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$8.00 | $16.00 | None | $13.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Erickson Advantage Champion (HMO-POS C-SNP)
|
$197.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $39.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Erickson Advantage Signature with Drugs (HMO-POS)
|
$197.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $39.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$228.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$4.00 | $8.00 | None | $13.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$228.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$4.00 | $8.00 | None | $13.08 |
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 |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$228.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$4.00 | $8.00 | None | $13.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare PPO Blue PlusRx (PPO)
|
$254.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$5.00 | $10.00 | None | $25.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue PlusRx (HMO)
|
$258.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$5.00 | $10.00 | None | $25.52 |
Browse Plan Formulary all covered insulin pay $35 or less |