AMPICILLIN CAPSULES 500MG 100 BOTTLE (100 BOT) (NDC: 00781214501)
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, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $16.37 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 7 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.00 | $0.00 | None | $16.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Silver (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$10.00 | $20.00 | None | $20.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $20.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$10.00 | $20.00 | None | $20.53 |
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 Access Preferred (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$4.00 | $0.00 | None | $11.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$4.00 | $0.00 | None | $11.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$4.00 | $0.00 | None | $11.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$4.00 | $0.00 | None | $11.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$4.00 | $0.00 | None | $11.65 |
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 | $20.02 |
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, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $21.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $21.57 |
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 | $21.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted CHOICE Ohio (PPO)
|
$0.00 |
$150* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$0.00 | $0.00 | None | $19.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted CORE Ohio (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $19.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted GIVEBACK Ohio (HMO)
|
$0.00 |
$350* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$10.00 | $25.00 | None | $19.42 |
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 |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$0.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$17.00 | $0.00 | None | $18.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H6622-014 (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $18.63 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-285 (PPO)
|
$0.00 |
$200* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $0.00 | None | $18.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-309 (PPO)
|
$0.00 |
$350* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $0.00 | None | $18.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-042 (PPO)
|
$0.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$17.00 | $0.00 | None | $18.64 |
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 | $19.29 |
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 |
MedMutual Advantage Access (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$8.00 | $0.00 | None | $20.40 |
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 | $19.29 |
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 | $19.66 |
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 | $20.40 |
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 | $19.10 |
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 | $20.40 |
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 |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$8.00 | $0.00 | None | $19.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$3.00 | $6.00 | None | $19.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Choice Care Select (HMO)
|
$0.00 |
$375 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$15.00 | $30.00 | None | $19.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
PrimeTime Health Plan Aultimate (HMO-POS)
|
$0.00 |
$150* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$15.00 | $45.00 | None | $22.76 |
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 | $18.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 | $20.10 |
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 Connected for MyCareOhio (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Tier 1 |
0% | 0% | None | $16.27 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback (HMO)
|
$0.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $0.00 | None | $13.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback Boost (HMO)
|
$0.00 |
$150* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$9.00 | $0.00 | None | $13.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$75* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$9.00 | $0.00 | None | $13.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Medicare (HMO)
|
$0.00 |
$75* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$9.00 | $0.00 | None | $13.93 |
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 | 2* |
Generic |
$7.00 | $0.00 | None | $13.93 |
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 Extra (HMO)
|
$10.40 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$10.00 | $30.00 | None | $11.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
|
$10.80 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $0.00 | None | $13.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist Complement (HMO)
|
$11.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $0.00 | None | $13.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-106 (PPO)
|
$14.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $0.00 | None | $18.63 |
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 | 2 |
Tier 2 |
$0.00 | $0.00 | None | $20.52 |
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. | 2 |
Generic |
$5.00 | $0.00 | None | $16.59 |
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 |
Devoted PRIME Ohio (HMO)
|
$19.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $19.42 |
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 | $18.13 |
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 | $18.13 |
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 | $19.29 |
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 | $20.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Plus Medicare (HMO)
|
$23.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $21.57 |
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 |
AARP Medicare Advantage Flex Plan 8 (HMO-POS)
|
$25.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $0.00 | None | $16.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Preferred Plus (HMO)
|
$25.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$4.00 | $0.00 | None | $11.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Value Plus H5525-041 (PPO)
|
$25.90 |
$260 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $0.00 | None | $18.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$26.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $19.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare (HMO D-SNP)
|
$28.50 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $21.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$28.60 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $19.42 |
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 Dual Advantage (HMO D-SNP)
|
$28.90 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$10.00 | $30.00 | None | $11.65 |
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 | $18.13 |
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 | $18.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP)
|
$29.30 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $16.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted DUAL Ohio - 2 (HMO D-SNP)
|
$33.70 |
$505 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
25% | 25% | None | $19.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
CommuniCare Advantage ISNP (HMO I-SNP)
|
$34.20 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $21.03 |
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 |
CommuniCare Advantage ISNP (HMO I-SNP)
|
$34.20 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $21.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
CommuniCare Advantage ISNP (HMO I-SNP)
|
$34.20 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $21.18 |
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 | $20.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted DUAL Ohio - 1 (HMO D-SNP)
|
$34.70 |
$505 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
25% | 25% | None | $19.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H6622-015 (HMO D-SNP)
|
$34.70 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $18.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Complete Care (HMO D-SNP)
|
$34.70 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$4.00 | $12.00 | None | $19.42 |
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 |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$34.70 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | None | $19.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Perennial Advantage Concierge (HMO C-SNP)
|
$34.70 |
$505* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$2.00 | $6.00 | None | $30.24 |
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 | $30.24 |
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 | 2 |
Tier 2 |
$0.00 | $0.00 | None | $16.72 |
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 | 2 |
Tier 2 |
15% | 15% | None | $16.78 |
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 | 2 |
Tier 2 |
15% | 15% | None | $16.78 |
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 | 2 |
Tier 2 |
25% | 25% | None | $16.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Valor Health Plan (HMO I-SNP)
|
$34.70 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $21.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Plus (HMO)
|
$37.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$2.00 | $0.00 | None | $11.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
PrimeTime Health Plan Classic (HMO-POS)
|
$39.00 |
$125* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$8.00 | $20.00 | None | $22.76 |
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 | $19.29 |
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 | $19.66 |
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 Choice (HMO)
|
$40.00 |
$55* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $20.40 |
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 | $20.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-051 (PPO)
|
$43.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$17.00 | $0.00 | None | $18.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
SummaCare Medicare Ruby (HMO)
|
$43.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$8.00 | $20.00 | None | $18.13 |
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 | $19.29 |
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 | $19.66 |
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 Select (PPO)
|
$44.00 |
$95* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $20.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Access (PPO)
|
$56.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$4.00 | $0.00 | None | $11.65 |
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 | $20.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
SummaCare Medicare Sapphire (HMO-POS)
|
$76.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$8.00 | $20.00 | None | $18.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Access Basic (Regional PPO)
|
$78.00 |
$50* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$6.00 | $0.00 | None | $11.65 |
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 | $19.29 |
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 |
MedMutual Advantage Preferred (PPO)
|
$80.00 |
$55* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $19.66 |
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 | $20.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Choice H8145-032 (PFFS)
|
$82.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $0.00 | None | $18.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R5495-002 (Regional PPO)
|
$84.00 |
$505* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$20.00 | $0.00 | None | $18.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Access Plus (PPO)
|
$87.00 |
$40* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$4.00 | $0.00 | None | $11.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
PrimeTime Health Plan Plus (HMO-POS)
|
$89.00 |
$75* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$8.00 | $20.00 | None | $22.76 |
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 |
Humana Gold Plus H6622-019 (HMO)
|
$90.00 |
$125* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$4.00 | $0.00 | None | $18.64 |
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 | $19.29 |
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 | $19.66 |
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 | $20.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier 2 (PPO)
|
$101.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $20.51 |
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. | 2 |
Generic |
$8.00 | $0.00 | None | $16.71 |
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 Premier 1 (PPO)
|
$120.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $20.53 |
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 | $19.29 |
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 | $19.66 |
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 | $20.40 |
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 | 2 |
Generic |
$10.00 | $25.00 | None | $20.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-030 (PPO)
|
$150.00 |
$100* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$4.00 | $0.00 | None | $18.64 |
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 |
SummaCare Medicare Emerald (HMO-POS)
|
$170.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$8.00 | $20.00 | None | $18.13 |
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. | 2 |
Generic |
$0.00 | $0.00 | None | $20.53 |
Browse Plan Formulary all covered insulin pay $35 or less |