ATOMOXETINE HCL 100 MG CAPSULE [Strattera] (30 CAPSULES ) (NDC: 68462027130)
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 Plan 1 (HMO-POS)
|
$0.00 |
$395 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $100.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Value Care (PPO)
|
$0.00 |
$395 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $100.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite Plan (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $95.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
Centers Plan for Medicare Advantage Care (HMO)
|
$0.00 |
$395* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | $37.50 | Q:30 /30Days | $53.26 |
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. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $44.16 |
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 |
Healthfirst Signature (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $138.95 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5970-015 (PPO)
|
$0.00 |
$250* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $50.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5970-018 (PPO)
|
$0.00 |
$310* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $50.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
MVP Medicare WellSelect with Part D (PPO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $106.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Tier 1 |
0% | 0% | Q:30 /30Days | $37.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Fidelis No Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $0.00 | Q:30 /30Days | $83.37 |
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 Open (PPO)
|
$0.00 |
$325 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | Q:30 /30Days | $85.82 |
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 |
4 |
Non-Preferred Drug |
48% | 48% | Q:30 /30Days | $83.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | Q:30 /30Days | $85.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist Open (PPO)
|
$8.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
46% | 46% | Q:30 /30Days | $271.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5970-001 (PPO)
|
$15.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $50.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO)
|
$16.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $90.62 |
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 Fidelis Assist (HMO-POS)
|
$17.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days | $83.37 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$20.50 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $142.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Fidelis Dual Plus (HMO D-SNP)
|
$21.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $142.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Discover Value Plan (PPO)
|
$24.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $98.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Fidelis Dual Access (HMO D-SNP)
|
$24.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $144.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
Empire MediBlue HealthPlus (HMO)
|
$25.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $225.26 |
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 |
Healthfirst CompleteCare (HMO D-SNP)
|
$26.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days | $151.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Healthfirst Increased Benefits Plan (HMO)
|
$29.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days | $151.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice SNP-DE H5970-020 (PPO D-SNP)
|
$32.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:30 /30Days | $50.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H3533-002 (HMO D-SNP)
|
$32.50 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:30 /30Days | $50.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Healthfirst Life Improvement Plan (HMO D-SNP)
|
$32.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days | $151.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Plan 2 (HMO-POS D-SNP)
|
$34.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:30 /30Days | $92.90 |
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 |
UnitedHealthcare Dual Complete Plan 2 (HMO-POS D-SNP)
|
$34.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:30 /30Days | $89.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Nursing Home Plan 2 (HMO I-SNP)
|
$35.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | Q:30 /30Days | $96.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$35.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $93.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Assure Plan (HMO D-SNP)
|
$36.50 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:30 /30Days | $86.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Elderplan Assist (HMO I-SNP)
|
$38.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | Q:30 /30Days | $46.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Centers Plan for Dual Coverage Care (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $56.06 |
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 |
Centers Plan for Medicaid Advantage Plus (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $54.87 |
Browse Plan Formulary all covered insulin pay $35 or less |
Centers Plan for Nursing Home Care (HMO I-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $54.87 |
Browse Plan Formulary all covered insulin pay $35 or less |
Elderplan Advantage For Nursing Home Residents (HMO I-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $46.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Elderplan Plus Long Term Care (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $40.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Dual (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $103.24 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Dual (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $82.80 |
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 |
EmblemHealth VIP Dual (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $82.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Empire MediBlue Dual Advantage Select (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $223.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Empire MediBlue HealthPlus Dual Connect (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $224.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Empire MediBlue HealthPlus Dual Plus (HMO D-SNP)
|
$38.90 |
$450 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $224.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Hamaspik Medicare Choice (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $70.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
Hamaspik Medicare Select (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $69.90 |
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 |
MVP DualAccess (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | None | $106.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Whole Health of New York NHC (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $112.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:30 /30Days | $95.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:30 /30Days | $89.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Plan 1 (HMO-POS D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:30 /30Days | $92.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Plan 1 (HMO-POS D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:30 /30Days | $89.33 |
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 1 (PPO I-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | Q:30 /30Days | $94.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $144.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
MVP Medicare Secure with Part D (HMO-POS)
|
$40.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $107.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Medicare Advantage Choice Plan 3 (Regional PPO)
|
$44.00 |
$100 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $90.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Empire MediBlue Select (HMO)
|
$45.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $225.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
MVP Medicare Patriot Plan with Part D (PPO)
|
$45.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $107.14 |
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 Value Plan (HMO)
|
$47.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $98.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plan (PPO)
|
$57.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $98.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
Empire MediBlue Plus (HMO)
|
$62.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:30 /30Days | $225.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Essential (HMO)
|
$65.00 |
$325 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $84.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Essential (HMO)
|
$65.00 |
$325 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $82.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Essential (HMO)
|
$65.00 |
$325 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $104.14 |
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)
|
$73.00 |
$295 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $100.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Medicare Advantage Choice Plan 4 (Regional PPO)
|
$82.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $90.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
MVP Medicare Secure Plus with Part D (HMO-POS)
|
$90.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $107.25 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Premium Ultra Open (PPO)
|
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
43% | 43% | Q:30 /30Days | $85.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
MVP Medicare WellSelect Plus with Part D (PPO)
|
$134.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $70.00 | None | $106.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
MVP Medicare Preferred Gold with Part D (HMO-POS)
|
$140.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $70.00 | None | $107.14 |
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 |
EmblemHealth VIP Gold (HMO)
|
$240.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $84.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Gold (HMO)
|
$240.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $82.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Gold (HMO)
|
$240.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $104.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Gold (HMO)
|
$240.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $82.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Gold Plus (HMO)
|
$254.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $88.28 |
Browse Plan Formulary all covered insulin pay $35 or less |