BOOSTRIX TDAP VACCINE SYRINGE (NDC: 58160084252)
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 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $75.00 | Q:1 /1Days | $99.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Choice (PPO)
|
$0.00 |
$225 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:1 /1Days | $99.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage SecureHorizons (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $75.00 | Q:1 /1Days | $99.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Freedom Plan (PPO)
|
$0.00 |
$200* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$47.00 | $141.00 | None | $98.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plan (HMO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $98.71 |
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 Prime Plan (HMO)
|
$0.00 |
$200* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$47.00 | $141.00 | None | $98.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$150* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$47.00 | $141.00 | None | $98.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerigroup Medicare-Medicaid Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | All Generics, All Brands | 1 |
Tier 1 |
0% | 0% | None | $87.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Choice (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$37.00 | $111.00 | None | $101.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Classic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $101.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $101.92 |
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 |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $101.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $101.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $102.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $101.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $101.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Comfort Plus (HMO I-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $80.00 | None | $87.53 |
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 |
Amerivantage Diabetes Care Plus (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $70.00 | None | $101.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Heart Care Plus (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $80.00 | None | $101.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Lung Care Plus (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $80.00 | None | $101.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Select Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $101.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Cross Medicare Advantage Choice Plus (PPO)
|
$0.00 |
$350 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $91.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Cross Medicare Advantage Classic (PPO)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$44.00 | $132.00 | None | $99.03 |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO)
|
$0.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$44.00 | $132.00 | None | $98.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Cross Medicare Advantage Dental Value (HMO)
|
$0.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$44.00 | $132.00 | None | $98.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Cross Medicare Advantage Health Choice (PPO)
|
$0.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$44.00 | $132.00 | None | $98.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Cross Medicare Advantage Saver (HMO)
|
$0.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$44.00 | $132.00 | None | $98.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Cross Medicare Advantage Value (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$44.00 | $132.00 | None | $99.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Cross Medicare Advantage Value (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $92.48 |
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. | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $99.69 |
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. | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $99.24 |
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. | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $99.53 |
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. | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $99.32 |
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. | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $99.87 |
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. | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $99.66 |
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 |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $99.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clover Health Choice (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $110.00 | None | $96.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community First Medicare Advantage Alamo Plan (HMO)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$30.00 | $75.00 | None | $112.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted BEWELL San Antonio - D (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $87.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted CORE San Antonio (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $87.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $95.31 |
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 H0028-030 (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $95.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana USAA Honor with Rx (PPO)
|
$0.00 |
$480* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $95.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-360 (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $95.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Imperial Insurance Company Traditional (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $90.00 | None | $89.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Imperial Insurance Traditional Plus (HMO)
|
$0.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $89.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Imperial Insurance Value (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $90.00 | None | $89.88 |
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 Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
0% | 0% | None | $87.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
0% | 0% | None | $87.53 |
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 | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $87.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Choice Care Select (HMO)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $87.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Balance (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $85.00 | None | $86.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Classic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $85.00 | None | $86.62 |
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 |
SCAN Heart First (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $85.00 | None | $86.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Venture (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | None | $86.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Superior HealthPlan STAR+PLUS Medicare-Medicaid (Medicare-Medicaid Plan)
|
$0.00 |
$0 | All Generics, All Brands | 2 |
Tier 2 |
0% | 0% | None | $88.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Chronic Complete (HMO-POS C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $75.00 | Q:1 /1Days | $99.35 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback (HMO)
|
$0.00 |
$350* | No additional gap coverage, only the Donut Hole Discount | 6* |
Select Care Drugs |
$0.00 | $0.00 | None | $99.41 |
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. | 6 |
Select Care Drugs |
$0.00 | $0.00 | None | $99.41 |
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 No Premium (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 6 |
Select Care Drugs |
$0.00 | $0.00 | None | $99.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$185* | Yes, but No Gap Coverage for this drug. | 6* |
Select Care Drugs |
$0.00 | $0.00 | None | $99.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Rx Plus Open (PPO)
|
$0.00 |
$300* | No additional gap coverage, only the Donut Hole Discount | 6* |
Select Care Drugs |
$0.00 | $0.00 | None | $99.63 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Specialty No Premium (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $99.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Harmony (HMO D-SNP)
|
$5.80 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $100.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Complement Assist (HMO)
|
$6.10 |
$505* | No additional gap coverage, only the Donut Hole Discount | 6* |
Select Care Drugs |
$0.00 | $0.00 | None | $99.66 |
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 |
Wellcare Dual Liberty Nurture (HMO D-SNP)
|
$6.30 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $100.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare (HMO D-SNP)
|
$7.40 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | None | $99.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare (HMO D-SNP)
|
$7.40 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | None | $99.24 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare (HMO D-SNP)
|
$7.40 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | None | $99.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare (HMO D-SNP)
|
$7.40 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | None | $99.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare (HMO D-SNP)
|
$7.40 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | None | $99.87 |
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 Dual Complete Plan (HMO D-SNP)
|
$8.50 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
$0.00 | $0.00 | None | $98.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Medicare Silver (Regional PPO C-SNP)
|
$8.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | Q:1 /1Days | $99.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-043 (PPO)
|
$10.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $95.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-043 (PPO)
|
$10.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $95.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-043 (PPO)
|
$10.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $95.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
|
$11.90 |
$505* | No additional gap coverage, only the Donut Hole Discount | 6* |
Select Care Drugs |
$0.00 | $0.00 | None | $99.64 |
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 |
UnitedHealthcare Dual Complete (HMO-POS D-SNP)
|
$16.40 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | Q:1 /1Days | $99.35 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H0028-036 (HMO D-SNP)
|
$16.50 |
$495 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$5.00 | $0.00 | None | $95.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$17.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $101.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$17.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $101.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$17.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $101.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$17.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $102.14 |
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 |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$17.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $101.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$17.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $101.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Plus Medicare (PPO)
|
$17.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $99.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Choice Plan (PPO)
|
$18.00 |
$300 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $98.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Dual Coordination (HMO D-SNP)
|
$18.70 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $101.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted PRIME San Antonio (HMO)
|
$18.70 |
$505* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $87.59 |
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 |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$21.20 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:1 /1Days | $99.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Liberty (HMO D-SNP)
|
$21.20 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $100.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Cross Medicare Advantage Dual Care Plus (HMO D-SNP)
|
$22.80 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $95.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$23.20 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $100.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage ESRD Care (HMO-POS C-SNP)
|
$23.30 |
$100 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $101.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$24.50 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $101.92 |
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 |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$24.50 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $101.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$24.50 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $101.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$24.50 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $102.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$24.50 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $101.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$24.50 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $101.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
American Health Advantage of Texas (HMO I-SNP)
|
$25.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $89.81 |
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 First Medicare Advantage D-SNP (HMO D-SNP)
|
$25.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | 25% | None | $112.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Imperial Insurance Company Dual (HMO D-SNP)
|
$25.00 |
$505 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
25% | 25% | None | $89.87 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Complete Care (HMO D-SNP)
|
$25.00 |
$505 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $87.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
ProCare Advantage (HMO-POS I-SNP)
|
$25.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $115.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
Provider Partners Texas Advantage Plan (HMO I-SNP)
|
$25.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $89.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Provider Partners Texas Community Plan (HMO I-SNP)
|
$25.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $89.92 |
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 |
Texas Independence Health Plan, Inc. (HMO I-SNP)
|
$25.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $89.77 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Choice (Regional PPO D-SNP)
|
$25.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
$0.00 | $0.00 | Q:1 /1Days | $99.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$25.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | Q:1 /1Days | $99.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$25.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $100.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP)
|
$27.00 |
$295* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$47.00 | $131.00 | Q:1 /1Days | $99.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R4182-004 (Regional PPO)
|
$41.00 |
$175* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$6.00 | $0.00 | None | $95.04 |
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 |
UnitedHealthcare Medicare Advantage Choice (Regional PPO)
|
$49.00 |
$395 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:1 /1Days | $99.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Choice H8145-084 (PFFS)
|
$70.00 |
$250* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$6.00 | $0.00 | None | $95.06 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R4182-003 (Regional PPO)
|
$84.00 |
$175* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $95.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-042 (PPO)
|
$93.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$7.00 | $0.00 | None | $95.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Cross Medicare Advantage Flex (PPO)
|
$213.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$44.00 | $132.00 | None | $98.69 |
Browse Plan Formulary all covered insulin pay $35 or less |