CLORAZEPATE 3.75 MG TABLET [Tranxene] (60 TABLETS ) (NDC: 51672404201)
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 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:720 /30Days | $116.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 2 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:720 /30Days | $116.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Walgreens Plan 1 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:720 /30Days | $119.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:90 /30Days | $103.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Freedom Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:90 /30Days | $99.72 |
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 |
Aetna Medicare Platinum Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:90 /30Days | $99.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:90 /30Days | $100.49 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Sunrise Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:90 /30Days | $133.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health AVA (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $15.00 | Q:120 /30Days | $133.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health Heart & Diabetes (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | Q:120 /30Days | $135.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health the ONE (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | Q:120 /30Days | $131.84 |
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 Choice (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$12.00 | $0.00 | None | $108.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$7.50 | $0.00 | None | $108.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$7.50 | $0.00 | None | $108.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Comfort (HMO I-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$7.50 | $0.00 | None | $45.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Comfort Plus (HMO I-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$7.50 | $0.00 | None | $45.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Diabetes Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$7.50 | $0.00 | None | $108.36 |
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, this drug has Gap Coverage. |
2 |
Generic |
$7.50 | $0.00 | None | $108.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage ESRD Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$7.50 | $0.00 | None | $108.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Heart Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$7.50 | $0.00 | None | $108.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Heart Care Plus (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$7.50 | $0.00 | None | $108.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Lung Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$7.50 | $0.00 | None | $108.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Lung Care Plus (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$7.50 | $0.00 | None | $108.36 |
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 Smart Value Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.50 | $0.00 | None | $108.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Banner Medicare Advantage Prime (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:90 /30Days | $120.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare Advantage Classic (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$9.00 | $9.00 | Q:180 /30Days | $72.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
BluePathway Plan 2 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $7.00 | Q:180 /30Days | $72.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Achieve Medicare (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:90 /30Days | $96.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Alliance Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:90 /30Days | $96.22 |
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 |
$47.00 | $141.00 | Q:90 /30Days | $96.22 |
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 |
$47.00 | $141.00 | Q:90 /30Days | $96.22 |
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. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:90 /30Days | $96.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Savings Medicare (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:90 /30Days | $96.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted CHOICE Arizona (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:180 /30Days | $42.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted GIVEBACK Arizona (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | P Q:180 /30Days | $42.36 |
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 |
Dialysis Plus (HMO-POS C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $12.00 | Q:180 /30Days | $77.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Honest Care (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $12.00 | Q:180 /30Days | $77.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H0028-021 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $141.27 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H0028-052 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $155.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-137 (PPO)
|
$0.00 |
$445 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$99.00 | $198.00 | None | $158.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-265 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $155.39 |
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 |
Imperial Insurance Company Traditional (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $10.00 | Q:180 /30Days | $106.75 |
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 |
2 |
Tier 2 |
25% | 25% | Q:180 /30Days | $106.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
Imperial Insurance Value (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $10.00 | Q:180 /30Days | $106.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Balance (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $115.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Classic (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $115.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Embrace (HMO I-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $115.53 |
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 |
SCAN Heart First (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $115.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Venture (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | None | $115.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Super Plus (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $12.00 | Q:180 /30Days | $77.40 |
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 |
$45.00 | $125.00 | Q:720 /30Days | $116.00 |
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 |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:180 /30Days | $99.53 |
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 |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:180 /30Days | $93.62 |
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 No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | P Q:180 /30Days | $99.53 |
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. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | P Q:180 /30Days | $93.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | P Q:180 /30Days | $92.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Specialty No Premium (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $0.00 | P Q:180 /30Days | $21.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
|
$12.20 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
46% | 46% | P Q:180 /30Days | $170.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
|
$12.20 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
46% | 46% | P Q:180 /30Days | $164.71 |
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 |
AARP Medicare Advantage Plus (HMO-POS)
|
$15.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:720 /30Days | $116.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-224 (PPO)
|
$23.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $155.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Walgreens Plan 2 (PPO)
|
$25.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:720 /30Days | $119.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Banner Medicare Advantage Plus (PPO)
|
$25.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:90 /30Days | $120.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Liberty (HMO D-SNP)
|
$25.20 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:180 /30Days | $148.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Value Plus H5216-197 (PPO)
|
$36.30 |
$450 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | None | $157.17 |
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 |
Banner Medicare Advantage Dual (HMO D-SNP)
|
$41.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | P Q:90 /30Days | $127.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Banner Medicare Advantage Dual (HMO D-SNP)
|
$42.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | P Q:90 /30Days | $127.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Dialysis Complete (HMO-POS C-SNP)
|
$42.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | Q:180 /30Days | $77.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Mercy Care Advantage (HMO D-SNP)
|
$42.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:180 /30Days | $41.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Mercy Care Advantage (HMO D-SNP)
|
$42.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:180 /30Days | $41.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Super Complete (HMO C-SNP)
|
$42.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | Q:180 /30Days | $77.40 |
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 |
UnitedHealthcare Dual Complete LP (HMO-POS D-SNP)
|
$42.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:720 /30Days | $127.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$42.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:720 /30Days | $127.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R7220-002 (Regional PPO)
|
$56.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
24% | 24% | None | $156.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueJourney (PPO)
|
$68.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$9.00 | $9.00 | Q:180 /30Days | $72.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plan (PPO)
|
$83.00 |
$175 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:90 /30Days | $99.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-335 (PPO)
|
$96.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $155.39 |
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 |
HumanaChoice H5216-034 (PPO)
|
$118.00 |
$225 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $156.18 |
Browse Plan Formulary all covered insulin pay $35 or less |