DALIRESP 250 MCG TABLET (30 tablets ) (NDC: 00310008828)
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. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:28 /28Days | $468.78 |
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. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:28 /28Days | $468.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $465.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $465.35 |
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. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:30 /30Days | $480.85 |
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 Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:30 /30Days | $480.26 |
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. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:30 /30Days | $481.03 |
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. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:30 /30Days | $479.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-285 (PPO)
|
$0.00 |
$200* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:28 /365Days | $464.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-309 (PPO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:28 /365Days | $465.34 |
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 |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:28 /365Days | $464.21 |
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, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $416.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Access (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $415.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $416.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $413.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $415.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $416.45 |
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, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $412.24 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $417.35 |
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 |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | P Q:30 /30Days | $418.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Extra (HMO)
|
$10.40 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:30 /30Days | $480.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-106 (PPO)
|
$14.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:28 /365Days | $464.96 |
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 |
4 |
Tier 4 |
$0.00 | $0.00 | None | $465.18 |
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 1 (HMO-POS)
|
$19.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P Q:28 /28Days | $468.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Secure (HMO)
|
$22.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $416.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Secure (HMO)
|
$22.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $415.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Flex Plan 8 (HMO-POS)
|
$25.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:28 /28Days | $468.58 |
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. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:30 /30Days | $480.92 |
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 |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:28 /365Days | $464.21 |
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 |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:30 /30Days | $480.43 |
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. |
4 |
Non-Preferred Drug |
25% | 25% | P Q:30 /30Days | $402.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice SNP-DE H5525-046 (PPO D-SNP)
|
$34.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:28 /365Days | $464.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete (HMO-POS D-SNP)
|
$34.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | P Q:28 /28Days | $467.77 |
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 |
4 |
Tier 4 |
$0.00 | $0.00 | P Q:28 /28Days | $465.81 |
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 |
4 |
Tier 4 |
15% | 15% | P Q:28 /28Days | $467.77 |
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, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $416.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $413.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $415.34 |
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% | P Q:30 /30Days | $416.12 |
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 |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:28 /365Days | $464.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Select (PPO)
|
$44.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $416.45 |
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, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $413.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Select (PPO)
|
$44.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $415.34 |
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. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:30 /30Days | $480.76 |
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 |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | P Q:30 /30Days | $418.61 |
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. |
4 |
Non-Preferred Drug |
41% | 41% | P Q:30 /30Days | $480.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Preferred (PPO)
|
$80.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $416.45 |
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, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $413.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Preferred (PPO)
|
$80.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $415.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Choice H8145-032 (PFFS)
|
$82.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:28 /365Days | $465.86 |
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 |
3 |
Preferred Brand |
18% | 18% | Q:28 /365Days | $464.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Plus (HMO)
|
$97.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $416.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Plus (HMO)
|
$97.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $413.55 |
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 Plus (HMO)
|
$97.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $415.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier 2 (PPO)
|
$101.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$99.00 | $297.00 | None | $465.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 3 (HMO-POS)
|
$109.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P Q:28 /28Days | $465.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier 1 (PPO)
|
$120.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$99.00 | $297.00 | None | $465.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Premium (PPO)
|
$134.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $413.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Premium (PPO)
|
$134.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $415.34 |
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 Premium (PPO)
|
$134.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $416.45 |
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 |
4 |
Non-Preferred Drug |
39% | 39% | None | $464.98 |
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 |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:28 /365Days | $464.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plus 1 (Regional PPO)
|
$198.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$99.00 | $297.00 | None | $464.98 |
Browse Plan Formulary all covered insulin pay $35 or less |