DAPTOMYCIN 350 MG VIAL [Cubicin RF] (ML ) (NDC: 16729043445)
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. |
5 |
Specialty Tier |
33% | n/a | None | $73.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Credit Plan (PPO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
27% | n/a | None | $249.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite Plan (PPO)
|
$0.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
30% | n/a | None | $208.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plus Plan (PPO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
29% | n/a | None | $269.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (HMO-POS)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | None | $269.60 |
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 |
CDPHP $0 Medicare Rx (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | None | $272.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
CDPHP Care Advantage (HMO C-SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | None | $272.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
CDPHP Vital Rx (PPO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
26% | n/a | None | $272.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Rx Saver (HMO)
|
$0.00 |
$395 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | None | $275.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Highmark Blue Shield Freedom Basic (PPO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | None | $275.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
Highmark Blue Shield Freedom Nation (PPO)
|
$0.00 |
$175 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $275.54 |
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 |
Highmark Blue Shield Freedom Value (HMO)
|
$0.00 |
$295 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | None | $275.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H3533-006 (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | None | $32.40 |
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. |
5 |
Specialty Tier |
29% | n/a | None | $32.40 |
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. |
5 |
Specialty Tier |
28% | n/a | None | $32.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
MediGold Cash Back No Premium (HMO)
|
$0.00 |
$275 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | None | $249.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
MediGold No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $249.30 |
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 No Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $249.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback Open (PPO)
|
$0.00 |
$325 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
27% | n/a | None | $249.30 |
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 |
5 |
Specialty Tier |
33% | n/a | None | $249.30 |
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. |
5 |
Specialty Tier |
33% | n/a | None | $249.30 |
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 |
5 |
Specialty Tier |
25% | n/a | None | $249.30 |
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. |
5 |
Specialty Tier |
33% | n/a | None | $32.40 |
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 Medicare Advantage Choice Plan 1 (Regional PPO)
|
$16.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
29% | n/a | None | $62.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Assure Plan (HMO D-SNP)
|
$17.20 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | None | $249.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Fidelis Assist (HMO-POS)
|
$17.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $249.30 |
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 | None | $249.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Discover Value Plan (PPO)
|
$23.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
29% | n/a | None | $269.60 |
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 | None | $249.30 |
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 H3533-013 (HMO)
|
$25.00 |
$275 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | None | $32.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Fidelis Dual Plus (HMO D-SNP)
|
$26.40 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $249.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
MediGold Plus (HMO)
|
$29.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $249.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
CDPHP Basic RX (HMO)
|
$31.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $272.42 |
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 |
5 |
Tier 5 |
$0.00 | $0.00 | None | $32.40 |
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 |
5 |
Tier 5 |
$0.00 | $0.00 | None | $32.40 |
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 Plan 2 (HMO-POS D-SNP)
|
$34.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | None | $51.85 |
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 |
5 |
Tier 5 |
$0.00 | $0.00 | None | $73.27 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$35.70 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $73.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plan (PPO)
|
$37.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
30% | n/a | None | $208.74 |
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 |
5 |
Specialty Tier |
25% | n/a | None | $274.38 |
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 |
5 |
Specialty Tier |
25% | n/a | None | $285.87 |
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 |
EmblemHealth VIP Dual (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $262.24 |
Browse Plan Formulary all covered insulin pay $35 or less |
Empire MediBlue Dual Advantage (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $178.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
Empire MediBlue Dual Advantage (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $178.15 |
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% | None | $30.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Nascentia Dual Advantage (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $25.85 |
Browse Plan Formulary all covered insulin pay $35 or less |
Nascentia Skilled Nursing Facility (HMO I-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $25.85 |
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 |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | None | $51.85 |
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 |
5 |
Tier 5 |
$0.00 | $0.00 | None | $73.27 |
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 |
5 |
Tier 5 |
$0.00 | $0.00 | None | $51.85 |
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 |
5 |
Tier 5 |
$0.00 | $0.00 | None | $73.27 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | None | $73.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | None | $73.73 |
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 Access Open (PPO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $249.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
CDPHP Flex Rx (PPO)
|
$39.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $272.42 |
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. |
5 |
Specialty Tier |
31% | n/a | None | $62.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Premium Enhanced (PFFS)
|
$53.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $249.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Highmark Blue Shield Freedom Plus (HMO)
|
$55.00 |
$275 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | None | $275.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
CDPHP Value Rx (HMO)
|
$58.30 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $272.42 |
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 |
UnitedHealthcare Medicare Advantage Choice Plan 4 (Regional PPO)
|
$82.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $62.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Empire MediBlue Access (PPO)
|
$90.00 |
$310 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | None | $178.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
Empire MediBlue Access (PPO)
|
$90.00 |
$310 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | None | $178.15 |
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 |
5 |
Specialty Tier |
33% | n/a | None | $249.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Highmark Blue Shield Senior Blue 652 (HMO)
|
$122.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $275.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
CDPHP Choice Rx (HMO)
|
$128.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $272.42 |
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 |
Wellcare Premium Ultra (PFFS)
|
$155.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $249.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Highmark Blue Shield Forever Blue 770 (PPO)
|
$199.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $275.54 |
Browse Plan Formulary all covered insulin pay $35 or less |