DEXTROAMPHETAMINE ER 15 MG CAPSULE [Dexedrine Spansule] (30 CAPSULES ) (NDC: 45963030509)
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 Open Plan 1 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:120 /30Days | $79.66 |
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 | Q:120 /30Days | $50.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:120 /30Days | $50.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Align Connect (HMO C-SNP)
|
$0.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $45.00 | None | $81.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
CCA Medicare Excel (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:120 /30Days | $133.81 |
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 |
HAP Medicare Flex (PPO)
|
$0.00 |
$505* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$15.00 | $0.00 | Q:120 /30Days | $29.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
HAP MSUHC Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | Q:120 /30Days | $27.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
HAP Senior Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | Q:120 /30Days | $27.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
HAP Senior Plus Option 1 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$12.00 | $0.00 | Q:120 /30Days | $29.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare + Kroger (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | Q:120 /30Days | $84.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | Q:120 /30Days | $83.34 |
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 |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | Q:120 /30Days | $84.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | Q:120 /30Days | $83.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $0.00 | Q:120 /30Days | $84.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $0.00 | Q:120 /30Days | $83.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $0.00 | Q:120 /30Days | $83.29 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $0.00 | Q:120 /30Days | $83.30 |
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 |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $0.00 | Q:120 /30Days | $83.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | Q:120 /30Days | $84.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | Q:120 /30Days | $83.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | Q:120 /30Days | $83.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
Zing Choice MI (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:120 /30Days | $142.94 |
Browse Plan Formulary all covered insulin pay $35 or less |
Zing Essential Wellness Diabetes and Heart MI (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:120 /30Days | $142.94 |
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 |
Zing Premium Giveback MI (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:120 /30Days | $142.94 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Assure Premier (HMO D-SNP)
|
$20.20 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:120 /30Days | $83.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Longevity Health Plan (HMO I-SNP)
|
$23.50 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $79.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Ideal (PPO)
|
$25.00 |
$125* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$13.00 | $0.00 | Q:120 /30Days | $84.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Ideal (PPO)
|
$25.00 |
$125* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$13.00 | $0.00 | Q:120 /30Days | $83.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Ideal (PPO)
|
$25.00 |
$125* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$13.00 | $0.00 | Q:120 /30Days | $83.29 |
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 |
PriorityMedicare Ideal (PPO)
|
$25.00 |
$125* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$13.00 | $0.00 | Q:120 /30Days | $83.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Ideal (PPO)
|
$25.00 |
$125* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$13.00 | $0.00 | Q:120 /30Days | $83.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
Zing Open Access MI (HMO-POS)
|
$25.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:120 /30Days | $142.94 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plus (PPO)
|
$27.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:120 /30Days | $50.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Open Plan 2 (PPO)
|
$28.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:120 /30Days | $79.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
Align Kidney Care (HMO C-SNP)
|
$32.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $45.00 | None | $81.38 |
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 |
Zing Dual Complete Plus MI (HMO D-SNP)
|
$32.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | Q:120 /30Days | $142.94 |
Browse Plan Formulary all covered insulin pay $35 or less |
Align Thrive (HMO I-SNP)
|
$32.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $45.00 | None | $81.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
CCA Medicare Maximum (HMO D-SNP)
|
$32.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
20% | 20% | Q:120 /30Days | $133.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
HAP Medicare Complete Duals (HMO D-SNP)
|
$32.70 |
$505* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$0.00 | $0.00 | Q:120 /30Days | $27.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare D-SNP (HMO D-SNP)
|
$32.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $60.00 | Q:120 /30Days | $81.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare D-SNP + Kroger (HMO D-SNP)
|
$32.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $60.00 | Q:120 /30Days | $82.57 |
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)
|
$32.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:120 /30Days | $77.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$32.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:120 /30Days | $77.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Select (HMO-POS D-SNP)
|
$32.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | Q:120 /30Days | $77.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Value (HMO-POS)
|
$34.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | Q:120 /30Days | $84.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Value (HMO-POS)
|
$34.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | Q:120 /30Days | $83.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Value (HMO-POS)
|
$34.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | Q:120 /30Days | $83.29 |
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 |
PriorityMedicare Value (HMO-POS)
|
$34.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | Q:120 /30Days | $83.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Value (HMO-POS)
|
$34.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | Q:120 /30Days | $83.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
CCA Medicare Ultima (HMO)
|
$40.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:120 /30Days | $133.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare (HMO-POS)
|
$61.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | Q:120 /30Days | $84.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare (HMO-POS)
|
$61.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | Q:120 /30Days | $83.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare (HMO-POS)
|
$61.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | Q:120 /30Days | $83.29 |
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 |
PriorityMedicare (HMO-POS)
|
$61.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | Q:120 /30Days | $83.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare (HMO-POS)
|
$61.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | Q:120 /30Days | $83.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
HAP Senior Plus Option 2 (PPO)
|
$70.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$12.00 | $0.00 | Q:120 /30Days | $29.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Merit (PPO)
|
$96.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | Q:120 /30Days | $83.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Merit (PPO)
|
$96.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | Q:120 /30Days | $83.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Merit (PPO)
|
$96.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | Q:120 /30Days | $84.64 |
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 |
PriorityMedicare Merit (PPO)
|
$96.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | Q:120 /30Days | $83.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Merit (PPO)
|
$96.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | Q:120 /30Days | $83.29 |
Browse Plan Formulary all covered insulin pay $35 or less |
HAP Senior Plus Option 1 (HMO-POS)
|
$99.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | Q:120 /30Days | $29.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
HAP Senior Plus Option 3 (PPO)
|
$165.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$12.00 | $0.00 | Q:120 /30Days | $29.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
HAP Senior Plus Option 4 (PPO)
|
$180.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$12.00 | $0.00 | Q:120 /30Days | $29.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
HAP Senior Plus Option 2 (HMO-POS)
|
$190.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | Q:120 /30Days | $29.18 |
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 |
PriorityMedicare Select (PPO)
|
$212.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $0.00 | Q:120 /30Days | $84.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Select (PPO)
|
$212.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $0.00 | Q:120 /30Days | $83.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Select (PPO)
|
$212.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $0.00 | Q:120 /30Days | $83.29 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Select (PPO)
|
$212.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $0.00 | Q:120 /30Days | $83.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Select (PPO)
|
$212.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $0.00 | Q:120 /30Days | $83.34 |
Browse Plan Formulary all covered insulin pay $35 or less |