EMTRIVA 10MG/ML SOLUTION (NDC: 61958060201)
2023 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
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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 Plan 2 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:850 /30Days | $136.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage SecureHorizons Focus (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:850 /30Days | $136.51 |
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 | None | $137.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Plus Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$99.00 | $297.00 | None | $137.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$99.00 | $297.00 | None | $137.00 |
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 |
Align Connect (HMO C-SNP)
|
$0.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | None | $159.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Align Thrive (HMO I-SNP)
|
$0.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | None | $159.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health AVA (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | Q:850 /30Days | $134.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health Balance (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | Q:850 /30Days | $132.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health CalPlus + Veterans (HMO)
|
$0.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | Q:850 /30Days | $134.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health Harmony (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | Q:850 /30Days | $134.30 |
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 |
Alignment Health Heart & Diabetes (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $187.50 | Q:850 /30Days | $134.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health My Choice CalPlus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:850 /30Days | $134.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health the ONE + Rite Aid (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:850 /30Days | $134.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Care On Site (HMO I-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:850 /30Days | $134.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Coordination Plus (HMO)
|
$0.00 |
$505 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:850 /30Days | $140.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Diabetes Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:850 /30Days | $140.90 |
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)
|
$0.00 |
$380 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:850 /30Days | $140.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Full Dual Advantage (HMO D-SNP)
|
$0.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:850 /30Days | $140.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Heart Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:850 /30Days | $140.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Lung Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:850 /30Days | $140.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:850 /30Days | $140.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue StartSmart Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:850 /30Days | $140.90 |
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 StartSmart Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:850 /30Days | $140.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Shield Inspire (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:24 /1Days | $136.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
Brand New Day Classic Care II Plan (HMO)
|
$0.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $129.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Brand New Day Classic Care II Plan (HMO)
|
$0.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $127.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Brand New Day Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $127.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Brand New Day Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $129.20 |
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 |
Brand New Day Select Care II Plan (HMO I-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $127.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
CCA Medicare Excel (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$90.00 | $180.00 | None | $126.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Central Health Focus Plan (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $70.00 | None | $129.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Central Health Premier Plan I (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $70.00 | None | $122.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Central Health Premier Plan I (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $70.00 | None | $130.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Essence Advantage Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $126.06 |
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 Dynamic Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $180.00 | Q:680 /28Days | $124.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Imperial Senior Value (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:680 /28Days | $124.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Imperial Strong (HMO)
|
$0.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | Q:680 /28Days | $124.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Imperial Traditional (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:680 /28Days | $124.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Kaiser Permanente Sr Adv Basic Santa Clara (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $128.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Options (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $250.00 | None | $127.58 |
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 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $138.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Connect (HMO D-SNP)
|
$9.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:850 /30Days | $140.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
|
$10.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
49% | 49% | None | $138.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$27.50 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | Q:850 /30Days | $136.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Advantage Medicare Medi-Cal Santa Clara (HMO D-SNP)
|
$29.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $128.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Essence Advantage Gold (HMO)
|
$30.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None | $126.06 |
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 |
Central Health Premier Plan II (HMO)
|
$34.50 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $70.00 | None | $130.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Central Health Premier Plan II (HMO)
|
$34.50 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $70.00 | None | $122.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Align Kidney Care (HMO C-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | None | $159.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Align Premier (HMO I-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $159.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Brand New Day Classic Care I Plan (HMO)
|
$38.90 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $127.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Brand New Day Classic Care I Plan (HMO)
|
$38.90 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $129.20 |
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 |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$38.90 |
$505 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
25% | 25% | None | $127.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$38.90 |
$505 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
25% | 25% | None | $129.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Brand New Day Select Choice II Plan (HMO I-SNP)
|
$38.90 |
$505 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
25% | 25% | None | $127.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
DualConnect (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $126.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Choice Plan 1 (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:850 /30Days | $136.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health Sutter Advantage (HMO)
|
$49.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:850 /30Days | $132.84 |
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 |
SCAN Classic (HMO)
|
$52.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $265.00 | None | $127.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Value Plus (HMO)
|
$54.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:850 /30Days | $140.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Value Plus (HMO)
|
$54.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:850 /30Days | $140.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Diabetes (HMO C-SNP)
|
$55.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:850 /30Days | $140.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Diabetes (HMO C-SNP)
|
$55.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:850 /30Days | $140.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Heart (HMO C-SNP)
|
$55.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:850 /30Days | $140.90 |
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 Heart (HMO C-SNP)
|
$55.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:850 /30Days | $140.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Lung (HMO C-SNP)
|
$55.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:850 /30Days | $140.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Lung (HMO C-SNP)
|
$55.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:850 /30Days | $140.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Kaiser Permanente Sr Adv Enhanced Santa Clara (HMO)
|
$65.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $128.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Focus (HMO-POS)
|
$77.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:850 /30Days | $136.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
Essence Advantage Platinum (HMO)
|
$79.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None | $126.06 |
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 SecureHorizons (HMO-POS)
|
$119.00 |
$355 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:850 /30Days | $136.51 |
Browse Plan Formulary all covered insulin pay $35 or less |