FENTANYL CITRATE OTFC 800 MCG LOZENGE HD [Actiq] (4 units ) (NDC: 00093786865)
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. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $1,453.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Walgreens (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $1,453.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $1,479.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plus Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $1,479.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Choice (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $934.54 |
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 |
Amerivantage Classic Plus (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $934.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
Ascension Complete Saint Thomas Access (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $1,372.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Ascension Complete Saint Thomas Access Plus (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $1,372.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Ascension Complete Saint Thomas Reward (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $1,372.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Ascension Complete Saint Thomas Secure (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $1,372.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueAdvantage Garnet (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:58 /30Days | $734.14 |
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 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $1,462.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $1,462.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $1,462.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $1,462.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $1,555.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$195 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:120 /30Days | $1,462.12 |
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 Savings Medicare (HMO)
|
$0.00 |
$195 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:120 /30Days | $1,555.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $1,555.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clover Health Choice (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P Q:120 /30Days | $918.85 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted CHOICE Tennessee (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $717.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted CORE Tennessee (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $717.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted GIVEBACK Tennessee (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $717.76 |
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 |
Farm Bureau Advantage (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P | $809.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H4461-029 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $1,209.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H4461-039 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $1,209.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-180 (PPO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | P Q:120 /30Days | $1,209.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-274 (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $1,209.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $1,372.62 |
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 Giveback Open (PPO)
|
$0.00 |
$90 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
31% | n/a | P Q:120 /30Days | $1,372.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $1,372.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$75 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
31% | n/a | P Q:120 /30Days | $1,372.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Balance Plus (HMO)
|
$9.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $934.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Classic (HMO)
|
$15.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $934.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Primary Medicare (HMO)
|
$16.50 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,555.80 |
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 Assist (HMO)
|
$17.10 |
$485 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $1,372.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plus Plan (HMO)
|
$18.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
31% | n/a | P Q:120 /30Days | $1,479.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Dual Premier (HMO D-SNP)
|
$22.20 |
$490 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $934.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare Plus (HMO D-SNP)
|
$22.50 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P Q:120 /30Days | $1,555.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Signature Advantage Plan (HMO I-SNP)
|
$28.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | P Q:120 /30Days | $1,557.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Dual Coordination (HMO D-SNP)
|
$28.70 |
$450 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $934.54 |
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 |
AARP Medicare Advantage Plan 2 (HMO-POS)
|
$31.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $1,453.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$33.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $1,453.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$35.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,453.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
American Health Advantage of Tennessee (HMO I-SNP)
|
$35.20 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P Q:120 /30Days | $1,557.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Full Dual Coordination (HMO D-SNP)
|
$35.20 |
$380 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | P Q:120 /30Days | $934.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueCare Plus (HMO D-SNP)
|
$35.20 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P Q:58 /30Days | $734.14 |
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 |
BlueCare Plus Choice (HMO D-SNP)
|
$35.20 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P Q:58 /30Days | $734.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueCare Plus Select (HMO D-SNP)
|
$35.20 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P Q:58 /30Days | $734.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted RESTORE PLUS Tennessee - D (HMO C-SNP)
|
$35.20 |
$505 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $717.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H4461-022 (HMO D-SNP)
|
$35.20 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P Q:120 /30Days | $1,209.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H4461-038 (HMO D-SNP)
|
$35.20 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P Q:120 /30Days | $1,209.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$35.20 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:120 /30Days | $1,172.00 |
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 |
NHC Advantage (HMO I-SNP)
|
$35.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | P Q:120 /30Days | $1,171.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Premier Medicare (HMO-POS)
|
$55.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | P Q:120 /30Days | $1,555.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueAdvantage Emerald (PPO)
|
$56.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:58 /30Days | $734.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-097 (PPO)
|
$58.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:120 /30Days | $1,209.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R7315-002 (Regional PPO)
|
$59.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
26% | n/a | P Q:120 /30Days | $1,209.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueAdvantage Ruby (PPO)
|
$107.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:58 /30Days | $734.14 |
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 |
BlueAdvantage Diamond (PPO)
|
$189.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:58 /30Days | $734.14 |
Browse Plan Formulary all covered insulin pay $35 or less |