FETZIMA 20-40 MG TITRATION PAK (28 EA ) (NDC: 00456220228)
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 | S Q:56 /365Days | $484.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 1 (HMO-POS)
|
$0.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:56 /365Days | $484.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $481.29 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (HMO-POS)
|
$0.00 |
$175 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $481.29 |
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 |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S Q:30 /30Days | $658.42 |
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 |
Align Thrive (HMO I-SNP)
|
$0.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S Q:30 /30Days | $658.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
CCA Medicare Preferred (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | $290.00 | S Q:30 /30Days | $619.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
CCA One Care (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Tier 4 |
0% | 0% | S Q:30 /30Days | $546.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Orange HMO (HMO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$86.00 | $172.00 | P | $438.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-138 (PPO)
|
$0.00 |
$275 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:28 /28Days | $494.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-249 (PPO)
|
$0.00 |
$295 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:28 /28Days | $466.27 |
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 |
Mass General Brigham Advantage (PPO)
|
$0.00 |
$275 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | P | $433.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue SaverRx (HMO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P | $488.06 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare PPO Blue SaverRx (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P | $488.06 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Whole Health Medicare Choice Care (HMO)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $426.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Whole Health Medicare Choice Care Select (HMO)
|
$0.00 |
$375 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $426.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Health Unify (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Tier 3 |
0% | 0% | S | $441.02 |
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 |
Tufts Medicare Preferred Access (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S | $441.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Saver Rx (HMO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S | $428.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Smart Saver Rx (HMO)
|
$0.00 |
$100 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S | $428.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Connected(r) for One Care (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Tier 2 |
0% | 0% | S Q:56 /365Days | $484.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback Open (PPO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | P | $483.96 |
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 |
4 |
Non-Preferred Drug |
45% | 45% | P | $483.96 |
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 Open (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
43% | 43% | P | $483.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Senior Care Options NHC (HMO D-SNP)
|
$17.80 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | S Q:56 /365Days | $484.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-250 (PPO)
|
$19.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:28 /28Days | $466.27 |
Browse Plan Formulary all covered insulin pay $35 or less |
CCA Medicare Value (PPO)
|
$20.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | S Q:30 /30Days | $619.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Senior Care Options (HMO D-SNP)
|
$20.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | S Q:56 /365Days | $484.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue ValueRx (HMO)
|
$35.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P | $488.10 |
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 |
Medicare HMO Blue ValueRx (HMO)
|
$35.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P | $488.06 |
Browse Plan Formulary all covered insulin pay $35 or less |
Longevity Health Plan (HMO I-SNP)
|
$36.20 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | Q:28 /180Days | $416.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Align Premier (HMO I-SNP)
|
$36.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | S Q:30 /30Days | $658.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
CCA Senior Care Options (HMO D-SNP)
|
$36.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
25% | 25% | S Q:30 /30Days | $619.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
NaviCare (HMO D-SNP)
|
$36.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P | $438.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Whole Health (HMO D-SNP)
|
$36.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P | $426.74 |
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 |
Senior Whole Health NHC (HMO D-SNP)
|
$36.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P | $426.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Health Plan Senior Care Options (HMO D-SNP)
|
$36.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | S | $417.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Health Plan Senior Care Options CW (HMO D-SNP)
|
$36.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | S | $417.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
WellSense Senior Care Options (HMO D-SNP)
|
$36.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:28 /180Days | $416.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 2 (HMO-POS)
|
$47.00 |
$175 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:56 /365Days | $484.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Super Saver HMO (HMO)
|
$52.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P | $438.47 |
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 |
Mass General Brigham Advantage Secure (HMO-POS)
|
$52.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | P | $433.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Choice (Regional PPO)
|
$53.00 |
$295 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:56 /365Days | $487.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$59.00 |
$225 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S | $422.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$59.00 |
$225 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S | $441.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$59.00 |
$225 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S | $457.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Premium Enhanced Open (PPO)
|
$60.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
43% | 43% | P | $483.96 |
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 |
Medicare PPO Blue ValueRx (PPO)
|
$75.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P | $488.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare PPO Blue ValueRx (PPO)
|
$75.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P | $488.06 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Green HMO (HMO)
|
$88.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$86.00 | $172.00 | P | $447.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Green HMO (HMO)
|
$88.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$86.00 | $172.00 | P | $460.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Green HMO (HMO)
|
$88.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$86.00 | $172.00 | P | $429.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue FlexRx (HMO-POS)
|
$95.00 |
$260 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P | $488.10 |
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 |
Medicare HMO Blue FlexRx (HMO-POS)
|
$95.00 |
$260 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P | $488.06 |
Browse Plan Formulary all covered insulin pay $35 or less |
Mass General Brigham Advantage Premier (PPO)
|
$140.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | P | $433.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$167.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S | $422.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$167.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S | $441.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$167.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S | $457.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Blue HMO (HMO)
|
$179.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$86.00 | $172.00 | P | $429.58 |
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 |
Fallon Medicare Plus Blue HMO (HMO)
|
$179.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$86.00 | $172.00 | P | $447.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Blue HMO (HMO)
|
$179.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$86.00 | $172.00 | P | $460.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$194.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S | $406.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$194.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S | $441.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$194.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S | $459.25 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$228.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$80.00 | $240.00 | S | $406.42 |
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 |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$228.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$80.00 | $240.00 | S | $441.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$228.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$80.00 | $240.00 | S | $459.25 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare PPO Blue PlusRx (PPO)
|
$254.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P | $488.06 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue PlusRx (HMO)
|
$258.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P | $488.06 |
Browse Plan Formulary all covered insulin pay $35 or less |