FETZIMA ER 80 MG CAPSULE (30 EA ) (NDC: 00456228030)
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)
![Email Prescription and/or Health Benefit details for AARP Medicare Advantage Choice Plan 2 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $517.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Flex Plan 1 (HMO-POS)
![Email Prescription and/or Health Benefit details for AARP Medicare Advantage Flex Plan 1 (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $518.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Credit Value (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Advantra Credit Value (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $515.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Gold (HMO-POS)
![Email Prescription and/or Health Benefit details for Aetna Medicare Advantra Gold (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $515.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Silver (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Advantra Silver (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $514.88 |
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 |
Aetna Medicare Value (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Value (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $515.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare Plus PPO Signature (PPO)
![Email Prescription and/or Health Benefit details for Community Blue Medicare Plus PPO Signature (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P Q:31 /31Days | $447.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic 360 Rx (HMO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Classic 360 Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $456.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic Essential Rx (HMO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Classic Essential Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $457.05 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Complete Rx (PPO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Preferred Complete Rx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $457.05 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Enhanced Rx (PPO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Preferred Enhanced Rx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $457.33 |
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 |
Geisinger Gold Preferred Enhanced Rx (PPO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Preferred Enhanced Rx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $457.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Enhanced Rx (PPO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Preferred Enhanced Rx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $456.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Choice H8145-052 (PFFS)
![Email Prescription and/or Health Benefit details for Humana Gold Choice H8145-052 (PFFS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $514.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana USAA Honor with Rx (PPO)
![Email Prescription and/or Health Benefit details for Humana USAA Honor with Rx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $516.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-051 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H5525-051 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $516.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-051 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H5525-051 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $516.07 |
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 |
HumanaChoice H5525-058 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H5525-058 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$505 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $516.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-060 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H5525-060 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $516.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life PPO Premier Rx (PPO)
![Email Prescription and/or Health Benefit details for UPMC for Life PPO Premier Rx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $456.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback (HMO)
![Email Prescription and/or Health Benefit details for Wellcare Giveback (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
44% | 44% | P Q:30 /30Days | $522.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback Open (PPO)
![Email Prescription and/or Health Benefit details for Wellcare Giveback Open (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | P Q:30 /30Days | $522.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
![Email Prescription and/or Health Benefit details for Wellcare No Premium (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | P Q:30 /30Days | $521.50 |
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)
![Email Prescription and/or Health Benefit details for Wellcare No Premium Open (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
43% | 43% | P Q:30 /30Days | $522.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
![Email Prescription and/or Health Benefit details for Wellcare Assist (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$13.50 |
$445 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:30 /30Days | $522.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist Open (PPO)
![Email Prescription and/or Health Benefit details for Wellcare Assist Open (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$14.20 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
46% | 46% | P Q:30 /30Days | $522.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Silver Plus (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Advantra Silver Plus (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$18.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $514.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-017 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H5525-017 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$18.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $516.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Deductible Rx (HMO)
![Email Prescription and/or Health Benefit details for UPMC for Life HMO Deductible Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$22.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $462.46 |
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 |
Aetna Medicare Advantra Premier (HMO-POS)
![Email Prescription and/or Health Benefit details for Aetna Medicare Advantra Premier (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$23.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $514.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life PPO Rx Choice (PPO)
![Email Prescription and/or Health Benefit details for UPMC for Life PPO Rx Choice (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$23.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $456.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
![Email Prescription and/or Health Benefit details for Wellcare Dual Access Open (PPO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$24.20 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:30 /30Days | $523.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Cares (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Aetna Medicare Advantra Cares (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$24.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | P Q:30 /30Days | $515.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare Plus PPO Distinct (PPO)
![Email Prescription and/or Health Benefit details for Community Blue Medicare Plus PPO Distinct (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$25.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P Q:31 /31Days | $447.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Low Premium Open (PPO)
![Email Prescription and/or Health Benefit details for Wellcare Low Premium Open (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
43% | 43% | P Q:30 /30Days | $522.14 |
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 |
Wellcare Dual Access (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Wellcare Dual Access (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:30 /30Days | $524.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice SNP-DE H5216-227 (PPO D-SNP)
![Email Prescription and/or Health Benefit details for HumanaChoice SNP-DE H5216-227 (PPO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$32.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | P Q:30 /30Days | $516.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Flex Plan 2 (HMO-POS)
![Email Prescription and/or Health Benefit details for AARP Medicare Advantage Flex Plan 2 (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$33.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $518.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete (HMO-POS D-SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Dual Complete (HMO-POS D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$33.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | S Q:30 /30Days | $520.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic Complete Rx (HMO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Classic Complete Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$34.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $457.85 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic Complete Rx (HMO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Classic Complete Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$34.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $457.00 |
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 |
AARP Medicare Advantage Choice Plan 1 (PPO)
![Email Prescription and/or Health Benefit details for AARP Medicare Advantage Choice Plan 1 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$35.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $517.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx Choice (HMO)
![Email Prescription and/or Health Benefit details for UPMC for Life HMO Rx Choice (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $462.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Select (HMO-POS D-SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Dual Complete Select (HMO-POS D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$38.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | S Q:30 /30Days | $520.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Caritas VIP Care (HMO D-SNP)
![Email Prescription and/or Health Benefit details for AmeriHealth Caritas VIP Care (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$41.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Brand |
25% | 25% | S | $467.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Secure Rx (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Geisinger Gold Secure Rx (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$41.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P Q:30 /30Days | $457.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
Highmark Wholecare Medicare Assured Diamond (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Highmark Wholecare Medicare Assured Diamond (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$41.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days | $504.19 |
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 Wholecare Medicare Assured Ruby (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Highmark Wholecare Medicare Assured Ruby (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$41.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:30 /30Days | $504.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Value Plus H5216-117 (PPO)
![Email Prescription and/or Health Benefit details for Humana Value Plus H5216-117 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$41.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $517.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Dual Complete Choice (PPO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$41.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | S Q:30 /30Days | $520.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life Complete Care (HMO D-SNP)
![Email Prescription and/or Health Benefit details for UPMC for Life Complete Care (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$41.10 |
$505 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
49% | 49% | P Q:30 /30Days | $462.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Silver (HMO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Silver (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$47.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $515.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-005 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H5525-005 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$58.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $516.31 |
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 |
Freedom Blue PPO ValueRx (PPO)
![Email Prescription and/or Health Benefit details for Freedom Blue PPO ValueRx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$66.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P Q:31 /31Days | $458.35 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R0923-002 (Regional PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice R0923-002 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$71.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:30 /30Days | $515.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Premier Plus (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Advantra Premier Plus (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$77.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$99.00 | $297.00 | P Q:30 /30Days | $514.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx (HMO)
![Email Prescription and/or Health Benefit details for UPMC for Life HMO Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$81.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $462.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Advantage Rx (PPO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Preferred Advantage Rx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$109.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $456.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Advantage Rx (PPO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Preferred Advantage Rx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$109.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $457.62 |
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 |
Geisinger Gold Classic Advantage Rx (HMO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Classic Advantage Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$115.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $457.05 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic Advantage Rx (HMO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Classic Advantage Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$115.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $457.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic Advantage Rx (HMO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Classic Advantage Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$115.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:30 /30Days | $457.85 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-120 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H5216-120 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$123.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | P Q:30 /30Days | $516.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Freedom Blue PPO Standard (PPO)
![Email Prescription and/or Health Benefit details for Freedom Blue PPO Standard (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$171.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P Q:31 /31Days | $458.35 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Gold Plan (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Gold Plan (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$176.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $515.18 |
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 |
Freedom Blue PPO Deluxe (PPO)
![Email Prescription and/or Health Benefit details for Freedom Blue PPO Deluxe (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$285.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P Q:31 /31Days | $458.35 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx Enhanced (HMO)
![Email Prescription and/or Health Benefit details for UPMC for Life HMO Rx Enhanced (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$295.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $462.96 |
Browse Plan Formulary all covered insulin pay $35 or less |