GLIPIZIDE ER 5 MG TABLET ER 24 [Glucotrol XL] (90 UNITS ) (NDC: 64980028005)
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, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:120 /30Days | $15.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 1 (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:120 /30Days | $17.06 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 1 (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:120 /30Days | $15.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Rebate (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:120 /30Days | $15.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plan (PPO)
|
$0.00 |
$150* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | Q:90 /30Days | $10.25 |
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 Select Plan (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:90 /30Days | $10.28 |
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 | 1* |
Preferred Generic |
$2.00 | $6.00 | None | $33.88 |
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 | 1* |
Preferred Generic |
$2.00 | $6.00 | None | $33.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue + Kroger (HMO)
|
$0.00 |
$150* | Yes, this drug has Gap Coverage. | 6* |
Select Care Drugs |
$0.00 | $0.00 | Q:120 /30Days | $10.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue + Kroger Access (PPO)
|
$0.00 |
$95* | Yes, this drug has Gap Coverage. | 6* |
Select Care Drugs |
$0.00 | $0.00 | Q:120 /30Days | $10.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Access (PPO)
|
$0.00 |
$95* | Yes, this drug has Gap Coverage. | 6* |
Select Care Drugs |
$0.00 | $0.00 | Q:120 /30Days | $9.99 |
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 Care on Site (HMO I-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$0.00 | $0.00 | Q:120 /30Days | $17.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue COPD (HMO C-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$0.00 | $0.00 | Q:120 /30Days | $10.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Diabetes and Heart Care (HMO C-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$0.00 | $0.00 | Q:120 /30Days | $10.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue ESRD Care (HMO C-SNP)
|
$0.00 |
$325* | Yes, this drug has Gap Coverage. | 6* |
Select Care Drugs |
$0.00 | $0.00 | Q:120 /30Days | $10.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Local (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$0.00 | $0.00 | Q:120 /30Days | $10.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Smart Fit (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 6 |
Select Care Drugs |
$10.00 | $20.00 | Q:120 /30Days | $10.08 |
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 | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:120 /30Days | $29.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:120 /30Days | $29.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clear Spring Health Essential (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$2.00 | $6.00 | Q:120 /30Days | $23.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clear Spring Health Essential (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$2.00 | $6.00 | Q:120 /30Days | $23.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$0.00 |
$150* | No additional gap coverage, only the Donut Hole Discount | 6* |
Select Care Drugs |
$0.00 | $0.00 | None | $10.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H5619-139 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $10.10 |
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 |
Humana Gold Plus H5619-139 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $10.09 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H6622-004 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $10.09 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-266 (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $10.09 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-308 (PPO)
|
$0.00 |
$485* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $10.09 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-312 (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $10.09 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125* | No additional gap coverage, only the Donut Hole Discount | 6* |
Select Care Drugs |
$0.00 | $0.00 | Q:90 /30Days | $13.22 |
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 |
Optima Medicare Value (HMO)
|
$0.00 |
$150* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | Q:120 /30Days | $20.77 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$4.10 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$10.00 | $0.00 | None | $10.09 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H6622-074 (HMO)
|
$15.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$2.00 | $0.00 | None | $10.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H6622-074 (HMO)
|
$15.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$2.00 | $0.00 | None | $10.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Assure Value (HMO D-SNP)
|
$19.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:90 /30Days | $10.52 |
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 | 1 |
Tier 1 |
$0.00 | $0.00 | Q:90 /30Days | $10.52 |
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)
|
$22.10 |
$505 | No additional gap coverage, only the Donut Hole Discount | 6 |
Select Care Drugs |
$10.00 | $30.00 | Q:120 /30Days | $10.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 2 (HMO-POS)
|
$23.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:120 /30Days | $17.06 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 2 (HMO-POS)
|
$23.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:120 /30Days | $15.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Virginia Premier Advantage Elite (HMO D-SNP)
|
$23.30 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:120 /30Days | $19.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Optima Community Complete (HMO D-SNP)
|
$25.40 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:120 /30Days | $19.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Extra (HMO)
|
$25.90 |
$505* | Yes, this drug has Gap Coverage. | 6* |
Select Care Drugs |
$0.00 | $0.00 | Q:120 /30Days | $10.04 |
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 Better Health of Virginia (HMO D-SNP)
|
$27.10 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:90 /30Days | $10.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Plus Medicare (HMO)
|
$29.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:120 /30Days | $29.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Plus Medicare (PPO)
|
$29.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:120 /30Days | $29.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Dual Access (PPO D-SNP)
|
$29.40 |
$505 | No additional gap coverage, only the Donut Hole Discount | 6 |
Select Care Drugs |
$10.00 | $30.00 | Q:120 /30Days | $9.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete ONE (HMO-POS D-SNP)
|
$29.60 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:120 /30Days | $17.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$29.80 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$2.00 | $0.00 | Q:120 /30Days | $17.13 |
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 ONE Plus (HMO-POS D-SNP)
|
$29.80 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:120 /30Days | $17.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete (HMO-POS D-SNP)
|
$33.20 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:120 /30Days | $17.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
Align Kidney Care (HMO C-SNP)
|
$34.50 |
$505* | No additional gap coverage, only the Donut Hole Discount | 6* |
Select Care Drugs |
$0.00 | $0.00 | None | $34.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Balance (HMO-POS D-SNP)
|
$34.50 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:120 /30Days | $17.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Full Dual Advantage (HMO D-SNP)
|
$34.60 |
$480 | No additional gap coverage, only the Donut Hole Discount | 6 |
Select Care Drugs |
$10.00 | $30.00 | Q:120 /30Days | $10.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Complete Care (HMO D-SNP)
|
$34.60 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:90 /30Days | $13.22 |
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 |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$34.60 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:90 /30Days | $13.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$34.60 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:120 /30Days | $17.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
|
$37.50 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | Q:120 /30Days | $16.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-144 (PPO)
|
$39.00 |
$265* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$4.00 | $0.00 | None | $10.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Choice H8145-004 (PFFS)
|
$68.00 |
$160* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$5.00 | $0.00 | None | $10.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Essential Plan (PPO)
|
$77.00 |
$300* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | Q:90 /30Days | $10.28 |
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 R1390-002 (Regional PPO)
|
$98.00 |
$480* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$8.00 | $0.00 | None | $10.08 |
Browse Plan Formulary all covered insulin pay $35 or less |