HYDROCORTISONE 2.5% CREAM /PE APP [Proctozone-HC] (30 GRAMS ) (NDC: 62559043130)
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. | 2 |
Generic |
$12.00 | $0.00 | None | $12.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Credit Plan (PPO)
|
$0.00 |
$350* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$10.00 | $20.00 | Q:30 /30Days | $15.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite Plan (PPO)
|
$0.00 |
$195* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $9.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plus Plan (PPO)
|
$0.00 |
$250* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$10.00 | $20.00 | Q:30 /30Days | $14.87 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (HMO-POS)
|
$0.00 |
$300* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$10.00 | $20.00 | Q:30 /30Days | $14.87 |
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 |
CDPHP $0 Medicare Rx (HMO)
|
$0.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$3.00 | $0.00 | None | $9.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
CDPHP Care Advantage (HMO C-SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$3.00 | $0.00 | None | $9.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
CDPHP Vital Rx (PPO)
|
$0.00 |
$300* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$3.00 | $0.00 | None | $9.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Rx Saver (HMO)
|
$0.00 |
$395* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$15.00 | $0.00 | None | $23.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Highmark Blue Shield Freedom Basic (PPO)
|
$0.00 |
$350* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$14.00 | $35.00 | None | $23.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Highmark Blue Shield Freedom Nation (PPO)
|
$0.00 |
$175* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$12.00 | $0.00 | None | $23.17 |
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 Blue Shield Freedom Value (HMO)
|
$0.00 |
$295* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $25.00 | None | $23.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H3533-006 (HMO)
|
$0.00 |
$300 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $16.27 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5970-015 (PPO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $16.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5970-018 (PPO)
|
$0.00 |
$310 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $16.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
MediGold Cash Back No Premium (HMO)
|
$0.00 |
$275* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$5.00 | $0.00 | None | $45.06 |
Browse Plan Formulary all covered insulin pay $35 or less |
MediGold No Premium (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $0.00 | None | $45.06 |
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 |
MVP Medicare WellSelect with Part D (PPO)
|
$0.00 |
$300* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$12.00 | $24.00 | None | $11.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Fidelis No Premium (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $18.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback Open (PPO)
|
$0.00 |
$325* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$7.00 | $0.00 | None | $17.21 |
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 | 2 |
Generic |
$7.00 | $0.00 | None | $16.25 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$7.00 | $0.00 | None | $17.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist Open (PPO)
|
$8.70 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $0.00 | None | $53.98 |
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 H5970-001 (PPO)
|
$15.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:60 /30Days | $16.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO)
|
$16.00 |
$200* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$12.00 | $0.00 | None | $15.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Assure Plan (HMO D-SNP)
|
$17.20 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | Q:30 /30Days | $17.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Fidelis Assist (HMO-POS)
|
$17.30 |
$505* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$20.00 | $0.00 | None | $18.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$20.50 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $56.37 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Discover Value Plan (PPO)
|
$23.00 |
$250* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$10.00 | $20.00 | Q:30 /30Days | $14.87 |
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 Fidelis Dual Access (HMO D-SNP)
|
$24.70 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $46.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H3533-013 (HMO)
|
$25.00 |
$275 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $16.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Fidelis Dual Plus (HMO D-SNP)
|
$26.40 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $56.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
MediGold Plus (HMO)
|
$29.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $0.00 | None | $45.06 |
Browse Plan Formulary all covered insulin pay $35 or less |
CDPHP Basic RX (HMO)
|
$31.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$3.00 | $0.00 | None | $9.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice SNP-DE H5970-020 (PPO D-SNP)
|
$32.30 |
$505 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | Q:60 /30Days | $16.29 |
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 SNP-DE H3533-002 (HMO D-SNP)
|
$32.50 |
$505 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | Q:60 /30Days | $16.29 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Plan 2 (HMO-POS D-SNP)
|
$34.10 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $16.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Plan 2 (HMO-POS D-SNP)
|
$34.10 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $12.49 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plan (PPO)
|
$37.00 |
$195* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $9.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Dual (HMO D-SNP)
|
$38.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $45.00 | None | $23.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Dual (HMO D-SNP)
|
$38.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $45.00 | None | $23.40 |
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 |
EmblemHealth VIP Dual (HMO D-SNP)
|
$38.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $45.00 | None | $23.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Empire MediBlue Dual Advantage (HMO D-SNP)
|
$38.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$10.00 | $30.00 | None | $36.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Empire MediBlue Dual Advantage (HMO D-SNP)
|
$38.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$10.00 | $30.00 | None | $36.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Hamaspik Medicare Select (HMO D-SNP)
|
$38.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $21.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
MVP DualAccess (HMO D-SNP)
|
$38.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $9.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
Nascentia Dual Advantage (HMO D-SNP)
|
$38.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $48.17 |
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 |
Nascentia Skilled Nursing Facility (HMO I-SNP)
|
$38.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $48.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$38.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $16.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$38.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $12.49 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Plan 1 (HMO-POS D-SNP)
|
$38.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $12.49 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Plan 1 (HMO-POS D-SNP)
|
$38.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $16.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP)
|
$38.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $12.33 |
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 |
UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)
|
$38.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $12.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
VNS Health Total (HMO D-SNP)
|
$38.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$8.00 | $24.00 | None | $15.24 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$38.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $46.63 |
Browse Plan Formulary all covered insulin pay $35 or less |
CDPHP Flex Rx (PPO)
|
$39.40 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$2.00 | $0.00 | None | $9.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
MVP Medicare Secure with Part D (HMO-POS)
|
$40.00 |
$150* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $20.00 | None | $10.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Empire MediBlue Plus (HMO)
|
$42.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $111.00 | None | $36.56 |
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 |
Empire MediBlue Plus (HMO)
|
$42.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $111.00 | None | $36.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Medicare Advantage Choice Plan 3 (Regional PPO)
|
$44.00 |
$100* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$14.00 | $0.00 | None | $15.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
MVP Medicare Patriot Plan with Part D (PPO)
|
$45.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | $30.00 | None | $10.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Premium Enhanced (PFFS)
|
$53.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | $0.00 | None | $22.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
Highmark Blue Shield Freedom Plus (HMO)
|
$55.00 |
$275* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$8.00 | $20.00 | None | $23.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
CDPHP Value Rx (HMO)
|
$58.30 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$2.00 | $0.00 | None | $9.82 |
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 Medicare Advantage Choice Plan 4 (Regional PPO)
|
$82.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.00 | $0.00 | None | $15.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
Empire MediBlue Access (PPO)
|
$90.00 |
$310* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$3.00 | $9.00 | None | $36.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Empire MediBlue Access (PPO)
|
$90.00 |
$310* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$3.00 | $9.00 | None | $36.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
MVP Medicare Secure Plus with Part D (HMO-POS)
|
$90.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$15.00 | $30.00 | None | $10.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Premium Ultra Open (PPO)
|
$115.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$5.00 | $0.00 | None | $17.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Highmark Blue Shield Senior Blue 652 (HMO)
|
$122.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | $25.00 | None | $23.17 |
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 |
MVP Medicare WellSelect Plus with Part D (PPO)
|
$125.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $20.00 | None | $11.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
CDPHP Choice Rx (HMO)
|
$128.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $9.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
MVP Medicare Preferred Gold with Part D (HMO-POS)
|
$140.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $20.00 | None | $10.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Premium Ultra (PFFS)
|
$155.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$5.00 | $0.00 | None | $22.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
Highmark Blue Shield Forever Blue 770 (PPO)
|
$199.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | $25.00 | None | $23.17 |
Browse Plan Formulary all covered insulin pay $35 or less |