ISOLYTE P IN 5% DEXTROSE INJECTION (24 X 500 ML BAG) (NDC: 00264773010)
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 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $126.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Choice Plan 2 (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $126.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $124.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $124.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Access (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $128.40 |
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 |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $128.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $128.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $128.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $128.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Ascension Complete St. Vincent Access (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $126.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Ascension Complete St. Vincent Access Plus (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $126.00 |
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 |
Ascension Complete St. Vincent Reward (HMO)
|
$0.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $126.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Ascension Complete St. Vincent Secure (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $126.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$0.00 |
$445 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$97.00 | $281.00 | None | $120.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H5619-049 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $120.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana USAA Honor with Rx (PPO)
|
$0.00 |
$350 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $120.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-192 (PPO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $120.00 |
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 |
HumanaChoice H5216-229 (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $120.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-309 (PPO)
|
$0.00 |
$350 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $120.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
IU Health Plans Medicare Flex Network (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$100.00 | $300.00 | None | $120.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
MDwise Medicare Inspire (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$100.00 | $225.00 | None | $115.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
MyTruAdvantage Choice (PPO)
|
$0.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $300.00 | None | $121.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
MyTruAdvantage Choice (PPO)
|
$0.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $300.00 | None | $121.20 |
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 |
MyTruAdvantage Choice Plus (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$90.00 | $300.00 | None | $121.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
MyTruAdvantage Choice Plus (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$90.00 | $300.00 | None | $121.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
MyTruAdvantage Select (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $300.00 | None | $121.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
MyTruAdvantage Select (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $300.00 | None | $121.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback (HMO)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
48% | 48% | None | $126.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
43% | 43% | None | $126.00 |
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 |
Wellcare No Premium Open (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
44% | 44% | None | $126.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
|
$12.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
47% | 47% | None | $126.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Low Premium Open (PPO)
|
$15.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
44% | 44% | None | $126.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Ascension Complete St. Vincent DSNP (HMO D-SNP)
|
$15.60 |
$505 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
41% | 41% | None | $126.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Access Preferred (PPO)
|
$19.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $128.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Extra (HMO)
|
$21.10 |
$505 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $128.40 |
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 |
AARP Medicare Advantage Choice Plan 1 (PPO)
|
$22.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $126.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Assure Premier (HMO D-SNP)
|
$23.10 |
$505 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | None | $124.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier (PPO)
|
$24.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $124.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Choice Select (PPO D-SNP)
|
$24.40 |
$505 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $126.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
MDwise Medicare Inspire Plus (HMO)
|
$25.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$100.00 | $225.00 | None | $115.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$26.70 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $126.00 |
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 |
Anthem MediBlue Dual Advantage (HMO D-SNP)
|
$28.10 |
$505 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $128.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
CareSource Dual Advantage (HMO D-SNP)
|
$28.10 |
$505 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
25% | 25% | None | $240.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
CommuniCare Advantage ISNP (HMO I-SNP)
|
$28.10 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | P | $114.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
CommuniCare Advantage ISNP (HMO I-SNP)
|
$28.10 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | P | $114.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
CommuniCare Advantage ISNP (HMO I-SNP)
|
$28.10 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | P | $114.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H5619-054 (HMO D-SNP)
|
$28.10 |
$505 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | None | $120.00 |
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 |
Humana Value Plus H5216-193 (PPO)
|
$28.10 |
$260 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$97.00 | $281.00 | None | $120.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
MDwise Medicare Inspire Duals (HMO D-SNP)
|
$28.10 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $115.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete (PPO D-SNP)
|
$28.10 |
$505 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | None | $126.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$28.10 |
$505 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $126.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$28.10 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $126.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R0865-003 (Regional PPO)
|
$33.00 |
$195 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $120.00 |
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 |
IU Health Plans Medicare Select Plus (HMO)
|
$46.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$100.00 | $300.00 | None | $120.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
IU Health Plans Medicare Select Plus (HMO)
|
$46.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$100.00 | $300.00 | None | $120.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
IU Health Plans Medicare Select Plus (HMO)
|
$46.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$100.00 | $300.00 | None | $120.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
MDwise Medicare Inspire Flex (HMO-POS)
|
$49.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$100.00 | $225.00 | None | $115.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Access Plus (PPO)
|
$54.00 |
$60 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $128.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-008 (PPO)
|
$75.00 |
$220 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $120.00 |
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 |
Anthem MediBlue Access Basic (Regional PPO)
|
$81.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
46% | 46% | None | $128.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Choice H8145-032 (PFFS)
|
$82.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $120.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plus (HMO-POS)
|
$187.00 |
$350 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $124.80 |
Browse Plan Formulary all covered insulin pay $35 or less |