LEVOXYL 100 MCG TABLET (90 tablets ) (NDC: 60793085401)
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. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $30.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Choice (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $30.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Credit Plan (PPO)
|
$0.00 |
$350 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $26.95 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plan (PPO)
|
$0.00 |
$195 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $21.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $21.02 |
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 |
CDPHP Vital Rx (PPO)
|
$0.00 |
$300* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$3.00 | $0.00 | None | $90.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
Highmark Blue Cross Blue Shield BlueSaver (HMO)
|
$0.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 3* |
Preferred Brand |
$42.00 | $105.00 | None | $78.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Highmark Blue Cross Blue Shield Senior Blue Basic (HMO)
|
$0.00 |
$350 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $105.00 | None | $78.42 |
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. | 3* |
Preferred Brand |
$47.00 | $131.00 | None | $91.33 |
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. | 3* |
Preferred Brand |
$47.00 | $131.00 | None | $91.36 |
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. | 3* |
Preferred Brand |
$47.00 | $131.00 | None | $91.36 |
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 |
Independent Health's Encompass 65 Edge (HMO)
|
$0.00 |
$505* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$3.00 | $7.50 | None | $134.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Independent Health's Encompass 65 Element (HMO)
|
$0.00 |
$150* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $134.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
MVP Medicare WellSelect with Part D (PPO)
|
$0.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $37.94 |
Browse Plan Formulary all covered insulin pay $35 or less |
Univera SeniorChoice Basic (HMO)
|
$0.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$14.00 | $28.00 | None | $78.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Univera SeniorChoice Extra (HMO)
|
$0.00 |
$350* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$12.00 | $24.00 | None | $78.42 |
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 | $22.94 |
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 Giveback Open (PPO)
|
$0.00 |
$325* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $20.30 |
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. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $20.30 |
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 | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $50.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5970-001 (PPO)
|
$15.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $91.36 |
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. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $27.23 |
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 | 3 |
Tier 3 |
$0.00 | $0.00 | None | $17.50 |
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 Fidelis Assist (HMO-POS)
|
$17.30 |
$505* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $22.94 |
Browse Plan Formulary all covered insulin pay $35 or less |
Univera SeniorChoice Access (PPO)
|
$19.00 |
$350* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$12.00 | $24.00 | None | $78.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Highmark Blue Cross Blue Shield Freedom Nation (PPO)
|
$22.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 3* |
Preferred Brand |
$42.00 | $105.00 | None | $78.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Discover Value Plan (PPO)
|
$23.00 |
$250 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $21.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 | $73.69 |
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. | 3* |
Preferred Brand |
$47.00 | $131.00 | None | $91.41 |
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 Plus (HMO D-SNP)
|
$26.40 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $73.67 |
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 | 3 |
Tier 3 |
$0.00 | $0.00 | None | $91.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H3533-002 (HMO D-SNP)
|
$32.50 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
$0.00 | $0.00 | None | $91.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
Univera SeniorChoice Advanced (HMO-POS)
|
$33.00 |
$100* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$14.00 | $28.00 | None | $78.42 |
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 | 3 |
Tier 3 |
$0.00 | $0.00 | None | $28.37 |
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 | 3 |
Tier 3 |
$0.00 | $0.00 | None | $25.53 |
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 |
Independent Health's Medicare Family Choice (HMO I-SNP)
|
$38.90 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$4.00 | $10.00 | None | $134.81 |
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 | 3 |
Tier 3 |
$0.00 | $0.00 | None | $25.72 |
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 | 3 |
Tier 3 |
$0.00 | $0.00 | None | $28.37 |
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 | 3 |
Tier 3 |
$0.00 | $0.00 | None | $25.53 |
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 | 3 |
Tier 3 |
$0.00 | $0.00 | None | $28.37 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)
|
$38.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $29.02 |
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 |
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 | $73.70 |
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 | $90.99 |
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 | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $37.46 |
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. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $27.23 |
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 | 3 |
Preferred Brand |
$45.00 | $90.00 | None | $37.46 |
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 | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $23.97 |
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 Cross Blue Shield Senior Blue Select (HMO)
|
$55.00 |
$175 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $105.00 | None | $78.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Univera SeniorChoice Value Plus (HMO-POS)
|
$60.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | $20.00 | None | $78.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Independent Health's Encompass 65 Core (HMO)
|
$65.00 |
$50* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $134.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Medicare Advantage Choice Plan 4 (Regional PPO)
|
$82.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $27.23 |
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. | 3 |
Preferred Brand |
$45.00 | $90.00 | None | $37.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
Univera SeniorChoice Secure (HMO-POS)
|
$98.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$5.00 | $10.00 | None | $78.42 |
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 |
Independent Health's Medicare Passport Advantage (PPO)
|
$99.00 |
$150* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $134.81 |
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 | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $20.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Highmark Blue Cross Blue Shield Senior Blue 651 (HMO)
|
$117.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $105.00 | None | $78.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Independent Health's Encompass 65 Basic (HMO)
|
$125.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $134.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
MVP Medicare WellSelect Plus with Part D (PPO)
|
$125.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $70.00 | None | $37.94 |
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. | 3 |
Preferred Brand |
$35.00 | $70.00 | None | $37.46 |
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 |
Highmark Blue Cross Blue Shield Forever Blue Value (PPO)
|
$142.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $105.00 | None | $78.42 |
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 | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $23.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
Highmark Blue Cross Blue Shield Forever Blue 751 (PPO)
|
$201.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $105.00 | None | $78.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Independent Health's Medicare Passport Prime (PPO)
|
$225.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $134.81 |
Browse Plan Formulary all covered insulin pay $35 or less |