LEVOXYL 175 MCG TABLET (90 tablets ) (NDC: 60793085901)
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 Flex Plan 2 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $34.87 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 2 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $34.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 3 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $36.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Rebate (HMO-POS)
|
$0.00 |
$435 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $36.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Essential Plan (PPO)
|
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $28.88 |
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 Premier Plan (PPO)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $141.00 | None | $14.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plus Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $7.38 |
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. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $15.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health AVA (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $100.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health Heart & Diabetes (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $100.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health Platinum (HMO-POS)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $100.07 |
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 |
Blue Medicare Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $83.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare Essential (HMO)
|
$0.00 |
$375* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $94.49 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare Essential (HMO)
|
$0.00 |
$375* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $85.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare Essential Plus (HMO-POS)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $85.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare Essential Plus (HMO-POS)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $95.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare Essential Plus (HMO-POS)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $97.79 |
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 |
Blue Medicare Essential Plus (HMO-POS)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $93.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $133.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $133.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$280* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$38.00 | $114.00 | None | $133.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Select Medicare (HMO)
|
$0.00 |
$195* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$42.00 | $126.00 | None | $134.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Savings Medicare (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $133.80 |
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 |
Devoted CORE North Carolina (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $58.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted GIVEBACK North Carolina (HMO)
|
$0.00 |
$395* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $58.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
HealthTeam Advantage Plan I (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $47.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H1036-291 (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $132.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-017 (PPO)
|
$0.00 |
$265 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $132.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Liberty Medicare Advantage (HMO C-SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $41.56 |
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 |
Wellcare Giveback Open (PPO)
|
$0.00 |
$250* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $18.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$150* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $18.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$150* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $18.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Value (HMO)
|
$0.00 |
$150* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $18.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plus Plan (HMO)
|
$7.00 |
$95* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $141.00 | None | $15.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist Open (PPO)
|
$14.00 |
$505* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $47.11 |
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 |
Alignment Health NC Duals (HMO D-SNP)
|
$19.00 |
$505* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $100.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$25.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $72.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare Plus (HMO D-SNP)
|
$26.50 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | None | $133.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 1 (HMO-POS)
|
$27.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $34.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Plus Medicare (HMO)
|
$27.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $133.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Assure Plan (HMO D-SNP)
|
$27.50 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | None | $19.75 |
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 |
Blue Medicare PPO Enhanced (PPO)
|
$29.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $91.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare PPO Enhanced (PPO)
|
$29.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $85.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP)
|
$30.80 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | None | $35.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Assisted Living Plan (HMO-POS I-SNP)
|
$30.90 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $35.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Medicare (HMO D-SNP)
|
$31.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $72.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare (HMO D-SNP)
|
$31.50 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $133.79 |
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 Flex Plan 1 (PPO)
|
$36.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $34.87 |
Browse Plan Formulary all covered insulin pay $35 or less |
Longevity Health Plan (HMO I-SNP)
|
$36.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $114.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Liberty Open (PPO D-SNP)
|
$37.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $72.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted PRIME North Carolina (HMO)
|
$38.40 |
$150* |
Yes, this drug has Gap Coverage. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $58.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Healthy Blue + Medicare (HMO D-SNP)
|
$38.40 |
$505* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $88.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H1036-168 (HMO-POS D-SNP)
|
$38.40 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $132.58 |
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 |
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
|
$38.40 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $41.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
Liberty Medicare Dual Plan (HMO D-SNP)
|
$38.40 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | None | $41.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
PruittHealth Premier (HMO I-SNP)
|
$38.40 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $42.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete (HMO-POS D-SNP)
|
$38.40 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $36.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$38.40 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | None | $34.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Select (HMO-POS D-SNP)
|
$38.40 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $36.67 |
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 (PPO I-SNP)
|
$38.40 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | None | $35.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-211 (PPO)
|
$47.00 |
$160* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | None | $132.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Premium Enhanced Open (PPO)
|
$55.00 |
$100* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $18.21 |
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 |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $132.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
HealthTeam Advantage Plan II (PPO)
|
$75.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $80.00 | None | $47.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R1390-002 (Regional PPO)
|
$98.00 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | None | $132.42 |
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 |
HumanaChoice H5216-336 (PPO)
|
$135.00 |
$190 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $132.66 |
Browse Plan Formulary all covered insulin pay $35 or less |