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 Plan 1 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $42.55 |
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 |
$45.00 | $125.00 | None | $42.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 4 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $42.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Walgreens Plan 1 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $42.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Walgreens Plan 2 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $42.55 |
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 Elite Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $13.05 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Freedom Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $48.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $42.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $50.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $38.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Plus Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $13.72 |
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 AVA (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $92.86 |
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 | $91.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health the ONE (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $92.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Comfort (HMO I-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$7.50 | $0.00 | None | $98.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Comfort Plus (HMO I-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$7.50 | $0.00 | None | $98.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Plus (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $61.51 |
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 |
Banner Medicare Advantage Prime (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $108.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Achieve Medicare (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $132.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Alliance Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $132.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $132.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $132.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $132.61 |
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 True Choice Savings Medicare (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $132.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted BEWELL Arizona (HMO C-SNP)
|
$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 CHOICE Arizona (PPO)
|
$0.00 |
$175* |
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 CORE Arizona (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 |
Humana Gold Plus H0028-027 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $130.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H0028-028 (HMO)
|
$0.00 |
$225 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $130.84 |
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 H0028-052 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $130.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H2463-003 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $130.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana USAA Honor with Rx (PPO)
|
$0.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $130.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-137 (PPO)
|
$0.00 |
$445 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $131.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-265 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $130.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Imperial Insurance Company Traditional (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $40.97 |
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 |
Imperial Insurance Traditional Plus (HMO)
|
$0.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $40.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
Imperial Insurance Value (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $40.97 |
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 |
2 |
Generic |
$12.00 | $24.00 | None | $54.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Choice Care Select (HMO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $40.00 | None | $54.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Balance (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $118.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Classic (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $118.80 |
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 |
SCAN Embrace (HMO I-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $118.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Heart First (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $118.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Venture (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $118.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Chronic Complete (HMO-POS C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $42.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback (HMO)
|
$0.00 |
$350* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $10.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback (HMO)
|
$0.00 |
$350* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $10.80 |
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 |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $10.80 |
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. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $10.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Essentials (HMO)
|
$0.00 |
$250* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $10.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$200* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $10.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Specialty No Premium (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $10.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
|
$12.20 |
$505* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $43.80 |
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 |
Wellcare Assist (HMO)
|
$12.20 |
$505* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $43.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-224 (PPO)
|
$23.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $130.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Walgreens Plan 3 (PPO)
|
$25.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $42.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
Banner Medicare Advantage Plus (PPO)
|
$25.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $108.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Liberty (HMO D-SNP)
|
$25.20 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $73.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted SELECT Arizona (HMO)
|
$28.40 |
$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 |
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 Plan 3 (HMO-POS)
|
$30.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $42.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Value Plus H5216-197 (PPO)
|
$36.30 |
$450 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
23% | 23% | None | $131.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted BEWELL PLUS Arizona (HMO C-SNP)
|
$37.50 |
$505 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
25% | 25% | None | $58.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H0028-023 (HMO)
|
$41.00 |
$225 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $131.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Banner Medicare Advantage Dual (HMO D-SNP)
|
$41.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $111.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Banner Medicare Advantage Dual (HMO D-SNP)
|
$42.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $111.80 |
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 |
BCBSAZ Health Choice Pathway (HMO D-SNP)
|
$42.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $32.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Mercy Care Advantage (HMO D-SNP)
|
$42.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $58.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Mercy Care Advantage (HMO D-SNP)
|
$42.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $58.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Mercy Care Advantage (HMO D-SNP)
|
$42.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $58.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Complete Care (HMO D-SNP)
|
$42.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $54.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete LP (HMO-POS D-SNP)
|
$42.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $40.17 |
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 |
UnitedHealthcare Dual Complete ONE (HMO-POS D-SNP)
|
$42.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $41.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$42.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | None | $42.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R7220-002 (Regional PPO)
|
$56.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
21% | 21% | None | $131.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plan (PPO)
|
$83.00 |
$175 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $48.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-335 (PPO)
|
$96.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $130.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-034 (PPO)
|
$118.00 |
$225 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $131.43 |
Browse Plan Formulary all covered insulin pay $35 or less |