OLMSRTN-AMLDPN-HCTZ 40-10-25MG TABLET [Tribenzor] (30 TABLETS ) (NDC: 49884079009)
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 Plan 2 (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $91.63 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Freedom Plus (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $91.63 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Harmony (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $91.63 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Rebate (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $91.63 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage SecureHorizons Focus (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $91.63 |
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 Plus Plan (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $18.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime II Plan (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $9.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $18.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $18.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health AVA (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$3.00 | $0.00 | Q:30 /30Days | $184.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health AVA (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$5.00 | $0.00 | Q:30 /30Days | $183.65 |
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 CalPlus + Veterans (HMO)
|
$0.00 |
$505* | No additional gap coverage, only the Donut Hole Discount | 6* |
Select Care Drugs |
$5.00 | $0.00 | Q:30 /30Days | $184.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health ESRD Balance (HMO C-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$5.00 | $0.00 | Q:30 /30Days | $182.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health Harmony (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$3.00 | $0.00 | Q:30 /30Days | $183.52 |
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. | 6 |
Select Care Drugs |
$5.00 | $0.00 | Q:30 /30Days | $185.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health My Choice (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$3.00 | $0.00 | Q:30 /30Days | $182.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health My Choice CalPlus (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$5.00 | $0.00 | Q:30 /30Days | $183.81 |
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 Platinum (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$5.00 | $0.00 | Q:30 /30Days | $182.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health PPO powered by Hoag (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$5.00 | $0.00 | Q:30 /30Days | $186.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health smartHMO (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$5.00 | $0.00 | Q:30 /30Days | $182.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health the ONE + Rite Aid (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$5.00 | $0.00 | Q:30 /30Days | $182.85 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Care On Site (HMO I-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$0.00 | $0.00 | None | $74.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Diabetes Care (HMO C-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$0.00 | $0.00 | None | $102.86 |
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 ESRD Care (HMO C-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$0.00 | $0.00 | None | $102.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Heart Care (HMO C-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$0.00 | $0.00 | None | $102.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Lung Care (HMO C-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$0.00 | $0.00 | None | $102.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $102.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $102.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue StartSmart Plus (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 6 |
Select Care Drugs |
$10.00 | $20.00 | None | $103.58 |
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 |
Anthem MediBlue Value Plus (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$0.00 | $0.00 | None | $102.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Astiva Health C-SNP Savings (HMO C-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $81.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Astiva Health Classic Plan (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $81.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Astiva Health Savings Plan (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $81.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $75.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Shield 65 Plus Plan 2 (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $74.72 |
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 |
Blue Shield AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$3.00 | $7.50 | None | $75.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Shield Inspire (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $75.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
Brand New Day Bridges Care Plan (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $10.00 | None | $63.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
Brand New Day Classic Care I Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $63.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
Brand New Day Classic Care I Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $63.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Brand New Day Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$9.00 | $18.00 | None | $63.73 |
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 |
Brand New Day Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$9.00 | $18.00 | None | $63.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Brand New Day Part B Savings Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.00 | $24.00 | None | $63.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Brand New Day Select Care I Plan (HMO I-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $63.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
Central Health Focus Plan (HMO C-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $63.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $63.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
Central Health Premier Plan II (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $63.27 |
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 |
Central Health Premier Plan II (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $63.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Central Health Savings Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $63.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Fortune Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $67.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Fortune Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $68.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Fortune Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $67.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Fortune Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $81.83 |
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 |
Clever Care Fortune Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $70.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $67.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $68.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $67.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $81.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $70.22 |
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 |
Clever Care Value Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$10.00 | $20.00 | None | $67.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Value Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$10.00 | $20.00 | None | $68.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Value Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$10.00 | $20.00 | None | $67.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Value Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$10.00 | $20.00 | None | $81.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Value Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$10.00 | $20.00 | None | $70.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:30 /30Days | $76.61 |
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 |
Humana Gold Plus H5619-146 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:30 /30Days | $76.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
Imperial Dynamic Plan (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $77.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Imperial Senior Value (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 6 |
Select Care Drugs |
$3.00 | $0.00 | Q:30 /30Days | $77.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Imperial Strong (HMO)
|
$0.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $77.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Imperial Traditional (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $77.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Providence Medicare Sycamore + Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $43.46 |
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 |
SCAN Balance (HMO C-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $40.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Classic (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $28.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Embrace (HMO I-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $28.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Healthy at Home (HMO I-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $39.26 |
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. | 2 |
Generic |
$0.00 | $0.00 | None | $28.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Venture (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $40.46 |
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 |
UnitedHealthcare Chronic Complete (HMO-POS C-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $91.63 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $19.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $13.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $19.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Best (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $20.29 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Specialty No Premium (HMO C-SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $20.30 |
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 Chronic Complete Focus (HMO C-SNP)
|
$11.30 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $91.63 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Low Premium (HMO)
|
$22.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $19.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Extra (HMO)
|
$23.00 |
$505* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $105.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H5619-149 (HMO)
|
$24.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:30 /30Days | $76.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage SecureHorizons Premier (HMO-POS)
|
$25.90 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $91.63 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Prime (HMO)
|
$26.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $28.11 |
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 |
Wellcare Dual Liberty (HMO D-SNP)
|
$26.10 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $25.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Jasmine Medicare Advantage (HMO C-SNP)
|
$31.80 |
$505 | Yes, this drug has Gap Coverage. | 2 |
Generic |
25% | 25% | None | $67.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Jasmine Medicare Advantage (HMO C-SNP)
|
$31.80 |
$505 | Yes, this drug has Gap Coverage. | 2 |
Generic |
25% | 25% | None | $68.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Jasmine Medicare Advantage (HMO C-SNP)
|
$31.80 |
$505 | Yes, this drug has Gap Coverage. | 2 |
Generic |
25% | 25% | None | $81.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Jasmine Medicare Advantage (HMO C-SNP)
|
$31.80 |
$505 | Yes, this drug has Gap Coverage. | 2 |
Generic |
25% | 25% | None | $70.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Central Health Premier Plan I (HMO)
|
$33.10 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $63.78 |
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 |
Central Health Premier Plan I (HMO)
|
$33.10 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $63.27 |
Browse Plan Formulary all covered insulin pay $35 or less |
Brand New Day Classic Care II Plan (HMO)
|
$36.70 |
$50 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.00 | $24.00 | None | $63.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Brand New Day Classic Care II Plan (HMO)
|
$36.70 |
$50 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.00 | $24.00 | None | $63.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
Astiva Health C-SNP Premium (HMO C-SNP)
|
$38.90 |
$505* | Yes, this drug has Gap Coverage. | 6* |
Select Care Drugs |
$0.00 | $0.00 | Q:30 /30Days | $81.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Shield TotalDual Plan (HMO D-SNP)
|
$38.90 |
$505 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
25% | 25% | None | $74.63 |
Browse Plan Formulary all covered insulin pay $35 or less |
Brand New Day Bridges Choice Plan (HMO C-SNP)
|
$38.90 |
$505 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
25% | 25% | None | $63.75 |
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 |
Brand New Day Dual Access Plan (HMO D-SNP)
|
$38.90 |
$505 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
25% | 25% | None | $63.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$38.90 |
$505 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
25% | 25% | None | $63.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$38.90 |
$505 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
25% | 25% | None | $63.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Brand New Day Select Choice I Plan (HMO I-SNP)
|
$38.90 |
$505 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $63.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Shield Enhanced (HMO)
|
$39.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $75.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Choice Plan 1 (PPO)
|
$48.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $91.63 |
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 Shield Select (PPO)
|
$67.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $74.27 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Choice Plan (PPO)
|
$87.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $10.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Access (PPO)
|
$170.00 |
$370* | No additional gap coverage, only the Donut Hole Discount | 6* |
Select Care Drugs |
$0.00 | $0.00 | None | $116.24 |
Browse Plan Formulary all covered insulin pay $35 or less |