OXYCODONE-ACETAMINOPHN 2.5-325 TABLET [Percocet] (30 TABLETS ) (NDC: 10702018401)
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 | Q:360 /30Days | $43.15 |
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 | Q:360 /30Days | $43.15 |
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 | Q:180 /30Days | $29.79 |
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 | Q:180 /30Days | $29.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (HMO-POS)
|
$0.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days | $29.34 |
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 |
Centers Plan for Medicare Advantage Care (HMO)
|
$0.00 |
$395* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | $37.50 | Q:360 /30Days | $42.66 |
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 |
2* |
Generic |
$12.00 | $0.00 | P Q:372 /31Days | $49.19 |
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 |
2* |
Generic |
$12.00 | $30.00 | P Q:372 /31Days | $49.19 |
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 | Q:360 /30Days | $39.72 |
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 | Q:360 /30Days | $39.70 |
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 | Q:360 /30Days | $39.70 |
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 |
2* |
Generic |
$20.00 | $50.00 | None | $42.17 |
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 |
2* |
Generic |
$15.00 | $37.50 | None | $42.17 |
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 | $49.19 |
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 | $49.19 |
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 |
2 |
Generic |
$15.00 | $0.00 | Q:360 /30Days | $19.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback Open (PPO)
|
$0.00 |
$325 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $74.00 | Q:360 /30Days | $20.28 |
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 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$37.00 | $74.00 | Q:360 /30Days | $20.57 |
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. |
3 |
Preferred Brand |
$37.00 | $74.00 | Q:360 /30Days | $20.28 |
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 |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:360 /30Days | $21.47 |
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 | Q:360 /30Days | $39.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
MVP Medicare Secure with Part D (HMO-POS)
|
$15.00 |
$300* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $20.00 | Q:360 /30Days | $39.97 |
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 | Q:360 /30Days | $43.40 |
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 |
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 | Q:180 /30Days | $41.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Fidelis Assist (HMO-POS)
|
$17.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:360 /30Days | $19.84 |
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 | $49.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$20.50 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:360 /30Days | $27.95 |
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 |
2* |
Generic |
$12.00 | $0.00 | P Q:372 /31Days | $49.19 |
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 | Q:180 /30Days | $29.34 |
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 Access (HMO D-SNP)
|
$24.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:360 /30Days | $27.09 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 | Q:360 /30Days | $26.09 |
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 | Q:360 /30Days | $39.67 |
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 | Q:360 /30Days | $39.68 |
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 | $49.19 |
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 | Q:360 /30Days | $43.60 |
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 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 | Q:360 /30Days | $43.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$35.70 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $43.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
Centers Plan for Medicaid Advantage Plus (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:360 /30Days | $42.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Centers Plan for Nursing Home Care (HMO I-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:360 /30Days | $42.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Independent Health's Medicare Family Choice (HMO I-SNP)
|
$38.90 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $37.50 | None | $42.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Nascentia Dual Advantage (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:360 /30Days | $46.43 |
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 |
Nascentia Skilled Nursing Facility (HMO I-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:360 /30Days | $46.43 |
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 | Q:360 /30Days | $43.69 |
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 | Q:360 /30Days | $43.12 |
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 | Q:360 /30Days | $43.60 |
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 | Q:360 /30Days | $43.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:360 /30Days | $43.12 |
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 1 (PPO I-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:360 /30Days | $43.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 | Q:360 /30Days | $27.03 |
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 | Q:360 /30Days | $43.40 |
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 |
2* |
Generic |
$15.00 | $30.00 | Q:360 /30Days | $39.97 |
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 |
3 |
Preferred Brand |
$37.00 | $74.00 | Q:360 /30Days | $20.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Highmark Blue Cross Blue Shield Senior Blue Select (HMO)
|
$55.00 |
$175* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $25.00 | P Q:372 /31Days | $49.19 |
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 Assure Advantage (HMO C-SNP)
|
$60.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$12.00 | $30.00 | None | $42.09 |
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 | $49.19 |
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 |
2* |
Generic |
$12.00 | $30.00 | None | $42.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
MVP Medicare WellSelect with Part D (PPO)
|
$80.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $20.00 | Q:360 /30Days | $39.97 |
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 | Q:360 /30Days | $43.40 |
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 | $49.19 |
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 |
2* |
Generic |
$15.00 | $37.50 | None | $42.17 |
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 |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:360 /30Days | $20.28 |
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 |
2 |
Generic |
$10.00 | $25.00 | P Q:372 /31Days | $49.19 |
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 |
2 |
Generic |
$10.00 | $25.00 | None | $42.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Highmark Blue Cross Blue Shield Forever Blue Value (PPO)
|
$142.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $25.00 | P Q:372 /31Days | $49.19 |
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 |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:360 /30Days | $20.52 |
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 751 (PPO)
|
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $20.00 | P Q:372 /31Days | $49.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
MVP Medicare Preferred Gold with Part D (HMO-POS)
|
$211.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $20.00 | Q:360 /30Days | $39.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
Independent Health's Medicare Passport Prime (PPO)
|
$225.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $25.00 | None | $42.17 |
Browse Plan Formulary all covered insulin pay $35 or less |