OXYCODONE-ACETAMINOPHN 7.5-325 TABLET [Percocet] (90 TABLETS ) (NDC: 00406052201)
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 | $46.11 |
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 | $46.11 |
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 | $43.77 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite Plan (PPO)
|
$0.00 |
$195 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days | $45.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plus Plan (PPO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days | $44.85 |
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 Value Plan (HMO-POS)
|
$0.00 |
$300 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days | $44.85 |
Browse Plan Formulary all covered insulin pay $35 or less |
CDPHP $0 Medicare Rx (HMO)
|
$0.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:240 /30Days | $17.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
CDPHP Vital Rx (PPO)
|
$0.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:240 /30Days | $17.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Rx Saver (HMO)
|
$0.00 |
$395* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$42.00 | $126.00 | Q:360 /30Days | $19.21 |
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 | $34.18 |
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 | $34.23 |
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 H5970-018 (PPO)
|
$0.00 |
$310* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $34.23 |
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 | 2* |
Generic |
$12.00 | $24.00 | Q:360 /30Days | $4.28 |
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:240 /30Days | $38.33 |
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:240 /30Days | $38.18 |
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:240 /30Days | $38.18 |
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:240 /30Days | $42.21 |
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 H5970-001 (PPO)
|
$15.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $34.23 |
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 | $45.84 |
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 | Q:180 /30Days | $19.49 |
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:240 /30Days | $38.33 |
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 | $44.85 |
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 | Q:240 /30Days | $51.41 |
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 |
Humana Gold Plus H3533-013 (HMO)
|
$25.00 |
$275* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $33.00 |
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:240 /30Days | $53.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
CDPHP Basic RX (HMO)
|
$31.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $90.00 | Q:240 /30Days | $17.33 |
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 | $33.59 |
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 | $33.40 |
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 | $45.64 |
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 | $46.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plan (PPO)
|
$37.00 |
$195 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days | $45.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Dual (HMO D-SNP)
|
$38.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:360 /30Days | $19.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Dual (HMO D-SNP)
|
$38.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:360 /30Days | $18.94 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Dual (HMO D-SNP)
|
$38.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:360 /30Days | $18.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Empire MediBlue Dual Advantage (HMO D-SNP)
|
$38.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:180 /30Days | $53.46 |
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 |
Empire MediBlue Dual Advantage (HMO D-SNP)
|
$38.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:180 /30Days | $44.48 |
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 | $57.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 | $57.78 |
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 | $46.51 |
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 | $45.64 |
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 | $45.64 |
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 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 | $46.19 |
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:240 /30Days | $51.71 |
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 | 3 |
Preferred Brand |
$44.00 | $88.00 | Q:240 /30Days | $17.34 |
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 | 2* |
Generic |
$10.00 | $20.00 | Q:360 /30Days | $4.28 |
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 | $45.84 |
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 | $4.28 |
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 |
Empire MediBlue Plus (HMO)
|
$54.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $111.00 | Q:180 /30Days | $49.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
Empire MediBlue Plus (HMO)
|
$54.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $111.00 | Q:180 /30Days | $53.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
CDPHP Value Rx (HMO)
|
$58.30 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $84.00 | Q:240 /30Days | $17.33 |
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 | $45.84 |
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. | 2 |
Generic |
$15.00 | $30.00 | Q:360 /30Days | $4.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
Empire MediBlue Access (PPO)
|
$91.00 |
$310 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$88.00 | $264.00 | Q:180 /30Days | $49.55 |
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 |
Empire MediBlue Access (PPO)
|
$91.00 |
$310 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$88.00 | $264.00 | Q:180 /30Days | $53.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare Bassett (HMO-POS)
|
$109.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$8.00 | $16.00 | None | $21.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare BluePlus (PPO)
|
$114.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $45.00 | None | $20.20 |
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:240 /30Days | $38.18 |
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. | 2 |
Generic |
$10.00 | $20.00 | Q:360 /30Days | $4.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
CDPHP Choice Rx (HMO)
|
$128.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $80.00 | Q:240 /30Days | $17.33 |
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 |
MVP Medicare Preferred Gold with Part D (HMO-POS)
|
$140.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $20.00 | Q:360 /30Days | $4.28 |
Browse Plan Formulary all covered insulin pay $35 or less |