POLYCIN EYE OINTMENT [Polytracin] (3.5 GRAMS ) (NDC: 00574402135)
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. | 2 |
Generic |
$10.00 | $0.00 | None | $9.71 |
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. | 2 |
Generic |
$8.00 | $0.00 | None | $9.71 |
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. | 2 |
Generic |
$12.00 | $0.00 | None | $9.71 |
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. | 2 |
Generic |
$0.00 | $0.00 | None | $22.82 |
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. | 2 |
Generic |
$0.00 | $0.00 | None | $22.82 |
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, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $10.00 | None | $22.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Freedom Plan (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$10.00 | $20.00 | None | $22.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plan (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$10.00 | $20.00 | None | $22.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plan (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$10.00 | $20.00 | None | $22.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Plan (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $22.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Plus Plan (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $10.00 | None | $22.40 |
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 |
Alignment Health AVA (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $15.00 | None | $21.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health Heart & Diabetes (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $21.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health the ONE (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $21.52 |
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 | $17.16 |
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 | $17.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$7.50 | $0.00 | None | $13.43 |
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 |
Banner Medicare Advantage Prime (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $10.00 | None | $16.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare Advantage Classic (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$9.00 | $9.00 | None | $11.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
BluePathway Plan 1 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | $7.00 | None | $11.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
BluePathway Plan 2 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | $7.00 | None | $11.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Achieve Medicare (HMO C-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $0.00 | None | $26.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Alliance Medicare (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $0.00 | None | $26.84 |
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 |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $0.00 | None | $26.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $0.00 | None | $26.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $0.00 | None | $26.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Savings Medicare (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $0.00 | None | $26.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted BEWELL Arizona (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $21.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted CHOICE Arizona (PPO)
|
$0.00 |
$175* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $21.28 |
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 |
Devoted CORE Arizona (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $21.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
Dialysis Plus (HMO-POS C-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $12.00 | None | $14.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Honest Care (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $12.00 | None | $14.78 |
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 | 2 |
Generic |
$5.00 | $0.00 | None | $11.44 |
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 | 2* |
Generic |
$15.00 | $0.00 | None | $11.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H0028-052 (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $0.00 | None | $11.44 |
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 H2463-003 (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $0.00 | None | $11.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana USAA Honor with Rx (PPO)
|
$0.00 |
$480* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $0.00 | None | $11.44 |
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 | 2* |
Generic |
$17.00 | $0.00 | None | $12.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-265 (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $0.00 | None | $11.44 |
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 | 1 |
Preferred Generic |
$3.00 | $6.00 | None | $14.44 |
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 | 1 |
Preferred Generic |
$15.00 | $30.00 | None | $14.44 |
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 | $5.68 |
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 | $5.68 |
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 | $5.68 |
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 | $5.68 |
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 | $5.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
Super Plus (HMO C-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $12.00 | None | $14.78 |
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 |
UnitedHealthcare Chronic Complete (HMO-POS C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$8.00 | $0.00 | None | $9.71 |
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 | 2* |
Generic |
$15.00 | $0.00 | None | $3.09 |
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 | 2* |
Generic |
$15.00 | $0.00 | None | $6.45 |
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. | 2 |
Generic |
$8.00 | $0.00 | None | $3.09 |
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. | 2 |
Generic |
$8.00 | $0.00 | None | $6.45 |
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. | 2 |
Generic |
$15.00 | $0.00 | None | $3.09 |
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 Open (PPO)
|
$0.00 |
$200* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$5.00 | $0.00 | None | $4.02 |
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 | $1.15 |
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 | 2 |
Generic |
$20.00 | $0.00 | None | $6.85 |
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 | 2 |
Generic |
$20.00 | $0.00 | None | $5.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-224 (PPO)
|
$23.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $11.44 |
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. | 2 |
Generic |
$0.00 | $0.00 | None | $22.82 |
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 Plus (PPO)
|
$25.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $10.00 | None | $16.40 |
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 | $8.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted SELECT Arizona (HMO)
|
$28.40 |
$150* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $21.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 3 (HMO-POS)
|
$30.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$8.00 | $0.00 | None | $9.71 |
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 | 2 |
Generic |
$16.00 | $0.00 | None | $11.44 |
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 | $21.28 |
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 |
Humana Gold Plus H0028-023 (HMO)
|
$41.00 |
$225* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $0.00 | None | $11.44 |
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 | 2 |
Tier 2 |
$0.00 | $0.00 | None | $16.40 |
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 | 2 |
Tier 2 |
$0.00 | $0.00 | None | $16.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 | $7.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
Dialysis Complete (HMO-POS C-SNP)
|
$42.60 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $14.78 |
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 | $6.83 |
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 |
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 | $6.83 |
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 | $6.83 |
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 | $14.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
Super Complete (HMO C-SNP)
|
$42.60 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
25% | 25% | None | $14.78 |
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 | 2 |
Tier 2 |
15% | 15% | None | $14.49 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete ONE (HMO-POS D-SNP)
|
$42.60 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $13.94 |
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)
|
$42.60 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $9.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare Advantage Plus (HMO)
|
$51.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$9.00 | $9.00 | None | $11.83 |
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 | 2 |
Generic |
$15.00 | $0.00 | None | $11.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueJourney (PPO)
|
$68.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$9.00 | $9.00 | None | $11.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plan (PPO)
|
$83.00 |
$175* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$10.00 | $20.00 | None | $22.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-335 (PPO)
|
$96.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$2.00 | $0.00 | None | $11.44 |
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 H5216-034 (PPO)
|
$118.00 |
$225* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | $0.00 | None | $11.44 |
Browse Plan Formulary all covered insulin pay $35 or less |