REVLIMID 5 MG CAPSULE (28.000 EA ) (NDC: 59572040528)
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 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $26,891.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Flex Plan 6 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $26,891.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:150 /30Days | $27,794.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:150 /30Days | $28,061.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:150 /30Days | $28,060.66 |
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 Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:150 /30Days | $28,061.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
MediGold Mount Carmel Cash Back No Premium (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
30% | n/a | P Q:28 /28Days | $24,236.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
MediGold Mount Carmel No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:28 /28Days | $24,236.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
MediGold Mount Carmel No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:28 /28Days | $24,236.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
MediGold Mount Carmel No Premium Choice (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
30% | n/a | P Q:28 /28Days | $24,236.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Access (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:28 /28Days | $24,140.84 |
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 |
MedMutual Advantage Access (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:28 /28Days | $25,544.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
31% | n/a | P Q:28 /28Days | $24,140.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
31% | n/a | P Q:28 /28Days | $24,578.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
31% | n/a | P Q:28 /28Days | $25,544.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:28 /28Days | $25,544.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:28 /28Days | $24,140.84 |
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 |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:28 /28Days | $25,544.99 |
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 |
5 |
Specialty Tier |
31% | n/a | P Q:28 /28Days | $23,936.87 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Choice Care Select (HMO)
|
$0.00 |
$375 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | P Q:28 /28Days | $23,936.87 |
Browse Plan Formulary all covered insulin pay $35 or less |
The Health Plan SecureCare - Option II (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | P Q:28 /28Days | $25,027.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback (HMO)
|
$0.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:28 /28Days | $27,301.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback Boost (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
30% | n/a | P Q:28 /28Days | $27,301.64 |
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 |
Wellcare No Premium (HMO)
|
$0.00 |
$75 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
31% | n/a | P Q:28 /28Days | $27,301.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Medicare (HMO)
|
$0.00 |
$75 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
31% | n/a | P Q:28 /28Days | $27,301.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:28 /28Days | $27,301.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Extra (HMO)
|
$10.40 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:150 /30Days | $28,060.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
|
$10.80 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:28 /28Days | $27,301.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist Complement (HMO)
|
$11.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:28 /28Days | $27,301.64 |
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 |
AARP Medicare Advantage Plan 2 (HMO-POS)
|
$20.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $26,891.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 2 (HMO-POS)
|
$20.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $27,508.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$26.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:28 /28Days | $27,311.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$28.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:28 /28Days | $27,311.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Dual Advantage (HMO D-SNP)
|
$28.90 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:150 /30Days | $28,060.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Secure (HMO)
|
$30.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
31% | n/a | P Q:28 /28Days | $24,140.84 |
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 |
MedMutual Advantage Secure (HMO)
|
$30.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
31% | n/a | P Q:28 /28Days | $25,544.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
CareSource Dual Advantage (HMO D-SNP)
|
$34.70 |
$505 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P Q:28 /28Days | $24,077.09 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Complete Care (HMO D-SNP)
|
$34.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:28 /28Days | $23,936.87 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$34.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:28 /28Days | $23,936.87 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete (HMO-POS D-SNP)
|
$34.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | P Q:30 /30Days | $26,696.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$34.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P Q:30 /30Days | $27,089.74 |
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 Select (HMO-POS D-SNP)
|
$34.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | P Q:30 /30Days | $26,696.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
32% | n/a | P Q:28 /28Days | $24,140.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
32% | n/a | P Q:28 /28Days | $24,578.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
32% | n/a | P Q:28 /28Days | $25,544.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
The Health Plan SecureCare SNP (HMO D-SNP)
|
$40.80 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P Q:28 /28Days | $24,801.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
MediGold Mount Carmel Plus (HMO)
|
$49.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:28 /28Days | $24,236.83 |
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 |
MedMutual Advantage Select (PPO)
|
$50.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
31% | n/a | P Q:28 /28Days | $24,140.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Select (PPO)
|
$50.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
31% | n/a | P Q:28 /28Days | $24,578.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Select (PPO)
|
$50.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
31% | n/a | P Q:28 /28Days | $25,544.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
The Health Plan SecureChoice - Option II (PPO)
|
$58.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | P Q:28 /28Days | $25,027.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Access Basic (Regional PPO)
|
$78.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
32% | n/a | P Q:150 /30Days | $28,060.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Preferred (PPO)
|
$80.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
32% | n/a | P Q:28 /28Days | $24,140.84 |
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 |
MedMutual Advantage Preferred (PPO)
|
$80.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
32% | n/a | P Q:28 /28Days | $24,578.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Preferred (PPO)
|
$80.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
32% | n/a | P Q:28 /28Days | $25,544.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Plus (HMO)
|
$97.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
32% | n/a | P Q:28 /28Days | $25,544.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Plus (HMO)
|
$97.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
32% | n/a | P Q:28 /28Days | $24,140.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Plus (HMO)
|
$97.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
32% | n/a | P Q:28 /28Days | $24,578.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
MediGold Mount Carmel Premier (HMO)
|
$120.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:28 /28Days | $24,236.83 |
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 |
MediGold Mount Carmel Premier (HMO)
|
$120.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:28 /28Days | $24,236.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Premium (PPO)
|
$136.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
32% | n/a | P Q:28 /28Days | $24,140.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Premium (PPO)
|
$136.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
32% | n/a | P Q:28 /28Days | $24,578.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Premium (PPO)
|
$136.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
32% | n/a | P Q:28 /28Days | $25,544.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plus 2 (Regional PPO)
|
$137.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:28 /28Days | $26,996.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plus 1 (Regional PPO)
|
$198.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:28 /28Days | $26,996.47 |
Browse Plan Formulary all covered insulin pay $35 or less |