SIGNIFOR 0.3 MG/ML AMPULE (ML ) (NDC: 55292013160)
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 | $315.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 1 (HMO-POS)
|
$0.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
30% | n/a | P | $315.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $316.32 |
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. |
5 |
Specialty Tier |
30% | n/a | P | $316.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Align Connect (HMO C-SNP)
|
$0.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $421.59 |
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 |
Align Thrive (HMO I-SNP)
|
$0.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $421.49 |
Browse Plan Formulary all covered insulin pay $35 or less |
CCA Medicare Preferred (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | P Q:60 /30Days | $422.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
CCA One Care (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Tier 3 |
0% | 0% | P Q:60 /30Days | $372.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Orange HMO (HMO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | P | $302.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Health New England Baystate Health Preferred (HMO)
|
$0.00 |
$270 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
26% | n/a | P Q:60 /30Days | $304.25 |
Browse Plan Formulary all covered insulin pay $35 or less |
Health New England Medicare Compass (PPO)
|
$0.00 |
$380 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
26% | n/a | P Q:60 /30Days | $304.25 |
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 |
Health New England Medicare Value (HMO)
|
$0.00 |
$380 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
26% | n/a | P Q:60 /30Days | $304.25 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue SaverRx (HMO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | P | $308.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare PPO Blue SaverRx (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P | $308.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Saver Rx (HMO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
29% | n/a | P Q:60 /30Days | $300.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Smart Saver Rx (HMO)
|
$0.00 |
$100 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
31% | n/a | P Q:60 /30Days | $300.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Connected(r) for One Care (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Tier 2 |
0% | 0% | P | $315.14 |
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 Giveback Open (PPO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
27% | n/a | P | $308.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $308.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $308.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Senior Care Options NHC (HMO D-SNP)
|
$17.80 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P | $315.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
CCA Medicare Value (PPO)
|
$20.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $422.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Senior Care Options (HMO D-SNP)
|
$20.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P | $315.14 |
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 |
Medicare HMO Blue ValueRx (HMO)
|
$35.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | P | $308.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue ValueRx (HMO)
|
$35.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | P | $308.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Align Premier (HMO I-SNP)
|
$36.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P Q:60 /30Days | $421.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
CCA Senior Care Options (HMO D-SNP)
|
$36.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $422.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
NaviCare (HMO D-SNP)
|
$36.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P | $302.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Health Plan Senior Care Options (HMO D-SNP)
|
$36.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:60 /30Days | $301.50 |
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 |
Tufts Health Plan Senior Care Options CW (HMO D-SNP)
|
$36.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:60 /30Days | $301.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Health New England Medicare Choice (HMO)
|
$46.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
26% | n/a | P Q:60 /30Days | $304.25 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 2 (HMO-POS)
|
$47.00 |
$175 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
30% | n/a | P | $315.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$48.00 |
$225 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
29% | n/a | P Q:60 /30Days | $300.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$48.00 |
$225 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
29% | n/a | P Q:60 /30Days | $300.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$48.00 |
$225 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
29% | n/a | P Q:60 /30Days | $300.15 |
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 |
Fallon Medicare Plus Super Saver HMO (HMO)
|
$52.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $302.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Choice (Regional PPO)
|
$53.00 |
$295 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | P | $315.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Premium Enhanced Open (PPO)
|
$60.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $308.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Green HMO (HMO)
|
$66.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | P | $302.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Green HMO (HMO)
|
$66.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | P | $302.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Green HMO (HMO)
|
$66.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | P | $302.12 |
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 |
Medicare PPO Blue ValueRx (PPO)
|
$75.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | P | $308.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare PPO Blue ValueRx (PPO)
|
$75.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | P | $308.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue FlexRx (HMO-POS)
|
$95.00 |
$260 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | P | $308.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue FlexRx (HMO-POS)
|
$95.00 |
$260 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | P | $308.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$97.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $300.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$97.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $300.15 |
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 |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$97.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $300.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
Health New England Medicare Compass Premier (PPO)
|
$99.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | P Q:60 /30Days | $304.25 |
Browse Plan Formulary all covered insulin pay $35 or less |
Health New England Medicare Plus (HMO)
|
$113.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | P Q:60 /30Days | $304.25 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Blue HMO (HMO)
|
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $302.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Blue HMO (HMO)
|
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $302.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Blue HMO (HMO)
|
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $302.12 |
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 |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$117.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $301.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$117.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $301.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$117.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $301.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$137.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $301.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$137.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $301.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$137.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $301.50 |
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 |
Health New England Medicare Premium (HMO)
|
$168.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | P Q:60 /30Days | $304.25 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare PPO Blue PlusRx (PPO)
|
$254.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | P | $308.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue PlusRx (HMO)
|
$258.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | P | $308.79 |
Browse Plan Formulary all covered insulin pay $35 or less |