SODIUM POLYSTYRENE SULF POWDER (454 GM ) (NDC: 10702003645)
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 Rebate (PPO)
|
$0.00 |
$395 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $80.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plus Plan 1 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $80.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Freedom Plan (PPO)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $141.00 | None | $46.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Freedom Plus Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $47.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $46.44 |
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 |
Anthem MediBlue Access Basic (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $78.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $78.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $142.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$195* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$42.00 | $126.00 | None | $142.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clover Health LiveHealthy (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$37.00 | $110.00 | None | $79.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Essence Advantage (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$5.00 | $12.50 | None | $70.14 |
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 |
Essence Advantage Choice (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$5.00 | $12.50 | None | $70.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice - Diabetes and Heart (PPO C-SNP)
|
$0.00 |
$145* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $131.00 | None | $61.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-154 (PPO)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $61.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-207 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $61.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-345 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $61.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-349 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $61.83 |
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 |
HumanaChoice R3392-004 (Regional PPO)
|
$0.00 |
$195 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $61.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Chronic Complete (PPO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $80.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Medicare Advantage Choice Plan 1 (PPO)
|
$0.00 |
$275 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $80.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback (HMO)
|
$0.00 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$5.00 | $0.00 | None | $17.62 |
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 |
$5.00 | $0.00 | None | $16.89 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$75* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$0.00 | $0.00 | None | $17.62 |
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 Choice H8145-069 (PFFS)
|
$9.00 |
$340 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $61.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-142 (PPO)
|
$9.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $61.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-142 (PPO)
|
$9.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $61.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Medicare Silver (Regional PPO C-SNP)
|
$9.50 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | None | $80.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP)
|
$15.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $80.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Enhanced Care (HMO D-SNP)
|
$17.20 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $78.81 |
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 Dual Preferred Plan (HMO D-SNP)
|
$19.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | None | $60.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Dual Select Plan (HMO D-SNP)
|
$19.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $60.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred GA Medicare (HMO)
|
$20.00 |
$280* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$42.00 | $126.00 | None | $142.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred GA Medicare (HMO)
|
$20.00 |
$280* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$42.00 | $126.00 | None | $135.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Extra (HMO)
|
$24.50 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $78.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Plus Medicare (HMO)
|
$25.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $137.88 |
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 TotalCare Plus (HMO D-SNP)
|
$26.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | None | $142.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare (HMO D-SNP)
|
$26.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $142.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plus Plan (PPO)
|
$28.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $48.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
|
$28.10 |
$475 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $48.85 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plus Plan 2 (HMO-POS)
|
$32.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $80.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Preferred Premium Plan (PPO)
|
$32.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $141.00 | None | $49.89 |
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 Choice Select LP (PPO D-SNP)
|
$32.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $80.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete (HMO-POS D-SNP)
|
$35.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $80.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Liberty (HMO D-SNP)
|
$36.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $66.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$37.20 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $66.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Dual Access (PPO D-SNP)
|
$37.30 |
$440 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $78.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Dual Advantage (HMO D-SNP)
|
$37.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $78.81 |
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 |
CareSource Dual Advantage (HMO D-SNP)
|
$37.30 |
$505 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
25% | 25% | None | $87.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clover Health LiveHealthy Value (PPO)
|
$37.30 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
22% | 22% | None | $79.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Georgia Health Advantage (HMO I-SNP)
|
$37.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $119.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
Georgia Health Advantage Choice (HMO I-SNP)
|
$37.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $119.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-284 (PPO)
|
$37.30 |
$505 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $61.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice SNP-DE H5216-205 (PPO D-SNP)
|
$37.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | None | $61.70 |
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 |
HumanaChoice SNP-DE H5216-206 (PPO D-SNP)
|
$37.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $61.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
PruittHealth Premier (HMO I-SNP)
|
$37.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $131.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Choice LP (PPO D-SNP)
|
$37.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | None | $80.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$37.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $66.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Essential (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $78.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Medicare Advantage Choice (Regional PPO)
|
$49.00 |
$295 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $80.22 |
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 Low Premium Open (PPO)
|
$55.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$0.00 | $0.00 | None | $17.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Access (PPO)
|
$59.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $78.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Premium Enhanced Open (PPO)
|
$85.00 |
$75* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$0.00 | $0.00 | None | $17.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R3392-002 (Regional PPO)
|
$103.00 |
$340 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $61.70 |
Browse Plan Formulary all covered insulin pay $35 or less |