TEMAZEPAM 15 MG CAPSULE [Restoril] (30 capsules ) (NDC: 67877014601)
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. |
2 |
Generic |
$14.00 | $0.00 | Q:30 /30Days | $8.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 1 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$14.00 | $0.00 | Q:30 /30Days | $8.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 1 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$14.00 | $0.00 | Q:30 /30Days | $8.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Rebate (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$14.00 | $0.00 | Q:30 /30Days | $8.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plan (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $10.21 |
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 |
Aetna Medicare Select Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $10.18 |
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 |
1* |
Preferred Generic |
$2.00 | $6.00 | Q:30 /30Days | $8.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
Align Freedom (HMO-POS)
|
$0.00 |
$505* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$2.00 | $6.00 | Q:30 /30Days | $8.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
Align Thrive (HMO I-SNP)
|
$0.00 |
$505* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$2.00 | $6.00 | Q:30 /30Days | $8.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue + Kroger (HMO)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$10.00 | $0.00 | Q:30 /30Days | $5.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue + Kroger Access (PPO)
|
$0.00 |
$95* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$13.00 | $0.00 | Q:30 /30Days | $5.90 |
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 (PPO)
|
$0.00 |
$95* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$13.00 | $0.00 | Q:30 /30Days | $5.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Care on Site (HMO I-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$7.50 | $0.00 | Q:30 /30Days | $2.85 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue COPD (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$9.50 | $0.00 | Q:30 /30Days | $5.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Diabetes and Heart Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$7.50 | $0.00 | Q:30 /30Days | $5.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue ESRD Care (HMO C-SNP)
|
$0.00 |
$325* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$10.00 | $0.00 | Q:30 /30Days | $5.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Local (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$9.50 | $0.00 | Q:30 /30Days | $5.65 |
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 Smart Fit (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$12.50 | $0.00 | Q:30 /30Days | $5.65 |
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 | Q:60 /365Days | $10.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:60 /365Days | $10.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $2.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H5619-139 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $2.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H5619-139 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $2.47 |
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 H6622-004 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:30 /30Days | $2.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-266 (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $2.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-308 (PPO)
|
$0.00 |
$485 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days | $2.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-312 (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:30 /30Days | $2.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
LifeWorks Freedom (HMO I-SNP)
|
$0.00 |
$505* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$2.00 | n/a | Q:30 /30Days | $7.54 |
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 |
2 |
Generic |
$12.00 | $24.00 | P Q:60 /30Days | $1.97 |
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 |
Optima Medicare Value (HMO)
|
$0.00 |
$150* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | Q:60 /30Days | $6.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$4.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days | $2.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H6622-074 (HMO)
|
$15.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days | $2.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H6622-074 (HMO)
|
$15.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days | $2.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Assure Value (HMO D-SNP)
|
$19.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | P Q:30 /30Days | $9.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Assure Premier (HMO D-SNP)
|
$20.20 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | P Q:30 /30Days | $9.92 |
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 Dual Advantage (HMO D-SNP)
|
$22.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $60.00 | Q:30 /30Days | $5.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 2 (HMO-POS)
|
$23.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$12.00 | $0.00 | Q:30 /30Days | $8.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 2 (HMO-POS)
|
$23.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$12.00 | $0.00 | Q:30 /30Days | $8.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Virginia Premier Advantage Elite (HMO D-SNP)
|
$23.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | Q:60 /30Days | $6.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Optima Community Complete (HMO D-SNP)
|
$25.40 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | Q:60 /30Days | $6.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Extra (HMO)
|
$25.90 |
$505* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$16.00 | $0.00 | Q:30 /30Days | $5.80 |
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 Better Health of Virginia (HMO D-SNP)
|
$27.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | P Q:30 /30Days | $9.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Plus Medicare (HMO)
|
$29.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:60 /365Days | $10.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Plus Medicare (PPO)
|
$29.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:60 /365Days | $10.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Dual Access (PPO D-SNP)
|
$29.40 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $60.00 | Q:30 /30Days | $5.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete ONE (HMO-POS D-SNP)
|
$29.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | Q:30 /30Days | $8.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete ONE Plus (HMO-POS D-SNP)
|
$29.80 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | Q:30 /30Days | $8.59 |
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 |
UnitedHealthcare Dual Complete (HMO-POS D-SNP)
|
$33.20 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | Q:30 /30Days | $8.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Align Kidney Care (HMO C-SNP)
|
$34.50 |
$505* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$2.00 | $6.00 | Q:30 /30Days | $8.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Balance (HMO-POS D-SNP)
|
$34.50 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | Q:30 /30Days | $8.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Full Dual Advantage (HMO D-SNP)
|
$34.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $60.00 | Q:30 /30Days | $5.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
LifeWorks Advantage I-SNP (HMO I-SNP)
|
$34.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | Q:30 /30Days | $7.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Complete Care (HMO D-SNP)
|
$34.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:60 /30Days | $1.97 |
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 |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$34.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
33% | 33% | P Q:60 /30Days | $1.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$34.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | Q:30 /30Days | $8.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
|
$37.50 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | Q:30 /30Days | $8.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-144 (PPO)
|
$39.00 |
$265 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $2.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Choice H8145-004 (PFFS)
|
$68.00 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days | $2.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Essential Plan (PPO)
|
$77.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $10.18 |
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 R1390-002 (Regional PPO)
|
$98.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days | $2.47 |
Browse Plan Formulary all covered insulin pay $35 or less |