TRAMADOL-ACETAMINOPHN 37.5-325 TABLET [Ultracet] (60 TABLETS ) (NDC: 53746061701)
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 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$6.00 | $0.00 | Q:240 /30Days | $13.35 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Choice (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | Q:240 /30Days | $13.37 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Choice Plan 2 (Regional PPO)
|
$0.00 |
$195* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$0.00 | $0.00 | Q:240 /30Days | $13.06 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Choice (HMO-POS)
|
$0.00 |
$195* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$0.00 | $0.00 | Q:240 /30Days | $9.63 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier (PPO)
|
$0.00 |
$300* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$0.00 | $0.00 | Q:240 /30Days | $9.58 |
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 Premier Plus (PPO)
|
$0.00 |
$150* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$0.00 | $0.00 | Q:240 /30Days | $8.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Select (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | Q:240 /30Days | $8.68 |
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 | Q:240 /30Days | $24.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health Platinum (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | Q:240 /30Days | $23.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Ascension Complete Florida Reward (HMO)
|
$0.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $74.00 | Q:240 /30Days | $24.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Ascension Complete Florida Reward II (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $74.00 | Q:240 /30Days | $24.26 |
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 |
Ascension Complete St. Vincent's Access POS (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $74.00 | Q:240 /30Days | $24.25 |
Browse Plan Formulary all covered insulin pay $35 or less |
Ascension Complete St. Vincent's Secure (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$37.00 | $74.00 | Q:240 /30Days | $24.25 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueMedicare Classic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $120.00 | Q:240 /30Days | $33.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueMedicare Premier (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $120.00 | Q:240 /30Days | $32.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueMedicare Value (PPO)
|
$0.00 |
$150 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:240 /30Days | $32.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
CareBreeze (HMO C-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | Q:240 /30Days | $9.28 |
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 |
CareBreeze Platinum (HMO C-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $0.00 | Q:240 /30Days | $9.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
CareComplete (HMO C-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | Q:240 /30Days | $9.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
CareComplete Platinum (HMO C-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $0.00 | Q:240 /30Days | $9.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
CareFree Platinum (HMO)
|
$0.00 |
$100* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $0.00 | Q:240 /30Days | $9.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
CareOne Platinum (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | Q:240 /30Days | $9.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
CareOne Plus (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | Q:240 /30Days | $9.28 |
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 |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $105.00 | Q:240 /30Days | $16.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $105.00 | Q:240 /30Days | $16.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $120.00 | Q:240 /30Days | $16.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted CHOICE (PPO)
|
$0.00 |
$150* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$0.00 | $0.00 | Q:240 /30Days | $31.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted CORE Jacksonville (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | Q:240 /30Days | $31.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted ESSENTIALS Jacksonville (HMO)
|
$0.00 |
$100* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$5.00 | $12.50 | Q:240 /30Days | $31.36 |
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 - Diabetes (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | Q:240 /30Days | $9.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus - Diabetes (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | Q:240 /30Days | $9.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H1036-068 (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | Q:240 /30Days | $9.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H1036-270 (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | Q:240 /30Days | $9.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice Florida H5216-070 (PPO)
|
$0.00 |
$175* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$10.00 | $0.00 | Q:240 /30Days | $9.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice Florida H7284-006 (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | Q:240 /30Days | $9.16 |
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 Florida H7284-009 (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | Q:240 /30Days | $9.22 |
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 | Q:240 /30Days | $13.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Choice Care Select (HMO)
|
$0.00 |
$450 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $40.00 | Q:240 /30Days | $13.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Connect Care (HMO C-SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $135.00 | Q:240 /30Days | $13.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Simply Extra (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:40 /5Days | $16.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
Simply Freedom (PPO)
|
$0.00 |
$150* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | Q:40 /5Days | $16.03 |
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 |
Simply More (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:40 /5Days | $16.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | Q:240 /30Days | $4.41 |
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 |
$0.00 | $0.00 | Q:240 /30Days | $4.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$150* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$0.00 | $0.00 | Q:240 /30Days | $4.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R5826-074 (Regional PPO)
|
$4.00 |
$395* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$20.00 | $0.00 | Q:240 /30Days | $9.25 |
Browse Plan Formulary all covered insulin pay $35 or less |
Ascension Complete St. Vincent's DSNP (HMO D-SNP)
|
$13.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:240 /30Days | $24.67 |
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 the ONE (HMO D-SNP)
|
$15.40 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $60.00 | Q:240 /30Days | $24.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
CareNeeds Plus (HMO D-SNP)
|
$17.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $0.00 | Q:240 /30Days | $9.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$18.60 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:240 /30Days | $33.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare Plus (HMO D-SNP)
|
$19.40 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
$0.00 | $0.00 | Q:240 /30Days | $16.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare (HMO D-SNP)
|
$19.60 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | Q:240 /30Days | $16.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Assure Plus (HMO D-SNP)
|
$22.30 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $45.00 | Q:240 /30Days | $15.80 |
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 |
Humana Gold Plus SNP-DE H1036-210 (HMO D-SNP)
|
$23.80 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$19.00 | $0.00 | Q:240 /30Days | $9.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted DUAL Jacksonville (HMO D-SNP)
|
$28.10 |
$505 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
25% | 25% | Q:240 /30Days | $31.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$35.20 |
$505 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:240 /30Days | $13.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueMedicare Complete (HMO D-SNP)
|
$35.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | 25% | Q:240 /30Days | $33.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted PREMIUM (HMO)
|
$35.90 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | Q:240 /30Days | $31.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted PREMIUM (HMO)
|
$35.90 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | Q:240 /30Days | $31.36 |
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 PREMIUM (HMO)
|
$35.90 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | Q:240 /30Days | $31.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Longevity Health Plan (HMO I-SNP)
|
$35.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | Q:240 /30Days | $11.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Complete Care (HMO D-SNP)
|
$35.90 |
$505 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:240 /30Days | $13.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Simply Complete (HMO D-SNP)
|
$35.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$15.00 | $45.00 | Q:40 /5Days | $20.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$35.90 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$12.00 | $0.00 | Q:240 /30Days | $12.94 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$35.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | Q:240 /30Days | $13.01 |
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 (PPO D-SNP)
|
$35.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | Q:240 /30Days | $13.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete LP (HMO-POS D-SNP)
|
$35.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | Q:240 /30Days | $13.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete ONE (HMO-POS D-SNP)
|
$35.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | Q:240 /30Days | $13.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete RP (Regional PPO D-SNP)
|
$35.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | Q:240 /30Days | $13.06 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$35.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | Q:240 /30Days | $13.09 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$35.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:240 /30Days | $35.55 |
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 Dual Liberty (HMO D-SNP)
|
$35.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:240 /30Days | $35.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Select (HMO D-SNP)
|
$35.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | Q:240 /30Days | $35.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueMedicare Choice (Regional PPO)
|
$49.90 |
$250 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $120.00 | Q:240 /30Days | $33.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Premium Enhanced Open (PPO)
|
$99.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | Q:240 /30Days | $4.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R5826-005 (Regional PPO)
|
$111.00 |
$100* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | $0.00 | Q:240 /30Days | $9.25 |
Browse Plan Formulary all covered insulin pay $35 or less |