TRIJARDY XR 10-5-1,000 MG TABLET BP 24H (30 units ) (NDC: 00597038013)
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 Mosaic Choice (PPO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $645.85 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Prime (HMO-POS)
|
$0.00 |
$295 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $645.85 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite Plan (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $640.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $640.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
Centers Plan for Medicare Advantage Care (HMO)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $117.50 | Q:30 /30Days | $583.98 |
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 True Choice Medicare (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $648.06 |
Browse Plan Formulary all covered insulin pay $35 or less |
Elderplan Flex (HMO)
|
$0.00 |
$375* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $94.00 | Q:30 /30Days | $577.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Reserve Classic (HMO)
|
$0.00 |
$325 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:30 /30Days | $567.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
Empire MediBlue HealthPlus (HMO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:30 /30Days | $662.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
Empire MediBlue HealthPlus Select (HMO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $105.00 | Q:30 /30Days | $663.29 |
Browse Plan Formulary all covered insulin pay $35 or less |
Empire MediBlue Select (HMO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:30 /30Days | $662.28 |
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 |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $47.00 | Q:30 /30Days | $651.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
Healthfirst Signature (HMO)
|
$0.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $47.00 | Q:30 /30Days | $651.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
Healthfirst Signature (PPO)
|
$0.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $47.00 | Q:30 /30Days | $651.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H3533-027 (HMO)
|
$0.00 |
$425 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $645.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5970-024 (PPO)
|
$0.00 |
$350* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $649.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5970-024 (PPO)
|
$0.00 |
$350* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $644.33 |
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 |
PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Tier 2 |
0% | 0% | Q:30 /30Days | $575.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Fidelis No Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$37.00 | $74.00 | Q:30 /30Days | $650.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback Open (PPO)
|
$0.00 |
$325 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $74.00 | Q:30 /30Days | $655.51 |
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 |
3 |
Preferred Brand |
$37.00 | $74.00 | Q:30 /30Days | $649.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $74.00 | Q:30 /30Days | $655.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO)
|
$16.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $649.03 |
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 |
Wellcare Assist (HMO)
|
$16.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:30 /30Days | $654.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$16.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $653.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Fidelis Assist (HMO-POS)
|
$17.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:30 /30Days | $650.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Fidelis Dual Plus (HMO D-SNP)
|
$21.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $653.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite Plan 3 (PPO)
|
$23.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $640.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H3533-032 (HMO)
|
$23.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $658.56 |
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 H3533-032 (HMO)
|
$23.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $644.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Fidelis Dual Access (HMO D-SNP)
|
$24.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $651.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
VNS Health EasyCare (HMO)
|
$25.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $575.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
Healthfirst CompleteCare (HMO D-SNP)
|
$26.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
19% | 19% | Q:30 /30Days | $651.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
Healthfirst Increased Benefits Plan (HMO)
|
$29.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $651.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Discover Value Plan (PPO)
|
$30.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $640.76 |
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 |
Healthfirst Life Improvement Plan (HMO D-SNP)
|
$32.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
16% | 16% | Q:30 /30Days | $651.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 2 (HMO-POS)
|
$34.00 |
$295 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $644.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Plan 2 (HMO-POS D-SNP)
|
$34.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:30 /30Days | $645.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Plan 2 (HMO-POS D-SNP)
|
$34.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:30 /30Days | $655.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Nursing Home Plan 2 (HMO I-SNP)
|
$35.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:30 /30Days | $645.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$35.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $643.51 |
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 Assure Plan (HMO D-SNP)
|
$36.50 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:30 /30Days | $640.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
Elderplan Assist (HMO I-SNP)
|
$38.00 |
$505* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $94.00 | Q:30 /30Days | $577.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
RiverSpring MAP (HMO D-SNP)
|
$38.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $568.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
RiverSpring Star (HMO I-SNP)
|
$38.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $568.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
ArchCare Advantage (HMO I-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $577.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Centers Plan for Dual Coverage Care (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $576.43 |
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 |
Centers Plan for Medicaid Advantage Plus (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $583.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
Centers Plan for Nursing Home Care (HMO I-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $583.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
Elderplan Advantage For Nursing Home Residents (HMO I-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $577.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Elderplan Extra Help (HMO)
|
$38.90 |
$505* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $94.00 | Q:30 /30Days | $577.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Elderplan For Medicaid Beneficiaries (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $577.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Elderplan Plus Long Term Care (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $577.04 |
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 |
EmblemHealth VIP Dual (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $567.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Dual (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $572.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Dual (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $590.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Dual Reserve (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $567.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
Empire MediBlue Dual Advantage (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $662.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Empire MediBlue Dual Advantage Select (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $663.27 |
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 |
Empire MediBlue Extra Select (HMO)
|
$38.90 |
$505 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $662.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
Empire MediBlue HealthPlus Dual Connect (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $662.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Empire MediBlue HealthPlus Dual Plus (HMO D-SNP)
|
$38.90 |
$450 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $662.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Hamaspik Medicare Choice (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $580.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
Hamaspik Medicare Select (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $580.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H3533-034 (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:30 /30Days | $643.73 |
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 H3533-034 (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:30 /30Days | $648.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
MetroPlus Advantage Plan (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $568.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
MetroPlus UltraCare (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $568.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Whole Health of New York NHC (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $568.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:30 /30Days | $645.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:30 /30Days | $655.01 |
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 Plan 1 (HMO-POS D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:30 /30Days | $645.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Plan 1 (HMO-POS D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:30 /30Days | $655.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:30 /30Days | $647.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
VillageCareMAX Medicare Health Advantage (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $573.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
VillageCareMAX Medicare Health Advantage FLEX (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $573.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
VNS Health EasyCare Plus (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $575.98 |
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 |
VNS Health Total (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
20% | 20% | Q:30 /30Days | $575.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $651.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Medicare Advantage Choice Plan 3 (Regional PPO)
|
$44.00 |
$100 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $649.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 1 (HMO-POS)
|
$52.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $644.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Medicare Advantage Choice Plan 4 (Regional PPO)
|
$82.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $649.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Gold (HMO)
|
$93.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days | $578.10 |
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 |
EmblemHealth VIP Gold (HMO)
|
$93.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days | $590.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Gold (HMO)
|
$93.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days | $574.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Gold (HMO)
|
$93.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days | $567.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plan (PPO)
|
$97.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $640.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
VillageCareMAX Medicare Total Advantage (HMO D-SNP)
|
$125.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $573.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
MetroPlus Platinum Plan (HMO)
|
$142.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $568.15 |
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 |
EmblemHealth VIP Gold Plus (HMO)
|
$254.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days | $570.93 |
Browse Plan Formulary all covered insulin pay $35 or less |