TRINTELLIX 20 MG TABLET (30 EA ) (NDC: 64764075030)
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. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $505.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Choice Plan 2 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:30 /30Days | $505.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $503.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $503.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Access (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:30 /30Days | $520.18 |
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 |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:30 /30Days | $520.06 |
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 | Q:30 /30Days | $520.04 |
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 | Q:30 /30Days | $520.16 |
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 | Q:30 /30Days | $520.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
CommuniCare Advantage CSNP (HMO C-SNP)
|
$0.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$92.00 | $270.00 | S Q:30 /30Days | $447.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
CommuniCare Advantage CSNP (HMO C-SNP)
|
$0.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$92.00 | $270.00 | S Q:30 /30Days | $457.33 |
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 |
CommuniCare Advantage CSNP (HMO C-SNP)
|
$0.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$92.00 | $270.00 | S Q:30 /30Days | $430.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$0.00 |
$445 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | S Q:30 /30Days | $506.27 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H5619-049 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $505.49 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana USAA Honor with Rx (PPO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $505.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-114 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $505.24 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-192 (PPO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $506.41 |
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 H5216-309 (PPO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $504.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
IU Health Plans Medicare Flex Network (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | P Q:30 /30Days | $446.87 |
Browse Plan Formulary all covered insulin pay $35 or less |
IU Health Plans Medicare Kidney Care (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | P Q:30 /30Days | $446.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
IU Health Plans Medicare Select Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | P Q:30 /30Days | $447.25 |
Browse Plan Formulary all covered insulin pay $35 or less |
IU Health Plans Medicare Select Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | P Q:30 /30Days | $446.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
IU Health Plans Medicare Select Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | P Q:30 /30Days | $447.08 |
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 |
MDwise Medicare Inspire (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $105.75 | Q:30 /30Days | $452.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
MyTruAdvantage Choice (PPO)
|
$0.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $300.00 | Q:30 /30Days | $454.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
MyTruAdvantage Choice (PPO)
|
$0.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $300.00 | Q:30 /30Days | $454.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
MyTruAdvantage Choice Plus (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $300.00 | Q:30 /30Days | $454.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
MyTruAdvantage Choice Plus (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $300.00 | Q:30 /30Days | $454.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
MyTruAdvantage Select (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $300.00 | Q:30 /30Days | $454.20 |
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 |
MyTruAdvantage Select (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $300.00 | Q:30 /30Days | $454.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback (HMO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | Q:30 /30Days | $510.47 |
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. |
4 |
Non-Preferred Drug |
43% | 43% | Q:30 /30Days | $510.47 |
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 |
4 |
Non-Preferred Drug |
44% | 44% | Q:30 /30Days | $510.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Zing Choice IN (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | S Q:30 /30Days | $475.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Zing Essential Wellness Diabetes and Heart IN (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | S Q:30 /30Days | $475.78 |
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 |
Zing Premium Giveback IN (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | S Q:30 /30Days | $475.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Zing Signature Care IN (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | S Q:30 /30Days | $475.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
|
$12.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
47% | 47% | Q:30 /30Days | $510.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Low Premium Open (PPO)
|
$15.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
44% | 44% | Q:30 /30Days | $510.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Access Preferred (PPO)
|
$19.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:30 /30Days | $520.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Extra (HMO)
|
$21.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | Q:30 /30Days | $520.18 |
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 |
AARP Medicare Advantage Choice Plan 1 (PPO)
|
$22.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:30 /30Days | $505.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Assure Premier (HMO D-SNP)
|
$23.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:30 /30Days | $503.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier (PPO)
|
$24.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $503.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Choice Select (PPO D-SNP)
|
$24.40 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | Q:30 /30Days | $506.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
MDwise Medicare Inspire Plus (HMO)
|
$25.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $105.75 | Q:30 /30Days | $452.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Zing Open Access IN (HMO-POS)
|
$25.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | S Q:30 /30Days | $475.78 |
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 Access Open (PPO D-SNP)
|
$26.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $512.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Dual Advantage (HMO D-SNP)
|
$28.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $520.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
CareSource Dual Advantage (HMO D-SNP)
|
$28.10 |
$505 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
25% | 25% | Q:30 /30Days | $435.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
CommuniCare Advantage ISNP (HMO I-SNP)
|
$28.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | Q:30 /30Days | $438.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
CommuniCare Advantage ISNP (HMO I-SNP)
|
$28.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | Q:30 /30Days | $457.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
CommuniCare Advantage ISNP (HMO I-SNP)
|
$28.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | Q:30 /30Days | $422.32 |
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 H5619-054 (HMO D-SNP)
|
$28.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | S Q:30 /30Days | $506.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Value Plus H5216-193 (PPO)
|
$28.10 |
$260 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | S Q:30 /30Days | $506.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
MDwise Medicare Inspire Duals (HMO D-SNP)
|
$28.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $452.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$28.10 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $505.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete (PPO D-SNP)
|
$28.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:30 /30Days | $506.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$28.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | Q:30 /30Days | $505.81 |
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 |
Wellcare Dual Access (HMO D-SNP)
|
$28.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $512.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
Zing Dual Complete Plus IN (HMO-POS D-SNP)
|
$28.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | S Q:30 /30Days | $475.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Zing Dual Platinum Plus IN (HMO-POS D-SNP)
|
$28.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | S Q:30 /30Days | $475.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R0865-003 (Regional PPO)
|
$33.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $504.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
MDwise Medicare Inspire Flex (HMO-POS)
|
$49.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $105.75 | Q:30 /30Days | $452.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Access Plus (PPO)
|
$54.00 |
$60 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:30 /30Days | $520.19 |
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 H5216-053 (PPO)
|
$55.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $505.35 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Access Basic (Regional PPO)
|
$81.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
46% | 46% | Q:30 /30Days | $520.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Choice H8145-032 (PFFS)
|
$82.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $504.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
IU Health Plans Medicare Choice (HMO-POS)
|
$98.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | P Q:30 /30Days | $446.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plus (HMO-POS)
|
$187.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $503.52 |
Browse Plan Formulary all covered insulin pay $35 or less |