XCOPRI 350 MG DAILY DOSE PACK TABLET (TABLETS ) (NDC: 71699010356)
2023 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
See your cost using a drug discount card: Compare prices at pharmacies near you |
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. | 5 |
Specialty Tier |
33% | n/a | P Q:56 /28Days | $2,398.19 |
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. | 5 |
Specialty Tier |
33% | n/a | P Q:56 /28Days | $2,398.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Rebate (HMO-POS)
|
$0.00 |
$395 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
26% | n/a | P Q:56 /28Days | $2,398.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | Q:56 /28Days | $2,407.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | Q:56 /28Days | $2,407.20 |
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 |
Aetna Medicare Premier Plus (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | Q:56 /28Days | $2,407.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueMedicare Premier (HMO)
|
$0.00 |
$100 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
31% | n/a | None | $2,320.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueMedicare Saver Choice (PPO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
29% | n/a | None | $2,320.80 |
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 | 5 |
Specialty Tier |
33% | n/a | P Q:56 /28Days | $2,364.29 |
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 | 5 |
Specialty Tier |
33% | n/a | P Q:56 /28Days | $2,364.29 |
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 | 5 |
Specialty Tier |
33% | n/a | P Q:56 /28Days | $2,364.29 |
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 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:56 /28Days | $2,364.29 |
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 | 5 |
Specialty Tier |
33% | n/a | P Q:56 /28Days | $2,364.29 |
Browse Plan Formulary all covered insulin pay $35 or less |
Essence Advantage (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:56 /28Days | $2,210.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Essence Advantage Plus (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:56 /28Days | $2,210.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Health Advantage Blue Classic (HMO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
29% | n/a | None | $2,320.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Health Advantage Blue Classic (HMO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
29% | n/a | None | $2,320.80 |
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 |
Health Advantage Blue Classic (HMO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
29% | n/a | None | $2,320.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Health Advantage Blue Premier (HMO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
29% | n/a | None | $2,320.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H5619-111 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | Q:56 /28Days | $2,329.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-231 (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | Q:56 /28Days | $2,329.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-337 (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | Q:56 /28Days | $2,329.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-337 (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | Q:56 /28Days | $2,329.54 |
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 H5216-337 (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | Q:56 /28Days | $2,329.54 |
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. | 5 |
Specialty Tier |
33% | n/a | P Q:56 /28Days | $2,398.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Vantage BASIC (HMO-POS)
|
$0.00 |
$505 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$100.00 | $300.00 | P | $2,829.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Vantage Giveback (HMO-POS)
|
$0.00 |
$505 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$100.00 | $300.00 | P | $2,828.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback (HMO)
|
$0.00 |
$445 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | Q:56 /28Days | $2,425.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback Dividend (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | Q:56 /28Days | $2,425.33 |
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 |
Wellcare No Premium (HMO)
|
$0.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
29% | n/a | Q:56 /28Days | $2,425.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Preferred (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | Q:56 /28Days | $2,425.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Medicare Silver (Regional PPO C-SNP)
|
$7.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | P Q:56 /28Days | $2,398.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
|
$17.30 |
$270 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | Q:56 /28Days | $2,425.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP)
|
$19.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:56 /28Days | $2,398.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist Compass (HMO)
|
$19.60 |
$95 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | Q:56 /28Days | $2,425.33 |
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 |
HumanaChoice H9070-005 (PPO)
|
$20.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | Q:56 /28Days | $2,329.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$20.70 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:56 /28Days | $2,431.95 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Liberty (HMO D-SNP)
|
$20.70 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:56 /28Days | $2,431.95 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Medicare Advantage Choice Plan 3 (Regional PPO)
|
$21.00 |
$245 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
29% | n/a | P Q:56 /28Days | $2,398.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Assure (HMO D-SNP)
|
$22.10 |
$505 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
$0.00 | $0.00 | Q:56 /28Days | $2,407.49 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tribute Select (HMO-POS I-SNP)
|
$26.10 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | Q:56 /28Days | $2,209.44 |
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 |
AARP Medicare Advantage Plan 2 (HMO-POS)
|
$27.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:56 /28Days | $2,398.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueMedicare Value Choice (PPO)
|
$29.00 |
$150 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
30% | n/a | None | $2,320.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H5619-122 (HMO)
|
$29.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | Q:56 /28Days | $2,329.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueMedicare Independence (HMO)
|
$31.30 |
$505 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $2,320.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H5619-123 (HMO-POS D-SNP)
|
$31.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
$0.00 | $0.00 | Q:56 /28Days | $2,329.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tribute Advantage (HMO-POS D-SNP)
|
$31.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:56 /28Days | $2,209.44 |
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 |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$31.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
$0.00 | $0.00 | P Q:56 /28Days | $2,398.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Choice Select (PPO D-SNP)
|
$31.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
15% | 15% | P Q:56 /28Days | $2,398.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Vantage DUAL PLUS (HMO-POS D-SNP)
|
$31.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | P | $2,827.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Vantage STANDARD (HMO-POS)
|
$31.90 |
$505 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$100.00 | $300.00 | P | $2,827.95 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO-POS D-SNP)
|
$31.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:56 /28Days | $2,431.95 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Liberty (HMO-POS D-SNP)
|
$31.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:56 /28Days | $2,431.95 |
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 (HMO)
|
$35.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | Q:56 /28Days | $2,425.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueMedicare Premier Choice (PPO)
|
$49.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $2,320.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R1532-002 (Regional PPO)
|
$54.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | Q:56 /28Days | $2,329.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Medicare Advantage Choice Plan 2 (Regional PPO)
|
$56.00 |
$275 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
28% | n/a | P Q:56 /28Days | $2,398.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-083 (PPO)
|
$68.00 |
$195 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
30% | n/a | Q:56 /28Days | $2,329.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueMedicare Preferred (PFFS)
|
$69.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $2,320.80 |
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 |
BlueMedicare Preferred (PFFS)
|
$69.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $2,320.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueMedicare Preferred (PFFS)
|
$69.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $2,320.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Choice H8145-122 (PFFS)
|
$131.00 |
$195 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
30% | n/a | Q:56 /28Days | $2,329.54 |
Browse Plan Formulary all covered insulin pay $35 or less |