XULTOPHY 100 UNIT-3.6MG/ML PEN (3 ML ) (NDC: 00169291115)
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 |
Aetna Medicare Advantra Credit Value (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $141.00 | Q:15 /30Days | $1,337.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Silver (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $141.00 | Q:15 /30Days | $1,337.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Silver Back (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $141.00 | Q:15 /30Days | $1,337.81 |
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. |
3 |
Preferred Brand |
$35 max* | $141.00 | Q:15 /30Days | $1,337.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $126.00 | Q:15 /30Days | $1,357.13 |
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 Savings Medicare (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $126.00 | Q:15 /30Days | $1,357.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35 max* | $120.00 | Q:15 /30Days | $1,186.35 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35 max* | $120.00 | Q:15 /30Days | $1,185.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35 max* | $120.00 | Q:15 /30Days | $1,186.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35 max* | $120.00 | Q:15 /30Days | $1,185.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35 max* | $120.00 | Q:15 /30Days | $1,190.91 |
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 |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35 max* | $120.00 | Q:15 /30Days | $1,186.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35 max* | $120.00 | Q:15 /30Days | $1,185.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35 max* | $120.00 | Q:15 /30Days | $1,186.35 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic 360 Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $70.50 | S Q:15 /30Days | $1,186.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $70.50 | S Q:15 /30Days | $1,186.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $70.50 | S Q:15 /30Days | $1,186.34 |
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 Choice H8145-052 (PFFS)
|
$0.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35 max* | $131.00 | Q:15 /30Days | $1,339.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H6622-035 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $131.00 | Q:15 /30Days | $1,346.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana USAA Honor with Rx (PPO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $131.00 | Q:15 /30Days | $1,336.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-051 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $131.00 | Q:15 /30Days | $1,340.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-051 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $131.00 | Q:15 /30Days | $1,336.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-058 (PPO)
|
$0.00 |
$505 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $131.00 | Q:15 /30Days | $1,336.93 |
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 H5525-060 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $131.00 | Q:15 /30Days | $1,336.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Silver Plus (PPO)
|
$18.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $141.00 | Q:15 /30Days | $1,337.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-017 (PPO)
|
$18.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $131.00 | Q:15 /30Days | $1,336.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Premier (HMO-POS)
|
$23.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $141.00 | Q:15 /30Days | $1,337.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$24.20 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$35 max* | $0.00 | Q:15 /30Days | $1,359.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Cares (HMO D-SNP)
|
$24.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$35 max* | $0.00 | Q:15 /30Days | $1,337.83 |
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 TotalCare Plus (HMO D-SNP)
|
$24.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$35 max* | $0.00 | Q:15 /30Days | $1,346.35 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare PPO Distinct (PPO)
|
$25.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35 max* | $120.00 | Q:15 /30Days | $1,186.35 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare PPO Distinct (PPO)
|
$25.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35 max* | $120.00 | Q:15 /30Days | $1,187.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare PPO Distinct (PPO)
|
$25.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35 max* | $120.00 | Q:15 /30Days | $1,185.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare PPO Distinct (PPO)
|
$25.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35 max* | $120.00 | Q:15 /30Days | $1,185.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Plus Medicare (PPO)
|
$28.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $126.00 | Q:15 /30Days | $1,357.13 |
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 H5525-006 (PPO)
|
$28.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35 max* | $131.00 | Q:15 /30Days | $1,345.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$29.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$35 max* | $0.00 | Q:15 /30Days | $1,361.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic Complete Rx (HMO)
|
$34.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $70.50 | S Q:15 /30Days | $1,186.35 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic Complete Rx (HMO)
|
$34.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $70.50 | S Q:15 /30Days | $1,186.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H6622-078 (HMO D-SNP)
|
$34.20 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$35 max* | $0.00 | Q:15 /30Days | $1,340.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H6622-078 (HMO D-SNP)
|
$34.20 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$35 max* | $0.00 | Q:15 /30Days | $1,342.22 |
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 |
Geisinger Gold Secure Rx (HMO D-SNP)
|
$41.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$35 max* | 15% | S Q:15 /30Days | $1,185.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Value Plus H5216-117 (PPO)
|
$41.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35 max* | $131.00 | Q:15 /30Days | $1,334.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life Complete Care (HMO D-SNP)
|
$41.10 |
$505 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $60.00 | Q:15 /30Days | $1,203.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $70.50 | S Q:15 /30Days | $1,186.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $70.50 | S Q:15 /30Days | $1,186.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $70.50 | S Q:15 /30Days | $1,186.79 |
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 Silver (HMO)
|
$47.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $141.00 | Q:15 /30Days | $1,337.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Freedom Blue PPO ValueRx (PPO)
|
$66.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35 max* | $115.00 | Q:15 /30Days | $1,186.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R0923-002 (Regional PPO)
|
$71.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35 max* | $131.00 | Q:15 /30Days | $1,336.63 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Premier Plus (PPO)
|
$77.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $111.00 | Q:15 /30Days | $1,337.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$84.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $70.50 | S Q:15 /30Days | $1,186.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$84.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $70.50 | S Q:15 /30Days | $1,186.53 |
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 H5216-120 (PPO)
|
$123.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35 max* | $131.00 | Q:15 /30Days | $1,336.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic Advantage Rx (HMO)
|
$144.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $70.50 | S Q:15 /30Days | $1,185.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic Advantage Rx (HMO)
|
$144.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $70.50 | S Q:15 /30Days | $1,186.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic Advantage Rx (HMO)
|
$144.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $70.50 | S Q:15 /30Days | $1,186.35 |
Browse Plan Formulary all covered insulin pay $35 or less |
Freedom Blue PPO Standard (PPO)
|
$171.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35 max* | $115.00 | Q:15 /30Days | $1,186.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Gold Plan (PPO)
|
$176.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $141.00 | Q:15 /30Days | $1,337.83 |
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 |
Freedom Blue PPO Deluxe (PPO)
|
$285.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35 max* | $115.00 | Q:15 /30Days | $1,186.48 |
Browse Plan Formulary all covered insulin pay $35 or less |