ZIPRASIDONE HCL 40 MG CAPSULE [Geodon] (60.000 EA ) (NDC: 55111025760)
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 Plan 2 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $66.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Walgreens (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $62.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $54.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Preferred Plan (PPO)
|
$0.00 |
$200* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $60.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $51.44 |
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 |
Aetna Medicare Value Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $60.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plus Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $60.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:120 /30Days | $128.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Comfort (HMO I-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$7.50 | $0.00 | Q:120 /30Days | $34.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage ESRD Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:120 /30Days | $128.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Health Plan of WA MA Plan 1 (HMO)
|
$0.00 |
$230* |
No additional gap coverage, only the Donut Hole Discount |
4* |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days | $54.10 |
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 |
Humana Gold Plus H5619-100 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $26.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-247 (PPO)
|
$0.00 |
$175 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $26.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
Kaiser Permanente Medicare Advantage Key (HMO)
|
$0.00 |
$100* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$10.00 | $0.00 | None | $47.95 |
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:60 /30Days | $171.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
PacificSource Medicare Explorer Rx 11 (PPO)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$12.00 | $24.00 | Q:60 /30Days | $103.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
PacificSource Medicare MyCare Choice Rx 34 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$9.00 | $18.00 | Q:60 /30Days | $99.89 |
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 |
Premera Blue Cross Medicare Advantage (HMO)
|
$0.00 |
$160* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$12.00 | $36.00 | Q:60 /30Days | $82.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
Premera Blue Cross Medicare Advantage Peak + Rx (HMO)
|
$0.00 |
$160* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$12.00 | $36.00 | Q:60 /30Days | $82.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence BlueAdvantage HMO (HMO)
|
$0.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$12.00 | $0.00 | Q:90 /30Days | $29.09 |
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 |
$90.00 | $180.00 | Q:60 /30Days | $83.47 |
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 |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:60 /30Days | $83.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:60 /30Days | $83.47 |
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)
|
$12.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
42% | 42% | Q:60 /30Days | $179.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Choice (PPO)
|
$19.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:60 /30Days | $65.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Amerivantage Dual Coordination (HMO D-SNP)
|
$19.40 |
$410 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:120 /30Days | $128.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$21.40 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days | $130.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Liberty (HMO D-SNP)
|
$22.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days | $130.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$23.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days | $130.22 |
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 |
Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)
|
$23.90 |
$450 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $26.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)
|
$23.90 |
$450 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $26.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)
|
$23.90 |
$450 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $26.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)
|
$23.90 |
$450 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $26.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence MedAdvantage + Rx Primary (PPO)
|
$28.00 |
$325* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$13.00 | $0.00 | Q:90 /30Days | $28.94 |
Browse Plan Formulary all covered insulin pay $35 or less |
Kaiser Permanente Medicare Advantage Vital (HMO)
|
$29.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.00 | $0.00 | None | $50.72 |
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 Value Plus H5619-134 (HMO)
|
$31.00 |
$450 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | 25% | None | $26.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
Premera Blue Cross Medicare Advantage Sound + Rx (HMO)
|
$34.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$12.00 | $36.00 | Q:60 /30Days | $82.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete (HMO-POS D-SNP)
|
$40.10 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:60 /30Days | $66.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Health Plan of WA Dual Plan (HMO D-SNP)
|
$41.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:60 /30Days | $50.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Health Plan of WA MA Plan 2 (HMO)
|
$41.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days | $51.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Complete Care (HMO D-SNP)
|
$41.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
46% | 46% | Q:60 /30Days | $171.52 |
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 |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$41.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
46% | 46% | Q:60 /30Days | $171.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$41.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $66.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$41.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:60 /30Days | $66.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Select (HMO-POS D-SNP)
|
$41.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:60 /30Days | $66.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$41.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:60 /30Days | $66.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 3 (HMO-POS)
|
$43.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:60 /30Days | $66.10 |
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 |
Regence BlueAdvantage HMO Plus (HMO)
|
$47.00 |
$100* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$12.00 | $24.00 | Q:90 /30Days | $29.09 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Choice Plan (PPO)
|
$49.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $58.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plus Plan (HMO-POS)
|
$53.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $54.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Premera Blue Cross Medicare Advantage Classic (HMO)
|
$54.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $30.00 | Q:60 /30Days | $82.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H5619-061 (HMO)
|
$57.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $26.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Health Plan of WA MA Plan 3 (HMO)
|
$70.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days | $57.55 |
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 |
Regence MedAdvantage + Rx Classic (PPO)
|
$77.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$13.00 | $26.00 | Q:90 /30Days | $27.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 1 (HMO-POS)
|
$86.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:60 /30Days | $66.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Select Plan (PPO)
|
$99.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $54.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
Kaiser Permanente Medicare Advantage Essential (HMO)
|
$99.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.00 | $0.00 | None | $50.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence MedAdvantage + Rx Enhanced (PPO)
|
$153.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$8.00 | $16.00 | Q:90 /30Days | $27.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-048 (PPO)
|
$199.00 |
$375 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | 25% | None | $26.45 |
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 |
Kaiser Permanente Medicare Advantage Optimal (HMO)
|
$296.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.00 | $0.00 | None | $50.72 |
Browse Plan Formulary all covered insulin pay $35 or less |