MIRTAZAPINE 7.5 MG TABLET (30 TABLETS ) (NDC: 13107000130)
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 Choice Plan 2 (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$10.00 | $0.00 | None | $32.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Flex Plan 1 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $0.00 | None | $32.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Butler Prime (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $28.25 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Central Value (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $10.00 | Q:30 /30Days | $25.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Credit Value (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $10.00 | Q:30 /30Days | $21.40 |
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 Advantra Silver (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $24.89 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $24.05 |
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. | 2 |
Generic |
$0.00 | $0.00 | None | $58.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $58.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Savings Medicare (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $58.22 |
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 |
$42.00 | $120.00 | None | $53.22 |
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 |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $120.00 | None | $54.20 |
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 |
$42.00 | $120.00 | None | $53.95 |
Browse Plan Formulary all covered insulin pay $35 or less |
Complete Blue PPO Signature (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $120.00 | None | $54.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
Complete Blue PPO Signature (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $120.00 | None | $53.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H6622-054 (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $31.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana USAA Honor with Rx (PPO)
|
$0.00 |
$250* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $0.00 | None | $29.20 |
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 |
HumanaChoice H5525-051 (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $0.00 | None | $29.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-051 (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $0.00 | None | $27.85 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-058 (PPO)
|
$0.00 |
$505* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $0.00 | None | $29.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-060 (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $29.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Premier Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $117.50 | None | $44.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life PPO Premier Rx (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $117.50 | None | $45.65 |
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 Giveback (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $74.00 | None | $40.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback Open (PPO)
|
$0.00 |
$350 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$37.00 | $74.00 | None | $40.80 |
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. | 3 |
Preferred Brand |
$37.00 | $74.00 | None | $40.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$160 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $74.00 | None | $40.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
|
$13.50 |
$445 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $48.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist Open (PPO)
|
$14.20 |
$395 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $48.62 |
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 Advantra Silver (PPO)
|
$17.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $25.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-017 (PPO)
|
$18.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $29.25 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Deductible Rx (HMO)
|
$22.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | $20.00 | None | $44.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life PPO Rx Choice (PPO)
|
$23.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | $20.00 | None | $45.65 |
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 |
$0.00 | $0.00 | None | $48.90 |
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 | 2 |
Tier 2 |
$0.00 | $0.00 | Q:30 /30Days | $26.34 |
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 |
Cigna TotalCare Plus (HMO D-SNP)
|
$24.70 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $58.95 |
Browse Plan Formulary all covered insulin pay $35 or less |
Complete Blue PPO Distinct (PPO)
|
$25.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $120.00 | None | $54.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
Complete Blue PPO Distinct (PPO)
|
$25.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $120.00 | None | $53.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Complete Blue PPO Distinct (PPO)
|
$25.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $120.00 | None | $53.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Plus Medicare (HMO)
|
$26.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $58.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Plus Medicare (PPO)
|
$27.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $58.22 |
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 |
Wellcare Low Premium Open (PPO)
|
$29.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $74.00 | None | $40.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$31.10 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $48.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice SNP-DE H5216-227 (PPO D-SNP)
|
$32.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $30.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Flex Plan 2 (HMO-POS)
|
$33.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$10.00 | $0.00 | None | $32.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life PPO High Deductible Rx (PPO)
|
$33.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | $20.00 | None | $45.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete (HMO-POS D-SNP)
|
$33.90 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $27.54 |
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 |
AARP Medicare Advantage Choice Plan 1 (PPO)
|
$35.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $0.00 | None | $32.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Gold (HMO)
|
$35.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $25.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx Choice (HMO)
|
$36.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | $20.00 | None | $44.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Select (HMO-POS D-SNP)
|
$38.10 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $27.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
|
$41.00 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $26.89 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Caritas VIP Care (HMO D-SNP)
|
$41.10 |
$505 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$8.00 | $24.00 | None | $25.69 |
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 |
15% | 15% | Q:30 /30Days | $22.09 |
Browse Plan Formulary all covered insulin pay $35 or less |
Highmark Wholecare Medicare Assured Diamond (HMO D-SNP)
|
$41.10 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$11.00 | $33.00 | None | $59.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP)
|
$41.10 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$13.00 | $39.00 | None | $59.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$41.10 |
$505 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $27.54 |
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 |
$30.00 | $60.00 | None | $44.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Silver (HMO)
|
$47.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $10.00 | Q:30 /30Days | $21.40 |
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 |
Security Blue HMO-POS ValueRx (HMO-POS)
|
$54.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $115.00 | None | $53.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Security Blue HMO-POS ValueRx (HMO-POS)
|
$54.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $115.00 | None | $53.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
Freedom Blue PPO ValueRx (PPO)
|
$68.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $115.00 | None | $53.26 |
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 | 2 |
Generic |
$20.00 | $0.00 | None | $29.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx (HMO)
|
$81.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$10.00 | $20.00 | None | $44.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-120 (PPO)
|
$123.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $0.00 | None | $29.20 |
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 |
Freedom Blue PPO Select (PPO)
|
$127.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $115.00 | None | $53.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life PPO Rx Enhanced (PPO)
|
$134.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | $20.00 | None | $45.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
Security Blue HMO-POS Standard (HMO-POS)
|
$159.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$44.00 | $110.00 | None | $51.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Security Blue HMO-POS Standard (HMO-POS)
|
$159.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$44.00 | $110.00 | None | $52.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Gold Plan (PPO)
|
$176.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $10.00 | Q:30 /30Days | $21.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Security Blue HMO-POS Deluxe (HMO-POS)
|
$220.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $105.00 | None | $51.07 |
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 |
Security Blue HMO-POS Deluxe (HMO-POS)
|
$220.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $105.00 | None | $52.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
Freedom Blue PPO Classic (PPO)
|
$250.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $115.00 | None | $53.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx Enhanced (HMO)
|
$295.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | $20.00 | None | $44.61 |
Browse Plan Formulary all covered insulin pay $35 or less |