ACITRETIN 17.5 MG CAPSULE [Soriatane] (CAPSULES ) (NDC: 42794008108)
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 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $319.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 1 (HMO-POS)
|
$0.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $319.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $53.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (HMO-POS)
|
$0.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $53.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Align Connect (HMO C-SNP)
|
$0.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $45.00 | None | $543.20 |
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 |
Align Thrive (HMO I-SNP)
|
$0.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $45.00 | None | $543.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
CCA Medicare Preferred (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | None | $680.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
CCA One Care (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Tier 2 |
0% | 0% | None | $600.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Orange HMO (HMO)
|
$0.00 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$7.00 | $14.00 | None | $180.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
Health New England Baystate Health Preferred (HMO)
|
$0.00 |
$270 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $285.00 | None | $130.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
Health New England Medicare Compass (PPO)
|
$0.00 |
$380 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $285.00 | None | $130.31 |
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 New England Medicare Value (HMO)
|
$0.00 |
$380 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $285.00 | None | $130.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue SaverRx (HMO)
|
$0.00 |
$300* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$8.00 | $16.00 | P | $276.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare PPO Blue SaverRx (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $20.00 | P | $276.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Saver Rx (HMO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $158.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Smart Saver Rx (HMO)
|
$0.00 |
$100 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $158.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Connected(r) for One Care (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Tier 1 |
0% | 0% | None | $331.93 |
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 |
Wellcare Giveback Open (PPO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | P | $177.94 |
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 |
45% | 45% | P | $177.94 |
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 |
43% | 43% | P | $177.94 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Senior Care Options NHC (HMO D-SNP)
|
$17.80 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $331.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
CCA Medicare Value (PPO)
|
$20.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | None | $680.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Senior Care Options (HMO D-SNP)
|
$20.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $331.93 |
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 |
Medicare HMO Blue ValueRx (HMO)
|
$35.00 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$6.00 | $12.00 | P | $276.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue ValueRx (HMO)
|
$35.00 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$6.00 | $12.00 | P | $276.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Align Premier (HMO I-SNP)
|
$36.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $512.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
CCA Senior Care Options (HMO D-SNP)
|
$36.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | None | $680.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
NaviCare (HMO D-SNP)
|
$36.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $180.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Health Plan Senior Care Options (HMO D-SNP)
|
$36.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $158.11 |
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 |
Tufts Health Plan Senior Care Options CW (HMO D-SNP)
|
$36.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $158.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
Health New England Medicare Choice (HMO)
|
$46.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $285.00 | None | $130.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 2 (HMO-POS)
|
$47.00 |
$175 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $319.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$48.00 |
$225 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $158.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$48.00 |
$225 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $158.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$48.00 |
$225 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $158.11 |
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 |
Fallon Medicare Plus Super Saver HMO (HMO)
|
$52.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$9.00 | $18.00 | None | $180.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Choice (Regional PPO)
|
$53.00 |
$295 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $317.29 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Premium Enhanced Open (PPO)
|
$60.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
43% | 43% | P | $177.94 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Green HMO (HMO)
|
$66.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$7.00 | $14.00 | None | $180.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Green HMO (HMO)
|
$66.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$7.00 | $14.00 | None | $180.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Green HMO (HMO)
|
$66.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$7.00 | $14.00 | None | $180.16 |
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 |
Medicare PPO Blue ValueRx (PPO)
|
$75.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$6.00 | $12.00 | P | $276.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare PPO Blue ValueRx (PPO)
|
$75.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$6.00 | $12.00 | P | $276.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue FlexRx (HMO-POS)
|
$95.00 |
$260* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$5.00 | $10.00 | P | $276.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue FlexRx (HMO-POS)
|
$95.00 |
$260* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$5.00 | $10.00 | P | $276.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$97.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $158.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$97.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $158.11 |
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 |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$97.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $158.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
Health New England Medicare Compass Premier (PPO)
|
$99.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $285.00 | None | $130.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
Health New England Medicare Plus (HMO)
|
$113.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $285.00 | None | $130.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Blue HMO (HMO)
|
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $14.00 | None | $180.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Blue HMO (HMO)
|
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $14.00 | None | $180.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Blue HMO (HMO)
|
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $14.00 | None | $180.16 |
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 |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$117.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $158.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$117.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $158.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$117.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $158.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$137.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$80.00 | $240.00 | None | $158.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$137.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$80.00 | $240.00 | None | $158.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$137.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$80.00 | $240.00 | None | $158.11 |
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 New England Medicare Premium (HMO)
|
$168.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $285.00 | None | $130.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare PPO Blue PlusRx (PPO)
|
$254.00 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$5.00 | $10.00 | P | $276.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue PlusRx (HMO)
|
$258.00 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$5.00 | $10.00 | P | $276.91 |
Browse Plan Formulary all covered insulin pay $35 or less |