ACETAZOLAMIDE 250 MG TABLET [Diamox] (30 TABLETS ) (NDC: 64380083406)
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. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $23.31 |
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. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $23.31 |
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 | None | $49.25 |
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 | None | $50.63 |
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 |
1* |
Preferred Generic |
$2.00 | $6.00 | None | $17.41 |
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 |
1* |
Preferred Generic |
$2.00 | $6.00 | None | $17.41 |
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 |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $8.64 |
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. |
1 |
Tier 1 |
0% | 0% | None | $7.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
eternalHealth Forever (HMO)
|
$0.00 |
$185 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $47.00 | None | $25.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
eternalHealth Freedom (PPO)
|
$0.00 |
$185 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $47.00 | None | $25.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
eternalHealth Give Back (PPO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $47.00 | None | $25.31 |
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 |
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 | $16.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-138 (PPO)
|
$0.00 |
$275 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $9.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-249 (PPO)
|
$0.00 |
$295 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $9.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Mass Advantage Basic (HMO)
|
$0.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $21.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
Mass Advantage Premiere (PPO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | None | $21.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
Mass General Brigham Advantage (PPO)
|
$0.00 |
$275 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$37.00 | $74.00 | None | $50.32 |
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 SaverRx (HMO)
|
$0.00 |
$300* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$8.00 | $16.00 | None | $37.37 |
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 | None | $37.37 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Health Unify (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Tier 2 |
0% | 0% | None | $10.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred Access (PPO)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$4.00 | $8.00 | None | $8.24 |
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. |
2* |
Generic |
$4.00 | $8.00 | None | $8.18 |
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. |
2* |
Generic |
$2.00 | $4.00 | None | $8.18 |
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 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 | $23.19 |
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 | $23.06 |
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 |
3 |
Preferred Brand |
$35.00 | $70.00 | None | $23.06 |
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 |
3 |
Preferred Brand |
$37.00 | $74.00 | None | $23.06 |
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 |
3 |
Tier 3 |
$0.00 | $0.00 | None | $23.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-250 (PPO)
|
$19.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $9.22 |
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 |
CCA Medicare Value (PPO)
|
$20.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $8.64 |
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 |
3 |
Tier 3 |
$0.00 | $0.00 | None | $23.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Central Green HMO (HMO)
|
$33.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$7.00 | $14.00 | None | $16.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
eternalHealth ForeverMore (HMO)
|
$35.00 |
$170 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $47.00 | None | $25.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
Longevity Health Plan (HMO I-SNP)
|
$36.20 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $33.45 |
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 | $17.27 |
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 |
CCA Senior Care Options (HMO D-SNP)
|
$36.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
25% | 25% | None | $8.64 |
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 | $16.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Whole Health (HMO D-SNP)
|
$36.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $62.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Whole Health NHC (HMO D-SNP)
|
$36.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $62.28 |
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 | $10.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 | $10.47 |
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 |
AARP Medicare Advantage Plan 2 (HMO-POS)
|
$47.00 |
$175 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $23.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
CCA Medicare Premier (PPO)
|
$50.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $8.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$51.00 |
$225* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$4.00 | $8.00 | None | $10.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 | $16.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Mass General Brigham Advantage Secure (HMO-POS)
|
$52.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$37.00 | $74.00 | None | $50.32 |
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. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $23.77 |
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)
|
$55.00 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$6.00 | $12.00 | None | $37.37 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue ValueRx (HMO)
|
$55.00 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$6.00 | $12.00 | None | $37.37 |
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 |
3 |
Preferred Brand |
$35.00 | $70.00 | None | $23.06 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare PPO Blue ValueRx (PPO)
|
$85.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$6.00 | $12.00 | None | $37.37 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare PPO Blue ValueRx (PPO)
|
$85.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$6.00 | $12.00 | None | $37.37 |
Browse Plan Formulary all covered insulin pay $35 or less |
Mass Advantage Plus (HMO)
|
$100.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $21.03 |
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 FlexRx (HMO-POS)
|
$105.00 |
$260* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$5.00 | $10.00 | None | $37.37 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue FlexRx (HMO-POS)
|
$105.00 |
$260* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$5.00 | $10.00 | None | $37.37 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Green HMO (HMO)
|
$119.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$7.00 | $14.00 | None | $16.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Green HMO (HMO)
|
$119.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$7.00 | $14.00 | None | $16.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Green HMO (HMO)
|
$119.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$7.00 | $14.00 | None | $16.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Central Blue HMO (HMO)
|
$128.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $14.00 | None | $16.53 |
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 |
Mass General Brigham Advantage Premier (PPO)
|
$140.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$37.00 | $74.00 | None | $50.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$174.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$4.00 | $8.00 | None | $10.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$204.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$8.00 | $16.00 | None | $12.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Blue HMO (HMO)
|
$238.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $14.00 | None | $16.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Blue HMO (HMO)
|
$238.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $14.00 | None | $16.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Blue HMO (HMO)
|
$238.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $14.00 | None | $16.53 |
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 |
Medicare PPO Blue PlusRx (PPO)
|
$254.00 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$5.00 | $10.00 | None | $37.37 |
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 | None | $37.37 |
Browse Plan Formulary all covered insulin pay $35 or less |