DEMECLOCYCLINE 150 MG TABLET [Declomycin] (60 TABLETS ) (NDC: 65162055410)
2024 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 from UHC NC-0014 (HMO-POS)
|
$0.00 |
$435 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $110.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC NC-0015 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $110.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC NC-0017 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $112.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $112.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$99.00 | $198.00 | None | $376.90 |
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 |
Blue Medicare Essential (HMO)
|
$0.00 |
$375 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$99.00 | $198.00 | None | $383.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare Essential (HMO)
|
$0.00 |
$375 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$99.00 | $198.00 | None | $397.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare Essential Plus (HMO-POS)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$99.00 | $198.00 | None | $391.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare Essential Plus (HMO-POS)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$99.00 | $198.00 | None | $383.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare Essential Plus (HMO-POS)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$99.00 | $198.00 | None | $412.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare Essential Plus (HMO-POS)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$99.00 | $198.00 | None | $376.79 |
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 |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $382.63 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $427.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $421.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $435.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $398.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Select Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $387.04 |
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 Medicare (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $382.63 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $427.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $421.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $435.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
HealthTeam Advantage Cardinal Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $282.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
|
$0.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $282.40 |
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 |
HealthTeam Advantage Plan I (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $282.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$0.00 |
$145 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:240 /30Days | $340.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H1036-291 (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:240 /30Days | $340.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-017 (PPO)
|
$0.00 |
$265 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:240 /30Days | $341.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-035 (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:240 /30Days | $340.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-050 (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:240 /30Days | $340.47 |
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 |
HumanaChoice H5525-071 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:240 /30Days | $340.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Liberty Medicare Advantage (HMO C-SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | None | $530.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare Enhanced (HMO-POS)
|
$19.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$99.00 | $198.00 | None | $383.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare Enhanced (HMO-POS)
|
$19.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$99.00 | $198.00 | None | $403.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare Enhanced (HMO-POS)
|
$19.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$99.00 | $198.00 | None | $393.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Plus Medicare (HMO)
|
$24.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $398.72 |
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 |
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
|
$29.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $112.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare PPO Enhanced (PPO)
|
$29.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$99.00 | $198.00 | None | $383.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare PPO Enhanced (PPO)
|
$29.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$99.00 | $198.00 | None | $395.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
|
$29.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $112.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Care Advantage NC-E001 (HMO-POS I-SNP)
|
$31.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $116.35 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare (HMO D-SNP)
|
$33.80 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $398.72 |
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 |
UHC Nursing Home Plan NC-F002 (HMO-POS I-SNP)
|
$35.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $119.29 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC NC-0016 (PPO)
|
$39.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $112.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare Plus (HMO D-SNP)
|
$39.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $398.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Care Advantage SC-E001 (PPO I-SNP)
|
$45.70 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $107.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
|
$46.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $530.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Healthy Blue + Medicare (HMO-POS D-SNP)
|
$46.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $279.91 |
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 |
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
|
$46.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:240 /30Days | $340.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H1036-307 (HMO D-SNP)
|
$46.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | Q:240 /30Days | $340.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H1036-309 (HMO D-SNP)
|
$46.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | Q:240 /30Days | $340.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-070 (PPO)
|
$46.90 |
$545 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:240 /30Days | $340.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice SNP-DE H5525-036 (PPO D-SNP)
|
$46.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:240 /30Days | $340.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice SNP-DE H5525-072 (PPO D-SNP)
|
$46.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | Q:240 /30Days | $340.47 |
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 |
HumanaChoice SNP-DE H5525-073 (PPO D-SNP)
|
$46.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | Q:240 /30Days | $340.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Liberty Medicare Dual Plan (HMO D-SNP)
|
$46.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $530.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Longevity Health Plan (HMO I-SNP)
|
$46.90 |
$545 |
to be determined |
1 |
Tier 1 |
25% | n/a | None | $328.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
|
$46.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $114.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete NC-S001 (PPO D-SNP)
|
$46.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $113.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
|
$46.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $114.39 |
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 |
HealthTeam Advantage Plan II (PPO)
|
$50.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $282.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-211 (PPO)
|
$55.00 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:240 /30Days | $343.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R1390-002 (Regional PPO)
|
$105.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:240 /30Days | $336.85 |
Browse Plan Formulary all covered insulin pay $35 or less |