HYDROCODONE-ACETAMIN 7.5-300 TABLET [Xodol] (60 TABLETS ) (NDC: 00406037705)
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 |
Aetna Medicare Choice (HMO-POS)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days | $24.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Credit (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:180 /30Days | $50.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days | $22.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$3.00 | $9.00 | Q:180 /30Days | $21.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Select Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$0.00 | $0.00 | Q:180 /30Days | $21.73 |
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 |
AvMed Medicare Access (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | $75.00 | Q:390 /30Days | $33.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
AvMed Medicare Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$25.00 | $62.50 | Q:390 /30Days | $33.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
AvMed Medicare Circle (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$0.00 | $0.00 | Q:390 /30Days | $33.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
AvMed Medicare One (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$0.00 | $0.00 | Q:390 /30Days | $33.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueMedicare Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | Q:180 /30Days | $59.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueMedicare Premier (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$50.00 | $150.00 | Q:180 /30Days | $59.21 |
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 |
CareBreeze Platinum (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$25.00 | $65.00 | Q:390 /30Days | $14.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
CareComplete Platinum (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$25.00 | $65.00 | Q:390 /30Days | $14.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
CareFree (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:390 /30Days | $14.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
CareFree Platinum (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:390 /30Days | $14.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
CareOne Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$0.00 | $0.00 | Q:390 /30Days | $14.21 |
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. |
3 |
Preferred Brand |
$0.00 | $0.00 | Q:390 /30Days | $44.36 |
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 Savings Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$10.00 | $30.00 | Q:390 /30Days | $44.36 |
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. |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:390 /30Days | $45.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
DrExtraCare (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $39.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
DrMax (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $39.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
DrSelect (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $39.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
DrValue (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $39.72 |
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 |
HealthSun HealthAdvantage Plan (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $90.29 |
Browse Plan Formulary all covered insulin pay $35 or less |
HealthSun HealthAdvantage Plus (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $90.29 |
Browse Plan Formulary all covered insulin pay $35 or less |
HealthSun VitalCare (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $90.29 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $110.00 | Q:390 /30Days | $14.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H1036-054C (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$0.00 | $0.00 | Q:390 /30Days | $14.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H1036-305 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $110.00 | Q:390 /30Days | $14.03 |
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 |
Humana Gold Plus Lung (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $110.00 | Q:390 /30Days | $14.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice Florida H5216-068 (PPO)
|
$0.00 |
$150* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:390 /30Days | $14.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice Florida H5216-311 (PPO)
|
$0.00 |
$350* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:390 /30Days | $14.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice Florida H7284-008 (PPO)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:390 /30Days | $14.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
Leon MediExtra (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Generic |
$0.00 | n/a | Q:180 /30Days | $39.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
Leon MediMore (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Generic |
$0.00 | n/a | Q:180 /30Days | $39.72 |
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 |
Simply Comfort (HMO I-SNP)
|
$0.00 |
$545* |
Yes, this drug has Gap Coverage. |
1* |
Preferred Generic |
$0.00 | n/a | Q:180 /30Days | $79.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Simply Extra (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:180 /30Days | $78.85 |
Browse Plan Formulary all covered insulin pay $35 or less |
Simply Extra Platinum (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:180 /30Days | $78.85 |
Browse Plan Formulary all covered insulin pay $35 or less |
Simply Freedom (PPO)
|
$0.00 |
$125* |
Yes, this drug has Gap Coverage. |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:180 /30Days | $78.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Simply Level (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:180 /30Days | $78.85 |
Browse Plan Formulary all covered insulin pay $35 or less |
Simply Level Platinum (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:180 /30Days | $78.85 |
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 |
Simply More (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:180 /30Days | $78.85 |
Browse Plan Formulary all covered insulin pay $35 or less |
Simply More Platinum (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:180 /30Days | $78.85 |
Browse Plan Formulary all covered insulin pay $35 or less |
Leon MediDual (HMO D-SNP)
|
$14.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
24% | n/a | Q:180 /30Days | $39.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
Simply Complete (HMO D-SNP)
|
$16.80 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$15.00 | $45.00 | Q:180 /30Days | $80.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
HealthSun MediSun Extra (HMO D-SNP)
|
$19.80 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | Q:180 /30Days | $90.29 |
Browse Plan Formulary all covered insulin pay $35 or less |
HealthSun MediMax (HMO)
|
$23.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | Q:180 /30Days | $90.29 |
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 Florida H7284-007 (PPO)
|
$25.00 |
$150* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$30.00 | $80.00 | Q:390 /30Days | $14.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare (HMO D-SNP)
|
$27.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:390 /30Days | $45.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare Plus (HMO D-SNP)
|
$27.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:390 /30Days | $45.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Fully Integrated H1036-280 (HMO D-SNP)
|
$29.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:390 /30Days | $15.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R5826-074 (Regional PPO)
|
$31.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:390 /30Days | $15.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
DrPlus (HMO D-SNP)
|
$31.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | Q:180 /30Days | $39.72 |
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 |
DrFlex (HMO D-SNP)
|
$31.80 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | Q:180 /30Days | $39.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Assure Plus (HMO D-SNP)
|
$32.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | 25% | Q:180 /30Days | $53.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
CareNeeds Platinum (HMO D-SNP)
|
$32.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:390 /30Days | $14.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
CareNeeds Plus (HMO D-SNP)
|
$34.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:390 /30Days | $14.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
Simply Complete Platinum (HMO D-SNP)
|
$37.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$15.00 | $45.00 | Q:180 /30Days | $80.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Assure (HMO D-SNP)
|
$37.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | 25% | Q:180 /30Days | $53.26 |
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 |
BlueMedicare Complete (HMO D-SNP)
|
$37.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | Q:180 /30Days | $59.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H1036-077A (HMO D-SNP)
|
$37.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:390 /30Days | $14.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H1036-304 (HMO D-SNP)
|
$37.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:390 /30Days | $14.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice Florida SNP-DE H7284-010 (PPO D-SNP)
|
$37.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:390 /30Days | $14.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R5826-005 (Regional PPO)
|
$173.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:390 /30Days | $15.08 |
Browse Plan Formulary all covered insulin pay $35 or less |