ADEMPAS 2.5 MG TABLET (90 EA ) (NDC: 50419025401)
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 WA-0002 (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P | $14,887.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC WA-0006 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P | $14,887.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC WA-0007 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P | $14,887.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite Plan (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P Q:90 /30Days | $14,612.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Extra Value Plan (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P Q:90 /30Days | $14,612.79 |
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 |
Aetna Medicare Preferred Plan (PPO)
|
$0.00 |
$150 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
30% | n/a | P Q:90 /30Days | $14,612.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare SmartFit Plan (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P Q:90 /30Days | $14,612.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (HMO-POS)
|
$0.00 |
$150 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
30% | n/a | P Q:90 /30Days | $14,612.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Health Plan of WA MA Plan 1 (HMO)
|
$0.00 |
$230 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
29% | n/a | P | $13,310.35 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H2486-006 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P Q:90 /30Days | $13,886.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H5619-063 (HMO)
|
$0.00 |
$500 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
25% | n/a | P Q:90 /30Days | $13,886.50 |
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 H5216-247 (PPO)
|
$0.00 |
$125 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
31% | n/a | P Q:90 /30Days | $13,886.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Kaiser Permanente Medicare Advantage Key (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
31% | 31% | P | $13,921.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
33% | n/a | P Q:90 /30Days | $14,253.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
33% | n/a | P Q:90 /30Days | $14,253.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Premera Blue Cross Medicare Advantage (HMO)
|
$0.00 |
$160 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
30% | n/a | P Q:90 /30Days | $14,510.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Providence Medicare Pine + Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P | $13,449.63 |
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 |
Regence BlueAdvantage HMO (HMO)
|
$0.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
28% | n/a | P Q:90 /30Days | $13,951.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence BlueAdvantage HMO (HMO)
|
$0.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
28% | n/a | P Q:90 /30Days | $13,951.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence MedAdvantage + Rx Core (PPO)
|
$0.00 |
$375 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
27% | n/a | P Q:90 /30Days | $13,951.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback (HMO)
|
$0.00 |
$440 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
26% | n/a | P Q:90 /30Days | $13,319.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Mutual of Omaha No Premium Open (PPO)
|
$0.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
31% | n/a | P Q:90 /30Days | $13,319.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
30% | n/a | P Q:90 /30Days | $13,319.50 |
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 |
Wellpoint Kidney Care (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P | $14,185.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
|
$14.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | n/a | P Q:90 /30Days | $13,319.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$20.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | P Q:90 /30Days | $13,329.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Liberty (HMO D-SNP)
|
$24.90 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | P Q:90 /30Days | $13,329.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Mutual of Omaha Low Premium Open (PPO)
|
$29.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
33% | n/a | P Q:90 /30Days | $13,319.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Dual Advantage (HMO D-SNP)
|
$29.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
15% | 15% | P | $14,209.49 |
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 WA-F001 (PPO I-SNP)
|
$29.90 |
$545 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | P | $14,887.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$33.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | P Q:90 /30Days | $14,253.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Complete Care (HMO D-SNP)
|
$33.10 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | P Q:90 /30Days | $14,253.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Value Plus H5619-134 (HMO)
|
$34.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | P Q:90 /30Days | $13,886.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Kaiser Permanente Medicare Advantage Vital (HMO)
|
$34.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | 33% | P | $13,921.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)
|
$35.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
$0.00 | $0.00 | P Q:90 /30Days | $13,886.50 |
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 H5619-136 (HMO D-SNP)
|
$35.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
$0.00 | $0.00 | P Q:90 /30Days | $13,886.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)
|
$35.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
$0.00 | $0.00 | P Q:90 /30Days | $13,886.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)
|
$35.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
$0.00 | $0.00 | P Q:90 /30Days | $13,886.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Providence Medicare Cottonwood + Rx (HMO-POS)
|
$35.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P | $13,449.63 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence MedAdvantage + Rx Primary (PPO)
|
$35.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
27% | n/a | P Q:90 /30Days | $13,951.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence MedAdvantage + Rx Primary (PPO)
|
$35.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
27% | n/a | P Q:90 /30Days | $13,951.93 |
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 |
Regence MedAdvantage + Rx Primary (PPO)
|
$35.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
27% | n/a | P Q:90 /30Days | $13,951.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$36.10 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | P Q:90 /30Days | $13,329.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Health Plan of WA MA Plan 2 (HMO)
|
$38.40 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
33% | n/a | P | $13,310.35 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC WA-0004 (PPO)
|
$39.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P | $14,887.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Choice Plan (PPO)
|
$39.00 |
$150 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
30% | n/a | P Q:90 /30Days | $14,612.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Health Plan of WA Dual Complete (HMO D-SNP)
|
$40.60 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | P | $13,327.16 |
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 |
Community Health Plan of WA Dual Select (HMO D-SNP)
|
$40.60 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | P | $13,327.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H5619-155 (HMO D-SNP)
|
$40.60 |
$545 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
$0.00 | $0.00 | P Q:90 /30Days | $13,886.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Care Advantage WA-E001 (PPO I-SNP)
|
$40.60 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
33% | n/a | P | $14,887.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete WA-D001 (PPO D-SNP)
|
$40.60 |
$545 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
15% | 15% | P | $14,887.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete WA-D002 (HMO-POS D-SNP)
|
$40.60 |
$545 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
15% | 15% | P | $14,887.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete WA-V001 (HMO-POS D-SNP)
|
$40.60 |
$545 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
15% | 15% | P | $14,887.82 |
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 WA-0005 (HMO-POS)
|
$42.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P | $14,887.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plus Plan (HMO-POS)
|
$43.00 |
$150 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
30% | n/a | P Q:90 /30Days | $14,612.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence BlueAdvantage HMO Plus (HMO)
|
$46.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
31% | n/a | P Q:90 /30Days | $13,951.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
Premera Blue Cross Medicare Advantage Classic (HMO)
|
$54.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
33% | n/a | P Q:90 /30Days | $14,510.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H5619-059 (HMO)
|
$60.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P Q:90 /30Days | $13,886.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Health Plan of WA MA Plan 3 (HMO)
|
$79.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
33% | n/a | P | $13,310.35 |
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 |
Regence MedAdvantage + Rx Classic (PPO)
|
$82.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
28% | n/a | P Q:90 /30Days | $13,951.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC WA-0010 (HMO-POS)
|
$84.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P | $14,887.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Select Plan (PPO)
|
$89.00 |
$150 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
30% | n/a | P Q:90 /30Days | $14,612.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Kaiser Permanente Medicare Advantage Essential (HMO)
|
$94.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | 33% | P | $13,921.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-047 (PPO)
|
$100.00 |
$320 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
28% | n/a | P Q:90 /30Days | $13,886.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence MedAdvantage + Rx Enhanced (PPO)
|
$147.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
29% | n/a | P Q:90 /30Days | $13,951.93 |
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 |
Kaiser Permanente Medicare Advantage Optimal (HMO)
|
$327.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | 33% | P | $13,921.76 |
Browse Plan Formulary all covered insulin pay $35 or less |