DILT XR 120 MG CAPSULE (100.000 EA ) (NDC: 60505001406)
2024 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
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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 GA-0004 (PPO)
|
$0.00 |
$395* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$14.00 | $0.00 | None | $10.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC GA-0005 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$14.00 | $0.00 | None | $10.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Freedom (PPO)
|
$0.00 |
$150* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$0.00 | $0.00 | None | $2.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Signature (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $1.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Grocery (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$13.00 | $0.00 | None | $9.99 |
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 |
Anthem Kidney Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | None | $9.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Medicare Advantage (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$11.00 | $0.00 | None | $9.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Medicare Advantage (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$13.00 | $0.00 | None | $9.81 |
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 |
2 |
Generic |
$10.00 | $0.00 | None | $24.02 |
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 |
2 |
Generic |
$10.00 | $0.00 | None | $24.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clear Spring Health Choice Plan (PPO)
|
$0.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$0.00 | $0.00 | None | $15.76 |
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 |
Clear Spring Health Select Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | None | $15.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clover Health LiveHealthy (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $125.00 | None | $13.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H4141-017 (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:60 /30Days | $13.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H4141-017 (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:60 /30Days | $14.27 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice - Diabetes and Heart (PPO C-SNP)
|
$0.00 |
$145* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$0.00 | $0.00 | Q:60 /30Days | $13.94 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-154 (PPO)
|
$0.00 |
$400* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | $0.00 | Q:60 /30Days | $13.79 |
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 |
HumanaChoice H5216-203 (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:60 /30Days | $13.77 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-203 (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:60 /30Days | $14.25 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-279 (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:60 /30Days | $13.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-345 (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:60 /30Days | $13.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R3392-004 (Regional PPO)
|
$0.00 |
$195* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$12.00 | $0.00 | Q:60 /30Days | $13.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Kaiser Permanente Senior Advantage Basic 1 (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $17.06 |
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 Senior Advantage Care Plus (HMO-POS)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $17.06 |
Browse Plan Formulary all covered insulin pay $35 or less |
Sonder Complete Health Medicare Advantage (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$10.00 | $0.00 | Q:60 /30Days | $20.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
Sonder Diabetes Wellness (HMO C-SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$15.00 | $0.00 | Q:60 /30Days | $20.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
Sonder Dual Complete (HMO D-SNP)
|
$0.00 |
$545 |
to be determined |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days | $20.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
Sonder Heart Healthy (HMO C-SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$15.00 | $0.00 | Q:60 /30Days | $20.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
Sonder Tiers Medicare Advantage (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$10.00 | $0.00 | Q:60 /30Days | $20.15 |
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 Complete Care GA-0003 (PPO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | None | $10.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Medicare Advantage GA-0002 (PPO)
|
$0.00 |
$295* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$14.00 | $0.00 | None | $10.63 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback (HMO)
|
$0.00 |
$545* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$5.00 | $0.00 | None | $8.77 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Mutual of Omaha No Premium Open (PPO)
|
$0.00 |
$200* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$5.00 | $0.00 | None | $8.77 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $0.00 | None | $8.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Together in Health (PPO I-SNP)
|
$18.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | Q:60 /30Days | $13.94 |
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 Value Plus (PPO)
|
$19.30 |
$300* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $0.00 | None | $2.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Complete Care GS-001A (Regional PPO C-SNP)
|
$20.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $10.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred GA Medicare (HMO)
|
$25.00 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$12.00 | $0.00 | None | $24.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred GA Medicare (HMO)
|
$25.00 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$12.00 | $0.00 | None | $24.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Plus Medicare (HMO)
|
$28.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$4.00 | $0.00 | None | $21.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Complete Care GS-0002 (Regional PPO C-SNP)
|
$28.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$12.00 | $0.00 | None | $10.58 |
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 |
Anthem Grocery (HMO D-SNP)
|
$28.30 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $8.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Dual Advantage (HMO D-SNP)
|
$29.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $8.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Dual Signature (HMO D-SNP)
|
$29.30 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $13.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete GA-D002 (HMO-POS D-SNP)
|
$31.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $10.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Dual Signature Select (PPO D-SNP)
|
$31.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $13.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Dual Signature Choice (PPO D-SNP)
|
$31.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $13.80 |
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 |
Anthem Extra Help (HMO)
|
$32.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $45.00 | None | $9.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare (HMO D-SNP)
|
$34.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $24.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
|
$35.00 |
$410 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $16.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clover Health LiveHealthy Value (PPO)
|
$35.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
23% | 22% | None | $13.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare Plus (HMO D-SNP)
|
$37.80 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $24.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC GA-0006 (HMO-POS)
|
$39.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | None | $10.62 |
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 Dual Complete GA-S001 (PPO D-SNP)
|
$41.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $10.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Liberty (HMO D-SNP)
|
$42.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $12.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Advantage Medicare Medicaid Plan 1 (HMO D-SNP)
|
$42.30 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$14.00 | $0.00 | None | $17.06 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Full Dual Advantage (PPO D-SNP)
|
$43.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $8.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H4141-003 (HMO D-SNP)
|
$43.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | Q:60 /30Days | $13.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare All Dual (HMO D-SNP)
|
$44.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $12.40 |
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 |
Anthem Full Dual Advantage (HMO D-SNP)
|
$44.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $8.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Full Dual Advantage 2 (HMO D-SNP)
|
$44.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $8.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
CareSource Dual Advantage (HMO D-SNP)
|
$44.20 |
$545 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | 25% | None | $16.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
Georgia Health Advantage (HMO I-SNP)
|
$44.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $19.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
Georgia Health Advantage Choice (HMO I-SNP)
|
$44.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $19.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-280 (PPO)
|
$44.20 |
$545 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$20.00 | $0.00 | Q:60 /30Days | $13.63 |
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 |
HumanaChoice H5216-280 (PPO)
|
$44.20 |
$545 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$20.00 | $0.00 | Q:60 /30Days | $13.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice SNP-DE H5216-205 (PPO D-SNP)
|
$44.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | Q:60 /30Days | $13.94 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice SNP-DE H5216-206 (PPO D-SNP)
|
$44.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | Q:60 /30Days | $13.94 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete GA-V001 (PPO D-SNP)
|
$44.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $10.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$44.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $12.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Preferred (PPO)
|
$46.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $1.00 |
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 H5216-073 (PPO)
|
$55.00 |
$360* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$17.00 | $0.00 | Q:60 /30Days | $13.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Medicare Advantage 2 (PPO)
|
$59.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$13.00 | $0.00 | None | $9.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Medicare Advantage GS-0001 (Regional PPO)
|
$62.00 |
$345* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$14.00 | $0.00 | None | $10.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
Kaiser Permanente Senior Advantage Enhanced 1 (HMO)
|
$66.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $17.06 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R3392-002 (Regional PPO)
|
$92.00 |
$340* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$17.00 | $0.00 | Q:60 /30Days | $13.79 |
Browse Plan Formulary all covered insulin pay $35 or less |