FETZIMA ER 80 MG CAPSULE (30 EA ) (NDC: 00456228030)
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 MA-0003 (HMO-POS)
|
$0.00 |
$195 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $507.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC MA-0006 (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $507.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Discover Plan (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $493.30 |
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 | P Q:30 /30Days | $493.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $493.30 |
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 Preferred (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$100.00 | $290.00 | S Q:30 /30Days | $766.04 |
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. | 4 |
Tier 4 |
0% | 0% | S Q:30 /30Days | $766.00 |
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 | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days | $488.02 |
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 | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days | $488.02 |
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 | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days | $488.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Orange (HMO)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$86.00 | $172.00 | P Q:30 /30Days | $495.91 |
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 |
HumanaChoice H5216-138 (PPO)
|
$0.00 |
$395 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $476.77 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-249 (PPO)
|
$0.00 |
$350 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $476.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Mass General Brigham Advantage (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | S | $493.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue SaverRx (HMO)
|
$0.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:30 /30Days | $486.96 |
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 | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:30 /30Days | $486.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Whole Health Medicare Choice Care (HMO)
|
$0.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $486.70 |
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 |
Senior Whole Health Medicare Choice Care Select (HMO)
|
$0.00 |
$375 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $486.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Health One Care (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Tier 3 |
0% | 0% | S | $487.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred Access Rx (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | S | $492.26 |
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. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | S | $492.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Smart Saver Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | S | $492.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Connected(r) for One Care (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Tier 2 |
0% | 0% | S Q:30 /30Days | $510.64 |
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 |
Wellcare Giveback Open (PPO)
|
$0.00 |
$545 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
47% | 47% | Q:30 /30Days | $550.24 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
48% | 48% | Q:30 /30Days | $550.24 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
43% | 43% | Q:30 /30Days | $550.24 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Whole Health NHC (HMO D-SNP)
|
$16.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | P Q:30 /30Days | $482.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
CCA Medicare Value (PPO)
|
$20.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$100.00 | $300.00 | S Q:30 /30Days | $766.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Health Plan Senior Care Options (HMO D-SNP)
|
$24.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | S | $488.83 |
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 |
Tufts Health Plan Senior Care Options CW (HMO D-SNP)
|
$24.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | S | $488.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
eternalHealth ForeverMore (HMO)
|
$25.00 |
$170 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days | $488.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Senior Care Options MA-Y001 (HMO D-SNP)
|
$26.90 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | S Q:30 /30Days | $510.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plus (PPO)
|
$27.00 |
$250 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
40% | 40% | P Q:30 /30Days | $493.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-250 (PPO)
|
$27.00 |
$295 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $476.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue ValueRx (HMO)
|
$28.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:30 /30Days | $488.75 |
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)
|
$28.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:30 /30Days | $486.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Whole Health (HMO D-SNP)
|
$31.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | P Q:30 /30Days | $482.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Senior Care Options NHC MA-Y002 (HMO D-SNP)
|
$31.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | S Q:30 /30Days | $510.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
CCA Senior Care Options (HMO D-SNP)
|
$43.50 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
25% | 25% | S Q:30 /30Days | $766.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Longevity Health Plan (HMO I-SNP)
|
$43.50 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | Q:30 /30Days | $491.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
WellSense Senior Care Options (HMO D-SNP)
|
$43.50 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $482.19 |
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 MA-0004 (HMO-POS)
|
$45.00 |
$175 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $507.21 |
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. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | S | $488.31 |
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. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | S | $494.07 |
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. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | S | $496.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Mass General Brigham Advantage Secure (HMO-POS)
|
$52.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | S | $493.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC NG-0001 (Regional PPO)
|
$58.00 |
$395 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $510.07 |
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 Super Saver (HMO)
|
$60.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:30 /30Days | $495.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare PPO Blue ValueRx (PPO)
|
$72.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:30 /30Days | $486.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare PPO Blue ValueRx (PPO)
|
$72.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:30 /30Days | $488.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Premium Enhanced Open (PPO)
|
$75.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
48% | 48% | Q:30 /30Days | $550.24 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Green (HMO)
|
$78.00 |
$175 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$86.00 | $172.00 | P Q:30 /30Days | $492.35 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Green (HMO)
|
$78.00 |
$175 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$86.00 | $172.00 | P Q:30 /30Days | $498.22 |
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 |
Fallon Medicare Plus Green (HMO)
|
$78.00 |
$175 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$86.00 | $172.00 | P Q:30 /30Days | $496.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue FlexRx (HMO-POS)
|
$78.00 |
$260 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:30 /30Days | $488.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue FlexRx (HMO-POS)
|
$78.00 |
$260 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:30 /30Days | $486.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Mass General Brigham Advantage Premier (PPO)
|
$140.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | S | $493.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$159.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | S | $496.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$159.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | S | $488.31 |
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 |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$159.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | S | $494.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Blue (HMO)
|
$174.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$86.00 | $172.00 | P Q:30 /30Days | $496.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Blue (HMO)
|
$174.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$86.00 | $172.00 | P Q:30 /30Days | $492.35 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Blue (HMO)
|
$174.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$86.00 | $172.00 | P Q:30 /30Days | $498.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$186.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | S | $496.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$186.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | S | $490.08 |
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 |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$186.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | S | $483.95 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue PlusRx (HMO)
|
$220.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:30 /30Days | $486.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$220.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$80.00 | $240.00 | S | $496.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$220.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$80.00 | $240.00 | S | $490.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$220.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$80.00 | $240.00 | S | $483.95 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare PPO Blue PlusRx (PPO)
|
$238.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:30 /30Days | $486.96 |
Browse Plan Formulary all covered insulin pay $35 or less |