HYDROCODONE-IBUPROFEN 7.5-200 TABLET [Vicoprofen] (120 TABLETS ) (NDC: 53746014501)
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-0001 (HMO-POS)
|
$0.00 |
$195 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:150 /30Days | $109.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC MA-0005 (PPO)
|
$0.00 |
$295 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:150 /30Days | $109.13 |
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. | 3 |
Preferred Brand |
20% | 20% | Q:150 /30Days | $44.17 |
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. | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:150 /30Days | $44.64 |
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. | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:150 /30Days | $44.64 |
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 |
CCA Medicare Preferred (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | Q:480 /30Days | $135.00 |
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. | 2 |
Tier 2 |
0% | 0% | Q:480 /30Days | $135.00 |
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 | 2* |
Generic |
$7.00 | $14.00 | None | $89.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-138 (PPO)
|
$0.00 |
$395* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$47.00 | $131.00 | Q:150 /30Days | $81.41 |
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. | 3* |
Preferred Brand |
$47.00 | $131.00 | Q:150 /30Days | $81.07 |
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 | 3 |
Preferred Brand |
$37.00 | $74.00 | Q:150 /30Days | $77.65 |
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 SaverRx (HMO)
|
$0.00 |
$300* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$8.00 | $16.00 | Q:150 /30Days | $70.60 |
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 | 2 |
Generic |
$10.00 | $20.00 | Q:150 /30Days | $70.60 |
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 | 2 |
Generic |
$12.00 | $24.00 | Q:150 /30Days | $59.09 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Whole Health Medicare Choice Care Select (HMO)
|
$0.00 |
$375 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $40.00 | Q:150 /30Days | $59.09 |
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. | 2 |
Tier 2 |
0% | 0% | Q:240 /30Days | $94.36 |
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. | 2 |
Generic |
$4.00 | $8.00 | Q:240 /30Days | $94.36 |
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 |
Tufts Medicare Preferred HMO Saver Rx (HMO)
|
$0.00 |
$250* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$4.00 | $8.00 | Q:240 /30Days | $94.36 |
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. | 2 |
Generic |
$2.00 | $4.00 | Q:240 /30Days | $94.36 |
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. | 1 |
Tier 1 |
0% | 0% | Q:150 /30Days | $108.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback Open (PPO)
|
$0.00 |
$545 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | Q:150 /30Days | $67.28 |
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 | 3 |
Preferred Brand |
$42.00 | $84.00 | Q:150 /30Days | $67.28 |
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 | 3 |
Preferred Brand |
$42.00 | $84.00 | Q:150 /30Days | $67.28 |
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 NHC (HMO D-SNP)
|
$16.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:150 /30Days | $59.09 |
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 | 2* |
Generic |
$0.00 | $0.00 | Q:480 /30Days | $135.00 |
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 | Q:240 /30Days | $94.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 | Q:240 /30Days | $94.36 |
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 | 3 |
Tier 3 |
$0.00 | $0.00 | Q:150 /30Days | $108.74 |
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. | 3 |
Preferred Brand |
20% | 20% | Q:150 /30Days | $44.17 |
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 H5216-250 (PPO)
|
$27.00 |
$295* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$47.00 | $131.00 | Q:150 /30Days | $81.07 |
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 | 2* |
Generic |
$6.00 | $12.00 | Q:150 /30Days | $70.60 |
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 | 2* |
Generic |
$6.00 | $12.00 | Q:150 /30Days | $70.60 |
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 | Q:150 /30Days | $59.09 |
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 | 3 |
Tier 3 |
$0.00 | $0.00 | Q:150 /30Days | $108.74 |
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 | 2 |
Generic |
25% | 25% | Q:480 /30Days | $135.00 |
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 |
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:50 /30Days | $121.36 |
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:50 /30Days | $120.06 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC MA-0002 (HMO-POS)
|
$49.00 |
$295 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:150 /30Days | $109.13 |
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 | 3 |
Preferred Brand |
$37.00 | $74.00 | Q:150 /30Days | $77.65 |
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. | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:150 /30Days | $108.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Super Saver (HMO)
|
$60.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$9.00 | $18.00 | None | $89.86 |
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 Basic Rx (HMO)
|
$61.00 |
$225* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$4.00 | $8.00 | Q:240 /30Days | $94.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$61.00 |
$225* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$4.00 | $8.00 | Q:240 /30Days | $94.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$61.00 |
$225* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$4.00 | $8.00 | Q:240 /30Days | $94.36 |
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 | 2 |
Generic |
$6.00 | $12.00 | Q:150 /30Days | $70.60 |
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 | 2 |
Generic |
$6.00 | $12.00 | Q:150 /30Days | $70.60 |
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 | 3 |
Preferred Brand |
$42.00 | $84.00 | Q:150 /30Days | $67.28 |
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 | 2* |
Generic |
$7.00 | $14.00 | None | $89.86 |
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 | 2* |
Generic |
$7.00 | $14.00 | None | $89.86 |
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 | 2* |
Generic |
$7.00 | $14.00 | None | $89.86 |
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 | 2* |
Generic |
$5.00 | $10.00 | Q:150 /30Days | $70.60 |
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 | 2* |
Generic |
$5.00 | $10.00 | Q:150 /30Days | $70.60 |
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 | 3 |
Preferred Brand |
$37.00 | $74.00 | Q:150 /30Days | $77.65 |
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 Blue (HMO)
|
$174.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | $14.00 | None | $89.86 |
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 | 2 |
Generic |
$7.00 | $14.00 | None | $89.86 |
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 | 2 |
Generic |
$7.00 | $14.00 | None | $89.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$181.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$4.00 | $8.00 | Q:240 /30Days | $94.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$181.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$4.00 | $8.00 | Q:240 /30Days | $94.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$181.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$4.00 | $8.00 | Q:240 /30Days | $94.36 |
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 |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$216.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$8.00 | $16.00 | Q:240 /30Days | $94.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$216.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$8.00 | $16.00 | Q:240 /30Days | $94.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$216.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$8.00 | $16.00 | Q:240 /30Days | $94.36 |
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 | 2* |
Generic |
$5.00 | $10.00 | Q:150 /30Days | $70.60 |
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 | 2* |
Generic |
$5.00 | $10.00 | Q:150 /30Days | $70.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$248.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$4.00 | $8.00 | Q:240 /30Days | $94.36 |
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 |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$248.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$4.00 | $8.00 | Q:240 /30Days | $94.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$248.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$4.00 | $8.00 | Q:240 /30Days | $94.36 |
Browse Plan Formulary all covered insulin pay $35 or less |