HYDROCODONE-IBUPROFEN 7.5-200 TABLET [Vicoprofen] (120 TABLETS ) (NDC: 53746014501)
2024 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
See your cost using a drug discount card: Compare prices at pharmacies near you |
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 PA-0002 (HMO-POS)
![Email Prescription and/or Health Benefit details for AARP Medicare Advantage from UHC PA-0002 (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:150 /30Days | $108.09 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC PA-0012 (PPO)
![Email Prescription and/or Health Benefit details for AARP Medicare Advantage from UHC PA-0012 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$295 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:150 /30Days | $108.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC PA-0017 (PPO)
![Email Prescription and/or Health Benefit details for AARP Medicare Advantage from UHC PA-0017 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:150 /30Days | $108.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Credit Value (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Advantra Credit Value (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:150 /30Days | $77.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Silver (HMO-POS)
![Email Prescription and/or Health Benefit details for Aetna Medicare Advantra Silver (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:150 /30Days | $54.58 |
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 |
Aetna Medicare Value (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Value (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
20% | 20% | Q:150 /30Days | $79.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Medicare (HMO)
![Email Prescription and/or Health Benefit details for Cigna Preferred Medicare (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:50 /30Days | $118.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Medicare (PPO)
![Email Prescription and/or Health Benefit details for Cigna True Choice Medicare (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:50 /30Days | $118.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Savings Medicare (PPO)
![Email Prescription and/or Health Benefit details for Cigna True Choice Savings Medicare (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:50 /30Days | $118.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana USAA Honor with Rx (PPO)
![Email Prescription and/or Health Benefit details for Humana USAA Honor with Rx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:150 /30Days | $81.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-051 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H5525-051 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:150 /30Days | $81.31 |
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 |
HumanaChoice H5525-051 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H5525-051 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:150 /30Days | $80.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-058 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H5525-058 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$505 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:150 /30Days | $81.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-060 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H5525-060 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:150 /30Days | $81.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Provider Partners Pennsylvania Community Plan (HMO I-SNP)
![Email Prescription and/or Health Benefit details for Provider Partners Pennsylvania Community Plan (HMO I-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $127.24 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Premier Rx (HMO)
![Email Prescription and/or Health Benefit details for UPMC for Life HMO Premier Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:150 /30Days | $116.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life PPO Premier Rx (PPO)
![Email Prescription and/or Health Benefit details for UPMC for Life PPO Premier Rx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:150 /30Days | $117.09 |
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)
![Email Prescription and/or Health Benefit details for Wellcare Giveback Open (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$545 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:150 /30Days | $76.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
![Email Prescription and/or Health Benefit details for Wellcare No Premium (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:150 /30Days | $76.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
![Email Prescription and/or Health Benefit details for Wellcare No Premium (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:150 /30Days | $76.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
![Email Prescription and/or Health Benefit details for Wellcare No Premium Open (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:150 /30Days | $76.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life PPO Rx Choice (PPO)
![Email Prescription and/or Health Benefit details for UPMC for Life PPO Rx Choice (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$19.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:150 /30Days | $129.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life PPO Rx Choice (PPO)
![Email Prescription and/or Health Benefit details for UPMC for Life PPO Rx Choice (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$19.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:150 /30Days | $114.07 |
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 |
Cigna Preferred Plus Medicare (HMO)
![Email Prescription and/or Health Benefit details for Cigna Preferred Plus Medicare (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$20.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:50 /30Days | $118.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Deductible Rx (HMO)
![Email Prescription and/or Health Benefit details for UPMC for Life HMO Deductible Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$20.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:150 /30Days | $116.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
![Email Prescription and/or Health Benefit details for Wellcare Assist (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$21.30 |
$435 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:150 /30Days | $76.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Gold (HMO-POS)
![Email Prescription and/or Health Benefit details for Aetna Medicare Advantra Gold (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$22.60 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:150 /30Days | $54.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-017 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H5525-017 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$26.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:150 /30Days | $81.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Plus Medicare (PPO)
![Email Prescription and/or Health Benefit details for Cigna True Choice Plus Medicare (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$27.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:50 /30Days | $118.60 |
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)
![Email Prescription and/or Health Benefit details for Aetna Medicare Value Plus (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:150 /30Days | $54.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
![Email Prescription and/or Health Benefit details for Wellcare Dual Access Open (PPO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:150 /30Days | $73.85 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete PA-V001 (HMO-POS D-SNP)
![Email Prescription and/or Health Benefit details for UHC Dual Complete PA-V001 (HMO-POS D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:150 /30Days | $108.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life PPO High Deductible Rx (PPO)
![Email Prescription and/or Health Benefit details for UPMC for Life PPO High Deductible Rx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:150 /30Days | $117.09 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Nursing Home Plan EX-F002 (PPO I-SNP)
![Email Prescription and/or Health Benefit details for UHC Nursing Home Plan EX-F002 (PPO I-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$32.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:150 /30Days | $107.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Care Advantage PA-E001 (PPO I-SNP)
![Email Prescription and/or Health Benefit details for UHC Care Advantage PA-E001 (PPO I-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$35.60 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:150 /30Days | $108.02 |
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 |
UPMC for Life HMO Rx Choice (HMO)
![Email Prescription and/or Health Benefit details for UPMC for Life HMO Rx Choice (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:150 /30Days | $129.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx Choice (HMO)
![Email Prescription and/or Health Benefit details for UPMC for Life HMO Rx Choice (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:150 /30Days | $114.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx Choice (HMO)
![Email Prescription and/or Health Benefit details for UPMC for Life HMO Rx Choice (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:150 /30Days | $122.85 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx Choice (HMO)
![Email Prescription and/or Health Benefit details for UPMC for Life HMO Rx Choice (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:150 /30Days | $116.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx Choice (HMO)
![Email Prescription and/or Health Benefit details for UPMC for Life HMO Rx Choice (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:150 /30Days | $104.09 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Silver (HMO-POS)
![Email Prescription and/or Health Benefit details for Aetna Medicare Silver (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$37.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:150 /30Days | $90.47 |
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 Advantra Cares (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Aetna Medicare Advantra Cares (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$38.30 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:150 /30Days | $49.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare Plus (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Cigna TotalCare Plus (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$38.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:50 /30Days | $108.85 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC PA-0003 (HMO-POS)
![Email Prescription and/or Health Benefit details for AARP Medicare Advantage from UHC PA-0003 (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$39.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:150 /30Days | $108.09 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Longevity Plan (HMO I-SNP)
![Email Prescription and/or Health Benefit details for Aetna Medicare Longevity Plan (HMO I-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$39.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:150 /30Days | $49.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete PA-S002 (HMO-POS D-SNP)
![Email Prescription and/or Health Benefit details for UHC Dual Complete PA-S002 (HMO-POS D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$39.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:150 /30Days | $108.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC PA-0014 (PPO)
![Email Prescription and/or Health Benefit details for AARP Medicare Advantage from UHC PA-0014 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$40.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:150 /30Days | $108.14 |
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 |
AmeriHealth Caritas VIP Care (HMO D-SNP)
![Email Prescription and/or Health Benefit details for AmeriHealth Caritas VIP Care (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$40.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $115.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Highmark Wholecare Medicare Assured Diamond (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Highmark Wholecare Medicare Assured Diamond (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$40.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:150 /30Days | $67.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Highmark Wholecare Medicare Assured Ruby (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$40.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:150 /30Days | $67.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Value Plus H5216-117 (PPO)
![Email Prescription and/or Health Benefit details for Humana Value Plus H5216-117 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$40.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:150 /30Days | $81.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice SNP-DE H5216-227 (PPO D-SNP)
![Email Prescription and/or Health Benefit details for HumanaChoice SNP-DE H5216-227 (PPO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$40.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:150 /30Days | $81.49 |
Browse Plan Formulary all covered insulin pay $35 or less |
Provider Partners Pennsylvania Advantage Plan (HMO I-SNP)
![Email Prescription and/or Health Benefit details for Provider Partners Pennsylvania Advantage Plan (HMO I-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$40.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $127.24 |
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 PA-S001 (PPO D-SNP)
![Email Prescription and/or Health Benefit details for UHC Dual Complete PA-S001 (PPO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$40.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:150 /30Days | $108.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life Complete Care (HMO D-SNP)
![Email Prescription and/or Health Benefit details for UPMC for Life Complete Care (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$40.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
49% | 49% | Q:150 /30Days | $116.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Wellcare Dual Access (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$40.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:150 /30Days | $74.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R0923-002 (Regional PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice R0923-002 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$46.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:150 /30Days | $81.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx (HMO)
![Email Prescription and/or Health Benefit details for UPMC for Life HMO Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$81.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:150 /30Days | $116.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-120 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H5216-120 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$123.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:150 /30Days | $81.20 |
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 |
UPMC for Life PPO Rx Enhanced (PPO)
![Email Prescription and/or Health Benefit details for UPMC for Life PPO Rx Enhanced (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$134.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:150 /30Days | $117.09 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Gold Plan (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Gold Plan (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$145.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:150 /30Days | $90.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx Enhanced (HMO)
![Email Prescription and/or Health Benefit details for UPMC for Life HMO Rx Enhanced (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$295.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:150 /30Days | $115.69 |
Browse Plan Formulary all covered insulin pay $35 or less |