MOUNJARO 7.5 MG/0.5 ML PEN INJECTOR (2 MLS ) (NDC: 00002148480)
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 TX-0006 (PPO)
|
$0.00 |
$245 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | P Q:2 /28Days | $1,079.49 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC TX-0009 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | P Q:2 /28Days | $1,079.24 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC TX-0015 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | P Q:2 /28Days | $1,079.49 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC TX-001P (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | P Q:2 /28Days | $1,079.27 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC TX-0031 (PPO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | P Q:2 /28Days | $1,079.49 |
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 |
Aetna Medicare Choice Plan (PPO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
20% | 20% | P Q:2 /28Days | $1,051.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Freedom Plan (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:2 /28Days | $1,051.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plan (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:2 /28Days | $1,051.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:2 /28Days | $1,051.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Alliance Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:2 /28Days | $1,002.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:2 /28Days | $1,001.90 |
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 Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:2 /28Days | $1,012.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:2 /28Days | $1,013.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:2 /28Days | $1,006.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:2 /28Days | $1,005.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:2 /28Days | $1,001.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:2 /28Days | $1,012.10 |
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 Savings Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:2 /28Days | $1,013.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:2 /28Days | $1,006.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:2 /28Days | $1,005.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:2 /28Days | $1,000.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:2 /28Days | $1,011.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:2 /28Days | $1,003.38 |
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 |
Devoted CORE Greater Houston (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:2 /28Days | $1,000.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted GIVEBACK Greater Houston (HMO)
|
$0.00 |
$395 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $117.50 | P Q:2 /28Days | $1,000.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H0028-042 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,014.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-043 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,014.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-043 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,017.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-043 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,013.52 |
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 |
KelseyCare Advantage Classic (HMO)
|
$0.00 |
$100 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:2 /28Days | $1,031.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
KelseyCare Advantage Freedom (HMO-POS)
|
$0.00 |
$100 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:2 /28Days | $1,031.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
KelseyCare Advantage Secure (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:2 /28Days | $1,031.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
KelseyCare Advantage Signature (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:2 /28Days | $1,031.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
KelseyCare Advantage Thrive (HMO-POS)
|
$0.00 |
$100 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $113.00 | P Q:2 /28Days | $1,031.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
Memorial Hermann Advantage (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:2 /28Days | $1,655.39 |
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 |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | P Q:2 /28Days | $1,000.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Choice Care Select (HMO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | P Q:2 /28Days | $1,000.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Complete Care TX-002P (HMO-POS C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | P Q:2 /28Days | $1,079.27 |
Browse Plan Formulary all covered insulin pay $35 or less |
Verda Noble Care (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $70.00 | P Q:2 /28Days | $1,032.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Verda Noble Chronic Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$32.00 | $64.00 | P Q:2 /28Days | $1,032.71 |
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 |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:2 /28Days | $897.62 |
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 |
Wellcare Mutual of Omaha No Premium Open (PPO)
|
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:2 /28Days | $898.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Mutual of Omaha No Premium Secure Open (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:2 /28Days | $898.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$275 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:2 /28Days | $897.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Rx Plus Open (PPO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:2 /28Days | $904.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare TexanPlus Classic No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:2 /28Days | $897.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare TexanPlus No Premium (HMO-POS)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:2 /28Days | $897.28 |
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 |
Wellpoint Kidney Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Tier 5 |
33% | n/a | P Q:2 /28Days | $1,048.27 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Medicare Advantage 2 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Tier 5 |
33% | n/a | P Q:2 /28Days | $1,047.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Tier 5 |
33% | n/a | P Q:2 /28Days | $1,047.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Complete Care TX-001A (Regional PPO C-SNP)
|
$10.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | P Q:2 /28Days | $1,079.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare (HMO D-SNP)
|
$11.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | P Q:2 /28Days | $1,001.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare (HMO D-SNP)
|
$11.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | P Q:2 /28Days | $1,012.10 |
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 TotalCare (HMO D-SNP)
|
$11.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | P Q:2 /28Days | $1,013.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare (HMO D-SNP)
|
$11.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | P Q:2 /28Days | $1,006.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare (HMO D-SNP)
|
$11.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | P Q:2 /28Days | $1,005.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted PRIME Greater Houston (HMO)
|
$15.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:2 /28Days | $1,000.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare All Dual Assure (HMO D-SNP)
|
$16.80 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P Q:2 /28Days | $902.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plus (PPO)
|
$18.70 |
$300 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:2 /28Days | $1,051.98 |
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 Dual Advantage 2 (HMO D-SNP)
|
$21.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | P Q:2 /28Days | $1,051.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Complete Care TX-0029 (Regional PPO C-SNP)
|
$22.00 |
$295* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $131.00 | P Q:2 /28Days | $1,079.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
|
$22.40 |
$535 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | P Q:2 /28Days | $902.05 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Liberty (HMO D-SNP)
|
$26.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:2 /28Days | $902.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage 2 (HMO D-SNP)
|
$27.30 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P Q:2 /28Days | $1,051.29 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$27.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:2 /28Days | $902.52 |
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 Dual Complete Plan (HMO D-SNP)
|
$28.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | P Q:2 /28Days | $1,051.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
American Health Advantage of Texas (HMO I-SNP)
|
$28.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P | $1,110.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Health Choice (HMO D-SNP)
|
$28.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:2 /28Days | $1,655.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Health Choice (HMO D-SNP)
|
$28.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:2 /28Days | $1,655.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Health Choice (HMO D-SNP)
|
$28.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:2 /28Days | $1,654.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H0028-031 (HMO D-SNP)
|
$28.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:2 /28Days | $1,016.40 |
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 |
Humana Gold Plus SNP-DE H0028-033 (HMO D-SNP)
|
$28.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:2 /28Days | $1,014.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H0028-064 (HMO D-SNP)
|
$28.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:2 /28Days | $1,013.95 |
Browse Plan Formulary all covered insulin pay $35 or less |
Memorial Hermann Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | P Q:2 /28Days | $1,655.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Complete Care (HMO D-SNP)
|
$28.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:2 /28Days | $1,000.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
Texas Independence Health Plan, Inc. (HMO I-SNP)
|
$28.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P Q:2 /28Days | $1,109.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete TX-D002 (HMO-POS D-SNP)
|
$28.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | P Q:2 /28Days | $1,079.31 |
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 |
UHC Dual Complete TX-D002 (HMO-POS D-SNP)
|
$28.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | P Q:2 /28Days | $1,079.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete TX-D002 (HMO-POS D-SNP)
|
$28.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | P Q:2 /28Days | $1,081.06 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete TX-S001 (Regional PPO D-SNP)
|
$28.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | P Q:2 /28Days | $1,079.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete TX-S003 (HMO-POS D-SNP)
|
$28.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | P Q:2 /28Days | $1,079.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Nursing Home Plan TX-F001 (PPO I-SNP)
|
$28.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | P Q:2 /28Days | $1,079.06 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$28.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:2 /28Days | $908.95 |
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 Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | P Q:2 /28Days | $1,051.27 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | P Q:2 /28Days | $1,051.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | P Q:2 /28Days | $1,051.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | P Q:2 /28Days | $1,051.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | P Q:2 /28Days | $1,051.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P Q:2 /28Days | $1,051.27 |
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 Full Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P Q:2 /28Days | $1,051.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P Q:2 /28Days | $1,051.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P Q:2 /28Days | $1,051.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Medicare Advantage TX-0030 (Regional PPO)
|
$48.00 |
$395 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | P Q:2 /28Days | $1,079.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R4182-004 (Regional PPO)
|
$49.00 |
$275 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,014.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-042 (PPO)
|
$65.00 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,014.30 |
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 |
HumanaChoice R4182-003 (Regional PPO)
|
$72.00 |
$175 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,014.08 |
Browse Plan Formulary all covered insulin pay $35 or less |