MOVANTIK 12.5 MG TABLET (30 TABLETS ) (NDC: 82625880101)
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 NC-0017 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $420.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC NC-0022 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $419.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Essential Plan (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $409.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plan (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $409.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $408.98 |
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 |
Blue Medicare Essential (HMO)
|
$0.00 |
$375* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$45.00 | $90.00 | None | $413.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare Essential (HMO)
|
$0.00 |
$375* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$45.00 | $90.00 | None | $410.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare Essential Plus (HMO-POS)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$45.00 | $90.00 | None | $413.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare Essential Plus (HMO-POS)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$45.00 | $90.00 | None | $410.05 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare Essential Plus (HMO-POS)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$45.00 | $90.00 | None | $407.63 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare Essential Plus (HMO-POS)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$45.00 | $90.00 | None | $411.16 |
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 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $394.20 |
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 |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $395.53 |
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 |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $392.55 |
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 |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $393.05 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $393.55 |
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 |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $394.20 |
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 |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $395.53 |
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 |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $392.55 |
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 |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $393.05 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted CORE North Carolina (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days | $389.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted GIVEBACK North Carolina (HMO)
|
$0.00 |
$395 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $117.50 | Q:30 /30Days | $389.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$0.00 |
$145* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $394.57 |
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 H1036-291 (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days | $394.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-017 (PPO)
|
$0.00 |
$265 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $394.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-035 (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $394.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-050 (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days | $394.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-071 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $394.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
Liberty Medicare Advantage (HMO C-SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35.00 | $90.00 | P | $643.53 |
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. |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:30 /30Days | tbd |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$450 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:30 /30Days | $392.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:30 /30Days | tbd |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Value (HMO)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:30 /30Days | $392.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plus Plan (HMO)
|
$7.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $409.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare Enhanced (HMO-POS)
|
$19.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $413.32 |
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 |
Blue Medicare Enhanced (HMO-POS)
|
$19.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $409.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare Enhanced (HMO-POS)
|
$19.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $411.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Plus Medicare (HMO)
|
$24.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $393.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted DUAL PLUS North Carolina (HMO D-SNP)
|
$27.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:30 /30Days | $389.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC NC-0021 (HMO-POS)
|
$29.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $419.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Medicare PPO Enhanced (PPO)
|
$29.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $413.32 |
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 |
Blue Medicare PPO Enhanced (PPO)
|
$29.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $410.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare All Dual Assure (HMO D-SNP)
|
$29.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $392.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted PREMIUM North Carolina (HMO)
|
$29.50 |
$545 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
25% | 25% | Q:30 /30Days | $389.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Nursing Home Plan NC-F001 (PPO I-SNP)
|
$29.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:30 /30Days | $419.85 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted DUAL North Carolina (HMO D-SNP)
|
$30.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:30 /30Days | $389.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare (HMO D-SNP)
|
$33.80 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | Q:30 /30Days | $393.55 |
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 Assist Open (PPO)
|
$36.40 |
$430 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:30 /30Days | tbd |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$37.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $392.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC NC-0016 (PPO)
|
$39.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $420.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare Plus (HMO D-SNP)
|
$39.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:30 /30Days | $393.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Assure Plan (HMO D-SNP)
|
$42.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:60 /30Days | $409.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Medicare (HMO D-SNP)
|
$42.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $392.14 |
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 |
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP)
|
$46.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P | $643.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Healthy Blue + Medicare (HMO-POS D-SNP)
|
$46.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | None | $417.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)
|
$46.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:30 /30Days | $394.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H1036-307 (HMO D-SNP)
|
$46.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:30 /30Days | $394.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H1036-309 (HMO D-SNP)
|
$46.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:30 /30Days | $394.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-070 (PPO)
|
$46.90 |
$545 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $394.57 |
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 SNP-DE H5525-036 (PPO D-SNP)
|
$46.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:30 /30Days | $394.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice SNP-DE H5525-072 (PPO D-SNP)
|
$46.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:30 /30Days | $394.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice SNP-DE H5525-073 (PPO D-SNP)
|
$46.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:30 /30Days | $394.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
Liberty Medicare Dual Plan (HMO D-SNP)
|
$46.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $643.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete NC-D001 (HMO-POS D-SNP)
|
$46.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:30 /30Days | $419.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete NC-S001 (PPO D-SNP)
|
$46.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:30 /30Days | $419.80 |
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 |
UHC Dual Complete NC-V001 (HMO-POS D-SNP)
|
$46.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:30 /30Days | $419.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Liberty Open (PPO D-SNP)
|
$46.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | tbd |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-211 (PPO)
|
$55.00 |
$160* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $394.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R1390-002 (Regional PPO)
|
$105.00 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $395.17 |
Browse Plan Formulary all covered insulin pay $35 or less |