OLMSRTN-AMLDPN-HCTZ 40-5-12.5 TABLET [Tribenzor] (30 TABLETS ) (NDC: 00093500656)
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 RI-0002 (HMO-POS)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC RI-0002 (HMO-POS)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC RI-0002 (HMO-POS)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC RI-0002 (HMO-POS)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC RI-0002 (HMO-POS)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $103.41 |
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 RI-0003 (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC RI-0003 (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC RI-0003 (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC RI-0003 (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC RI-0003 (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Plan (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $7.81 |
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 Explorer Plan (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $7.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Plan (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $7.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Plan (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $7.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Plan (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $7.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $11.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $11.18 |
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 Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $7.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $7.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $7.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $7.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $7.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueCHiP for Medicare Value (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $72.84 |
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 |
BlueCHiP for Medicare Value (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $72.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueCHiP for Medicare Value (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $72.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueCHiP for Medicare Value (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $72.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueCHiP for Medicare Value (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $72.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-062 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $64.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-062 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $64.52 |
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 |
HumanaChoice H5525-062 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $64.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-063 (PPO)
|
$0.00 |
$395 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $64.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-063 (PPO)
|
$0.00 |
$395 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $64.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-063 (PPO)
|
$0.00 |
$395 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $64.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Neighborhood INTEGRITY (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Tier 1 |
0% | 0% | Q:30 /30Days | $120.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Neighborhood INTEGRITY (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Tier 1 |
0% | 0% | Q:30 /30Days | $120.01 |
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 |
Neighborhood INTEGRITY (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Tier 1 |
0% | 0% | Q:30 /30Days | $120.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Neighborhood INTEGRITY (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Tier 1 |
0% | 0% | Q:30 /30Days | $120.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Neighborhood INTEGRITY (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Tier 1 |
0% | 0% | Q:30 /30Days | $120.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
6 |
Tier 6 |
$0.00 | $0.00 | Q:30 /30Days | $19.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
6 |
Tier 6 |
$0.00 | $0.00 | Q:30 /30Days | $19.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
6 |
Tier 6 |
$0.00 | $0.00 | Q:30 /30Days | $19.80 |
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 |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
6 |
Tier 6 |
$0.00 | $0.00 | Q:30 /30Days | $19.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
6 |
Tier 6 |
$0.00 | $0.00 | Q:30 /30Days | $19.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
6 |
Tier 6 |
$0.00 | $0.00 | Q:30 /30Days | $19.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
6 |
Tier 6 |
$0.00 | $0.00 | Q:30 /30Days | $19.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
6 |
Tier 6 |
$0.00 | $0.00 | Q:30 /30Days | $19.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
6 |
Tier 6 |
$0.00 | $0.00 | Q:30 /30Days | $19.80 |
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 |
Wellcare No Premium Open (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
6 |
Tier 6 |
$0.00 | $0.00 | Q:30 /30Days | $19.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Nursing Home Plan EX-F005 (PPO I-SNP)
|
$20.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $54.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Nursing Home Plan EX-F005 (PPO I-SNP)
|
$20.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $54.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Nursing Home Plan EX-F005 (PPO I-SNP)
|
$20.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $54.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Nursing Home Plan EX-F005 (PPO I-SNP)
|
$20.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $54.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Nursing Home Plan EX-F005 (PPO I-SNP)
|
$20.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $54.16 |
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 |
AARP Medicare Advantage from UHC RI-0001 (HMO-POS)
|
$25.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC RI-0001 (HMO-POS)
|
$25.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC RI-0001 (HMO-POS)
|
$25.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC RI-0001 (HMO-POS)
|
$25.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC RI-0001 (HMO-POS)
|
$25.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plus (PPO)
|
$28.00 |
$250* |
Yes, this drug has Gap Coverage. |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $7.81 |
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)
|
$28.00 |
$250* |
Yes, this drug has Gap Coverage. |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $7.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plus (PPO)
|
$28.00 |
$250* |
Yes, this drug has Gap Coverage. |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $7.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plus (PPO)
|
$28.00 |
$250* |
Yes, this drug has Gap Coverage. |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $7.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plus (PPO)
|
$28.00 |
$250* |
Yes, this drug has Gap Coverage. |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $7.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-061 (PPO)
|
$28.00 |
$545 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $64.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-061 (PPO)
|
$28.00 |
$545 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $64.52 |
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 |
HumanaChoice H5525-061 (PPO)
|
$28.00 |
$545 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $64.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$32.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $21.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$32.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $21.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$32.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $21.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$32.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $21.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$32.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $21.30 |
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 |
UHC Care Advantage RI-E002 (PPO I-SNP)
|
$33.00 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days | $76.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Care Advantage RI-E002 (PPO I-SNP)
|
$33.00 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days | $76.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Nursing Home Plan RI-F001 (PPO I-SNP)
|
$34.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Nursing Home Plan RI-F001 (PPO I-SNP)
|
$34.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Nursing Home Plan RI-F001 (PPO I-SNP)
|
$34.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Nursing Home Plan RI-F001 (PPO I-SNP)
|
$34.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $103.41 |
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 Nursing Home Plan RI-F001 (PPO I-SNP)
|
$34.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueRI for Duals (HMO D-SNP)
|
$35.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | Q:30 /30Days | $79.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueRI for Duals (HMO D-SNP)
|
$35.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | Q:30 /30Days | $79.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueRI for Duals (HMO D-SNP)
|
$35.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | Q:30 /30Days | $79.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueRI for Duals (HMO D-SNP)
|
$35.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | Q:30 /30Days | $79.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueRI for Duals (HMO D-SNP)
|
$35.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | Q:30 /30Days | $79.12 |
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 Dual Liberty Open (PPO D-SNP)
|
$35.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $21.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Liberty Open (PPO D-SNP)
|
$35.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $21.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Liberty Open (PPO D-SNP)
|
$35.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $21.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Liberty Open (PPO D-SNP)
|
$35.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $21.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Liberty Open (PPO D-SNP)
|
$35.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $21.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete RI-S002 (HMO-POS D-SNP)
|
$42.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $103.41 |
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 RI-S002 (HMO-POS D-SNP)
|
$42.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete RI-S002 (HMO-POS D-SNP)
|
$42.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete RI-S002 (HMO-POS D-SNP)
|
$42.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete RI-S002 (HMO-POS D-SNP)
|
$42.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Care Advantage RI-E001 (PPO I-SNP)
|
$43.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Care Advantage RI-E001 (PPO I-SNP)
|
$43.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days | $103.41 |
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 Care Advantage RI-E001 (PPO I-SNP)
|
$43.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete RI-S001 (PPO D-SNP)
|
$43.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete RI-S001 (PPO D-SNP)
|
$43.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete RI-S001 (PPO D-SNP)
|
$43.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete RI-S001 (PPO D-SNP)
|
$43.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete RI-S001 (PPO D-SNP)
|
$43.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $103.41 |
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 RI-V001 (HMO-POS D-SNP)
|
$43.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete RI-V001 (HMO-POS D-SNP)
|
$43.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete RI-V001 (HMO-POS D-SNP)
|
$43.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete RI-V001 (HMO-POS D-SNP)
|
$43.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete RI-V001 (HMO-POS D-SNP)
|
$43.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $103.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueCHiP for Medicare Standard with Drugs (HMO)
|
$55.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $72.84 |
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 |
BlueCHiP for Medicare Standard with Drugs (HMO)
|
$55.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $72.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueCHiP for Medicare Standard with Drugs (HMO)
|
$55.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $72.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueCHiP for Medicare Standard with Drugs (HMO)
|
$55.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $72.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueCHiP for Medicare Standard with Drugs (HMO)
|
$55.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $72.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC NG-0001 (Regional PPO)
|
$58.00 |
$395* |
Yes, this drug has Gap Coverage. |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $49.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueCHiP for Medicare Extra (HMO-POS)
|
$105.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$4.00 | $0.00 | Q:30 /30Days | $72.84 |
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 |
BlueCHiP for Medicare Extra (HMO-POS)
|
$105.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$4.00 | $0.00 | Q:30 /30Days | $72.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueCHiP for Medicare Extra (HMO-POS)
|
$105.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$4.00 | $0.00 | Q:30 /30Days | $72.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueCHiP for Medicare Extra (HMO-POS)
|
$105.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$4.00 | $0.00 | Q:30 /30Days | $72.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueCHiP for Medicare Extra (HMO-POS)
|
$105.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$4.00 | $0.00 | Q:30 /30Days | $72.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueCHiP for Medicare Plus (HMO)
|
$130.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$6.00 | $0.00 | Q:30 /30Days | $72.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueCHiP for Medicare Plus (HMO)
|
$130.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$6.00 | $0.00 | Q:30 /30Days | $72.84 |
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 |
BlueCHiP for Medicare Plus (HMO)
|
$130.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$6.00 | $0.00 | Q:30 /30Days | $72.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueCHiP for Medicare Plus (HMO)
|
$130.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$6.00 | $0.00 | Q:30 /30Days | $72.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueCHiP for Medicare Plus (HMO)
|
$130.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$6.00 | $0.00 | Q:30 /30Days | $72.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
HealthMate for Medicare (PPO)
|
$143.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $72.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
HealthMate for Medicare (PPO)
|
$143.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $72.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
HealthMate for Medicare (PPO)
|
$143.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $72.84 |
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 |
HealthMate for Medicare (PPO)
|
$143.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $72.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
HealthMate for Medicare (PPO)
|
$143.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $72.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueCHiP for Medicare Preferred (HMO-POS)
|
$237.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$6.00 | $0.00 | Q:30 /30Days | $72.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueCHiP for Medicare Preferred (HMO-POS)
|
$237.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$6.00 | $0.00 | Q:30 /30Days | $72.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueCHiP for Medicare Preferred (HMO-POS)
|
$237.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$6.00 | $0.00 | Q:30 /30Days | $72.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueCHiP for Medicare Preferred (HMO-POS)
|
$237.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$6.00 | $0.00 | Q:30 /30Days | $72.84 |
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 |
BlueCHiP for Medicare Preferred (HMO-POS)
|
$237.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$6.00 | $0.00 | Q:30 /30Days | $72.84 |
Browse Plan Formulary all covered insulin pay $35 or less |