OZEMPIC 2 MG/DOSE (8 MG/3 ML) PEN INJCTR (3 MLS ) (NDC: 00169477212)
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 |
Aetna Medicare Advantra (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:3 /28Days | $953.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Freedom (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:3 /28Days | $953.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Giveback Choice (PPO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
20% | 20% | P Q:3 /28Days | $953.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Signature (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:3 /28Days | $953.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue adVantage Classic (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:3 /28Days | $894.97 |
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 adVantage Classic (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:3 /28Days | $901.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue adVantage Classic (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:3 /28Days | $896.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue adVantage Classic (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:3 /28Days | $896.49 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue adVantage Classic (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:3 /28Days | $895.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue adVantage Giveback (HMO-POS)
|
$0.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:3 /28Days | $899.25 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue adVantage Liberty (PPO)
|
$0.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:3 /28Days | $899.25 |
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 BR Clinic-BR Gen H1951-055 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:3 /28Days | $921.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana FMOL Baton Rouge H1951-053 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:3 /28Days | $921.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H1951-048 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:3 /28Days | $917.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H1951-048 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:3 /28Days | $921.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Select Partner Plan H1951-039 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:3 /28Days | $920.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-325 (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:3 /28Days | $920.09 |
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 |
Ochsner Health Plan Freedom (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:3 /28Days | $931.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Ochsner Health Plan Freedom (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:3 /28Days | $934.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Ochsner Health Plan Premier (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:3 /28Days | $931.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Ochsner Health Plan Premier (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:3 /28Days | $934.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Peoples Health Choices (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:3 /28Days | $979.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
Peoples Health Choices 65 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:3 /28Days | $980.90 |
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 |
Peoples Health Choices 65 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:3 /28Days | $976.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
Peoples Health Choices 65 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:3 /28Days | $979.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
Peoples Health Choices 65 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:3 /28Days | $979.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
Peoples Health Medicare Advantage LA-0004 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:3 /28Days | $979.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Endurance (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:3 /28Days | $832.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback Open (PPO)
|
$0.00 |
$545 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:3 /28Days | $832.28 |
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 |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:3 /28Days | $831.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:3 /28Days | $834.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:3 /28Days | $829.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:3 /28Days | $832.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plus (PPO)
|
$20.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:3 /28Days | $953.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plus Signature (PPO)
|
$24.10 |
$150 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P Q:3 /28Days | $953.44 |
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 All Dual Assure (HMO D-SNP)
|
$25.80 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P Q:3 /28Days | $832.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
|
$25.90 |
$315 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | P Q:3 /28Days | $832.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Dual Signature Select (PPO D-SNP)
|
$27.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | P Q:3 /28Days | $953.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Dual Signature Choice (PPO D-SNP)
|
$29.80 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | P Q:3 /28Days | $953.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue adVantage Dual Plus (HMO-POS D-SNP)
|
$30.30 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | P Q:3 /28Days | $900.09 |
Browse Plan Formulary all covered insulin pay $35 or less |
Healthy Blue Enhanced Care (HMO D-SNP)
|
$30.30 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | P Q:3 /28Days | $952.92 |
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 |
Healthy Blue Dual Advantage (HMO D-SNP)
|
$32.80 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | P Q:3 /28Days | $952.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Dual Select (HMO D-SNP)
|
$35.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | P Q:3 /28Days | $953.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Pinnacle Liberty (HMO D-SNP)
|
$38.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:3 /28Days | $832.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Freedom Access (HMO D-SNP)
|
$39.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:3 /28Days | $832.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H1951-057 (HMO D-SNP)
|
$41.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:3 /28Days | $920.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Peoples Health Secure Health (HMO-POS D-SNP)
|
$44.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | P Q:3 /28Days | $979.31 |
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 |
Peoples Health Secure Complete (HMO-POS D-SNP)
|
$45.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | P Q:3 /28Days | $979.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-064 (PPO)
|
$46.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:3 /28Days | $920.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Dual Preferred (HMO D-SNP)
|
$46.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | P Q:3 /28Days | $953.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
American Health Advantage of Louisiana (HMO I-SNP)
|
$46.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P | $1,010.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue adVantage Reliance (HMO-POS)
|
$46.20 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:3 /28Days | $899.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue adVantage Reliance (HMO-POS)
|
$46.20 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:3 /28Days | $895.53 |
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 |
Humana Gold Plus SNP-DE H1951-032 (HMO D-SNP)
|
$46.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:3 /28Days | $919.77 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H1951-056 (HMO D-SNP)
|
$46.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:3 /28Days | $920.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice SNP-DE H5216-332 (PPO D-SNP)
|
$46.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:3 /28Days | $919.77 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete LA-S001 (PPO D-SNP)
|
$46.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | P Q:3 /28Days | $979.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete LA-S003 (HMO-POS D-SNP)
|
$46.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | P Q:3 /28Days | $979.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue adVantage Premier (PPO)
|
$100.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:3 /28Days | $899.25 |
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 R0110-003 (Regional PPO)
|
$150.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:3 /28Days | $919.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue adVantage Platinum (HMO-POS)
|
$169.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:3 /28Days | $899.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue adVantage Platinum (HMO-POS)
|
$169.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | P Q:3 /28Days | $895.53 |
Browse Plan Formulary all covered insulin pay $35 or less |