SULFACETAMIDE SOD 10% TOP SUSP (118.000 ML ) (NDC: 45802089626)
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 Elite Plan (PPO)
|
$0.00 |
$300 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $60.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$300 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $58.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Select Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | None | $61.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Centers Plan for Medicare Advantage Care (HMO)
|
$0.00 |
$395* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | $37.50 | None | $99.10 |
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 |
$47.00 | $141.00 | None | $88.89 |
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 |
Elderplan Flex (HMO-POS)
|
$0.00 |
$375 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:118 /30Days | $84.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Elderplan Select (HMO-POS I-SNP)
|
$0.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | 25% | Q:118 /30Days | $84.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:118 /30Days | $48.27 |
Browse Plan Formulary all covered insulin pay $35 or less |
Healthfirst Signature (HMO)
|
$0.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:118 /30Days | $48.27 |
Browse Plan Formulary all covered insulin pay $35 or less |
Healthfirst Signature (PPO)
|
$0.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:118 /30Days | $48.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H3533-027 (HMO)
|
$0.00 |
$425 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:118 /30Days | $124.87 |
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 H5970-024 (PPO)
|
$0.00 |
$425 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:118 /30Days | $107.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5970-024 (PPO)
|
$0.00 |
$425 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:118 /30Days | $128.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Tier 1 |
0% | 0% | None | $98.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Fidelis No Premium (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | Q:118 /30Days | $96.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback Open (PPO)
|
$0.00 |
$500 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | Q:118 /30Days | $90.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$425 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
47% | 47% | Q:118 /30Days | $89.70 |
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 |
$450 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | Q:118 /30Days | $90.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Medicare Advantage (HMO)
|
$16.00 |
$350 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$94.00 | $282.00 | None | $49.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist Open (PPO)
|
$20.60 |
$510 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
46% | 46% | Q:118 /30Days | $90.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Discover Value Plan (PPO)
|
$24.00 |
$250 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | None | $141.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Dual (HMO D-SNP)
|
$24.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $83.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Dual (HMO D-SNP)
|
$24.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $94.64 |
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 |
EmblemHealth VIP Dual Reserve (HMO D-SNP)
|
$24.80 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $83.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
VNS Health EasyCare (HMO)
|
$25.00 |
$145 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $60.00 | None | $98.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Whole Health of New York NHC (HMO D-SNP)
|
$25.10 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:118 /30Days | $84.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Whole Health Medicare Complete Care (HMO D-SNP)
|
$26.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:118 /30Days | $84.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Whole Health Medicare Complete Care (HMO D-SNP)
|
$26.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:118 /30Days | $84.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Fidelis Assist (HMO-POS)
|
$27.50 |
$430 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | Q:118 /30Days | $96.18 |
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 |
Humana Gold Plus H3533-032 (HMO)
|
$29.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:118 /30Days | $128.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H3533-032 (HMO)
|
$29.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:118 /30Days | $100.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Plus Medicare (PPO)
|
$32.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $88.89 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
|
$32.30 |
$540 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | 45% | Q:118 /30Days | $84.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP)
|
$33.90 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | Q:118 /30Days | $84.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Elderplan Assist (HMO-POS I-SNP)
|
$34.50 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | 25% | Q:118 /30Days | $84.78 |
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 |
Elderplan Extra Help (HMO-POS)
|
$34.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:118 /30Days | $84.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$35.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:118 /30Days | $87.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Healthfirst Increased Benefits Plan (HMO)
|
$39.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | Q:118 /30Days | $48.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Hamaspik Medicare Choice (HMO D-SNP)
|
$42.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $97.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
Hamaspik Medicare Select (HMO D-SNP)
|
$42.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $101.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Healthfirst Life Improvement Plan (HMO D-SNP)
|
$43.30 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | Q:118 /30Days | $48.26 |
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 Fidelis Dual Access (HMO D-SNP)
|
$44.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:118 /30Days | $95.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
Healthfirst CompleteCare (HMO D-SNP)
|
$45.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | Q:118 /30Days | $48.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Elderplan Advantage For Nursing Home Residents (HMO-POS I-SNP)
|
$48.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | Q:118 /30Days | $84.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Healthfirst Connection Plan (HMO D-SNP)
|
$48.60 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
44% | 44% | Q:118 /30Days | $48.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Assure Plan (HMO D-SNP)
|
$48.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | None | $141.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Full Dual Advantage (HMO D-SNP)
|
$48.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | None | $45.34 |
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 |
Anthem Full Dual Advantage Select (HMO D-SNP)
|
$48.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | None | $45.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem HealthPlus Full Dual Advantage (HMO D-SNP)
|
$48.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | None | $45.05 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem HealthPlus Full Dual Advantage LTSS (HMO D-SNP)
|
$48.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | None | $45.05 |
Browse Plan Formulary all covered insulin pay $35 or less |
Centers Plan for Dual Coverage Care (HMO D-SNP)
|
$48.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $99.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Centers Plan for Medicaid Advantage Plus (HMO D-SNP)
|
$48.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $99.06 |
Browse Plan Formulary all covered insulin pay $35 or less |
Centers Plan for Nursing Home Care (HMO I-SNP)
|
$48.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $99.06 |
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 |
Elderplan Plus Long Term Care (HMO-POS D-SNP)
|
$48.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | Q:118 /30Days | $84.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H3533-034 (HMO D-SNP)
|
$48.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | Q:118 /30Days | $109.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H3533-034 (HMO D-SNP)
|
$48.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | Q:118 /30Days | $129.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice SNP-DE H5970-026 (PPO D-SNP)
|
$48.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | Q:118 /30Days | $120.27 |
Browse Plan Formulary all covered insulin pay $35 or less |
MetroPlus Advantage Plan (HMO D-SNP)
|
$48.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:118 /30Days | $64.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
MetroPlus UltraCare (HMO D-SNP)
|
$48.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:118 /30Days | $64.17 |
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 |
RiverSpring MAP (HMO D-SNP)
|
$48.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $108.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
RiverSpring Star (HMO I-SNP)
|
$48.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $108.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
VillageCareMAX Medicare Health Advantage FLEX Plan (HMO D-SNP)
|
$48.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
19% | 19% | None | $98.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
VillageCareMAX Medicare Health Advantage Plan (HMO D-SNP)
|
$48.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
21% | 21% | None | $98.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
VillageCareMAX Medicare Select Advantage Plan (HMO)
|
$48.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
23% | 23% | None | $98.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
VillageCareMAX Medicare Total Advantage Plan (HMO D-SNP)
|
$48.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
24% | 24% | None | $98.65 |
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 |
VNS Health EasyCare Plus (HMO D-SNP)
|
$48.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $98.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
VNS Health Total (HMO D-SNP)
|
$48.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $98.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$48.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:118 /30Days | $96.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Fidelis Dual Plus (HMO D-SNP)
|
$48.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:118 /30Days | $90.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plan (PPO)
|
$49.00 |
$150 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $58.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Gold (HMO)
|
$82.00 |
$200 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $95.17 |
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 |
EmblemHealth VIP Gold (HMO)
|
$82.00 |
$200 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $83.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Gold (HMO)
|
$82.00 |
$200 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $91.06 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Premium Ultra Open (PPO)
|
$110.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | Q:118 /30Days | $90.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
MetroPlus Platinum Plan (HMO)
|
$132.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | Q:118 /30Days | $64.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plan (PPO)
|
$171.00 |
$250 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | None | $141.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Gold Plus (HMO)
|
$241.00 |
$200 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $86.15 |
Browse Plan Formulary all covered insulin pay $35 or less |