TACROLIMUS 0.1% OINTMENT [Protopic] (30 GRAMS ) (NDC: 68462053435)
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 PA-0006 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | S | $50.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC PA-0011 (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | S | $50.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC PA-0012 (PPO)
|
$0.00 |
$295 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | S | $50.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC PA-0015 (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | S | $50.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Credit Value (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days | $42.98 |
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 |
Aetna Medicare Advantra Gold (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days | $41.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Silver (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days | $39.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Deluxe Plan (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days | $43.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Essentials Plan (PPO)
|
$0.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
40% | 40% | Q:60 /30Days | $52.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Silver Back (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days | $39.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare The Valley Plan (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days | $36.67 |
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 (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days | $37.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $275.00 | Q:100 /28Days | $108.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $275.00 | Q:100 /28Days | $108.85 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $275.00 | Q:100 /28Days | $109.24 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $275.00 | Q:100 /28Days | $108.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $275.00 | Q:100 /28Days | $108.48 |
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 |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $275.00 | Q:100 /28Days | $109.09 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $275.00 | Q:100 /28Days | $108.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $275.00 | Q:100 /28Days | $108.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic 360 Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | Q:60 /30Days | $102.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | Q:60 /30Days | $101.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | Q:60 /30Days | $101.06 |
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 |
Humana Gold Choice H8145-052 (PFFS)
|
$0.00 |
$360 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:200 /30Days | $49.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H6622-036 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:200 /30Days | $48.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana USAA Honor with Rx (PPO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:200 /30Days | $49.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-051 (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:200 /30Days | $51.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-051 (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:200 /30Days | $47.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-058 (PPO)
|
$0.00 |
$505 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:200 /30Days | $49.30 |
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 H5525-060 (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:200 /30Days | $49.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Jefferson Health Plans Complete (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:100 /30Days | $129.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Jefferson Health Plans Flex (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:100 /30Days | $129.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life PPO Premier Rx (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $91.80 |
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. | 4 |
Non-Preferred Drug |
49% | 49% | Q:100 /30Days | $139.18 |
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. | 4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $130.64 |
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 |
Wellcare No Premium (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
48% | 48% | Q:100 /30Days | $139.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$160 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
43% | 43% | Q:100 /30Days | $139.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plus (PPO)
|
$14.60 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days | $39.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$15.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $0.00 | Q:60 /30Days | $107.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$15.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $0.00 | Q:60 /30Days | $98.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$15.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $0.00 | Q:60 /30Days | $107.50 |
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 |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$15.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $0.00 | Q:60 /30Days | $100.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$15.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $0.00 | Q:60 /30Days | $99.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Deductible Rx (HMO)
|
$20.80 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $117.50 | Q:100 /30Days | $91.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Premier (HMO-POS)
|
$21.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days | $39.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
|
$21.30 |
$435 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
48% | 48% | Q:100 /30Days | $96.85 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Value Rx (HMO)
|
$23.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $0.00 | Q:60 /30Days | $98.32 |
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 |
UPMC for Life PPO Rx Choice (PPO)
|
$23.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $117.50 | Q:100 /30Days | $91.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life PPO Rx Choice (PPO)
|
$23.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $117.50 | Q:100 /30Days | $91.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC PA-0007 (PPO)
|
$25.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | S | $50.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-017 (PPO)
|
$26.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:200 /30Days | $49.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare PPO Distinct (PPO)
|
$27.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $275.00 | Q:100 /28Days | $108.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare PPO Distinct (PPO)
|
$27.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $275.00 | Q:100 /28Days | $108.74 |
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 |
Community Blue Medicare PPO Distinct (PPO)
|
$27.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $275.00 | Q:100 /28Days | $109.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare PPO Distinct (PPO)
|
$27.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $275.00 | Q:100 /28Days | $108.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$29.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:100 /30Days | $84.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete PA-V001 (HMO-POS D-SNP)
|
$29.50 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | S | $50.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life PPO High Deductible Rx (PPO)
|
$29.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $117.50 | Q:100 /30Days | $91.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Nursing Home Plan EX-F002 (PPO I-SNP)
|
$32.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | S | $50.36 |
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 |
Geisinger Gold Classic Complete Rx (HMO)
|
$34.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | Q:60 /30Days | $100.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic Complete Rx (HMO)
|
$34.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | Q:60 /30Days | $108.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Dual Preferred (PPO D-SNP)
|
$35.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | Q:60 /30Days | $51.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx Choice (HMO)
|
$36.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $117.50 | Q:100 /30Days | $91.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx Choice (HMO)
|
$36.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $117.50 | Q:100 /30Days | $91.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx Choice (HMO)
|
$36.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $117.50 | Q:100 /30Days | $91.80 |
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 |
UPMC for Life HMO Rx Choice (HMO)
|
$36.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $117.50 | Q:100 /30Days | $91.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx Choice (HMO)
|
$36.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $117.50 | Q:100 /30Days | $91.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Silver (HMO-POS)
|
$37.00 |
$250 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days | $62.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Cares (HMO D-SNP)
|
$38.30 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | Q:60 /30Days | $58.09 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life Complete Care (HMO D-SNP)
|
$38.60 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
49% | 49% | Q:100 /30Days | $92.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H6622-078 (HMO D-SNP)
|
$38.90 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | Q:200 /30Days | $49.19 |
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 H6622-078 (HMO D-SNP)
|
$38.90 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | Q:200 /30Days | $47.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Longevity Plan (HMO I-SNP)
|
$39.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | Q:60 /30Days | $55.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete PA-S002 (HMO-POS D-SNP)
|
$39.90 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | S | $50.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Caritas VIP Care (HMO D-SNP)
|
$40.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | S | $53.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Secure Rx (HMO D-SNP)
|
$40.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | Q:60 /30Days | $98.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
Highmark Wholecare Medicare Assured Diamond (HMO D-SNP)
|
$40.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
40% | 40% | S | $117.26 |
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 |
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP)
|
$40.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
46% | 46% | S | $117.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Value Plus H5216-117 (PPO)
|
$40.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:200 /30Days | $52.94 |
Browse Plan Formulary all covered insulin pay $35 or less |
Jefferson Health Plans Prime (HMO-POS)
|
$40.20 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:100 /30Days | $129.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Jefferson Health Plans Special (HMO D-SNP)
|
$40.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:100 /30Days | $129.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete PA-S001 (PPO D-SNP)
|
$40.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | S | $50.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$40.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:100 /30Days | $84.50 |
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 |
Community Blue Medicare PPO Premier (PPO)
|
$46.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | Q:100 /28Days | $108.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare PPO Premier (PPO)
|
$46.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | Q:100 /28Days | $108.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare PPO Premier (PPO)
|
$46.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | Q:100 /28Days | $109.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare PPO Premier (PPO)
|
$46.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | Q:100 /28Days | $108.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R0923-002 (Regional PPO)
|
$46.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:200 /30Days | $49.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
Jefferson Health Plans Flex Plus (PPO)
|
$49.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:100 /30Days | $129.21 |
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 H5525-005 (PPO)
|
$53.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:200 /30Days | $48.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Freedom Blue PPO ValueRx (PPO)
|
$58.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:100 /28Days | $108.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Premier Plus (PPO)
|
$67.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days | $39.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$79.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | Q:60 /30Days | $105.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$79.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | Q:60 /30Days | $99.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx (HMO)
|
$81.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $117.50 | Q:100 /30Days | $91.80 |
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 |
Geisinger Gold Classic Advantage Rx (HMO)
|
$100.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | Q:60 /30Days | $107.89 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic Advantage Rx (HMO)
|
$100.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | Q:60 /30Days | $99.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic Advantage Rx (HMO)
|
$100.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $0.00 | Q:60 /30Days | $101.37 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-120 (PPO)
|
$123.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:200 /30Days | $49.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life PPO Rx Enhanced (PPO)
|
$134.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $117.50 | Q:100 /30Days | $91.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Gold Plan (PPO)
|
$145.00 |
$250 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days | $62.60 |
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 |
Freedom Blue PPO Standard (PPO)
|
$164.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$13.00 | $27.00 | Q:100 /28Days | $108.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Freedom Blue PPO Deluxe (PPO)
|
$278.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$13.00 | $27.00 | Q:100 /28Days | $108.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx Enhanced (HMO)
|
$295.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $117.50 | Q:100 /30Days | $91.80 |
Browse Plan Formulary all covered insulin pay $35 or less |