TESTOSTERONE 1.62% (2.5 G) GEL PACKET [AndroGel] (75 grams ) (NDC: 45802036665)
2024 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
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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 |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:450 /90Days | $310.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:450 /90Days | $311.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:450 /90Days | $310.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:450 /90Days | $310.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:450 /90Days | $306.89 |
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 |
HAP Medicare Connect (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | P | $276.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
HAP Medicare Explore (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | P | $276.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
HAP MSUHC Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | P | $276.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana USAA Honor with Rx (PPO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | P Q:150 /30Days | $289.24 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice - Diabetes and Heart (PPO C-SNP)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $131.00 | P Q:150 /30Days | $287.49 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-306 (PPO)
|
$0.00 |
$545 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | P Q:150 /30Days | $289.24 |
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 H5216-384 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | P Q:150 /30Days | $291.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare Plus Blue + Meijer (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:450 /90Days | $375.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare Plus Blue + Meijer (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:450 /90Days | $332.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare Plus Blue + Meijer (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:450 /90Days | $374.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare Plus Blue + Meijer (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:450 /90Days | $383.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare Plus Blue + Meijer (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:450 /90Days | $380.86 |
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 |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:450 /90Days | $375.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:450 /90Days | $332.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:450 /90Days | $374.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:450 /90Days | $383.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:450 /90Days | $380.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare Plus Blue PPO Part B Credit (PPO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:450 /90Days | $380.86 |
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 |
Medicare Plus Blue PPO Part B Credit (PPO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:450 /90Days | $375.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare Plus Blue PPO Part B Credit (PPO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:450 /90Days | $332.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare Plus Blue PPO Part B Credit (PPO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:450 /90Days | $374.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare Plus Blue PPO Part B Credit (PPO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:450 /90Days | $383.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
PHP Medicare Advantage (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P Q:150 /30Days | $284.25 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | P Q:150 /30Days | $300.48 |
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 |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | P Q:150 /30Days | $271.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | P Q:150 /30Days | $293.77 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:150 /30Days | $271.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:150 /30Days | $211.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:150 /30Days | $205.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:150 /30Days | $293.77 |
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 |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:150 /30Days | $300.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Thrive (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:150 /30Days | $271.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:150 /30Days | $271.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:150 /30Days | $293.77 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:150 /30Days | $300.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
Sparrow Advantage (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $237.50 | P Q:150 /30Days | $292.82 |
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 H5216-380 (PPO)
|
$19.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | P Q:150 /30Days | $293.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Ideal (PPO)
|
$19.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:150 /30Days | $271.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Ideal (PPO)
|
$19.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:150 /30Days | $211.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Ideal (PPO)
|
$19.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:150 /30Days | $205.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Ideal (PPO)
|
$19.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:150 /30Days | $293.77 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Ideal (PPO)
|
$19.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:150 /30Days | $300.48 |
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 |
Sparrow Advantage Plus (HMO-POS)
|
$25.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $237.50 | P Q:150 /30Days | $292.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Value Plus H5216-382 (PPO)
|
$28.20 |
$260 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | P Q:150 /30Days | $291.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Value (HMO-POS)
|
$31.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:150 /30Days | $271.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Value (HMO-POS)
|
$31.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:150 /30Days | $211.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Value (HMO-POS)
|
$31.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:150 /30Days | $205.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Value (HMO-POS)
|
$31.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:150 /30Days | $293.77 |
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 |
PriorityMedicare Value (HMO-POS)
|
$31.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:150 /30Days | $300.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice SNP-DE H5216-385 (PPO D-SNP)
|
$35.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | P Q:150 /30Days | $289.24 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice SNP-DE H5216-388 (PPO D-SNP)
|
$35.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | P Q:150 /30Days | $290.37 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare D-SNP (HMO D-SNP)
|
$35.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | P Q:150 /30Days | $278.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare D-SNP Advantage (HMO D-SNP)
|
$35.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | P Q:150 /30Days | $281.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare (HMO-POS)
|
$59.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:150 /30Days | $271.65 |
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 |
PriorityMedicare (HMO-POS)
|
$59.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:150 /30Days | $211.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare (HMO-POS)
|
$59.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:150 /30Days | $205.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare (HMO-POS)
|
$59.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:150 /30Days | $293.77 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare (HMO-POS)
|
$59.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:150 /30Days | $300.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare Plus Blue PPO Vitality (PPO)
|
$78.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:450 /90Days | $332.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare Plus Blue PPO Vitality (PPO)
|
$78.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:450 /90Days | $374.68 |
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 |
Medicare Plus Blue PPO Vitality (PPO)
|
$78.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:450 /90Days | $383.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare Plus Blue PPO Vitality (PPO)
|
$78.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:450 /90Days | $380.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare Plus Blue PPO Vitality (PPO)
|
$78.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:450 /90Days | $375.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-011 (PPO)
|
$84.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | P Q:150 /30Days | $287.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:150 /30Days | $293.77 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:150 /30Days | $300.48 |
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 |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:150 /30Days | $271.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:150 /30Days | $211.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:150 /30Days | $205.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$102.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $76.00 | P Q:450 /90Days | $310.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$102.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $76.00 | P Q:450 /90Days | $311.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$102.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $76.00 | P Q:450 /90Days | $310.96 |
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 |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$102.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $76.00 | P Q:450 /90Days | $310.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$102.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $76.00 | P Q:450 /90Days | $306.89 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R3887-002 (Regional PPO)
|
$105.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | P Q:150 /30Days | $289.24 |
Browse Plan Formulary all covered insulin pay $35 or less |
HAP Senior Plus (HMO-POS)
|
$110.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | P | $271.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare Plus Blue PPO Signature (PPO)
|
$120.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:450 /90Days | $380.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare Plus Blue PPO Signature (PPO)
|
$120.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:450 /90Days | $375.64 |
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 |
Medicare Plus Blue PPO Signature (PPO)
|
$120.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:450 /90Days | $332.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare Plus Blue PPO Signature (PPO)
|
$120.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:450 /90Days | $374.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare Plus Blue PPO Signature (PPO)
|
$120.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P Q:450 /90Days | $383.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
HAP Senior Plus (PPO)
|
$165.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | P | $276.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Select (PPO)
|
$212.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:150 /30Days | $300.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Select (PPO)
|
$212.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:150 /30Days | $271.65 |
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 |
PriorityMedicare Select (PPO)
|
$212.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:150 /30Days | $211.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Select (PPO)
|
$212.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:150 /30Days | $205.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
PriorityMedicare Select (PPO)
|
$212.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:150 /30Days | $293.77 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare Plus Blue PPO Assure (PPO)
|
$216.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $74.00 | P Q:450 /90Days | $380.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare Plus Blue PPO Assure (PPO)
|
$216.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $74.00 | P Q:450 /90Days | $375.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare Plus Blue PPO Assure (PPO)
|
$216.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $74.00 | P Q:450 /90Days | $332.59 |
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 |
Medicare Plus Blue PPO Assure (PPO)
|
$216.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $74.00 | P Q:450 /90Days | $374.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare Plus Blue PPO Assure (PPO)
|
$216.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $74.00 | P Q:450 /90Days | $383.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$226.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $76.00 | P Q:450 /90Days | $310.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$226.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $76.00 | P Q:450 /90Days | $310.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$226.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $76.00 | P Q:450 /90Days | $306.89 |
Browse Plan Formulary all covered insulin pay $35 or less |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$226.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $76.00 | P Q:450 /90Days | $310.47 |
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 |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$226.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $76.00 | P Q:450 /90Days | $311.23 |
Browse Plan Formulary all covered insulin pay $35 or less |