TIVICAY 10 MG TABLET (NDC: 49702022613)
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 |
AARP Medicare Advantage from UHC WA-0002 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:30 /30Days | $450.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC WA-0006 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $450.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC WA-0007 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $450.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $442.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare SmartFit Elite Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
20% | 20% | None | $442.82 |
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 |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days | $413.39 |
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. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days | $413.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Health Plan of WA MA Plan 1 (HMO)
|
$0.00 |
$230* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$37.00 | $110.00 | None | $410.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus - Diabetes (HMO C-SNP)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $427.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H2486-007 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $427.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H5619-056 (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $427.81 |
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 |
HumanaChoice H5216-247 (PPO)
|
$0.00 |
$125 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $427.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Kaiser Permanente Senior Advantage Value (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $436.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $442.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $442.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
PacificSource Medicare Explorer Rx 11 (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
29% | 29% | Q:30 /30Days | $442.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
PacificSource Medicare MyCare Choice Rx 34 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
31% | 31% | Q:30 /30Days | $442.75 |
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 |
PacificSource Medicare MyCare Rx 40 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
31% | 31% | Q:30 /30Days | $442.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
Providence Medicare Timber + Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $74.00 | None | $413.87 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence BlueAdvantage HMO (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:240 /30Days | $436.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence BlueAdvantage HMO (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:240 /30Days | $436.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence BlueAdvantage HMO (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:240 /30Days | $436.18 |
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 | None | $414.64 |
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 Mutual of Omaha No Premium Open (PPO)
|
$0.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $84.00 | None | $414.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence MedAdvantage + Rx Primary (PPO)
|
$22.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:240 /30Days | $436.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence MedAdvantage + Rx Primary (PPO)
|
$22.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:240 /30Days | $436.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence MedAdvantage + Rx Primary (PPO)
|
$22.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:240 /30Days | $436.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Low Premium Open (PPO)
|
$24.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | None | $414.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Providence Medicare Bridge + Rx (HMO-POS)
|
$29.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $74.00 | None | $413.87 |
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 |
Wellcare Mutual of Omaha Low Premium Open (PPO)
|
$29.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $84.00 | None | $414.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Nursing Home Plan WA-F001 (PPO I-SNP)
|
$29.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | Q:30 /30Days | $450.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$33.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $442.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Complete Care (HMO D-SNP)
|
$33.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $442.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Value Plus H5619-134 (HMO)
|
$34.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | Q:60 /30Days | $427.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)
|
$35.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:60 /30Days | $427.81 |
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 |
Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)
|
$35.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:60 /30Days | $427.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)
|
$35.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:60 /30Days | $427.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)
|
$35.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:60 /30Days | $427.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$36.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $415.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Health Plan of WA MA Plan 2 (HMO)
|
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$37.00 | $110.00 | None | $410.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC WA-0004 (PPO)
|
$39.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:30 /30Days | $450.78 |
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 |
Aetna Medicare Choice Plan (PPO)
|
$39.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $442.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Health Plan of WA Dual Complete (HMO D-SNP)
|
$40.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $410.85 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Health Plan of WA Dual Select (HMO D-SNP)
|
$40.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $410.85 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Care Advantage WA-E001 (PPO I-SNP)
|
$40.60 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $450.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete WA-D001 (PPO D-SNP)
|
$40.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | Q:30 /30Days | $450.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete WA-D002 (HMO-POS D-SNP)
|
$40.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | Q:30 /30Days | $450.78 |
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 |
UHC Dual Complete WA-V001 (HMO-POS D-SNP)
|
$40.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | Q:30 /30Days | $450.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence BlueAdvantage HMO Plus (HMO)
|
$41.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | Q:240 /30Days | $436.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence BlueAdvantage HMO Plus (HMO)
|
$41.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | Q:240 /30Days | $436.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC WA-0005 (HMO-POS)
|
$42.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:30 /30Days | $450.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Kaiser Permanente Senior Advantage Standard (HMO-POS)
|
$46.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $436.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H5619-059 (HMO)
|
$60.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $427.81 |
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 |
Providence Medicare Choice + Rx (HMO-POS)
|
$71.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $74.00 | None | $413.87 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence MedAdvantage + Rx Classic (PPO)
|
$72.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | Q:240 /30Days | $436.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence MedAdvantage + Rx Classic (PPO)
|
$72.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | Q:240 /30Days | $436.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence MedAdvantage + Rx Classic (PPO)
|
$72.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | Q:240 /30Days | $436.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Health Plan of WA MA Plan 3 (HMO)
|
$79.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$37.00 | $110.00 | None | $410.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC WA-0010 (HMO-POS)
|
$84.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:30 /30Days | $450.78 |
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 |
HumanaChoice H5216-047 (PPO)
|
$100.00 |
$320 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $427.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Kaiser Permanente Senior Advantage Enhanced (HMO-POS)
|
$131.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $436.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence MedAdvantage + Rx Enhanced (PPO)
|
$151.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | Q:240 /30Days | $436.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence MedAdvantage + Rx Enhanced (PPO)
|
$151.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | Q:240 /30Days | $436.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Providence Medicare Extra + Rx (HMO)
|
$155.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $74.00 | None | $413.87 |
Browse Plan Formulary all covered insulin pay $35 or less |