TOVET EMOLLIENT 0.05% FOAM [Olux-E] (100 grams ) (NDC: 43538095210)
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 |
Aetna Medicare Elite 3 (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite 3 (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite 3 (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite 3 (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite 3 (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
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 Elite 3 (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite 3 (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite 3 (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite 3 (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite 3 (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite 3 (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
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 Elite 3 (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite 3 (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite 3 (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite 3 (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite 3 (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite 3 (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
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 Elite 3 (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite 3 (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite 3 (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite 3 (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Elite (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Elite (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
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 |
Aetna Medicare Explorer Elite (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Elite (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Elite (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Elite (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Elite (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Elite (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
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 |
Aetna Medicare Explorer Elite (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Elite (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Elite (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Elite (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Elite (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Elite (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
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 |
Aetna Medicare Explorer Elite (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Elite (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Value (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Value (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Value (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Value (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
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 |
Aetna Medicare Explorer Value (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Value (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Value (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Value (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Value (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Value (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
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 |
Aetna Medicare Premier Plan (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plan (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plan (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plan (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plan (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plan (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
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 |
Aetna Medicare Premier Plan (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plan (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Credit (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Credit (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Credit (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Credit (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
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 Prime Credit (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Credit (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Credit (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Credit (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Credit (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Credit (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
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 Prime Value (HMO-POS)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Value (HMO-POS)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Value (HMO-POS)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Value (HMO-POS)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Value (HMO-POS)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Value (HMO-POS)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
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 Prime Value (HMO-POS)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Value (HMO-POS)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Value (HMO-POS)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Value (HMO-POS)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Value (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Value (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
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 Prime Value (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Value (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Value (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Value (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Value (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Value (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
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 Prime Value (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Value (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $395.96 |
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 |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Medicare Core (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
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 |
AmeriHealth Medicare Core (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Medicare Core (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Medicare Core (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Medicare Core (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Medicare Core (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Medicare Core (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
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 |
AmeriHealth Medicare Secure (PPO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Medicare Secure (PPO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Medicare Secure (PPO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Medicare Secure (PPO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Medicare Secure (PPO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Medicare Secure (PPO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
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 |
AmeriHealth Medicare Secure (PPO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Medicare Ultimate (PPO)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Medicare Ultimate (PPO)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Medicare Ultimate (PPO)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Medicare Ultimate (PPO)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Medicare Ultimate (PPO)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
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 |
AmeriHealth Medicare Ultimate (PPO)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Medicare Ultimate (PPO)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Jefferson Health Plans Silver (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:100 /30Days | $311.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Jefferson Health Plans Silver (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:100 /30Days | $311.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Jefferson Health Plans Silver (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:100 /30Days | $311.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Jefferson Health Plans Silver (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:100 /30Days | $311.67 |
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 |
Jefferson Health Plans Silver (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:100 /30Days | $311.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Medicare Advantage (HMO)
|
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:100 /30Days | $543.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Medicare Advantage (HMO)
|
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:100 /30Days | $543.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Medicare Advantage (HMO)
|
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:100 /30Days | $543.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Medicare Advantage (HMO)
|
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:100 /30Days | $543.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Medicare Advantage (HMO)
|
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:100 /30Days | $543.38 |
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 |
Wellpoint Medicare Advantage (HMO)
|
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:100 /30Days | $543.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Medicare Advantage (HMO)
|
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:100 /30Days | $543.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Medicare Advantage (HMO)
|
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:100 /30Days | $543.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Bronze Plan (PPO)
|
$15.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Bronze Plan (PPO)
|
$15.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Bronze Plan (PPO)
|
$15.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
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 Bronze Plan (PPO)
|
$15.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Bronze Plan (PPO)
|
$15.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Bronze Plan (PPO)
|
$15.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Bronze Plan (PPO)
|
$15.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Bronze Plan (PPO)
|
$15.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Bronze Plan (PPO)
|
$15.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
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 Bronze Plan (PPO)
|
$15.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Bronze Plan (PPO)
|
$15.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Bronze Plan (PPO)
|
$15.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Bronze Plan (PPO)
|
$15.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Bronze Plan (PPO)
|
$15.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Bronze Plan (PPO)
|
$15.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
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 Bronze Plan (PPO)
|
$15.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Bronze Plan (PPO)
|
$15.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Bronze Plan (PPO)
|
$15.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Bronze Plan (PPO)
|
$15.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Bronze Plan (PPO)
|
$15.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Bronze Plan (PPO)
|
$15.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
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 |
Jefferson Health Plans Platinum (HMO-POS)
|
$20.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:100 /30Days | $311.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Jefferson Health Plans Platinum (HMO-POS)
|
$20.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:100 /30Days | $311.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Jefferson Health Plans Platinum (HMO-POS)
|
$20.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:100 /30Days | $311.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Jefferson Health Plans Platinum (HMO-POS)
|
$20.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:100 /30Days | $311.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Jefferson Health Plans Platinum (HMO-POS)
|
$20.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:100 /30Days | $311.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Extra Help (HMO)
|
$28.30 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
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 |
Wellpoint Extra Help (HMO)
|
$28.30 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Extra Help (HMO)
|
$28.30 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Extra Help (HMO)
|
$28.30 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Extra Help (HMO)
|
$28.30 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Extra Help (HMO)
|
$28.30 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Extra Help (HMO)
|
$28.30 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
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 |
Wellpoint Kidney Care (HMO-POS C-SNP)
|
$33.90 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$94.00 | $282.00 | Q:100 /30Days | $543.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Kidney Care (HMO-POS C-SNP)
|
$33.90 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$94.00 | $282.00 | Q:100 /30Days | $543.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Kidney Care (HMO-POS C-SNP)
|
$33.90 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$94.00 | $282.00 | Q:100 /30Days | $543.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Kidney Care (HMO-POS C-SNP)
|
$33.90 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$94.00 | $282.00 | Q:100 /30Days | $543.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Kidney Care (HMO-POS C-SNP)
|
$33.90 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$94.00 | $282.00 | Q:100 /30Days | $543.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Kidney Care (HMO-POS C-SNP)
|
$33.90 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$94.00 | $282.00 | Q:100 /30Days | $543.38 |
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 |
Wellpoint Kidney Care (HMO-POS C-SNP)
|
$33.90 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$94.00 | $282.00 | Q:100 /30Days | $543.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Kidney Care (HMO-POS C-SNP)
|
$33.90 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$94.00 | $282.00 | Q:100 /30Days | $543.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Kidney Care (HMO-POS C-SNP)
|
$33.90 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$94.00 | $282.00 | Q:100 /30Days | $543.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Kidney Care (HMO-POS C-SNP)
|
$33.90 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$94.00 | $282.00 | Q:100 /30Days | $543.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Kidney Care (HMO-POS C-SNP)
|
$33.90 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$94.00 | $282.00 | Q:100 /30Days | $543.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Discover Value Plan (PPO)
|
$35.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
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 Discover Value Plan (PPO)
|
$35.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Discover Value Plan (PPO)
|
$35.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Discover Value Plan (PPO)
|
$35.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Discover Value Plan (PPO)
|
$35.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Discover Value Plan (PPO)
|
$35.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Discover Value Plan (PPO)
|
$35.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
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 Discover Value Plan (PPO)
|
$35.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Discover Value Plan (PPO)
|
$35.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Discover Value Plan (PPO)
|
$35.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Discover Value Plan (PPO)
|
$35.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Discover Value Plan (PPO)
|
$35.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Discover Value Plan (PPO)
|
$35.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
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 Discover Value Plan (PPO)
|
$35.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Discover Value Plan (PPO)
|
$35.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Discover Value Plan (PPO)
|
$35.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Discover Value Plan (PPO)
|
$35.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Discover Value Plan (PPO)
|
$35.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Discover Value Plan (PPO)
|
$35.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $179.13 |
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 |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$35.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$35.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$35.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$35.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$35.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$35.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
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 |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$35.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$35.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$35.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$35.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$35.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$35.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
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 |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$35.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$35.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$35.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$35.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$35.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$35.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
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 |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$35.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$35.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$35.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare SNJ Prime Elite (PPO)
|
$37.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare SNJ Prime Elite (PPO)
|
$37.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare SNJ Prime Elite (PPO)
|
$37.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
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 |
Aetna Medicare SNJ Prime Elite (PPO)
|
$37.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare SNJ Prime Elite (PPO)
|
$37.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare SNJ Prime Elite (PPO)
|
$37.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare SNJ Prime Elite (PPO)
|
$37.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare SNJ Prime Elite (PPO)
|
$37.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Medicare Enhanced (PPO)
|
$37.30 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
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 |
AmeriHealth Medicare Enhanced (PPO)
|
$37.30 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Medicare Enhanced (PPO)
|
$37.30 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Medicare Enhanced (PPO)
|
$37.30 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Medicare Enhanced (PPO)
|
$37.30 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Medicare Enhanced (PPO)
|
$37.30 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Medicare Enhanced (PPO)
|
$37.30 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $193.92 |
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 |
Aetna Medicare Prime Premier (PPO)
|
$39.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Premier (PPO)
|
$39.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Premier (PPO)
|
$39.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Premier (PPO)
|
$39.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Premier (PPO)
|
$39.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Premier (PPO)
|
$39.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
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 Prime Premier (PPO)
|
$39.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Premier (PPO)
|
$39.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Premier (PPO)
|
$39.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Premier (PPO)
|
$39.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Assure Premier Plus (HMO D-SNP)
|
$39.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Assure Premier Plus (HMO D-SNP)
|
$39.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:100 /30Days | $615.13 |
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 Assure Premier Plus (HMO D-SNP)
|
$39.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Assure Premier Plus (HMO D-SNP)
|
$39.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Assure Premier Plus (HMO D-SNP)
|
$39.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Assure Premier Plus (HMO D-SNP)
|
$39.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Assure Premier Plus (HMO D-SNP)
|
$39.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Assure Premier Plus (HMO D-SNP)
|
$39.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:100 /30Days | $615.13 |
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 Assure Premier Plus (HMO D-SNP)
|
$39.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Assure Premier Plus (HMO D-SNP)
|
$39.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Assure Premier Plus (HMO D-SNP)
|
$39.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Assure Premier Plus (HMO D-SNP)
|
$39.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Assure Premier Plus (HMO D-SNP)
|
$39.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Assure Premier Plus (HMO D-SNP)
|
$39.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:100 /30Days | $615.13 |
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 Assure Premier Plus (HMO D-SNP)
|
$39.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Assure Premier Plus (HMO D-SNP)
|
$39.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Assure Premier Plus (HMO D-SNP)
|
$39.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Assure Premier Plus (HMO D-SNP)
|
$39.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Assure Premier Plus (HMO D-SNP)
|
$39.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Assure Premier Plus (HMO D-SNP)
|
$39.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:100 /30Days | $615.13 |
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 Assure Premier Plus (HMO D-SNP)
|
$39.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage Secure (HMO-POS D-SNP)
|
$44.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage Secure (HMO-POS D-SNP)
|
$44.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage Secure (HMO-POS D-SNP)
|
$44.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage Secure (HMO-POS D-SNP)
|
$44.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage Secure (HMO-POS D-SNP)
|
$44.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
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 |
Wellpoint Full Dual Advantage Secure (HMO-POS D-SNP)
|
$44.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage Secure (HMO-POS D-SNP)
|
$44.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage Secure (HMO-POS D-SNP)
|
$44.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage Secure (HMO-POS D-SNP)
|
$44.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage Secure (HMO-POS D-SNP)
|
$44.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage Secure (HMO-POS D-SNP)
|
$44.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
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 |
Wellpoint Full Dual Advantage Secure (HMO-POS D-SNP)
|
$44.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage Secure (HMO-POS D-SNP)
|
$44.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage Secure (HMO-POS D-SNP)
|
$44.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage Secure (HMO-POS D-SNP)
|
$44.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage Secure (HMO-POS D-SNP)
|
$44.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage Secure (HMO-POS D-SNP)
|
$44.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
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 |
Wellpoint Full Dual Advantage Secure (HMO-POS D-SNP)
|
$44.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage Secure (HMO-POS D-SNP)
|
$44.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage Secure (HMO-POS D-SNP)
|
$44.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage Secure (HMO-POS D-SNP)
|
$44.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:100 /30Days | $639.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier (HMO-POS)
|
$57.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier (HMO-POS)
|
$57.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
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 |
Aetna Medicare Explorer Premier (HMO-POS)
|
$57.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier (HMO-POS)
|
$57.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier (HMO-POS)
|
$57.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier (HMO-POS)
|
$57.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier (HMO-POS)
|
$57.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier (HMO-POS)
|
$57.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
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 |
Aetna Medicare Explorer Premier 2 (PPO)
|
$79.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier 2 (PPO)
|
$79.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier 2 (PPO)
|
$79.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier 2 (PPO)
|
$79.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier 2 (PPO)
|
$79.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier 2 (PPO)
|
$79.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
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 |
Aetna Medicare Explorer Premier 2 (PPO)
|
$79.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier Plus (HMO-POS)
|
$84.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier Plus (HMO-POS)
|
$84.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier Plus (HMO-POS)
|
$84.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier Plus (HMO-POS)
|
$84.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier Plus (HMO-POS)
|
$84.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
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 Explorer Premier Plus (HMO-POS)
|
$84.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier Plus (HMO-POS)
|
$84.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier Plus (HMO-POS)
|
$84.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier Plus (HMO-POS)
|
$84.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier Plus (HMO-POS)
|
$84.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier Plus (HMO-POS)
|
$84.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
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 Explorer Premier Plus (HMO-POS)
|
$84.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier Plus (HMO-POS)
|
$84.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier (PPO)
|
$87.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier (PPO)
|
$87.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier (PPO)
|
$87.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier (PPO)
|
$87.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
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 |
Aetna Medicare Explorer Premier (PPO)
|
$87.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier (PPO)
|
$87.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier (PPO)
|
$87.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier (PPO)
|
$87.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier (PPO)
|
$87.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Premier (PPO)
|
$87.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $395.96 |
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 |
Aetna Medicare Premier (Regional PPO)
|
$111.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $179.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plan (PPO)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plan (PPO)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plan (PPO)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plan (PPO)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plan (PPO)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
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 Platinum Plan (PPO)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plan (PPO)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plan (PPO)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plan (PPO)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plan (PPO)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plan (PPO)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
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 Platinum Plan (PPO)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plan (PPO)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plan (PPO)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plan (PPO)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plan (PPO)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plan (PPO)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
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 Platinum Plan (PPO)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plan (PPO)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plan (PPO)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plan (PPO)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:100 /30Days | $615.13 |
Browse Plan Formulary all covered insulin pay $35 or less |