TRELEGY ELLIPTA 100-62.5-25 (60 EA ) (NDC: 00173088710)
2024 Medicare Prescription Drug Plan (MAPD) Information
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Plan Name |
Monthly Prem. |
De- duct- ible |
Does Plan Offer Additional Gap Coverage |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Plan’s Avg. Retail Drug Price 30-Day |
Tier Nbr. |
Tier Desc. |
30-Day Prfrd. Pharm |
90-Day Mail Order |
AARP Medicare Advantage from UHC ST-0003 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $665.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC ST-0004 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $665.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Walgreens from UHC ST-0002 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $655.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $647.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Gold Advantage (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $647.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Aetna Medicare SmartFit (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
20% | 20% | Q:60 /30Days | $647.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare SmartSaver Elite (HMO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $648.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Medicare Advantage (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:60 /30Days | $647.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Medicare Advantage (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:60 /30Days | $646.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Medicare Advantage (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:60 /30Days | $647.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days | $627.73 |
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 True Choice Medicare (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days | $627.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Savings Medicare (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:60 /30Days | $627.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
Essence Advantage (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$39.00 | $97.50 | Q:60 /30Days | $643.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
Essence Advantage Choice (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days | $643.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
Essence Advantage Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$39.00 | $97.50 | Q:60 /30Days | $643.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $626.20 |
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 H0028-014 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $626.05 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-318 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $625.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-318 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $627.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-318 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $629.09 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medica Advantage with SSM Value (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $117.50 | Q:60 /30Days | $1,018.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
Provider Partners Missouri Community Plan (HMO I-SNP)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $686.39 |
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 Complete Care MO-0001 (PPO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $665.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback (HMO)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:60 /30Days | $545.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Mutual of Omaha No Premium Open (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:60 /30Days | $549.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:60 /30Days | $543.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Option 1 (HMO-POS)
|
$19.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $647.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Mutual of Omaha Low Premium Open (PPO)
|
$19.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:60 /30Days | $549.11 |
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 Complete Care AM-001A (Regional PPO C-SNP)
|
$19.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:60 /30Days | $665.37 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
|
$21.50 |
$425 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:60 /30Days | $545.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Essence Advantage Choice Plus (PPO)
|
$22.20 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:60 /30Days | $643.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Dual Advantage (HMO D-SNP)
|
$26.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:60 /30Days | $648.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$27.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days | $546.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Option 2 (HMO)
|
$28.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $647.44 |
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 Dual Access Open (PPO D-SNP)
|
$28.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days | $549.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Complete Care AM-0001 (Regional PPO C-SNP)
|
$31.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $665.37 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Care Advantage MO-E001 (PPO I-SNP)
|
$32.30 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $666.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare (HMO D-SNP)
|
$33.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:60 /30Days | $627.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare Plus (HMO D-SNP)
|
$33.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:60 /30Days | $627.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC ST-0001 (PPO)
|
$34.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:60 /30Days | $665.84 |
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 Plus (HMO)
|
$36.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
20% | 20% | Q:60 /30Days | $648.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Nursing Home Plan MO-F001 (PPO I-SNP)
|
$36.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:60 /30Days | $665.87 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Full Dual Advantage (HMO D-SNP)
|
$37.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:60 /30Days | $648.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier (PPO)
|
$40.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $647.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Choice H8145-006 (PFFS)
|
$40.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $626.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
NHC Advantage (HMO I-SNP)
|
$42.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | Q:60 /30Days | $1,018.88 |
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 Assure (HMO D-SNP)
|
$43.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:60 /30Days | $647.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
American Health Advantage of Missouri (HMO I-SNP)
|
$43.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $686.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
American Health Advantage of Missouri Choice (HMO I-SNP)
|
$43.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $686.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP)
|
$43.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:60 /30Days | $626.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Provider Partners Missouri Advantage Plan (HMO I-SNP)
|
$43.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $686.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete MO-S001 (HMO-POS D-SNP)
|
$43.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:60 /30Days | $665.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
UHC Dual Complete MO-S002 (PPO D-SNP)
|
$43.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:60 /30Days | $665.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete MO-V001 (HMO-POS D-SNP)
|
$43.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:60 /30Days | $665.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Medicare Advantage 2 (PPO)
|
$44.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:60 /30Days | $646.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Essence Advantage Plus (HMO)
|
$53.80 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$34.00 | $85.00 | Q:60 /30Days | $643.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-032 (PPO)
|
$61.00 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $626.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R1532-002 (Regional PPO)
|
$62.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
18% | 18% | Q:60 /30Days | $625.14 |
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 Medicare Advantage AM-0002 (Regional PPO)
|
$71.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $665.37 |
Browse Plan Formulary all covered insulin pay $35 or less |