XARELTO 15 MG TABLET (30.000 EA ) (NDC: 50458057830)
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 VA-0005 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $576.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC VA-0011 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $576.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC VA-0011 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $576.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC VA-0013 (HMO-POS)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $576.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC VA-0017 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $576.07 |
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 Select Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $560.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare SmartFit (HMO-POS)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
20% | 20% | Q:30 /30Days | $560.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem I Carelon Chronic Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:60 /30Days | $559.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem I Carelon Home Care (HMO I-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $80.00 | Q:60 /30Days | $545.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem I Carelon Lung Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $80.00 | Q:60 /30Days | $559.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem I Carelon Medicare Advantage (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $80.00 | Q:60 /30Days | $559.88 |
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 |
Anthem I Carelon Premium Savings (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $80.00 | Q:60 /30Days | $559.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Kidney Care (HMO C-SNP)
|
$0.00 |
$325 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:60 /30Days | $559.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Medicare Advantage (PPO)
|
$0.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:60 /30Days | $559.93 |
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 | None | $683.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | None | $683.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clear Spring Health Essential (HMO C-SNP)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $105.00 | Q:60 /30Days | $549.71 |
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 |
Clear Spring Health Essential (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:60 /30Days | $549.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Erickson Advantage Liberty (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:60 /30Days | $575.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Choice H8145-004 (PFFS)
|
$0.00 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $542.85 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$0.00 |
$145* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $543.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H5619-157 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $543.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H6622-083 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:60 /30Days | $543.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HumanaChoice H5216-266 (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $543.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-308 (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $543.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-312 (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:60 /30Days | $543.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:30 /30Days | $533.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Sentara Medicare Value (HMO)
|
$0.00 |
$150* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$42.00 | $84.00 | None | $531.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Sentara Community Complete Select (HMO D-SNP)
|
$14.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | None | $533.91 |
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 |
Sentara Community Complete (HMO D-SNP)
|
$17.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | None | $533.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Together in Health (PPO I-SNP)
|
$18.30 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:60 /30Days | $543.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$21.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $543.89 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Plus Medicare (HMO)
|
$23.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | None | $683.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Plus Medicare (PPO)
|
$23.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | None | $683.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Extra Help (HMO)
|
$25.10 |
$545 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $559.96 |
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 |
AARP Medicare Advantage from UHC VA-0012 (HMO-POS)
|
$29.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $576.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC VA-0012 (HMO-POS)
|
$29.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $576.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Dual Advantage (HMO D-SNP)
|
$29.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:60 /30Days | $560.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$30.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $533.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Assure Value (HMO D-SNP)
|
$33.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:30 /30Days | $560.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Nursing Home Plan EX-F004 (PPO I-SNP)
|
$35.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:60 /30Days | $575.62 |
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 |
Molina Medicare Complete Care (HMO D-SNP)
|
$36.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $533.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Better Health of Virginia (HMO D-SNP)
|
$38.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:30 /30Days | $560.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Assure Premier (HMO D-SNP)
|
$38.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:30 /30Days | $560.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Dual Advantage (PPO D-SNP)
|
$38.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:60 /30Days | $560.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Full Dual Advantage (HMO D-SNP)
|
$38.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:60 /30Days | $560.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Full Dual Advantage 2 (HMO D-SNP)
|
$38.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:60 /30Days | $560.40 |
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 |
Anthem Full Dual Advantage Support (HMO D-SNP)
|
$38.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:60 /30Days | $560.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H6622-085 (HMO)
|
$38.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $543.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-363 (PPO)
|
$38.50 |
$545 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $543.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete VA-Q001 (HMO-POS D-SNP)
|
$38.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:60 /30Days | $575.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete VA-S001 (PPO D-SNP)
|
$38.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:60 /30Days | $575.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete VA-S002 (HMO-POS D-SNP)
|
$38.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:60 /30Days | $575.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
UHC Dual Complete VA-V001 (HMO-POS D-SNP)
|
$38.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:60 /30Days | $575.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete VA-Y001 (HMO-POS D-SNP)
|
$38.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:60 /30Days | $575.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete VA-Y002 (HMO-POS D-SNP)
|
$38.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:60 /30Days | $575.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-144 (PPO)
|
$39.00 |
$265* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $543.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Erickson Advantage Freedom (HMO-POS)
|
$64.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:60 /30Days | $575.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Choice Plan (PPO)
|
$88.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $560.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HumanaChoice R1390-002 (Regional PPO)
|
$105.00 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $542.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
Erickson Advantage Signature (HMO-POS)
|
$168.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:60 /30Days | $575.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
Erickson Advantage Champion (HMO-POS C-SNP)
|
$188.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:60 /30Days | $575.65 |
Browse Plan Formulary all covered insulin pay $35 or less |