PROTRIPTYLINE HCL 5 MG TABLET [Vivactil] (60 tablets ) (NDC: 00054021025)
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 OH-0004 (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $110.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC OH-0005 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $110.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC OH-0005 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $113.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC OH-0010 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $110.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC OH-0017 (HMO-POS)
|
$0.00 |
$395 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $112.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Aetna Medicare Premier (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $81.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare SmartFit (PPO)
|
$0.00 |
$400 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
40% | 40% | P | $108.57 |
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 |
$100.00 | $300.00 | P | $84.47 |
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. | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | P | $229.52 |
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. | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | P | $223.21 |
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. | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | P | $138.73 |
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 |
Anthem Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | P | $177.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted CHOICE Ohio (PPO)
|
$0.00 |
$150 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $115.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted CORE Ohio (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $115.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted GIVEBACK Ohio (HMO)
|
$0.00 |
$545 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $115.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana USAA Honor with Rx (PPO)
|
$0.00 |
$350 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $217.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-285 (PPO)
|
$0.00 |
$200 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $205.38 |
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 |
HumanaChoice H5216-309 (PPO)
|
$0.00 |
$545 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $217.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | None | $230.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | None | $223.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | None | $274.78 |
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 | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $103.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Choice Care Select (HMO)
|
$0.00 |
$375 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $103.98 |
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 |
Mount Carmel MediGold Cash Back No Premium (HMO)
|
$0.00 |
$150 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $140.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Mount Carmel MediGold No Premium (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $133.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Mount Carmel MediGold No Premium (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $142.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
Mount Carmel MediGold No Premium Choice (PPO)
|
$0.00 |
$150 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $140.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
The Health Plan SecureCare - Option II (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $275.00 | None | $261.29 |
Browse Plan Formulary all covered insulin pay $35 or less |
The Health Plan SecureChoice Optimum (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $275.00 | None | $261.29 |
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 |
The Health Plan SecureChoice Optimum (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $275.00 | None | $271.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback (HMO)
|
$0.00 |
$275 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | None | $190.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$75 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | None | $190.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | None | $190.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare All Dual Assure (HMO D-SNP)
|
$17.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $190.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Together in Health (PPO I-SNP)
|
$18.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $205.38 |
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 |
Devoted PRIME Ohio (HMO)
|
$19.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $115.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Extra Help (HMO)
|
$19.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $156.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Complete Care (HMO D-SNP)
|
$20.50 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $103.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
|
$21.40 |
$535 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | 45% | None | $190.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-106 (PPO)
|
$22.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $200.77 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC OH-0006 (HMO-POS)
|
$24.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $110.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
AARP Medicare Advantage from UHC OH-0006 (HMO-POS)
|
$24.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $113.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Dual Advantage (HMO D-SNP)
|
$26.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | P | $234.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$26.90 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $192.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$27.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $103.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted DUAL PLUS Ohio (HMO D-SNP)
|
$28.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $115.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC OH-0008 (HMO-POS)
|
$29.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $110.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
AARP Medicare Advantage from UHC OH-0008 (HMO-POS)
|
$29.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $113.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-042 (PPO)
|
$30.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $205.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted DUAL Ohio (HMO D-SNP)
|
$30.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $115.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-023 (PPO)
|
$36.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $202.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Assure 1 (HMO D-SNP)
|
$36.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | P | $99.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Value Plus H5525-041 (PPO)
|
$37.10 |
$260 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$97.00 | $281.00 | None | $205.38 |
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 |
Wellcare Dual Access (HMO D-SNP)
|
$37.80 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $184.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Full Dual Advantage (HMO D-SNP)
|
$38.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | P | $234.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
The Health Plan SecureCare SNP (HMO D-SNP)
|
$40.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $262.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
CareSource Dual Advantage (HMO D-SNP)
|
$40.90 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | None | $238.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice SNP-DE H5525-046 (PPO D-SNP)
|
$40.90 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $205.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete OH-D002 (HMO-POS D-SNP)
|
$40.90 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $111.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
UHC Dual Complete OH-S001 (PPO D-SNP)
|
$40.90 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | None | $112.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete OH-V002 (HMO-POS D-SNP)
|
$40.90 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $111.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Valor Health Plan (HMO I-SNP)
|
$40.90 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $133.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Mount Carmel MediGold Plus (HMO)
|
$47.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$75.00 | $150.00 | None | $142.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R5495-002 (Regional PPO)
|
$51.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $205.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Choice H8145-032 (PFFS)
|
$63.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $220.41 |
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 Medicare Advantage (Regional PPO)
|
$73.00 |
$50 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
41% | 41% | P | $156.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Choice (HMO)
|
$93.00 |
$55 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | None | $223.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Choice (HMO)
|
$93.00 |
$55 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | None | $230.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Choice (HMO)
|
$93.00 |
$55 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | None | $274.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Select (PPO)
|
$93.00 |
$95 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | None | $274.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Select (PPO)
|
$93.00 |
$95 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | None | $230.11 |
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 |
MedMutual Advantage Select (PPO)
|
$93.00 |
$95 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | None | $223.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
The Health Plan SecureChoice - Option II (PPO)
|
$93.40 |
$100 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $275.00 | None | $261.29 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-030 (PPO)
|
$115.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$97.00 | $281.00 | None | $205.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Mount Carmel MediGold Premier (HMO)
|
$119.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$75.00 | $150.00 | None | $142.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
Mount Carmel MediGold Premier (HMO)
|
$119.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$75.00 | $150.00 | None | $133.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Plus (HMO)
|
$127.00 |
$55 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | None | $230.11 |
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 |
MedMutual Advantage Plus (HMO)
|
$127.00 |
$55 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | None | $223.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Plus (HMO)
|
$127.00 |
$55 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | None | $274.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Preferred (PPO)
|
$143.00 |
$55 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | None | $223.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Preferred (PPO)
|
$143.00 |
$55 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | None | $230.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Preferred (PPO)
|
$143.00 |
$55 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | None | $274.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plus 2 (Regional PPO)
|
$149.00 |
$250 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
40% | 40% | P | $69.36 |
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 |
MedMutual Advantage Premium (PPO)
|
$193.00 |
$55 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | None | $274.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Premium (PPO)
|
$193.00 |
$55 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | None | $230.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Premium (PPO)
|
$193.00 |
$55 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | None | $223.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plus 1 (Regional PPO)
|
$208.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $69.36 |
Browse Plan Formulary all covered insulin pay $35 or less |