CABLIVI 11 MG KIT (unit ) (NDC: 58468022501)
2024 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
See your cost using a drug discount card: Compare prices at pharmacies near you |
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-0005 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $8,283.21 |
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. | 5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $8,869.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC OH-0009 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $8,869.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC OH-0016 (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $8,869.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC OH-0016 (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $8,869.90 |
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 |
AARP Medicare Advantage from UHC OH-0017 (HMO-POS)
|
$0.00 |
$395 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
27% | n/a | P Q:30 /30Days | $8,283.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
30% | n/a | P Q:30 /30Days | $8,273.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H6622-022 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $8,273.34 |
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. | 5 |
Tier 5 |
27% | n/a | P Q:30 /30Days | $8,273.34 |
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. | 5 |
Tier 5 |
30% | n/a | P Q:30 /30Days | $8,273.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-309 (PPO)
|
$0.00 |
$545 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
25% | n/a | P Q:30 /30Days | $8,273.34 |
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 Access (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P | $7,928.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Access (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P | $7,289.23 |
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. | 5 |
Tier 5 |
31% | n/a | P | $7,928.90 |
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. | 5 |
Tier 5 |
31% | n/a | P | $7,289.23 |
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. | 5 |
Tier 5 |
31% | n/a | P | $7,928.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$100 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
31% | n/a | P | $7,928.90 |
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 |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$100 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
31% | n/a | P | $7,289.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
SummaCare Medicare Topaz (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $8,137.33 |
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 | 5 |
Tier 5 |
33% | n/a | P | $7,289.23 |
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 | 5 |
Tier 5 |
33% | n/a | P | $7,923.75 |
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 | 5 |
Tier 5 |
33% | n/a | P | $7,289.23 |
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 | 5 |
Tier 5 |
25% | 25% | P Q:30 /30Days | $8,273.34 |
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 |
SummaCare Medicare Jade with Bene-FlexTM (HMO)
|
$20.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $8,137.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
SummaCare Medicare Jade with Bene-FlexTM (HMO)
|
$20.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $8,137.33 |
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. | 5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $8,869.90 |
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. | 5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $8,283.21 |
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. | 5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $8,869.90 |
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. | 5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $8,283.21 |
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 H5525-042 (PPO)
|
$30.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | n/a | P Q:30 /30Days | $8,273.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Secure (HMO)
|
$30.00 |
$95 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
31% | n/a | P | $7,928.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Secure (HMO)
|
$30.00 |
$95 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
31% | n/a | P | $7,289.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
SummaCare Medicare Garnet (HMO)
|
$30.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $8,137.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
SummaCare Medicare Garnet (HMO)
|
$30.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $8,137.33 |
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 | 5 |
Tier 5 |
29% | n/a | P Q:30 /30Days | $8,273.34 |
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 Choice (HMO)
|
$40.00 |
$55 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
32% | n/a | P | $7,289.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
32% | n/a | P | $7,928.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
32% | n/a | P | $7,928.90 |
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% | P | $7,289.23 |
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 | 5 |
Tier 5 |
$0.00 | $0.00 | P | $7,939.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H6622-015 (HMO D-SNP)
|
$40.90 |
$545 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
$0.00 | $0.00 | P Q:30 /30Days | $8,273.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Plus SNP-DE H6622-087 (HMO D-SNP)
|
$40.90 |
$545 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
$0.00 | $0.00 | P Q:30 /30Days | $8,273.34 |
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 | 5 |
Tier 5 |
15% | 15% | P Q:30 /30Days | $8,273.34 |
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 | 5 |
Tier 5 |
15% | 15% | P Q:30 /30Days | $8,869.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete OH-S001 (PPO D-SNP)
|
$40.90 |
$545 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
$0.00 | $0.00 | P Q:30 /30Days | $8,283.21 |
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 | 5 |
Tier 5 |
15% | 15% | P Q:30 /30Days | $8,869.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-024 (PPO)
|
$41.00 |
$100 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
31% | n/a | P Q:30 /30Days | $8,273.34 |
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)
|
$49.00 |
$95 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
31% | n/a | P | $7,289.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Select (PPO)
|
$49.00 |
$95 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
31% | n/a | P | $7,928.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Select (PPO)
|
$49.00 |
$95 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
31% | n/a | P | $7,928.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
SummaCare Medicare Ruby (HMO)
|
$50.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $8,137.33 |
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 | 5 |
Tier 5 |
25% | 25% | P Q:30 /30Days | $8,273.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H6622-019 (HMO)
|
$73.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
31% | n/a | P Q:30 /30Days | $8,273.34 |
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 Preferred (PPO)
|
$73.00 |
$55 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
32% | n/a | P | $7,289.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Preferred (PPO)
|
$73.00 |
$55 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
32% | n/a | P | $7,928.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Preferred (PPO)
|
$73.00 |
$55 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
32% | n/a | P | $7,928.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
SummaCare Medicare Sapphire (HMO-POS)
|
$79.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $8,137.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Plus (HMO)
|
$90.00 |
$55 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
32% | n/a | P | $7,928.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Plus (HMO)
|
$90.00 |
$55 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
32% | n/a | P | $7,928.90 |
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 |
MedMutual Advantage Plus (HMO)
|
$90.00 |
$55 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
32% | n/a | P | $7,289.23 |
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 | 5 |
Tier 5 |
31% | n/a | P | $7,289.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC OH-0001 (HMO-POS)
|
$104.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $8,283.21 |
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 | 5 |
Tier 5 |
31% | n/a | P Q:30 /30Days | $8,273.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Premium (PPO)
|
$129.00 |
$55 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
32% | n/a | P | $7,289.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Premium (PPO)
|
$129.00 |
$55 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
32% | n/a | P | $7,928.90 |
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 |
MedMutual Advantage Premium (PPO)
|
$129.00 |
$55 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
32% | n/a | P | $7,928.90 |
Browse Plan Formulary all covered insulin pay $35 or less |