PROMETHAZINE 6.25 MG/5 ML SYRUP [Prometh Plain] (120 mls ) (NDC: 60432060816)
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 PA-0002 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $7.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC PA-0012 (PPO)
|
$0.00 |
$295 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $7.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC PA-0017 (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $7.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Credit Value (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $2.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Silver (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $3.71 |
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 |
Aetna Medicare Value (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | P | $4.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | P | $8.26 |
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. | 2 |
Generic |
$0.00 | $0.00 | P | $8.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Savings Medicare (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | P | $8.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Provider Partners Pennsylvania Community Plan (HMO I-SNP)
|
$0.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $7.37 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Premier Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $117.50 | None | $6.98 |
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 |
UPMC for Life PPO Premier Rx (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $117.50 | None | $7.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback Open (PPO)
|
$0.00 |
$545 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | P | $6.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $84.00 | P | $6.12 |
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 | P | $7.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$160 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $84.00 | P | $6.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life PPO Rx Choice (PPO)
|
$19.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | None | $7.04 |
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 |
UPMC for Life PPO Rx Choice (PPO)
|
$19.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | None | $7.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Plus Medicare (HMO)
|
$20.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | P | $8.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Deductible Rx (HMO)
|
$20.80 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | None | $6.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
|
$21.30 |
$435 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $94.00 | P | $5.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Gold (HMO-POS)
|
$22.60 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $3.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Value Rx (HMO)
|
$23.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $0.00 | P | $11.38 |
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 |
Cigna True Choice Plus Medicare (PPO)
|
$27.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | P | $8.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plus (PPO)
|
$29.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $3.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$29.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | P | $6.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete PA-V001 (HMO-POS D-SNP)
|
$29.50 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | None | $7.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life PPO High Deductible Rx (PPO)
|
$29.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | None | $7.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Nursing Home Plan EX-F002 (PPO I-SNP)
|
$32.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $7.67 |
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 |
UHC Care Advantage PA-E001 (PPO I-SNP)
|
$35.60 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $7.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx Choice (HMO)
|
$36.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | None | $6.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx Choice (HMO)
|
$36.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | None | $7.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx Choice (HMO)
|
$36.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | None | $6.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx Choice (HMO)
|
$36.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | None | $7.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx Choice (HMO)
|
$36.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | None | $7.04 |
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 Silver (HMO-POS)
|
$37.00 |
$250 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | P | $5.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Cares (HMO D-SNP)
|
$38.30 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | P | $4.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare Plus (HMO D-SNP)
|
$38.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | P | $6.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC PA-0003 (HMO-POS)
|
$39.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $7.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Longevity Plan (HMO I-SNP)
|
$39.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | P | $5.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete PA-S002 (HMO-POS D-SNP)
|
$39.90 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
$0.00 | $0.00 | None | $7.69 |
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 PA-0014 (PPO)
|
$40.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $7.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
AmeriHealth Caritas VIP Care (HMO D-SNP)
|
$40.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | P | $5.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Secure Rx (HMO D-SNP)
|
$40.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | P | $11.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
Highmark Wholecare Medicare Assured Diamond (HMO D-SNP)
|
$40.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$13.00 | $39.00 | P | $5.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP)
|
$40.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $60.00 | P | $5.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Provider Partners Pennsylvania Advantage Plan (HMO I-SNP)
|
$40.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $7.37 |
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 PA-S001 (PPO D-SNP)
|
$40.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
$0.00 | $0.00 | None | $7.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life Complete Care (HMO D-SNP)
|
$40.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$35.00 | $70.00 | None | $6.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$40.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | P | $6.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare HMO Prestige (HMO)
|
$41.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | P | $9.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Complete Blue PPO Premier (PPO)
|
$46.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | P | $9.89 |
Browse Plan Formulary all covered insulin pay $35 or less |
Complete Blue PPO Premier (PPO)
|
$46.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | P | $8.36 |
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 |
Complete Blue PPO Premier (PPO)
|
$46.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | P | $9.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx (HMO)
|
$81.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $6.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life PPO Rx Enhanced (PPO)
|
$134.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | None | $7.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Gold Plan (PPO)
|
$145.00 |
$250 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | P | $5.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
Freedom Blue PPO Select (PPO)
|
$158.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$13.00 | $27.00 | P | $9.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Security Blue HMO-POS Standard (HMO-POS)
|
$182.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$13.00 | $32.50 | P | $8.88 |
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 |
Security Blue HMO-POS Standard (HMO-POS)
|
$182.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$13.00 | $32.50 | P | $8.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Security Blue HMO-POS Deluxe (HMO-POS)
|
$245.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$13.00 | $32.50 | P | $8.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Security Blue HMO-POS Deluxe (HMO-POS)
|
$245.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$13.00 | $32.50 | P | $8.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Freedom Blue PPO Classic (PPO)
|
$271.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$13.00 | $27.00 | P | $9.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx Enhanced (HMO)
|
$295.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | None | $6.74 |
Browse Plan Formulary all covered insulin pay $35 or less |