TRINTELLIX 5 MG TABLET (30 EA ) (NDC: 64764072030)
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 |
Aetna Medicare Advantra (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $481.87 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Freedom (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $482.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Giveback Choice (PPO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days | $481.95 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Signature (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $481.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue adVantage Classic (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $453.28 |
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 |
Blue adVantage Classic (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $448.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue adVantage Classic (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $451.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue adVantage Classic (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $451.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue adVantage Classic (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $459.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue adVantage Giveback (HMO-POS)
|
$0.00 |
$195 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $454.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue adVantage Liberty (PPO)
|
$0.00 |
$195 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $454.12 |
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 - Diabetes and Heart (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$99.00 | $287.00 | S Q:30 /30Days | $463.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H1951-047 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$99.00 | $287.00 | S Q:30 /30Days | $463.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H1951-047 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$99.00 | $287.00 | S Q:30 /30Days | $463.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana LCMC Advantage H1951-051 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$99.00 | $287.00 | S Q:30 /30Days | $463.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Select Partner Plan H1951-038 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$99.00 | $287.00 | S Q:30 /30Days | $463.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-325 (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$99.00 | $287.00 | S Q:30 /30Days | $465.11 |
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 |
Ochsner Health Plan Freedom (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $472.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
Ochsner Health Plan Freedom (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $473.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Ochsner Health Plan Premier (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $472.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
Ochsner Health Plan Premier (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $473.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Peoples Health Choices (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $495.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Peoples Health Choices 65 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $493.79 |
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 |
Peoples Health Choices 65 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $496.35 |
Browse Plan Formulary all covered insulin pay $35 or less |
Peoples Health Choices 65 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $497.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
Peoples Health Choices 65 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $495.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Peoples Health Medicare Advantage LA-0004 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $497.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Endurance (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days | $503.90 |
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. | 4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days | $503.90 |
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 |
Wellcare No Premium (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days | $525.46 |
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. | 4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days | $513.70 |
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. | 4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days | $491.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days | $504.93 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plus (PPO)
|
$20.00 |
$150 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $482.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plus Signature (PPO)
|
$24.10 |
$150 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $482.47 |
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 |
Wellcare All Dual Assure (HMO D-SNP)
|
$25.80 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $504.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
|
$25.90 |
$315 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | Q:30 /30Days | $504.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Dual Signature Select (PPO D-SNP)
|
$27.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | Q:30 /30Days | $482.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Dual Signature Choice (PPO D-SNP)
|
$29.80 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | Q:30 /30Days | $482.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue adVantage Dual Plus (HMO-POS D-SNP)
|
$30.30 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | Q:30 /30Days | $454.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Healthy Blue Enhanced Care (HMO D-SNP)
|
$30.30 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | Q:30 /30Days | $482.23 |
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 |
Healthy Blue Dual Advantage (HMO D-SNP)
|
$32.80 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | Q:30 /30Days | $482.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Dual Select (HMO D-SNP)
|
$35.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | Q:30 /30Days | $482.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Dual Signature (HMO D-SNP)
|
$37.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | Q:30 /30Days | $481.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Pinnacle Liberty (HMO D-SNP)
|
$38.60 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $505.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Freedom Access (HMO D-SNP)
|
$39.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $505.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H1951-057 (HMO D-SNP)
|
$41.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | S Q:30 /30Days | $464.33 |
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 |
Peoples Health Secure Health (HMO-POS D-SNP)
|
$44.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | Q:30 /30Days | $495.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Peoples Health Secure Complete (HMO-POS D-SNP)
|
$45.10 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | Q:30 /30Days | $495.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-064 (PPO)
|
$46.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$99.00 | $287.00 | S Q:30 /30Days | $464.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Dual Preferred (HMO D-SNP)
|
$46.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | Q:30 /30Days | $481.94 |
Browse Plan Formulary all covered insulin pay $35 or less |
American Health Advantage of Louisiana (HMO I-SNP)
|
$46.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | Q:30 /30Days | $508.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue adVantage Reliance (HMO-POS)
|
$46.20 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $448.73 |
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 |
Blue adVantage Reliance (HMO-POS)
|
$46.20 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $454.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H1951-032 (HMO D-SNP)
|
$46.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | S Q:30 /30Days | $464.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H1951-056 (HMO D-SNP)
|
$46.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | S Q:30 /30Days | $464.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice SNP-DE H5216-332 (PPO D-SNP)
|
$46.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | S Q:30 /30Days | $464.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete LA-S001 (PPO D-SNP)
|
$46.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | Q:30 /30Days | $495.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete LA-S003 (HMO-POS D-SNP)
|
$46.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | Q:30 /30Days | $495.22 |
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 |
Blue adVantage Premier (PPO)
|
$100.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $454.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R0110-003 (Regional PPO)
|
$150.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$99.00 | $287.00 | S Q:30 /30Days | $463.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue adVantage Platinum (HMO-POS)
|
$169.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $448.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue adVantage Platinum (HMO-POS)
|
$169.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $454.66 |
Browse Plan Formulary all covered insulin pay $35 or less |