ACETAMINOP-CODEINE 120-12 MG/5 SOLUTION (360 MLS ) (NDC: 64950037416)
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 GA-0004 (PPO)
|
$0.00 |
$395* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$14.00 | $0.00 | Q:4500 /30Days | $11.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC GA-0005 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$14.00 | $0.00 | Q:4500 /30Days | $11.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Walgreens from UHC GA-0001 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | Q:4500 /30Days | $10.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Freedom (PPO)
|
$0.00 |
$150* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$0.00 | $0.00 | Q:2700 /30Days | $168.37 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Freedom Plus (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | Q:2700 /30Days | $174.56 |
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 (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | Q:2700 /30Days | $176.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Kidney Care (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:900 /30Days | $8.68 |
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. | 3 |
Preferred Brand |
$35.00 | $70.00 | Q:900 /30Days | $8.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Medicare Advantage (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $70.00 | Q:900 /30Days | $8.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clear Spring Health Choice Plan (PPO)
|
$0.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$0.00 | $0.00 | None | $7.27 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clear Spring Health Select Plus (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | None | $7.27 |
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 Silver Plan (HMO C-SNP)
|
$0.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$0.00 | $0.00 | None | $7.27 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clover Health LiveHealthy (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$8.00 | $0.00 | Q:2700 /30Days | $8.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H4141-017 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:2700 /30Days | $7.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H4141-017 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:2700 /30Days | $6.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice - Diabetes and Heart (PPO C-SNP)
|
$0.00 |
$145* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$47.00 | $131.00 | Q:2700 /30Days | $11.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-154 (PPO)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:2700 /30Days | $11.23 |
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 |
HumanaChoice H5216-203 (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:2700 /30Days | $6.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-203 (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:2700 /30Days | $7.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-345 (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:2700 /30Days | $11.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-349 (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:2700 /30Days | $14.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R3392-004 (Regional PPO)
|
$0.00 |
$195 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:2700 /30Days | $11.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Complete Care GA-0003 (PPO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | Q:4500 /30Days | $11.12 |
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 |
UHC Medicare Advantage GA-0002 (PPO)
|
$0.00 |
$295* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$14.00 | $0.00 | Q:4500 /30Days | $11.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback (HMO)
|
$0.00 |
$545* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$5.00 | $0.00 | Q:2700 /30Days | $8.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Mutual of Omaha No Premium Open (PPO)
|
$0.00 |
$200* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$5.00 | $0.00 | Q:2700 /30Days | $8.39 |
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. | 2 |
Generic |
$0.00 | $0.00 | Q:2700 /30Days | $9.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Together in Health (PPO I-SNP)
|
$18.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | Q:2700 /30Days | $11.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
PruittHealth Premier Advantage (HMO I-SNP)
|
$20.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | n/a | Q:4980 /30Days | $308.23 |
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 |
UHC Complete Care GS-001A (Regional PPO C-SNP)
|
$20.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | Q:4500 /30Days | $11.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plus Signature (PPO)
|
$22.30 |
$300* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $0.00 | Q:2700 /30Days | $174.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plus (PPO)
|
$25.20 |
$300* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $0.00 | Q:2700 /30Days | $173.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Preferred Premium (PPO)
|
$28.00 |
$150* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$0.00 | $0.00 | Q:2700 /30Days | $173.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Complete Care GS-0002 (Regional PPO C-SNP)
|
$28.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.00 | $0.00 | Q:4500 /30Days | $11.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Dual Advantage (HMO D-SNP)
|
$29.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | Q:900 /30Days | $9.14 |
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 Dual Signature (HMO D-SNP)
|
$29.30 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | Q:2700 /30Days | $174.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Dual Select (HMO D-SNP)
|
$30.10 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | Q:2700 /30Days | $173.63 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Dual Signature Select (PPO D-SNP)
|
$31.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | Q:2700 /30Days | $174.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete GA-D002 (HMO-POS D-SNP)
|
$31.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | Q:4500 /30Days | $11.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Extra Help (HMO)
|
$32.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:900 /30Days | $8.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Dual Signature Choice (PPO D-SNP)
|
$33.30 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | Q:2700 /30Days | $174.53 |
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 H5525-024 (PPO)
|
$34.00 |
$295 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:2700 /30Days | $9.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
|
$35.00 |
$410 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:2700 /30Days | $19.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clover Health LiveHealthy Value (PPO)
|
$35.50 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$8.00 | $0.00 | Q:2700 /30Days | $8.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clear Spring Health Deluxe Plan (HMO D-SNP)
|
$36.10 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $7.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC GA-0006 (HMO-POS)
|
$39.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $0.00 | Q:4500 /30Days | $11.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete GA-S001 (PPO D-SNP)
|
$41.60 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | Q:4500 /30Days | $11.12 |
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 |
Wellcare Dual Liberty (HMO D-SNP)
|
$42.10 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:2700 /30Days | $17.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Full Dual Advantage (PPO D-SNP)
|
$43.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
$0.00 | $0.00 | Q:900 /30Days | $9.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H4141-003 (HMO D-SNP)
|
$43.50 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
$0.00 | $0.00 | Q:2700 /30Days | $7.24 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare All Dual (HMO D-SNP)
|
$44.10 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | Q:2700 /30Days | $17.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Full Dual Advantage (HMO D-SNP)
|
$44.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
$0.00 | $0.00 | Q:900 /30Days | $9.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Full Dual Advantage 2 (HMO D-SNP)
|
$44.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
$0.00 | $0.00 | Q:900 /30Days | $9.14 |
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 |
CareSource Dual Advantage (HMO D-SNP)
|
$44.20 |
$545 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
25% | 25% | Q:4500 /30Days | $123.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Georgia Health Advantage (HMO I-SNP)
|
$44.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $205.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
Georgia Health Advantage Choice (HMO I-SNP)
|
$44.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $205.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-284 (PPO)
|
$44.20 |
$545 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:2700 /30Days | $14.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice SNP-DE H5216-205 (PPO D-SNP)
|
$44.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
$0.00 | $0.00 | Q:2700 /30Days | $11.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice SNP-DE H5216-206 (PPO D-SNP)
|
$44.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | Q:2700 /30Days | $11.23 |
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 |
PruittHealth Premier (HMO I-SNP)
|
$44.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | Q:4980 /30Days | $308.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
PruittHealth Premier D-SNP (HMO D-SNP)
|
$44.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | n/a | Q:4980 /30Days | $308.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete GA-D001 (PPO D-SNP)
|
$44.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | Q:4500 /30Days | $10.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete GA-V001 (PPO D-SNP)
|
$44.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | Q:4500 /30Days | $11.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$44.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:2700 /30Days | $17.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Medicare Advantage 2 (PPO)
|
$59.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $70.00 | Q:900 /30Days | $8.68 |
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 Medicare Advantage GS-0001 (Regional PPO)
|
$62.00 |
$345* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$14.00 | $0.00 | Q:4500 /30Days | $11.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R3392-002 (Regional PPO)
|
$92.00 |
$340 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:2700 /30Days | $11.23 |
Browse Plan Formulary all covered insulin pay $35 or less |