AUVELITY ER 45-105 MG TABLET IR ER (60 UNITS ) (NDC: 81968004530)
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 |
Humana Gold Plus H4007-012 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$10.00 | $20.00 | P Q:60 /30Days | $1,110.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H4007-020 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$20.00 | $50.00 | P Q:60 /30Days | $1,110.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H4007-021 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$15.00 | $35.00 | P Q:60 /30Days | $1,110.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H4007-024 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$15.00 | $35.00 | P Q:60 /30Days | $1,110.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H4007-025 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$15.00 | $35.00 | P Q:60 /30Days | $1,110.23 |
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 |
Humana Gold Plus H4007-028 (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$0.00 | $0.00 | P Q:60 /30Days | $1,110.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H4007-029 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$0.00 | $0.00 | P Q:60 /30Days | $1,110.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H4007-016 (HMO D-SNP)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | P Q:60 /30Days | $1,110.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H4007-018 (HMO D-SNP)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | P Q:60 /30Days | $1,110.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H4007-019 (HMO D-SNP)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | P Q:60 /30Days | $1,110.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H4007-026 (HMO D-SNP)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | P Q:60 /30Days | $1,110.23 |
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 |
Humana Gold Plus SNP-DE H4007-027 (HMO D-SNP)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | P Q:60 /30Days | $1,110.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H4007-030 (HMO D-SNP)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | P Q:60 /30Days | $1,110.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
MCS Classicare Efectivo (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$14.00 | $28.00 | Q:60 /30Days | $1,108.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
MCS Classicare En Tu Hogar (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$15.00 | $30.00 | Q:60 /30Days | $1,108.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
MCS Classicare Essential (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$0.00 | $0.00 | Q:60 /30Days | $1,108.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
MCS Classicare Exacto (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$0.00 | $0.00 | Q:60 /30Days | $1,108.81 |
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 |
MCS Classicare Excede (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$0.00 | $0.00 | Q:60 /30Days | $1,108.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
MCS Classicare Excede (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$0.00 | $0.00 | Q:60 /30Days | $1,108.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
MCS Classicare Firme (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$0.00 | $0.00 | Q:60 /30Days | $1,108.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
MCS Classicare Hero (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
25% | 25% | Q:60 /30Days | $1,108.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
MCS Classicare InteliCare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$0.00 | $0.00 | Q:60 /30Days | $1,108.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
MCS Classicare Platino Ideal (HMO D-SNP)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | Q:60 /30Days | $1,108.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
MCS Classicare Platino MasCa$h (HMO D-SNP)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | Q:60 /30Days | $1,108.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
MCS Classicare Platino Maximo (HMO D-SNP)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | Q:60 /30Days | $1,108.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
MCS Classicare Platino Maximo (HMO D-SNP)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | Q:60 /30Days | $1,108.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
MCS Classicare Platino Maximo (HMO D-SNP)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | Q:60 /30Days | $1,108.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
MCS Classicare Platino Progreso (HMO D-SNP)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | Q:60 /30Days | $1,108.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
MCS Classicare Platino Total (HMO D-SNP)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | Q:60 /30Days | $1,108.81 |
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 |
MCS Classicare Primero (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$0.00 | $0.00 | Q:60 /30Days | $1,108.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
MMM Balance (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Tier 5 |
33% | n/a | S Q:60 /30Days | $1,118.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
MMM Deluxe (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Tier 5 |
33% | n/a | S Q:60 /30Days | $1,118.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
MMM Diamante Platino (HMO D-SNP)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | S Q:60 /30Days | $1,118.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
MMM Dorado Platino (HMO D-SNP)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | S Q:60 /30Days | $1,118.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
MMM Elite (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Tier 5 |
33% | n/a | S Q:60 /30Days | $1,118.67 |
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 |
MMM Encanto (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Tier 5 |
33% | n/a | S Q:60 /30Days | $1,118.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
MMM Plenitud (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Tier 5 |
33% | n/a | S Q:60 /30Days | $1,118.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
MMM Plus Platino (HMO D-SNP)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | S Q:60 /30Days | $1,118.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
MMM Relax Platino (HMO D-SNP)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | S Q:60 /30Days | $1,118.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
MMM Supremo (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Tier 5 |
33% | n/a | S Q:60 /30Days | $1,118.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
MMM Valioso (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Tier 5 |
33% | n/a | S Q:60 /30Days | $1,118.67 |
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 |
MMM Valor Platino (HMO D-SNP)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | S Q:60 /30Days | $1,118.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
PMC Max (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Tier 5 |
33% | n/a | S Q:60 /30Days | $1,118.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
PMC Premier Platino (HMO D-SNP)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | S Q:60 /30Days | $1,118.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Triple S Advantage AhorroMax (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$35.00 | $70.00 | S Q:60.000 /30Days | $1,126.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Triple S Advantage Brillante (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$40.00 | $80.00 | S Q:60.000 /30Days | $1,126.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Triple S Advantage Contigo Plus (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$10.00 | $20.00 | S Q:60.000 /30Days | $1,126.67 |
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 |
Triple S Advantage Enlace Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$15.00 | $30.00 | S Q:60.000 /30Days | $1,126.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Triple S Advantage Magno (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$25.00 | $50.00 | S Q:60.000 /30Days | $1,126.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Triple S Advantage Optimo Plus (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$40.00 | $80.00 | S Q:60.000 /30Days | $1,126.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Triple S Advantage Platino Advance (HMO D-SNP)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | S Q:60.000 /30Days | $1,126.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Triple S Advantage Platino Blindao (HMO D-SNP)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | S Q:60.000 /30Days | $1,126.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Triple S Advantage Platino Enlace (HMO D-SNP)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | S Q:60.000 /30Days | $1,126.67 |
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 |
Triple S Advantage Platino Plus (HMO D-SNP)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | S Q:60.000 /30Days | $1,126.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Triple S Advantage Platino Selecto (HMO D-SNP)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | S Q:60.000 /30Days | $1,126.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Triple S Advantage Platino Titan (HMO D-SNP)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | S Q:60.000 /30Days | $1,126.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Triple S Advantage Real (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$5.00 | $10.00 | S Q:60.000 /30Days | $1,126.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
MMM Unico (HMO-POS)
|
$15.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Tier 5 |
33% | n/a | S Q:60 /30Days | $1,118.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Triple S Advantage Optimo Xtra (PPO)
|
$30.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$30.00 | $60.00 | S Q:60.000 /30Days | $1,126.67 |
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 |
HumanaChoice Value H2029-001 (PPO)
|
$44.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$40.00 | $110.00 | P Q:60 /30Days | $1,110.23 |
Browse Plan Formulary all covered insulin pay $35 or less |