ACITRETIN 10 MG CAPSULE [Soriatane] (30 CAPSULES ) (NDC: 42794008008)
2024 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
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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-0006 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $141.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC PA-0011 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $126.61 |
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. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $132.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC PA-0015 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $141.32 |
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 | $137.23 |
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 |
Aetna Medicare Advantra Gold (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $165.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Silver (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $144.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Deluxe Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P | $164.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Essentials Plan (PPO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | P | $132.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Silver Back (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $134.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare The Valley Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P | $123.45 |
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 | $139.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P | $567.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P | $494.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P | $550.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P | $561.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P | $567.28 |
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 |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P | $517.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P | $548.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P | $561.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic 360 Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $150.00 | P Q:60 /30Days | $452.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $150.00 | P Q:60 /30Days | $459.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $150.00 | P Q:60 /30Days | $458.92 |
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 H6622-036 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:90 /30Days | $250.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana USAA Honor with Rx (PPO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:90 /30Days | $253.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-051 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:90 /30Days | $250.87 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-051 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:90 /30Days | $254.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-058 (PPO)
|
$0.00 |
$505 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:90 /30Days | $253.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-060 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:90 /30Days | $253.58 |
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 Giveback Open (PPO)
|
$0.00 |
$545 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
49% | 49% | P | $239.20 |
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% | P | $226.99 |
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 |
4 |
Non-Preferred Drug |
48% | 48% | P | $239.20 |
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 |
4 |
Non-Preferred Drug |
43% | 43% | P | $239.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plus (PPO)
|
$14.60 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $144.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$15.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $150.00 | P Q:60 /30Days | $449.10 |
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 |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$15.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $150.00 | P Q:60 /30Days | $433.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$15.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $150.00 | P Q:60 /30Days | $468.89 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$15.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $150.00 | P Q:60 /30Days | $452.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$15.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $150.00 | P Q:60 /30Days | $458.87 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Premier (HMO-POS)
|
$21.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P | $144.50 |
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 |
4 |
Non-Preferred Drug |
48% | 48% | P | $239.53 |
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 |
Geisinger Gold Value Rx (HMO)
|
$23.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $150.00 | P Q:60 /30Days | $462.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC PA-0007 (PPO)
|
$25.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $126.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-017 (PPO)
|
$26.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:90 /30Days | $253.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare PPO Distinct (PPO)
|
$27.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P | $494.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare PPO Distinct (PPO)
|
$27.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P | $558.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare PPO Distinct (PPO)
|
$27.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P | $561.28 |
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 |
Community Blue Medicare PPO Distinct (PPO)
|
$27.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P | $567.28 |
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 | $175.47 |
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 |
4 |
Tier 4 |
15% | 15% | None | $132.92 |
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 |
4 |
Tier 4 |
25% | 25% | None | $130.49 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic Complete Rx (HMO)
|
$34.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $150.00 | P Q:60 /30Days | $492.49 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic Complete Rx (HMO)
|
$34.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $150.00 | P Q:60 /30Days | $447.76 |
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 Preferred (PPO D-SNP)
|
$35.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | P | $143.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Silver (HMO-POS)
|
$37.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P | $185.94 |
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 | $145.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life Complete Care (HMO D-SNP)
|
$38.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
49% | 49% | P | $327.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H6622-078 (HMO D-SNP)
|
$38.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | P Q:90 /30Days | $250.87 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H6622-078 (HMO D-SNP)
|
$38.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | P Q:90 /30Days | $250.72 |
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 Longevity Plan (HMO I-SNP)
|
$39.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | P | $144.56 |
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 |
4 |
Tier 4 |
$0.00 | $0.00 | None | $132.92 |
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 | $181.97 |
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 Q:60 /30Days | $466.26 |
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 |
4 |
Non-Preferred Drug |
40% | 40% | P | $421.22 |
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 |
4 |
Non-Preferred Drug |
46% | 46% | P | $421.22 |
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 |
Humana Value Plus H5216-117 (PPO)
|
$40.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:90 /30Days | $256.27 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete PA-S001 (PPO D-SNP)
|
$40.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $132.92 |
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 | $182.06 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare PPO Premier (PPO)
|
$46.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P | $567.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare PPO Premier (PPO)
|
$46.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P | $494.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Blue Medicare PPO Premier (PPO)
|
$46.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P | $558.60 |
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 |
Community Blue Medicare PPO Premier (PPO)
|
$46.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P | $561.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R0923-002 (Regional PPO)
|
$46.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:90 /30Days | $253.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-005 (PPO)
|
$53.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:90 /30Days | $251.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Freedom Blue PPO ValueRx (PPO)
|
$58.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P | $553.63 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Advantra Premier Plus (PPO)
|
$67.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $144.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$79.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $150.00 | P Q:60 /30Days | $449.28 |
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 |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$79.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $150.00 | P Q:60 /30Days | $477.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic Advantage Rx (HMO)
|
$100.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $150.00 | P Q:60 /30Days | $490.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic Advantage Rx (HMO)
|
$100.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $150.00 | P Q:60 /30Days | $446.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic Advantage Rx (HMO)
|
$100.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $150.00 | P Q:60 /30Days | $449.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-120 (PPO)
|
$123.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | P Q:90 /30Days | $253.58 |
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 | $185.94 |
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 |
Freedom Blue PPO Standard (PPO)
|
$164.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P | $553.63 |
Browse Plan Formulary all covered insulin pay $35 or less |
Freedom Blue PPO Deluxe (PPO)
|
$278.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P | $553.63 |
Browse Plan Formulary all covered insulin pay $35 or less |