AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin] (30 BOT) (NDC: 00781187431)
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. |
2 |
Generic |
$10.00 | $0.00 | None | $23.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC PA-0011 (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $25.65 |
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. |
2* |
Generic |
$14.00 | $0.00 | None | $28.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC PA-0015 (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$10.00 | $0.00 | None | $23.27 |
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 | None | $56.98 |
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 |
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 | None | $58.65 |
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 | None | $60.80 |
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% | None | $60.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $53.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueJourney Essential (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $30.00 | None | $90.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Capital Blue Cross Select (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$5.00 | $15.00 | None | $90.90 |
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 |
Capital Blue Cross Value (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$12.00 | $36.00 | None | $89.79 |
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 |
2 |
Generic |
$5.00 | $0.00 | None | $102.86 |
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 |
2 |
Generic |
$5.00 | $0.00 | None | $98.51 |
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 |
2 |
Generic |
$5.00 | $0.00 | None | $96.51 |
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 |
2 |
Generic |
$5.00 | $0.00 | None | $99.17 |
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. |
2 |
Generic |
$20.00 | $0.00 | None | $148.14 |
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 |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | None | $148.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana USAA Honor with Rx (PPO)
|
$0.00 |
$250* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $0.00 | None | $62.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-051 (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $0.00 | None | $55.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-051 (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $0.00 | None | $65.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-058 (PPO)
|
$0.00 |
$505* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $0.00 | None | $62.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-060 (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $62.78 |
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 |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $93.48 |
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 | None | $35.74 |
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 | None | $35.74 |
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 | None | $60.80 |
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 |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $93.47 |
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% | None | $60.80 |
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 |
Capital Blue Cross Enhanced (PPO)
|
$22.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | None | $89.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life PPO Rx Choice (PPO)
|
$23.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $93.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC PA-0007 (PPO)
|
$25.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $25.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-017 (PPO)
|
$26.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $63.37 |
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 |
2 |
Generic |
$0.00 | $0.00 | None | $98.51 |
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 |
2 |
Generic |
$0.00 | $0.00 | None | $100.28 |
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 |
2 |
Generic |
$0.00 | $0.00 | None | $97.15 |
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 |
2 |
Generic |
$0.00 | $0.00 | None | $102.86 |
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 | None | $34.49 |
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 |
2 |
Tier 2 |
15% | 15% | None | $28.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 | None | $40.75 |
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 |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $96.09 |
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 HMO Rx Choice (HMO)
|
$36.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $93.70 |
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 |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $92.98 |
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 |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $91.33 |
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 |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $97.18 |
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% | None | $57.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | None | $142.43 |
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 Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | None | $148.25 |
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 | None | $37.15 |
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% | None | $36.71 |
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 |
2 |
Tier 2 |
$0.00 | $0.00 | None | $28.68 |
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 | None | $51.51 |
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% | None | $145.55 |
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 |
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 | None | $79.90 |
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 | None | $79.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Value Plus H5216-117 (PPO)
|
$40.20 |
$545* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$20.00 | $0.00 | None | $67.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice SNP-DE H5216-227 (PPO D-SNP)
|
$40.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $67.71 |
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 |
2 |
Tier 2 |
$0.00 | $0.00 | None | $28.68 |
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 |
4 |
Non-Preferred Drug |
49% | 49% | None | $92.94 |
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 |
Community Blue Medicare PPO Premier (PPO)
|
$46.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | None | $98.51 |
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 |
2 |
Generic |
$0.00 | $0.00 | None | $100.28 |
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 |
2 |
Generic |
$0.00 | $0.00 | None | $97.15 |
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 |
2 |
Generic |
$0.00 | $0.00 | None | $102.86 |
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 |
2 |
Generic |
$20.00 | $0.00 | None | $63.27 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$50.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $0.00 | None | $147.59 |
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)
|
$50.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $0.00 | None | $146.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$50.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $0.00 | None | $138.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$50.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $0.00 | None | $142.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$50.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $0.00 | None | $151.01 |
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 |
2 |
Generic |
$15.00 | $0.00 | None | $60.69 |
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 |
2 |
Generic |
$13.00 | $27.00 | None | $98.83 |
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 |
BlueJourney Classic (PPO)
|
$60.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$5.00 | $15.00 | None | $90.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueJourney Value (HMO)
|
$65.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$5.00 | $15.00 | None | $90.90 |
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 | None | $60.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
UPMC for Life HMO Rx (HMO)
|
$81.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $93.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$94.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | None | $148.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$94.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | None | $145.24 |
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 |
BlueJourney Premier (HMO)
|
$117.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | None | $90.90 |
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 |
2 |
Generic |
$15.00 | $0.00 | None | $62.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic Advantage Rx (HMO)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | None | $152.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic Advantage Rx (HMO)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | None | $140.87 |
Browse Plan Formulary all covered insulin pay $35 or less |
Geisinger Gold Classic Advantage Rx (HMO)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | None | $142.14 |
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% | None | $57.26 |
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 |
2 |
Generic |
$13.00 | $27.00 | None | $98.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
BlueJourney Prime (PPO)
|
$177.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$5.00 | $15.00 | None | $90.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Freedom Blue PPO Deluxe (PPO)
|
$278.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$13.00 | $27.00 | None | $98.83 |
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 |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $93.52 |
Browse Plan Formulary all covered insulin pay $35 or less |