BELSOMRA 5 MG TABLET (NDC: 00006000530)
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 OH-0007 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $449.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC OH-0007 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $448.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC OH-0012 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $449.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC OH-0015 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $449.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC OH-0015 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $448.92 |
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 |
AARP Medicare Advantage from UHC OH-0017 (HMO-POS)
|
$0.00 |
$395 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $449.21 |
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. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:30 /30Days | $432.69 |
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. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:30 /30Days | $436.44 |
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. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:30 /30Days | $436.54 |
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. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:30 /30Days | $436.14 |
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. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:30 /30Days | $436.43 |
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 |
Buckeye Health Plan - MyCare Ohio (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Tier 2 |
0% | 0% | Q:30 /30Days | $426.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $432.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $432.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $432.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:120 /30Days | $423.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H6622-021 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:120 /30Days | $425.46 |
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 H6622-021 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:120 /30Days | $425.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana USAA Honor with Rx (PPO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:120 /30Days | $423.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-285 (PPO)
|
$0.00 |
$200* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:120 /30Days | $423.27 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-309 (PPO)
|
$0.00 |
$545 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:120 /30Days | $423.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dividend Giveback (HMO)
|
$0.00 |
$330 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:30 /30Days | $432.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback (HMO)
|
$0.00 |
$275 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:30 /30Days | $429.84 |
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 |
$75 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:30 /30Days | $429.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Essential (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:30 /30Days | $431.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:30 /30Days | $429.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare All Dual Assure (HMO D-SNP)
|
$17.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $430.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Together in Health (PPO I-SNP)
|
$18.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:120 /30Days | $423.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Extra Help (HMO)
|
$19.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $435.27 |
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 |
Wellcare Assist (HMO)
|
$21.40 |
$535 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:30 /30Days | $429.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC OH-0003 (HMO-POS)
|
$23.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $449.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC OH-0003 (HMO-POS)
|
$23.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $448.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC OH-0003 (HMO-POS)
|
$23.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $449.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Medicare Advantage 2 (HMO)
|
$25.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:30 /30Days | $435.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Nursing Home Plan OH-F002 (HMO-POS I-SNP)
|
$25.30 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:30 /30Days | $449.09 |
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 |
Anthem Dual Advantage (HMO D-SNP)
|
$26.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | Q:30 /30Days | $436.87 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$26.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $430.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Plus Medicare (HMO)
|
$27.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $432.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H6622-055 (HMO)
|
$27.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:120 /30Days | $425.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Extra (HMO-POS D-SNP)
|
$29.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $432.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-042 (PPO)
|
$30.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:120 /30Days | $423.20 |
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 |
Cigna TotalCare (HMO D-SNP)
|
$34.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:30 /30Days | $433.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-023 (PPO)
|
$36.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:120 /30Days | $423.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Medicare Advantage 3 (HMO)
|
$37.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:30 /30Days | $436.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Value Plus H5525-041 (PPO)
|
$37.10 |
$260 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:120 /30Days | $423.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$37.80 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $430.22 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare Plus (HMO D-SNP)
|
$38.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:30 /30Days | $433.11 |
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 |
Anthem Full Dual Advantage (HMO D-SNP)
|
$38.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:30 /30Days | $436.87 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H6622-015 (HMO D-SNP)
|
$40.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:120 /30Days | $423.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H6622-087 (HMO D-SNP)
|
$40.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:120 /30Days | $423.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice SNP-DE H5525-046 (PPO D-SNP)
|
$40.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:120 /30Days | $423.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete OH-D001 (HMO-POS D-SNP)
|
$40.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:30 /30Days | $448.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete OH-S001 (PPO D-SNP)
|
$40.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:30 /30Days | $449.21 |
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 Dual Complete OH-V001 (HMO-POS D-SNP)
|
$40.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:30 /30Days | $448.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Nursing Home Plan OH-F001 (PPO I-SNP)
|
$40.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:30 /30Days | $448.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
Valor Health Plan (HMO I-SNP)
|
$40.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | Q:30 /30Days | $461.05 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Medicare Advantage 3 (PPO)
|
$49.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:30 /30Days | $435.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R5495-002 (Regional PPO)
|
$51.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:120 /30Days | $423.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Choice H8145-032 (PFFS)
|
$63.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:120 /30Days | $424.45 |
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 |
Anthem Medicare Advantage 4 (PPO)
|
$69.00 |
$40 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:30 /30Days | $434.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Medicare Advantage (Regional PPO)
|
$73.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
41% | 41% | Q:30 /30Days | $435.27 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H6622-019 (HMO)
|
$73.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:120 /30Days | $423.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC OH-0001 (HMO-POS)
|
$104.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $448.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-030 (PPO)
|
$115.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:120 /30Days | $423.27 |
Browse Plan Formulary all covered insulin pay $35 or less |