ACYCLOVIR 800 MG TABLET (100 EA ) (NDC: 31722077801)
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 TX-0006 (PPO)
|
$0.00 |
$245* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $12.94 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC TX-0009 (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $13.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC TX-0015 (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $12.94 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC TX-001P (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $13.29 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC TX-0031 (PPO)
|
$0.00 |
$350* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $12.94 |
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 |
Aetna Medicare Freedom Plan (PPO)
|
$0.00 |
$150* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$0.00 | $0.00 | None | $6.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plan (HMO)
|
$0.00 |
$150* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$0.00 | $0.00 | None | $6.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $6.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$150* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$0.00 | $0.00 | None | $6.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$300* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $0.00 | None | $12.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Cross Medicare Advantage Basic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$8.00 | $16.00 | None | $29.10 |
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 |
Blue Cross Medicare Advantage Choice Plus (PPO)
|
$0.00 |
$545* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$8.00 | $16.00 | None | $31.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Cross Medicare Advantage Classic (PPO)
|
$0.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$8.00 | $24.00 | None | $39.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Cross Medicare Advantage Dental Premier (PPO)
|
$0.00 |
$545* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$8.00 | $24.00 | None | $40.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Cross Medicare Advantage Dental Value (HMO)
|
$0.00 |
$545* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$8.00 | $24.00 | None | $40.89 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Cross Medicare Advantage Health Choice (PPO)
|
$0.00 |
$545* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$8.00 | $24.00 | None | $40.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Cross Medicare Advantage Saver (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$8.00 | $24.00 | None | $40.54 |
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 |
Blue Cross Medicare Advantage Value (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$8.00 | $24.00 | None | $36.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Alliance Medicare (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$4.00 | $0.00 | None | $78.69 |
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. | 2 |
Generic |
$4.00 | $0.00 | None | $78.30 |
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. | 2 |
Generic |
$4.00 | $0.00 | None | $69.75 |
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. | 2 |
Generic |
$4.00 | $0.00 | None | $88.90 |
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. | 2 |
Generic |
$4.00 | $0.00 | None | $70.57 |
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 Preferred Medicare (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$4.00 | $0.00 | None | $81.57 |
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. | 2 |
Generic |
$4.00 | $0.00 | None | $78.30 |
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. | 2 |
Generic |
$4.00 | $0.00 | None | $69.75 |
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. | 2 |
Generic |
$4.00 | $0.00 | None | $88.90 |
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. | 2 |
Generic |
$4.00 | $0.00 | None | $70.57 |
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. | 2 |
Generic |
$4.00 | $0.00 | None | $81.57 |
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 Preferred Savings Medicare (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$4.00 | $0.00 | None | $83.25 |
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. | 2 |
Generic |
$4.00 | $0.00 | None | $74.14 |
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. | 2 |
Generic |
$4.00 | $0.00 | None | $76.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted CORE Greater Houston (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $72.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted GIVEBACK Greater Houston (HMO)
|
$0.00 |
$395* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$7.00 | $17.50 | None | $72.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Erickson Advantage Guardian (HMO-POS I-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $13.62 |
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 |
Erickson Advantage Liberty (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $13.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H0028-042 (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $32.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-043 (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $0.00 | None | $33.63 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-043 (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $0.00 | None | $36.09 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-043 (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $0.00 | None | $33.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-358 (PPO)
|
$0.00 |
$395* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $0.00 | None | $33.31 |
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 |
KelseyCare Advantage Classic (HMO)
|
$0.00 |
$100* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$0.00 | $0.00 | None | $44.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
KelseyCare Advantage Freedom (HMO-POS)
|
$0.00 |
$100* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$0.00 | $0.00 | None | $44.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
KelseyCare Advantage Secure (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $44.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
KelseyCare Advantage Signature (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $44.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
KelseyCare Advantage Thrive (HMO-POS)
|
$0.00 |
$100* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $13.00 | None | $44.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Memorial Hermann Advantage (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $90.86 |
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 |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Tier 1 |
0% | 0% | None | $20.49 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Tier 1 |
0% | 0% | None | $20.49 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$3.00 | $6.00 | None | $22.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Choice Care Select (HMO)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$15.00 | $30.00 | None | $22.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Balance (HMO C-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $17.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Classic (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $17.13 |
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 |
SCAN Heart First (HMO C-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $17.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Venture (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $17.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Complete Care TX-002P (HMO-POS C-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $13.29 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Connected (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Tier 1 |
0% | 0% | None | $13.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Verda Noble Care (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $41.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Verda Noble Chronic Care (HMO C-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $41.70 |
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 (HMO)
|
$0.00 |
$545* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$5.00 | $0.00 | None | $19.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Mutual of Omaha No Premium Open (PPO)
|
$0.00 |
$200* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $15.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Mutual of Omaha No Premium Secure Open (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $15.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$275* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $15.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Rx Plus Open (PPO)
|
$0.00 |
$300* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$0.00 | $0.00 | None | $20.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare TexanPlus Classic No Premium (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $15.39 |
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 TexanPlus No Premium (HMO-POS)
|
$0.00 |
$250* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $15.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Chronic Care (HMO C-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$7.50 | $0.00 | None | $122.94 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Home Care (HMO I-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$7.50 | $0.00 | None | $331.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Kidney Care (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.00 | $0.00 | None | $110.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Lung Care (HMO C-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$7.50 | $0.00 | None | $122.94 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Medicare Advantage 2 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $0.00 | None | $112.36 |
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 |
Wellpoint Select (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $0.00 | None | $122.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint STAR+PLUS MMP (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Tier 2 |
0% | 0% | None | $252.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Complete Care TX-001A (Regional PPO C-SNP)
|
$10.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $12.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare (HMO D-SNP)
|
$11.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $91.75 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare (HMO D-SNP)
|
$11.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $81.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare (HMO D-SNP)
|
$11.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $101.76 |
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 |
Cigna TotalCare (HMO D-SNP)
|
$11.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $80.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare (HMO D-SNP)
|
$11.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $97.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Devoted PRIME Greater Houston (HMO)
|
$15.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $72.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare All Dual Assure (HMO D-SNP)
|
$16.80 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $40.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete TX-D01P (HMO-POS D-SNP)
|
$20.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $13.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Dual Advantage 2 (HMO D-SNP)
|
$21.10 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $139.17 |
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 |
Blue Cross Medicare Advantage Dual Care Plus (HMO D-SNP)
|
$21.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $35.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Complete Care TX-0029 (Regional PPO C-SNP)
|
$22.00 |
$295* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$4.00 | $0.00 | None | $12.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
|
$22.40 |
$535 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $0.00 | None | $50.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plus (PPO)
|
$23.00 |
$300* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $0.00 | None | $12.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Liberty (HMO D-SNP)
|
$26.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $40.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage 2 (HMO D-SNP)
|
$27.30 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $139.23 |
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 |
Wellcare Dual Access (HMO D-SNP)
|
$27.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $40.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Dual Complete Plan (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $34.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Health Choice (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $86.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Health Choice (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $89.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Health Choice (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $89.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H0028-031 (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $32.91 |
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 H0028-033 (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $32.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H0028-064 (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $32.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Memorial Hermann Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $90.87 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Complete Care (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $22.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
ProCare Advantage (HMO-POS I-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $88.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
Provider Partners Texas Advantage Plan (HMO I-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $71.68 |
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 |
SCAN Strive (HMO C-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $19.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Texas Independence Health Plan, Inc. (HMO I-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $73.25 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Care Advantage EX-E001 (PPO I-SNP)
|
$28.40 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$2.00 | $0.00 | None | $12.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete TX-D002 (HMO-POS D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $13.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete TX-D002 (HMO-POS D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $14.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete TX-D002 (HMO-POS D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $8.46 |
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 |
UHC Dual Complete TX-S001 (Regional PPO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $12.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete TX-S003 (HMO-POS D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $12.77 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete TX-V01P (HMO-POS D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $13.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Nursing Home Plan TX-F001 (PPO I-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $12.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $40.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $139.15 |
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 |
Wellpoint Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $139.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $139.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $138.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $139.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $139.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $139.18 |
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 |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $138.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $139.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Choice H8145-084 (PFFS)
|
$45.00 |
$250* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$12.00 | $0.00 | None | $33.33 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Medicare Advantage TX-0030 (Regional PPO)
|
$48.00 |
$395* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$4.00 | $0.00 | None | $12.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R4182-004 (Regional PPO)
|
$49.00 |
$275* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$13.00 | $0.00 | None | $33.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
Erickson Advantage Freedom (HMO-POS)
|
$64.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $13.62 |
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 H5216-042 (PPO)
|
$65.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$12.00 | $0.00 | None | $33.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R4182-003 (Regional PPO)
|
$72.00 |
$175* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$10.00 | $0.00 | None | $33.58 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Cross Medicare Advantage Choice Premier (PPO)
|
$88.00 |
$295* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$8.00 | $16.00 | None | $31.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Erickson Advantage Signature (HMO-POS)
|
$168.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $13.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Erickson Advantage Champion (HMO-POS C-SNP)
|
$188.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $13.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Cross Medicare Advantage Flex (PPO)
|
$238.00 |
$545* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$8.00 | $24.00 | None | $40.83 |
Browse Plan Formulary all covered insulin pay $35 or less |