2024 Medicare Part D Plan’s Negotiated Retail Drug Price
| 2024 Medicare Advantage Prescription Drug Price Information | ||||||
|
UHC Complete Care CA-07AP (HMO C-SNP) (H0543-247-0) Benefits & Contact Info  
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less. | ||||||
Click on a letter below to view the UHC Complete Care CA-07AP (HMO C-SNP) Formulary A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 0-9 | ||||||
XALKORI 50 MG PELLET DSP CP  | ||||||
| Plan’s average negotiated retail drug price in in San Luis Obispo, CA: CMS MA Region 24, includes: CA | n/a* 30-Day Supply 90-Day Supply (calculated) | |||||
| Formulary (Drug List) drug tier: | Tier 5 | |||||
| Does this plan offer any Gap coverage? | No Gap Coverage | |||||
| Does this drug have Gap coverage? | No, this drug IS NOT covered in the gap, but all drugs receive the donut hole discount. | |||||
| Drug Usage Management Restrictions: | Prior Authorization | |||||
| Formulary (Drug List) Tier Cost-Sharing Details | ||||||
| Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less. | ||||||
| 30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing |
|||||
| Preferred Pharmacy | Standard Pharmacy | Mail- Order** | Preferred Pharmacy | Standard Pharmacy | Mail- Order** | |
| Initial $545 Deductible Cost Sharing: | ||||||
| 100% | 100% | 100% | 100% | 100% | 100% | |
| Initial Coverage Phase Cost-Sharing: | ||||||
| 25% | 25% | 25% | 25% | 25% | 25% | |
| Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Generics 75%): | ||||||
| 25% | 25% | 25% | 25% | 25% | 25% | |
| Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Brand 75%): | ||||||
| 25% | 25% | 25% | 25% | 25% | 25% | |
| Catastrophic Coverage Phase Cost-Sharing (all Formulary Drugs): | ||||||
| $0 | $0 | $0 | $0 | $0 | $0 | |
| Your Estimated Cost for Purchases During Each Coverage Phase | ||||||
| 30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing |
|||||
| Preferred Pharmacy | Standard Pharmacy | Mail- Order** | Preferred Pharmacy | Standard Pharmacy | Mail- Order** | |
| Your Estimated Cost in Deductible Phase: | ||||||
| TBD | TBD | TBD | TBD | TBD | TBD | |
| Your Estimated Cost Initial Coverage Phase: | ||||||
| TBD | TBD | TBD | TBD | TBD | TBD | |
| Your Estimated Cost in Gap if Drug is Generic (75% discount): | ||||||
| TBD | TBD | TBD | TBD | TBD | TBD | |
| Your Estimated Cost in Gap if Drug is Brand-Name (75% discount): | ||||||
| TBD | TBD | TBD | TBD | TBD | TBD | |
| Your Estimated Cost in Catastrophic Coverage (all Formulary Drugs): | ||||||
| $0 | $0 | $0 | $0 | $0 | $0 | |
| Tier Cost-Sharing Details and Your Costs with Explanations | ||||||
| 30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing |
|||||
| Preferred Pharmacy | Standard Pharmacy | Mail- Order** | Preferred Pharmacy | Standard Pharmacy | Mail- Order** | |
| --- If you purchase during the Initial Deductible Phase --- | ||||||
| Initial $545 Deductible Cost Sharing: | ||||||
| 100% | 100% | 100% | 100% | 100% | 100% | |
| Your Estimated Cost in Deductible Phase: | ||||||
| TBD | TBD | TBD | TBD | TBD | TBD | |
| --- If you purchase during the Initial Coverage Phase --- | ||||||
| Initial Coverage Phase Cost-Sharing: | ||||||
| 25% | 25% | 25% | 25% | 25% | 25% | |
| Your Estimated Cost Initial Coverage Phase: | ||||||
| TBD | TBD | TBD | TBD | TBD | TBD | |
| --- If you purchase during the Coverage Gap Phase (Donut Hole) --- | ||||||
| Your Estimated Cost in Gap if Drug is Generic (75% discount): | ||||||
| TBD | TBD | TBD | TBD | TBD | TBD | |
| Your Estimated Cost in Gap if Drug is Brand-Name (75% discount): | ||||||
| TBD | TBD | TBD | TBD | TBD | TBD | |
| --- If you purchase during the Catastrophic Coverage Phase --- | ||||||
| Catastrophic Coverage Phase Cost-Sharing (all Formulary Drugs): | ||||||
| $0 | $0 | $0 | $0 | $0 | $0 | |
| Your Estimated Cost in Catastrophic Coverage (all Formulary Drugs): | ||||||
| $0 | $0 | $0 | $0 | $0 | $0 | |
| Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
| Beginning with plan year 2024, the Inflation Reduction Act (IRA) of 2022 eliminates beneficiary cost-sharing once your TrOOP reaches $8,000 -- the established maximum cap on out-of-pocket spending for Part D formulary drugs (RxMOOP). | ||||||
| UHC Complete Care CA-07AP (HMO C-SNP) Average Negotiated Retail Drug Price History | ||||||
| 30-Day Supply | 90 Day Supply | |||||
| This is a new NDC (national drug code) for this plan. Pricing history is not available. This plan may have offered XALKORI 50 MG PELLET DSP CP using a different NDC in the past. | ||||||
| Notes:
*The Medicare drug plan’s average negotiated retail drug price is based on several variables: the medication, the quantity of your prescription, the specific Medicare Part D plan, and the pharmacies in the plan’s service area. In this case, the average of the XALKORI 50 MG PELLET DSP CP prices that the UHC Complete Care CA-07AP (HMO C-SNP) has negotiated with each of the retail pharmacies in the plan’s service area (in San Luis Obispo, CA: CMS MA Region 24, includes: CA). In other words, when you use the UHC Complete Care CA-07AP (HMO C-SNP) to purchase XALKORI 50 MG PELLET DSP CP, you may pay slightly more or slightly less than the figures shown in the table above depending on the pharmacy where you fill your prescription and the quantity of your prescription. **The mail-order cost-sharing is the plan’s "preferred" mail-order cost-sharing. |
||||||
| Return to the UHC Complete Care CA-07AP (HMO C-SNP) 2024 Formulary Browser by choosing a letter below: A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 0-9 | ||||||