2024 Medicare Part D Plan’s Negotiated Retail Drug Price
| 2024 Medicare Prescription Drug Price Information | ||||||
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AARP Medicare Rx Walgreens from UHC (PDP) (S5921-383-0) 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 AARP Medicare Rx Walgreens from UHC (PDP) 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 | ||||||
| This Plan Uses Lower Cost-Sharing for Preferred Pharmacies | ||||||
BELSOMRA 20 MG TABLET  | ||||||
| Plan’s average negotiated retail drug price in CMS PDP Region 11, includes: FL | $431.86* 30-Day Supply $1,295.47* 90-Day Supply | |||||
| Formulary (Drug List) drug tier: | Tier #3: Preferred Brand | |||||
| Does this plan offer any Gap coverage? | Yes | |||||
| 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: | Quantity Limit:30/30Days | |||||
| 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 |
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| Preferred Pharmacy | Standard Pharmacy | Mail- Order** | Preferred Pharmacy | Standard Pharmacy | Mail- Order** | |
| Initial $410 Deductible Cost Sharing: | ||||||
| 100% | 100% | n/a | 100% | 100% | 100% | |
| Initial Coverage Phase Cost-Sharing: | ||||||
| $40.00 | $45.00 | n/a | $120.00 | $135.00 | $120.00 | |
| Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Generics 75%): | ||||||
| 25% | 25% | n/a | 25% | 25% | 25% | |
| Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Brand 75%): | ||||||
| 25% | 25% | n/a | 25% | 25% | 25% | |
| Catastrophic Coverage Phase Cost-Sharing (all Formulary Drugs): | ||||||
| $0 | $0 | n/a | $0 | $0 | $0 | |
| Your Estimated Cost for Purchases During Each Coverage Phase | ||||||
| 30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing |
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| Preferred Pharmacy | Standard Pharmacy | Mail- Order** | Preferred Pharmacy | Standard Pharmacy | Mail- Order** | |
| Your Estimated Cost in Deductible Phase: | ||||||
| $431.86 | $431.86 | n/a | $530.00 | $545.00 | $530.00 | |
| Your Estimated Cost Initial Coverage Phase: | ||||||
| $40.00 | $45.00 | n/a | $120.00 | $135.00 | $120.00 | |
| Your Estimated Cost in Gap if Drug is Generic (75% discount): | ||||||
| $107.96 | $107.96 | n/a | $323.87 | $323.87 | $323.87 | |
| Your Estimated Cost in Gap if Drug is Brand-Name (75% discount): | ||||||
| $107.96 | $107.96 | n/a | $323.87 | $323.87 | $323.87 | |
| Your Estimated Cost in Catastrophic Coverage (all Formulary Drugs): | ||||||
| $0 | $0 | n/a | $0 | $0 | $0 | |
| Tier Cost-Sharing Details and Your Costs with Explanations | ||||||
| 30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing |
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| Preferred Pharmacy | Standard Pharmacy | Mail- Order** | Preferred Pharmacy | Standard Pharmacy | Mail- Order** | |
| --- If you purchase during the Initial Deductible Phase --- | ||||||
| Initial $410 Deductible Cost Sharing: | ||||||
| 100% | 100% | n/a | 100% | 100% | 100% | |
| Your Estimated Cost in Deductible Phase: | ||||||
| $431.86 | $431.86 | n/a | $530.00 | $545.00 | $530.00 | |
| Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
| For a purchase of this drug made during the initial deductible phase, you cross over into other phases of your plan’s coverage (straddle claim). So you pay 100% of the drug cost up to your deductible of $410 and the remaining amount ($431.86-$410) (price - deductible) falls into your initial coverage phase (ICP). For the ICP portion of your coverage, your cost-sharing would be an additional $40.00, a flat co-pay up to your coverage limit of . Since your estimated cost for a purchase made during the deductible phase would be $410.00 from the deductible phase + $40.00 from initial coverage phase, which is greater than the negotiated retail price of $431.86, you would pay $431.86 | ||||||
| --- If you purchase during the Initial Coverage Phase --- | ||||||
| Initial Coverage Phase Cost-Sharing: | ||||||
| $40.00 | $45.00 | n/a | $120.00 | $135.00 | $120.00 | |
| Your Estimated Cost Initial Coverage Phase: | ||||||
| $40.00 | $45.00 | n/a | $120.00 | $135.00 | $120.00 | |
| Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
| The cost-sharing for purchases made during the initial coverage phase (ICP) would be a flat fee of $40.00. | ||||||
| --- If you purchase during the Coverage Gap Phase (Donut Hole) --- | ||||||
| Your Estimated Cost in Gap if Drug is Generic (75% discount): | ||||||
| $107.96 | $107.96 | n/a | $323.87 | $323.87 | $323.87 | |
| Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
| Your cost is the negotiated retail price of $431.86 x 25%. | ||||||
| Your Estimated Cost in Gap if Drug is Brand-Name (75% discount): | ||||||
| $107.96 | $107.96 | n/a | $323.87 | $323.87 | $323.87 | |
| Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
| Your costs is the negotiated retail price of $431.86 x 25%. | ||||||
| --- If you purchase during the Catastrophic Coverage Phase --- | ||||||
| Catastrophic Coverage Phase Cost-Sharing (all Formulary Drugs): | ||||||
| $0 | $0 | n/a | $0 | $0 | $0 | |
| Your Estimated Cost in Catastrophic Coverage (all Formulary Drugs): | ||||||
| $0 | $0 | n/a | $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). | ||||||
| AARP Medicare Rx Walgreens from UHC (PDP) Average Negotiated Retail Drug Price History | ||||||
| 30-Day Supply | 90 Day Supply | |||||
| March, 2024: | $431.86 | $1,295.47 | ||||
| January, 2024: | $411.38 | $1,234.07 | ||||
| September, 2023: | $462.83 | $1,388.41 | ||||
| June, 2023: | $453.30 | $1,359.90 | ||||
| March, 2023: | $438.30 | $1,314.90 | ||||
| January, 2023: | $417.60 | $1,252.80 | ||||
| September, 2022: | $428.10 | $1,284.30 | ||||
| June, 2022: | $428.10 | $1,284.30 | ||||
| March, 2022: | $428.10 | $1,284.30 | ||||
| January, 2022: | $408.00 | $1,224.00 | ||||
| September, 2021: | $407.70 | $1,223.10 | ||||
| June, 2021: | $407.70 | $1,223.10 | ||||
| March, 2021: | $407.70 | $1,223.10 | ||||
| January, 2021: | $388.20 | $1,164.60 | ||||
| September, 2020: | $360.90 | $1,082.70 | ||||
| June, 2020: | $360.90 | $1,082.70 | ||||
| March, 2020: | $360.90 | $1,082.70 | ||||
| January, 2020: | $343.50 | $1,030.50 | ||||
| September, 2019: | $344.20 | $1,030.52 | ||||
| June, 2019: | $344.20 | $1,030.53 | ||||
| March, 2019: | $344.20 | $1,030.57 | ||||
| January, 2019: | $327.54 | $980.65 | ||||
| September, 2018: | $330.61 | $987.97 | ||||
| June, 2018: | $330.68 | $988.06 | ||||
| March, 2018: | $330.34 | $987.69 | ||||
| January, 2018: | $305.92 | $914.53 | ||||
| September, 2017: | $303.42 | $907.32 | ||||
| June, 2017: | $303.43 | $907.32 | ||||
| March, 2017: | $319.62 | $895.15 | ||||
| January, 2017: | $296.90 | $826.26 | ||||
| September, 2016: | ||||||
| June, 2016: | ||||||
| April, 2016: | ||||||
| January, 2016: | ||||||
| September, 2015: | ||||||
| June, 2015: | ||||||
| April, 2015: | ||||||
| January, 2015: | ||||||
| September, 2014: | ||||||
| June, 2014: | ||||||
| March, 2014: | ||||||
| January, 2014: | ||||||
| October, 2013: | ||||||
| January, 2013: | -- | |||||
| April, 2012: | -- | |||||
| September, 2010: | -- | |||||
| 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 BELSOMRA 20 MG TABLET prices that the AARP Medicare Rx Walgreens from UHC (PDP) has negotiated with each of the retail pharmacies in the plan’s service area (CMS PDP Region 11, includes: FL). In other words, when you use the AARP Medicare Rx Walgreens from UHC (PDP) to purchase BELSOMRA 20 MG TABLET, 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 example average retail prices used above are based on a quantity of 30 for the 30-day supply and a quantity of 90 for the 90-day supply. **The mail-order cost-sharing is the plan’s "preferred" mail-order cost-sharing. |
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| Return to the AARP Medicare Rx Walgreens from UHC (PDP) 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 | ||||||