VANCOMYCIN HCL 125 MG CAPSULE [Vancocin] (40 capsules ) (NDC: 68180016613)
2022 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 Plan 7 (HMO)
|
$0.00 |
$175 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:120 /30Days | $221.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Walgreens (PPO)
|
$0.00 |
$225 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:120 /30Days | $227.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Silver (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:120 /30Days | $222.80 |
Browse Plan Formulary |
Aetna Medicare Premier (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:120 /30Days | $132.00 |
Browse Plan Formulary |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:120 /30Days | $249.60 |
Browse Plan Formulary |
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 MediBlue Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:240 /30Days | $368.40 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:240 /30Days | $352.80 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:240 /30Days | $363.20 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:240 /30Days | $377.60 |
Browse Plan Formulary |
CareSource Advantage Zero Premium (HMO)
|
$0.00 |
$175 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | P Q:40 /10Days | $112.80 |
Browse Plan Formulary |
CareSource MyCare Ohio (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
1 |
Tier 1 |
0% | 0% | P Q:40 /10Days | $104.80 |
Browse Plan Formulary |
|
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 |
Devoted Health Core (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:80 /180Days | $459.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Devoted Health Saver (HMO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:80 /180Days | $459.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-285 (PPO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:120 /30Days | $90.00 |
Browse Plan Formulary |
HumanaChoice H5525-042 (PPO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:120 /30Days | $90.00 |
Browse Plan Formulary |
MedMutual Advantage Access (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:40 /10Days | $187.20 |
Browse Plan Formulary |
MedMutual Advantage Access (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:40 /10Days | $188.80 |
Browse Plan Formulary |
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 |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:40 /10Days | $187.20 |
Browse Plan Formulary |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:40 /10Days | $191.60 |
Browse Plan Formulary |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:40 /10Days | $188.80 |
Browse Plan Formulary |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:40 /10Days | $188.80 |
Browse Plan Formulary |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:40 /10Days | $187.20 |
Browse Plan Formulary |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:40 /10Days | $188.80 |
Browse Plan Formulary |
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 Medicare Choice Care (HMO)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$12.00 | $24.00 | Q:80 /180Days | $306.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
PrimeTime Health Plan Aultimate (HMO-POS)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $125.00 | None | $69.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SummaCare Medicare Topaz (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:56 /14Days | $90.00 |
Browse Plan Formulary |
The Health Plan SecureCare - Option II (HMO)
|
$0.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | P Q:40 /10Days | $179.60 |
Browse Plan Formulary |
UnitedHealthcare Connected for MyCareOhio (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
1 |
Tier 1 |
0% | 0% | Q:120 /30Days | $227.20 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | Q:80 /180Days | $364.40 |
Browse Plan Formulary |
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 Boost (HMO)
|
$0.00 |
$75 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:80 /180Days | $364.00 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$75 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:80 /180Days | $364.40 |
Browse Plan Formulary |
Wellcare No Premium Medicare (HMO)
|
$0.00 |
$75 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:80 /180Days | $364.00 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
43% | 43% | Q:80 /180Days | $364.00 |
Browse Plan Formulary |
HumanaChoice H5216-106 (PPO)
|
$15.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:120 /30Days | $90.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Assist (HMO)
|
$16.80 |
$480 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
42% | 42% | Q:80 /180Days | $531.20 |
Browse Plan Formulary |
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 Complement (HMO)
|
$17.60 |
$480 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
42% | 42% | Q:80 /180Days | $535.20 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 1 (HMO)
|
$19.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:120 /30Days | $221.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Anthem MediBlue Preferred Plus (HMO)
|
$19.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:240 /30Days | $361.60 |
Browse Plan Formulary |
Humana Value Plus H5525-041 (PPO)
|
$21.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | P Q:120 /30Days | $90.40 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$22.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:240 /30Days | $363.20 |
Browse Plan Formulary |
MedMutual Advantage Secure (HMO)
|
$22.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:40 /10Days | $187.20 |
Browse Plan Formulary |
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 |
MedMutual Advantage Secure (HMO)
|
$22.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:40 /10Days | $188.80 |
Browse Plan Formulary |
Aetna Medicare Assure 1 (HMO D-SNP)
|
$23.20 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | Q:120 /30Days | $240.00 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 8 (HMO)
|
$25.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:120 /30Days | $221.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice SNP-DE H5525-046 (PPO D-SNP)
|
$27.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:120 /30Days | $90.40 |
Browse Plan Formulary |
CareSource Advantage (HMO)
|
$30.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | P Q:40 /10Days | $112.80 |
Browse Plan Formulary |
Devoted Health Prime (HMO)
|
$31.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:80 /180Days | $459.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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)
|
$32.00 |
$480 |
Some Generics |
4 |
Non-Preferred Drug |
50% | 50% | Q:80 /180Days | $530.40 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO-POS D-SNP)
|
$33.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | Q:120 /30Days | $220.80 |
Browse Plan Formulary |
Aetna Medicare Premier Plus 2 (Regional PPO)
|
$33.40 |
$260 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:120 /30Days | $103.20 |
Browse Plan Formulary |
Anthem MediBlue Dual Advantage (HMO D-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:240 /30Days | $363.20 |
Browse Plan Formulary |
CareSource Dual Advantage (HMO D-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | P Q:40 /10Days | $112.80 |
Browse Plan Formulary |
CommuniCare Advantage ISNP (HMO I-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $487.20 |
Browse Plan Formulary |
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 |
CommuniCare Advantage ISNP (HMO I-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $554.00 |
Browse Plan Formulary |
CommuniCare Advantage ISNP (HMO I-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $728.80 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
33% | 33% | Q:80 /180Days | $306.80 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP1 (HMO D-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | Q:120 /30Days | $220.80 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | Q:120 /30Days | $232.80 |
Browse Plan Formulary |
Valor Health Plan (HMO I-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $465.20 |
Browse Plan Formulary |
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 |
PrimeTime Health Plan Classic (HMO-POS)
|
$39.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $125.00 | None | $69.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:40 /10Days | $187.20 |
Browse Plan Formulary |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:40 /10Days | $191.60 |
Browse Plan Formulary |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:40 /10Days | $188.80 |
Browse Plan Formulary |
The Health Plan SecureCare SNP (HMO D-SNP)
|
$40.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | P Q:40 /10Days | $179.60 |
Browse Plan Formulary |
Anthem MediBlue Access Basic (Regional PPO)
|
$41.50 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
41% | 41% | P Q:240 /30Days | $363.20 |
Browse Plan Formulary |
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 |
SummaCare Medicare Ruby (HMO)
|
$43.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:56 /14Days | $91.20 |
Browse Plan Formulary |
HumanaChoice H5216-051 (PPO)
|
$44.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:120 /30Days | $90.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MedMutual Advantage Select (PPO)
|
$44.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:40 /10Days | $187.20 |
Browse Plan Formulary |
MedMutual Advantage Select (PPO)
|
$44.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:40 /10Days | $191.60 |
Browse Plan Formulary |
MedMutual Advantage Select (PPO)
|
$44.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:40 /10Days | $188.80 |
Browse Plan Formulary |
Aetna Medicare Premier Plus 1 (Regional PPO)
|
$44.50 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$99.00 | $297.00 | Q:120 /30Days | $130.40 |
Browse Plan Formulary |
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 R5495-002 (Regional PPO)
|
$47.80 |
$480 |
No |
4 |
Non-Preferred Drug |
20% | 20% | P Q:120 /30Days | $90.00 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$55.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | P Q:240 /30Days | $360.40 |
Browse Plan Formulary |
Anthem MediBlue Access (PPO)
|
$56.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:240 /30Days | $363.20 |
Browse Plan Formulary |
SummaCare Medicare Sapphire (HMO-POS)
|
$76.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:56 /14Days | $91.60 |
Browse Plan Formulary |
MedMutual Advantage Preferred (PPO)
|
$80.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:40 /10Days | $187.20 |
Browse Plan Formulary |
MedMutual Advantage Preferred (PPO)
|
$80.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:40 /10Days | $191.60 |
Browse Plan Formulary |
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 |
MedMutual Advantage Preferred (PPO)
|
$80.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:40 /10Days | $188.80 |
Browse Plan Formulary |
Humana Gold Choice H8145-032 (PFFS)
|
$83.00 |
$225 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:120 /30Days | $90.00 |
Browse Plan Formulary |
Anthem MediBlue Access Plus (PPO)
|
$89.00 |
$40 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:240 /30Days | $354.40 |
Browse Plan Formulary |
PrimeTime Health Plan Plus (HMO-POS)
|
$89.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $125.00 | None | $69.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MedMutual Advantage Plus (HMO)
|
$97.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:40 /10Days | $187.20 |
Browse Plan Formulary |
MedMutual Advantage Plus (HMO)
|
$97.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:40 /10Days | $191.60 |
Browse Plan Formulary |
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 |
MedMutual Advantage Plus (HMO)
|
$97.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:40 /10Days | $188.80 |
Browse Plan Formulary |
The Health Plan SecureChoice - Option II (PPO)
|
$100.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | P Q:40 /10Days | $179.60 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 3 (HMO)
|
$111.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:120 /30Days | $230.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Premier 2 (PPO)
|
$118.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:120 /30Days | $239.60 |
Browse Plan Formulary |
MedMutual Advantage Premium (PPO)
|
$134.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:40 /10Days | $191.60 |
Browse Plan Formulary |
MedMutual Advantage Premium (PPO)
|
$134.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:40 /10Days | $188.80 |
Browse Plan Formulary |
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 |
MedMutual Advantage Premium (PPO)
|
$134.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P Q:40 /10Days | $187.20 |
Browse Plan Formulary |
Aetna Medicare Premier 1 (PPO)
|
$149.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:120 /30Days | $242.00 |
Browse Plan Formulary |
HumanaChoice H5525-030 (PPO)
|
$151.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | P Q:120 /30Days | $90.00 |
Browse Plan Formulary |
SummaCare Medicare Emerald (HMO-POS)
|
$180.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:56 /14Days | $90.00 |
Browse Plan Formulary |