Medicare Advantage Drug Cost for Tri Vylibra Lo
There are 63 Medicare Advantage Plans with additional prescription drug coverage for Tri Vylibra Lo available to residents in Texas. The average retail unit cost (e.g. per pill) for a 30-day supply at in-area retail pharmacies is $0.87 ($26.16). Tri-vylibra Lo is typically listed as a Tier 4 drug on the formulary and does not require prior authorization.
Below is the average retail cost and your co-pay for Tri Vylibra Lo in Texas. You can also see if each plan requires prior authorization, step therapy or has drug quantity limits. Please check the formulary for different brand and generic drug names. Every Medicare Advantage Plan will vary in coverage, co-pays, costs and premiums. This chart can help you sort through different plan details to find a Medicare Advantage Plan in Bexar with the best coverage and the cheapest prices for your medications in Texas.
| Proprietary Name: | Tri-vylibra Lo |
|---|---|
| Generic Name: | Norgestimate And Ethinyl Estradiol |
| Drug Package: | 3 Package In 1 Carton |
| Drug Strength: | |
| Substance: | |
| Dosage Form: | Kit |
| Route: | |
| Labeler: | Afaxys Pharma, Llc |
| Pen Name: | Human Prescription Drug |
| NDC# | 50102023113 |
| RX# | 2104192 |
| Days Supply: | 30 |
| Coverage Phase: | Initial Coverage |
| Plan Year: | 2023 |
| County: | Bexar |
Select Another State:
Select Another County:
Medicare Advantage Coverage for Tri Vylibra Lo in Texas
Click the Plan Name for More Details
Click the header to sort
| Plan Name ⇅ |
Tier Level |
Your Cost Preferred |
Cost Non Preferred |
Cost |
Limit Amt/ Days |
Prior Auth Y/N |
Step Therapy Y/N |
Avg Unit Cost (x30) |
|---|---|---|---|---|---|---|---|---|
| AARP Medicare Advantage |
4 | NA | $100 | NA | / | N | N | $0.68 ($20.33) |
| AARP Medicare Advantage Choice |
4 | NA | $100 | NA | / | N | N | $0.68 ($20.33) |
| AARP Medicare Advantage SecureHorizons |
4 | NA | $100 | NA | / | N | N | $0.68 ($20.33) |
| Aetna Medicare Choice Plan |
2 | $10 | $20 | $10 | / | N | N | $0.39 ($11.66) |
| Aetna Medicare Premier Plan |
2 | $10 | $20 | $10 | / | N | N | $0.39 ($11.66) |
| Aetna Medicare Prime Plan |
2 | $10 | $20 | $10 | / | N | N | $0.39 ($11.66) |
| Aetna Medicare Value Plan |
2 | $0 | $20 | $0 | / | N | N | $0.39 ($11.66) |
| Amerivantage Choice |
3 | $37 | $47 | NA | / | N | N | $0.24 ($7.10) |
| Amerivantage Classic |
3 | $42 | $47 | NA | / | N | N | $0.24 ($7.10) |
| Amerivantage Classic Plus |
3 | $42 | $47 | NA | / | N | N | $0.24 ($7.10) |
| Amerivantage Select Plus |
3 | $42 | $47 | NA | / | N | N | $0.24 ($7.10) |
| Blue Cross Medicare Advantage Choice Plus |
3 | $47 | $47 | $47 | / | N | N | $0.48 ($14.44) |
| Blue Cross Medicare Advantage Classic |
4 | $85 | $100 | $85 | / | N | N | $0.48 ($14.44) |
| Blue Cross Medicare Advantage Flex |
4 | $85 | $100 | $85 | / | N | N | $0.52 ($15.70) |
| Blue Cross Medicare Advantage Value |
3 | $47 | $47 | $47 | / | N | N | $0.48 ($14.44) |
| Cigna Preferred Medicare |
3 | $42 | $47 | $42 | / | N | N | $0.37 ($11.24) |
| Cigna Preferred Savings Medicare |
3 | $42 | $47 | $42 | / | N | N | $0.37 ($11.24) |
| Cigna True Choice Medicare |
3 | $42 | $47 | $42 | / | N | N | $0.37 ($11.24) |
| Cigna True Choice Plus Medicare |
3 | $42 | $47 | $42 | / | N | N | $0.37 ($11.24) |
| Clover Health Choice |
3 | $37 | $47 | NA | / | N | N | $1.00 ($30.10) |
| Community First Medicare Advantage Alamo Plan |
2 | NA | $7 | NA | / | N | N | $0.44 ($13.17) |
| Devoted CORE San Antonio |
3 | NA | $40 | NA | / | N | N | $0.96 ($28.65) |
| Devoted PRIME San Antonio |
3 | NA | 25% | NA | / | N | N | $0.96 ($28.65) |
| Humana Gold Choice H8145-084 |
4 | NA | $99 | $99 | / | N | N | $0.36 ($10.79) |
| Humana Gold Plus H0028-030 |
4 | NA | $99 | $99 | / | N | N | $0.36 ($10.79) |
| HumanaChoice H5216-042 |
4 | NA | $99 | $99 | / | N | N | $0.36 ($10.79) |
| HumanaChoice H5216-043 |
4 | NA | $99 | $99 | / | N | N | $0.36 ($10.79) |
| HumanaChoice R4182-003 |
4 | NA | $99 | $99 | / | N | N | $0.36 ($10.79) |
| HumanaChoice R4182-004 |
4 | NA | $99 | $99 | / | N | N | $0.36 ($10.79) |
| Molina Medicare Choice Care |
2 | NA | $12 | NA | / | N | N | $1.30 ($39.02) |
| Molina Medicare Choice Care Select |
2 | NA | $20 | NA | / | N | N | $1.30 ($39.02) |
| UnitedHealthcare Medicare Advantage Choice |
4 | NA | $100 | NA | / | N | N | $0.68 ($20.33) |
| Wellcare Assist |
3 | $47 | $47 | $47 | / | N | N | $3.22 ($96.73) |
| Wellcare Complement Assist |
3 | $47 | $47 | $47 | / | N | N | $3.14 ($94.12) |
| Wellcare No Premium |
3 | $37 | $47 | $37 | / | N | N | $2.22 ($66.69) |
| Wellcare No Premium Rx Plus Open |
3 | $35 | $45 | $35 | / | N | N | $0.85 ($25.41) |
Return to Drug List
SNP Prescription Drug Cost for Tri Vylibra Lo
Click the header to sort
Do any Medicare Advantage Plans Cover Tri Vylibra Lo? Yes, 63 Medicare Advantage Plans cover this drug in Texas.
How much does Tri Vylibra Lo Cost? $0.87, the average retail cost in Texas is $0.87 per unit or $26.16 for a 30-day supply at in-area pharmacies.
What Tier is Tri Vylibra Lo? Tier 4, most Advantage Plans list Tri Vylibra Lo on Tier 4 on their formulary. Usually, the higher the tier, the more you have to pay for the medication.
Do I need Prior Authorization for Tri Vylibra Lo? No, the majority of Medicare Prescription Plans do not require prior authorization from your doctor for Tri Vylibra Lo.
Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible. Some plans offer select Pre-deductible drug Coverage
2.Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit.
3.Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $7550 in 2022.
4.Catastrophic: Anything over $7550 you will receive a significant increase in coverage.
Formulary Definitions:
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Cost Preferred: Your Cost for the Drug at the Providers In Network Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non Preferred: Your Cost for the Prescription Drug at a Non-Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization in order to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Avg Unit Cost: Average unit cost (e.g. per pill) for specified days supply at in-area retail pharmacies. A pharmacy is considered in-area when it is geographically located in the service area.
What if a drug I need is not listed?
Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plans formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.
Last updated on
Source:CMS Formulary Data Q4 2022
Source:NDC Directory by FDA.gov
**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.