OMEPRAZOLE 10MG CAPSULE DELAYED RELEASE (30 CT) (30 BOT) (NDC: 00378521193)
2015 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
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 MedicareComplete Choice Plan 2 (Regional PPO)
![Email Prescription and/or Health Benefit details for AARP MedicareComplete Choice Plan 2 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$8.00 | $16.00 | None | $11.39 |
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Aetna Medicare Value Plan (HMO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Value Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | Q:30 /30Days | $24.77 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
![Email Prescription and/or Health Benefit details for Amerivantage Classic + Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | Q:30 /30Days | $17.54 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
![Email Prescription and/or Health Benefit details for Amerivantage Specialty + Rx (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$320 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:30 /30Days | $17.54 |
Browse Plan Formulary |
AvMed Medicare Choice (HMO)
![Email Prescription and/or Health Benefit details for AvMed Medicare Choice (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.00 | $21.00 | Q:60 /30Days | $15.47 |
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 |
BlueMedicare HMO LifeTime (HMO)
![Email Prescription and/or Health Benefit details for BlueMedicare HMO LifeTime (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$2.00 | $6.00 | Q:30 /30Days | $12.54 |
Browse Plan Formulary |
BlueMedicare HMO MyTime (HMO)
![Email Prescription and/or Health Benefit details for BlueMedicare HMO MyTime (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $12.59 |
Browse Plan Formulary |
CareDirect (HMO SNP)
![Email Prescription and/or Health Benefit details for CareDirect (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days | $9.59 |
Browse Plan Formulary |
CareHeart (HMO SNP)
![Email Prescription and/or Health Benefit details for CareHeart (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days | $9.59 |
Browse Plan Formulary |
CareOne (HMO)
![Email Prescription and/or Health Benefit details for CareOne (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days | $9.59 |
Browse Plan Formulary |
Coventry Summit Ideal (HMO)
![Email Prescription and/or Health Benefit details for Coventry Summit Ideal (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $19.51 |
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 |
Coventry Vista Ideal (HMO)
![Email Prescription and/or Health Benefit details for Coventry Vista Ideal (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $12.84 |
Browse Plan Formulary |
Freedom Medicare Plan Rx (HMO)
![Email Prescription and/or Health Benefit details for Freedom Medicare Plan Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $13.86 |
Browse Plan Formulary |
Freedom VIP Savings (HMO SNP)
![Email Prescription and/or Health Benefit details for Freedom VIP Savings (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $13.58 |
Browse Plan Formulary |
Freedom VIP Savings COPD (HMO SNP)
![Email Prescription and/or Health Benefit details for Freedom VIP Savings COPD (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $13.58 |
Browse Plan Formulary |
HealthSun HealthAdvantage Plan (HMO)
![Email Prescription and/or Health Benefit details for HealthSun HealthAdvantage Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | n/a | None | $20.96 |
Browse Plan Formulary |
Humana Gold Plus - Diabetes (HMO SNP)
![Email Prescription and/or Health Benefit details for Humana Gold Plus - Diabetes (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days | $9.59 |
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 |
Humana Gold Plus - Heart (HMO SNP)
![Email Prescription and/or Health Benefit details for Humana Gold Plus - Heart (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days | $9.59 |
Browse Plan Formulary |
Humana Gold Plus H1036-065C (HMO)
![Email Prescription and/or Health Benefit details for Humana Gold Plus H1036-065C (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days | $9.59 |
Browse Plan Formulary |
Humana Gold Plus H1036-237 (HMO)
![Email Prescription and/or Health Benefit details for Humana Gold Plus H1036-237 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$10.00 | $0.00 | Q:60 /30Days | $9.59 |
Browse Plan Formulary |
Humana Gold Plus H1036-237 (HMO)
![Email Prescription and/or Health Benefit details for Humana Gold Plus H1036-237 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$10.00 | $0.00 | Q:60 /30Days | $9.59 |
Browse Plan Formulary |
HumanaChoice R5826-074 (Regional PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice R5826-074 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $0.00 | Q:60 /30Days | $9.59 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax (HMO)
![Email Prescription and/or Health Benefit details for Medica HealthCare Plans MedicareMax (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $11.48 |
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 |
Optimum Gold Rewards Plan (HMO-POS)
![Email Prescription and/or Health Benefit details for Optimum Gold Rewards Plan (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $14.13 |
Browse Plan Formulary |
Optimum Platinum Plan (HMO-POS)
![Email Prescription and/or Health Benefit details for Optimum Platinum Plan (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $14.13 |
Browse Plan Formulary |
Preferred Choice Broward (HMO)
![Email Prescription and/or Health Benefit details for Preferred Choice Broward (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $11.48 |
Browse Plan Formulary |
WellCare Dividend (HMO)
![Email Prescription and/or Health Benefit details for WellCare Dividend (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$3.00 | $0.00 | None | $14.87 |
Browse Plan Formulary |
WellCare Essential (HMO-POS)
![Email Prescription and/or Health Benefit details for WellCare Essential (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $15.57 |
Browse Plan Formulary |
WellCare Value (HMO)
![Email Prescription and/or Health Benefit details for WellCare Value (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $15.76 |
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 |
Humana Gold Plus SNP-DE H1036-103A (HMO SNP)
![Email Prescription and/or Health Benefit details for Humana Gold Plus SNP-DE H1036-103A (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$13.30 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days | $9.59 |
Browse Plan Formulary |
CareNeeds (HMO SNP)
![Email Prescription and/or Health Benefit details for CareNeeds (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$15.80 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$0.00 | $0.00 | Q:60 /30Days | $9.59 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
![Email Prescription and/or Health Benefit details for WellCare Access (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$17.70 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $14.15 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
![Email Prescription and/or Health Benefit details for WellCare Liberty (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$18.90 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $14.15 |
Browse Plan Formulary |
WellCare Select (HMO SNP)
![Email Prescription and/or Health Benefit details for WellCare Select (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$19.90 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $14.08 |
Browse Plan Formulary |
BlueMedicare Regional PPO (Regional PPO)
![Email Prescription and/or Health Benefit details for BlueMedicare Regional PPO (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$20.20 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$5.00 | $15.00 | Q:30 /30Days | $12.57 |
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 |
Medica HealthCare Plans MedicareMax Plus (HMO-POS SNP)
![Email Prescription and/or Health Benefit details for Medica HealthCare Plans MedicareMax Plus (HMO-POS SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$24.30 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $11.33 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Nursing Home Plan (PPO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$24.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $11.45 |
Browse Plan Formulary |
Preferred Medicare Assist (HMO-POS SNP)
![Email Prescription and/or Health Benefit details for Preferred Medicare Assist (HMO-POS SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$24.40 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $11.33 |
Browse Plan Formulary |
Coventry Summit Maximum (HMO SNP)
![Email Prescription and/or Health Benefit details for Coventry Summit Maximum (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$24.60 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $13.15 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
![Email Prescription and/or Health Benefit details for Molina Medicare Options Plus (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$24.80 |
$320* |
Yes, but No Gap Coverage for this drug. |
1* |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $17.21 |
Browse Plan Formulary |
Freedom Medi-Medi Full (HMO SNP)
![Email Prescription and/or Health Benefit details for Freedom Medi-Medi Full (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $14.11 |
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 |
Freedom Medi-Medi Partial (HMO SNP)
![Email Prescription and/or Health Benefit details for Freedom Medi-Medi Partial (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $14.11 |
Browse Plan Formulary |
HealthSun MediMax (HMO)
![Email Prescription and/or Health Benefit details for HealthSun MediMax (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
25% | n/a | None | $14.72 |
Browse Plan Formulary |
Optimum Emerald Full (HMO SNP)
![Email Prescription and/or Health Benefit details for Optimum Emerald Full (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$25.80 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $14.15 |
Browse Plan Formulary |
Optimum Emerald Partial (HMO SNP)
![Email Prescription and/or Health Benefit details for Optimum Emerald Partial (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$25.80 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $14.15 |
Browse Plan Formulary |
Sunshine Health Advantage (HMO SNP)
![Email Prescription and/or Health Benefit details for Sunshine Health Advantage (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$25.80 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $19.70 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Dual Complete RP (Regional PPO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $11.39 |
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 |
Aetna Medicare Premier Plan (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Premier Plan (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$35.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$3.00 | $9.00 | Q:30 /30Days | $24.88 |
Browse Plan Formulary |
HumanaChoice R5826-005 (Regional PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice R5826-005 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$39.40 |
$100* |
Yes, but No Gap Coverage for this drug. |
2* |
Non-Preferred Generic |
$8.00 | $0.00 | Q:60 /30Days | $9.59 |
Browse Plan Formulary |
HumanaChoice H5415-056 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H5415-056 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$43.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$10.00 | $0.00 | Q:60 /30Days | $9.59 |
Browse Plan Formulary |
Humana Gold Choice H8145-061 (PFFS)
![Email Prescription and/or Health Benefit details for Humana Gold Choice H8145-061 (PFFS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$101.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$15.00 | $0.00 | Q:60 /30Days | $9.59 |
Browse Plan Formulary |
BlueMedicare PPO (PPO)
![Email Prescription and/or Health Benefit details for BlueMedicare PPO (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$127.10 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$2.00 | $6.00 | Q:30 /30Days | $12.54 |
Browse Plan Formulary |
Aetna Medicare Select Plus Plan (HMO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Select Plus Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$139.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$3.00 | $7.50 | Q:30 /30Days | $24.03 |
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 |
Aetna Medicare Select Plus Plan (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Select Plus Plan (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$139.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$3.00 | $7.50 | Q:30 /30Days | $23.00 |
Browse Plan Formulary |