ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT) (100 TABLETS BOT) (NDC: 62175012937)
2018 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 |
Aetna Better Health Premier Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Generic Drugs |
0% | n/a | None | $18.13 |
Browse Plan Formulary |
AmeriHealth Caritas VIP Care Plus (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Generic Drugs |
0% | n/a | None | $13.66 |
Browse Plan Formulary |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$2.00 | $6.00 | None | $18.18 |
Browse Plan Formulary |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$2.00 | $6.00 | None | $18.37 |
Browse Plan Formulary |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$2.00 | $6.00 | None | $18.29 |
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 |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$3.00 | $9.00 | None | $18.73 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$3.00 | $9.00 | None | $18.70 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$3.00 | $9.00 | None | $18.30 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$3.00 | $9.00 | None | $18.36 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$3.00 | $9.00 | None | $18.04 |
Browse Plan Formulary |
HAP Midwest MI Health Link (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Generic Drugs |
0% | n/a | None | $17.95 |
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 |
HAP Senior Plus (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | n/a | None | $15.06 |
Browse Plan Formulary |
Humana Gold Plus H8908-004 (HMO)
|
$0.00 |
$405* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | $0.00 | None | $17.41 |
Browse Plan Formulary |
MeridianCare Enhanced (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | n/a | None | $12.27 |
Browse Plan Formulary |
MeridianCare Essential (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | n/a | None | $11.98 |
Browse Plan Formulary |
Michigan Complete Health (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Generic Drugs |
0% | n/a | None | $16.18 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Generic Drugs |
0% | n/a | None | $17.89 |
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 |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | n/a | None | $14.12 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | n/a | None | $14.48 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | n/a | None | $13.64 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | n/a | None | $14.82 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | n/a | None | $15.03 |
Browse Plan Formulary |
HAP Senior Plus Option 1 (PPO)
|
$15.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
25% | n/a | None | $15.06 |
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 |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$13.00 | n/a | None | $14.12 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$13.00 | n/a | None | $14.48 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$13.00 | n/a | None | $13.64 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$13.00 | n/a | None | $14.82 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$13.00 | n/a | None | $15.03 |
Browse Plan Formulary |
HumanaChoice R3887-002 (Regional PPO)
|
$20.00 |
$405 | to be determined | 2 |
Generic |
25% | 25% | None | $17.61 |
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 |
BCN Advantage HMO HealthySaver (HMO)
|
$23.00 |
$100* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$2.00 | $6.00 | None | $18.18 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$23.00 |
$100* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$2.00 | $6.00 | None | $18.37 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$23.00 |
$100* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$2.00 | $6.00 | None | $18.29 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$24.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$11.00 | $33.00 | None | $18.32 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$24.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$11.00 | $33.00 | None | $18.04 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$24.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$11.00 | $33.00 | None | $18.27 |
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 |
Medicare Plus Blue PPO Essential (PPO)
|
$24.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$11.00 | $33.00 | None | $18.83 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$24.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$11.00 | $33.00 | None | $18.72 |
Browse Plan Formulary |
Humana Value Plus H5216-133 (PPO)
|
$26.90 |
$280 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | $0.00 | None | $17.41 |
Browse Plan Formulary |
MeridianCare Extra (HMO SNP)
|
$33.30 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
25% | n/a | None | $12.27 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$33.30 |
$405* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$0.00 | n/a | None | $17.89 |
Browse Plan Formulary |
HAP Senior Plus Option 1 (HMO-POS)
|
$45.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | n/a | None | $15.06 |
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 H8908-001 (HMO)
|
$47.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $0.00 | None | $17.45 |
Browse Plan Formulary |
MeridianCare Elite (HMO)
|
$47.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | None | $12.27 |
Browse Plan Formulary |
BCN Advantage HMO ConnectedCare (HMO)
|
$56.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$1.00 | $3.00 | None | $18.18 |
Browse Plan Formulary |
HAP Senior Plus Henry Ford Tiered Access (HMO)
|
$60.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | n/a | None | $15.07 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$63.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | None | $14.12 |
Browse Plan Formulary |
HAP Senior Plus Option 2 (HMO-POS)
|
$85.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | n/a | None | $15.06 |
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 |
PriorityMedicare Merit (PPO)
|
$86.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | n/a | None | $15.03 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$86.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | n/a | None | $14.82 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$86.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | n/a | None | $13.64 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$86.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | n/a | None | $14.48 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$86.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | n/a | None | $14.12 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$92.00 |
$115* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$5.00 | $10.00 | None | $10.74 |
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 H5216-011 (PPO)
|
$106.00 |
$105* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | $0.00 | None | $17.41 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$109.50 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$11.00 | $33.00 | None | $18.72 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$109.50 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$11.00 | $33.00 | None | $18.04 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$109.50 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$11.00 | $33.00 | None | $18.27 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$109.50 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$11.00 | $33.00 | None | $18.83 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$109.50 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$11.00 | $33.00 | None | $18.32 |
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 |
HAP Senior Plus Option 2 (PPO)
|
$118.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | n/a | None | $15.06 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$140.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$8.00 | n/a | None | $14.12 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$164.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$1.00 | $3.00 | None | $18.73 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$164.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$1.00 | $3.00 | None | $18.70 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$164.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$1.00 | $3.00 | None | $18.04 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$164.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$1.00 | $3.00 | None | $18.36 |
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 |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$164.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$1.00 | $3.00 | None | $18.30 |
Browse Plan Formulary |
HAP Senior Plus Option 3 (HMO-POS)
|
$170.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | n/a | None | $15.06 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$172.50 |
$105* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $30.00 | None | $18.27 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$172.50 |
$105* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $30.00 | None | $18.32 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$172.50 |
$105* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $30.00 | None | $18.72 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$172.50 |
$105* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $30.00 | None | $18.83 |
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 |
Medicare Plus Blue PPO Signature (PPO)
|
$172.50 |
$105* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $30.00 | None | $18.04 |
Browse Plan Formulary |
HAP Senior Plus Option 3 (PPO)
|
$190.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | n/a | None | $15.06 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$198.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | n/a | None | $15.03 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$198.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | n/a | None | $14.82 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$198.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | n/a | None | $13.64 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$198.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | n/a | None | $14.48 |
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 |
PriorityMedicare Select (PPO)
|
$198.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | n/a | None | $14.12 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$301.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$1.00 | $3.00 | None | $18.30 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$301.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$1.00 | $3.00 | None | $18.04 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$301.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$1.00 | $3.00 | None | $18.36 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$301.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$1.00 | $3.00 | None | $18.73 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$301.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$1.00 | $3.00 | None | $18.70 |
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 |
Medicare Plus Blue PPO Assure (PPO)
|
$312.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$9.00 | $27.00 | None | $18.83 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$312.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$9.00 | $27.00 | None | $18.04 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$312.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$9.00 | $27.00 | None | $18.72 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$312.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$9.00 | $27.00 | None | $18.32 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$312.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$9.00 | $27.00 | None | $18.27 |
Browse Plan Formulary |