ACETAMINOPHEN-COD #2 TABLET (100 EA ) (NDC: 13107005801)
2019 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 |
Advantra Northern Pennsylvania Gold (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $25.00 | Q:180 /30Days | $37.60 |
Browse Plan Formulary |
Advantra Silver (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $21.00 |
Browse Plan Formulary |
AdvantraOne (PPO)
|
$0.00 |
$395* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$10.00 | $25.00 | Q:180 /30Days | $40.89 |
Browse Plan Formulary |
Aetna Medicare Silver (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $10.00 | Q:180 /30Days | $33.40 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
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 |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
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 |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
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 |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
HumanaChoice H5525-038 (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:390 /30Days | $16.31 |
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 R0923-002 (Regional PPO)
|
$21.90 |
$0 | to be determined | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:390 /30Days | $16.41 |
Browse Plan Formulary |
UPMC for Life HMO Deductible with Rx (HMO)
|
$22.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | $20.00 | Q:390 /30Days | $21.85 |
Browse Plan Formulary |
Humana Value Plus H5216-117 (PPO)
|
$26.50 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:390 /30Days | $16.36 |
Browse Plan Formulary |
Advantra Silver Plus (HMO)
|
$27.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $20.96 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$27.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $40.00 | P Q:403 /31Days | $20.27 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$27.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $40.00 | P Q:403 /31Days | $21.49 |
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 |
Advantra Silver Plus (PPO)
|
$29.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $20.34 |
Browse Plan Formulary |
UPMC for Life PPO High Deductible with Rx (PPO)
|
$35.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | $20.00 | Q:390 /30Days | $21.64 |
Browse Plan Formulary |
Allwell Dual Medicare (HMO SNP)
|
$37.00 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
All Formulary Drugs |
$0.00 | $0.00 | None | $14.02 |
Browse Plan Formulary |
Geisinger Gold Secure Rx (HMO SNP)
|
$37.00 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
All Formulary Drugs |
15% | 15% | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
UPMC for Life Dual (HMO SNP)
|
$37.00 |
$415 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$6.00 | $12.00 | Q:390 /30Days | $22.21 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
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 |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
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 |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
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 |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
HumanaChoice H5525-007 (PPO)
|
$45.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:390 /30Days | $16.33 |
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 Silver Plan (HMO)
|
$47.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $26.54 |
Browse Plan Formulary |
Humana Gold Choice H8145-052 (PFFS)
|
$58.00 |
$360* | No additional gap coverage, only the Donut Hole Discount | 3* |
Preferred Brand |
$47.00 | $131.00 | Q:390 /30Days | $16.43 |
Browse Plan Formulary |
Security Blue HMO-POS ValueRx (HMO-POS)
|
$60.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $40.00 | P Q:403 /31Days | $21.20 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$67.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $21.80 |
Browse Plan Formulary |
Freedom Blue PPO ValueRx (PPO)
|
$74.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $40.00 | P Q:403 /31Days | $21.20 |
Browse Plan Formulary |
UPMC for Life HMO Rx (HMO)
|
$81.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | $20.00 | Q:390 /30Days | $21.85 |
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 |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$112.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$112.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$112.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$112.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$112.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$112.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
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 |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$112.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$112.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$112.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
HumanaChoice H5216-121 (PPO)
|
$117.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:390 /30Days | $16.33 |
Browse Plan Formulary |
Freedom Blue PPO Select (PPO)
|
$133.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $40.00 | P Q:403 /31Days | $21.20 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$135.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | $20.00 | Q:390 /30Days | $21.64 |
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 Gold Plan (PPO)
|
$147.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $26.54 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$158.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$158.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$158.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$158.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$158.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
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 |
Geisinger Gold Classic Advantage Rx (HMO)
|
$158.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$158.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$158.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$158.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | $30.00 | Q:390 /30Days | $33.69 |
Browse Plan Formulary |
Security Blue HMO-POS Standard (HMO-POS)
|
$187.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$13.00 | $32.50 | P Q:403 /31Days | $19.49 |
Browse Plan Formulary |
Security Blue HMO-POS Deluxe (HMO-POS)
|
$227.50 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$13.00 | $32.50 | P Q:403 /31Days | $19.49 |
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 Blue PPO Classic (PPO)
|
$269.50 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$15.00 | $40.00 | P Q:403 /31Days | $21.20 |
Browse Plan Formulary |
UPMC for Life HMO Rx Enhanced (HMO)
|
$290.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | $20.00 | Q:390 /30Days | $21.81 |
Browse Plan Formulary |