AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE [Augmentin] (20 BOT) (NDC: 00093227034)
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 |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$95* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$5.00 | $10.00 | None | $46.11 |
Browse Plan Formulary |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$11.00 | $33.00 | None | $35.76 |
Browse Plan Formulary |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$11.00 | $33.00 | None | $33.62 |
Browse Plan Formulary |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$11.00 | $33.00 | None | $33.62 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | None | $34.82 |
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 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | None | $33.62 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | None | $22.13 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | None | $19.36 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | None | $35.76 |
Browse Plan Formulary |
HAP Primary Choice Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $25.00 | None | $39.93 |
Browse Plan Formulary |
HAP Senior Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $25.00 | None | $39.03 |
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 |
MeridianCare Enhanced (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $60.00 | None | $35.94 |
Browse Plan Formulary |
MeridianCare Essential (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $30.00 | None | $32.15 |
Browse Plan Formulary |
MeridianCare Essential Clarity (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $30.00 | None | $32.15 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$125* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | $0.00 | None | $28.21 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$125* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | $0.00 | None | $39.99 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$125* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | $0.00 | None | $34.21 |
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 |
$125* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | $0.00 | None | $37.41 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$125* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | $0.00 | None | $39.99 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$14.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | None | $19.35 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$14.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | None | $35.76 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$14.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | None | $34.81 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$14.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | None | $33.57 |
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 |
Medicare Plus Blue PPO Essential (PPO)
|
$14.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | None | $22.13 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | $0.00 | None | $39.99 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | $0.00 | None | $28.21 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | $0.00 | None | $39.99 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | $0.00 | None | $34.21 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | $0.00 | None | $37.41 |
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 1 (PPO)
|
$15.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $25.00 | None | $39.03 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$22.00 |
$100* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$11.00 | $33.00 | None | $33.62 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$22.00 |
$100* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$11.00 | $33.00 | None | $33.62 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$22.00 |
$100* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$11.00 | $33.00 | None | $35.76 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$30.10 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
42% | 42% | None | $43.19 |
Browse Plan Formulary |
MeridianCare Extra (HMO SNP)
|
$32.90 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | None | $35.94 |
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 |
MeridianCare Extra Smile (HMO SNP)
|
$32.90 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | None | $35.94 |
Browse Plan Formulary |
Erickson Advantage Guardian (HMO-POS SNP)
|
$33.10 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | None | $40.46 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$42.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | None | $39.99 |
Browse Plan Formulary |
HAP Senior Plus Option 1 (HMO-POS)
|
$45.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $25.00 | None | $39.03 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$47.00 |
$95* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$0.00 | $0.00 | None | $46.11 |
Browse Plan Formulary |
MeridianCare Elite (HMO)
|
$47.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $20.00 | None | $35.94 |
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 |
MeridianCare Elite Clarity (HMO)
|
$47.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $20.00 | None | $35.94 |
Browse Plan Formulary |
MeridianCare Elite Smile (HMO)
|
$47.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $20.00 | None | $35.94 |
Browse Plan Formulary |
Erickson Advantage Freedom (HMO-POS)
|
$48.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | None | $40.46 |
Browse Plan Formulary |
BCN Advantage HMO ConnectedCare (HMO)
|
$55.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $30.00 | None | $35.76 |
Browse Plan Formulary |
HAP Senior Plus Option 2 (PPO)
|
$55.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $25.00 | None | $39.03 |
Browse Plan Formulary |
HAP Senior Plus Henry Ford Tiered Access (HMO)
|
$65.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $25.00 | None | $39.93 |
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 (HMO-POS)
|
$75.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $25.00 | None | $39.03 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$78.40 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | None | $33.57 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$78.40 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | None | $22.13 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$78.40 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | None | $19.35 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$78.40 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | None | $35.76 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$78.40 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | None | $34.81 |
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)
|
$85.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | None | $28.21 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$85.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | None | $39.99 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$85.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | None | $34.21 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$85.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | None | $37.41 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$85.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | None | $39.99 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$87.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | None | $46.11 |
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 |
PriorityMedicare (HMO-POS)
|
$113.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | None | $39.99 |
Browse Plan Formulary |
HAP Senior Plus Option 3 (PPO)
|
$118.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $25.00 | None | $39.03 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$127.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | None | $22.13 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$127.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | None | $19.36 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$127.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | None | $35.76 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$127.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | None | $34.82 |
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)
|
$127.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | None | $33.62 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$143.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $30.00 | None | $34.81 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$143.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $30.00 | None | $33.57 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$143.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $30.00 | None | $22.13 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$143.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $30.00 | None | $19.35 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$143.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $30.00 | None | $35.76 |
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 |
HAP Senior Plus Option 3 (HMO-POS)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $25.00 | None | $39.03 |
Browse Plan Formulary |
HAP Senior Plus Option 4 (PPO)
|
$190.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $25.00 | None | $39.03 |
Browse Plan Formulary |
Erickson Advantage Champion (HMO-POS SNP)
|
$195.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | None | $40.46 |
Browse Plan Formulary |
Erickson Advantage Signature with Drugs (HMO-POS)
|
$195.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | None | $40.46 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$197.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $0.00 | None | $37.41 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$197.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $0.00 | None | $39.99 |
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)
|
$197.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $0.00 | None | $28.21 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$197.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $0.00 | None | $39.99 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$197.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $0.00 | None | $34.21 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$282.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | None | $19.36 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$282.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | None | $35.76 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$282.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | None | $34.82 |
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 Prestige (HMO-POS)
|
$282.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | None | $33.62 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$282.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | None | $22.13 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$313.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | None | $22.13 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$313.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | None | $19.35 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$313.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | None | $35.76 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$313.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | None | $34.81 |
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)
|
$313.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | None | $33.57 |
Browse Plan Formulary |