CHANTIX STARTING MONTH BOX (53 EA ) (NDC: 00069047103)
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 Silver (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $487.36 |
Browse Plan Formulary |
Advantra Southeast Prime (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $487.36 |
Browse Plan Formulary |
AdvantraOne (PPO)
|
$0.00 |
$395 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $487.39 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $487.36 |
Browse Plan Formulary |
Aetna Medicare Silver (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $487.41 |
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 |
Allwell Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $471.66 |
Browse Plan Formulary |
Cigna-HealthSpring Alliance (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:56 /28Days | $514.97 |
Browse Plan Formulary |
Clover Health Choice (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | P | $476.51 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $460.22 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $458.90 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $460.17 |
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. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $458.90 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $460.00 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $459.07 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $458.90 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $459.49 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $458.90 |
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. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $460.22 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $458.90 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $460.17 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $458.90 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $460.00 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $459.07 |
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. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $458.90 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $459.49 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $458.90 |
Browse Plan Formulary |
Humana Gold Plus H6622-037 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:56 /28Days | $501.08 |
Browse Plan Formulary |
Humana Gold Plus H6622-039 (HMO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:56 /28Days | $501.08 |
Browse Plan Formulary |
HumanaChoice H5525-038 (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:56 /28Days | $501.11 |
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 |
Keystone 65 Basic Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $469.81 |
Browse Plan Formulary |
Keystone 65 Focus Rx (HMO-POS)
|
$10.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $469.81 |
Browse Plan Formulary |
Cigna-HealthSpring Preferred (HMO)
|
$15.00 |
$280 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:56 /28Days | $515.15 |
Browse Plan Formulary |
UPMC for Life HMO Deductible with Rx (HMO)
|
$15.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:106 /365Days | $464.95 |
Browse Plan Formulary |
HumanaChoice R0923-002 (Regional PPO)
|
$21.90 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:56 /28Days | $501.16 |
Browse Plan Formulary |
AARP MedicareComplete (HMO)
|
$23.00 |
$230 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $510.61 |
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 |
UnitedHealthcare Dual Complete (HMO SNP)
|
$25.90 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
3 |
All Formulary Drugs |
$0.00 | $0.00 | None | $509.39 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete ONE (HMO SNP)
|
$26.70 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
3 |
All Formulary Drugs |
$0.00 | $0.00 | None | $509.39 |
Browse Plan Formulary |
Cigna-HealthSpring Achieve (HMO SNP)
|
$29.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:56 /28Days | $515.15 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H6622-038 (HMO SNP)
|
$31.40 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:56 /28Days | $500.99 |
Browse Plan Formulary |
Erickson Advantage Guardian (HMO-POS SNP)
|
$33.10 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$28.00 | $74.00 | None | $509.14 |
Browse Plan Formulary |
Cigna-HealthSpring TotalCare (HMO SNP)
|
$33.50 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
3 |
All Formulary Drugs |
15% | 15% | Q:56 /28Days | $515.15 |
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 Cares (HMO SNP)
|
$35.50 |
$270 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $487.38 |
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 | $471.66 |
Browse Plan Formulary |
Cigna-HealthSpring Traditions (HMO SNP)
|
$37.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
3 |
All Formulary Drugs |
25% | n/a | Q:56 /28Days | $515.02 |
Browse Plan Formulary |
Clover Health Choice Value (PPO)
|
$37.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | P | $476.51 |
Browse Plan Formulary |
Gateway Health Medicare Assured Diamond (HMO SNP)
|
$37.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | S | $469.86 |
Browse Plan Formulary |
Gateway Health Medicare Assured Ruby (HMO SNP)
|
$37.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | S | $469.86 |
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 |
Health Partners Medicare Special (HMO SNP)
|
$37.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
15% | 15% | None | $477.79 |
Browse Plan Formulary |
Keystone First VIP Choice (HMO SNP)
|
$37.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Brand |
25% | 25% | Q:106 /365Days | $472.60 |
Browse Plan Formulary |
Provider Partners Pennsylvania Advantage Plan (HMO SNP)
|
$37.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
25% | 25% | None | $488.28 |
Browse Plan Formulary |
Sunrise Advantage Plan I-SNP (HMO SNP)
|
$37.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | n/a | None | $481.64 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 2 (PPO SNP)
|
$37.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
3 |
All Formulary Drugs |
25% | 25% | None | $509.46 |
Browse Plan Formulary |
UPMC for Life Dual (HMO SNP)
|
$37.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
46% | 46% | Q:106 /365Days | $465.62 |
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. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $458.90 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $459.49 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $458.90 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $459.91 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $458.90 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $459.47 |
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 |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $458.90 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $458.99 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $459.07 |
Browse Plan Formulary |
Sunrise Advantage Plan (HMO)
|
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | n/a | None | $481.64 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $460.17 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $458.90 |
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. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $460.00 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $459.07 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $458.90 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $459.49 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $458.90 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $460.22 |
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. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $458.90 |
Browse Plan Formulary |
HumanaChoice H5525-005 (PPO)
|
$45.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:56 /28Days | $501.08 |
Browse Plan Formulary |
Aetna Medicare Silver Plan (HMO)
|
$47.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $487.39 |
Browse Plan Formulary |
Erickson Advantage Freedom (HMO-POS)
|
$48.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $509.14 |
Browse Plan Formulary |
Sunrise Advantage Plan C-SNP (HMO SNP)
|
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | n/a | None | $481.64 |
Browse Plan Formulary |
UPMC for Life HMO Rx (HMO)
|
$55.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:106 /365Days | $464.95 |
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 |
AARP MedicareComplete Choice (PPO)
|
$58.00 |
$325* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | None | $510.61 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$67.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $487.36 |
Browse Plan Formulary |
Keystone 65 Select Rx (HMO)
|
$68.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $470.63 |
Browse Plan Formulary |
Health Partners Medicare Prime (HMO)
|
$71.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $478.03 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (HMO)
|
$73.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $487.36 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$87.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $458.90 |
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)
|
$87.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $459.49 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$87.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $458.90 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$87.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $460.22 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$87.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $458.90 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$87.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $460.17 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$87.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $458.90 |
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)
|
$87.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $460.00 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$87.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $459.07 |
Browse Plan Formulary |
Cigna-HealthSpring PreferredPlus (HMO)
|
$125.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:56 /28Days | $515.15 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$135.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $458.99 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$135.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $459.07 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$135.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $458.90 |
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)
|
$135.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $458.90 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$135.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $459.49 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$135.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $458.90 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$135.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $459.91 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$135.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $459.47 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$135.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $150.00 | Q:53 /180Days | $458.90 |
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. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $487.39 |
Browse Plan Formulary |
HumanaChoice H5216-122 (PPO)
|
$147.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:56 /28Days | $501.08 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$167.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $487.36 |
Browse Plan Formulary |
Sunrise Advantage Plan Gold (HMO SNP)
|
$175.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | n/a | None | $481.64 |
Browse Plan Formulary |
Erickson Advantage Champion (HMO-POS SNP)
|
$195.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $509.14 |
Browse Plan Formulary |
Erickson Advantage Signature with Drugs (HMO-POS)
|
$195.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $509.14 |
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 |
Keystone 65 Preferred Rx (HMO)
|
$229.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $470.63 |
Browse Plan Formulary |
Personal Choice 65 Rx (PPO)
|
$289.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $470.63 |
Browse Plan Formulary |