Telmisartan-Amlodipine 80-10 MG [Micardis] (NDC: 68180019906)
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 |
AARP MedicareComplete SecureHorizons Focus (HMO)
|
$0.00 |
$0 |
to be determined |
1 |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days | $110.95 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Focus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days | $110.95 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 |
to be determined |
1 |
Preferred Generic |
$4.00 | $0.00 | Q:30 /30Days | $110.95 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$4.00 | $0.00 | Q:30 /30Days | $110.95 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
1 |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days | $110.95 |
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 SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days | $110.95 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 |
to be determined |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $53.67 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $53.67 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
to be determined |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $53.67 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $53.67 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $114.20 |
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 |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $114.20 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$42.00 | $84.00 | None | $114.64 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | None | $114.64 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $7.50 | S Q:1 /1Days | $122.11 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$5.00 | $7.50 | S Q:1 /1Days | $122.11 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$10.00 | $15.00 | S Q:1 /1Days | $122.11 |
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 |
Central Health Focus Plan (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$75.00 | $150.00 | None | $120.49 |
Browse Plan Formulary |
Central Health Focus Plan (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $150.00 | None | $120.49 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$0.00 |
$415 |
to be determined |
4 |
Non-Preferred Drug |
25% | 25% | None | $120.49 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$75.00 | $150.00 | None | $120.49 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $150.00 | None | $120.49 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
to be determined |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $112.99 |
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 |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $112.99 |
Browse Plan Formulary |
Easy Choice Freedom Plan (HMO SNP)
|
$0.00 |
$415* |
to be determined |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $112.99 |
Browse Plan Formulary |
Golden State (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $20.00 | None | $133.85 |
Browse Plan Formulary |
Golden State (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $20.00 | None | $133.96 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$90.00 | $260.00 | None | $118.49 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$90.00 | $260.00 | None | $118.49 |
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 |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $260.00 | None | $118.49 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $260.00 | None | $118.49 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$90.00 | $260.00 | None | $118.49 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$90.00 | $260.00 | None | $118.49 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$90.00 | $260.00 | None | $118.49 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $260.00 | None | $118.49 |
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 |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:30 /30Days | $90.80 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:30 /30Days | $90.80 |
Browse Plan Formulary |
Imperial Senior Value (HMO SNP) (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$5.00 | $10.00 | None | $108.85 |
Browse Plan Formulary |
Imperial Traditional (HMO) (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$5.00 | $10.00 | None | $108.85 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$15.00 | $30.00 | None | $132.04 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$15.00 | $30.00 | None | $132.04 |
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 |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Generic Drugs |
0% | 0% | None | $129.20 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | 0% | None | $129.20 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$0.00 |
$415* |
to be determined |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $89.60 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$17.00 | $34.00 | None | $132.04 |
Browse Plan Formulary |
Easy Choice Rx (HMO)
|
$12.00 |
$415* |
to be determined |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $112.99 |
Browse Plan Formulary |
Easy Choice Rx (HMO)
|
$12.00 |
$415* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $112.99 |
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 |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$12.50 |
$0 |
to be determined |
2 |
Generic |
$15.00 | $30.00 | None | $132.04 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$12.50 |
$0 |
to be determined |
2 |
Generic |
$15.00 | $30.00 | None | $132.04 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$15.20 |
$415* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $89.60 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$16.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $260.00 | None | $118.49 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$16.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $260.00 | None | $118.49 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Assure (HMO)
|
$16.10 |
$415 |
to be determined |
1 |
All Formulary Drugs |
25% | 25% | Q:30 /30Days | $113.61 |
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 MedicareComplete Assure (HMO)
|
$16.10 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
25% | 25% | Q:30 /30Days | $113.61 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Premier (HMO)
|
$18.30 |
$0 |
to be determined |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $110.95 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Premier (HMO)
|
$18.30 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $110.95 |
Browse Plan Formulary |
Easy Choice Freedom Plan (HMO SNP)
|
$19.00 |
$415* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $112.99 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$26.30 |
$415* |
to be determined |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $112.99 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$26.30 |
$415* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $112.99 |
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 |
Humana Value Plus H5619-037 (HMO)
|
$33.30 |
$415 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $90.61 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$33.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $90.61 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$34.80 |
$415 |
to be determined |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $114.20 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$34.80 |
$415 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $114.20 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$34.80 |
$415 |
to be determined |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $114.64 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$34.80 |
$415 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $114.64 |
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 |
Central Health Medi-Medi Plan (HMO SNP)
|
$34.80 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | None | $120.49 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$34.80 |
$415 |
to be determined |
4 |
Non-Preferred Drug |
25% | 25% | None | $120.49 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$34.80 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | None | $120.49 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$34.80 |
$320 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $82.32 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$34.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $82.32 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $79.74 |
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 |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $107.38 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $107.38 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $107.38 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $79.74 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $107.38 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $107.38 |
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 Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $107.38 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $78.45 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $107.38 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $78.45 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $107.38 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$34.80 |
$285 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $80.65 |
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 Net Seniority Plus Sapphire Premier (HMO)
|
$34.80 |
$285 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $80.65 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier II (HMO)
|
$34.80 |
$280 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $80.65 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier II (HMO)
|
$34.80 |
$280 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $80.65 |
Browse Plan Formulary |
Imperial Traditional Plus (HMO) (HMO)
|
$34.80 |
$415 |
to be determined |
2 |
Generic |
25% | 25% | None | $108.85 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$34.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$17.00 | $34.00 | None | $132.04 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$40.90 |
$0 |
to be determined |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $52.85 |
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 |
Aetna Medicare Choice Plan (PPO)
|
$73.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days | $52.85 |
Browse Plan Formulary |