APTIVUS 250MG CAPSULE (120 BOTPL) (NDC: 00597000302)
2020 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 Medicare Advantage Choice Plan 3 (PPO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | 33% | Q:120 /30Days | $1,888.80 |
Browse Plan Formulary |
Aetna Medicare Advantra Credit Value (PPO)
|
$0.00 |
$250 |
No |
5 |
Tier 5 |
28% | n/a | None | $1,796.40 |
Browse Plan Formulary |
Aetna Medicare Advantra Silver (PPO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $1,862.40 |
Browse Plan Formulary |
Aetna Medicare Elite (HMO)
|
$0.00 |
$150 |
No |
5 |
Tier 5 |
30% | n/a | None | $1,789.20 |
Browse Plan Formulary |
Aetna Medicare Value (PPO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $1,789.20 |
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 |
BlueJourney Essential (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | Q:120 /30Days | $1,785.60 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $1,776.00 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $1,776.00 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $1,776.00 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $1,776.00 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $1,776.00 |
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 |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $1,776.00 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $1,776.00 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $1,776.00 |
Browse Plan Formulary |
Geisinger Gold Classic 360 Rx (HMO)
|
$0.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,754.40 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,754.40 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,754.40 |
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 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,754.40 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,754.40 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,699.20 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,754.40 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,754.40 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,754.40 |
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 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,754.40 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,754.40 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,754.40 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,699.20 |
Browse Plan Formulary |
Health Partners Medicare Simple (HMO-POS)
|
$0.00 |
$350 |
No |
3 |
Tier 3 |
$47.00 | $94.00 | Q:120 /30Days | $1,729.20 |
Browse Plan Formulary |
Humana Gold Plus H6622-036 (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | Q:120 /30Days | $1,818.00 |
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 H5525-038 (PPO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | Q:120 /30Days | $1,862.40 |
Browse Plan Formulary |
Vibra Health Plan Essential (PPO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | Q:120 /30Days | $1,784.40 |
Browse Plan Formulary |
AARP Medicare Advantage (HMO)
|
$15.50 |
$130 |
No |
5 |
Tier 5 |
30% | 30% | Q:120 /30Days | $1,888.80 |
Browse Plan Formulary |
HumanaChoice R0923-002 (Regional PPO)
|
$16.30 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | Q:120 /30Days | $1,862.40 |
Browse Plan Formulary |
Aetna Medicare Advantra Cares (HMO D-SNP)
|
$20.40 |
$200 |
No |
5 |
Tier 5 |
29% | n/a | None | $1,797.60 |
Browse Plan Formulary |
UPMC for Life HMO Deductible with Rx (HMO)
|
$22.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $1,737.60 |
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 D-SNP)
|
$22.90 |
$435 |
No |
5 |
Tier 5 |
$0.00 | $0.00 | Q:120 /30Days | $1,891.20 |
Browse Plan Formulary |
AARP Medicare Advantage Choice Plan 1 (PPO)
|
$25.00 |
$95 |
No |
5 |
Tier 5 |
31% | 31% | Q:120 /30Days | $1,888.80 |
Browse Plan Formulary |
BlueJourney Alliance Heart and Diabetes Care (HMO C-SNP)
|
$25.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | Q:120 /30Days | $1,785.60 |
Browse Plan Formulary |
Vibra Health Plan Enhanced Complete (PPO)
|
$25.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | Q:120 /30Days | $1,784.40 |
Browse Plan Formulary |
Aetna Medicare Advantra Premier (HMO)
|
$27.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $1,862.40 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H6622-038 (HMO D-SNP)
|
$28.20 |
$410 |
No |
5 |
Tier 5 |
25% | n/a | Q:120 /30Days | $1,862.40 |
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 |
BlueJourney Alliance Lung Care (HMO C-SNP)
|
$33.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | Q:120 /30Days | $1,785.60 |
Browse Plan Formulary |
Allwell Dual Medicare (HMO D-SNP)
|
$34.00 |
$435 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | None | $1,885.20 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $1,776.00 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $1,776.00 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $1,776.00 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $1,776.00 |
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 Nursing Home Plan 2 (PPO I-SNP)
|
$35.40 |
$435 |
No |
5 |
Tier 5 |
25% | 25% | Q:120 /30Days | $1,890.00 |
Browse Plan Formulary |
AmeriHealth Caritas VIP Care (HMO D-SNP)
|
$35.60 |
$435 |
No |
2 |
Tier 2 |
25% | 25% | Q:120 /30Days | $1,735.20 |
Browse Plan Formulary |
Gateway Health Medicare Assured Diamond (HMO D-SNP)
|
$35.60 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | None | $1,744.80 |
Browse Plan Formulary |
Gateway Health Medicare Assured Ruby (HMO D-SNP)
|
$35.60 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | None | $1,744.80 |
Browse Plan Formulary |
Geisinger Gold Secure Rx (HMO D-SNP)
|
$35.60 |
$435 |
No |
1 |
Tier 1 |
15% | 15% | Q:120 /30Days | $1,699.20 |
Browse Plan Formulary |
Health Partners Medicare Prime (HMO-POS)
|
$35.60 |
$350 |
No |
3 |
Tier 3 |
$47.00 | $94.00 | Q:120 /30Days | $1,729.20 |
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 |
Health Partners Medicare Special (HMO D-SNP)
|
$35.60 |
$435 |
No |
1 |
Tier 1 |
15% | 15% | Q:120 /30Days | $1,729.20 |
Browse Plan Formulary |
UPMC for Life Dual (HMO D-SNP)
|
$35.60 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | None | $1,737.60 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,699.20 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,742.40 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,742.40 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,742.40 |
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 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,742.40 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,742.40 |
Browse Plan Formulary |
BlueJourney Alliance Assisted Care (HMO I-SNP)
|
$40.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | Q:120 /30Days | $1,785.60 |
Browse Plan Formulary |
UPMC for Life HMO Rx Choice (HMO)
|
$40.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $1,737.60 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,754.40 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,754.40 |
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 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,754.40 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,754.40 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,699.20 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,754.40 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$47.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $1,776.00 |
Browse Plan Formulary |
HumanaChoice H5525-007 (PPO)
|
$48.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | Q:120 /30Days | $1,862.40 |
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 |
BlueJourney Classic (PPO)
|
$49.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | Q:120 /30Days | $1,785.60 |
Browse Plan Formulary |
BlueJourney Value (HMO)
|
$50.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | Q:120 /30Days | $1,785.60 |
Browse Plan Formulary |
AARP Medicare Advantage Choice Plan 2 (PPO)
|
$58.00 |
$150 |
No |
5 |
Tier 5 |
30% | 30% | Q:120 /30Days | $1,888.80 |
Browse Plan Formulary |
Aetna Medicare Silver (HMO)
|
$59.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $1,796.40 |
Browse Plan Formulary |
Freedom Blue PPO ValueRx (PPO)
|
$70.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $1,776.00 |
Browse Plan Formulary |
Aetna Medicare Advantra Premier Plus (PPO)
|
$72.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $1,862.40 |
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 Premier Plus (PPO)
|
$79.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $1,862.40 |
Browse Plan Formulary |
UPMC for Life HMO Rx (HMO)
|
$81.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $1,737.60 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$87.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,754.40 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$87.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,754.40 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$87.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,699.20 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$87.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,754.40 |
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 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,754.40 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$87.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,754.40 |
Browse Plan Formulary |
HumanaChoice H5216-120 (PPO)
|
$126.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | Q:120 /30Days | $1,862.40 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$135.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,742.40 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$135.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,742.40 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$135.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,699.20 |
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 |
Geisinger Gold Classic Advantage Rx (HMO)
|
$135.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,742.40 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$135.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,742.40 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$135.00 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $150.00 | Q:120 /30Days | $1,742.40 |
Browse Plan Formulary |
Aetna Medicare Gold Plan (PPO)
|
$146.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $1,796.40 |
Browse Plan Formulary |
BlueJourney Premier (HMO)
|
$148.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | Q:120 /30Days | $1,785.60 |
Browse Plan Formulary |
BlueJourney Prime (PPO)
|
$170.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | Q:120 /30Days | $1,785.60 |
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 Standard (PPO)
|
$185.50 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $1,776.00 |
Browse Plan Formulary |
Freedom Blue PPO Deluxe (PPO)
|
$288.50 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $1,776.00 |
Browse Plan Formulary |
UPMC for Life HMO Rx Enhanced (HMO)
|
$301.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $1,732.80 |
Browse Plan Formulary |