BICILL LA PFS 600MU 1ML PED (TEN 4ML CTG) (NDC: 60793070210)
2021 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 (PPO)
|
$0.00 |
$345 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $3,761.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $3,761.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Plus Plan (PPO)
|
$0.00 |
$300 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $3,707.60 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$0.00 |
$250 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $3,708.40 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$250 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $3,707.60 |
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 |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$150 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $3,707.60 |
Browse Plan Formulary |
Allwell Medicare (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $3,726.40 |
Browse Plan Formulary |
Allwell Medicare (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $3,717.60 |
Browse Plan Formulary |
Amerivantage Care To You Plus (HMO I-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | None | $3,431.20 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,725.20 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,651.20 |
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 |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,725.20 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,710.40 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,701.60 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,606.80 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,606.80 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,725.20 |
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 |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,651.20 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,725.20 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,710.40 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,701.60 |
Browse Plan Formulary |
Amerivantage Select (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $3,725.20 |
Browse Plan Formulary |
Amerivantage Select Plus (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $3,725.20 |
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 |
Blue Cross Medicare Advantage Choice Plus (PPO)
|
$0.00 |
$350 |
No |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | None | $3,492.00 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Value (HMO)
|
$0.00 |
$195 |
No |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | None | $3,474.80 |
Browse Plan Formulary |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$190 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $3,548.80 |
Browse Plan Formulary |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$190 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $3,708.00 |
Browse Plan Formulary |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$190 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $3,674.80 |
Browse Plan Formulary |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$190 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $3,699.60 |
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 |
Clover Health Choice (PPO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $3,480.00 |
Browse Plan Formulary |
Clover Health Classic (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $3,480.00 |
Browse Plan Formulary |
Devoted Health Core San Antonio (HMO)
|
$0.00 |
$195 |
No |
4 |
Non-Preferred Drug |
$99.00 | $297.00 | None | $3,461.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$0.00 |
$200 |
No |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None | $3,704.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H0028-030 (HMO)
|
$0.00 |
$195 |
No |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None | $3,704.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Imperial Insurance Company Traditional (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $3,584.40 |
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 |
Imperial Insurance Value (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $3,584.40 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | None | $3,431.20 |
Browse Plan Formulary |
Superior HealthPlan STAR+PLUS Medicare-Medicaid (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | None | $3,431.20 |
Browse Plan Formulary |
UnitedHealthcare Chronic Complete (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $3,761.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Dual Complete Choice (Regional PPO D-SNP)
|
$0.00 |
$445 |
No |
4 |
Tier 4 |
$0.00 | $0.00 | None | $3,771.60 |
Browse Plan Formulary |
WellCare Dividend Prime (HMO)
|
$0.00 |
$300 |
No |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $3,727.20 |
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 |
WellCare Guardian (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $3,727.60 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
WellCare Prime (PPO)
|
$0.00 |
$250 |
No |
4 |
Non-Preferred Drug |
45% | 45% | None | $3,729.20 |
Browse Plan Formulary |
WellCare Rx Plus (PPO)
|
$0.00 |
$300 |
No |
4 |
Non-Preferred Drug |
45% | 45% | None | $3,727.20 |
Browse Plan Formulary |
WellCare TexanPlus Classic (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $3,728.80 |
Browse Plan Formulary |
WellCare Value (HMO-POS)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | None | $3,727.20 |
Browse Plan Formulary |
UnitedHealthcare Medicare Silver (Regional PPO C-SNP)
|
$4.90 |
$445 |
No |
4 |
Tier 4 |
25% | 25% | None | $3,771.60 |
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 |
Cigna TotalCare (HMO D-SNP)
|
$7.00 |
$445 |
No |
4 |
Tier 4 |
15% | 15% | P | $3,548.80 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$7.00 |
$445 |
No |
4 |
Tier 4 |
15% | 15% | P | $3,708.00 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$7.00 |
$445 |
No |
4 |
Tier 4 |
15% | 15% | P | $3,674.80 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$9.40 |
$445 |
No |
4 |
Tier 4 |
15% | 15% | P | $3,699.60 |
Browse Plan Formulary |
HumanaChoice H5216-043 (PPO)
|
$10.00 |
$295 |
No |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None | $3,704.00 |
Browse Plan Formulary |
HumanaChoice H5216-043 (PPO)
|
$10.00 |
$295 |
No |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None | $3,716.40 |
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 |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP)
|
$11.70 |
$295 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $3,771.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Allwell Medicare Complement (HMO)
|
$14.10 |
$445 |
No |
4 |
Non-Preferred Drug |
47% | 47% | None | $3,729.60 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$15.00 |
$300 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $3,707.60 |
Browse Plan Formulary |
Amerivantage Choice (PPO)
|
$15.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,725.20 |
Browse Plan Formulary |
WellCare Compass (HMO)
|
$16.20 |
$445 |
No |
4 |
Non-Preferred Drug |
50% | 50% | None | $3,727.20 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$16.40 |
$445 |
No |
4 |
Tier 4 |
15% | 15% | None | $3,761.20 |
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 |
WellCare Access (HMO D-SNP)
|
$17.70 |
$445 |
No |
4 |
Non-Preferred Drug |
50% | 50% | None | $3,727.20 |
Browse Plan Formulary |
Allwell Dual Medicare Harmony (HMO D-SNP)
|
$20.30 |
$445 |
No |
4 |
Non-Preferred Drug |
49% | 49% | None | $3,729.20 |
Browse Plan Formulary |
WellCare Liberty (HMO D-SNP)
|
$20.30 |
$445 |
No |
4 |
Non-Preferred Drug |
50% | 50% | None | $3,727.20 |
Browse Plan Formulary |
Aetna Medicare Dual Complete Plan (HMO D-SNP)
|
$20.60 |
$220 |
No |
4 |
Non-Preferred Drug |
35% | 35% | None | $3,711.60 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$20.60 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,606.80 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$20.60 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,725.20 |
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 |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$20.60 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,651.20 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$20.60 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,725.20 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$20.60 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,710.40 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$20.60 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,701.60 |
Browse Plan Formulary |
Allwell Medicare Nurture (HMO D-SNP)
|
$22.50 |
$445 |
No |
4 |
Non-Preferred Drug |
49% | 49% | None | $3,729.20 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO D-SNP)
|
$22.50 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,606.80 |
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 |
Amerivantage Dual Coordination (HMO D-SNP)
|
$22.50 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,725.20 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO D-SNP)
|
$22.50 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,651.20 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO D-SNP)
|
$22.50 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,725.20 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO D-SNP)
|
$22.50 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,710.40 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO D-SNP)
|
$22.50 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,701.60 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$22.50 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,606.80 |
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 |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$22.50 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,725.20 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$22.50 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,651.20 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$22.50 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,725.20 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$22.50 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,710.40 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$22.50 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,701.60 |
Browse Plan Formulary |
Amerivantage Dual Secure (HMO D-SNP)
|
$22.50 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $3,725.20 |
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 |
Amerivantage ESRD Care (HMO-POS C-SNP)
|
$22.50 |
$100 |
No |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | None | $3,700.00 |
Browse Plan Formulary |
Devoted Health Prime San Antonio (HMO)
|
$22.50 |
$195 |
No |
4 |
Non-Preferred Drug |
$99.00 | $297.00 | None | $3,461.20 |
Browse Plan Formulary select insulin pay $30 copay but not this drug |
Humana Gold Plus SNP-DE H0028-036 (HMO D-SNP)
|
$22.50 |
$445 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $3,704.00 |
Browse Plan Formulary |
Imperial Insurance Company Dual (HMO D-SNP)
|
$22.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | None | $3,594.80 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$22.50 |
$445 |
No |
4 |
Non-Preferred Drug |
32% | 32% | None | $3,431.20 |
Browse Plan Formulary |
ProCare Advantage (HMO I-SNP)
|
$22.50 |
$445 |
No |
1 |
Tier 1 |
25% | n/a | None | $3,526.40 |
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 |
WellCare Imperial (PPO D-SNP)
|
$22.50 |
$445 |
No |
4 |
Non-Preferred Drug |
46% | 46% | None | $3,727.20 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Dual Care Plus (HMO D-SNP)
|
$23.30 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | None | $3,470.80 |
Browse Plan Formulary |
HumanaChoice R4182-004 (Regional PPO)
|
$37.10 |
$175 |
No |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None | $3,715.60 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice (Regional PPO)
|
$38.80 |
$395 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $3,771.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice R4182-003 (Regional PPO)
|
$41.00 |
$175 |
No |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None | $3,715.60 |
Browse Plan Formulary |
HumanaChoice H5216-042 (PPO)
|
$93.00 |
$175 |
No |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None | $3,715.20 |
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 |
Humana Gold Choice H8145-084 (PFFS)
|
$96.00 |
$250 |
No |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | None | $3,717.60 |
Browse Plan Formulary |