BUPRENORPHINE 15 MCG/HR PATCH [Butrans] (4 patches ) (NDC: 42858058640)
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 Plan 3 (PPO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:4 /28Days | $449.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Credit Value (PPO)
|
$0.00 |
$250 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /28Days | $172.88 |
Browse Plan Formulary |
Aetna Medicare Advantra Silver (PPO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /28Days | $196.00 |
Browse Plan Formulary |
Aetna Medicare Elite (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /28Days | $167.56 |
Browse Plan Formulary |
Aetna Medicare St. Luke's Prime Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /28Days | $163.36 |
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 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /28Days | $167.08 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P Q:4 /28Days | $412.68 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P Q:4 /28Days | $429.80 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P Q:4 /28Days | $422.16 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P Q:4 /28Days | $443.16 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P Q:4 /28Days | $412.68 |
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 |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P Q:4 /28Days | $431.32 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P Q:4 /28Days | $416.16 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P Q:4 /28Days | $443.16 |
Browse Plan Formulary |
Geisinger Gold Classic 360 Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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. |
2 |
Generic |
$20.00 | $30.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred 360 Rx (PPO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $0.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred 360 Rx (PPO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $0.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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 |
2 |
Generic |
$20.00 | $30.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$20.00 | $30.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$20.00 | $30.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$20.00 | $30.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$20.00 | $30.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$20.00 | $30.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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 H6622-036 (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:4 /28Days | $412.04 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5525-038 (PPO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:4 /28Days | $412.16 |
Browse Plan Formulary |
UPMC for Life HMO Deductible with Rx (HMO)
|
$22.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:4 /28Days | $459.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage (HMO)
|
$23.50 |
$130 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:4 /28Days | $449.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice Plan 1 (PPO)
|
$25.00 |
$95 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:4 /28Days | $449.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Premier (HMO)
|
$25.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /28Days | $196.00 |
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 |
Humana Gold Plus SNP-DE H6622-038 (HMO D-SNP)
|
$26.10 |
$445 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:4 /28Days | $412.12 |
Browse Plan Formulary |
Aetna Medicare Advantra Cares (HMO D-SNP)
|
$27.30 |
$220 |
No |
4 |
Non-Preferred Drug |
35% | 35% | P Q:4 /28Days | $187.12 |
Browse Plan Formulary |
HumanaChoice R0923-002 (Regional PPO)
|
$29.60 |
$0 |
No |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:4 /28Days | $412.24 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$30.10 |
$445 |
No |
4 |
Tier 4 |
$0.00 | $0.00 | Q:4 /28Days | $452.32 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P Q:4 /28Days | $431.32 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P Q:4 /28Days | $416.16 |
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 Distinct (PPO)
|
$35.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P Q:4 /28Days | $443.16 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | P Q:4 /28Days | $412.68 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
|
$37.20 |
$445 |
No |
4 |
Tier 4 |
25% | 25% | Q:4 /28Days | $447.84 |
Browse Plan Formulary |
AmeriHealth Caritas VIP Care (HMO D-SNP)
|
$37.40 |
$445 |
No |
1 |
Generic |
$5.00 | $15.00 | Q:4 /28Days | $375.68 |
Browse Plan Formulary |
Geisinger Gold Secure Rx (HMO D-SNP)
|
$37.50 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | Q:4 /28Days | $214.48 |
Browse Plan Formulary |
UPMC for Life Complete Care (HMO D-SNP)
|
$37.50 |
$445 |
No |
4 |
Non-Preferred Drug |
49% | 49% | S Q:4 /28Days | $462.88 |
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. |
2 |
Generic |
$20.00 | $30.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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 |
UPMC for Life HMO Rx Choice (HMO)
|
$40.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:4 /28Days | $459.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
No |
2 |
Generic |
$5.00 | $0.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
No |
2 |
Generic |
$5.00 | $0.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Premier Plus (PPO)
|
$47.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$99.00 | $297.00 | P Q:4 /28Days | $184.28 |
Browse Plan Formulary |
HumanaChoice H5525-007 (PPO)
|
$54.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:4 /28Days | $412.12 |
Browse Plan Formulary |
AARP Medicare Advantage Choice Plan 2 (PPO)
|
$58.00 |
$150 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:4 /28Days | $449.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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 |
UPMC for Life PPO Rx Enhanced (PPO)
|
$60.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:4 /28Days | $451.96 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Silver (HMO)
|
$69.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /28Days | $173.48 |
Browse Plan Formulary |
Freedom Blue PPO ValueRx (PPO)
|
$70.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P Q:4 /28Days | $427.48 |
Browse Plan Formulary |
UPMC for Life HMO Rx (HMO)
|
$81.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:4 /28Days | $459.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$85.00 |
$0 |
No |
2 |
Generic |
$20.00 | $30.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$85.00 |
$0 |
No |
2 |
Generic |
$20.00 | $30.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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)
|
$85.00 |
$0 |
No |
2 |
Generic |
$20.00 | $30.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$85.00 |
$0 |
No |
2 |
Generic |
$20.00 | $30.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$85.00 |
$0 |
No |
2 |
Generic |
$20.00 | $30.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$85.00 |
$0 |
No |
2 |
Generic |
$20.00 | $30.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Premier Plus (PPO)
|
$100.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /28Days | $183.72 |
Browse Plan Formulary |
HumanaChoice H5216-120 (PPO)
|
$127.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:4 /28Days | $412.16 |
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)
|
$136.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$136.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$136.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$136.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$136.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$136.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | Q:4 /28Days | $214.48 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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)
|
$169.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /28Days | $167.36 |
Browse Plan Formulary |
Freedom Blue PPO Standard (PPO)
|
$175.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P Q:4 /28Days | $427.48 |
Browse Plan Formulary |
Freedom Blue PPO Deluxe (PPO)
|
$289.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P Q:4 /28Days | $427.48 |
Browse Plan Formulary |
UPMC for Life HMO Rx Enhanced (HMO)
|
$302.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:4 /28Days | $459.24 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |