DALFAMPRIDINE ER 10 MG TABLET ER 12H [Ampyra] (60 TABLETS ) (NDC: 65862086360)
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 |
Aetna Medicare Premier (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P | $258.60 |
Browse Plan Formulary |
Aetna Medicare Value (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $258.60 |
Browse Plan Formulary |
Ascension Complete Michigan Reward (HMO)
|
$0.00 |
$390 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $402.60 |
Browse Plan Formulary |
Ascension Complete Michigan Secure (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $402.60 |
Browse Plan Formulary |
BCN Advantage Prime Value (HMO-POS)
|
$0.00 |
$50 |
No |
5 |
Specialty Tier |
32% | n/a | P Q:62 /31Days | $1,542.60 |
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 |
BCN Advantage Prime Value (HMO-POS)
|
$0.00 |
$50 |
No |
5 |
Specialty Tier |
32% | n/a | P Q:62 /31Days | $926.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage Prime Value (HMO-POS)
|
$0.00 |
$50 |
No |
5 |
Specialty Tier |
32% | n/a | P Q:62 /31Days | $975.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage Prime Value (HMO-POS)
|
$0.00 |
$50 |
No |
5 |
Specialty Tier |
32% | n/a | P Q:62 /31Days | $772.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage Prime Value (HMO-POS)
|
$0.00 |
$50 |
No |
5 |
Specialty Tier |
32% | n/a | P Q:62 /31Days | $1,165.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HAP Senior Plus (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P | $666.00 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
HAP Senior Plus Option 1 (PPO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P | $649.20 |
Browse Plan Formulary select insulin pay $15-$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 H8908-004 (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | P Q:60 /30Days | $599.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$100 |
No |
5 |
Specialty Tier |
31% | n/a | P Q:62 /31Days | $1,549.80 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$100 |
No |
5 |
Specialty Tier |
31% | n/a | P Q:62 /31Days | $1,228.80 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$100 |
No |
5 |
Specialty Tier |
31% | n/a | P Q:62 /31Days | $1,264.80 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$100 |
No |
5 |
Specialty Tier |
31% | n/a | P Q:62 /31Days | $1,180.80 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$100 |
No |
5 |
Specialty Tier |
31% | n/a | P Q:62 /31Days | $1,350.60 |
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 |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,156.80 |
Browse Plan Formulary |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,473.00 |
Browse Plan Formulary |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,488.60 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$100 |
No |
5 |
Specialty Tier |
31% | n/a | P Q:60 /30Days | $1,156.80 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$100 |
No |
5 |
Specialty Tier |
31% | n/a | P Q:60 /30Days | $1,523.40 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$100 |
No |
5 |
Specialty Tier |
31% | n/a | P Q:60 /30Days | $1,489.80 |
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 |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$100 |
No |
5 |
Specialty Tier |
31% | n/a | P Q:60 /30Days | $1,473.00 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$100 |
No |
5 |
Specialty Tier |
31% | n/a | P Q:60 /30Days | $1,488.60 |
Browse Plan Formulary |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350 |
No |
5 |
Specialty Tier |
26% | n/a | P Q:60 /30Days | $1,156.80 |
Browse Plan Formulary |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350 |
No |
5 |
Specialty Tier |
26% | n/a | P Q:60 /30Days | $1,473.00 |
Browse Plan Formulary |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350 |
No |
5 |
Specialty Tier |
26% | n/a | P Q:60 /30Days | $1,488.60 |
Browse Plan Formulary |
Reliance Principle Plan (HMO)
|
$0.00 |
$125 |
No |
5 |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $198.60 |
Browse Plan Formulary select insulin pay $10 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 |
WellCare Dividend (HMO)
|
$0.00 |
$445 |
No |
3 |
Preferred Brand |
$47.00 | $94.00 | P | $627.00 |
Browse Plan Formulary |
WellCare Essential (HMO-POS)
|
$0.00 |
$0 |
No |
2 |
Generic |
$15.00 | $0.00 | P | $627.00 |
Browse Plan Formulary |
WellCare Exclusive (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$10.00 | $0.00 | P | $627.00 |
Browse Plan Formulary |
WellCare Explore (HMO-POS)
|
$0.00 |
$0 |
No |
2 |
Generic |
$10.00 | $0.00 | P | $627.00 |
Browse Plan Formulary |
Zing Choice MI (HMO)
|
$0.00 |
$0 |
No |
1 |
Preferred Generic |
$2.00 | $14.00 | Q:60 /30Days | $91.20 |
Browse Plan Formulary |
Zing Essential Wellness MI (HMO C-SNP)
|
$0.00 |
$0 |
No |
1 |
Preferred Generic |
$2.00 | $14.00 | Q:60 /30Days | $91.20 |
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 |
Zing Open Access MI (HMO-POS)
|
$0.00 |
$0 |
No |
1 |
Preferred Generic |
$2.00 | $14.00 | Q:60 /30Days | $91.20 |
Browse Plan Formulary |
WellCare Elite Smile (HMO-POS)
|
$14.10 |
$0 |
No |
2 |
Generic |
$10.00 | $0.00 | P | $627.00 |
Browse Plan Formulary |
BCN Advantage Community Value (HMO-POS)
|
$20.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $1,542.60 |
Browse Plan Formulary |
BCN Advantage Community Value (HMO-POS)
|
$20.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $817.80 |
Browse Plan Formulary |
HumanaChoice H8087-001 (PPO)
|
$20.00 |
$75 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | P Q:60 /30Days | $597.60 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$20.00 |
$125 |
No |
5 |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $1,473.00 |
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 |
PriorityMedicare Ideal (PPO)
|
$20.00 |
$125 |
No |
5 |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $1,488.60 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$20.00 |
$125 |
No |
5 |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $1,156.80 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$20.00 |
$125 |
No |
5 |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $1,523.40 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$20.00 |
$125 |
No |
5 |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $1,489.80 |
Browse Plan Formulary |
Humana Value Plus H8087-002 (PPO)
|
$22.50 |
$260 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | P Q:60 /30Days | $593.40 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H8908-005 (HMO D-SNP)
|
$25.40 |
$425 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | P Q:60 /30Days | $599.40 |
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 |
HAP Empowered Duals (HMO D-SNP)
|
$30.10 |
$445 |
No |
5 |
Tier 5 |
$0.00 | $0.00 | P | $582.60 |
Browse Plan Formulary |
Longevity Health Plan (HMO I-SNP)
|
$30.10 |
$445 |
No |
1 |
Tier 1 |
25% | n/a | Q:60 /30Days | $93.00 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$30.10 |
$445 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | P | $493.20 |
Browse Plan Formulary |
PriorityMedicare D-SNP (HMO D-SNP)
|
$30.10 |
$445 |
No |
5 |
Tier 5 |
$0.00 | $0.00 | P Q:60 /30Days | $1,183.20 |
Browse Plan Formulary |
Reliance Dual Care Plus (HMO D-SNP)
|
$30.10 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:60 /30Days | $187.80 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$30.10 |
$445 |
No |
3 |
Tier 3 |
$0.00 | $0.00 | Q:60 /30Days | $152.40 |
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 Extra Plus (HMO-POS D-SNP)
|
$30.10 |
$445 |
No |
3 |
Preferred Brand |
$47.00 | $94.00 | P | $627.00 |
Browse Plan Formulary |
HumanaChoice R3887-002 (Regional PPO)
|
$32.40 |
$380 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | P Q:60 /30Days | $597.60 |
Browse Plan Formulary |
Aetna Medicare Premier Plus (PPO)
|
$34.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $258.60 |
Browse Plan Formulary |
Reliance Cardinal Plan (HMO)
|
$40.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $198.60 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
Humana Gold Plus H8908-001 (HMO)
|
$45.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | P Q:60 /30Days | $599.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$45.00 |
$75 |
No |
5 |
Specialty Tier |
31% | n/a | P Q:60 /30Days | $1,488.60 |
Browse Plan Formulary select insulin pay $15-$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 |
PriorityMedicare Value (HMO-POS)
|
$45.00 |
$75 |
No |
5 |
Specialty Tier |
31% | n/a | P Q:60 /30Days | $1,156.80 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$45.00 |
$75 |
No |
5 |
Specialty Tier |
31% | n/a | P Q:60 /30Days | $1,523.40 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$45.00 |
$75 |
No |
5 |
Specialty Tier |
31% | n/a | P Q:60 /30Days | $1,489.80 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$45.00 |
$75 |
No |
5 |
Specialty Tier |
31% | n/a | P Q:60 /30Days | $1,473.00 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
WellCare Elite (HMO-POS)
|
$47.00 |
$0 |
No |
2 |
Generic |
$10.00 | $0.00 | P | $627.00 |
Browse Plan Formulary |
BCN Advantage HMO ConnectedCare (HMO)
|
$57.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $1,528.20 |
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 |
HAP Senior Plus Option 2 (PPO)
|
$60.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P | $649.20 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
Medicare Plus Blue PPO Vitality (PPO)
|
$80.00 |
$100 |
No |
5 |
Specialty Tier |
31% | n/a | P Q:62 /31Days | $1,264.80 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$80.00 |
$100 |
No |
5 |
Specialty Tier |
31% | n/a | P Q:62 /31Days | $1,180.80 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$80.00 |
$100 |
No |
5 |
Specialty Tier |
31% | n/a | P Q:62 /31Days | $1,350.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$80.00 |
$100 |
No |
5 |
Specialty Tier |
31% | n/a | P Q:62 /31Days | $1,549.80 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$80.00 |
$100 |
No |
5 |
Specialty Tier |
31% | n/a | P Q:62 /31Days | $1,228.80 |
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 |
HAP Senior Plus Option 1 (HMO-POS)
|
$85.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P | $649.20 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Merit (PPO)
|
$90.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,473.00 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$90.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,488.60 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$90.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,156.80 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$90.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,523.40 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$90.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,489.80 |
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 |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$104.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $926.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$104.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $975.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$104.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $772.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$104.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $1,165.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$104.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $1,542.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
PriorityMedicare (HMO-POS)
|
$120.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,156.80 |
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 |
PriorityMedicare (HMO-POS)
|
$120.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,523.40 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$120.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,489.80 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$120.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,473.00 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$120.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,488.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$122.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $1,549.80 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$122.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $1,228.80 |
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 |
Medicare Plus Blue PPO Signature (PPO)
|
$122.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $1,264.80 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$122.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $1,180.80 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$122.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $1,350.60 |
Browse Plan Formulary |
HAP Senior Plus Option 3 (PPO)
|
$160.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P | $649.20 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
HAP Senior Plus Option 2 (HMO-POS)
|
$190.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P | $649.20 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
HAP Senior Plus Option 4 (PPO)
|
$200.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P | $649.20 |
Browse Plan Formulary select insulin pay $15-$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 |
PriorityMedicare Select (PPO)
|
$206.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,156.80 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$206.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,523.40 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$206.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,489.80 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$206.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,473.00 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$206.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,488.60 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$227.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $1,542.60 |
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 |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$227.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $926.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$227.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $975.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$227.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $772.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$227.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $1,165.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Medicare Plus Blue PPO Assure (PPO)
|
$260.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $1,549.80 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$260.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $1,228.80 |
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 |
Medicare Plus Blue PPO Assure (PPO)
|
$260.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $1,264.80 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$260.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $1,180.80 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$260.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $1,350.60 |
Browse Plan Formulary |