FENTANYL 50 MCG/HR PATCH TD72 [Duragesic] (5.000 EA ) (NDC: 00406905076)
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 Advantra Credit Value (PPO)
|
$0.00 |
$250 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:10 /30Days | $102.40 |
Browse Plan Formulary |
Aetna Medicare Advantra Gold (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:10 /30Days | $123.00 |
Browse Plan Formulary |
Aetna Medicare Advantra Silver (PPO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:10 /30Days | $123.20 |
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:10 /30Days | $125.30 |
Browse Plan Formulary |
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:10 /30Days | $106.20 |
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 |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $12.00 | P Q:17 /30Days | $80.20 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $12.00 | P Q:17 /30Days | $81.20 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $12.00 | P Q:17 /30Days | $81.10 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $12.00 | P Q:17 /30Days | $82.40 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $12.00 | P Q:17 /30Days | $80.20 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $12.00 | P Q:17 /30Days | $81.00 |
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 |
2 |
Generic |
$5.00 | $12.00 | P Q:17 /30Days | $81.10 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $12.00 | P Q:17 /30Days | $82.40 |
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:10 /30Days | $35.00 |
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:10 /30Days | $35.00 |
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:10 /30Days | $35.00 |
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:10 /30Days | $35.00 |
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:10 /30Days | $35.00 |
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:10 /30Days | $35.00 |
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:10 /30Days | $35.00 |
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:10 /30Days | $35.00 |
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:10 /30Days | $35.00 |
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:10 /30Days | $35.00 |
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:10 /30Days | $35.00 |
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:10 /30Days | $35.00 |
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:10 /30Days | $35.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Health Partners Medicare Complete (HMO-POS)
|
$0.00 |
$0 |
No |
2 |
Generic |
$10.00 | $20.00 | Q:10 /30Days | $52.10 |
Browse Plan Formulary |
Humana Gold Plus H6622-036 (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:20 /30Days | $52.70 |
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:20 /30Days | $53.30 |
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 |
Vibra Essential Advocate (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:15 /30Days | $107.80 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Vibra Essential Advocate (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:15 /30Days | $106.30 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Humana Gold Choice H8145-052 (PFFS)
|
$8.00 |
$360 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:20 /30Days | $53.70 |
Browse Plan Formulary |
Aetna Medicare Advantra Silver Plus (PPO)
|
$19.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:10 /30Days | $124.00 |
Browse Plan Formulary |
UPMC for Life HMO Deductible with Rx (HMO)
|
$22.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $117.50 | P Q:10 /30Days | $66.50 |
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:10 /30Days | $123.20 |
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 |
Vibra Health Plan Enhanced Complete (PPO)
|
$26.00 |
$0 |
No |
3 |
Preferred Brand |
$40.00 | $120.00 | P Q:15 /30Days | $106.90 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Humana Gold Plus SNP-DE H6622-038 (HMO D-SNP)
|
$26.10 |
$445 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:20 /30Days | $52.70 |
Browse Plan Formulary |
Humana Value Plus H5216-117 (PPO)
|
$26.90 |
$420 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:20 /30Days | $53.90 |
Browse Plan Formulary |
Aetna Medicare Advantra Cares (HMO D-SNP)
|
$27.30 |
$220 |
No |
4 |
Non-Preferred Drug |
35% | 35% | P Q:10 /30Days | $117.20 |
Browse Plan Formulary |
HumanaChoice R0923-002 (Regional PPO)
|
$29.60 |
$0 |
No |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:20 /30Days | $53.50 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$30.10 |
$445 |
No |
4 |
Tier 4 |
$0.00 | $0.00 | Q:15 /30Days | $109.20 |
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 |
Allwell Dual Medicare (HMO D-SNP)
|
$34.20 |
$445 |
No |
4 |
Non-Preferred Drug |
48% | 48% | P Q:10 /30Days | $49.30 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 |
No |
2 |
Generic |
$5.00 | $12.00 | P Q:17 /30Days | $81.00 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 |
No |
2 |
Generic |
$5.00 | $12.00 | P Q:17 /30Days | $81.10 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 |
No |
2 |
Generic |
$5.00 | $12.00 | P Q:17 /30Days | $82.40 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 |
No |
2 |
Generic |
$5.00 | $12.00 | P Q:17 /30Days | $80.20 |
Browse Plan Formulary |
UPMC for Life PPO High Deductible with Rx (PPO)
|
$35.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $117.50 | P Q:10 /30Days | $66.10 |
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 |
UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
|
$37.20 |
$445 |
No |
4 |
Tier 4 |
25% | 25% | Q:15 /30Days | $109.10 |
Browse Plan Formulary |
AmeriHealth Caritas VIP Care (HMO D-SNP)
|
$37.40 |
$445 |
No |
1 |
Generic |
$5.00 | $15.00 | Q:10 /30Days | $67.30 |
Browse Plan Formulary |
Geisinger Gold Secure Rx (HMO D-SNP)
|
$37.50 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | Q:10 /30Days | $35.00 |
Browse Plan Formulary |
Health Partners Medicare Prime (HMO-POS)
|
$37.50 |
$0 |
No |
2 |
Generic |
$10.00 | $20.00 | Q:10 /30Days | $52.10 |
Browse Plan Formulary |
Health Partners Medicare Special (HMO D-SNP)
|
$37.50 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | Q:10 /30Days | $52.10 |
Browse Plan Formulary |
UPMC for Life Complete Care (HMO D-SNP)
|
$37.50 |
$445 |
No |
3 |
Preferred Brand |
$18.00 | $45.00 | P Q:10 /30Days | $67.90 |
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:10 /30Days | $35.00 |
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:10 /30Days | $35.00 |
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:10 /30Days | $35.00 |
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:10 /30Days | $35.00 |
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:10 /30Days | $35.00 |
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:10 /30Days | $35.00 |
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 |
3 |
Preferred Brand |
$47.00 | $117.50 | P Q:10 /30Days | $66.50 |
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:10 /30Days | $35.00 |
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:10 /30Days | $35.00 |
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:10 /30Days | $122.20 |
Browse Plan Formulary |
HumanaChoice H5525-007 (PPO)
|
$54.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:20 /30Days | $53.60 |
Browse Plan Formulary |
Aetna Medicare Silver (HMO)
|
$69.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:10 /30Days | $109.80 |
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 |
Freedom Blue PPO ValueRx (PPO)
|
$70.00 |
$0 |
No |
2 |
Generic |
$13.00 | $27.00 | P Q:17 /30Days | $81.50 |
Browse Plan Formulary |
UPMC for Life HMO Rx (HMO)
|
$81.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $117.50 | P Q:10 /30Days | $66.50 |
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:10 /30Days | $35.00 |
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:10 /30Days | $35.00 |
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:10 /30Days | $35.00 |
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:10 /30Days | $35.00 |
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:10 /30Days | $35.00 |
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:10 /30Days | $35.00 |
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:10 /30Days | $125.20 |
Browse Plan Formulary |
HumanaChoice H5216-120 (PPO)
|
$127.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:20 /30Days | $53.20 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$136.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | Q:10 /30Days | $35.00 |
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:10 /30Days | $35.00 |
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 Advantage Rx (HMO)
|
$136.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | Q:10 /30Days | $35.00 |
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:10 /30Days | $35.00 |
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:10 /30Days | $35.00 |
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:10 /30Days | $35.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UPMC for Life PPO Rx Enhanced (PPO)
|
$136.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $117.50 | P Q:10 /30Days | $66.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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:10 /30Days | $102.70 |
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)
|
$175.00 |
$0 |
No |
2 |
Generic |
$13.00 | $27.00 | P Q:17 /30Days | $81.50 |
Browse Plan Formulary |
Freedom Blue PPO Deluxe (PPO)
|
$289.00 |
$0 |
No |
2 |
Generic |
$13.00 | $27.00 | P Q:17 /30Days | $81.50 |
Browse Plan Formulary |
UPMC for Life HMO Rx Enhanced (HMO)
|
$302.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $117.50 | P Q:10 /30Days | $66.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |