MEDROXYPROGESTERONE 150 MG/ML VIAL [Depo-Provera] (1 ml ) (NDC: 59762453701)
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 2 (PPO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $53.81 |
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 | None | $62.83 |
Browse Plan Formulary |
Aetna Medicare Advantra Value (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $71.12 |
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 | None | $68.59 |
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 | None | $67.41 |
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 Medicare (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $36.08 |
Browse Plan Formulary |
Allwell Medicare (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $33.55 |
Browse Plan Formulary |
Allwell Medicare Boost (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $36.08 |
Browse Plan Formulary |
Cigna Achieve Medicare (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $72.89 |
Browse Plan Formulary |
Cigna Alliance Medicare (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $72.89 |
Browse Plan Formulary |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $72.89 |
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 |
3 |
Preferred Brand |
$40.00 | $110.00 | None | $39.52 |
Browse Plan Formulary |
Erickson Advantage Liberty with Drugs (HMO-POS)
|
$0.00 |
$400 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $57.16 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic 360 Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | None | $16.25 |
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 | None | $16.25 |
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 | None | $16.25 |
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 | None | $16.25 |
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 | None | $16.25 |
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 | None | $16.25 |
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 | None | $16.25 |
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 | None | $16.25 |
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 | None | $16.25 |
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 | None | $16.25 |
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 | None | $16.25 |
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 | None | $16.25 |
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 | None | $16.25 |
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 | None | $33.44 |
Browse Plan Formulary |
Humana Gold Plus H6622-037 (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$8.00 | $0.00 | Q:1 /90Days | $33.72 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5525-038 (PPO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$17.00 | $0.00 | Q:1 /90Days | $33.56 |
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 H5525-047 (PPO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$15.00 | $0.00 | Q:1 /90Days | $33.72 |
Browse Plan Formulary |
Keystone 65 Basic Rx (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$10.00 | $20.00 | None | $51.29 |
Browse Plan Formulary |
Keystone 65 Focus Rx (HMO-POS)
|
$0.00 |
$0 |
No |
2 |
Generic |
$10.00 | $20.00 | None | $51.29 |
Browse Plan Formulary |
Personal Choice 65 Prime Rx (PPO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$10.00 | $20.00 | None | $51.29 |
Browse Plan Formulary |
Cigna Traditions Medicare (HMO I-SNP)
|
$24.50 |
$445 |
No |
4 |
Tier 4 |
25% | n/a | None | $72.89 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$25.50 |
$445 |
No |
4 |
Tier 4 |
15% | 15% | None | $72.89 |
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 |
2 |
Generic |
$19.00 | $0.00 | Q:1 /90Days | $33.37 |
Browse Plan Formulary |
Erickson Advantage Guardian (HMO-POS I-SNP)
|
$28.80 |
$0 |
No |
4 |
Non-Preferred Drug |
$70.00 | $200.00 | None | $57.15 |
Browse Plan Formulary select insulin pay $28 copay but not this drug |
AARP Medicare Advantage (HMO)
|
$29.00 |
$200 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $53.81 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Cigna Preferred Medicare (HMO)
|
$29.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $72.89 |
Browse Plan Formulary |
Allwell Medicare Complement (HMO)
|
$29.50 |
$445 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $35.36 |
Browse Plan Formulary |
HumanaChoice R0923-002 (Regional PPO)
|
$29.60 |
$0 |
No |
2 |
Generic |
$20.00 | $0.00 | Q:1 /90Days | $33.74 |
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)
|
$30.10 |
$445 |
No |
4 |
Tier 4 |
$0.00 | $0.00 | None | $53.32 |
Browse Plan Formulary |
Aetna Medicare Advantra Cares (HMO D-SNP)
|
$30.90 |
$130 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $71.12 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
|
$37.20 |
$445 |
No |
4 |
Tier 4 |
25% | 25% | None | $52.01 |
Browse Plan Formulary |
Keystone First VIP Choice (HMO D-SNP)
|
$37.40 |
$445 |
No |
1 |
Generic |
$5.00 | $15.00 | None | $28.73 |
Browse Plan Formulary |
Allwell Dual Medicare (HMO D-SNP)
|
$37.50 |
$445 |
No |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $36.08 |
Browse Plan Formulary |
Clover Health Choice Value (PPO)
|
$37.50 |
$445 |
No |
3 |
Preferred Brand |
22% | 22% | None | $39.52 |
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 |
Gateway Health Medicare Assured Diamond (HMO D-SNP)
|
$37.50 |
$445 |
No |
2 |
Generic |
$19.00 | $57.00 | None | $57.59 |
Browse Plan Formulary |
Gateway Health Medicare Assured Ruby (HMO D-SNP)
|
$37.50 |
$445 |
No |
2 |
Generic |
$20.00 | $60.00 | None | $57.59 |
Browse Plan Formulary |
Geisinger Gold Secure Rx (HMO D-SNP)
|
$37.50 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | None | $16.25 |
Browse Plan Formulary |
Health Partners Medicare Prime (HMO-POS)
|
$37.50 |
$0 |
No |
2 |
Generic |
$10.00 | $20.00 | None | $33.44 |
Browse Plan Formulary |
Health Partners Medicare Special (HMO D-SNP)
|
$37.50 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | None | $33.44 |
Browse Plan Formulary |
Provider Partners Pennsylvania Advantage Plan (HMO I-SNP)
|
$37.50 |
$445 |
No |
1 |
Tier 1 |
25% | 25% | None | $75.52 |
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 |
Provider Partners Pennsylvania Community Plan (HMO I-SNP)
|
$37.50 |
$445 |
No |
1 |
Tier 1 |
25% | 25% | None | $75.52 |
Browse Plan Formulary |
UPMC for Life Complete Care (HMO D-SNP)
|
$37.50 |
$445 |
No |
2 |
Generic |
$10.00 | $20.00 | Q:1 /84Days | $40.44 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $16.25 |
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 | None | $16.25 |
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 | None | $16.25 |
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 | None | $16.25 |
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 Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $16.25 |
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 | None | $16.25 |
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 | None | $16.25 |
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 | None | $16.25 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Premier (HMO)
|
$49.00 |
$150 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $71.12 |
Browse Plan Formulary |
Aetna Medicare Advantra Premier Plus (PPO)
|
$49.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $71.12 |
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 |
Keystone 65 Select Rx (HMO)
|
$56.50 |
$0 |
No |
2 |
Generic |
$9.00 | $18.00 | None | $51.29 |
Browse Plan Formulary |
AARP Medicare Advantage Choice Plan 1 (PPO)
|
$58.00 |
$295 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $53.81 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Cigna True Choice Plus Medicare (PPO)
|
$59.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $72.89 |
Browse Plan Formulary |
HumanaChoice H5525-005 (PPO)
|
$62.00 |
$0 |
No |
2 |
Generic |
$15.00 | $0.00 | Q:1 /90Days | $33.72 |
Browse Plan Formulary |
Aetna Medicare Silver (HMO)
|
$69.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $62.54 |
Browse Plan Formulary |
Erickson Advantage Freedom (HMO-POS)
|
$70.00 |
$200 |
No |
4 |
Non-Preferred Drug |
$85.00 | $245.00 | None | $57.16 |
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 | None | $16.25 |
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 | None | $16.25 |
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 | None | $16.25 |
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 | None | $16.25 |
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 | None | $16.25 |
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 | None | $16.25 |
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 Premier (HMO)
|
$100.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $71.12 |
Browse Plan Formulary |
HumanaChoice H5216-120 (PPO)
|
$127.00 |
$0 |
No |
2 |
Generic |
$15.00 | $0.00 | Q:1 /90Days | $33.53 |
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 | None | $16.25 |
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 | None | $16.25 |
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 | None | $16.25 |
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 | None | $16.25 |
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 | None | $16.25 |
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 | None | $16.25 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Cigna Preferred Plus Medicare (HMO)
|
$139.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $72.89 |
Browse Plan Formulary |
Aetna Medicare Gold Plan (PPO)
|
$169.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $62.54 |
Browse Plan Formulary |
Aetna Medicare Premier Plus (HMO)
|
$185.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $71.12 |
Browse Plan Formulary |
Erickson Advantage Champion (HMO-POS C-SNP)
|
$199.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$85.00 | $245.00 | None | $57.16 |
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 |
Erickson Advantage Signature with Drugs (HMO-POS)
|
$199.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$85.00 | $245.00 | None | $57.16 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Keystone 65 Preferred Rx (HMO)
|
$230.00 |
$0 |
No |
2 |
Generic |
$9.00 | $18.00 | None | $51.29 |
Browse Plan Formulary |
Personal Choice 65 Rx (PPO)
|
$290.00 |
$0 |
No |
2 |
Generic |
$9.00 | $18.00 | None | $51.29 |
Browse Plan Formulary |