ROTARIX VACCINE SUSPENSION (NDC: 58160085452)
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 | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $272.16 |
Browse Plan Formulary |
Aetna Medicare Advantra Silver (PPO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $272.16 |
Browse Plan Formulary |
Aetna Medicare Value (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $272.16 |
Browse Plan Formulary |
Allwell Medicare (HMO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $275.92 |
Browse Plan Formulary |
Allwell Medicare (HMO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $275.92 |
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 Boost (HMO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $275.92 |
Browse Plan Formulary |
BlueJourney Essential (HMO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$40.00 | $120.00 | None | $254.08 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
BlueJourney Select (PPO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$40.00 | $120.00 | None | $254.08 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $120.00 | None | $253.86 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $120.00 | None | $253.86 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $120.00 | None | $253.86 |
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 | 3 |
Preferred Brand |
$47.00 | $120.00 | None | $253.86 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $120.00 | None | $253.84 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $120.00 | None | $253.84 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $120.00 | None | $253.84 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $120.00 | None | $253.84 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
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, this drug has Gap Coverage. | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | No | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
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 | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | No | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | No | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | No | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | No | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Health Partners Medicare Complete (HMO-POS)
|
$0.00 |
$0 | No | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $273.04 |
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 H6622-035 (HMO)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $261.34 |
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 | None | $261.34 |
Browse Plan Formulary |
Vibra Essential Advocate (PPO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$40.00 | $120.00 | None | $254.38 |
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 | None | $254.38 |
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 | None | $261.34 |
Browse Plan Formulary |
Aetna Medicare Advantra Silver Plus (PPO)
|
$19.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $272.16 |
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 |
UPMC for Life HMO Deductible with Rx (HMO)
|
$22.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $117.50 | None | $253.92 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Premier (HMO)
|
$25.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $272.16 |
Browse Plan Formulary |
Vibra Health Plan Enhanced Complete (PPO)
|
$26.00 |
$0 | No | 3 |
Preferred Brand |
$40.00 | $120.00 | None | $254.38 |
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 | None | $261.34 |
Browse Plan Formulary |
Aetna Medicare Advantra Cares (HMO D-SNP)
|
$27.30 |
$220 | No | 3 |
Preferred Brand |
25% | 25% | None | $272.16 |
Browse Plan Formulary |
HumanaChoice H5525-006 (PPO)
|
$28.00 |
$0 | No | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $261.34 |
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 Complement (HMO)
|
$29.50 |
$445 | No | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $275.92 |
Browse Plan Formulary |
HumanaChoice R0923-002 (Regional PPO)
|
$29.60 |
$0 | No | 4 |
Non-Preferred Drug |
$99.00 | $287.00 | None | $261.34 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$30.10 |
$445 | No | 3 |
Tier 3 |
$0.00 | $0.00 | Q:1 /1Days | $269.42 |
Browse Plan Formulary |
Allwell Dual Medicare (HMO D-SNP)
|
$34.20 |
$445 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $275.92 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $120.00 | None | $253.84 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $120.00 | None | $253.84 |
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 | 3 |
Preferred Brand |
$47.00 | $120.00 | None | $253.84 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $120.00 | None | $253.84 |
Browse Plan Formulary |
AmeriHealth Caritas VIP Care (HMO D-SNP)
|
$37.40 |
$445 | No | 2 |
Brand |
25% | 25% | None | $250.68 |
Browse Plan Formulary |
Gateway Health Medicare Assured Diamond (HMO D-SNP)
|
$37.50 |
$445 | No | 4 |
Non-Preferred Drug |
49% | 49% | None | $271.34 |
Browse Plan Formulary |
Gateway Health Medicare Assured Ruby (HMO D-SNP)
|
$37.50 |
$445 | No | 4 |
Non-Preferred Drug |
50% | 50% | None | $271.34 |
Browse Plan Formulary |
Geisinger Gold Secure Rx (HMO D-SNP)
|
$37.50 |
$445 | No | 1 |
Tier 1 |
15% | 15% | None | $244.64 |
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 |
Health Partners Medicare Prime (HMO-POS)
|
$37.50 |
$0 | No | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $273.04 |
Browse Plan Formulary |
Health Partners Medicare Special (HMO D-SNP)
|
$37.50 |
$445 | No | 1 |
Tier 1 |
$0.00 | $0.00 | None | $273.04 |
Browse Plan Formulary |
UPMC for Life Complete Care (HMO D-SNP)
|
$37.50 |
$445 | No | 3 |
Preferred Brand |
$18.00 | $45.00 | None | $253.92 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
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, this drug has Gap Coverage. | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UPMC for Life HMO Rx Choice (HMO)
|
$40.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $117.50 | None | $253.92 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 | No | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 | No | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
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 Advantra Premier Plus (PPO)
|
$47.00 |
$0 | No | 3 |
Preferred Brand |
$37.00 | $111.00 | None | $272.16 |
Browse Plan Formulary |
BlueJourney Classic (PPO)
|
$49.00 |
$0 | No | 3 |
Preferred Brand |
$40.00 | $120.00 | None | $254.08 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
BlueJourney Value (HMO)
|
$51.00 |
$0 | No | 3 |
Preferred Brand |
$40.00 | $120.00 | None | $254.08 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
UPMC for Life PPO Rx Enhanced (PPO)
|
$60.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $117.50 | None | $253.92 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Silver (HMO)
|
$69.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $272.16 |
Browse Plan Formulary |
Freedom Blue PPO ValueRx (PPO)
|
$70.00 |
$0 | No | 3 |
Preferred Brand |
$45.00 | $115.00 | None | $253.84 |
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 |
UPMC for Life HMO Rx (HMO)
|
$81.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $117.50 | None | $253.92 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$85.00 |
$0 | No | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$85.00 |
$0 | No | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$85.00 |
$0 | No | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$85.00 |
$0 | No | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$85.00 |
$0 | No | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
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 | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BlueJourney Premier (HMO)
|
$106.00 |
$0 | No | 3 |
Preferred Brand |
$40.00 | $80.00 | None | $254.08 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
HumanaChoice H5216-120 (PPO)
|
$127.00 |
$0 | No | 4 |
Non-Preferred Drug |
$97.00 | $281.00 | None | $261.34 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$150.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$150.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$150.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
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)
|
$150.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$150.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$150.00 |
$0 | Yes, this drug has Gap Coverage. | 6 |
Vaccines |
$0.00 | n/a | None | $244.64 |
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. | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $272.16 |
Browse Plan Formulary |
BlueJourney Prime (PPO)
|
$171.00 |
$0 | No | 3 |
Preferred Brand |
$40.00 | $120.00 | None | $254.08 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Freedom Blue PPO Standard (PPO)
|
$175.00 |
$0 | No | 3 |
Preferred Brand |
$45.00 | $115.00 | None | $253.84 |
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 Deluxe (PPO)
|
$289.00 |
$0 | No | 3 |
Preferred Brand |
$45.00 | $115.00 | None | $253.84 |
Browse Plan Formulary |
UPMC for Life HMO Rx Enhanced (HMO)
|
$302.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $117.50 | None | $253.92 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |