SUMATRIPTAN 20 MG NASAL SPRAY [Imitrex] (6 UNITS ) (NDC: 00781652386)
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 Freedom Plus (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:12 /30Days | $260.88 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons Focus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:12 /30Days | $260.88 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:12 /30Days | $260.88 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Plus Plan (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$0.00 | $0.00 | Q:12 /30Days | $75.54 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$10.00 | $25.00 | Q:12 /30Days | $73.44 |
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 Select Plan (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$10.00 | $25.00 | Q:12 /30Days | $76.68 |
Browse Plan Formulary |
Anthem MediBlue Care On Site (HMO I-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | None | $276.78 |
Browse Plan Formulary |
Anthem MediBlue Diabetes Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | None | $276.78 |
Browse Plan Formulary |
Anthem MediBlue ESRD Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | None | $276.78 |
Browse Plan Formulary |
Anthem MediBlue Heart Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | None | $276.78 |
Browse Plan Formulary |
Anthem MediBlue Lung Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | None | $276.78 |
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 |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $207.00 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $203.34 |
Browse Plan Formulary |
Anthem MediBlue StartSmart Plus (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $276.78 |
Browse Plan Formulary |
Anthem MediBlue Value Plus (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | None | $276.78 |
Browse Plan Formulary |
Astiva Health Advantage (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:18 /30Days | $372.66 |
Browse Plan Formulary |
AVA (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | Q:12 /30Days | $258.42 |
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 |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:18 /30Days | $187.74 |
Browse Plan Formulary |
Blue Shield 65 Plus Plan 2 (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:18 /30Days | $188.22 |
Browse Plan Formulary |
Blue Shield AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:18 /30Days | $187.74 |
Browse Plan Formulary |
Blue Shield Inspire (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:18 /30Days | $187.74 |
Browse Plan Formulary |
Blue Shield Vital (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:18 /30Days | $187.74 |
Browse Plan Formulary |
Brand New Day Bridges Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | Q:12 /30Days | $262.02 |
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 |
Brand New Day Classic Care I Plan (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:12 /30Days | $261.96 |
Browse Plan Formulary |
Brand New Day Classic Care II Plan (HMO)
|
$0.00 |
$50 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:12 /30Days | $262.02 |
Browse Plan Formulary |
Brand New Day Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | Q:12 /30Days | $261.96 |
Browse Plan Formulary select insulin pay $9-$20 copay but not this drug |
Brand New Day Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | Q:12 /30Days | $262.02 |
Browse Plan Formulary select insulin pay $9-$20 copay but not this drug |
Brand New Day Harmony Care Plan (HMO C-SNP)
|
$0.00 |
$100* |
No |
2* |
Generic |
$10.00 | $20.00 | Q:12 /30Days | $262.02 |
Browse Plan Formulary |
Brand New Day Select Care I Plan (HMO I-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | Q:12 /30Days | $261.96 |
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 |
Central Health Focus Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$75.00 | $150.00 | Q:12 /30Days | $258.30 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$75.00 | $150.00 | Q:12 /30Days | $258.30 |
Browse Plan Formulary |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $10.00 | Q:12 /30Days | $258.30 |
Browse Plan Formulary select insulin pay $5-$35 copay but not this drug |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $10.00 | Q:12 /30Days | $258.30 |
Browse Plan Formulary select insulin pay $5-$35 copay but not this drug |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $10.00 | Q:12 /30Days | $258.30 |
Browse Plan Formulary select insulin pay $5-$35 copay but not this drug |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:12 /30Days | $152.04 |
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 |
Health Net Jade (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:12 /30Days | $152.10 |
Browse Plan Formulary |
Heart & Diabetes (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$75.00 | $187.50 | Q:12 /30Days | $258.30 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:12 /30Days | $259.44 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Imperial Dynamic Plan (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$75.00 | $180.00 | Q:18 /30Days | $369.48 |
Browse Plan Formulary |
Imperial Senior Value (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:18 /30Days | $371.40 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Imperial Traditional (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:18 /30Days | $371.40 |
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 |
Inter Valley Health Plan Service To Seniors (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $10.00 | None | $253.98 |
Browse Plan Formulary select insulin pay $11-$35 copay but not this drug |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$10.00 | $20.00 | None | $307.20 |
Browse Plan Formulary |
My Choice (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:12 /30Days | $258.30 |
Browse Plan Formulary |
OneCare Connect (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | n/a | Q:12 /30Days | $299.76 |
Browse Plan Formulary |
Platinum (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$75.00 | $187.50 | Q:12 /30Days | $258.30 |
Browse Plan Formulary |
SCAN Balance (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $265.00 | None | $259.02 |
Browse Plan Formulary select insulin pay $0 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 |
SCAN Classic (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $265.00 | None | $265.74 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Healthy at Home (HMO I-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $263.22 |
Browse Plan Formulary |
SCAN Heart First (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $265.00 | None | $265.74 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
WellCare Best (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$0.00 | $0.00 | Q:12 /30Days | $142.68 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$10.00 | $0.00 | Q:12 /30Days | $139.08 |
Browse Plan Formulary |
WellCare Plus (HMO)
|
$4.60 |
$445 |
No |
4 |
Non-Preferred Drug |
44% | 44% | Q:12 /30Days | $131.34 |
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 |
Anthem MediBlue Coordination Plus (HMO)
|
$12.20 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $207.00 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$17.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:12 /30Days | $152.76 |
Browse Plan Formulary |
CalPlus (HMO)
|
$20.10 |
$445 |
No |
4 |
Non-Preferred Drug |
23% | 23% | Q:12 /30Days | $258.36 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$20.40 |
$445 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:12 /30Days | $259.50 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$22.50 |
$445 |
No |
4 |
Tier 4 |
25% | 25% | Q:12 /30Days | $262.50 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | None | $276.78 |
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 |
Anthem MediBlue Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | None | $285.30 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | None | $276.78 |
Browse Plan Formulary |
Health Net Sapphire Premier (HMO)
|
$25.40 |
$445 |
No |
4 |
Non-Preferred Drug |
45% | 45% | Q:12 /30Days | $177.60 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$26.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $265.00 | None | $265.74 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Health Net Amber II (HMO D-SNP)
|
$26.60 |
$445 |
No |
4 |
Non-Preferred Drug |
46% | 46% | Q:12 /30Days | $178.62 |
Browse Plan Formulary |
Health Net Sapphire Premier II (HMO)
|
$26.70 |
$445 |
No |
4 |
Non-Preferred Drug |
47% | 47% | Q:12 /30Days | $177.60 |
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 |
Health Net Amber I (HMO D-SNP)
|
$27.80 |
$445 |
No |
4 |
Non-Preferred Drug |
41% | 41% | Q:12 /30Days | $178.62 |
Browse Plan Formulary |
AARP Medicare Advantage SecureHorizons Premier (HMO)
|
$28.20 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:12 /30Days | $260.88 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Health Net Sapphire (HMO)
|
$28.50 |
$445 |
No |
4 |
Non-Preferred Drug |
46% | 46% | Q:12 /30Days | $178.14 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$28.90 |
$0 |
No |
2 |
Tier 2 |
$15.00 | $30.00 | None | $307.26 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP)
|
$30.50 |
$445 |
No |
2 |
Tier 2 |
15% | 15% | None | $307.26 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $185.82 |
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 |
Astiva Health Value (HMO)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:18 /30Days | $372.66 |
Browse Plan Formulary |
Blue Shield Coordinated Choice Plan (HMO)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:18 /30Days | $187.92 |
Browse Plan Formulary |
Blue Shield TotalDual Plan (HMO D-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:18 /30Days | $187.86 |
Browse Plan Formulary |
Brand New Day Bridges Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:12 /30Days | $262.02 |
Browse Plan Formulary |
Brand New Day Classic Choice Plan (HMO)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:12 /30Days | $262.02 |
Browse Plan Formulary |
Brand New Day Dual Access Plan (HMO D-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:12 /30Days | $261.96 |
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 |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:12 /30Days | $262.02 |
Browse Plan Formulary |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:12 /30Days | $261.96 |
Browse Plan Formulary |
Brand New Day Harmony Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:12 /30Days | $262.02 |
Browse Plan Formulary |
Brand New Day Select Choice I Plan (HMO I-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:12 /30Days | $261.96 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:12 /30Days | $258.30 |
Browse Plan Formulary |
Clever Care Balance Medicare Advantage (HMO)
|
$31.50 |
$435 |
No |
2 |
Generic |
25% | 25% | Q:12 /30Days | $258.30 |
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 |
Clever Care Balance Medicare Advantage (HMO)
|
$31.50 |
$435 |
No |
2 |
Generic |
25% | 25% | Q:12 /30Days | $258.30 |
Browse Plan Formulary |
Clever Care Balance Medicare Advantage (HMO)
|
$31.50 |
$435 |
No |
2 |
Generic |
25% | 25% | Q:12 /30Days | $258.30 |
Browse Plan Formulary |
Imperial Traditional Plus (HMO)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:18 /30Days | $371.40 |
Browse Plan Formulary |
Inter Valley Health Plan Vitality Plus (HMO)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $253.98 |
Browse Plan Formulary |
OneCare (HMO D-SNP)
|
$31.50 |
$0 |
No |
1 |
Generic |
$0.00 | n/a | Q:12 /30Days | $299.76 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | None | $265.32 |
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 Choice Plan (PPO)
|
$89.00 |
$0 |
No |
2 |
Generic |
$10.00 | $25.00 | Q:12 /30Days | $44.70 |
Browse Plan Formulary |
Anthem MediBlue Access (PPO)
|
$172.00 |
$370 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $203.34 |
Browse Plan Formulary |