VICTOZA 3-PAK 18 MG/3 ML PEN (9ML ) (NDC: 00169406013)
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 |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:9 /30Days | $1,073.07 |
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 | Q:9 /30Days | $1,073.07 |
Browse Plan Formulary |
Align Connect (HMO C-SNP)
|
$0.00 |
$445 |
No |
3 |
Preferred Brand |
$45.00 | n/a | Q:9 /30Days | $1,012.05 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage Prime Value (HMO-POS)
|
$0.00 |
$50 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:27 /90Days | $990.81 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage Prime Value (HMO-POS)
|
$0.00 |
$50 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:27 /90Days | $994.05 |
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 |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:27 /90Days | $991.62 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage Prime Value (HMO-POS)
|
$0.00 |
$50 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:27 /90Days | $992.79 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage Prime Value (HMO-POS)
|
$0.00 |
$50 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:27 /90Days | $991.71 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Erickson Advantage Liberty with Drugs (HMO-POS)
|
$0.00 |
$400 |
No |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:9 /30Days | $1,083.15 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HAP Primary Choice (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | S | $989.91 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
HAP Senior Plus (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | S | $990.72 |
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 |
HAP Senior Plus Option 1 (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | S | $990.54 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
Humana Gold Plus H8908-004 (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:9 /30Days | $1,072.08 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$100 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:27 /90Days | $990.81 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$100 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:27 /90Days | $994.32 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$100 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:27 /90Days | $992.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$100 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:27 /90Days | $992.79 |
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 Essential (PPO)
|
$0.00 |
$100 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:27 /90Days | $991.62 |
Browse Plan Formulary |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
40% | 40% | S | $985.95 |
Browse Plan Formulary |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
40% | 40% | S | $980.01 |
Browse Plan Formulary |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
40% | 40% | S | $978.57 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$100 |
No |
4 |
Non-Preferred Drug |
45% | 45% | S | $978.57 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$100 |
No |
4 |
Non-Preferred Drug |
45% | 45% | S | $985.95 |
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 |
4 |
Non-Preferred Drug |
45% | 45% | S | $976.86 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$100 |
No |
4 |
Non-Preferred Drug |
45% | 45% | S | $976.59 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$100 |
No |
4 |
Non-Preferred Drug |
45% | 45% | S | $980.01 |
Browse Plan Formulary |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350 |
No |
4 |
Non-Preferred Drug |
45% | 45% | S | $985.95 |
Browse Plan Formulary |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350 |
No |
4 |
Non-Preferred Drug |
45% | 45% | S | $980.01 |
Browse Plan Formulary |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350 |
No |
4 |
Non-Preferred Drug |
45% | 45% | S | $978.57 |
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 |
Reliance Principle Plan (HMO)
|
$0.00 |
$125 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:9 /30Days | $1,015.29 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
WellCare Dividend (HMO)
|
$0.00 |
$445 |
No |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:9 /30Days | $1,073.79 |
Browse Plan Formulary |
WellCare Essential (HMO-POS)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:9 /30Days | $1,073.79 |
Browse Plan Formulary |
WellCare Exclusive (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:9 /30Days | $1,073.79 |
Browse Plan Formulary |
WellCare Explore (HMO-POS)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:9 /30Days | $1,073.79 |
Browse Plan Formulary |
Zing Choice MI (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$35.00 | $90.00 | Q:9 /30Days | $1,004.58 |
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 |
Zing Essential Wellness MI (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$35.00 | $90.00 | Q:9 /30Days | $1,004.58 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Zing Open Access MI (HMO-POS)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$35.00 | $90.00 | Q:9 /30Days | $1,004.58 |
Browse Plan Formulary |
WellCare Elite Smile (HMO-POS)
|
$14.10 |
$0 |
No |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:9 /30Days | $1,073.79 |
Browse Plan Formulary |
BCN Advantage Community Value (HMO-POS)
|
$20.00 |
$0 |
No |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:27 /90Days | $990.81 |
Browse Plan Formulary |
BCN Advantage Community Value (HMO-POS)
|
$20.00 |
$0 |
No |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:27 /90Days | $991.80 |
Browse Plan Formulary |
HumanaChoice H8087-001 (PPO)
|
$20.00 |
$75 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:9 /30Days | $1,068.93 |
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 |
4 |
Non-Preferred Drug |
50% | 50% | S | $985.95 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$20.00 |
$125 |
No |
4 |
Non-Preferred Drug |
50% | 50% | S | $976.86 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$20.00 |
$125 |
No |
4 |
Non-Preferred Drug |
50% | 50% | S | $976.59 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$20.00 |
$125 |
No |
4 |
Non-Preferred Drug |
50% | 50% | S | $980.01 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$20.00 |
$125 |
No |
4 |
Non-Preferred Drug |
50% | 50% | S | $978.57 |
Browse Plan Formulary |
HumanaChoice H5216-133 (PPO)
|
$21.00 |
$150* |
No |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:9 /30Days | $1,072.53 |
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 Assure Premier (HMO D-SNP)
|
$22.00 |
$220 |
No |
3 |
Preferred Brand |
25% | 25% | Q:9 /30Days | $1,073.07 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H8908-005 (HMO D-SNP)
|
$25.40 |
$425 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:9 /30Days | $1,072.08 |
Browse Plan Formulary |
Erickson Advantage Guardian (HMO-POS I-SNP)
|
$28.80 |
$0 |
No |
3 |
Preferred Brand |
$28.00 | $74.00 | Q:9 /30Days | $1,083.15 |
Browse Plan Formulary select insulin pay $28 copay but not this drug |
Align Thrive (HMO I-SNP)
|
$30.10 |
$445 |
No |
1 |
Tier 1 |
25% | n/a | Q:9 /30Days | $1,012.05 |
Browse Plan Formulary |
HAP Empowered Duals (HMO D-SNP)
|
$30.10 |
$445 |
No |
3 |
Tier 3 |
$0.00 | $0.00 | S | $989.10 |
Browse Plan Formulary |
Longevity Health Plan (HMO I-SNP)
|
$30.10 |
$445 |
No |
1 |
Tier 1 |
25% | n/a | Q:9 /30Days | $1,011.96 |
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 |
Molina Medicare Complete Care (HMO D-SNP)
|
$30.10 |
$445 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:9 /30Days | $988.65 |
Browse Plan Formulary |
PriorityMedicare D-SNP (HMO D-SNP)
|
$30.10 |
$445 |
No |
4 |
Tier 4 |
$0.00 | $0.00 | S | $991.98 |
Browse Plan Formulary |
Reliance Dual Care Plus (HMO D-SNP)
|
$30.10 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | Q:9 /30Days | $1,015.11 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$30.10 |
$445 |
No |
3 |
Tier 3 |
$0.00 | $0.00 | Q:9 /30Days | $1,083.24 |
Browse Plan Formulary |
WellCare Extra Plus (HMO-POS D-SNP)
|
$30.10 |
$445 |
No |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:9 /30Days | $1,073.79 |
Browse Plan Formulary |
HumanaChoice R3887-002 (Regional PPO)
|
$32.40 |
$380 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:9 /30Days | $1,069.65 |
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 Premier Plus (PPO)
|
$34.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:9 /30Days | $1,073.07 |
Browse Plan Formulary |
Reliance Cardinal Plan (HMO)
|
$40.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:9 /30Days | $1,015.29 |
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 | Q:9 /30Days | $1,072.08 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$45.00 |
$75 |
No |
4 |
Non-Preferred Drug |
50% | 50% | S | $985.95 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$45.00 |
$75 |
No |
4 |
Non-Preferred Drug |
50% | 50% | S | $976.86 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$45.00 |
$75 |
No |
4 |
Non-Preferred Drug |
50% | 50% | S | $976.59 |
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 |
4 |
Non-Preferred Drug |
50% | 50% | S | $980.01 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$45.00 |
$75 |
No |
4 |
Non-Preferred Drug |
50% | 50% | S | $978.57 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
WellCare Elite (HMO-POS)
|
$47.00 |
$0 |
No |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:9 /30Days | $1,073.79 |
Browse Plan Formulary |
BCN Advantage HMO ConnectedCare (HMO)
|
$57.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:27 /90Days | $990.72 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HAP Senior Plus Option 2 (PPO)
|
$60.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | S | $990.54 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
Erickson Advantage Freedom (HMO-POS)
|
$70.00 |
$200* |
No |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:9 /30Days | $1,083.15 |
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 |
Medicare Plus Blue PPO Vitality (PPO)
|
$77.00 |
$100 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:27 /90Days | $990.81 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$77.00 |
$100 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:27 /90Days | $994.32 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$77.00 |
$100 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:27 /90Days | $992.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$77.00 |
$100 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:27 /90Days | $992.79 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$77.00 |
$100 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:27 /90Days | $991.62 |
Browse Plan Formulary |
HAP Senior Plus Option 1 (HMO-POS)
|
$85.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | S | $990.54 |
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 Merit (PPO)
|
$90.00 |
$0 |
No |
4 |
Non-Preferred Drug |
50% | 50% | S | $976.86 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$90.00 |
$0 |
No |
4 |
Non-Preferred Drug |
50% | 50% | S | $976.59 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$90.00 |
$0 |
No |
4 |
Non-Preferred Drug |
50% | 50% | S | $980.01 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$90.00 |
$0 |
No |
4 |
Non-Preferred Drug |
50% | 50% | S | $978.57 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$90.00 |
$0 |
No |
4 |
Non-Preferred Drug |
50% | 50% | S | $985.95 |
Browse Plan Formulary |
HAP Senior Plus Henry Ford Tiered Access (HMO)
|
$95.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | S | $989.37 |
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 |
HumanaChoice H5216-011 (PPO)
|
$99.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:9 /30Days | $1,072.53 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$120.00 |
$0 |
No |
4 |
Non-Preferred Drug |
45% | 45% | S | $985.95 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$120.00 |
$0 |
No |
4 |
Non-Preferred Drug |
45% | 45% | S | $976.86 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$120.00 |
$0 |
No |
4 |
Non-Preferred Drug |
45% | 45% | S | $976.59 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$120.00 |
$0 |
No |
4 |
Non-Preferred Drug |
45% | 45% | S | $980.01 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$120.00 |
$0 |
No |
4 |
Non-Preferred Drug |
45% | 45% | S | $978.57 |
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)
|
$129.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:27 /90Days | $990.81 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$129.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:27 /90Days | $994.05 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$129.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:27 /90Days | $991.62 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$129.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:27 /90Days | $992.79 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$129.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:27 /90Days | $991.71 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Medicare Plus Blue PPO Signature (PPO)
|
$135.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:27 /90Days | $990.81 |
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)
|
$135.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:27 /90Days | $994.32 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$135.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:27 /90Days | $992.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$135.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:27 /90Days | $992.79 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$135.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:27 /90Days | $991.62 |
Browse Plan Formulary |
HAP Senior Plus Option 3 (PPO)
|
$160.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | S | $990.54 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
HAP Senior Plus Option 2 (HMO-POS)
|
$190.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | S | $990.54 |
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 |
Erickson Advantage Champion (HMO-POS C-SNP)
|
$199.00 |
$0 |
No |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:9 /30Days | $1,083.15 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Erickson Advantage Signature with Drugs (HMO-POS)
|
$199.00 |
$0 |
No |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:9 /30Days | $1,083.15 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HAP Senior Plus Option 4 (PPO)
|
$200.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $105.00 | S | $990.54 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Select (PPO)
|
$206.00 |
$0 |
No |
4 |
Non-Preferred Drug |
45% | 45% | S | $985.95 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$206.00 |
$0 |
No |
4 |
Non-Preferred Drug |
45% | 45% | S | $976.86 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$206.00 |
$0 |
No |
4 |
Non-Preferred Drug |
45% | 45% | S | $976.59 |
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 Select (PPO)
|
$206.00 |
$0 |
No |
4 |
Non-Preferred Drug |
45% | 45% | S | $980.01 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$206.00 |
$0 |
No |
4 |
Non-Preferred Drug |
45% | 45% | S | $978.57 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$264.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:27 /90Days | $990.81 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$264.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:27 /90Days | $994.05 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$264.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:27 /90Days | $991.62 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$264.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:27 /90Days | $992.79 |
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)
|
$264.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:27 /90Days | $991.71 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Medicare Plus Blue PPO Assure (PPO)
|
$299.00 |
$0 |
No |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:27 /90Days | $994.32 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$299.00 |
$0 |
No |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:27 /90Days | $992.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$299.00 |
$0 |
No |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:27 /90Days | $992.79 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$299.00 |
$0 |
No |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:27 /90Days | $991.62 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$299.00 |
$0 |
No |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:27 /90Days | $990.81 |
Browse Plan Formulary |