XCOPRI 150-200 MG TITRATION PK TABLET DS PK (UNITS ) (NDC: 71699020328)
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 | 5 |
Specialty Tier |
33% | n/a | P Q:28 /28Days | $1,092.56 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Credit Value (PPO)
|
$0.00 |
$250 | No | 5 |
Specialty Tier |
28% | n/a | None | $1,103.76 |
Browse Plan Formulary |
Aetna Medicare Advantra Value (HMO)
|
$0.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | None | $1,103.76 |
Browse Plan Formulary |
Aetna Medicare Elite (HMO)
|
$0.00 |
$150 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
30% | n/a | None | $1,103.76 |
Browse Plan Formulary |
Aetna Medicare Main Line Health Prime (HMO)
|
$0.00 |
$150 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
30% | n/a | None | $1,103.76 |
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 Value (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $1,103.76 |
Browse Plan Formulary |
Allwell Medicare (HMO)
|
$0.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | Q:28 /28Days | $1,118.88 |
Browse Plan Formulary |
Allwell Medicare (HMO)
|
$0.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | Q:28 /28Days | $1,118.88 |
Browse Plan Formulary |
Allwell Medicare Boost (HMO)
|
$0.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | Q:28 /28Days | $1,118.88 |
Browse Plan Formulary |
Cigna Achieve Medicare (HMO C-SNP)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $1,073.80 |
Browse Plan Formulary |
Cigna Alliance Medicare (HMO)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $1,073.80 |
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 |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $1,073.80 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
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. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
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. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
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. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
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. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
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. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
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 | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Health Partners Medicare Complete (HMO-POS)
|
$0.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | None | $1,107.40 |
Browse Plan Formulary |
Humana Gold Plus H6622-037 (HMO)
|
$0.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | P Q:28 /28Days | $1,065.12 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5525-038 (PPO)
|
$0.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | P Q:28 /28Days | $1,065.12 |
Browse Plan Formulary |
HumanaChoice H5525-047 (PPO)
|
$0.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | P Q:28 /28Days | $1,065.12 |
Browse Plan Formulary |
Keystone 65 Basic Rx (HMO)
|
$0.00 |
$0 | No | 5 |
Specialty Tier |
33% | 33% | S | $1,059.52 |
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 |
Personal Choice 65 Prime Rx (PPO)
|
$0.00 |
$0 | No | 5 |
Specialty Tier |
33% | 33% | S | $1,059.52 |
Browse Plan Formulary |
Humana Gold Choice H8145-052 (PFFS)
|
$8.00 |
$360 | No | 5 |
Specialty Tier |
26% | n/a | P Q:28 /28Days | $1,065.12 |
Browse Plan Formulary |
Keystone 65 Focus Rx (HMO-POS)
|
$15.00 |
$0 | No | 5 |
Specialty Tier |
33% | 33% | S | $1,059.52 |
Browse Plan Formulary |
Cigna Traditions Medicare (HMO I-SNP)
|
$24.50 |
$445 | No | 4 |
Tier 4 |
25% | n/a | P | $1,073.80 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$25.50 |
$445 | No | 4 |
Tier 4 |
15% | 15% | P | $1,073.80 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H6622-038 (HMO D-SNP)
|
$26.10 |
$445 | No | 5 |
Specialty Tier |
25% | n/a | P Q:28 /28Days | $1,065.12 |
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 |
AARP Medicare Advantage (HMO)
|
$29.00 |
$200 | No | 5 |
Specialty Tier |
29% | n/a | P Q:28 /28Days | $1,092.56 |
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 | P | $1,073.80 |
Browse Plan Formulary |
Allwell Medicare Complement (HMO)
|
$29.50 |
$445 | No | 5 |
Specialty Tier |
25% | n/a | Q:28 /28Days | $1,118.88 |
Browse Plan Formulary |
HumanaChoice R0923-002 (Regional PPO)
|
$29.60 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | P Q:28 /28Days | $1,065.12 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$30.10 |
$445 | No | 5 |
Tier 5 |
$0.00 | $0.00 | P Q:28 /28Days | $1,092.56 |
Browse Plan Formulary |
Aetna Medicare Advantra Cares (HMO D-SNP)
|
$30.90 |
$130 | No | 5 |
Specialty Tier |
30% | n/a | None | $1,105.16 |
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 |
UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
|
$37.20 |
$445 | No | 5 |
Tier 5 |
25% | 25% | P Q:28 /28Days | $1,092.56 |
Browse Plan Formulary |
Keystone First VIP Choice (HMO D-SNP)
|
$37.40 |
$445 | No | 2 |
Brand |
25% | 25% | S | $1,016.68 |
Browse Plan Formulary |
Allwell Dual Medicare (HMO D-SNP)
|
$37.50 |
$445 | No | 5 |
Specialty Tier |
25% | n/a | Q:28 /28Days | $1,118.88 |
Browse Plan Formulary |
Gateway Health Medicare Assured Diamond (HMO D-SNP)
|
$37.50 |
$445 | No | 5 |
Specialty Tier |
25% | n/a | P Q:28 /28Days | $1,100.40 |
Browse Plan Formulary |
Gateway Health Medicare Assured Ruby (HMO D-SNP)
|
$37.50 |
$445 | No | 5 |
Specialty Tier |
25% | n/a | P Q:28 /28Days | $1,100.40 |
Browse Plan Formulary |
Geisinger Gold Secure Rx (HMO D-SNP)
|
$37.50 |
$445 | No | 1 |
Tier 1 |
15% | 15% | P Q:28 /180Days | $992.04 |
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 Partners Medicare Prime (HMO-POS)
|
$37.50 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | None | $1,107.40 |
Browse Plan Formulary |
Health Partners Medicare Special (HMO D-SNP)
|
$37.50 |
$445 | No | 1 |
Tier 1 |
$0.00 | $0.00 | None | $1,107.40 |
Browse Plan Formulary |
Provider Partners Pennsylvania Advantage Plan (HMO I-SNP)
|
$37.50 |
$445 | No | 1 |
Tier 1 |
25% | 25% | Q:28 /28Days | $1,064.00 |
Browse Plan Formulary |
Provider Partners Pennsylvania Community Plan (HMO I-SNP)
|
$37.50 |
$445 | No | 1 |
Tier 1 |
25% | 25% | Q:28 /28Days | $1,064.00 |
Browse Plan Formulary |
UPMC for Life Complete Care (HMO D-SNP)
|
$37.50 |
$445 | No | 5 |
Specialty Tier |
25% | n/a | P Q:56 /365Days | $1,030.12 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
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. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
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. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
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. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
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. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
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. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
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 Enhanced Rx (PPO)
|
$45.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Premier (HMO)
|
$49.00 |
$150 | No | 5 |
Specialty Tier |
30% | n/a | None | $1,103.76 |
Browse Plan Formulary |
Aetna Medicare Advantra Premier Plus (PPO)
|
$49.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | None | $1,103.76 |
Browse Plan Formulary |
AARP Medicare Advantage Choice Plan 1 (PPO)
|
$58.00 |
$295 | No | 5 |
Specialty Tier |
27% | n/a | P Q:28 /28Days | $1,092.56 |
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 | P | $1,073.80 |
Browse Plan Formulary |
HumanaChoice H5525-005 (PPO)
|
$62.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | P Q:28 /28Days | $1,065.12 |
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 |
Aetna Medicare Silver (HMO)
|
$69.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | None | $1,103.76 |
Browse Plan Formulary |
Keystone 65 Select Rx (HMO)
|
$82.50 |
$0 | No | 5 |
Specialty Tier |
33% | 33% | S | $1,059.52 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$85.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$85.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$85.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$85.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
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 | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$85.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Premier (HMO)
|
$100.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | None | $1,103.76 |
Browse Plan Formulary |
HumanaChoice H5216-120 (PPO)
|
$127.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | P Q:28 /28Days | $1,065.12 |
Browse Plan Formulary |
Cigna Preferred Plus Medicare (HMO)
|
$139.00 |
$0 | No | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $1,073.80 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$150.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
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, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$150.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$150.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$150.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$150.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$100.00 | $150.00 | P Q:28 /180Days | $992.04 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Personal Choice 65 Rx (PPO)
|
$161.00 |
$0 | No | 5 |
Specialty Tier |
33% | 33% | S | $1,059.52 |
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 |
Aetna Medicare Gold Plan (PPO)
|
$169.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $1,103.76 |
Browse Plan Formulary |
Aetna Medicare Premier Plus (HMO)
|
$185.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | None | $1,103.76 |
Browse Plan Formulary |
Keystone 65 Preferred Rx (HMO)
|
$258.00 |
$0 | No | 5 |
Specialty Tier |
33% | 33% | S | $1,059.52 |
Browse Plan Formulary |