TOLTERODINE TART ER 4 MG CAPSULE ER 24H [Detrol LA] (30 capsules ) (NDC: 13668019030)
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 (PPO)
|
$0.00 |
$150 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $101.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice Plan 2 (Regional PPO)
|
$0.00 |
$395 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $101.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Choice (HMO-POS)
|
$0.00 |
$195 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days | $133.80 |
Browse Plan Formulary |
Aetna Medicare Credit (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days | $117.60 |
Browse Plan Formulary |
Aetna Medicare Premier (PPO)
|
$0.00 |
$300 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days | $136.50 |
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)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days | $138.90 |
Browse Plan Formulary |
Aetna Medicare Select (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | S Q:30 /30Days | $131.10 |
Browse Plan Formulary select insulin pay $20 copay but not this drug |
AvMed Medicare Access (HMO-POS)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$75.00 | $187.50 | S Q:30 /30Days | $178.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AvMed Medicare Choice (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$75.00 | $187.50 | S Q:30 /30Days | $178.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AvMed Medicare Circle (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$75.00 | $187.50 | S Q:30 /30Days | $178.50 |
Browse Plan Formulary select insulin pay $30-$35 copay but not this drug |
AvMed Medicare Premium Saver (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$80.00 | $200.00 | S Q:30 /30Days | $178.50 |
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 |
BlueMedicare Classic (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$10.00 | $30.00 | Q:30 /30Days | $96.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BlueMedicare Premier (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $91.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BlueMedicare Saver (HMO)
|
$0.00 |
$50 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $117.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BlueMedicare Value (PPO)
|
$0.00 |
$150 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $117.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Bright Advantage Health Dollars (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$4.00 | $8.00 | Q:30 /30Days | $66.30 |
Browse Plan Formulary |
Bright Advantage Part B Savings (PPO)
|
$0.00 |
$400 |
No |
2 |
Generic |
$20.00 | $40.00 | Q:30 /30Days | $66.30 |
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 |
CareComplete (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:30 /30Days | $109.80 |
Browse Plan Formulary select insulin pay $12-$35 copay but not this drug |
CareFree (HMO)
|
$0.00 |
$100 |
No |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:30 /30Days | $109.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
CareOne (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$75.00 | $215.00 | Q:30 /30Days | $110.10 |
Browse Plan Formulary select insulin pay $10-$35 copay but not this drug |
Devoted Health Core Broward (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | S Q:30 /30Days | $210.90 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Devoted Health Essentials Broward (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S Q:30 /30Days | $210.90 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Freedom VIP Savings (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:30 /30Days | $117.60 |
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 |
Freedom VIP Savings COPD (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Non-Preferred Drug |
$80.00 | $160.00 | Q:30 /30Days | $117.60 |
Browse Plan Formulary |
HealthSun HealthAdvantage Plan (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $123.00 |
Browse Plan Formulary |
Humana Gold Plus - Diabetes (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $245.00 | Q:30 /30Days | $109.80 |
Browse Plan Formulary select insulin pay $10-$35 copay but not this drug |
Humana Gold Plus H1036-065C (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$75.00 | $215.00 | Q:30 /30Days | $110.10 |
Browse Plan Formulary select insulin pay $10-$35 copay but not this drug |
Humana Gold Plus H1036-237 (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$80.00 | $230.00 | Q:30 /30Days | $109.80 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
Humana Gold Plus H1036-237 (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$80.00 | $230.00 | Q:30 /30Days | $110.10 |
Browse Plan Formulary select insulin pay $20-$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 Florida H5216-068 (PPO)
|
$0.00 |
$150 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $109.80 |
Browse Plan Formulary |
HumanaChoice R5826-074 (Regional PPO)
|
$0.00 |
$395 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $110.40 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $101.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MMM ELITE (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$0.00 | $0.00 | S Q:30 /30Days | $158.40 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
MMM EXTRA (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$10.00 | $30.00 | S Q:30 /30Days | $158.40 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Optimum Gold Rewards Plan (HMO)
|
$0.00 |
$0 |
No |
3 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:30 /30Days | $117.60 |
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 |
Optimum Platinum Plan (HMO)
|
$0.00 |
$0 |
No |
3 |
Non-Preferred Drug |
$65.00 | $130.00 | Q:30 /30Days | $117.60 |
Browse Plan Formulary |
Oscar + Holy Cross + Memorial Health (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$0.00 | $0.00 | S Q:30 /30Days | $147.60 |
Browse Plan Formulary |
PHP (HMO C-SNP)
|
$0.00 |
$445 |
No |
1 |
Generic |
15% | n/a | None | $35.70 |
Browse Plan Formulary |
Preferred Choice Broward (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $101.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Simply Comfort (HMO I-SNP)
|
$0.00 |
$445 |
No |
2 |
Generic |
$5.00 | n/a | Q:30 /30Days | $117.60 |
Browse Plan Formulary |
Simply Extra (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$20.00 | $60.00 | Q:30 /30Days | $117.60 |
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 |
Simply Level (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $117.60 |
Browse Plan Formulary |
Simply More (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $117.60 |
Browse Plan Formulary |
SOLIS SPF 007 (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$0.00 | $0.00 | None | $53.70 |
Browse Plan Formulary |
WellCare Champion (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | S Q:30 /30Days | $47.40 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
WellCare Dividend Prime (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $0.00 | S Q:30 /30Days | $47.40 |
Browse Plan Formulary |
WellCare Elite (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | S Q:30 /30Days | $47.40 |
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 |
WellCare Guardian (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | S Q:30 /30Days | $47.40 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
WellCare Premier (PPO)
|
$0.00 |
$100* |
No |
2* |
Generic |
$0.00 | $0.00 | S Q:30 /30Days | $53.40 |
Browse Plan Formulary |
CareNeeds PLUS (HMO D-SNP)
|
$16.30 |
$445 |
No |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days | $109.80 |
Browse Plan Formulary |
Humana Fully Integrated H1036-282 (HMO D-SNP)
|
$19.90 |
$445 |
No |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days | $110.10 |
Browse Plan Formulary |
Simply Complete (HMO D-SNP)
|
$24.80 |
$445* |
No |
2* |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $123.00 |
Browse Plan Formulary |
WellCare Reserve (HMO D-SNP)
|
$26.40 |
$445 |
No |
4 |
Non-Preferred Drug |
50% | 50% | S Q:30 /30Days | $47.40 |
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 |
Preferred Medicare Assist Plan 1 (HMO D-SNP)
|
$27.10 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | None | $102.00 |
Browse Plan Formulary |
Preferred Medicare Assist Plan 2 (HMO D-SNP)
|
$27.20 |
$445 |
No |
4 |
Tier 4 |
$0.00 | $0.00 | None | $102.00 |
Browse Plan Formulary |
WellCare Access (HMO D-SNP)
|
$28.10 |
$445 |
No |
4 |
Non-Preferred Drug |
50% | 50% | S Q:30 /30Days | $55.20 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-103A (HMO D-SNP)
|
$28.90 |
$445 |
No |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days | $110.10 |
Browse Plan Formulary |
Allwell Dual Medicare (HMO D-SNP)
|
$29.10 |
$445 |
No |
4 |
Non-Preferred Drug |
50% | 50% | S Q:30 /30Days | $120.00 |
Browse Plan Formulary |
Aetna Medicare Assure Plus (HMO D-SNP)
|
$29.50 |
$250 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days | $96.30 |
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 |
HealthSun MediSun Plus (HMO D-SNP)
|
$29.50 |
$435 |
No |
2 |
Generic |
25% | 25% | Q:30 /30Days | $117.60 |
Browse Plan Formulary |
WellCare Liberty (HMO D-SNP)
|
$30.50 |
$445 |
No |
4 |
Non-Preferred Drug |
50% | 50% | S Q:30 /30Days | $55.20 |
Browse Plan Formulary |
Aetna Medicare Assure (HMO D-SNP)
|
$30.80 |
$250 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days | $96.30 |
Browse Plan Formulary |
Allwell Medicare Nurture (HMO D-SNP)
|
$30.80 |
$445 |
No |
4 |
Non-Preferred Drug |
49% | 49% | S Q:30 /30Days | $121.20 |
Browse Plan Formulary |
BlueMedicare Complete (HMO D-SNP)
|
$30.80 |
$445* |
No |
2* |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $87.60 |
Browse Plan Formulary |
Devoted Health Dual Broward (HMO D-SNP)
|
$30.80 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | S Q:30 /30Days | $210.90 |
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 |
Devoted Health Prime Broward (HMO)
|
$30.80 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | S Q:30 /30Days | $210.90 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Freedom Medi-Medi Full (HMO D-SNP)
|
$30.80 |
$445 |
No |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $117.60 |
Browse Plan Formulary |
Freedom Medi-Medi Partial (HMO D-SNP)
|
$30.80 |
$445 |
No |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $117.60 |
Browse Plan Formulary |
HealthSun MediMax (HMO)
|
$30.80 |
$445 |
No |
2 |
Generic |
25% | 25% | Q:30 /30Days | $117.60 |
Browse Plan Formulary |
Longevity Health Plan (HMO I-SNP)
|
$30.80 |
$445 |
No |
1 |
Tier 1 |
25% | n/a | None | $51.90 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax Plus (HMO D-SNP)
|
$30.80 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | None | $102.00 |
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 |
MMM PLATINUM (HMO D-SNP)
|
$30.80 |
$445 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days | $158.40 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$30.80 |
$445 |
No |
4 |
Non-Preferred Drug |
33% | 33% | S Q:30 /30Days | $214.80 |
Browse Plan Formulary |
Optimum Emerald Full (HMO D-SNP)
|
$30.80 |
$445 |
No |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $117.60 |
Browse Plan Formulary |
Optimum Emerald Partial (HMO D-SNP)
|
$30.80 |
$445 |
No |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $117.60 |
Browse Plan Formulary |
Simply Care (HMO I-SNP)
|
$30.80 |
$445 |
No |
2 |
Generic |
$5.00 | n/a | Q:30 /30Days | $117.60 |
Browse Plan Formulary |
Simply Select (HMO)
|
$30.80 |
$445* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $117.60 |
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 |
SOLIS SPF 012 (HMO D-SNP)
|
$30.80 |
$0 |
No |
2 |
Generic |
0% | 0% | None | $53.70 |
Browse Plan Formulary |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$30.80 |
$200 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $101.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$30.80 |
$445 |
No |
4 |
Tier 4 |
15% | 15% | None | $101.40 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$30.80 |
$445 |
No |
4 |
Tier 4 |
15% | 15% | None | $101.40 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO D-SNP)
|
$30.80 |
$445 |
No |
4 |
Tier 4 |
15% | 15% | None | $101.40 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$30.80 |
$445 |
No |
4 |
Tier 4 |
25% | 25% | None | $101.40 |
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 |
HumanaChoice R5826-005 (Regional PPO)
|
$42.90 |
$100 |
No |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:30 /30Days | $110.40 |
Browse Plan Formulary |
BlueMedicare Choice (Regional PPO)
|
$47.90 |
$250* |
No |
2* |
Generic |
$10.00 | $30.00 | Q:30 /30Days | $95.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-065 (PPO)
|
$52.00 |
$350 |
No |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:30 /30Days | $109.80 |
Browse Plan Formulary |
WellCare Prime (PPO)
|
$75.00 |
$0 |
No |
2 |
Generic |
$0.00 | $0.00 | S Q:30 /30Days | $53.40 |
Browse Plan Formulary |
Humana Gold Choice H8145-061 (PFFS)
|
$101.00 |
$200 |
No |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:30 /30Days | $110.40 |
Browse Plan Formulary |
BlueMedicare Select (PPO)
|
$146.80 |
$305 |
No |
2 |
Generic |
$10.00 | $30.00 | Q:30 /30Days | $95.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |