OCTAGAM 10% VIAL (NDC: 68982085001)
2022 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 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
30% | n/a | P | $382.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice Plan 2 (Regional PPO)
|
$0.00 |
$395 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
26% | n/a | P | $383.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Choice (HMO-POS)
|
$0.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
29% | n/a | P | $402.00 |
Browse Plan Formulary |
Aetna Medicare Credit (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $382.00 |
Browse Plan Formulary |
Aetna Medicare Premier (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | P | $402.20 |
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. |
5 |
Specialty Tier |
30% | n/a | P | $401.00 |
Browse Plan Formulary |
Aetna Medicare Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $361.40 |
Browse Plan Formulary select insulin pay $20 copay but not this drug |
AvMed Medicare Access (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $349.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AvMed Medicare Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $349.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AvMed Medicare Circle (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $349.40 |
Browse Plan Formulary select insulin pay $30-$35 copay but not this drug |
AvMed Medicare Premium Saver (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $349.40 |
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 |
Bright Advantage Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics |
5 |
Specialty Tier |
33% | n/a | P | $360.80 |
Browse Plan Formulary select insulin pay $0-$25 copay but not this drug |
Bright Advantage Health Dollars Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $360.80 |
Browse Plan Formulary |
Bright Advantage Part B Savings Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $360.80 |
Browse Plan Formulary |
Bright Advantage Part B Savings Plan (PPO)
|
$0.00 |
$110 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $348.80 |
Browse Plan Formulary |
Devoted Health Core Broward (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $340.60 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Devoted Health Essentials Broward (HMO)
|
$0.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | P | $340.60 |
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 |
Devoted Health Latitude South Florida (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
30% | n/a | P | $340.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
DrMax-B (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $360.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
DrValue-B (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $360.80 |
Browse Plan Formulary |
Freedom VIP Savings (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
4 |
Specialty Tier |
33% | n/a | P | $345.00 |
Browse Plan Formulary |
Freedom VIP Savings COPD (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
4 |
Specialty Tier |
33% | n/a | P | $345.00 |
Browse Plan Formulary |
HealthSun HealthAdvantage Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $246.60 |
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 |
HealthSun HealthAdvantage Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $246.60 |
Browse Plan Formulary |
MedicareMax (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $384.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MMM ELITE (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $349.40 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
MMM EXTRA (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $349.40 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | P | $349.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Molina Medicare Choice Care Select (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $349.20 |
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 Connect Care (HMO C-SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $349.20 |
Browse Plan Formulary |
Optimum Gold Rewards Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Specialty Tier |
33% | n/a | P | $345.00 |
Browse Plan Formulary |
Optimum Platinum Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Specialty Tier |
33% | n/a | P | $345.00 |
Browse Plan Formulary |
Oscar + Holy Cross + Memorial - with $1500 O-Card (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $349.40 |
Browse Plan Formulary |
Oscar + Holy Cross + Memorial - with Refund Bonus (HMO)
|
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $349.40 |
Browse Plan Formulary |
Oscar + Holy Cross + Memorial (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $349.40 |
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 |
PHP (HMO C-SNP)
|
$0.00 |
$480 |
Few Generics |
4 |
Specialty Tier |
25% | n/a | P | $431.00 |
Browse Plan Formulary |
Preferred Choice Broward (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $384.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Simply Care (HMO I-SNP)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $345.20 |
Browse Plan Formulary |
Simply Comfort (HMO I-SNP)
|
$0.00 |
$480 |
Some Generics, Few Brands |
5 |
Specialty Tier |
25% | n/a | P | $345.20 |
Browse Plan Formulary |
Simply Extra (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $344.80 |
Browse Plan Formulary |
Simply Level (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
5 |
Specialty Tier |
33% | n/a | P | $344.80 |
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 |
Simply More (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $344.80 |
Browse Plan Formulary |
SOLIS SPF 007 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $412.60 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $266.40 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $266.40 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$100 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
31% | n/a | P | $268.20 |
Browse Plan Formulary |
Wellcare Specialty Giveback (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
5 |
Specialty Tier |
33% | n/a | P | $266.40 |
Browse Plan Formulary select insulin pay $10 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 |
Wellcare Specialty No Premium (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
5 |
Specialty Tier |
33% | n/a | P | $266.40 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
DrPlus-B (HMO-POS D-SNP)
|
$26.50 |
$0 |
Many Generics, Some Brands |
5 |
Specialty Tier |
33% | n/a | P | $360.80 |
Browse Plan Formulary |
Aetna Medicare Assure Plus (HMO D-SNP)
|
$27.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $382.00 |
Browse Plan Formulary |
Wellcare Dual Reserve (HMO D-SNP)
|
$30.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $260.60 |
Browse Plan Formulary |
MedicareMax Plus 2 (HMO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P | $368.20 |
Browse Plan Formulary |
Preferred Medicare Assist Plan 2 (HMO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P | $368.20 |
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 Dual Complete RP (Regional PPO D-SNP)
|
$31.50 |
$480 |
No |
5 |
Tier 5 |
15% | 15% | P | $383.00 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$32.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $262.20 |
Browse Plan Formulary |
Preferred Medicare Assist Plan 1 (HMO D-SNP)
|
$34.00 |
$480 |
Some Generics, Few Brands |
5 |
Specialty Tier |
25% | n/a | P | $368.20 |
Browse Plan Formulary |
Aetna Medicare Assure (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $382.00 |
Browse Plan Formulary |
Bright Advantage Embrace Assist Plan (HMO C-SNP)
|
$34.30 |
$480 |
Some Generics |
5 |
Specialty Tier |
25% | n/a | P | $348.80 |
Browse Plan Formulary |
Bright Advantage Embrace Choice Plan (HMO C-SNP)
|
$34.30 |
$480 |
Some Generics |
5 |
Specialty Tier |
25% | n/a | P | $348.80 |
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 |
Devoted Health Dual Broward (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $340.60 |
Browse Plan Formulary |
Devoted Health Prime South Florida (HMO)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $340.60 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Devoted Health Prime South Florida (HMO)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $340.60 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Devoted Health Prime South Florida (HMO)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $340.60 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Florida Complete Care (HMO I-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P | $353.80 |
Browse Plan Formulary |
Florida Complete Care- In The Community (HMO I-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P | $353.80 |
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 |
Freedom Medi-Medi Full (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
25% | n/a | P | $345.40 |
Browse Plan Formulary |
Freedom Medi-Medi Partial (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
25% | n/a | P | $345.40 |
Browse Plan Formulary |
HealthSun MediMax (HMO)
|
$34.30 |
$430 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $344.80 |
Browse Plan Formulary |
HealthSun MediSun Extra (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $344.80 |
Browse Plan Formulary |
HealthSun MediSun Plus (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $344.80 |
Browse Plan Formulary |
Longevity Health Plan (HMO I-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | P | $346.20 |
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 |
MedicareMax Plus 1 (HMO D-SNP)
|
$34.30 |
$480 |
Some Generics, Few Brands |
5 |
Specialty Tier |
25% | n/a | P | $368.20 |
Browse Plan Formulary |
MMM PLATINUM (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $349.40 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$34.30 |
$480 |
Some Generics, Few Brands |
5 |
Specialty Tier |
25% | n/a | P | $349.20 |
Browse Plan Formulary |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$34.30 |
$480 |
Some Generics, Few Brands |
5 |
Specialty Tier |
25% | n/a | P | $349.20 |
Browse Plan Formulary |
Optimum Emerald Full (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
25% | n/a | P | $345.40 |
Browse Plan Formulary |
Optimum Emerald Partial (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
25% | n/a | P | $345.40 |
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 |
Simply Complete (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $246.60 |
Browse Plan Formulary |
SOLIS SPF 012 (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $412.40 |
Browse Plan Formulary |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$34.30 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | P | $383.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | P | $383.00 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | P | $383.40 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $383.00 |
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 |
Wellcare Dual Liberty (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $262.20 |
Browse Plan Formulary |
Wellcare Dual Medicare (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $260.60 |
Browse Plan Formulary |
Wellcare Dual Nurture (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $262.80 |
Browse Plan Formulary |
Wellcare Premium Enhanced Open (PPO)
|
$85.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $268.20 |
Browse Plan Formulary |