AZITHROMYCIN 1 GM POWDER PACKET (3 EA ) (NDC: 59762305102)
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 |
Aetna Medicare Choice Plan (PPO)
|
$0.00 |
$300 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $69.84 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $69.75 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$150* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$47.00 | $141.00 | None | $69.75 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $45.36 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $43.77 |
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 |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $45.00 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $47.25 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $43.86 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $48.12 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $43.05 |
Browse Plan Formulary |
Amerivantage ESRD Care Plus (HMO C-SNP)
|
$0.00 |
$0 | Few Generics | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $45.93 |
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 |
Blue Cross Medicare Advantage Choice Plus (PPO)
|
$0.00 |
$480 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $74.01 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Classic (PPO)
|
$0.00 |
$480 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $74.40 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Value (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $74.37 |
Browse Plan Formulary |
BSW SeniorCare Advantage (PPO)
|
$0.00 |
$300* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$14.00 | $0.00 | None | $70.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Care N' Care Choice (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$14.00 | $28.00 | None | $77.19 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Care N' Care Classic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.00 | $24.00 | None | $77.19 |
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 |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$190* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$42.00 | $126.00 | None | $72.12 |
Browse Plan Formulary |
Cigna Preferred Medicare (PPO)
|
$0.00 |
$190* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$42.00 | $126.00 | None | $72.12 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$190* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$42.00 | $126.00 | None | $72.12 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Global Classic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $65.52 |
Browse Plan Formulary |
Global Special Care (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $65.52 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Global Special Care Savings (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $65.52 |
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 |
Humana Gold Plus H0028-043 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $65.49 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H0028-043 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $66.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Imperial Insurance Company Traditional (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $10.00 | None | $74.04 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Imperial Insurance Traditional Plus (HMO)
|
$0.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $74.04 |
Browse Plan Formulary |
Imperial Insurance Value (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 2 |
Generic |
$5.00 | $10.00 | None | $74.04 |
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 | 2 |
Generic |
$12.00 | $24.00 | None | $65.52 |
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 |
Molina Medicare Choice Care Select (HMO)
|
$0.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $40.00 | None | $65.52 |
Browse Plan Formulary |
Southwestern Health Select (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $0.00 | None | $77.25 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Giveback (HMO)
|
$0.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$20.00 | $40.00 | None | $65.52 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$20.00 | $40.00 | None | $65.52 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$20.00 | $40.00 | None | $65.52 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$20.00 | $40.00 | None | $65.52 |
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 |
Wellcare Giveback (HMO)
|
$0.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$20.00 | $40.00 | None | $65.52 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$20.00 | $40.00 | None | $65.52 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$20.00 | $40.00 | None | $65.52 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$20.00 | $40.00 | None | $65.52 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$20.00 | $40.00 | None | $65.52 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$20.00 | $40.00 | None | $65.52 |
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 |
Wellcare No Premium Medicare (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $74.00 | None | $58.41 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$200 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $70.00 | None | $65.52 |
Browse Plan Formulary |
Wellcare No Premium Rx Plus Open (PPO)
|
$0.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$35.00 | $70.00 | None | $65.52 |
Browse Plan Formulary |
Wellcare TexanPlus No Premium (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$20.00 | $40.00 | None | $65.52 |
Browse Plan Formulary |
Aetna Medicare Choice II Plan (PPO)
|
$10.00 |
$200* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$47.00 | $141.00 | None | $69.75 |
Browse Plan Formulary |
HumanaChoice H5216-043 (PPO)
|
$10.00 |
$250* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$47.00 | $131.00 | None | $65.46 |
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 |
HumanaChoice H5216-043 (PPO)
|
$10.00 |
$250* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$47.00 | $131.00 | None | $65.61 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Complement Assist (HMO)
|
$14.90 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $49.92 |
Browse Plan Formulary |
Amerivantage Choice (PPO)
|
$15.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$37.00 | $111.00 | None | $45.27 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$17.90 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | None | $72.12 |
Browse Plan Formulary |
Aetna Medicare Dual Complete Plan (HMO D-SNP)
|
$18.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $69.75 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Dual Care Plus (HMO D-SNP)
|
$18.80 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $77.31 |
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 Assist (HMO)
|
$20.60 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $65.52 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H0028-031 (HMO D-SNP)
|
$24.40 |
$475 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $65.67 |
Browse Plan Formulary |
American Health Advantage of Texas (HMO I-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $74.31 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $45.36 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $48.12 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $43.77 |
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 |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $45.00 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $47.25 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $43.05 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $43.86 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $43.86 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $43.77 |
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 |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $45.00 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $47.25 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $43.05 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $48.12 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H0028-032 (HMO D-SNP)
|
$25.10 |
$460 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $65.85 |
Browse Plan Formulary |
Imperial Insurance Company Dual (HMO D-SNP)
|
$25.10 |
$480 | Many Generics, Some Brands | 2 |
Generic |
25% | 25% | None | $74.01 |
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)
|
$25.10 |
$480 | Some Generics | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $65.52 |
Browse Plan Formulary |
Texas Independence Health Plan, Inc. (HMO I-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $74.07 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $90.00 | None | $65.52 |
Browse Plan Formulary |
Wellcare Dual Access Harmony (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $49.44 |
Browse Plan Formulary |
Wellcare Dual Access Open (PPO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $65.52 |
Browse Plan Formulary |
Wellcare Dual Liberty (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $65.52 |
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 |
Wellcare Dual Liberty Nurture (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $49.38 |
Browse Plan Formulary |
HumanaChoice R4182-004 (Regional PPO)
|
$43.60 |
$175 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $65.61 |
Browse Plan Formulary |
HumanaChoice R4182-003 (Regional PPO)
|
$51.00 |
$175 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $65.61 |
Browse Plan Formulary |
Care N' Care Choice Plus (PPO)
|
$55.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.00 | $24.00 | None | $77.19 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Blue Cross Medicare Advantage Choice Premier (PPO)
|
$62.00 |
$295 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $74.01 |
Browse Plan Formulary |
HumanaChoice H5216-042 (PPO)
|
$94.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 3* |
Preferred Brand |
$47.00 | $131.00 | None | $65.46 |
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 |
Humana Gold Choice H8145-084 (PFFS)
|
$97.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 3* |
Preferred Brand |
$47.00 | $131.00 | None | $65.46 |
Browse Plan Formulary |
Care N' Care Choice Premium (PPO)
|
$200.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $20.00 | None | $77.19 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |