BUPRENORPHN-NALOXN 2-0.5 MG TABLET SUSLIGUAL [Suboxone] (30 tablets ) (NDC: 00054018813)
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 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $0.00 | Q:90 /30Days | $84.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice (PPO)
|
$0.00 |
$150* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$10.00 | $0.00 | Q:90 /30Days | $84.30 |
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. | 2* |
Generic |
$14.00 | $28.00 | Q:90 /30Days | $77.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AdventHealth SunSaver Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $0.00 | Q:90 /30Days | $106.20 |
Browse Plan Formulary |
Aetna Medicare Choice (HMO-POS)
|
$0.00 |
$195* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$0.00 | $0.00 | Q:90 /30Days | $9.30 |
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 |
Aetna Medicare Premier (PPO)
|
$0.00 |
$300* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$0.00 | $0.00 | Q:90 /30Days | $8.40 |
Browse Plan Formulary |
Aetna Medicare Premier Plus (PPO)
|
$0.00 |
$150* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$0.00 | $0.00 | Q:90 /30Days | $6.60 |
Browse Plan Formulary |
Aetna Medicare Select (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | Q:90 /30Days | $6.60 |
Browse Plan Formulary select insulin pay $20 copay but not this drug |
BlueMedicare Classic (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$10.00 | $30.00 | Q:120 /30Days | $119.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BlueMedicare Premier (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | Q:120 /30Days | $119.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BlueMedicare Value (PPO)
|
$0.00 |
$150* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$8.00 | $24.00 | Q:120 /30Days | $124.20 |
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 |
Bright Advantage Health Dollars Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | Q:90 /30Days | $38.70 |
Browse Plan Formulary |
Bright Advantage Health Dollars Plan (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | Q:90 /30Days | $38.70 |
Browse Plan Formulary |
Bright Advantage Part B Savings Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$15.00 | $30.00 | Q:90 /30Days | $38.70 |
Browse Plan Formulary |
Bright Advantage Part B Savings Plan (PPO)
|
$0.00 |
$110 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | Q:90 /30Days | $38.70 |
Browse Plan Formulary |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$0.00 | $0.00 | Q:360 /30Days | $52.80 |
Browse Plan Formulary |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$4.00 | $0.00 | Q:360 /30Days | $52.80 |
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 additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$4.00 | $0.00 | Q:360 /30Days | $52.80 |
Browse Plan Formulary |
Devoted Health Core Greater Orlando (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | Q:90 /30Days | $103.50 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Devoted Health Essentials Greater Orlando (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$5.00 | $0.00 | Q:90 /30Days | $103.50 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Devoted Health Latitude Greater Orlando (PPO)
|
$0.00 |
$150* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$0.00 | $0.00 | Q:90 /30Days | $103.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
FHCP Medicare Premier Advantage (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $12.00 | None | $38.40 |
Browse Plan Formulary |
FHCP Medicare Premier Plus (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$7.00 | $18.00 | None | $57.00 |
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 |
FHCP Medicare Rx Savings (HMO)
|
$0.00 |
$395* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $27.00 | None | $38.40 |
Browse Plan Formulary |
Freedom Platinum Plan Rx (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:360 /30Days | $72.90 |
Browse Plan Formulary |
Freedom Platinum Rewards Plan Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:360 /30Days | $73.20 |
Browse Plan Formulary |
Freedom VIP Care (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Some Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:360 /30Days | $73.20 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Freedom VIP Savings (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Some Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:360 /30Days | $73.20 |
Browse Plan Formulary select insulin pay $0-$10 copay but not this drug |
Freedom VIP Savings COPD (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:360 /30Days | $73.20 |
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 Choice Care (HMO)
|
$0.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$12.00 | $24.00 | Q:90 /30Days | $111.90 |
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 | 2 |
Generic |
$20.00 | $40.00 | Q:90 /30Days | $111.90 |
Browse Plan Formulary |
Molina Medicare Connect Care (HMO C-SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$8.00 | $24.00 | Q:90 /30Days | $111.90 |
Browse Plan Formulary |
Optimum Diamond Rewards (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:360 /30Days | $73.20 |
Browse Plan Formulary |
Optimum Diamond Rewards COPD (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:360 /30Days | $73.20 |
Browse Plan Formulary |
Optimum Gold Rewards Plan (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | Q:360 /30Days | $73.20 |
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 |
Simply Care (HMO I-SNP)
|
$0.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$5.00 | n/a | Q:360 /30Days | $73.20 |
Browse Plan Formulary |
Simply Comfort (HMO I-SNP)
|
$0.00 |
$480 | Some Generics, Few Brands | 2 |
Generic |
$5.00 | n/a | Q:360 /30Days | $73.20 |
Browse Plan Formulary |
Simply Extra (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$10.00 | $0.00 | Q:360 /30Days | $72.90 |
Browse Plan Formulary |
Simply Level (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 2 |
Generic |
$0.00 | $0.00 | Q:360 /30Days | $72.90 |
Browse Plan Formulary |
Simply More (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | Q:360 /30Days | $72.90 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150* | Some Generics | 2* |
Generic |
$0.00 | $0.00 | Q:90 /30Days | $74.70 |
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 |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150* | Some Generics | 2* |
Generic |
$0.00 | $0.00 | Q:90 /30Days | $89.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150* | Some Generics | 2* |
Generic |
$0.00 | $0.00 | Q:90 /30Days | $75.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150* | Some Generics | 2* |
Generic |
$0.00 | $0.00 | Q:90 /30Days | $83.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Giveback (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | Q:90 /30Days | $8.40 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | Q:90 /30Days | $8.40 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$100* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$0.00 | $0.00 | Q:90 /30Days | $9.00 |
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 Specialty Giveback (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 2 |
Generic |
$0.00 | $0.00 | Q:90 /30Days | $12.30 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
Wellcare Specialty No Premium (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 2 |
Generic |
$0.00 | $0.00 | Q:90 /30Days | $10.50 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
Cigna TotalCare Plus (HMO D-SNP)
|
$20.80 |
$480* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$13.00 | $0.00 | Q:360 /30Days | $52.80 |
Browse Plan Formulary |
Cigna Primary Medicare (HMO)
|
$23.60 |
$480* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$12.00 | $0.00 | Q:360 /30Days | $52.80 |
Browse Plan Formulary |
Aetna Medicare Assure (HMO D-SNP)
|
$25.20 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$5.00 | $15.00 | Q:90 /30Days | $6.30 |
Browse Plan Formulary |
Aetna Medicare Assure Plus (HMO D-SNP)
|
$30.80 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$5.00 | $15.00 | Q:90 /30Days | $6.30 |
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 |
UnitedHealthcare Dual Complete RP (Regional PPO D-SNP)
|
$31.50 |
$480 | No | 2 |
Tier 2 |
15% | 15% | Q:90 /30Days | $77.40 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$32.30 |
$480* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$0.00 | $0.00 | Q:90 /30Days | $35.40 |
Browse Plan Formulary |
Wellcare Dual Medicare (HMO D-SNP)
|
$33.70 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$8.00 | $0.00 | Q:90 /30Days | $27.60 |
Browse Plan Formulary |
American Health Advantage of Florida (HMO I-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $108.30 |
Browse Plan Formulary |
BlueMedicare Complete (HMO D-SNP)
|
$34.30 |
$480* | Some Generics, Few Brands | 2* |
Generic |
$0.00 | $0.00 | Q:120 /30Days | $121.80 |
Browse Plan Formulary |
Devoted Health Dual Greater Orlando (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
25% | 25% | Q:90 /30Days | $103.50 |
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 |
Devoted Health Prime (HMO)
|
$34.30 |
$480* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$0.00 | $0.00 | Q:90 /30Days | $104.10 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Devoted Health Prime (HMO)
|
$34.30 |
$480* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$0.00 | $0.00 | Q:90 /30Days | $103.50 |
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% | Q:90 /30Days | $131.10 |
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% | Q:90 /30Days | $131.10 |
Browse Plan Formulary |
Freedom Medi-Medi Full (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$10.00 | $30.00 | Q:360 /30Days | $73.20 |
Browse Plan Formulary |
Freedom Medi-Medi Partial (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$10.00 | $30.00 | Q:360 /30Days | $73.20 |
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 |
Longevity Health Plan (HMO I-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | Q:360 /30Days | $36.30 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$34.30 |
$480* | Some Generics, Few Brands | 2* |
Generic |
$0.00 | $0.00 | Q:90 /30Days | $111.90 |
Browse Plan Formulary |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$34.30 |
$480* | Some Generics, Few Brands | 2* |
Generic |
$0.00 | $0.00 | Q:90 /30Days | $111.90 |
Browse Plan Formulary |
Optimum Emerald Full (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$10.00 | $30.00 | Q:360 /30Days | $73.20 |
Browse Plan Formulary |
Optimum Emerald Partial (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$10.00 | $30.00 | Q:360 /30Days | $73.20 |
Browse Plan Formulary |
Simply Complete (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $60.00 | Q:360 /30Days | $84.60 |
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 |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$34.30 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$12.00 | $0.00 | Q:90 /30Days | $78.30 |
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 | 2 |
Tier 2 |
15% | 15% | Q:90 /30Days | $80.10 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | Q:90 /30Days | $75.60 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | Q:90 /30Days | $78.90 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | Q:90 /30Days | $78.90 |
Browse Plan Formulary |
Wellcare Dual Liberty (HMO D-SNP)
|
$34.30 |
$480* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$0.00 | $0.00 | Q:90 /30Days | $35.40 |
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 Dual Nurture (HMO D-SNP)
|
$34.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $0.00 | Q:90 /30Days | $27.60 |
Browse Plan Formulary |
Wellcare Dual Reserve (HMO D-SNP)
|
$34.30 |
$480* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$0.00 | $0.00 | Q:90 /30Days | $36.60 |
Browse Plan Formulary |
BlueMedicare Choice (Regional PPO)
|
$47.90 |
$250* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$10.00 | $30.00 | Q:120 /30Days | $102.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Premium Enhanced Open (PPO)
|
$85.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | Q:90 /30Days | $9.00 |
Browse Plan Formulary |