DESVENLAFAXINE SUC ER 100 MG TABLET ER 24H [Pristiq] (30 tablets ) (NDC: 00054040113)
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 Value (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | P Q:30 /30Days | $46.20 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$50 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:360 /90Days | $25.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$50 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:360 /90Days | $25.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$50 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:360 /90Days | $27.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$50 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:360 /90Days | $26.10 |
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 |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$50 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:360 /90Days | $26.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H8087-004 (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $24.00 |
Browse Plan Formulary |
McLaren Medicare Inspire (HMO)
|
$0.00 |
$100* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$12.50 | $28.13 | Q:30 /30Days | $21.60 |
Browse Plan Formulary select insulin pay $10-$35 copay but not this drug |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:360 /90Days | $28.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:360 /90Days | $28.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:360 /90Days | $29.10 |
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 |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:360 /90Days | $28.20 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:360 /90Days | $30.60 |
Browse Plan Formulary |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$12.00 | $24.00 | P Q:30 /30Days | $86.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$8.00 | $0.00 | Q:30 /30Days | $56.10 |
Browse Plan Formulary |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$8.00 | $0.00 | Q:30 /30Days | $56.40 |
Browse Plan Formulary |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$8.00 | $0.00 | Q:30 /30Days | $56.10 |
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 |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $0.00 | Q:30 /30Days | $56.40 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $0.00 | Q:30 /30Days | $55.80 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $0.00 | Q:30 /30Days | $56.40 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $0.00 | Q:30 /30Days | $56.10 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $0.00 | Q:30 /30Days | $56.10 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $0.00 | Q:30 /30Days | $56.10 |
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 |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $0.00 | Q:30 /30Days | $56.10 |
Browse Plan Formulary |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $0.00 | Q:30 /30Days | $56.40 |
Browse Plan Formulary |
Aetna Medicare Premier (PPO)
|
$19.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | P Q:30 /30Days | $46.20 |
Browse Plan Formulary |
HumanaChoice H8087-001 (PPO)
|
$20.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $24.00 |
Browse Plan Formulary |
Humana Value Plus H8087-002 (PPO)
|
$20.60 |
$260 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $24.00 |
Browse Plan Formulary |
HumanaChoice SNP-DE H8087-003 (PPO D-SNP)
|
$21.80 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $24.00 |
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 |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$13.00 | $0.00 | Q:30 /30Days | $56.10 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$13.00 | $0.00 | Q:30 /30Days | $56.40 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$13.00 | $0.00 | Q:30 /30Days | $55.80 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$13.00 | $0.00 | Q:30 /30Days | $56.40 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$13.00 | $0.00 | Q:30 /30Days | $56.10 |
Browse Plan Formulary |
McLaren Medicare Inspire Plus (HMO)
|
$25.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.50 | $28.13 | Q:30 /30Days | $21.60 |
Browse Plan Formulary select insulin pay $10-$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 |
McLaren Medicare Inspire Duals (HMO D-SNP)
|
$31.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $21.60 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$31.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
33% | 33% | P Q:30 /30Days | $86.10 |
Browse Plan Formulary |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$31.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
33% | 33% | P Q:30 /30Days | $86.10 |
Browse Plan Formulary |
PriorityMedicare D-SNP (HMO D-SNP)
|
$31.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$13.00 | $39.00 | Q:30 /30Days | $51.30 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$31.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
$0.00 | $0.00 | Q:120 /30Days | $64.80 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$31.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
$0.00 | $0.00 | Q:120 /30Days | $65.10 |
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 R3887-002 (Regional PPO)
|
$34.10 |
$480 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $24.00 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$35.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $0.00 | Q:30 /30Days | $56.10 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$35.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $0.00 | Q:30 /30Days | $56.40 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$35.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $0.00 | Q:30 /30Days | $55.80 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$35.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $0.00 | Q:30 /30Days | $56.40 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$35.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $0.00 | Q:30 /30Days | $56.10 |
Browse Plan Formulary select insulin pay $15-$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 |
McLaren Medicare Inspire Flex (HMO-POS)
|
$49.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.50 | $28.13 | Q:30 /30Days | $21.60 |
Browse Plan Formulary select insulin pay $10-$35 copay but not this drug |
McLaren Medicare Inspire Flex (HMO-POS)
|
$49.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.50 | $28.13 | Q:30 /30Days | $21.60 |
Browse Plan Formulary select insulin pay $10-$35 copay but not this drug |
PriorityMedicare Merit (PPO)
|
$76.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | $0.00 | Q:30 /30Days | $56.40 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$76.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | $0.00 | Q:30 /30Days | $55.80 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$76.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | $0.00 | Q:30 /30Days | $56.40 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$76.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | $0.00 | Q:30 /30Days | $56.10 |
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 |
PriorityMedicare Merit (PPO)
|
$76.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | $0.00 | Q:30 /30Days | $56.10 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$80.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:360 /90Days | $30.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$80.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:360 /90Days | $28.20 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$80.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:360 /90Days | $29.10 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$80.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:360 /90Days | $28.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$80.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:360 /90Days | $28.50 |
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 |
PriorityMedicare (HMO-POS)
|
$85.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$8.00 | $0.00 | Q:30 /30Days | $56.10 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$85.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$8.00 | $0.00 | Q:30 /30Days | $56.40 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$85.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$8.00 | $0.00 | Q:30 /30Days | $55.80 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$85.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$8.00 | $0.00 | Q:30 /30Days | $56.40 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$85.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$8.00 | $0.00 | Q:30 /30Days | $56.10 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$104.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$38.00 | $114.00 | Q:360 /90Days | $26.40 |
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 |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$104.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$38.00 | $114.00 | Q:360 /90Days | $25.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$104.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$38.00 | $114.00 | Q:360 /90Days | $25.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$104.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$38.00 | $114.00 | Q:360 /90Days | $27.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$104.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$38.00 | $114.00 | Q:360 /90Days | $26.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Medicare Plus Blue PPO Signature (PPO)
|
$122.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:360 /90Days | $28.20 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$122.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:360 /90Days | $29.10 |
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 |
Medicare Plus Blue PPO Signature (PPO)
|
$122.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:360 /90Days | $28.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$122.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:360 /90Days | $28.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$122.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:360 /90Days | $30.60 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$149.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | $0.00 | Q:30 /30Days | $56.40 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$149.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | $0.00 | Q:30 /30Days | $56.10 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$149.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | $0.00 | Q:30 /30Days | $56.40 |
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 |
PriorityMedicare Select (PPO)
|
$149.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | $0.00 | Q:30 /30Days | $55.80 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$149.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | $0.00 | Q:30 /30Days | $56.10 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$228.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$38.00 | $114.00 | Q:360 /90Days | $26.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$228.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$38.00 | $114.00 | Q:360 /90Days | $26.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$228.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$38.00 | $114.00 | Q:360 /90Days | $27.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$228.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$38.00 | $114.00 | Q:360 /90Days | $25.80 |
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 |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$228.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$38.00 | $114.00 | Q:360 /90Days | $25.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Medicare Plus Blue PPO Assure (PPO)
|
$261.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$37.00 | $111.00 | Q:360 /90Days | $30.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$261.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$37.00 | $111.00 | Q:360 /90Days | $28.20 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$261.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$37.00 | $111.00 | Q:360 /90Days | $29.10 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$261.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$37.00 | $111.00 | Q:360 /90Days | $28.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$261.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$37.00 | $111.00 | Q:360 /90Days | $28.50 |
Browse Plan Formulary |