RUFINAMIDE 200 MG TABLET [Banzel] (60 TABLETS ) (NDC: 68462071308)
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. | 5 |
Specialty Tier |
33% | n/a | P Q:480 /30Days | $339.60 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$50 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
32% | n/a | P Q:496 /31Days | $363.00 |
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. | 5 |
Specialty Tier |
32% | n/a | P Q:496 /31Days | $363.00 |
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. | 5 |
Specialty Tier |
32% | n/a | P Q:496 /31Days | $363.00 |
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. | 5 |
Specialty Tier |
32% | n/a | P Q:496 /31Days | $363.00 |
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. | 5 |
Specialty Tier |
32% | n/a | P Q:496 /31Days | $363.00 |
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 | 5 |
Specialty Tier |
33% | n/a | P Q:480 /30Days | $210.00 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $330.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $330.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $330.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $330.60 |
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 |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $330.60 |
Browse Plan Formulary |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
31% | n/a | P Q:480 /30Days | $187.80 |
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 | 5 |
Specialty Tier |
33% | n/a | P | $320.40 |
Browse Plan Formulary |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $320.40 |
Browse Plan Formulary |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $320.40 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $320.40 |
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 |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $320.40 |
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 | 5 |
Specialty Tier |
33% | n/a | P | $320.40 |
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 | 5 |
Specialty Tier |
33% | n/a | P | $320.40 |
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 | 5 |
Specialty Tier |
33% | n/a | P | $320.40 |
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 | 5 |
Specialty Tier |
26% | n/a | P | $320.40 |
Browse Plan Formulary |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
26% | n/a | P | $320.40 |
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 Vital (PPO)
|
$0.00 |
$350 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
26% | n/a | P | $320.40 |
Browse Plan Formulary |
Aetna Medicare Premier (PPO)
|
$11.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:480 /30Days | $339.60 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$16.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
31% | n/a | P | $320.40 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$16.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
31% | n/a | P | $320.40 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$16.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
31% | n/a | P | $320.40 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$16.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
31% | n/a | P | $320.40 |
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 |
PriorityMedicare Value (HMO-POS)
|
$16.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
31% | n/a | P | $320.40 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
HumanaChoice H8087-001 (PPO)
|
$20.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:480 /30Days | $210.00 |
Browse Plan Formulary |
Humana Value Plus H8087-002 (PPO)
|
$20.60 |
$260 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
28% | n/a | P Q:480 /30Days | $210.00 |
Browse Plan Formulary |
HumanaChoice SNP-DE H8087-003 (PPO D-SNP)
|
$21.80 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:480 /30Days | $210.00 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
30% | n/a | P | $320.40 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
30% | n/a | P | $320.40 |
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 Ideal (PPO)
|
$24.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
30% | n/a | P | $320.40 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
30% | n/a | P | $320.40 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
30% | n/a | P | $320.40 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$31.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:480 /30Days | $187.80 |
Browse Plan Formulary |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$31.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:480 /30Days | $187.80 |
Browse Plan Formulary |
PriorityMedicare D-SNP (HMO D-SNP)
|
$31.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P | $320.40 |
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 |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$31.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
$0.00 | $0.00 | None | $639.60 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$31.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
$0.00 | $0.00 | None | $639.60 |
Browse Plan Formulary |
HumanaChoice R3887-002 (Regional PPO)
|
$34.10 |
$480 | No | 5 |
Specialty Tier |
25% | n/a | P Q:480 /30Days | $210.00 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $330.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $330.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $330.60 |
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 |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $330.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $330.60 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$63.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $320.40 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$63.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $320.40 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$63.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $320.40 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$63.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $320.40 |
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 Merit (PPO)
|
$63.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $320.40 |
Browse Plan Formulary |
HumanaChoice H5216-009 (PPO)
|
$71.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:480 /30Days | $210.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
PriorityMedicare (HMO-POS)
|
$74.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $320.40 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$74.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $320.40 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$74.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $320.40 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$74.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $320.40 |
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 (HMO-POS)
|
$74.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $320.40 |
Browse Plan Formulary |
Humana Gold Choice H8145-006 (PFFS)
|
$78.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:480 /30Days | $210.00 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$80.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $363.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$80.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $363.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$80.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $363.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$80.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $363.00 |
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)
|
$80.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $363.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Medicare Plus Blue PPO Signature (PPO)
|
$97.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $330.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$97.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $330.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$97.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $330.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$97.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $330.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$97.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $330.60 |
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 |
PriorityMedicare Select (PPO)
|
$159.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $320.40 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$159.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $320.40 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$159.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $320.40 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$159.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $320.40 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$159.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $320.40 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$179.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $363.00 |
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)
|
$179.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $363.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$179.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $363.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$179.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $363.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$179.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $363.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Medicare Plus Blue PPO Assure (PPO)
|
$201.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $330.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$201.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $330.60 |
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 |
Medicare Plus Blue PPO Assure (PPO)
|
$201.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $330.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$201.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $330.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$201.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:496 /31Days | $330.60 |
Browse Plan Formulary |