SULFACETAMIDE 10% EYE OINTMENT (3.5 GM ) (NDC: 00574419035)
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. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:42 /30Days | $62.04 |
Browse Plan Formulary |
Ascension Complete Michigan Access (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$37.00 | $74.00 | None | $56.76 |
Browse Plan Formulary |
Ascension Complete Michigan Access Plus (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$37.00 | $74.00 | None | $56.76 |
Browse Plan Formulary |
Ascension Complete Michigan Reward (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$37.00 | $74.00 | None | $56.76 |
Browse Plan Formulary |
Ascension Complete Michigan Secure (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $74.00 | None | $56.76 |
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 |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$50* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$11.00 | $0.00 | Q:7 /30Days | $47.20 |
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. |
2* |
Generic |
$11.00 | $0.00 | Q:7 /30Days | $45.20 |
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. |
2* |
Generic |
$11.00 | $0.00 | Q:7 /30Days | $47.20 |
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. |
2* |
Generic |
$11.00 | $0.00 | Q:7 /30Days | $45.20 |
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. |
2* |
Generic |
$11.00 | $0.00 | Q:7 /30Days | $47.20 |
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 | None | $56.44 |
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 |
McLaren Medicare Inspire (HMO)
|
$0.00 |
$100* |
Yes, this drug has Gap Coverage. |
1* |
Preferred Generic |
$3.50 | $7.88 | None | $52.68 |
Browse Plan Formulary select insulin pay $10-$35 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 | $60.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
PriorityMedicare Compass (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $0.00 | None | $59.92 |
Browse Plan Formulary |
PriorityMedicare Compass (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $0.00 | None | $46.88 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $0.00 | None | $46.88 |
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 | None | $46.88 |
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 |
2 |
Generic |
$15.00 | $0.00 | None | $59.92 |
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 | None | $59.92 |
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 | None | $46.88 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
Medicare Plus Blue PPO Essential (PPO)
|
$10.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$11.00 | $0.00 | Q:7 /30Days | $47.08 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$10.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$11.00 | $0.00 | Q:7 /30Days | $45.20 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$10.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$11.00 | $0.00 | Q:7 /30Days | $47.08 |
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)
|
$10.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$11.00 | $0.00 | Q:7 /30Days | $45.20 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$10.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$11.00 | $0.00 | Q:7 /30Days | $47.08 |
Browse Plan Formulary |
Aetna Medicare Premier (PPO)
|
$19.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:42 /30Days | $62.04 |
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 | None | $56.44 |
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 | None | $56.44 |
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 | None | $56.44 |
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 | None | $59.92 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$13.00 | $0.00 | None | $59.92 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$13.00 | $0.00 | None | $46.88 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$13.00 | $0.00 | None | $46.88 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$13.00 | $0.00 | None | $46.88 |
Browse Plan Formulary |
McLaren Medicare Inspire Plus (HMO)
|
$25.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$3.50 | $7.88 | None | $52.68 |
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 |
Ascension Complete Michigan DSNP (HMO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$46.00 | $92.00 | None | $56.48 |
Browse Plan Formulary |
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 | None | $52.68 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $60.40 |
Browse Plan Formulary |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $60.40 |
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 | None | $45.20 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $58.20 |
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 Choice (PPO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $58.20 |
Browse Plan Formulary |
HumanaChoice R3887-002 (Regional PPO)
|
$34.10 |
$480 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $56.44 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$47.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | None | $59.92 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$47.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | None | $59.92 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$47.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | None | $46.88 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$47.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | None | $46.88 |
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)
|
$47.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | None | $46.88 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
McLaren Medicare Inspire Flex (HMO-POS)
|
$49.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$3.50 | $7.88 | None | $52.68 |
Browse Plan Formulary select insulin pay $10-$35 copay but not this drug |
McLaren Medicare Inspire Flex (HMO-POS)
|
$49.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$3.50 | $7.88 | None | $52.68 |
Browse Plan Formulary select insulin pay $10-$35 copay but not this drug |
BCN Advantage HMO ConnectedCare (HMO)
|
$58.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | Q:7 /30Days | $47.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Medicare Plus Blue PPO Vitality (PPO)
|
$85.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$11.00 | $0.00 | Q:7 /30Days | $47.08 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$85.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$11.00 | $0.00 | Q:7 /30Days | $45.20 |
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 |
Medicare Plus Blue PPO Vitality (PPO)
|
$85.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$11.00 | $0.00 | Q:7 /30Days | $47.08 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$85.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$11.00 | $0.00 | Q:7 /30Days | $45.20 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$85.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$11.00 | $0.00 | Q:7 /30Days | $47.08 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$103.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | None | $59.92 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$103.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | None | $59.92 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$103.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | None | $46.88 |
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)
|
$103.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | None | $46.88 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$103.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | None | $46.88 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$121.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | None | $59.92 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$121.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | None | $59.92 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$121.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | None | $46.88 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$121.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | None | $46.88 |
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)
|
$121.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | None | $46.88 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.00 | $0.00 | Q:7 /30Days | $47.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.00 | $0.00 | Q:7 /30Days | $45.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.00 | $0.00 | Q:7 /30Days | $47.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.00 | $0.00 | Q:7 /30Days | $45.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.00 | $0.00 | Q:7 /30Days | $47.20 |
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 |
Medicare Plus Blue PPO Signature (PPO)
|
$152.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | Q:7 /30Days | $47.08 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$152.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | Q:7 /30Days | $45.20 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$152.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | Q:7 /30Days | $47.08 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$152.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | Q:7 /30Days | $45.20 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$152.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | Q:7 /30Days | $47.08 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$225.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $0.00 | None | $59.92 |
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)
|
$225.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $0.00 | None | $59.92 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$225.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $0.00 | None | $46.88 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$225.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $0.00 | None | $46.88 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$225.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $0.00 | None | $46.88 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$238.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.00 | $0.00 | Q:7 /30Days | $45.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$238.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.00 | $0.00 | Q:7 /30Days | $47.20 |
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 |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$238.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.00 | $0.00 | Q:7 /30Days | $45.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$238.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.00 | $0.00 | Q:7 /30Days | $47.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$238.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.00 | $0.00 | Q:7 /30Days | $47.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Medicare Plus Blue PPO Assure (PPO)
|
$301.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.00 | $0.00 | Q:7 /30Days | $47.08 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$301.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.00 | $0.00 | Q:7 /30Days | $45.20 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$301.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.00 | $0.00 | Q:7 /30Days | $47.08 |
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)
|
$301.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.00 | $0.00 | Q:7 /30Days | $47.08 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$301.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.00 | $0.00 | Q:7 /30Days | $45.20 |
Browse Plan Formulary |