TOLTERODINE TART ER 2 MG CAPSULE ER 24H [Detrol LA] (30 CAPSULES ) (NDC: 00093716356)
2022 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
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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 Choice Plan 2 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $87.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Plan 1 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $87.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Credit Value (PPO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days | $84.00 |
Browse Plan Formulary |
Aetna Medicare Advantra Value (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days | $87.90 |
Browse Plan Formulary |
Aetna Medicare Elite (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days | $129.90 |
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 Value (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days | $85.50 |
Browse Plan Formulary |
Cigna Achieve Medicare (HMO C-SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $94.20 |
Browse Plan Formulary |
Cigna Alliance Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $94.20 |
Browse Plan Formulary |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $94.20 |
Browse Plan Formulary |
Clover Health Choice (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | S Q:30 /30Days | $180.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Erickson Advantage Liberty with Drugs (HMO-POS)
|
$0.00 |
$400 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $94.50 |
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 |
Geisinger Gold Classic 360 Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | Q:30 /30Days | $34.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | Q:30 /30Days | $34.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | Q:30 /30Days | $34.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Health Partners Medicare Complete (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $143.70 |
Browse Plan Formulary |
Humana Gold Plus H6622-037 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $107.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5525-051 (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $107.70 |
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 |
HumanaChoice H5525-051 (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $112.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Keystone 65 Basic Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $23.10 |
Browse Plan Formulary |
Keystone 65 Focus Rx (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $23.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Personal Choice 65 Prime Rx (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $23.10 |
Browse Plan Formulary |
Personal Choice 65 Saver Rx (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $23.10 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | S Q:30 /30Days | $126.90 |
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 Open (PPO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | S Q:30 /30Days | $128.40 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
46% | 46% | S Q:30 /30Days | $133.50 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
43% | 43% | S Q:30 /30Days | $128.40 |
Browse Plan Formulary |
Aetna Medicare Advantra Premier (HMO)
|
$16.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days | $87.90 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H6622-078 (HMO D-SNP)
|
$23.70 |
$450 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $107.70 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H6622-078 (HMO D-SNP)
|
$23.70 |
$450 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $111.60 |
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 |
Wellcare Assist Open (PPO)
|
$24.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
43% | 43% | S Q:30 /30Days | $128.40 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 2 (HMO)
|
$27.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $87.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Cares (HMO D-SNP)
|
$28.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | S Q:30 /30Days | $131.10 |
Browse Plan Formulary |
Wellcare Low Premium Open (PPO)
|
$29.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
43% | 43% | S Q:30 /30Days | $128.40 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$29.80 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $94.20 |
Browse Plan Formulary |
Cigna TotalCare Plus (HMO D-SNP)
|
$29.80 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $96.90 |
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 |
Erickson Advantage Guardian (HMO-POS I-SNP)
|
$32.30 |
$0 |
Some Generics |
4 |
Non-Preferred Drug |
$70.00 | $200.00 | None | $94.50 |
Browse Plan Formulary select insulin pay $28 copay but not this drug |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$33.90 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $86.10 |
Browse Plan Formulary |
HumanaChoice R0923-002 (Regional PPO)
|
$34.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:30 /30Days | $111.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Cigna Preferred Medicare (HMO)
|
$35.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $94.20 |
Browse Plan Formulary |
Wellcare Assist (HMO)
|
$36.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
42% | 42% | S Q:30 /30Days | $126.60 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | Q:30 /30Days | $35.40 |
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 |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | Q:30 /30Days | $34.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
|
$40.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $85.20 |
Browse Plan Formulary |
Clover Health Choice Value (PPO)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | S Q:30 /30Days | $180.60 |
Browse Plan Formulary |
Geisinger Gold Secure Rx (HMO D-SNP)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $34.80 |
Browse Plan Formulary |
Health Partners Medicare Prime (HMO-POS)
|
$40.70 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $143.70 |
Browse Plan Formulary |
Health Partners Medicare Special (HMO D-SNP)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $143.70 |
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 |
Highmark Wholecare Medicare Assured Diamond (HMO D-SNP)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$41.00 | $123.00 | Q:30 /30Days | $63.00 |
Browse Plan Formulary |
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $63.00 |
Browse Plan Formulary |
Keystone First VIP Choice (HMO D-SNP)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$6.00 | $18.00 | S | $29.70 |
Browse Plan Formulary |
Provider Partners Pennsylvania Advantage Plan (HMO I-SNP)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $113.10 |
Browse Plan Formulary |
Provider Partners Pennsylvania Community Plan (HMO I-SNP)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $113.10 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Select (HMO D-SNP)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $86.10 |
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 |
UPMC for Life Complete Care (HMO D-SNP)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$19.00 | $38.00 | None | $90.00 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$40.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | S Q:30 /30Days | $121.50 |
Browse Plan Formulary |
AARP Medicare Advantage Choice Plan 1 (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $87.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $0.00 | Q:30 /30Days | $35.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $0.00 | Q:30 /30Days | $34.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $0.00 | Q:30 /30Days | $34.50 |
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 |
Aetna Medicare Advantra Premier Plus (PPO)
|
$50.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days | $87.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Personal Choice 65 Elite Rx (PPO)
|
$51.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $23.10 |
Browse Plan Formulary |
Keystone 65 Select Rx (HMO)
|
$57.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $23.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Cigna True Choice Plus Medicare (PPO)
|
$60.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $94.20 |
Browse Plan Formulary |
HumanaChoice H5525-005 (PPO)
|
$62.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $107.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Silver (HMO)
|
$65.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days | $131.70 |
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 |
Erickson Advantage Freedom (HMO-POS)
|
$70.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $245.00 | None | $94.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$86.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | Q:30 /30Days | $34.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$86.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | Q:30 /30Days | $35.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Premier (HMO-POS)
|
$96.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days | $131.10 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$122.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | Q:30 /30Days | $34.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$122.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | Q:30 /30Days | $34.80 |
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 |
Geisinger Gold Classic Advantage Rx (HMO)
|
$122.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | Q:30 /30Days | $35.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-120 (PPO)
|
$128.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:30 /30Days | $111.30 |
Browse Plan Formulary |
Cigna Preferred Plus Medicare (HMO)
|
$135.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $94.20 |
Browse Plan Formulary |
Aetna Medicare Premier Plus (HMO)
|
$146.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days | $87.90 |
Browse Plan Formulary |
Aetna Medicare Gold Plan (PPO)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days | $84.30 |
Browse Plan Formulary |
Erickson Advantage Champion (HMO-POS C-SNP)
|
$199.00 |
$0 |
Some Generics |
4 |
Non-Preferred Drug |
$85.00 | $245.00 | None | $94.50 |
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 |
Erickson Advantage Signature with Drugs (HMO-POS)
|
$199.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $245.00 | None | $94.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Keystone 65 Preferred Rx (HMO)
|
$231.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $23.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Personal Choice 65 Rx (PPO)
|
$294.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $23.10 |
Browse Plan Formulary |