Vimpat 100mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC (60 TABLET, FILM COATED ) (NDC: 00131247835)
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 Freedom Plus (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $1,057.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Freedom Plus (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $1,057.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Harmony (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $1,057.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Harmony (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $1,057.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons Focus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $1,057.80 |
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 |
AARP Medicare Advantage SecureHorizons Focus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $1,057.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $1,057.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $1,057.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Plus Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $1,074.60 |
Browse Plan Formulary |
Aetna Medicare Plus Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $1,074.60 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $1,075.20 |
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 |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $1,075.20 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $1,074.60 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $1,074.60 |
Browse Plan Formulary |
Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
0% | 0% | Q:60 /30Days | $958.80 |
Browse Plan Formulary |
Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan)
|
$0.00 |
$0 | All Generics, All Brands | 2 |
Tier 2 |
0% | 0% | Q:60 /30Days | $958.80 |
Browse Plan Formulary |
Anthem MediBlue Care On Site (HMO I-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:60 /30Days | $958.80 |
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 |
Anthem MediBlue Care On Site (HMO I-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:60 /30Days | $958.80 |
Browse Plan Formulary |
Anthem MediBlue Diabetes Care (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:60 /30Days | $1,080.00 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Anthem MediBlue Diabetes Care (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:60 /30Days | $1,080.00 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Anthem MediBlue Dual Advantage (HMO D-SNP)
|
$0.00 |
$480 | Few Generics | 5 |
Specialty Tier |
25% | n/a | Q:60 /30Days | $1,079.40 |
Browse Plan Formulary |
Anthem MediBlue Dual Advantage (HMO D-SNP)
|
$0.00 |
$480 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | Q:60 /30Days | $1,079.40 |
Browse Plan Formulary |
Anthem MediBlue ESRD Care (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:60 /30Days | $1,080.00 |
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 |
Anthem MediBlue ESRD Care (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:60 /30Days | $1,080.00 |
Browse Plan Formulary |
Anthem MediBlue Heart Care (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:60 /30Days | $1,080.00 |
Browse Plan Formulary |
Anthem MediBlue Heart Care (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:60 /30Days | $1,080.00 |
Browse Plan Formulary |
Anthem MediBlue Lung Care (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:60 /30Days | $1,080.00 |
Browse Plan Formulary |
Anthem MediBlue Lung Care (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:60 /30Days | $1,080.00 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $1,080.00 |
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 |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $1,080.00 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $1,080.00 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $1,080.00 |
Browse Plan Formulary |
Anthem MediBlue StartSmart Plus (HMO)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:60 /30Days | $1,080.00 |
Browse Plan Formulary |
Anthem MediBlue StartSmart Plus (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:60 /30Days | $1,080.00 |
Browse Plan Formulary |
Anthem MediBlue Value Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:60 /30Days | $1,080.00 |
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 |
Anthem MediBlue Value Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:60 /30Days | $1,080.00 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:60 /30Days | $1,083.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:60 /30Days | $1,083.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Inter Valley Health Plan Service To Seniors (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
25% | 25% | Q:60 /30Days | $1,076.40 |
Browse Plan Formulary select insulin pay $11-$35 copay but not this drug |
SCAN Balance (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $265.00 | None | $1,082.40 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
SCAN Balance (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 4 |
Non-Preferred Drug |
$95.00 | $265.00 | None | $1,082.40 |
Browse Plan Formulary select insulin pay $0 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 |
SCAN Classic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $265.00 | None | $1,078.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Classic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $265.00 | None | $1,078.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Connections (HMO D-SNP)
|
$0.00 |
$480 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
25% | 25% | None | $1,076.40 |
Browse Plan Formulary |
SCAN Connections at Home (HMO D-SNP)
|
$0.00 |
$480 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
25% | 25% | None | $1,076.40 |
Browse Plan Formulary |
SCAN Embrace (HMO I-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$99.00 | $277.00 | None | $1,078.20 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
SCAN Embrace (HMO I-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 4 |
Non-Preferred Drug |
$99.00 | $277.00 | None | $1,078.20 |
Browse Plan Formulary select insulin pay $0 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 |
SCAN Healthy at Home (HMO I-SNP)
|
$0.00 |
$0 | Some Generics | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,079.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Healthy at Home (HMO I-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,079.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Prime (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $265.00 | None | $1,078.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Venture (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $265.00 | None | $1,082.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Venture (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $265.00 | None | $1,082.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Chronic Complete (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $1,057.80 |
Browse Plan Formulary select insulin pay $25 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 Chronic Complete (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $1,057.80 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
Anthem MediBlue Coordination Plus (HMO)
|
$2.10 |
$480 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | Q:60 /30Days | $1,080.00 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$2.10 |
$480 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | Q:60 /30Days | $1,080.00 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$21.50 |
$480 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:60 /30Days | $1,080.00 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$21.50 |
$480 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:60 /30Days | $1,080.00 |
Browse Plan Formulary |
Anthem MediBlue Connect (HMO D-SNP)
|
$22.00 |
$480 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
25% | 25% | Q:60 /30Days | $1,079.40 |
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 |
Anthem MediBlue Connect (HMO D-SNP)
|
$22.00 |
$480 | Many Generics, Some Brands | 4 |
Non-Preferred Drug |
25% | 25% | Q:60 /30Days | $1,079.40 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$22.60 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $1,082.40 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$22.60 |
$480 | No | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $1,082.40 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$25.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $265.00 | None | $1,078.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Anthem MediBlue Extra (HMO)
|
$25.70 |
$480 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | Q:60 /30Days | $1,080.60 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$25.70 |
$480 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | Q:60 /30Days | $1,080.60 |
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 |
AARP Medicare Advantage SecureHorizons Premier (HMO)
|
$29.70 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $1,057.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons Premier (HMO)
|
$29.70 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $1,057.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$32.70 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | Q:60 /30Days | $1,057.80 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$32.70 |
$480 | No | 4 |
Tier 4 |
25% | 25% | Q:60 /30Days | $1,057.80 |
Browse Plan Formulary |
Inter Valley Health Plan Vitality Plus (HMO)
|
$33.20 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | 25% | Q:60 /30Days | $1,076.40 |
Browse Plan Formulary |
SCAN Connections (HMO D-SNP)
|
$33.20 |
$480 | Some Generics | 4 |
Non-Preferred Drug |
25% | 25% | None | $1,076.40 |
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 |
SCAN Connections at Home (HMO D-SNP)
|
$33.20 |
$480 | Some Generics | 4 |
Non-Preferred Drug |
25% | 25% | None | $1,076.40 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$33.20 |
$480 | No | 4 |
Non-Preferred Drug |
25% | 25% | None | $1,078.80 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$33.20 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | 25% | None | $1,078.80 |
Browse Plan Formulary |
VillageHealth (HMO-POS C-SNP)
|
$33.20 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | 25% | None | $1,078.20 |
Browse Plan Formulary |
VillageHealth (HMO-POS C-SNP)
|
$33.20 |
$480 | No | 4 |
Non-Preferred Drug |
25% | 25% | None | $1,078.20 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$48.50 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $1,077.60 |
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 |
Aetna Medicare Choice Plan (PPO)
|
$90.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $1,077.60 |
Browse Plan Formulary |