FLUCYTOSINE 500 MG CAPSULE [Ancobon] (14 capsules ) (NDC: 42494034001)
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 Elite Plan (PPO)
|
$0.00 |
$300 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
28% | n/a | None | $1,394.82 |
Browse Plan Formulary |
Centers Plan for Medicare Advantage Care (HMO)
|
$0.00 |
$395 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $909.44 |
Browse Plan Formulary |
EmblemHealth VIP Value (HMO)
|
$0.00 |
$325* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | $0.00 | None | $832.72 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$295 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
26% | 26% | P | $913.92 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Healthfirst Signature (HMO)
|
$0.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
26% | 26% | P | $913.92 |
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 |
Humana Gold Plus H3533-027 (HMO)
|
$0.00 |
$425 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $438.20 |
Browse Plan Formulary |
HumanaChoice H5970-024 (PPO)
|
$0.00 |
$350 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
27% | n/a | None | $438.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5970-024 (PPO)
|
$0.00 |
$350 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
27% | n/a | None | $438.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | All Generics, All Brands | 1 |
Tier 1 |
0% | 0% | None | $909.44 |
Browse Plan Formulary |
Wellcare Giveback Open (PPO)
|
$0.00 |
$325 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
27% | n/a | P | $1,667.40 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $1,667.40 |
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 |
Wellcare No Premium Open (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $1,667.40 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO)
|
$16.00 |
$300 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
28% | n/a | None | $1,556.24 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Fidelis Dual Plus (HMO D-SNP)
|
$18.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P | $1,667.40 |
Browse Plan Formulary |
Wellcare Fidelis Dual Access (HMO D-SNP)
|
$20.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P | $1,667.40 |
Browse Plan Formulary |
Aetna Medicare Assure Plan (HMO D-SNP)
|
$23.20 |
$400 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
26% | n/a | None | $1,250.90 |
Browse Plan Formulary |
Empire MediBlue HealthPlus (HMO)
|
$25.00 |
$350 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
27% | n/a | None | $729.40 |
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 |
VNSNY CHOICE EasyCare (HMO)
|
$25.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $909.44 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$27.60 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P | $1,667.40 |
Browse Plan Formulary |
Wellcare Assist Open (PPO)
|
$30.70 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P | $1,667.40 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice Plan 3 (Regional PPO)
|
$34.20 |
$250 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
28% | n/a | None | $1,556.24 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
EmblemHealth VIP Passport (HMO)
|
$34.40 |
$350* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | $0.00 | None | $815.92 |
Browse Plan Formulary |
Longevity Health Plan (HMO I-SNP)
|
$36.60 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $793.52 |
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 Premier Plus Plan (PPO)
|
$37.00 |
$350 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
27% | n/a | None | $1,583.40 |
Browse Plan Formulary |
Wellcare Dual Access Open (PPO D-SNP)
|
$37.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P | $1,667.40 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Plan 2 (HMO D-SNP)
|
$37.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
$0.00 | $0.00 | None | $1,556.24 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Plan 2 (HMO D-SNP)
|
$37.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
$0.00 | $0.00 | None | $1,556.24 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H3533-034 (HMO D-SNP)
|
$38.90 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $438.20 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H3533-034 (HMO D-SNP)
|
$38.90 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $438.20 |
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 |
Humana Gold Plus H3533-010 (HMO)
|
$39.60 |
$250 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
28% | n/a | None | $438.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Elderplan For Medicaid Beneficiaries (HMO D-SNP)
|
$39.90 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | P | $1,283.66 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO D-SNP)
|
$39.90 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | 25% | P | $913.92 |
Browse Plan Formulary |
Elderplan Assist (HMO I-SNP)
|
$42.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | 25% | P | $1,283.66 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)
|
$42.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $1,556.24 |
Browse Plan Formulary |
AgeWell New York Advantage Plus (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
$0.00 | $0.00 | None | $109.48 |
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 |
AgeWell New York CareWell (HMO I-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $109.48 |
Browse Plan Formulary |
AgeWell New York FeelWell (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
$0.00 | $0.00 | None | $109.48 |
Browse Plan Formulary |
AgeWell New York LiveWell (HMO)
|
$42.40 |
$350 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
27% | 27% | None | $109.48 |
Browse Plan Formulary |
Centers Plan for Dual Coverage Care (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $909.44 |
Browse Plan Formulary |
Centers Plan for Medicaid Advantage Plus (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $909.44 |
Browse Plan Formulary |
Centers Plan for Nursing Home Care (HMO I-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $909.44 |
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 |
Elderplan Advantage For Nursing Home Residents (HMO I-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | P | $1,283.66 |
Browse Plan Formulary |
Elderplan Plus Long Term Care (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | P | $1,283.66 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $815.92 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $826.98 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $858.06 |
Browse Plan Formulary |
EmblemHealth VIP Dual Select (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $825.02 |
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 |
EmblemHealth VIP Solutions (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $825.02 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage (HMO D-SNP)
|
$42.40 |
$480 | Some Generics | 5 |
Specialty Tier |
25% | n/a | None | $743.12 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage Select (HMO D-SNP)
|
$42.40 |
$480 | Some Generics | 5 |
Specialty Tier |
25% | n/a | None | $752.64 |
Browse Plan Formulary |
Empire MediBlue HealthPlus Dual Connect (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $752.64 |
Browse Plan Formulary |
Empire MediBlue HealthPlus Dual Plus (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $752.64 |
Browse Plan Formulary |
Hamaspik Medicare Choice (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $686.84 |
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 |
Hamaspik Medicare Select (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $686.84 |
Browse Plan Formulary |
Healthfirst Connection Plan (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | 25% | P | $913.92 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | 25% | P | $913.92 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | 25% | P | $913.92 |
Browse Plan Formulary |
Integra Harmony (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $1,045.94 |
Browse Plan Formulary |
Integra Synergy Medicaid Advantage Plus (MAP) (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $1,045.94 |
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 |
RiverSpring MAP (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $1,560.16 |
Browse Plan Formulary |
RiverSpring Star (HMO I-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $1,560.16 |
Browse Plan Formulary |
Senior Whole Health Medicare Complete Care (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | P | $1,396.64 |
Browse Plan Formulary |
Senior Whole Health of New York NHC (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | P | $1,396.64 |
Browse Plan Formulary |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$42.40 |
$200 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
29% | n/a | None | $1,556.24 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
$0.00 | $0.00 | None | $1,556.24 |
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 Plan 1 (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
$0.00 | $0.00 | None | $1,556.24 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 2 (HMO I-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $1,556.24 |
Browse Plan Formulary |
VNSNY CHOICE EasyCare Plus (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $909.44 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $909.44 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$51.00 |
$350 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
27% | n/a | None | $729.40 |
Browse Plan Formulary |
Empire MediBlue Select (HMO)
|
$51.00 |
$350 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
27% | n/a | None | $729.40 |
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 Medicare Advantage Choice Plan 4 (Regional PPO)
|
$51.50 |
$150 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
30% | n/a | None | $1,556.24 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
EmblemHealth VIP Essential (HMO)
|
$55.00 |
$325* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | $0.00 | None | $826.98 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$55.00 |
$325* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | $0.00 | None | $858.06 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$55.00 |
$325* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | $0.00 | None | $858.06 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$55.00 |
$325* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | $0.00 | None | $815.92 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$89.00 |
$250 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
28% | n/a | None | $1,583.40 |
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 |
Aetna Medicare Premier Plan (PPO)
|
$99.00 |
$250 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
28% | n/a | None | $1,401.96 |
Browse Plan Formulary |
Wellcare Premium Ultra Open (PPO)
|
$121.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $1,667.40 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$124.50 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $0.00 | None | $826.98 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$124.50 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $0.00 | None | $858.06 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$124.50 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $0.00 | None | $858.06 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$124.50 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $0.00 | None | $815.92 |
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 |
EmblemHealth VIP Gold Plus (HMO)
|
$261.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $0.00 | None | $825.02 |
Browse Plan Formulary |