AUSTEDO 6 MG TABLET (NDC: 68546017060)
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 Plan 7 (HMO)
|
$0.00 |
$175 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
30% | n/a | P Q:120 /30Days | $2,299.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Walgreens (PPO)
|
$0.00 |
$225 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
29% | n/a | P Q:120 /30Days | $2,280.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Premier (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $2,460.00 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO-POS)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $2,449.80 |
Browse Plan Formulary |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $2,457.00 |
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 Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $2,534.70 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $2,538.00 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $2,538.00 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $2,538.00 |
Browse Plan Formulary |
Anthem MediBlue Prime Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $2,533.80 |
Browse Plan Formulary |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $2,364.90 |
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 |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $2,364.90 |
Browse Plan Formulary |
Devoted Health Core (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $2,095.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Devoted Health Saver (HMO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | P Q:60 /30Days | $2,095.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Cleveland Clinic Preferred (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $2,367.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H6622-014 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $2,364.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-285 (PPO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | P Q:60 /30Days | $2,367.00 |
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 |
HumanaChoice H5525-042 (PPO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | P Q:60 /30Days | $2,367.00 |
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:60 /30Days | $2,149.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Paramount Elite Standard (HMO)
|
$0.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
32% | n/a | P Q:60 /30Days | $2,123.70 |
Browse Plan Formulary |
PrimeTime Health Plan Aultimate (HMO-POS)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | P | $2,183.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SummaCare Medicare Topaz (HMO)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
5* |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $2,145.30 |
Browse Plan Formulary |
UnitedHealthcare Connected for MyCareOhio (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
2 |
Tier 2 |
0% | 0% | P Q:120 /30Days | $2,307.30 |
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 Dividend Giveback (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $2,536.50 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $2,529.30 |
Browse Plan Formulary |
Wellcare Giveback Boost (HMO)
|
$0.00 |
$75 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
31% | n/a | P Q:60 /30Days | $2,529.60 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$75 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
31% | n/a | P Q:60 /30Days | $2,529.30 |
Browse Plan Formulary |
Wellcare No Premium Essential (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $2,532.60 |
Browse Plan Formulary |
Wellcare No Premium Medicare (HMO)
|
$0.00 |
$75 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
31% | n/a | P Q:60 /30Days | $2,529.60 |
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 No Premium Open (PPO)
|
$0.00 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $2,529.60 |
Browse Plan Formulary |
HumanaChoice H5216-106 (PPO)
|
$15.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $2,366.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$16.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | P Q:60 /30Days | $2,367.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Assist (HMO)
|
$16.80 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $2,481.00 |
Browse Plan Formulary |
Wellcare Assist Complement (HMO)
|
$17.60 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $2,481.00 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 1 (HMO)
|
$19.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $2,299.80 |
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 |
Anthem MediBlue Preferred Plus (HMO)
|
$19.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $2,536.80 |
Browse Plan Formulary |
Humana Gold Plus H6622-070 (HMO)
|
$21.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $2,364.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Anthem MediBlue Extra (HMO)
|
$22.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $2,536.80 |
Browse Plan Formulary |
Aetna Medicare Assure 1 (HMO D-SNP)
|
$23.20 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $2,473.20 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 8 (HMO)
|
$25.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $2,299.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus SNP-DE H6622-015 (HMO D-SNP)
|
$27.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $2,367.30 |
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 |
Paramount Elite Prime (HMO)
|
$28.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $2,123.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Perennial Advantage Strive (HMO I-SNP)
|
$28.20 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P | $2,500.50 |
Browse Plan Formulary |
SummaCare Medicare Garnet (HMO)
|
$29.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $2,145.30 |
Browse Plan Formulary |
SummaCare Medicare Garnet (HMO)
|
$29.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $2,145.30 |
Browse Plan Formulary |
Wellcare Dual Access Extra (HMO-POS D-SNP)
|
$29.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $2,478.60 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)
|
$29.80 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $2,268.00 |
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 |
Devoted Health Prime (HMO)
|
$31.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $2,095.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Perennial Advantage Concierge (HMO C-SNP)
|
$31.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $2,500.50 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$32.00 |
$480 |
Some Generics |
5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $2,481.00 |
Browse Plan Formulary |
Aetna Medicare Premier Plus 2 (Regional PPO)
|
$33.40 |
$260 |
No |
5 |
Specialty Tier |
28% | n/a | P Q:60 /30Days | $2,473.20 |
Browse Plan Formulary |
Anthem MediBlue Dual Advantage (HMO D-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $2,536.80 |
Browse Plan Formulary |
CommuniCare Advantage ISNP (HMO I-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | P Q:60 /30Days | $1,863.90 |
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 |
CommuniCare Advantage ISNP (HMO I-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | P Q:60 /30Days | $2,234.10 |
Browse Plan Formulary |
CommuniCare Advantage ISNP (HMO I-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | P Q:60 /30Days | $2,007.60 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $2,149.20 |
Browse Plan Formulary |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$33.50 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | P Q:120 /30Days | $2,268.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Dual Complete LP (HMO D-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | P Q:120 /30Days | $2,269.50 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $2,279.40 |
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 |
Valor Health Plan (HMO I-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | P Q:60 /30Days | $1,751.10 |
Browse Plan Formulary |
PrimeTime Health Plan Classic (HMO-POS)
|
$39.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P | $2,183.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Anthem MediBlue Access Basic (Regional PPO)
|
$41.50 |
$200 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
29% | n/a | P Q:120 /30Days | $2,536.80 |
Browse Plan Formulary |
SummaCare Medicare Ruby (HMO)
|
$43.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $2,145.30 |
Browse Plan Formulary |
Aetna Medicare Premier Plus 1 (Regional PPO)
|
$44.50 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $2,473.20 |
Browse Plan Formulary |
HumanaChoice R5495-002 (Regional PPO)
|
$47.80 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $2,367.00 |
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)
|
$55.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $2,538.00 |
Browse Plan Formulary |
Anthem MediBlue Access (PPO)
|
$56.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $2,536.80 |
Browse Plan Formulary |
Paramount Elite Enhanced (HMO)
|
$68.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $2,123.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-024 (PPO)
|
$76.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | P Q:60 /30Days | $2,367.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SummaCare Medicare Sapphire (HMO-POS)
|
$76.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $2,145.30 |
Browse Plan Formulary |
Anthem MediBlue Access Plus (PPO)
|
$89.00 |
$40 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
32% | n/a | P Q:120 /30Days | $2,535.30 |
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 |
PrimeTime Health Plan Plus (HMO-POS)
|
$89.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | P | $2,183.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H6622-019 (HMO)
|
$91.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | P Q:60 /30Days | $2,367.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Plan 3 (HMO)
|
$111.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $2,276.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Premier 2 (PPO)
|
$118.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $2,473.20 |
Browse Plan Formulary |
Aetna Medicare Premier 1 (PPO)
|
$149.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $2,472.90 |
Browse Plan Formulary |
HumanaChoice H5525-030 (PPO)
|
$151.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | P Q:60 /30Days | $2,367.00 |
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 |
SummaCare Medicare Emerald (HMO-POS)
|
$180.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $2,145.30 |
Browse Plan Formulary |