BYETTA 5 MCG DOSE PEN INJ (1.2 ML ) (NDC: 00310651201)
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 Choice (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:1 /30Days | $712.25 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice Plan 2 (Regional PPO)
|
$0.00 |
$395 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:1 /30Days | $710.01 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Choice (HMO-POS)
|
$0.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:1 /30Days | $720.22 |
Browse Plan Formulary |
Aetna Medicare Credit (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:1 /30Days | $721.04 |
Browse Plan Formulary |
Aetna Medicare Premier (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:1 /30Days | $720.43 |
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 (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:1 /30Days | $721.04 |
Browse Plan Formulary |
Aetna Medicare Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | Q:1 /30Days | $721.04 |
Browse Plan Formulary select insulin pay $20 copay but not this drug |
AvMed Medicare Access (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $187.50 | Q:1 /30Days | $646.33 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AvMed Medicare Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $187.50 | Q:1 /30Days | $646.33 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AvMed Medicare Circle (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $187.50 | Q:1 /30Days | $646.33 |
Browse Plan Formulary select insulin pay $30-$35 copay but not this drug |
AvMed Medicare Premium Saver (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$80.00 | $200.00 | Q:1 /30Days | $646.33 |
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 |
BlueMedicare Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | S Q:2 /30Days | $672.12 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BlueMedicare Premier (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | S Q:2 /30Days | $680.44 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Devoted Health Core Broward (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | Q:1 /30Days | $633.15 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Devoted Health Essentials Broward (HMO)
|
$0.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:1 /30Days | $633.15 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Devoted Health Latitude South Florida (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:1 /30Days | $633.28 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
DrMax-B (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:1 /30Days | $648.14 |
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 |
DrValue-B (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S Q:1 /30Days | $648.14 |
Browse Plan Formulary |
Freedom VIP Savings (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
3 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:1 /30Days | $641.01 |
Browse Plan Formulary |
Freedom VIP Savings COPD (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
3 |
Non-Preferred Drug |
$80.00 | $160.00 | Q:1 /30Days | $640.99 |
Browse Plan Formulary |
MedicareMax (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:1 /30Days | $712.55 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MMM ELITE (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$15.00 | $45.00 | Q:1 /30Days | $649.34 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
MMM EXTRA (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:1 /30Days | $649.34 |
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 |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:1 /30Days | $649.34 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Molina Medicare Choice Care Select (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:1 /30Days | $649.34 |
Browse Plan Formulary |
Molina Medicare Connect Care (HMO C-SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:1 /30Days | $649.34 |
Browse Plan Formulary |
Optimum Gold Rewards Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Drug |
$70.00 | $140.00 | Q:1 /30Days | $640.99 |
Browse Plan Formulary |
Optimum Platinum Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Drug |
$50.00 | $100.00 | Q:1 /30Days | $640.99 |
Browse Plan Formulary |
Oscar + Holy Cross + Memorial - with $1500 O-Card (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $225.00 | Q:1 /30Days | $649.34 |
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 |
Oscar + Holy Cross + Memorial - with Refund Bonus (HMO)
|
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $225.00 | Q:1 /30Days | $649.34 |
Browse Plan Formulary |
Oscar + Holy Cross + Memorial (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $225.00 | Q:1 /30Days | $649.34 |
Browse Plan Formulary |
Preferred Choice Broward (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:1 /30Days | $712.55 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Simply Care (HMO I-SNP)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | n/a | Q:1 /30Days | $640.99 |
Browse Plan Formulary |
Simply Comfort (HMO I-SNP)
|
$0.00 |
$480 |
Some Generics, Few Brands |
3 |
Preferred Brand |
25% | n/a | Q:1 /30Days | $640.99 |
Browse Plan Formulary |
Simply Extra (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:1 /30Days | $641.07 |
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 |
Simply Level (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
3 |
Preferred Brand |
$35.00 | $105.00 | Q:1 /30Days | $641.07 |
Browse Plan Formulary |
Simply More (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$25.00 | $75.00 | Q:1 /30Days | $641.07 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$80.00 | $160.00 | Q:1 /30Days | $709.13 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$65.00 | $130.00 | Q:1 /30Days | $709.13 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$100 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:1 /30Days | $707.37 |
Browse Plan Formulary |
Wellcare Specialty Giveback (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
4 |
Non-Preferred Drug |
$70.00 | $140.00 | Q:1 /30Days | $709.08 |
Browse Plan Formulary select insulin pay $10 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 |
Wellcare Specialty No Premium (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
4 |
Non-Preferred Drug |
$65.00 | $130.00 | Q:1 /30Days | $708.25 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
DrPlus-B (HMO-POS D-SNP)
|
$26.50 |
$0 |
Many Generics, Some Brands |
4 |
Non-Preferred Drug |
$35.00 | $105.00 | S Q:1 /30Days | $648.14 |
Browse Plan Formulary |
Aetna Medicare Assure Plus (HMO D-SNP)
|
$27.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | Q:1 /30Days | $721.04 |
Browse Plan Formulary |
Wellcare Dual Reserve (HMO D-SNP)
|
$30.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
39% | 39% | Q:1 /30Days | $705.72 |
Browse Plan Formulary |
MedicareMax Plus 2 (HMO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:1 /30Days | $712.29 |
Browse Plan Formulary |
Preferred Medicare Assist Plan 2 (HMO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:1 /30Days | $712.29 |
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 RP (Regional PPO D-SNP)
|
$31.50 |
$480 |
No |
4 |
Tier 4 |
15% | 15% | Q:1 /30Days | $710.01 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$32.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:1 /30Days | $705.42 |
Browse Plan Formulary |
Preferred Medicare Assist Plan 1 (HMO D-SNP)
|
$34.00 |
$480 |
Some Generics, Few Brands |
4 |
Non-Preferred Drug |
25% | 25% | Q:1 /30Days | $712.29 |
Browse Plan Formulary |
Aetna Medicare Assure (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | Q:1 /30Days | $721.04 |
Browse Plan Formulary |
BlueMedicare Complete (HMO D-SNP)
|
$34.30 |
$480 |
Some Generics, Few Brands |
4 |
Non-Preferred Drug |
$92.00 | $276.00 | S Q:2 /30Days | $679.54 |
Browse Plan Formulary |
Devoted Health Dual Broward (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | Q:1 /30Days | $633.15 |
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 South Florida (HMO)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | Q:1 /30Days | $633.67 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Devoted Health Prime South Florida (HMO)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | Q:1 /30Days | $633.15 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Devoted Health Prime South Florida (HMO)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | Q:1 /30Days | $632.93 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Florida Complete Care (HMO I-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:1 /30Days | $659.04 |
Browse Plan Formulary |
Florida Complete Care- In The Community (HMO I-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:1 /30Days | $659.04 |
Browse Plan Formulary |
Freedom Medi-Medi Full (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:1 /30Days | $641.00 |
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 |
Freedom Medi-Medi Partial (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:1 /30Days | $641.00 |
Browse Plan Formulary |
Longevity Health Plan (HMO I-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | P Q:1 /30Days | $643.72 |
Browse Plan Formulary |
MedicareMax Plus 1 (HMO D-SNP)
|
$34.30 |
$480 |
Some Generics, Few Brands |
4 |
Non-Preferred Drug |
25% | 25% | Q:1 /30Days | $712.29 |
Browse Plan Formulary |
MMM PLATINUM (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | Q:1 /30Days | $649.34 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$34.30 |
$480 |
Some Generics, Few Brands |
4 |
Non-Preferred Drug |
34% | 34% | Q:1 /30Days | $649.34 |
Browse Plan Formulary |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$34.30 |
$480 |
Some Generics, Few Brands |
4 |
Non-Preferred Drug |
31% | 31% | Q:1 /30Days | $649.34 |
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 |
Optimum Emerald Full (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:1 /30Days | $641.00 |
Browse Plan Formulary |
Optimum Emerald Partial (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:1 /30Days | $641.00 |
Browse Plan Formulary |
Simply Complete (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:1 /30Days | $664.61 |
Browse Plan Formulary |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$34.30 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:1 /30Days | $709.71 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | Q:1 /30Days | $710.96 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | Q:1 /30Days | $709.23 |
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 Nursing Home Plan (PPO I-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | Q:1 /30Days | $710.11 |
Browse Plan Formulary |
Wellcare Dual Liberty (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:1 /30Days | $705.42 |
Browse Plan Formulary |
Wellcare Dual Medicare (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
49% | 49% | Q:1 /30Days | $705.71 |
Browse Plan Formulary |
Wellcare Dual Nurture (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
44% | 44% | Q:1 /30Days | $705.42 |
Browse Plan Formulary |
BlueMedicare Choice (Regional PPO)
|
$47.90 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | S Q:2 /30Days | $673.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Premium Enhanced Open (PPO)
|
$85.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:1 /30Days | $707.37 |
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 |
BlueMedicare Select (PPO)
|
$147.90 |
$305 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | S Q:2 /30Days | $675.05 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |