ASENAPINE 2.5 MG TABLET SUBLIGUAL [Saphris] (30 TABLETS ) (NDC: 62332054460)
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 |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $242.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $243.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $243.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $243.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $243.30 |
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 |
HAP Choice Medicare - West Michigan Option 1 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | P | $228.60 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
HumanaChoice H8087-004 (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:60 /30Days | $251.70 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $196.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $199.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $199.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $199.50 |
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 |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $199.50 |
Browse Plan Formulary |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$12.00 | $24.00 | Q:60 /30Days | $136.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | S Q:60 /30Days | $227.40 |
Browse Plan Formulary |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | S Q:60 /30Days | $231.00 |
Browse Plan Formulary |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | S Q:60 /30Days | $231.00 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | S Q:60 /30Days | $227.40 |
Browse Plan Formulary select insulin pay $20-$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 |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | S Q:60 /30Days | $231.00 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | S Q:60 /30Days | $231.00 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | S Q:60 /30Days | $231.00 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | S Q:60 /30Days | $231.00 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | S Q:60 /30Days | $227.40 |
Browse Plan Formulary |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | S Q:60 /30Days | $231.00 |
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 |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | S Q:60 /30Days | $231.00 |
Browse Plan Formulary |
HumanaChoice H8087-001 (PPO)
|
$20.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:60 /30Days | $251.70 |
Browse Plan Formulary |
Humana Value Plus H8087-002 (PPO)
|
$20.60 |
$260 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | P Q:60 /30Days | $251.70 |
Browse Plan Formulary |
HumanaChoice SNP-DE H8087-003 (PPO D-SNP)
|
$21.80 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:60 /30Days | $251.70 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | S Q:60 /30Days | $231.00 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | S Q:60 /30Days | $227.40 |
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 |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | S Q:60 /30Days | $231.00 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | S Q:60 /30Days | $231.00 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | S Q:60 /30Days | $231.00 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
33% | 33% | Q:60 /30Days | $136.50 |
Browse Plan Formulary |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
33% | 33% | Q:60 /30Days | $136.50 |
Browse Plan Formulary |
PriorityMedicare D-SNP (HMO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | S Q:60 /30Days | $227.40 |
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 Dual Complete (HMO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:60 /30Days | $240.60 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:60 /30Days | $240.60 |
Browse Plan Formulary |
HumanaChoice R3887-002 (Regional PPO)
|
$34.10 |
$480 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:60 /30Days | $247.50 |
Browse Plan Formulary |
HAP Choice Medicare - West Michigan Option 2 (HMO)
|
$35.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | P | $228.60 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$35.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | S Q:60 /30Days | $227.40 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$35.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | S Q:60 /30Days | $231.00 |
Browse Plan Formulary select insulin pay $15-$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 |
PriorityMedicare Value (HMO-POS)
|
$35.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | S Q:60 /30Days | $231.00 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$35.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | S Q:60 /30Days | $231.00 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$35.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | S Q:60 /30Days | $231.00 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $199.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $199.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $196.50 |
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 |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $199.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $199.50 |
Browse Plan Formulary |
HumanaChoice H5216-009 (PPO)
|
$71.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:60 /30Days | $251.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
PriorityMedicare Merit (PPO)
|
$76.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | S Q:60 /30Days | $231.00 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$76.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | S Q:60 /30Days | $231.00 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$76.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | S Q:60 /30Days | $227.40 |
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 |
PriorityMedicare Merit (PPO)
|
$76.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | S Q:60 /30Days | $231.00 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$76.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | S Q:60 /30Days | $231.00 |
Browse Plan Formulary |
Humana Gold Choice H8145-006 (PFFS)
|
$78.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:60 /30Days | $251.70 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$80.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:180 /90Days | $243.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$80.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:180 /90Days | $243.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$80.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:180 /90Days | $243.30 |
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 |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$80.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:180 /90Days | $242.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$80.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:180 /90Days | $243.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
PriorityMedicare (HMO-POS)
|
$85.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | S Q:60 /30Days | $227.40 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$85.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | S Q:60 /30Days | $231.00 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$85.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | S Q:60 /30Days | $231.00 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$85.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | S Q:60 /30Days | $231.00 |
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 |
PriorityMedicare (HMO-POS)
|
$85.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | S Q:60 /30Days | $231.00 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$97.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $196.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$97.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $199.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$97.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $199.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$97.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $199.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$97.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $199.50 |
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 |
PriorityMedicare Select (PPO)
|
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | S Q:60 /30Days | $227.40 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | S Q:60 /30Days | $231.00 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | S Q:60 /30Days | $231.00 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | S Q:60 /30Days | $231.00 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | S Q:60 /30Days | $231.00 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$179.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:180 /90Days | $242.10 |
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 |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$179.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:180 /90Days | $243.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$179.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:180 /90Days | $243.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$179.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:180 /90Days | $243.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$179.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:180 /90Days | $243.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Medicare Plus Blue PPO Assure (PPO)
|
$201.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:180 /90Days | $196.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$201.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:180 /90Days | $199.50 |
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 |
Medicare Plus Blue PPO Assure (PPO)
|
$201.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:180 /90Days | $199.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$201.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:180 /90Days | $199.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$201.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:180 /90Days | $199.50 |
Browse Plan Formulary |