XCOPRI 50-100 MG TITRATION PAK TABLET DS PK (UNITS ) (NDC: 71699020228)
2021 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 | No | 5 |
Specialty Tier |
30% | n/a | P Q:28 /28Days | $1,092.56 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Walgreens (PPO)
|
$0.00 |
$225 | No | 5 |
Specialty Tier |
29% | n/a | P Q:28 /28Days | $1,089.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Silver (PPO)
|
$0.00 |
$150 | No | 5 |
Specialty Tier |
30% | n/a | None | $1,103.76 |
Browse Plan Formulary |
Aetna Medicare Premier (HMO)
|
$0.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | None | $1,103.76 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$150 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
30% | n/a | None | $1,103.76 |
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 Value Plan (PPO)
|
$0.00 |
$150 | No | 5 |
Specialty Tier |
30% | n/a | None | $1,103.76 |
Browse Plan Formulary |
Allwell Medicare (HMO)
|
$0.00 |
$75 | No | 5 |
Specialty Tier |
31% | n/a | Q:28 /28Days | $1,115.52 |
Browse Plan Formulary |
Allwell Medicare Boost (HMO)
|
$0.00 |
$75 | No | 5 |
Specialty Tier |
31% | n/a | Q:28 /28Days | $1,115.52 |
Browse Plan Formulary |
Anthem MediBlue Essential (HMO)
|
$0.00 |
$60 | No | 5 |
Specialty Tier |
32% | n/a | Q:56 /365Days | $1,120.00 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | Q:56 /365Days | $1,120.00 |
Browse Plan Formulary |
Anthem MediBlue Prime Select (HMO)
|
$0.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | Q:56 /365Days | $1,120.00 |
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 |
Bright Advantage University Hospitals (HMO)
|
$0.00 |
$445 | No | 5 |
Specialty Tier |
25% | n/a | S Q:56 /365Days | $1,064.00 |
Browse Plan Formulary |
Bright Advantage University Hospitals Choice (PPO)
|
$0.00 |
$445 | No | 5 |
Specialty Tier |
25% | n/a | S Q:56 /365Days | $1,064.00 |
Browse Plan Formulary |
Buckeye Health Plan - MyCare Ohio (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
0% | 0% | P | $1,079.40 |
Browse Plan Formulary |
CareSource Advantage Zero Premium (HMO)
|
$0.00 |
$150 | No | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:56 /28Days | $1,028.44 |
Browse Plan Formulary |
CareSource MyCare Ohio (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
0% | 0% | Q:56 /28Days | $1,028.44 |
Browse Plan Formulary |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $1,073.80 |
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 |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $1,073.80 |
Browse Plan Formulary |
Devoted Health Core (HMO)
|
$0.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | Q:28 /28Days | $1,099.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Devoted Health Saver (HMO)
|
$0.00 |
$200 | No | 5 |
Specialty Tier |
29% | n/a | Q:28 /28Days | $1,099.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Cleveland Clinic Preferred (HMO)
|
$0.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | P Q:28 /28Days | $1,065.12 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H6622-022 (HMO)
|
$0.00 |
$150 | No | 5 |
Specialty Tier |
30% | n/a | P Q:28 /28Days | $1,065.12 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5525-042 (PPO)
|
$0.00 |
$250 | No | 5 |
Specialty Tier |
28% | n/a | P Q:28 /28Days | $1,065.12 |
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 |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95 | No | 4 |
Non-Preferred Drug |
50% | 50% | Q:56 /28Days | $1,030.68 |
Browse Plan Formulary |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95 | No | 4 |
Non-Preferred Drug |
50% | 50% | Q:56 /28Days | $1,030.68 |
Browse Plan Formulary |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95 | No | 4 |
Non-Preferred Drug |
50% | 50% | Q:56 /28Days | $1,030.68 |
Browse Plan Formulary |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Drug |
50% | 50% | Q:56 /28Days | $1,030.68 |
Browse Plan Formulary |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$0 | No | 4 |
Non-Preferred Drug |
50% | 50% | Q:56 /28Days | $1,030.68 |
Browse Plan Formulary |
Paramount Elite - Standard Medical & Drug (HMO)
|
$0.00 |
$50 | No | 5 |
Specialty Tier |
32% | n/a | Q:28 /28Days | $1,095.36 |
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 Topaz (HMO)
|
$0.00 |
$150 | No | 4 |
Non-Preferred Brand |
$100.00 | $300.00 | None | $1,038.80 |
Browse Plan Formulary |
UnitedHealthcare Connected for MyCareOhio (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
0% | 0% | P Q:28 /28Days | $1,092.56 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$445 | No | 5 |
Specialty Tier |
25% | n/a | Q:28 /28Days | $1,118.88 |
Browse Plan Formulary |
WellCare Essential (HMO-POS)
|
$0.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | Q:28 /28Days | $1,118.88 |
Browse Plan Formulary |
WellCare Exclusive (HMO)
|
$0.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | Q:28 /28Days | $1,118.88 |
Browse Plan Formulary |
Allwell Medicare Complement (HMO)
|
$9.60 |
$445 | No | 5 |
Specialty Tier |
25% | n/a | Q:28 /28Days | $1,118.88 |
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 - Diabetes and Heart (HMO C-SNP)
|
$15.00 |
$200 | No | 5 |
Specialty Tier |
29% | n/a | P Q:28 /28Days | $1,065.12 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-106 (PPO)
|
$15.00 |
$125 | No | 5 |
Specialty Tier |
30% | n/a | P Q:28 /28Days | $1,065.12 |
Browse Plan Formulary |
Anthem MediBlue Preferred Plus (HMO)
|
$19.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | Q:56 /365Days | $1,120.00 |
Browse Plan Formulary |
MedMutual Advantage Secure (HMO)
|
$20.00 |
$95 | No | 4 |
Non-Preferred Drug |
50% | 50% | Q:56 /28Days | $1,030.68 |
Browse Plan Formulary |
MedMutual Advantage Secure (HMO)
|
$20.00 |
$95 | No | 4 |
Non-Preferred Drug |
50% | 50% | Q:56 /28Days | $1,030.68 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 1 (HMO)
|
$21.00 |
$150 | No | 5 |
Specialty Tier |
30% | n/a | P Q:28 /28Days | $1,092.56 |
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 |
Allwell Dual Medicare (HMO D-SNP)
|
$21.10 |
$150 | No | 5 |
Specialty Tier |
30% | n/a | Q:28 /28Days | $1,118.88 |
Browse Plan Formulary |
CareSource Advantage (HMO)
|
$21.60 |
$75 | No | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:56 /28Days | $1,028.44 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)
|
$22.00 |
$445 | No | 5 |
Tier 5 |
25% | 25% | P Q:28 /28Days | $1,092.56 |
Browse Plan Formulary |
Devoted Health Prime (HMO)
|
$22.80 |
$150 | No | 5 |
Specialty Tier |
30% | n/a | Q:28 /28Days | $1,099.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Premier Plus 2 (Regional PPO)
|
$25.30 |
$190 | No | 5 |
Specialty Tier |
29% | n/a | None | $1,103.76 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$25.30 |
$445 | No | 5 |
Specialty Tier |
25% | n/a | Q:56 /365Days | $1,120.00 |
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 |
Aetna Medicare Assure 1 (HMO D-SNP)
|
$26.20 |
$220 | No | 5 |
Specialty Tier |
29% | n/a | None | $1,103.76 |
Browse Plan Formulary |
Aetna Medicare Assure (HMO D-SNP)
|
$27.50 |
$130 | No | 5 |
Specialty Tier |
30% | n/a | None | $1,105.16 |
Browse Plan Formulary |
Paramount Elite - Prime Medical & Drug (HMO)
|
$28.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | Q:28 /28Days | $1,095.36 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SummaCare Medicare Garnet (HMO)
|
$29.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $300.00 | None | $1,038.80 |
Browse Plan Formulary |
SummaCare Medicare Garnet (HMO)
|
$29.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $300.00 | None | $1,038.80 |
Browse Plan Formulary |
Anthem MediBlue Dual Advantage (HMO D-SNP)
|
$29.80 |
$445 | No | 5 |
Specialty Tier |
25% | n/a | Q:56 /365Days | $1,120.00 |
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 |
CareSource Dual Advantage (HMO D-SNP)
|
$29.80 |
$445 | No | 4 |
Non-Preferred Drug |
25% | 25% | Q:56 /28Days | $1,028.44 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H6622-015 (HMO D-SNP)
|
$29.80 |
$420 | No | 5 |
Specialty Tier |
25% | n/a | P Q:28 /28Days | $1,065.12 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$29.80 |
$445 | No | 5 |
Specialty Tier |
25% | n/a | Q:28 /28Days | $1,095.92 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$29.80 |
$445 | No | 5 |
Specialty Tier |
25% | n/a | Q:28 /28Days | $1,095.92 |
Browse Plan Formulary |
Provider Partners Ohio Advantage Plan (HMO I-SNP)
|
$29.80 |
$445 | No | 1 |
Tier 1 |
25% | 25% | Q:28 /28Days | $1,064.00 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP (HMO D-SNP)
|
$29.80 |
$445 | No | 5 |
Tier 5 |
15% | 15% | P Q:28 /28Days | $1,092.56 |
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 2 (PPO I-SNP)
|
$29.80 |
$445 | No | 5 |
Tier 5 |
25% | 25% | P Q:28 /28Days | $1,092.56 |
Browse Plan Formulary |
Valor Health Plan (HMO I-SNP)
|
$29.80 |
$445 | No | 1 |
Tier 1 |
25% | n/a | Q:28 /28Days | $1,064.00 |
Browse Plan Formulary |
WellCare Extra Plus (HMO-POS D-SNP)
|
$29.80 |
$445 | No | 5 |
Specialty Tier |
25% | n/a | Q:28 /28Days | $1,118.88 |
Browse Plan Formulary |
Bright Advantage University Hospitals Choice Plus (PPO)
|
$34.00 |
$445 | No | 5 |
Specialty Tier |
25% | n/a | S Q:56 /365Days | $1,064.00 |
Browse Plan Formulary |
MedMutual Advantage Choice (HMO)
|
$34.00 |
$55 | No | 4 |
Non-Preferred Drug |
50% | 50% | Q:56 /28Days | $1,030.68 |
Browse Plan Formulary |
MedMutual Advantage Choice (HMO)
|
$34.00 |
$55 | No | 4 |
Non-Preferred Drug |
50% | 50% | Q:56 /28Days | $1,030.68 |
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 |
MedMutual Advantage Choice (HMO)
|
$34.00 |
$55 | No | 4 |
Non-Preferred Drug |
50% | 50% | Q:56 /28Days | $1,030.68 |
Browse Plan Formulary |
Anthem MediBlue Access Basic (Regional PPO)
|
$36.10 |
$200 | No | 5 |
Specialty Tier |
29% | n/a | Q:56 /365Days | $1,120.00 |
Browse Plan Formulary |
Aetna Medicare Premier Plus 1 (Regional PPO)
|
$38.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | None | $1,103.76 |
Browse Plan Formulary |
MedMutual Advantage Select (PPO)
|
$38.00 |
$95 | No | 4 |
Non-Preferred Drug |
50% | 50% | Q:56 /28Days | $1,030.68 |
Browse Plan Formulary |
MedMutual Advantage Select (PPO)
|
$38.00 |
$95 | No | 4 |
Non-Preferred Drug |
50% | 50% | Q:56 /28Days | $1,030.68 |
Browse Plan Formulary |
MedMutual Advantage Select (PPO)
|
$38.00 |
$95 | No | 4 |
Non-Preferred Drug |
50% | 50% | Q:56 /28Days | $1,030.68 |
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 R5495-002 (Regional PPO)
|
$39.00 |
$380 | No | 5 |
Specialty Tier |
26% | n/a | P Q:28 /28Days | $1,065.12 |
Browse Plan Formulary |
SummaCare Medicare Ruby (HMO)
|
$43.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $300.00 | None | $1,038.80 |
Browse Plan Formulary |
Humana Gold Plus H6622-011 (HMO)
|
$46.00 |
$195 | No | 5 |
Specialty Tier |
29% | n/a | P Q:28 /28Days | $1,065.12 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Anthem MediBlue Access (PPO)
|
$56.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | Q:56 /365Days | $1,120.00 |
Browse Plan Formulary |
Anthem MediBlue Access (PPO)
|
$56.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | Q:56 /365Days | $1,120.00 |
Browse Plan Formulary |
Paramount Elite - Enhanced Medical & Drug (HMO)
|
$68.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | None | $1,095.36 |
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 |
MedMutual Advantage Preferred (PPO)
|
$74.00 |
$55 | No | 4 |
Non-Preferred Drug |
50% | 50% | Q:56 /28Days | $1,030.68 |
Browse Plan Formulary |
MedMutual Advantage Preferred (PPO)
|
$74.00 |
$55 | No | 4 |
Non-Preferred Drug |
50% | 50% | Q:56 /28Days | $1,030.68 |
Browse Plan Formulary |
MedMutual Advantage Preferred (PPO)
|
$74.00 |
$55 | No | 4 |
Non-Preferred Drug |
50% | 50% | Q:56 /28Days | $1,030.68 |
Browse Plan Formulary |
HumanaChoice H5216-024 (PPO)
|
$75.00 |
$100 | No | 5 |
Specialty Tier |
31% | n/a | P Q:28 /28Days | $1,065.12 |
Browse Plan Formulary |
SummaCare Medicare Sapphire (HMO-POS)
|
$76.00 |
$0 | No | 4 |
Non-Preferred Brand |
$100.00 | $300.00 | None | $1,038.80 |
Browse Plan Formulary |
Anthem MediBlue Access Plus (PPO)
|
$89.00 |
$40 | No | 5 |
Specialty Tier |
32% | n/a | Q:56 /365Days | $1,120.00 |
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 |
Humana Gold Plus H6622-019 (HMO)
|
$90.00 |
$125 | No | 5 |
Specialty Tier |
30% | n/a | P Q:28 /28Days | $1,065.12 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MedMutual Advantage Plus (HMO)
|
$95.00 |
$55 | No | 4 |
Non-Preferred Drug |
50% | 50% | Q:56 /28Days | $1,030.68 |
Browse Plan Formulary |
MedMutual Advantage Plus (HMO)
|
$95.00 |
$55 | No | 4 |
Non-Preferred Drug |
50% | 50% | Q:56 /28Days | $1,030.68 |
Browse Plan Formulary |
MedMutual Advantage Plus (HMO)
|
$95.00 |
$55 | No | 4 |
Non-Preferred Drug |
50% | 50% | Q:56 /28Days | $1,030.68 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 3 (HMO)
|
$111.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | P Q:28 /28Days | $1,092.56 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Premier 2 (PPO)
|
$124.00 |
$0 | No | 5 |
Specialty Tier |
33% | n/a | None | $1,103.76 |
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 |
MedMutual Advantage Premium (PPO)
|
$128.00 |
$55 | No | 4 |
Non-Preferred Drug |
50% | 50% | Q:56 /28Days | $1,030.68 |
Browse Plan Formulary |
MedMutual Advantage Premium (PPO)
|
$128.00 |
$55 | No | 4 |
Non-Preferred Drug |
50% | 50% | Q:56 /28Days | $1,030.68 |
Browse Plan Formulary |
MedMutual Advantage Premium (PPO)
|
$128.00 |
$55 | No | 4 |
Non-Preferred Drug |
50% | 50% | Q:56 /28Days | $1,030.68 |
Browse Plan Formulary |
Aetna Medicare Premier 1 (PPO)
|
$140.00 |
$150 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
30% | n/a | None | $1,103.76 |
Browse Plan Formulary |
HumanaChoice H5525-030 (PPO)
|
$155.00 |
$100 | No | 5 |
Specialty Tier |
31% | n/a | P Q:28 /28Days | $1,065.12 |
Browse Plan Formulary |
SummaCare Medicare Emerald (HMO-POS)
|
$180.00 |
$0 | No | 4 |
Non-Preferred Brand |
$95.00 | $285.00 | None | $1,038.80 |
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