AJOVY 225 MG/1.5 ML AUTOINJECT (1.5 mls ) (NDC: 51759020210)
2022 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
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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 | P | $871.26 |
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 | P | $872.60 |
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 | P | $858.96 |
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 | P | $872.38 |
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 | P | $869.84 |
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 Senior Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | P | $870.98 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
HAP Senior Plus Option 1 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | P | $871.04 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
McLaren Medicare Inspire (HMO)
|
$0.00 |
$100 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $105.75 | P Q:2 /30Days | $860.78 |
Browse Plan Formulary select insulin pay $10-$35 copay but not this drug |
Medicare Plus Blue PPO Essential (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P | $871.26 |
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 | P | $871.48 |
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 | P | $858.96 |
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 | P | $872.38 |
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 | P | $869.32 |
Browse Plan Formulary |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | P Q:2 /30Days | $852.98 |
Browse Plan Formulary |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | P Q:2 /30Days | $847.94 |
Browse Plan Formulary |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | P Q:2 /30Days | $853.24 |
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% | P Q:2 /30Days | $852.98 |
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% | P Q:2 /30Days | $847.24 |
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% | P Q:2 /30Days | $854.40 |
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% | P Q:2 /30Days | $847.94 |
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% | P Q:2 /30Days | $853.24 |
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% | P Q:2 /30Days | $852.98 |
Browse Plan Formulary |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:2 /30Days | $847.94 |
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 |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:2 /30Days | $853.24 |
Browse Plan Formulary |
Sparrow Advantage (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $112.50 | P Q:2 /30Days | $862.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:2 /30Days | $854.40 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:2 /30Days | $847.94 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:2 /30Days | $853.24 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:2 /30Days | $852.98 |
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% | P Q:2 /30Days | $847.24 |
Browse Plan Formulary |
McLaren Medicare Inspire Plus (HMO)
|
$25.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $105.75 | P Q:2 /30Days | $860.78 |
Browse Plan Formulary select insulin pay $10-$35 copay but not this drug |
Sparrow Advantage Plus (HMO-POS)
|
$25.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $112.50 | P Q:2 /30Days | $862.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
McLaren Medicare Inspire Duals (HMO D-SNP)
|
$31.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:2 /30Days | $860.78 |
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% | P Q:2 /30Days | $852.40 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$35.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:2 /30Days | $847.94 |
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% | P Q:2 /30Days | $853.24 |
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% | P Q:2 /30Days | $852.98 |
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% | P Q:2 /30Days | $847.24 |
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% | P Q:2 /30Days | $854.40 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
McLaren Medicare Inspire Flex (HMO-POS)
|
$49.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $105.75 | P Q:2 /30Days | $860.78 |
Browse Plan Formulary select insulin pay $10-$35 copay but not this drug |
McLaren Medicare Inspire Flex (HMO-POS)
|
$49.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $105.75 | P Q:2 /30Days | $860.78 |
Browse Plan Formulary select insulin pay $10-$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 Senior Plus Option 2 (PPO)
|
$65.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | P | $871.04 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
Medicare Plus Blue PPO Vitality (PPO)
|
$70.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P | $871.48 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$70.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P | $858.96 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$70.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P | $872.38 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$70.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P | $869.32 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$70.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P | $871.26 |
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% | P Q:2 /30Days | $847.94 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$76.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:2 /30Days | $853.24 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$76.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:2 /30Days | $852.98 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$76.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:2 /30Days | $847.24 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$76.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:2 /30Days | $854.40 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$85.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:2 /30Days | $852.98 |
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% | P Q:2 /30Days | $847.24 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$85.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:2 /30Days | $854.40 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$85.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:2 /30Days | $847.94 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$85.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:2 /30Days | $853.24 |
Browse Plan Formulary |
HAP Senior Plus Option 1 (HMO-POS)
|
$90.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | P | $871.04 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$112.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $114.00 | P | $871.26 |
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)
|
$112.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $114.00 | P | $872.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$112.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $114.00 | P | $858.96 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$112.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $114.00 | P | $872.38 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$112.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $114.00 | P | $869.84 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Medicare Plus Blue PPO Signature (PPO)
|
$147.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P | $871.26 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$147.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P | $871.48 |
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 |
Medicare Plus Blue PPO Signature (PPO)
|
$147.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P | $858.96 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$147.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P | $872.38 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$147.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P | $869.32 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:2 /30Days | $852.98 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:2 /30Days | $847.24 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:2 /30Days | $854.40 |
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 Select (PPO)
|
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:2 /30Days | $847.94 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:2 /30Days | $853.24 |
Browse Plan Formulary |
HAP Senior Plus Option 3 (PPO)
|
$165.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | P | $871.04 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
HAP Senior Plus Option 2 (HMO-POS)
|
$190.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | P | $871.04 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
HAP Senior Plus Option 4 (PPO)
|
$200.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | P | $871.04 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$245.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $114.00 | P | $871.26 |
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)
|
$245.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $114.00 | P | $872.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$245.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $114.00 | P | $858.96 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$245.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $114.00 | P | $872.38 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$245.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $114.00 | P | $869.84 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Medicare Plus Blue PPO Assure (PPO)
|
$258.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $111.00 | P | $871.26 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$258.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $111.00 | P | $871.48 |
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 |
Medicare Plus Blue PPO Assure (PPO)
|
$258.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $111.00 | P | $858.96 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$258.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $111.00 | P | $872.38 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$258.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $111.00 | P | $869.32 |
Browse Plan Formulary |