BUPRENORPHINE 5 MCG/HR PATCH [Butrans] (4 patches ) (NDC: 42858075040)
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 |
Aetna Medicare Premier (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /28Days | $102.92 |
Browse Plan Formulary |
Aetna Medicare Value (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /28Days | $177.40 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prime Value (HMO-POS)
|
$0.00 |
$50 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | Q:12 /84Days | $172.64 |
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. | 4 |
Non-Preferred Drug |
50% | 50% | Q:12 /84Days | $182.16 |
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. | 4 |
Non-Preferred Drug |
50% | 50% | Q:12 /84Days | $175.04 |
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 Prime Value (HMO-POS)
|
$0.00 |
$50 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | Q:12 /84Days | $155.16 |
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. | 4 |
Non-Preferred Drug |
50% | 50% | Q:12 /84Days | $174.12 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Covenant Advantage (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$90.00 | $237.50 | P Q:4 /28Days | $182.24 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HAP Senior Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $0.00 | Q:4 /28Days | $183.04 |
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. | 2 |
Generic |
$10.00 | $0.00 | Q:4 /28Days | $182.52 |
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 | Q:4 /28Days | $193.00 |
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 |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$12.00 | $24.00 | P Q:4 /28Days | $187.16 |
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% | Q:4 /28Days | $176.80 |
Browse Plan Formulary |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
40% | 40% | Q:4 /28Days | $184.64 |
Browse Plan Formulary |
PriorityMedicare Edge (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
40% | 40% | Q:4 /28Days | $185.68 |
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% | Q:4 /28Days | $176.80 |
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% | Q:4 /28Days | $184.64 |
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% | Q:4 /28Days | $166.56 |
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% | Q:4 /28Days | $183.64 |
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% | Q:4 /28Days | $185.68 |
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% | Q:4 /28Days | $176.80 |
Browse Plan Formulary |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | 45% | Q:4 /28Days | $184.64 |
Browse Plan Formulary |
PriorityMedicare Vital (PPO)
|
$0.00 |
$350 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | 45% | Q:4 /28Days | $185.68 |
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 |
Medicare Plus Blue PPO Essential (PPO)
|
$10.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | Q:12 /84Days | $144.44 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$10.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | Q:12 /84Days | $156.08 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$10.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | Q:12 /84Days | $161.96 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$10.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | Q:12 /84Days | $165.16 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$10.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | Q:12 /84Days | $155.24 |
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 | Q:4 /28Days | $193.00 |
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 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 | Q:4 /28Days | $193.00 |
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 | Q:4 /28Days | $193.00 |
Browse Plan Formulary |
Aetna Medicare Assure Premier (HMO D-SNP)
|
$23.50 |
$425 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | 25% | P Q:4 /28Days | $166.08 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | Q:4 /28Days | $183.64 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | Q:4 /28Days | $166.56 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | Q:4 /28Days | $184.64 |
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% | Q:4 /28Days | $176.80 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$24.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | Q:4 /28Days | $185.68 |
Browse Plan Formulary |
Covenant Advantage Plus (HMO-POS)
|
$25.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$90.00 | $237.50 | P Q:4 /28Days | $182.24 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Longevity Health Plan (HMO I-SNP)
|
$31.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | P Q:4 /28Days | $149.56 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$31.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | P Q:4 /28Days | $187.16 |
Browse Plan Formulary |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$31.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | P Q:4 /28Days | $187.16 |
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 D-SNP (HMO D-SNP)
|
$31.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | Q:4 /28Days | $182.76 |
Browse Plan Formulary |
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:4 /28Days | $208.20 |
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:4 /28Days | $208.12 |
Browse Plan Formulary |
HumanaChoice R3887-002 (Regional PPO)
|
$34.10 |
$480 | No | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:4 /28Days | $192.92 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$50.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | Q:4 /28Days | $166.56 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$50.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | Q:4 /28Days | $185.68 |
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)
|
$50.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | Q:4 /28Days | $184.64 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$50.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | Q:4 /28Days | $183.64 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
PriorityMedicare Value (HMO-POS)
|
$50.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | Q:4 /28Days | $176.80 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
BCN Advantage HMO ConnectedCare (HMO)
|
$58.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
48% | 48% | Q:12 /84Days | $178.84 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HAP Senior Plus Option 2 (PPO)
|
$65.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $0.00 | Q:4 /28Days | $182.52 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
HumanaChoice H5216-009 (PPO)
|
$71.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:4 /28Days | $193.04 |
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 |
Medicare Plus Blue PPO Vitality (PPO)
|
$85.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | Q:12 /84Days | $156.08 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$85.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | Q:12 /84Days | $161.96 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$85.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | Q:12 /84Days | $155.24 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$85.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | Q:12 /84Days | $144.44 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$85.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | Q:12 /84Days | $165.16 |
Browse Plan Formulary |
HAP Senior Plus Option 1 (HMO-POS)
|
$90.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $0.00 | Q:4 /28Days | $182.52 |
Browse Plan Formulary select insulin pay $25 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 Merit (PPO)
|
$98.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | Q:4 /28Days | $184.64 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$98.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | Q:4 /28Days | $176.80 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$98.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | Q:4 /28Days | $185.68 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$98.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | Q:4 /28Days | $183.64 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$98.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | Q:4 /28Days | $166.56 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$124.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
45% | 45% | Q:12 /84Days | $155.16 |
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)
|
$124.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
45% | 45% | Q:12 /84Days | $174.12 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$124.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
45% | 45% | Q:12 /84Days | $172.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$124.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
45% | 45% | Q:12 /84Days | $175.04 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$124.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
45% | 45% | Q:12 /84Days | $182.16 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
PriorityMedicare (HMO-POS)
|
$127.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | 45% | Q:4 /28Days | $183.64 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$127.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | 45% | Q:4 /28Days | $185.68 |
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 |
PriorityMedicare (HMO-POS)
|
$127.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | 45% | Q:4 /28Days | $166.56 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$127.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | 45% | Q:4 /28Days | $184.64 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$127.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | 45% | Q:4 /28Days | $176.80 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$152.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
48% | 48% | Q:12 /84Days | $156.08 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$152.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
48% | 48% | Q:12 /84Days | $161.96 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$152.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
48% | 48% | Q:12 /84Days | $155.24 |
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)
|
$152.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
48% | 48% | Q:12 /84Days | $144.44 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$152.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
48% | 48% | Q:12 /84Days | $165.16 |
Browse Plan Formulary |
HAP Senior Plus Option 3 (PPO)
|
$165.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $0.00 | Q:4 /28Days | $182.52 |
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. | 2 |
Generic |
$10.00 | $0.00 | Q:4 /28Days | $182.52 |
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. | 2 |
Generic |
$10.00 | $0.00 | Q:4 /28Days | $182.52 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
PriorityMedicare Select (PPO)
|
$214.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | 45% | Q:4 /28Days | $176.80 |
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 |
PriorityMedicare Select (PPO)
|
$214.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | 45% | Q:4 /28Days | $185.68 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$214.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | 45% | Q:4 /28Days | $183.64 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$214.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | 45% | Q:4 /28Days | $166.56 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$214.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | 45% | Q:4 /28Days | $184.64 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$238.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
45% | 45% | Q:12 /84Days | $155.16 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$238.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
45% | 45% | Q:12 /84Days | $175.04 |
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)
|
$238.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
45% | 45% | Q:12 /84Days | $182.16 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$238.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
45% | 45% | Q:12 /84Days | $172.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$238.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
45% | 45% | Q:12 /84Days | $174.12 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Medicare Plus Blue PPO Assure (PPO)
|
$301.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
45% | 45% | Q:12 /84Days | $161.96 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$301.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
45% | 45% | Q:12 /84Days | $165.16 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$301.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
45% | 45% | Q:12 /84Days | $144.44 |
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)
|
$301.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
45% | 45% | Q:12 /84Days | $155.24 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$301.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
45% | 45% | Q:12 /84Days | $156.08 |
Browse Plan Formulary |