Forever Blue 770 (PPO)
$104.40 /month
Monthly Premium
$615.00
Annual Deductible
971
Drugs Covered
1
States Served
Top Covered Drugs
Most popular medications covered by this plan, ordered by national search frequency. Click any drug to see exact copay, restrictions, and alternatives.
| # | Drug Name | Type | Tier | 30-Day Copay | |
|---|---|---|---|---|---|
| 1 | Xtandi enzalutamide | Brand | Tier 5 | 0.3% coinsurance | Details |
| 2 | PredniSONE | Brand | Tier 1 | $0.00 | Details |
| 3 | PIQRAY alpelisib | Brand | Tier 5 | 0.3% coinsurance | Details |
| 4 | JAYPIRCA pirtobrutinib | Brand | Tier 5 | 0.3% coinsurance | Details |
| 5 | GARDASIL 9 Human Papillomavirus 9-valent Vaccine, Recombinant | Brand | Tier 3 | 0.2% coinsurance | Details |
| 6 | Nitroglycerin nitroglycerin | Brand | Tier 2 | $3.00 | Details |
| 7 | Nefazodone Hydrochloride | Brand | Tier 2 | $3.00 | Details |
| 8 | Mekinist trametinib | Brand | Tier 5 | 0.3% coinsurance | Details |
| 9 | Gilotrif afatinib | Brand | Tier 5 | 0.3% coinsurance | Details |
| 10 | ELIQUIS 30-Day Starter Pack 30-Day Starter Pack apixaban | Brand | Tier 3 | 0.2% coinsurance | Details |
| 11 | Diazepam | Brand | Tier 2 | $3.00 | Details |
| 12 | Chlorpromazine Hydrochloride | Brand | Tier 4 | 0.3% coinsurance | Details |
| 13 | Pilocarpine Hydrochloride | Brand | Tier 3 | 0.2% coinsurance | Details |
| 14 | Ciprofloxacin | Brand | Tier 1 | $0.00 | Details |
| 15 | Warfarin Sodium | Brand | Tier 1 | $0.00 | Details |
| 16 | Chlorpromazine Hydrochloride | Brand | Tier 4 | 0.3% coinsurance | Details |
| 17 | Xtandi enzalutamide | Brand | Tier 5 | 0.3% coinsurance | Details |
| 18 | SOMAVERT pegvisomant | Brand | Tier 5 | 0.3% coinsurance | Details |
| 19 | Digoxin | Brand | Tier 2 | $3.00 | Details |
| 20 | DELSTRIGO doravirine, lamivudine, and tenofovir disoproxil fumarate | Brand | Tier 5 | 0.3% coinsurance | Details |
Showing 20 of 971 covered drugs.
States Served (1)
This plan is available to Medicare beneficiaries in the following states.
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