Freedom Blue PPO Standard (PPO)
$65.20 /month
Monthly Premium
$0.00
Annual Deductible
970
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 | SCEMBLIX asciminib | Brand | Tier 5 | 0.3% coinsurance | Details |
| 2 | VALPROIC ACID | Brand | Tier 2 | $11.00 | Details |
| 3 | Jardiance Empagliflozin | Brand | Tier 3 | $45.00 | Details |
| 4 | Xospata gilteritinib | Brand | Tier 5 | 0.3% coinsurance | Details |
| 5 | Buspirone Hydrochloride | Brand | Tier 2 | $11.00 | Details |
| 6 | Diltiazem Hydrochloride | Brand | Tier 2 | $11.00 | Details |
| 7 | Perphenazine perphenazine | Brand | Tier 4 | $100.00 | Details |
| 8 | Phenobarbital Oral Solution Phenobarbital Oral | Brand | Tier 2 | $11.00 | Details |
| 9 | VAQTA hepatitis A vaccine, inactivated | Brand | Tier 3 | $45.00 | Details |
| 10 | Dexamethasone | Brand | Tier 1 | $0.00 | Details |
| 11 | Chlorpromazine Hydrochloride | Brand | Tier 4 | $100.00 | Details |
| 12 | Rufinamide | Brand | Tier 5 | 0.3% coinsurance | Details |
| 13 | Dicyclomine Hydrochloride | Brand | Tier 2 | $11.00 | Details |
| 14 | Exemestane | Brand | Tier 4 | $100.00 | Details |
| 15 | Abrysvo Respiratory Syncytial Virus Vaccine | Brand | Tier 3 | $45.00 | Details |
| 16 | Fiasp insulin aspart injection | Brand | Tier 3 | $45.00 | Details |
| 17 | Baclofen | Brand | Tier 2 | $11.00 | Details |
| 18 | Dexamethasone | Brand | Tier 1 | $0.00 | Details |
| 19 | Medroxyprogesterone Acetate | Brand | Tier 2 | $11.00 | Details |
| 20 | Clozapine | Brand | Tier 4 | $100.00 | Details |
Showing 20 of 970 covered drugs.
States Served (1)
This plan is available to Medicare beneficiaries in the following states.
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