Keystone 65 Essential Rx (HMO-POS)
$31.00 /month
Monthly Premium
$0.00
Annual Deductible
973
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 | RotaTeq Rotavirus Vaccine, Live, Oral, Pentavalent | Brand | Tier 4 | 0.3% coinsurance | Details |
| 2 | PREVYMIS LETERMOVIR | Brand | Tier 5 | 0.3% coinsurance | Details |
| 3 | Dexamethasone | Brand | Tier 2 | $0.00 | Details |
| 4 | Nitroglycerin nitroglycerin | Brand | Tier 3 | 0.3% coinsurance | Details |
| 5 | Chlorpromazine Hydrochloride | Brand | Tier 4 | 0.3% coinsurance | Details |
| 6 | ZEJULA niraparib | Brand | Tier 5 | 0.3% coinsurance | Details |
| 7 | KOSELUGO SELUMETINIB | Brand | Tier 5 | 0.3% coinsurance | Details |
| 8 | Exemestane | Brand | Tier 4 | 0.3% coinsurance | Details |
| 9 | Dexamethasone | Brand | Tier 2 | $0.00 | Details |
| 10 | Probenecid | Brand | Tier 3 | 0.3% coinsurance | Details |
| 11 | Acarbose | Brand | Tier 1 | $0.00 | Details |
| 12 | RETEVMO selpercatinib | Brand | Tier 5 | 0.3% coinsurance | Details |
| 13 | Nitroglycerin nitroglycerin | Brand | Tier 3 | 0.3% coinsurance | Details |
| 14 | TicoVac Tick-Borne Encephalitis Vaccine | Brand | Tier 1 | $0.00 | Details |
| 15 | VERQUVO vericiguat | Brand | Tier 4 | 0.3% coinsurance | Details |
| 16 | REYATAZ ATAZANAVIR | Brand | Tier 5 | 0.3% coinsurance | Details |
| 17 | Amoxicillin and Clavulanate Potassium | Brand | Tier 4 | 0.3% coinsurance | Details |
| 18 | M-M-R II measles, mumps, and rubella virus vaccine live | Brand | Tier 1 | $0.00 | Details |
| 19 | amiloride hydrochloride | Brand | Tier 2 | $0.00 | Details |
| 20 | EVOTAZ atazanavir and cobicistat | Brand | Tier 5 | 0.3% coinsurance | Details |
Showing 20 of 973 covered drugs.
States Served (1)
This plan is available to Medicare beneficiaries in the following states.
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