Keystone 65 Select Rx (HMO)
$47.00 /month
Monthly Premium
$0.00
Annual Deductible
1,043
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 | Enoxaparin Sodium Enoxaparin sodium | Brand | Tier 4 | 0.4% coinsurance | Details |
| 2 | Neomycin Sulfate | Brand | Tier 2 | $0.00 | Details |
| 3 | Ceftriaxone Sodium | Brand | Tier 2 | $0.00 | Details |
| 4 | Danazol | Brand | Tier 4 | 0.4% coinsurance | Details |
| 5 | Balsalazide Disodium | Brand | Tier 4 | 0.4% coinsurance | Details |
| 6 | Rufinamide | Brand | Tier 4 | 0.4% coinsurance | Details |
| 7 | Isosorbide Dinitrate | Brand | Tier 4 | 0.4% coinsurance | Details |
| 8 | Loxapine | Brand | Tier 4 | 0.4% coinsurance | Details |
| 9 | Fetzima LEVOMILNACIPRAN HYDROCHLORIDE | Brand | Tier 4 | 0.4% coinsurance | Details |
| 10 | Buspirone Hydrochloride | Brand | Tier 2 | $0.00 | Details |
| 11 | Thioridazine Hydrochloride thioridazine hydrochloride | Brand | Tier 3 | 0.3% coinsurance | Details |
| 12 | RETEVMO selpercatinib | Brand | Tier 5 | 0.3% coinsurance | Details |
| 13 | WELIREG belzutifan | Brand | Tier 5 | 0.3% coinsurance | Details |
| 14 | RYDAPT | Brand | Tier 5 | 0.3% coinsurance | Details |
| 15 | KISQALI ribociclib | Brand | Tier 5 | 0.3% coinsurance | Details |
| 16 | bexarotene | Brand | Tier 5 | 0.3% coinsurance | Details |
| 17 | JANUVIA sitagliptin | Brand | Tier 3 | 0.3% coinsurance | Details |
| 18 | Xalkori CRIZOTINIB | Brand | Tier 5 | 0.3% coinsurance | Details |
| 19 | Fosamprenavir Calcium fosamprenavir calcium | Brand | Tier 5 | 0.3% coinsurance | Details |
| 20 | TRETINOIN tretinoin | Brand | Tier 3 | 0.3% coinsurance | Details |
Showing 20 of 1,043 covered drugs.
States Served (1)
This plan is available to Medicare beneficiaries in the following states.
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