PacificSource Medicare Essentials Rx 6 (HMO)
$105.90 /month
Monthly Premium
$99.00
Annual Deductible
1,037
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 | VAQTA hepatitis A vaccine, inactivated | Brand | Tier 3 | $0.00 | Details |
| 2 | Fetzima LEVOMILNACIPRAN HYDROCHLORIDE | Brand | Tier 4 | $0.00 | Details |
| 3 | Xalkori CRIZOTINIB | Brand | Tier 5 | $0.00 | Details |
| 4 | Amoxicillin | Brand | Tier 2 | $0.00 | Details |
| 5 | Imatinib Mesylate | Brand | Tier 2 | $0.00 | Details |
| 6 | HYDROCODONE BITARTRATE AND ACETAMINOPHEN | Brand | Tier 4 | $0.00 | Details |
| 7 | TicoVac Tick-Borne Encephalitis Vaccine | Brand | Tier 3 | $0.00 | Details |
| 8 | Carbidopa and levodopa | Brand | Tier 2 | $0.00 | Details |
| 9 | Levothyroxine Sodium levothyroxine sodium | Brand | Tier 2 | $0.00 | Details |
| 10 | Clozapine | Brand | Tier 4 | $0.00 | Details |
| 11 | Amoxicillin | Brand | Tier 2 | $0.00 | Details |
| 12 | Trifluoperazine Hydrochloride trifluoperazine hydrochloride | Brand | Tier 2 | $0.00 | Details |
| 13 | Ciprofloxacin in Dextrose ciprofloxacin | Brand | Tier 4 | $0.00 | Details |
| 14 | Thioridazine Hydrochloride thioridazine hydrochloride | Brand | Tier 2 | $0.00 | Details |
| 15 | Chlorhexidine Gluconate | Brand | Tier 2 | $0.00 | Details |
| 16 | Lorbrena lorlatinib | Brand | Tier 5 | $0.00 | Details |
| 17 | PIQRAY alpelisib | Brand | Tier 5 | $0.00 | Details |
| 18 | Isosorbide Dinitrate | Brand | Tier 2 | $0.00 | Details |
| 19 | Acarbose | Brand | Tier 2 | $0.00 | Details |
| 20 | Enoxaparin Sodium Enoxaparin sodium | Brand | Tier 2 | $0.00 | Details |
Showing 20 of 1,037 covered drugs.
States Served (1)
This plan is available to Medicare beneficiaries in the following states.
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