Providence Medicare Prime + Rx (HMO)
$0.00 /month
Monthly Premium
Among the lowest-premium plans in 2026
$250.00
Annual Deductible
992
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 | NOVOLOG insulin aspart | Brand | Tier 3 | $47.00 | Details |
| 2 | Fetzima LEVOMILNACIPRAN HYDROCHLORIDE | Brand | Tier 4 | $100.00 | Details |
| 3 | POSACONAZOLE Posaconazole | Brand | Tier 5 | 0.3% coinsurance | Details |
| 4 | Warfarin Sodium | Brand | Tier 1 | $0.00 | Details |
| 5 | Potassium Chloride | Brand | Tier 2 | $10.00 | Details |
| 6 | Trifluoperazine Hydrochloride trifluoperazine hydrochloride | Brand | Tier 3 | $47.00 | Details |
| 7 | TRETINOIN tretinoin | Brand | Tier 3 | $47.00 | Details |
| 8 | Mercaptopurine | Brand | Tier 3 | $47.00 | Details |
| 9 | ELIQUIS apixaban | Brand | Tier 3 | $47.00 | Details |
| 10 | Balsalazide Disodium | Brand | Tier 3 | $47.00 | Details |
| 11 | BOSULIF Bosutinib | Brand | Tier 5 | 0.3% coinsurance | Details |
| 12 | RotaTeq Rotavirus Vaccine, Live, Oral, Pentavalent | Brand | Tier 3 | $47.00 | Details |
| 13 | Diazepam | Brand | Tier 3 | $47.00 | Details |
| 14 | Depo-SubQ Provera medroxyprogesterone acetate | Brand | Tier 4 | $100.00 | Details |
| 15 | Fluphenazine Hydrochloride | Brand | Tier 4 | $100.00 | Details |
| 16 | Xospata gilteritinib | Brand | Tier 5 | 0.3% coinsurance | Details |
| 17 | Mekinist trametinib | Brand | Tier 5 | 0.3% coinsurance | Details |
| 18 | Loxapine | Brand | Tier 2 | $10.00 | Details |
| 19 | ZEJULA niraparib | Brand | Tier 5 | 0.3% coinsurance | Details |
| 20 | Risperidone | Brand | Tier 4 | $100.00 | Details |
Showing 20 of 992 covered drugs.
States Served (1)
This plan is available to Medicare beneficiaries in the following states.
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