SummaCare Medicare Sapphire (HMO-POS)
$83.00 /month
Monthly Premium
$50.00
Annual Deductible
1,057
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 | Vizimpro dacomitinib | Brand | Tier 5 | 0.3% coinsurance | Details |
| 2 | Diazepam | Brand | Tier 1 | $0.00 | Details |
| 3 | NOVOLOG insulin aspart | Brand | Tier 3 | $41.00 | Details |
| 4 | PredniSONE | Brand | Tier 1 | $0.00 | Details |
| 5 | Fetzima LEVOMILNACIPRAN HYDROCHLORIDE | Brand | Tier 4 | 0.4% coinsurance | Details |
| 6 | Amoxicillin | Brand | Tier 1 | $0.00 | Details |
| 7 | Rufinamide | Brand | Tier 5 | 0.3% coinsurance | Details |
| 8 | Prograf Tacrolimus | Brand | Tier 4 | 0.4% coinsurance | Details |
| 9 | BOSULIF Bosutinib | Brand | Tier 5 | 0.3% coinsurance | Details |
| 10 | Isoniazid | Brand | Tier 1 | $0.00 | Details |
| 11 | Erlotinib | Brand | Tier 5 | 0.3% coinsurance | Details |
| 12 | PREVYMIS LETERMOVIR | Brand | Tier 5 | 0.3% coinsurance | Details |
| 13 | GARDASIL 9 Human Papillomavirus 9-valent Vaccine, Recombinant | Brand | Tier 3 | $41.00 | Details |
| 14 | Doxepin Hydrochloride doxepin hydrochloride | Brand | Tier 3 | $41.00 | Details |
| 15 | Pilocarpine Hydrochloride | Brand | Tier 4 | 0.4% coinsurance | Details |
| 16 | TicoVac Tick-Borne Encephalitis Vaccine | Brand | Tier 3 | $41.00 | Details |
| 17 | Potassium Chloride potassium chloride | Brand | Tier 2 | $0.00 | Details |
| 18 | Ampicillin and Sulbactam | Brand | Tier 4 | 0.4% coinsurance | Details |
| 19 | ETHOSUXIMIDE | Brand | Tier 3 | $41.00 | Details |
| 20 | Leucovorin Calcium | Brand | Tier 3 | $41.00 | Details |
Showing 20 of 1,057 covered drugs.
States Served (1)
This plan is available to Medicare beneficiaries in the following states.
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