ST. LUKE’S CHARGE 10002800 BELIMUMAB 120 MG IV SOLR Insurance and Self Pay Discounts 250 J0490 49401-101-01 $277.59

Aurora ST. LUKE’S
CHARGE
10002800
BELIMUMAB 120 MG IV SOLR
Rev 250
CPT J0490
NDC 49401-101-01

Fee $277.59

Self-Pay $150.34

Insurance

Minimum $138.80
Maximum $235.95
Aetna W $133.53
Aetna PPO $231.50
Anthem Blue Priority $84.22
Anthem Blue Preferred $84.22
Anthem PPO $235.95
Aurora Caregiver $62.85
Centivo $77.79
Cigna GPPO $166.35
Cigna PPO $234.82
Common Ground ETF Network $82.60
Common Ground Exchange Envision $82.60
Common Ground Group Envision $82.60
Everpointe Elite $80.56
Health EOS Plus $169.33
Health EOS PPO $222.08
HealthPartners ETF $75.08
HealthPartners Robin Focused $93.78
HealthPartners Broad $208.19
HPS $85.06
HST $136.00
Humana HPN $65.71
Humana HMO $65.71
Humana PPO $234.82
Molina Exchange $141.05
Quartz One $136.00
Quartz Group $163.19
Trilogy $151.70
UHC Individual Exchange $63.12
UHC Charter $63.12
UHC Nexus $63.12
UHC HMO $63.54
UHC PPO $234.84
WPS Aurora Featured Network $142.82
WPS Arise $150.34
WPS Statewide $150.34