ST. LUKE’S CHARGE 10002800 OMALIZUMAB 75 MG/0.5ML SC SOSY Insurance and Self Pay Discounts 250 J2357 50242-214-01 $353.89

Aurora ST. LUKE’S
CHARGE
10002800
OMALIZUMAB 75 MG/0.5ML SC SOSY
Rev 250
CPT J2357
NDC 50242-214-01

Fee $353.89

Self-Pay $191.38

Insurance

Minimum $176.95
Maximum $300.80
Aetna W $98.31
Aetna PPO $295.13
Anthem Blue Priority $61.95
Anthem Blue Preferred $61.95
Anthem PPO $300.80
Aurora Caregiver $46.20
Centivo $57.20
Cigna GPPO $212.07
Cigna PPO $299.36
Common Ground ETF Network $60.76
Common Ground Exchange Envision $60.76
Common Ground Group Envision $60.76
Everpointe Elite $59.28
Health EOS Plus $215.88
Health EOS PPO $283.11
HealthPartners ETF $55.22
HealthPartners Robin Focused $68.96
HealthPartners Broad $265.42
HPS $62.56
HST $173.38
Humana HPN $48.34
Humana HMO $48.34
Humana PPO $299.36
Molina Exchange $105.83
Quartz One $173.38
Quartz Group $208.05
Trilogy $193.02
UHC Individual Exchange $47.71
UHC Charter $47.71
UHC Nexus $47.71
UHC HMO $48.13
UHC PPO $299.40
WPS Aurora Featured Network $181.81
WPS Arise $191.38
WPS Statewide $191.38