DICYCLOMINE HCL 10MG/5ML SYRUP (1 PINT (473ML) BOT) (NDC: 00603116158)
2013 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
Plan Name |
Monthly Prem. |
De- duct- ible |
Does Plan Offer Additional Gap Coverage |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Plan’s Avg. Retail Drug Price 30-Day |
Tier Nbr. |
Tier Desc. |
30-Day Prfrd. Pharm |
90-Day Mail Order |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $82.93 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $82.93 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $84.02 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $82.93 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $83.69 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HealthPlus MedicarePlus-AdvantageHMO-POS Option 0 (HMO-POS)
|
$0.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$6.00 | $12.00 | None | $40.00 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$12.50 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $83.07 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$12.50 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $82.93 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$12.50 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $82.93 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$12.50 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $82.93 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$12.50 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $84.02 |
Browse Plan Formulary |
|
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HumanaChoice R5826-072 (Regional PPO)
|
$20.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $57.42 |
Browse Plan Formulary |
HealthPlus MedicarePlus-Advantage D-SNP (HMO SNP)
|
$23.60 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $40.00 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$32.70 |
$325* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Generic |
$0.00 | $0.00 | None | $82.67 |
Browse Plan Formulary |
Meridian Advantage Plan of Michigan (HMO SNP)
|
$34.10 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
n/a | n/a | P | $82.56 |
Browse Plan Formulary |
CareSource Advantage (HMO SNP)
|
$34.20 |
$325* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Generic |
$0.00 | $0.00 | None | $83.14 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$34.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
n/a | n/a | P | $40.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HumanaChoice R5826-006 (Regional PPO)
|
$37.50 |
$0 |
Few Generics, Few Brands |
1 |
Preferred Generic |
$8.00 | $0.00 | None | $57.42 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$44.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$6.00 | $15.00 | None | $84.10 |
Browse Plan Formulary |
HAP Senior Plus - Henry Ford (HMO)
|
$54.00 |
$50 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$2.00 | $5.00 | None | $84.10 |
Browse Plan Formulary |
Humana Gold Plus H8908-001 (HMO)
|
$59.00 |
$0 |
Few Generics, Few Brands |
1 |
Preferred Generic |
$7.00 | $0.00 | None | $58.08 |
Browse Plan Formulary |
HealthPlus MedicarePlus-AdvantageHMO-POS Option 1 (HMO-POS)
|
$79.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$7.00 | $14.00 | None | $40.00 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$86.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $82.93 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Medicare Plus Blue PPO Vitality (PPO)
|
$86.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $84.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$86.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $83.07 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$86.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $82.93 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$86.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $82.93 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$94.00 |
$25 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$2.00 | $5.00 | None | $84.10 |
Browse Plan Formulary |
Alliance Medicare PPO (PPO)
|
$103.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$2.00 | $5.00 | None | $84.10 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $82.93 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $84.02 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $83.69 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $82.93 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $82.93 |
Browse Plan Formulary |
HAP Senior Plus - Henry Ford (HMO)
|
$122.00 |
$50 |
All Generics |
1 |
Preferred Generic |
$2.00 | $5.00 | None | $84.10 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HealthPlus MedicarePlus-AdvantageHMO-POS Option 2 (HMO-POS)
|
$125.00 |
$0 |
All Generics |
1 |
Generic |
$6.00 | $12.00 | None | $40.00 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$125.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None | $82.93 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$125.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None | $82.93 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$125.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None | $84.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$125.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None | $83.07 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$125.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None | $82.93 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$169.00 |
$25 |
All Generics |
1 |
Preferred Generic |
$2.00 | $5.00 | None | $84.10 |
Browse Plan Formulary |
Alliance Medicare PPO (PPO)
|
$174.00 |
$50 |
All Generics |
1 |
Preferred Generic |
$4.00 | $10.00 | None | $84.10 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$218.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $83.69 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$218.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $82.93 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$218.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $82.93 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$218.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $82.93 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$218.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $84.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$244.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $82.93 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$244.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $82.93 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$244.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $82.93 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$244.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $82.93 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$244.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $82.93 |
Browse Plan Formulary |