XIFAXAN 200MG TABLET (30 BOT) (NDC: 65649030103)
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 | 4 |
Tier 4 |
25% | 25% | Q:9 /3Days | $1,259.65 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | Q:9 /3Days | $1,265.67 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | Q:9 /3Days | $1,265.76 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | Q:9 /3Days | $1,252.30 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | Q:9 /3Days | $1,256.76 |
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 | 2 |
Preferred Brand |
$33.00 | $66.00 | None | $1,223.41 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$12.50 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $1,259.65 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$12.50 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $1,259.47 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$12.50 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $1,261.87 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$12.50 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $1,251.61 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$12.50 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $1,252.23 |
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 | 3 |
Tier 3 |
25% | 25% | P Q:9 /30Days | $1,245.14 |
Browse Plan Formulary |
HealthPlus MedicarePlus-Advantage D-SNP (HMO SNP)
|
$23.60 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $1,223.44 |
Browse Plan Formulary |
HumanaChoice R5826-006 (Regional PPO)
|
$37.50 |
$0 | Few Generics, Few Brands | 3 |
Non-Preferred Brand |
$80.00 | $230.00 | P Q:9 /30Days | $1,245.14 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$55.60 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:31 /31Days | $1,246.86 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$76.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $1,251.61 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$76.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $1,259.65 |
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)
|
$76.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $1,252.23 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$76.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $1,261.87 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$76.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $1,259.47 |
Browse Plan Formulary |
HealthPlus MedicarePlus-AdvantageHMO-POS Option 1 (HMO-POS)
|
$79.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$39.00 | $78.00 | None | $1,223.41 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$96.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$80.00 | $200.00 | Q:9 /3Days | $1,259.65 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$96.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$80.00 | $200.00 | Q:9 /3Days | $1,265.67 |
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)
|
$96.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$80.00 | $200.00 | Q:9 /3Days | $1,265.76 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$96.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$80.00 | $200.00 | Q:9 /3Days | $1,252.30 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$96.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$80.00 | $200.00 | Q:9 /3Days | $1,256.76 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$97.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:31 /31Days | $1,247.61 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$97.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:31 /31Days | $1,248.65 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$97.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:31 /31Days | $1,246.86 |
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 | 2 |
Preferred Brand |
$35.00 | $70.00 | None | $1,223.41 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$132.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $1,259.65 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$132.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $1,259.47 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$132.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $1,252.23 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$132.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $1,251.61 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$132.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $1,261.87 |
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-AdvantagePPO Enhanced (PPO)
|
$136.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$35.00 | $70.00 | None | $1,224.37 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$136.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$80.00 | $200.00 | Q:31 /31Days | $1,246.86 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$154.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$85.00 | $212.50 | Q:31 /31Days | $1,246.86 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$213.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:9 /3Days | $1,259.65 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$213.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:9 /3Days | $1,265.67 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$213.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:9 /3Days | $1,265.76 |
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)
|
$213.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:9 /3Days | $1,252.30 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$213.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$75.00 | $187.50 | Q:9 /3Days | $1,256.76 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$240.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $1,251.93 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$240.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $1,252.23 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$240.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $1,251.61 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$240.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $1,252.18 |
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 Assure (PPO)
|
$240.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $1,256.65 |
Browse Plan Formulary |