EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H (30 PATCHES CRTN) (NDC: 49502090130)
2014 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 |
AARP MedicareComplete Choice Plan 2 (Regional PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | 33% | S | $1,118.08 |
Browse Plan Formulary |
AARP MedicareComplete Plus (HMO-POS)
|
$0.00 |
$0 | Few Generics | 5 |
Specialty Tier |
33% | 33% | S | $1,118.20 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$0 | Few Generics | 3 |
Non-Preferred Brand |
$95.00 | $190.00 | P S Q:1 /1Days | $1,116.97 |
Browse Plan Formulary |
Amerivantage Classic+ Rx Plan (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | P Q:30 /30Days | $1,111.59 |
Browse Plan Formulary |
AvMed Medicare Choice (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$70.00 | $210.00 | Q:30 /30Days | $1,132.91 |
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 |
BlueMedicare HMO LifeTime (HMO)
|
$0.00 |
$0 | Many Generics | 5 |
Specialty Tier |
33% | 33% | None | $1,115.80 |
Browse Plan Formulary |
BlueMedicare HMO PrimeTime (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | 33% | None | $1,115.80 |
Browse Plan Formulary |
BlueMedicare Regional PPO (Regional PPO)
|
$0.00 |
$30 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | 25% | None | $1,116.33 |
Browse Plan Formulary |
CareDirect (HMO SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 5 |
Specialty Tier |
33% | n/a | Q:30 /30Days | $1,104.59 |
Browse Plan Formulary |
CareFree PLUS (HMO)
|
$0.00 |
$0 | Few Generics, Few Brands | 5 |
Specialty Tier |
33% | n/a | Q:30 /30Days | $1,104.59 |
Browse Plan Formulary |
CareHeart (HMO SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 5 |
Specialty Tier |
33% | n/a | Q:30 /30Days | $1,104.59 |
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 |
CareOne (HMO)
|
$0.00 |
$0 | Some Generics, Few Brands | 5 |
Specialty Tier |
33% | n/a | Q:30 /30Days | $1,104.59 |
Browse Plan Formulary |
Clear Skies (HMO SNP)
|
$0.00 |
$0 | All Generics | 3 |
Non-Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days | $1,147.05 |
Browse Plan Formulary |
Coventry Summit Ideal (HMO)
|
$0.00 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
$45.00 | $135.00 | S Q:30 /30Days | $1,136.80 |
Browse Plan Formulary |
Coventry Vista Ideal (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$75.00 | $225.00 | S Q:30 /30Days | $1,136.80 |
Browse Plan Formulary |
Day Break (HMO)
|
$0.00 |
$0 | All Generics | 3 |
Non-Preferred Brand |
$60.00 | $180.00 | Q:30 /30Days | $1,147.05 |
Browse Plan Formulary |
Freedom Medicare Plan Rx (HMO)
|
$0.00 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
$80.00 | $160.00 | P Q:30 /30Days | $1,100.17 |
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 |
Freedom VIP Savings (HMO SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$80.00 | $160.00 | P Q:30 /30Days | $1,100.60 |
Browse Plan Formulary |
Freedom VIP Savings COPD (HMO SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$80.00 | $160.00 | P Q:30 /30Days | $1,100.60 |
Browse Plan Formulary |
Healthy Advantage Plan (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
33% | n/a | None | $1,112.66 |
Browse Plan Formulary |
Humana Gold Plus H1036-065C (HMO)
|
$0.00 |
$0 | Some Generics, Few Brands | 5 |
Specialty Tier |
33% | n/a | Q:30 /30Days | $1,104.59 |
Browse Plan Formulary |
Humana Gold Plus H1036-224 (HMO)
|
$0.00 |
$0 | Few Generics, Few Brands | 5 |
Specialty Tier |
33% | n/a | Q:30 /30Days | $1,104.59 |
Browse Plan Formulary |
Humana Gold Plus SNP-CVD/CHF H1036-186 (HMO SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 5 |
Specialty Tier |
33% | n/a | Q:30 /30Days | $1,104.59 |
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 |
Humana Gold Plus SNP-DB H1036-121C (HMO SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 5 |
Specialty Tier |
33% | n/a | Q:30 /30Days | $1,104.59 |
Browse Plan Formulary |
HumanaChoice R5826-074 (Regional PPO)
|
$0.00 |
$150 | Few Generics, Few Brands | 5 |
Specialty Tier |
29% | n/a | Q:30 /30Days | $1,106.94 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Specialty Tier |
33% | n/a | S | $1,118.20 |
Browse Plan Formulary |
Optimum Gold Rewards Plan (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$80.00 | $160.00 | P Q:30 /30Days | $1,096.68 |
Browse Plan Formulary |
Optimum Platinum Plan (HMO-POS)
|
$0.00 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
$69.00 | $138.00 | P Q:30 /30Days | $1,096.68 |
Browse Plan Formulary |
PHP (HMO SNP)
|
$0.00 |
$310 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
25% | n/a | None | $1,146.10 |
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 |
Preferred Choice Broward (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Specialty Tier |
33% | 33% | S | $1,118.20 |
Browse Plan Formulary |
Simply Clear (HMO SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
25% | n/a | P Q:30 /30Days | $1,099.01 |
Browse Plan Formulary |
Simply Extra (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$75.00 | n/a | P Q:30 /30Days | $1,102.02 |
Browse Plan Formulary |
Simply Level (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$30.00 | n/a | P Q:30 /30Days | $1,102.02 |
Browse Plan Formulary |
Simply More (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$30.00 | n/a | P Q:30 /30Days | $1,102.02 |
Browse Plan Formulary |
Simply Options (HMO-POS)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$40.00 | n/a | P Q:30 /30Days | $1,102.02 |
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 |
SunPlus Advantage Plan (HMO)
|
$0.00 |
$0 | All Generics, All Brands | 4 |
Non-Preferred Brand |
$0.00 | n/a | None | $1,112.66 |
Browse Plan Formulary |
SunPlus Diabetes Special Needs Plan (HMO SNP)
|
$0.00 |
$0 | All Generics, All Brands | 4 |
Non-Preferred Brand |
$0.00 | n/a | None | $1,112.66 |
Browse Plan Formulary |
Sunrise (HMO)
|
$0.00 |
$0 | All Generics | 3 |
Non-Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days | $1,147.05 |
Browse Plan Formulary |
Humana Gold Plus SNP-I H1036-185 (HMO SNP)
|
$7.70 |
$310 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | Q:30 /30Days | $1,104.59 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-103A (HMO SNP)
|
$8.00 |
$310 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | Q:30 /30Days | $1,104.59 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
|
$9.40 |
$310 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:31 /31Days | $1,136.58 |
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 |
WellCare Access (HMO SNP)
|
$10.40 |
$310 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:31 /31Days | $1,136.58 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-162 (HMO SNP)
|
$10.50 |
$310 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | Q:30 /30Days | $1,104.59 |
Browse Plan Formulary |
WellCare Select (HMO SNP)
|
$11.60 |
$310 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:31 /31Days | $1,140.48 |
Browse Plan Formulary |
CareNeeds PLUS (HMO SNP)
|
$11.70 |
$310 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | Q:30 /30Days | $1,104.59 |
Browse Plan Formulary |
CareNeeds (HMO SNP)
|
$17.00 |
$310 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | Q:30 /30Days | $1,104.59 |
Browse Plan Formulary |
Coventry Summit Maximum (HMO SNP)
|
$18.90 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
$76.00 | $228.00 | S Q:30 /30Days | $1,137.77 |
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 |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$19.80 |
$310 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | S | $1,118.40 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax Plus (HMO-POS SNP)
|
$20.60 |
$0 | Many Generics | 4 |
Specialty Tier |
25% | n/a | S | $1,117.82 |
Browse Plan Formulary |
Advantage by Sunshine Health (HMO SNP)
|
$21.00 |
$310 | Many Generics | 2 |
Preferred Brand |
$45.00 | $45.00 | None | $1,136.30 |
Browse Plan Formulary |
Preferred Medicare Assist (HMO-POS SNP)
|
$21.20 |
$0 | Many Generics | 4 |
Specialty Tier |
25% | 25% | S | $1,117.82 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO SNP)
|
$21.80 |
$310 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
15% | 15% | S | $1,118.08 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$22.00 |
$310 | Many Generics, Few Brands | 3 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:30 /30Days | $1,111.59 |
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 |
Amerivantage Specialty + Rx (HMO SNP)
|
$22.10 |
$310 | Some Generics | 4 |
Non-Preferred Brand |
25% | 25% | P Q:30 /30Days | $1,111.59 |
Browse Plan Formulary |
Coventry Vista Maximum Choice (HMO SNP)
|
$22.10 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$76.00 | $228.00 | S Q:30 /30Days | $1,137.53 |
Browse Plan Formulary |
Freedom Medi-Medi Full (HMO SNP)
|
$22.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
n/a | n/a | P Q:30 /30Days | $1,096.17 |
Browse Plan Formulary |
Freedom Medi-Medi Partial (HMO SNP)
|
$22.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | P Q:30 /30Days | $1,096.17 |
Browse Plan Formulary |
MediMax (HMO)
|
$22.10 |
$310 | Call plan for details | 4 |
Non-Preferred Brand |
25% | n/a | None | $1,111.25 |
Browse Plan Formulary |
Optimum Emerald Full (HMO SNP)
|
$22.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
n/a | n/a | P Q:30 /30Days | $1,095.87 |
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 |
Optimum Emerald Partial (HMO SNP)
|
$22.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | P Q:30 /30Days | $1,095.87 |
Browse Plan Formulary |
Simply Care (HMO SNP)
|
$22.10 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$25.00 | n/a | P Q:30 /30Days | $1,102.02 |
Browse Plan Formulary |
Simply Comfort (HMO SNP)
|
$22.10 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$25.00 | n/a | P Q:30 /30Days | $1,102.02 |
Browse Plan Formulary |
Simply Complete (HMO SNP)
|
$22.10 |
$310 | Many Generics | 4 |
Non-Preferred Brand |
$75.00 | n/a | P Q:30 /30Days | $1,102.02 |
Browse Plan Formulary |
Touch Institutional Special Needs Plan (HMO SNP)
|
$22.10 |
$310 | Some Generics | 4 |
Non-Preferred Brand |
25% | 25% | P Q:30 /30Days | $1,111.02 |
Browse Plan Formulary |
Sunny Days (HMO SNP)
|
$33.90 |
$0 | All Generics | 3 |
Non-Preferred Brand |
25% | 25% | Q:30 /30Days | $1,147.05 |
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 |
Aetna Medicare Premier Plan (PPO)
|
$35.00 |
$310 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$95.00 | $190.00 | P S Q:1 /1Days | $1,116.97 |
Browse Plan Formulary |
HumanaChoice R5826-005 (Regional PPO)
|
$36.60 |
$0 | Few Generics, Few Brands | 5 |
Specialty Tier |
33% | n/a | Q:30 /30Days | $1,106.94 |
Browse Plan Formulary |
HumanaChoice H5415-056 (PPO)
|
$45.00 |
$0 | Few Generics, Few Brands | 5 |
Specialty Tier |
33% | n/a | Q:30 /30Days | $1,111.05 |
Browse Plan Formulary |
Humana Gold Choice H8145-061 (PFFS)
|
$103.00 |
$0 | Few Generics, Few Brands | 5 |
Specialty Tier |
33% | n/a | Q:30 /30Days | $1,107.61 |
Browse Plan Formulary |
BlueMedicare PPO (PPO)
|
$127.00 |
$0 | Many Generics | 5 |
Specialty Tier |
33% | 33% | None | $1,115.85 |
Browse Plan Formulary |