EQUETRO CAPSULES 200MG 120 BOT (120 BOT) (NDC: 30698042112)
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 | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $186.20 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$0 | Few Generics | 3 |
Non-Preferred Brand |
$95.00 | $190.00 | Q:8 /1Days | $186.57 |
Browse Plan Formulary |
BlueMedicare HMO LifeTime (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$50.00 | $150.00 | None | $185.96 |
Browse Plan Formulary |
BlueMedicare HMO PrimeTime (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$50.00 | $150.00 | None | $185.96 |
Browse Plan Formulary |
BlueMedicare Regional PPO (Regional PPO)
|
$0.00 |
$30 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $285.00 | None | $185.52 |
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 |
CareDirect (HMO SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 4 |
Non-Preferred Brand |
$35.00 | $95.00 | None | $185.18 |
Browse Plan Formulary |
CareFree PLUS (HMO)
|
$0.00 |
$0 | Few Generics, Few Brands | 4 |
Non-Preferred Brand |
$45.00 | $125.00 | None | $185.18 |
Browse Plan Formulary |
CareHeart (HMO SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 4 |
Non-Preferred Brand |
$35.00 | $95.00 | None | $185.18 |
Browse Plan Formulary |
CareOne PLUS (HMO)
|
$0.00 |
$0 | Some Generics, Few Brands | 4 |
Non-Preferred Brand |
$35.00 | $95.00 | None | $185.18 |
Browse Plan Formulary |
Clear Skies (HMO SNP)
|
$0.00 |
$0 | All Generics | 3 |
Non-Preferred Brand |
$20.00 | $60.00 | None | $191.53 |
Browse Plan Formulary |
Coventry Summit Ideal (HMO)
|
$0.00 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
$35.00 | $105.00 | None | $188.56 |
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 |
Coventry Summit Plus (HMO)
|
$0.00 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
$60.00 | $180.00 | None | $188.56 |
Browse Plan Formulary |
Coventry Vista Ideal (HMO)
|
$0.00 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
$30.00 | $90.00 | None | $188.56 |
Browse Plan Formulary |
Day Break (HMO)
|
$0.00 |
$0 | All Generics | 3 |
Non-Preferred Brand |
$20.00 | $60.00 | None | $191.53 |
Browse Plan Formulary |
Healthy Advantage Plan (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
33% | n/a | None | $185.33 |
Browse Plan Formulary |
Humana Gold Plus H1036-054C (HMO)
|
$0.00 |
$0 | Some Generics, Few Brands | 4 |
Non-Preferred Brand |
$35.00 | $95.00 | None | $185.18 |
Browse Plan Formulary |
Humana Gold Plus H1036-164 (HMO)
|
$0.00 |
$0 | Few Generics, Few Brands | 4 |
Non-Preferred Brand |
$45.00 | $125.00 | None | $185.18 |
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 |
Humana Gold Plus SNP-CVD/CHF H1036-189 (HMO SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 4 |
Non-Preferred Brand |
$35.00 | $95.00 | None | $185.18 |
Browse Plan Formulary |
Humana Gold Plus SNP-DB H1036-188 (HMO SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 4 |
Non-Preferred Brand |
$35.00 | $95.00 | None | $185.18 |
Browse Plan Formulary |
HumanaChoice R5826-074 (Regional PPO)
|
$0.00 |
$150 | Few Generics, Few Brands | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $183.69 |
Browse Plan Formulary |
Leon Medical Centers Health Plans - Leon Cares (HMO)
|
$0.00 |
$0 | Many Generics | 1 |
Generic |
$0.00 | n/a | None | $184.24 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax (HMO-POS)
|
$0.00 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
$25.00 | n/a | None | $186.01 |
Browse Plan Formulary |
Preferred Choice Dade (HMO-POS)
|
$0.00 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
$25.00 | $65.00 | None | $186.01 |
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 Complete Care (HMO)
|
$0.00 |
$0 | Many Generics, Some Brands | 3 |
Non-Preferred Brand |
$25.00 | $65.00 | None | $186.01 |
Browse Plan Formulary |
Preferred Special Care Miami-Dade (HMO SNP)
|
$0.00 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
$25.00 | $65.00 | None | $186.01 |
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 | None | $182.23 |
Browse Plan Formulary |
Simply Extra (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$55.00 | n/a | None | $182.19 |
Browse Plan Formulary |
Simply Level (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$15.00 | n/a | None | $182.19 |
Browse Plan Formulary |
Simply More (HMO)
|
$0.00 |
$0 | All Generics, All Brands | 4 |
Non-Preferred Brand |
$10.00 | n/a | None | $182.19 |
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 |
Simply Options (HMO-POS)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$30.00 | n/a | None | $182.19 |
Browse Plan Formulary |
SunPlus Advantage Plan (HMO)
|
$0.00 |
$0 | All Generics, All Brands | 4 |
Non-Preferred Brand |
$0.00 | n/a | None | $185.33 |
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 | $185.33 |
Browse Plan Formulary |
Sunrise (HMO)
|
$0.00 |
$0 | All Generics | 3 |
Non-Preferred Brand |
$10.00 | $30.00 | None | $191.53 |
Browse Plan Formulary |
Sunny Days (HMO SNP)
|
$3.60 |
$0 | All Generics | 3 |
Non-Preferred Brand |
25% | 25% | None | $191.53 |
Browse Plan Formulary |
Humana Gold Plus SNP-I H1036-187 (HMO SNP)
|
$7.80 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $185.18 |
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 |
Humana Gold Plus SNP-DE H1036-077A (HMO SNP)
|
$11.80 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $185.18 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-163 (HMO SNP)
|
$12.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $185.18 |
Browse Plan Formulary |
CareNeeds PLUS (HMO SNP)
|
$13.60 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$91.00 | $263.00 | None | $185.18 |
Browse Plan Formulary |
CareNeeds (HMO SNP)
|
$17.50 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $185.18 |
Browse Plan Formulary |
Coventry Summit Maximum (HMO SNP)
|
$18.90 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
$76.00 | $228.00 | None | $189.32 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$19.90 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $186.35 |
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 |
Medica HealthCare Plans MedicareMax Plus (HMO-POS SNP)
|
$20.60 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
25% | n/a | None | $185.99 |
Browse Plan Formulary |
Preferred Medicare Assist (HMO-POS SNP)
|
$21.20 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
25% | 25% | None | $185.99 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO SNP)
|
$21.80 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $186.20 |
Browse Plan Formulary |
Coventry Vista Maximum (HMO SNP)
|
$22.10 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$76.00 | $228.00 | None | $189.01 |
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 | None | $189.58 |
Browse Plan Formulary |
MediMax (HMO)
|
$22.10 |
$310 | Call plan for details | 4 |
Non-Preferred Brand |
25% | n/a | None | $185.24 |
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 |
Simply Care (HMO SNP)
|
$22.10 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$25.00 | n/a | None | $182.19 |
Browse Plan Formulary |
Simply Comfort (HMO SNP)
|
$22.10 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$25.00 | n/a | None | $182.19 |
Browse Plan Formulary |
Simply Complete (HMO SNP)
|
$22.10 |
$310 | Many Generics | 4 |
Non-Preferred Brand |
$75.00 | n/a | None | $182.19 |
Browse Plan Formulary |
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 | Q:8 /1Days | $186.57 |
Browse Plan Formulary |
HumanaChoice R5826-005 (Regional PPO)
|
$36.60 |
$0 | Few Generics, Few Brands | 4 |
Non-Preferred Brand |
$85.00 | $245.00 | None | $183.69 |
Browse Plan Formulary |
HumanaChoice H5415-056 (PPO)
|
$45.00 |
$0 | Few Generics, Few Brands | 4 |
Non-Preferred Brand |
$85.00 | $245.00 | None | $185.61 |
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 Choice H8145-061 (PFFS)
|
$103.00 |
$0 | Few Generics, Few Brands | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $183.85 |
Browse Plan Formulary |