PRISTIQ 100MG TABLET SR 24HR (30 BOT) (NDC: 00008122230)
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 SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 | Some Generics | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | P Q:120 /30Days | $218.15 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 | Some Generics | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | P Q:120 /30Days | $218.15 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 | Few Generics | 3 |
Non-Preferred Brand |
50% | 50% | S Q:1 /1Days | $218.36 |
Browse Plan Formulary |
Blue Cross Senior Secure Plan I (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$90.00 | $270.00 | P Q:120 /30Days | $217.77 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$85.00 | $170.00 | S Q:120 /30Days | $217.95 |
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 |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
$70.00 | $140.00 | S Q:120 /30Days | $217.95 |
Browse Plan Formulary |
Brand New Day Dementia with Enhanced Drug Benefits (HMO SNP)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$90.00 | $270.00 | S Q:30 /30Days | $223.28 |
Browse Plan Formulary |
Brand New Day Diabetes with Enhanced Drug Benefits (HMO SNP)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$90.00 | $270.00 | S Q:30 /30Days | $223.28 |
Browse Plan Formulary |
Brand New Day Enhanced Drug Savings for So Cal (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$90.00 | $270.00 | S Q:30 /30Days | $223.30 |
Browse Plan Formulary |
Care1st AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$50.00 | $100.00 | P | $219.92 |
Browse Plan Formulary |
Care1st AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$60.00 | $120.00 | P | $219.60 |
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 |
CareMore Breathe (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$85.00 | $212.50 | Q:120 /30Days | $225.22 |
Browse Plan Formulary |
CareMore Connect (HMO SNP)
|
$0.00 |
$310 | Many Generics | 4 |
Non-Preferred Brand |
25% | 25% | Q:120 /30Days | $225.21 |
Browse Plan Formulary |
CareMore ESRD (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$85.00 | $212.50 | Q:120 /30Days | $225.22 |
Browse Plan Formulary |
CareMore Heart (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$85.00 | $212.50 | Q:120 /30Days | $225.22 |
Browse Plan Formulary |
CareMore Reliance (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$85.00 | $212.50 | Q:120 /30Days | $225.22 |
Browse Plan Formulary |
CareMore StartSmart Plus (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:120 /30Days | $225.22 |
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 |
CareMore Touch (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$85.00 | $212.50 | Q:120 /30Days | $225.22 |
Browse Plan Formulary |
CareMore Value Plus (HMO)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$85.00 | $212.50 | Q:120 /30Days | $224.17 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 | All Generics | 4 |
Non-Preferred Brand |
$50.00 | $100.00 | Q:30 /30Days | $224.17 |
Browse Plan Formulary |
Citizens Choice Healthplan (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$30.00 | $60.00 | None | $218.21 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | Q:30 /30Days | $220.01 |
Browse Plan Formulary |
Golden State Medicare Health Plan, Golden (HMO)
|
$0.00 |
$0 | Many Generics, Few Brands | 2 |
Preferred Brand |
$40.00 | $80.00 | Q:124 /31Days | $218.08 |
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 |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$95.00 | $238.00 | None | $216.50 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$95.00 | $238.00 | None | $216.66 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $216.66 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $216.50 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $216.55 |
Browse Plan Formulary |
Health Net Seniority Plus Ruby (HMO)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $216.66 |
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 |
Health Net Seniority Plus Ruby (HMO)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $216.50 |
Browse Plan Formulary |
Heart First (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 3 |
Preferred Brand |
$40.00 | $80.00 | S | $217.77 |
Browse Plan Formulary |
Humana Gold Plus H0108-011 (HMO)
|
$0.00 |
$0 | Some Generics, Few Brands | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:30 /30Days | $214.37 |
Browse Plan Formulary |
Inter Valley Health Plan Service To Seniors (HMO)
|
$0.00 |
$0 | Some Generics | 4 |
Non-Preferred Brand |
$79.00 | $158.00 | Q:30 /30Days | $224.17 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 | All Generics, Few Brands | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $238.62 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 3 |
Preferred Brand |
$40.00 | $80.00 | S | $217.77 |
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 |
SCAN Classic (HMO)
|
$0.00 |
$0 | Many Generics | 3 |
Preferred Brand |
$40.00 | $80.00 | S | $218.00 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 | Many Generics | 3 |
Preferred Brand |
$39.00 | $78.00 | S | $217.61 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$4.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $237.37 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$14.40 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $237.37 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 3 (HMO)
|
$16.20 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | P Q:120 /30Days | $218.08 |
Browse Plan Formulary |
Care1st TotalDual Plan (HMO SNP)
|
$20.70 |
$310 | Few Generics | 4 |
Non-Preferred Brand |
25% | 25% | P | $219.22 |
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 |
Molina Medicare Options Plus (HMO SNP)
|
$21.60 |
$310 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $217.02 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$24.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
n/a | n/a | S | $218.00 |
Browse Plan Formulary |
Easy Choice Freedom Plan (HMO SNP)
|
$24.40 |
$310 | Call plan for details | 4 |
Non-Preferred Brand |
25% | 17% | Q:30 /30Days | $219.22 |
Browse Plan Formulary |
Coordinated Choice Plan (HMO)
|
$26.30 |
$310 | Few Generics | 4 |
Non-Preferred Brand |
25% | 25% | P | $220.21 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$28.00 |
$310 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | S | $217.71 |
Browse Plan Formulary |
Brand New Day Dementia with Extra Care (HMO SNP)
|
$28.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | S Q:30 /30Days | $223.28 |
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 |
Brand New Day Diabetes with Extra Care (HMO SNP)
|
$28.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | S Q:30 /30Days | $223.28 |
Browse Plan Formulary |
Brand New Day Dual Coverage (HMO SNP)
|
$28.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | S Q:30 /30Days | $223.28 |
Browse Plan Formulary |
Brand New Day Extra Care (HMO)
|
$28.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | S Q:30 /30Days | $223.30 |
Browse Plan Formulary |
Brand New Day for Mental Illness (HMO SNP)
|
$28.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | S Q:30 /30Days | $223.30 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$28.10 |
$310 | Many Generics | 4 |
Non-Preferred Brand |
25% | 25% | Q:30 /30Days | $224.17 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$28.10 |
$310 | Many Generics | 4 |
Non-Preferred Brand |
25% | 25% | Q:30 /30Days | $224.17 |
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 |
Health Net Seniority Plus Amber I (HMO SNP)
|
$28.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $216.55 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$28.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $216.55 |
Browse Plan Formulary |
L.A. Care Health Plan Medicare Advantage (HMO SNP)
|
$28.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
n/a | n/a | S Q:30 /30Days | $222.85 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$28.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
n/a | n/a | S | $218.00 |
Browse Plan Formulary |
VillageHealth (HMO SNP)
|
$28.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | S | $217.77 |
Browse Plan Formulary |
Inter Valley Health Plan Total Fit (HMO)
|
$30.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$79.00 | $237.00 | Q:30 /30Days | $224.17 |
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 |
Anthem Medicare Preferred Standard (PPO)
|
$80.00 |
$149 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$85.00 | $255.00 | P Q:120 /30Days | $218.00 |
Browse Plan Formulary |