Phenelzine Sulfate 15mg/1 60 TABLET BOTTLE (60 TABLET in 1 BOTTLE ) (NDC: 43386036021)
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 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$9.00 | $18.00 | None | $54.29 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 | Few Generics | 1 |
Generic |
$10.00 | $20.00 | None | $58.40 |
Browse Plan Formulary |
Blue Medicare Advantage Classic (HMO)
|
$0.00 |
$0 | Few Generics | 2 |
Non-Preferred Generic |
$14.00 | $42.00 | None | $58.32 |
Browse Plan Formulary |
CareMore Breathe (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 2 |
Non-Preferred Generic |
$5.00 | $12.50 | None | $58.48 |
Browse Plan Formulary |
CareMore Diabetes (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 2 |
Non-Preferred Generic |
$5.00 | $12.50 | None | $58.48 |
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 Heart (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 2 |
Non-Preferred Generic |
$5.00 | $12.50 | None | $58.48 |
Browse Plan Formulary |
CareMore StartSmart Plus (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$8.00 | $20.00 | None | $58.48 |
Browse Plan Formulary |
CareMore Value Plus (HMO)
|
$0.00 |
$0 | Many Generics | 2 |
Non-Preferred Generic |
$5.00 | $12.50 | None | $58.48 |
Browse Plan Formulary |
Cigna Medicare Select Plus Rx-Diabetes Heart (HMO SNP)
|
$0.00 |
$0 | Many Generics | 2 |
Non-Preferred Generic |
$9.00 | $18.00 | None | $37.28 |
Browse Plan Formulary |
Cigna Medicare Select Plus Rx-Standard (HMO)
|
$0.00 |
$0 | Many Generics | 2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $37.28 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$15.00 | $30.00 | None | $57.42 |
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 Jade Cardiovascular (HMO SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$15.00 | $30.00 | None | $57.42 |
Browse Plan Formulary |
Health Net Ruby 4 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $57.42 |
Browse Plan Formulary |
Health Net Ruby Select (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$15.00 | $30.00 | None | $57.42 |
Browse Plan Formulary |
Heart First (HMO SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $57.61 |
Browse Plan Formulary |
Humana Gold Plus H2649-032 (HMO)
|
$0.00 |
$0 | Few Generics, Few Brands | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $47.34 |
Browse Plan Formulary |
Humana Gold Plus SNP-CLD H2649-037 (HMO SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $47.34 |
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/DM H2649-036 (HMO SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $47.34 |
Browse Plan Formulary |
Phoenix Advantage (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $57.43 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $57.61 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $57.61 |
Browse Plan Formulary |
Blue Medicare Advantage Plus (HMO)
|
$17.00 |
$0 | Few Generics | 2 |
Non-Preferred Generic |
$13.00 | $39.00 | None | $58.32 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$19.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $54.47 |
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 |
ONECare by Care1st Health Plan Arizona, Inc. (HMO SNP)
|
$23.70 |
$310 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
25% | n/a | None | $60.60 |
Browse Plan Formulary |
Advantage by Bridgeway Health Solutions (HMO SNP)
|
$27.40 |
$310 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $59.50 |
Browse Plan Formulary |
Health Choice Generations (HMO SNP)
|
$27.40 |
$310 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $62.31 |
Browse Plan Formulary |
Health Net Amber (HMO SNP)
|
$27.40 |
$310 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$12.00 | $24.00 | None | $57.42 |
Browse Plan Formulary |
Maricopa Care Advantage (HMO SNP)
|
$27.50 |
$310 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $60.32 |
Browse Plan Formulary |
Mercy Care Advantage (HMO SNP)
|
$27.50 |
$310 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $57.41 |
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 |
Mercy Care Advantage (HMO SNP)
|
$27.50 |
$310 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $57.41 |
Browse Plan Formulary |
Mercy Care Advantage (HMO SNP)
|
$27.50 |
$310 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $57.41 |
Browse Plan Formulary |
Phoenix Advantage Plus (HMO SNP)
|
$27.50 |
$310 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $57.44 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$27.50 |
$310 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $54.31 |
Browse Plan Formulary |
HumanaChoice R5826-014 P (Regional PPO)
|
$32.30 |
$175 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $47.38 |
Browse Plan Formulary |
Phoenix Advantage Select (HMO)
|
$39.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $57.43 |
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 Ruby 1 (HMO)
|
$49.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$15.00 | $30.00 | None | $57.42 |
Browse Plan Formulary |
Health Net Ruby 1 (HMO)
|
$49.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$15.00 | $30.00 | None | $57.42 |
Browse Plan Formulary |
Health Net Ruby 1 (HMO)
|
$49.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$15.00 | $30.00 | None | $60.96 |
Browse Plan Formulary |
Blue Medicare Advantage Premier (HMO)
|
$55.00 |
$0 | Few Generics | 2 |
Non-Preferred Generic |
$12.00 | $36.00 | None | $58.32 |
Browse Plan Formulary |
Humana Gold Plus H2649-030 (HMO-POS)
|
$79.00 |
$0 | Few Generics, Few Brands | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $47.34 |
Browse Plan Formulary |
HumanaChoice H0317-001 (PPO)
|
$122.00 |
$0 | Few Generics, Few Brands | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $47.34 |
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 H8145-103 (PFFS)
|
$180.00 |
$0 | Few Generics, Few Brands | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $47.38 |
Browse Plan Formulary |