KALETRA 50-200MG TABLET (120 BOT) (NDC: 00074679922)
2015 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 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $874.32 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $866.56 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $867.72 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $868.28 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $875.44 |
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 |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $872.65 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $876.97 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $877.78 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $880.77 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $873.61 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $873.50 |
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 Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $870.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $873.22 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $875.44 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $866.74 |
Browse Plan Formulary |
HumanaChoice R5826-006 (Regional PPO)
|
$28.20 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | Q:150 /30Days | $870.02 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$52.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
31% | n/a | None | $877.78 |
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 H5216-010 (PPO)
|
$57.00 |
$320 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | Q:150 /30Days | $871.16 |
Browse Plan Formulary |
McLaren Advantage Sapphire (HMO)
|
$68.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Specialty Tier |
29% | n/a | Q:120 /30Days | $892.26 |
Browse Plan Formulary |
McLaren Advantage Sapphire (HMO)
|
$68.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Specialty Tier |
29% | n/a | Q:120 /30Days | $892.57 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$71.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $880.77 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$71.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $873.61 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$71.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $872.65 |
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 |
PriorityMedicare Merit (PPO)
|
$71.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $876.97 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$71.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $877.78 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$95.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $866.74 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$95.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $873.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$95.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $873.22 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$95.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $870.50 |
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)
|
$95.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $875.44 |
Browse Plan Formulary |
McLaren Advantage Diamond (HMO)
|
$108.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Specialty Tier |
29% | n/a | Q:120 /30Days | $892.26 |
Browse Plan Formulary |
McLaren Advantage Diamond (HMO)
|
$108.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Specialty Tier |
29% | n/a | Q:120 /30Days | $892.57 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$121.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $875.44 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$121.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $868.28 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$121.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $867.72 |
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)
|
$121.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $866.56 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$121.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $874.32 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$136.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $877.78 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$145.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $872.65 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$145.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $873.61 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$145.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $880.77 |
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 |
PriorityMedicare Select (PPO)
|
$145.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $877.78 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$145.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $876.97 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$166.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
30% | n/a | None | $873.22 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$166.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
30% | n/a | None | $875.44 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$166.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
30% | n/a | None | $870.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$166.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
30% | n/a | None | $866.74 |
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 Signature (PPO)
|
$166.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
30% | n/a | None | $873.50 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$257.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $866.56 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$257.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $875.44 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$257.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $868.28 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$257.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $867.72 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$257.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $874.32 |
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)
|
$283.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $873.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$283.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $866.74 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$283.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $873.22 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$283.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $870.50 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$283.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $875.44 |
Browse Plan Formulary |