LOTRONEX TABLETS .5MG 30 BOTPL (30 BOTPL) (NDC: 65483089403)
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 | 3 |
Tier 3 |
25% | 25% | Q:68 /34Days | $826.54 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | Q:68 /34Days | $825.60 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | Q:68 /34Days | $820.83 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | Q:68 /34Days | $820.83 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | Q:68 /34Days | $825.14 |
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 | $834.49 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $837.11 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $837.38 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $832.16 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $826.37 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | P | $826.26 |
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 | 3 |
Tier 3 |
25% | 25% | P | $822.87 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | P | $820.83 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | P | $825.14 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | P | $825.60 |
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:60 /30Days | $823.91 |
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 | $837.38 |
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:60 /30Days | $820.41 |
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 | None | $848.42 |
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 | None | $847.27 |
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 | $832.16 |
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 | $826.37 |
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 | $834.49 |
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 | $837.11 |
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 | $837.38 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$95.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | P | $825.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$95.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | P | $826.26 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$95.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | P | $820.83 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$95.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | P | $822.87 |
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 |
Medicare Plus Blue PPO Vitality (PPO)
|
$95.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | P | $825.14 |
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 | None | $848.42 |
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 | None | $847.27 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$121.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | Q:68 /34Days | $825.14 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$121.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | Q:68 /34Days | $820.83 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$121.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | Q:68 /34Days | $820.83 |
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. | 3 |
Preferred Brand |
$40.00 | $100.00 | Q:68 /34Days | $825.60 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$121.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | Q:68 /34Days | $826.54 |
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 | $837.38 |
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 | $834.49 |
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 | $826.37 |
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 | $832.16 |
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 | $837.38 |
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 | $837.11 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$166.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | P | $820.83 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$166.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | P | $825.14 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$166.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | P | $822.87 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$166.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | P | $825.60 |
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 |
Medicare Plus Blue PPO Signature (PPO)
|
$166.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | P | $826.26 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$257.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $87.50 | Q:68 /34Days | $825.60 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$257.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $87.50 | Q:68 /34Days | $825.14 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$257.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $87.50 | Q:68 /34Days | $820.83 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$257.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $87.50 | Q:68 /34Days | $820.83 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$257.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $87.50 | Q:68 /34Days | $826.54 |
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. | 3 |
Preferred Brand |
$40.00 | $100.00 | P | $826.26 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$283.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | P | $825.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$283.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | P | $820.83 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$283.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | P | $822.87 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$283.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | P | $825.14 |
Browse Plan Formulary |