Atelvia 35mg/1 36 DOSE PACK CASE / 4 TABLET, DELAYED RELEASE in 1 DOSE PACK (36 DOSE PACK in 1 CASE / ) (NDC: 00430097903)
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 |
PriorityMedicare Ideal (PPO)
![Email Prescription and/or Health Benefit details for PriorityMedicare Ideal (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $198.13 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
![Email Prescription and/or Health Benefit details for PriorityMedicare Ideal (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $197.75 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
![Email Prescription and/or Health Benefit details for PriorityMedicare Ideal (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $198.07 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
![Email Prescription and/or Health Benefit details for PriorityMedicare Ideal (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $197.51 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
![Email Prescription and/or Health Benefit details for PriorityMedicare Ideal (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $198.19 |
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 |
Medicare Plus Blue PPO Essential (PPO)
![Email Prescription and/or Health Benefit details for Medicare Plus Blue PPO Essential (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | S Q:12 /84Days | $196.40 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
![Email Prescription and/or Health Benefit details for Medicare Plus Blue PPO Essential (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | S Q:12 /84Days | $197.56 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
![Email Prescription and/or Health Benefit details for Medicare Plus Blue PPO Essential (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | S Q:12 /84Days | $196.59 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
![Email Prescription and/or Health Benefit details for Medicare Plus Blue PPO Essential (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | S Q:12 /84Days | $197.52 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
![Email Prescription and/or Health Benefit details for Medicare Plus Blue PPO Essential (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | S Q:12 /84Days | $196.37 |
Browse Plan Formulary |
HumanaChoice R5826-006 (Regional PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice R5826-006 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$28.20 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | Q:4 /28Days | $195.75 |
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 Value (HMO-POS)
![Email Prescription and/or Health Benefit details for PriorityMedicare Value (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$54.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $198.13 |
Browse Plan Formulary |
McLaren Advantage Sapphire (HMO)
![Email Prescription and/or Health Benefit details for McLaren Advantage Sapphire (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$68.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$35.00 | $78.75 | Q:4 /28Days | $201.53 |
Browse Plan Formulary |
McLaren Advantage Sapphire (HMO)
![Email Prescription and/or Health Benefit details for McLaren Advantage Sapphire (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$68.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$35.00 | $78.75 | Q:4 /28Days | $201.28 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
![Email Prescription and/or Health Benefit details for PriorityMedicare Merit (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$80.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $198.13 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
![Email Prescription and/or Health Benefit details for PriorityMedicare Merit (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$80.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $197.75 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
![Email Prescription and/or Health Benefit details for PriorityMedicare Merit (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$80.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $198.07 |
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)
![Email Prescription and/or Health Benefit details for PriorityMedicare Merit (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$80.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $198.19 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
![Email Prescription and/or Health Benefit details for PriorityMedicare Merit (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$80.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $197.51 |
Browse Plan Formulary |
Humana Gold Choice H8145-005 (PFFS)
![Email Prescription and/or Health Benefit details for Humana Gold Choice H8145-005 (PFFS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$83.00 |
$320 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:4 /28Days | $196.26 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
![Email Prescription and/or Health Benefit details for Medicare Plus Blue PPO Vitality (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$95.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | S Q:12 /84Days | $196.37 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
![Email Prescription and/or Health Benefit details for Medicare Plus Blue PPO Vitality (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$95.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | S Q:12 /84Days | $196.40 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
![Email Prescription and/or Health Benefit details for Medicare Plus Blue PPO Vitality (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$95.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | S Q:12 /84Days | $197.56 |
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 |
Medicare Plus Blue PPO Vitality (PPO)
![Email Prescription and/or Health Benefit details for Medicare Plus Blue PPO Vitality (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$95.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | S Q:12 /84Days | $196.59 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
![Email Prescription and/or Health Benefit details for Medicare Plus Blue PPO Vitality (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$95.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | S Q:12 /84Days | $197.52 |
Browse Plan Formulary |
McLaren Advantage Diamond (HMO)
![Email Prescription and/or Health Benefit details for McLaren Advantage Diamond (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$108.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$35.00 | $78.75 | Q:4 /28Days | $201.53 |
Browse Plan Formulary |
McLaren Advantage Diamond (HMO)
![Email Prescription and/or Health Benefit details for McLaren Advantage Diamond (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$108.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$35.00 | $78.75 | Q:4 /28Days | $201.28 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
![Email Prescription and/or Health Benefit details for PriorityMedicare (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$147.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$85.00 | $212.50 | None | $198.13 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
![Email Prescription and/or Health Benefit details for PriorityMedicare Select (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$159.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$85.00 | $212.50 | None | $198.19 |
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 |
PriorityMedicare Select (PPO)
![Email Prescription and/or Health Benefit details for PriorityMedicare Select (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$159.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$85.00 | $212.50 | None | $197.51 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
![Email Prescription and/or Health Benefit details for PriorityMedicare Select (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$159.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$85.00 | $212.50 | None | $198.13 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
![Email Prescription and/or Health Benefit details for PriorityMedicare Select (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$159.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$85.00 | $212.50 | None | $197.75 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
![Email Prescription and/or Health Benefit details for PriorityMedicare Select (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$159.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$85.00 | $212.50 | None | $198.07 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
![Email Prescription and/or Health Benefit details for Medicare Plus Blue PPO Signature (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$166.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:12 /84Days | $197.52 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
![Email Prescription and/or Health Benefit details for Medicare Plus Blue PPO Signature (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$166.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:12 /84Days | $196.37 |
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)
![Email Prescription and/or Health Benefit details for Medicare Plus Blue PPO Signature (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$166.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:12 /84Days | $196.40 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
![Email Prescription and/or Health Benefit details for Medicare Plus Blue PPO Signature (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$166.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:12 /84Days | $197.56 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
![Email Prescription and/or Health Benefit details for Medicare Plus Blue PPO Signature (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$166.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:12 /84Days | $196.59 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
![Email Prescription and/or Health Benefit details for Medicare Plus Blue PPO Assure (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$283.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:12 /84Days | $196.59 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
![Email Prescription and/or Health Benefit details for Medicare Plus Blue PPO Assure (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$283.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:12 /84Days | $197.52 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
![Email Prescription and/or Health Benefit details for Medicare Plus Blue PPO Assure (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$283.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:12 /84Days | $196.37 |
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)
![Email Prescription and/or Health Benefit details for Medicare Plus Blue PPO Assure (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$283.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:12 /84Days | $196.40 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
![Email Prescription and/or Health Benefit details for Medicare Plus Blue PPO Assure (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$283.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | S Q:12 /84Days | $197.56 |
Browse Plan Formulary |