Clorazepate Dipotassium 3.75mg/1 500 TABLET BOTTLE, PLASTIC (500 TABLET in 1 BOTTLE, P ) (NDC: 00378003005)
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 |
Fidelis Medicare $0 Premium (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$18.00 | $36.00 | P Q:120 /30Days | $20.71 |
Browse Plan Formulary |
Humana Gold Plus H3533-006 (HMO)
|
$0.00 |
$320 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $20.09 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (Regional PPO)
|
$0.00 |
$225* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
$8.00 | $16.00 | Q:720 /30Days | $12.20 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Enhanced (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$9.00 | $27.00 | Q:60 /30Days | $25.69 |
Browse Plan Formulary |
WellCare Value (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$14.00 | $35.00 | None | $18.16 |
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 |
Fidelis Long Term Care Advantage (HMO SNP)
|
$3.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | P Q:120 /30Days | $20.71 |
Browse Plan Formulary |
Humana Gold Plus H3533-013 (HMO)
|
$22.40 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $20.09 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$27.10 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | Q:720 /30Days | $12.16 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$28.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$2.00 | $5.00 | None | $19.06 |
Browse Plan Formulary |
CDPHP Basic RX (HMO)
|
$29.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $90.00 | P Q:120 /30Days | $21.32 |
Browse Plan Formulary |
Fidelis Dual Advantage (HMO SNP)
|
$33.10 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$9.00 | $18.00 | P Q:120 /30Days | $20.71 |
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 |
Today's Options Premier Plus 350B (PFFS)
|
$34.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $45.00 | P Q:120 /30Days | $22.89 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Classic (HMO)
|
$34.10 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | Q:60 /30Days | $25.69 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO SNP)
|
$35.40 |
$320 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$21.00 | $42.00 | P Q:120 /30Days | $20.71 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H3533-002 (HMO SNP)
|
$36.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$80.00 | $230.00 | None | $20.09 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Preferred (HMO SNP)
|
$36.30 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | Q:60 /30Days | $25.69 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
|
$36.30 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$2.00 | $5.00 | None | $18.38 |
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 |
Fidelis Medicaid Advantage Plus (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$12.00 | $24.00 | P Q:120 /30Days | $20.71 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$36.90 |
$240* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
$15.00 | $30.00 | P Q:120 /30Days | $20.71 |
Browse Plan Formulary |
Forever Blue Medicare PPO Value (PPO)
|
$36.90 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$20.00 | $50.00 | None | $39.18 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Maximum (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | Q:60 /30Days | $25.69 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | Q:60 /30Days | $25.69 |
Browse Plan Formulary |
CDPHP Value Rx (HMO)
|
$45.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $90.00 | P Q:120 /30Days | $21.32 |
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 |
BasiCare with Part D (PPO)
|
$49.70 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $15.86 |
Browse Plan Formulary |
HumanaChoice H5970-008 (PPO)
|
$55.00 |
$320 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $20.09 |
Browse Plan Formulary |
BlueShield Senior Blue 650 Part D (HMO-POS)
|
$63.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$25.00 | $62.50 | None | $39.18 |
Browse Plan Formulary |
Empire MediBlue Freedom I (PPO)
|
$71.00 |
$304 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $120.00 | Q:120 /30Days | $45.50 |
Browse Plan Formulary |
Today's Options Premier Plus 150A (PFFS)
|
$85.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $40.00 | P Q:120 /30Days | $22.89 |
Browse Plan Formulary |
CDPHP Choice Rx (HMO)
|
$95.50 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $90.00 | P Q:120 /30Days | $21.32 |
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 |
GoldValue with Part D (HMO-POS)
|
$103.60 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$15.00 | $30.00 | None | $15.86 |
Browse Plan Formulary |
BlueShield Senior Blue HMO 652 PartD (HMO)
|
$119.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$15.00 | $37.50 | None | $39.18 |
Browse Plan Formulary |
Gold PPO with Part D (PPO)
|
$122.60 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $15.86 |
Browse Plan Formulary |
CDPHP Core Rx (PPO)
|
$134.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $90.00 | P Q:120 /30Days | $21.32 |
Browse Plan Formulary |
HumanaChoice H5970-010 (PPO)
|
$157.00 |
$320 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $20.09 |
Browse Plan Formulary |
Preferred Gold with Part D (HMO-POS)
|
$167.40 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $15.86 |
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 |
BlueShield Forever Blue Medicare PPO 750 (PPO)
|
$187.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$15.00 | $37.50 | None | $39.18 |
Browse Plan Formulary |
CDPHP Classic Rx (PPO)
|
$194.50 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $80.00 | P Q:120 /30Days | $21.32 |
Browse Plan Formulary |
CDPHP Prime Rx (PPO)
|
$276.50 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $80.00 | P Q:120 /30Days | $21.32 |
Browse Plan Formulary |