DILANTIN CAPSULES 30 MG ER (100 BOT ) (NDC: 00071374066)
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 |
Advantra Silver (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
50% | 50% | None | $20.07 |
Browse Plan Formulary |
Advantra Silver (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
50% | 50% | None | $20.08 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None | $17.98 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None | $18.09 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None | $17.53 |
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 |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None | $17.92 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None | $17.93 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None | $17.53 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None | $17.92 |
Browse Plan Formulary |
Humana Gold Plus H6859-001 (HMO)
|
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $19.94 |
Browse Plan Formulary |
UPMC for Life HMO Deductible with Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$45.00 | $112.50 | None | $19.83 |
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 |
Cigna-HealthSpring TotalCare (HMO SNP)
|
$25.40 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $20.13 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$27.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | None | $19.60 |
Browse Plan Formulary |
Cigna-HealthSpring Achieve (HMO SNP)
|
$28.50 |
$280* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None | $20.22 |
Browse Plan Formulary |
AdvantraOne (PPO)
|
$29.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
50% | 50% | None | $20.09 |
Browse Plan Formulary |
Cigna-HealthSpring Preferred (HMO)
|
$29.50 |
$280* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None | $20.19 |
Browse Plan Formulary |
Cigna-HealthSpring Preferred (HMO)
|
$29.50 |
$280* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | None | $20.22 |
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 |
Advantra Cares (HMO SNP)
|
$33.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $19.90 |
Browse Plan Formulary |
AmeriHealth VIP Care (HMO SNP)
|
$33.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $20.09 |
Browse Plan Formulary |
Gateway Health Medicare Assured Diamond (HMO SNP)
|
$33.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | n/a | None | $20.52 |
Browse Plan Formulary |
Gateway Health Medicare Assured Ruby (HMO SNP)
|
$33.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | None | $20.52 |
Browse Plan Formulary |
Geisinger Gold Secure Rx (HMO SNP)
|
$33.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $17.90 |
Browse Plan Formulary |
HumanaChoice H5525-006 (PPO)
|
$34.00 |
$320 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $19.88 |
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 |
UPMC for Life PPO High Deductible with Rx (PPO)
|
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$45.00 | $112.50 | None | $19.83 |
Browse Plan Formulary |
HumanaChoice R5826-002 (Regional PPO)
|
$39.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $19.85 |
Browse Plan Formulary |
Gateway Health Medicare Assured Gold (HMO SNP)
|
$46.30 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $20.52 |
Browse Plan Formulary |
Advantra Silver Plus (HMO)
|
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
50% | 50% | None | $20.11 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (HMO)
|
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
50% | 50% | None | $19.88 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (PPO)
|
$49.00 |
$230 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $19.61 |
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 H8145-052 (PFFS)
|
$62.00 |
$320 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $19.86 |
Browse Plan Formulary |
Advantra Silver Plus (PPO)
|
$67.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
50% | 50% | None | $20.08 |
Browse Plan Formulary |
Freedom Blue PPO HD Rx (PPO)
|
$70.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $20.29 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$70.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None | $17.53 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$70.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None | $17.92 |
Browse Plan Formulary |
SeniorBlue - Option 2 (PPO)
|
$72.40 |
$0 |
to be determined |
3 |
Tier 3 |
$38.00 | $114.00 | None | $20.54 |
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 |
Gateway Health Medicare Assured Platinum (HMO SNP)
|
$77.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $20.52 |
Browse Plan Formulary |
Freedom Blue PPO ValueRx (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $20.29 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$116.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
50% | 50% | None | $20.08 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$124.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
50% | 50% | None | $19.88 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None | $17.93 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None | $18.09 |
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 |
Geisinger Gold Classic Advantage Rx (HMO)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None | $17.98 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None | $17.53 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | None | $17.92 |
Browse Plan Formulary |
Aetna Medicare Select Plus Plan (PPO)
|
$139.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
50% | 50% | None | $19.90 |
Browse Plan Formulary |
SeniorBlue - Option 1 (PPO)
|
$191.90 |
$0 |
to be determined |
3 |
Tier 3 |
$38.00 | $114.00 | None | $20.54 |
Browse Plan Formulary |
Freedom Blue PPO Standard (PPO)
|
$246.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None | $20.29 |
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 |
Freedom Blue PPO Deluxe (PPO)
|
$296.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None | $20.29 |
Browse Plan Formulary |