Diazepam 10mg/2mL 2 SYRINGE, PLASTIC in 1 PACKAGE / 2 mL in 1 SYRINGE, PLASTIC (2 SYRINGE, PLASTIC in 1 P ) (NDC: 00093613832)
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 |
AARP MedicareComplete (HMO)
|
$0.00 |
$265 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $246.32 |
Browse Plan Formulary |
AARP MedicareComplete Choice Plan 2 (Regional PPO)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $242.64 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $120.00 | Q:2 /1Days | $281.10 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
|
$0.00 |
$320 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $120.00 | Q:2 /1Days | $281.10 |
Browse Plan Formulary |
BlueMedicare HMO LifeTime (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:20 /30Days | $285.88 |
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 |
BlueMedicare HMO MyTime (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$80.00 | $240.00 | Q:20 /30Days | $291.79 |
Browse Plan Formulary |
CareDirect (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$85.00 | $245.00 | None | $278.52 |
Browse Plan Formulary |
CareOne PLUS (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$85.00 | $245.00 | None | $278.52 |
Browse Plan Formulary |
Freedom Medicare Plan Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Non-Preferred Brand |
$85.00 | $170.00 | P | $162.01 |
Browse Plan Formulary |
Freedom Platinum Plan Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Non-Preferred Brand |
$75.00 | $150.00 | P | $176.61 |
Browse Plan Formulary |
Freedom VIP Care (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Non-Preferred Brand |
$75.00 | $150.00 | P | $159.14 |
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 |
Freedom VIP Savings (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Non-Preferred Brand |
$80.00 | $160.00 | P | $159.14 |
Browse Plan Formulary |
Freedom VIP Savings COPD (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Non-Preferred Brand |
$80.00 | $160.00 | P | $159.14 |
Browse Plan Formulary |
Humana Gold Plus - Diabetes (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$85.00 | $245.00 | None | $278.52 |
Browse Plan Formulary |
Humana Gold Plus H1036-146 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$85.00 | $245.00 | None | $278.52 |
Browse Plan Formulary |
HumanaChoice R5826-074 (Regional PPO)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $272.31 |
Browse Plan Formulary |
Optimum Diamond Rewards (HMO-POS SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Non-Preferred Brand |
$80.00 | $160.00 | P | $162.60 |
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 |
Optimum Diamond Rewards COPD (HMO-POS SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Tier 3 |
$80.00 | $160.00 | P | $161.70 |
Browse Plan Formulary |
Optimum Gold Rewards Plan (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Non-Preferred Brand |
$80.00 | $160.00 | P | $176.30 |
Browse Plan Formulary |
Preferred Secure Option (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $242.51 |
Browse Plan Formulary |
Simply Level (HMO SNP)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $280.01 |
Browse Plan Formulary |
Simply More (HMO)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $280.01 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $274.20 |
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 |
WellCare Essential (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $284.85 |
Browse Plan Formulary |
WellCare Value (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $271.09 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$17.70 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$90.00 | $225.00 | None | $275.28 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
|
$18.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$90.00 | $225.00 | None | $275.28 |
Browse Plan Formulary |
CareNeeds (HMO SNP)
|
$19.20 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $278.52 |
Browse Plan Formulary |
WellCare Select (HMO SNP)
|
$19.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$90.00 | $225.00 | None | $276.96 |
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 |
BlueMedicare Regional PPO (Regional PPO)
|
$20.20 |
$100 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:20 /30Days | $286.40 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$24.30 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $243.14 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-213 (HMO SNP)
|
$24.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $278.52 |
Browse Plan Formulary |
Freedom Medi-Medi Full (HMO SNP)
|
$25.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | P | $158.80 |
Browse Plan Formulary |
Freedom Medi-Medi Partial (HMO SNP)
|
$25.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | P | $158.80 |
Browse Plan Formulary |
Optimum Emerald Full (HMO SNP)
|
$25.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$95.00 | $285.00 | P | $160.33 |
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 |
Optimum Emerald Partial (HMO SNP)
|
$25.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$95.00 | $285.00 | P | $160.33 |
Browse Plan Formulary |
Simply Complete (HMO SNP)
|
$25.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $280.01 |
Browse Plan Formulary |
Sunshine Health Advantage (HMO SNP)
|
$25.80 |
$320* | No additional gap coverage, only the Donut Hole Discount | 1* |
Generic |
$0.00 | $0.00 | Q:50 /30Days | $262.14 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO SNP)
|
$25.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $242.64 |
Browse Plan Formulary |
HumanaChoice R5826-005 (Regional PPO)
|
$39.40 |
$100 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$85.00 | $245.00 | None | $272.31 |
Browse Plan Formulary |
WellCare Choice (HMO-POS)
|
$46.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $282.27 |
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 H8145-061 (PFFS)
|
$101.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $272.53 |
Browse Plan Formulary |
BlueMedicare PPO (PPO)
|
$127.10 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:20 /30Days | $286.50 |
Browse Plan Formulary |