EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H (30 PATCHES CRTN) (NDC: 49502090030)
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 |
5 |
Specialty Tier |
33% | n/a | S Q:30 /30Days | $1,424.38 |
Browse Plan Formulary |
Advantra Silver (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | S Q:30 /30Days | $1,410.37 |
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 | $1,372.37 |
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 | $1,373.62 |
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 | $1,379.46 |
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 | $1,393.82 |
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 | $1,378.71 |
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 | $1,378.71 |
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 | $1,372.37 |
Browse Plan Formulary |
Humana Gold Plus H6859-001 (HMO)
|
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | Q:30 /30Days | $1,380.94 |
Browse Plan Formulary |
UPMC for Life HMO Deductible with Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None | $1,413.67 |
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 | $1,391.26 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$27.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | None | $1,400.81 |
Browse Plan Formulary |
Cigna-HealthSpring Achieve (HMO SNP)
|
$28.50 |
$280 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | None | $1,391.26 |
Browse Plan Formulary |
AdvantraOne (PPO)
|
$29.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | S Q:30 /30Days | $1,424.95 |
Browse Plan Formulary |
Cigna-HealthSpring Preferred (HMO)
|
$29.50 |
$280 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | None | $1,389.49 |
Browse Plan Formulary |
Cigna-HealthSpring Preferred (HMO)
|
$29.50 |
$280 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | None | $1,398.13 |
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 |
5 |
Tier 5 |
15% | 15% | S Q:30 /30Days | $1,406.99 |
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 | $1,403.33 |
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 | Q:30 /30Days | $1,412.44 |
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 | Q:30 /30Days | $1,412.44 |
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 | $1,382.07 |
Browse Plan Formulary |
HumanaChoice H5525-006 (PPO)
|
$34.00 |
$320 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | Q:30 /30Days | $1,380.94 |
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 |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None | $1,413.67 |
Browse Plan Formulary |
HumanaChoice R5826-002 (Regional PPO)
|
$39.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | Q:30 /30Days | $1,389.28 |
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 | Q:30 /30Days | $1,412.44 |
Browse Plan Formulary |
Advantra Silver Plus (HMO)
|
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | S Q:30 /30Days | $1,410.37 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (HMO)
|
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | S Q:30 /30Days | $1,405.55 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (PPO)
|
$49.00 |
$230* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | 33% | None | $1,389.07 |
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 |
Humana Gold Choice H8145-052 (PFFS)
|
$62.00 |
$320 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | Q:30 /30Days | $1,381.32 |
Browse Plan Formulary |
Advantra Silver Plus (PPO)
|
$67.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | S Q:30 /30Days | $1,410.69 |
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 | $1,425.36 |
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 | $1,378.71 |
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 | $1,372.37 |
Browse Plan Formulary |
SeniorBlue - Option 2 (PPO)
|
$72.40 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P | $1,404.16 |
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 |
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 | Q:30 /30Days | $1,412.44 |
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 | $1,425.36 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$116.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | S Q:30 /30Days | $1,410.37 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$124.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | S Q:30 /30Days | $1,405.53 |
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 | $1,378.71 |
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 | $1,372.37 |
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 |
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 | $1,373.62 |
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 | $1,379.46 |
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 | $1,393.82 |
Browse Plan Formulary |
Aetna Medicare Select Plus Plan (PPO)
|
$139.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | S Q:30 /30Days | $1,405.46 |
Browse Plan Formulary |
SeniorBlue - Option 1 (PPO)
|
$191.90 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P | $1,404.16 |
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 | $1,425.36 |
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 | $1,425.36 |
Browse Plan Formulary |