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 (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | S Q:30 /30Days | $1,405.55 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | S Q:30 /30Days | $1,405.27 |
Browse Plan Formulary |
Anthem Dual Advantage (HMO SNP)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,411.61 |
Browse Plan Formulary |
Anthem Senior Advantage Basic (HMO)
|
$0.00 |
$153* | No additional gap coverage, only the Donut Hole Discount | 5* |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,411.61 |
Browse Plan Formulary |
Buckeye Health Plan - MyCareOhio (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Brand Drugs |
0% | 0% | None | $1,417.84 |
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 |
CareSource MyCare Ohio (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Brand Drugs |
0% | 0% | P Q:30 /30Days | $1,397.13 |
Browse Plan Formulary |
Gateway Health Medicare Assured Select (HMO)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days | $1,416.83 |
Browse Plan Formulary |
HealthSpan Medicare Standard (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $1,410.99 |
Browse Plan Formulary |
SummaCare Medicare Topaz (HMO)
|
$0.00 |
$100 | to be determined | 4 |
Tier 4 |
$95.00 | $285.00 | Q:30 /30Days | $1,408.73 |
Browse Plan Formulary |
UnitedHealthcare Connected for MyCareOhio (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Brand Drugs |
0% | 0% | None | $1,399.28 |
Browse Plan Formulary |
HealthSpan Medicare Core 2 (HMO)
|
$2.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $1,410.52 |
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 |
UnitedHealthcare Dual Complete (HMO SNP)
|
$11.60 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
15% | 15% | None | $1,396.74 |
Browse Plan Formulary |
Paramount Elite - Standard Medical and Drug (HMO)
|
$23.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $80.00 | Q:30 /30Days | $1,402.59 |
Browse Plan Formulary |
HealthSpan Medicare Plus IV (Cost)
|
$27.20 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $1,410.30 |
Browse Plan Formulary |
Buckeye Health Plan Advantage (HMO SNP)
|
$28.60 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $1,420.98 |
Browse Plan Formulary |
Gateway Health Medicare Assured Diamond (HMO SNP)
|
$28.60 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | n/a | Q:30 /30Days | $1,416.83 |
Browse Plan Formulary |
Gateway Health Medicare Assured Ruby (HMO SNP)
|
$28.60 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | n/a | Q:30 /30Days | $1,416.83 |
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 |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$28.60 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $1,396.34 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$29.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 5* |
Specialty Tier |
33% | 33% | None | $1,399.58 |
Browse Plan Formulary |
Humana Gold Plus H8953-002 (HMO)
|
$29.00 |
$320 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | Q:30 /30Days | $1,382.21 |
Browse Plan Formulary |
SummaCare Medicare Ruby (HMO)
|
$32.00 |
$0 | to be determined | 4 |
Tier 4 |
$95.00 | $285.00 | Q:30 /30Days | $1,408.73 |
Browse Plan Formulary |
HumanaChoice R5826-007 (Regional PPO)
|
$32.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | Q:30 /30Days | $1,391.22 |
Browse Plan Formulary |
HealthSpan Medicare Plus III (Cost)
|
$37.10 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $1,410.30 |
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 Gold (HMO SNP)
|
$39.80 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days | $1,416.83 |
Browse Plan Formulary |
Blue Medicare Access Value (Regional PPO)
|
$40.80 |
$115* | No additional gap coverage, only the Donut Hole Discount | 5* |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,411.51 |
Browse Plan Formulary |
HealthSpan Medicare Plus II (Cost)
|
$42.10 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $1,410.30 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$47.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | S Q:30 /30Days | $1,405.55 |
Browse Plan Formulary |
HealthSpan Medicare Enhanced (HMO)
|
$52.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $1,410.99 |
Browse Plan Formulary |
HealthSpan Medicare Plus I - B only (Cost)
|
$52.10 |
$0 | to be determined | 4 |
Tier 4 |
$95.00 | $190.00 | None | $1,410.30 |
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 |
Anthem Medicare Preferred Standard (PPO)
|
$56.00 |
$165* | No additional gap coverage, only the Donut Hole Discount | 5* |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,422.29 |
Browse Plan Formulary |
Anthem Medicare Preferred Standard (PPO)
|
$56.00 |
$165* | No additional gap coverage, only the Donut Hole Discount | 5* |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,404.01 |
Browse Plan Formulary |
Gateway Health Medicare Assured Choice (HMO)
|
$57.80 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days | $1,416.83 |
Browse Plan Formulary |
Paramount Elite - Enhanced Medical and Drug (HMO)
|
$68.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $80.00 | Q:30 /30Days | $1,402.59 |
Browse Plan Formulary |
HumanaChoice H6609-082 (PPO)
|
$72.00 |
$320 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | Q:30 /30Days | $1,392.07 |
Browse Plan Formulary |
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 | $1,416.83 |
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 |
SummaCare Medicare Sapphire (HMO-POS)
|
$78.00 |
$0 | to be determined | 4 |
Tier 4 |
$95.00 | $285.00 | Q:30 /30Days | $1,408.73 |
Browse Plan Formulary |
Gateway Health Medicare Assured Prime (HMO)
|
$82.80 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days | $1,416.83 |
Browse Plan Formulary |
Anthem Medicare Preferred Select (PPO)
|
$91.00 |
$151* | No additional gap coverage, only the Donut Hole Discount | 5* |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,403.35 |
Browse Plan Formulary |
Anthem Medicare Preferred Select (PPO)
|
$91.00 |
$151* | No additional gap coverage, only the Donut Hole Discount | 5* |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,411.20 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$100.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | S Q:30 /30Days | $1,405.36 |
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 |
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 |
HealthSpan Medicare Plus I (Cost)
|
$148.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Tier 4 |
$95.00 | $190.00 | None | $1,410.30 |
Browse Plan Formulary |
SummaCare Medicare Emerald (HMO-POS)
|
$182.00 |
$0 | to be determined | 4 |
Tier 4 |
$95.00 | $285.00 | Q:30 /30Days | $1,408.73 |
Browse Plan Formulary |