EQUETRO CAPSULES 200MG 120 BOT (120 BOT) (NDC: 30698042112)
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 Mosaic (HMO)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $189.62 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$260 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $189.62 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
50% | 50% | None | $192.24 |
Browse Plan Formulary |
AgeWell New York FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | P | $191.03 |
Browse Plan Formulary |
Amerivantage Balance + Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:240 /30Days | $190.52 |
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 |
Amerivantage Specialty + Rx (HMO SNP)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$89.00 | $267.00 | Q:240 /30Days | $190.64 |
Browse Plan Formulary |
Empire Dual Advantage (HMO SNP)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:240 /30Days | $190.52 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$257 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:240 /30Days | $189.31 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$257 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:240 /30Days | $190.87 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$257 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:240 /30Days | $191.03 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$257 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:240 /30Days | $191.57 |
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 Medicare $0 Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $191.14 |
Browse Plan Formulary |
HealthPlus Amerigroup FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | Q:240 /30Days | $190.52 |
Browse Plan Formulary |
Humana Gold Plus H3533-016 (HMO)
|
$0.00 |
$320 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $190.10 |
Browse Plan Formulary |
Liberty Health Advantage Preferred Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$75.00 | $225.00 | None | $196.13 |
Browse Plan Formulary |
RiverSpring FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | None | $193.92 |
Browse Plan Formulary |
Touchstone Health Medicare Freedom (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None | $196.13 |
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 |
Touchstone Health Medicare Power (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None | $196.13 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (Regional PPO)
|
$0.00 |
$225 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $189.84 |
Browse Plan Formulary |
Fidelis Long Term Care Advantage (HMO SNP)
|
$3.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $191.14 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H3533-018 (HMO SNP)
|
$28.70 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $190.10 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$29.00 |
$230 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $189.62 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$30.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $189.76 |
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 |
LiveWell (HMO)
|
$32.90 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P | $191.03 |
Browse Plan Formulary |
Fidelis Dual Advantage (HMO SNP)
|
$33.10 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $191.14 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO SNP)
|
$35.40 |
$320 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $191.14 |
Browse Plan Formulary |
Amida Care Live Life Advantage (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
25% | 25% | None | $190.52 |
Browse Plan Formulary |
Amida Care True Life Advantage (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $190.52 |
Browse Plan Formulary |
BeWell (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P | $191.03 |
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 |
CareWell (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P | $191.03 |
Browse Plan Formulary |
FeelWell (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $191.03 |
Browse Plan Formulary |
Fidelis Medicaid Advantage Plus (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $191.14 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$36.90 |
$240 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $191.14 |
Browse Plan Formulary |
Liberty Health Advantage Dual Power (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $196.13 |
Browse Plan Formulary |
Touchstone Health Medicare Grand (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $196.13 |
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 |
Touchstone Health Medicare Prestige (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $196.13 |
Browse Plan Formulary |
Touchstone Health Medicare Total (HMO)
|
$36.90 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None | $196.13 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $189.66 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
50% | 50% | None | $192.24 |
Browse Plan Formulary |
Empire MediBlue Freedom I (PPO)
|
$71.00 |
$304 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:240 /30Days | $191.08 |
Browse Plan Formulary |