FETZIMA ER 120 MG CAPSULE (30 EA ) (NDC: 00456221230)
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 |
$255 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | S Q:30 /30Days | $282.46 |
Browse Plan Formulary |
Fallon Senior Plan Super Saver Rx (HMO)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$76.00 | $228.00 | P | $295.88 |
Browse Plan Formulary |
Fallon Senior Plan Super Saver Rx (HMO)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$76.00 | $228.00 | P | $295.88 |
Browse Plan Formulary |
Fallon Senior Plan Super Saver Rx (HMO)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$76.00 | $228.00 | P | $295.88 |
Browse Plan Formulary |
Fallon Senior Plan Super Saver Rx (HMO)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$76.00 | $228.00 | P | $295.88 |
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 |
Fallon Senior Plan Super Saver Rx (HMO)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$76.00 | $228.00 | P | $295.88 |
Browse Plan Formulary |
Medicare PPO Blue SaverRx (PPO)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | S Q:30 /30Days | $283.70 |
Browse Plan Formulary |
Tufts Health Unify (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Brand Drugs |
0% | 0% | S | $302.25 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Saver Rx (HMO)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $285.00 | S | $302.25 |
Browse Plan Formulary |
UnitedHealthcare Senior Care Options (HMO SNP)
|
$22.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | S Q:30 /30Days | $282.46 |
Browse Plan Formulary |
Medicare HMO Blue ValueRx (HMO)
|
$27.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | S Q:30 /30Days | $283.70 |
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)
|
$28.30 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | S Q:30 /30Days | $282.46 |
Browse Plan Formulary |
Tufts Health Plan Senior Care Options (HMO SNP)
|
$29.60 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | S | $302.25 |
Browse Plan Formulary |
NaviCare (HMO SNP)
|
$29.70 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
25% | 25% | P | $293.09 |
Browse Plan Formulary |
Senior Whole Health (HMO SNP)
|
$29.70 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | S Q:30 /30Days | $283.72 |
Browse Plan Formulary |
Senior Whole Health NHC (HMO SNP)
|
$29.70 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | S Q:30 /30Days | $283.72 |
Browse Plan Formulary |
AARP MedicareComplete Choice (Regional PPO)
|
$29.90 |
$255 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | S Q:30 /30Days | $282.46 |
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 |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$35.90 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $285.00 | S | $302.25 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$35.90 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $285.00 | S | $302.25 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$35.90 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $285.00 | S | $302.25 |
Browse Plan Formulary |
Fallon Senior Plan Saver Enhanced RX (HMO)
|
$46.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$76.00 | $228.00 | P | $295.88 |
Browse Plan Formulary |
Fallon Senior Plan Saver Enhanced RX (HMO)
|
$46.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$76.00 | $228.00 | P | $295.88 |
Browse Plan Formulary |
Fallon Senior Plan Saver Enhanced RX (HMO)
|
$46.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$76.00 | $228.00 | P | $295.88 |
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 |
Fallon Senior Plan Saver Enhanced RX (HMO)
|
$46.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$76.00 | $228.00 | P | $295.88 |
Browse Plan Formulary |
Harvard Pilgrim Stride Value Rx (HMO)
|
$46.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | S | $285.54 |
Browse Plan Formulary |
Medicare PPO Blue ValueRx (PPO)
|
$49.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | S Q:30 /30Days | $283.70 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$120.30 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $285.00 | S | $302.25 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$120.30 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $285.00 | S | $302.25 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$120.30 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $285.00 | S | $302.25 |
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 |
Harvard Pilgrim Stride Value Rx Plus (HMO)
|
$136.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | S | $285.50 |
Browse Plan Formulary |
Fallon Senior Plan Plus Enhanced RX (HMO)
|
$152.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$76.00 | $228.00 | P | $295.88 |
Browse Plan Formulary |
Fallon Senior Plan Plus Enhanced RX (HMO)
|
$152.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$76.00 | $228.00 | P | $295.88 |
Browse Plan Formulary |
Fallon Senior Plan Plus Enhanced RX (HMO)
|
$152.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$76.00 | $228.00 | P | $295.88 |
Browse Plan Formulary |
Fallon Senior Plan Plus Enhanced RX (HMO)
|
$152.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$76.00 | $228.00 | P | $295.88 |
Browse Plan Formulary |
Medicare PPO Blue PlusRx (PPO)
|
$153.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | S Q:30 /30Days | $283.70 |
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 |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$154.40 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $285.00 | S | $302.25 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$154.40 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $285.00 | S | $302.25 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$154.40 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $285.00 | S | $302.25 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$188.20 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$80.00 | $240.00 | S | $302.25 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$188.20 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$80.00 | $240.00 | S | $302.25 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$188.20 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$80.00 | $240.00 | S | $302.25 |
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 |
Medicare HMO Blue PlusRx (HMO)
|
$193.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | S Q:30 /30Days | $283.70 |
Browse Plan Formulary |