HALOPERIDOL LAC 5MG/ML VIAL (1 X 10 ML PKG) (NDC: 00703704501)
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 Northern Pennsylvania Gold (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
50% | 50% | None | $56.87 |
Browse Plan Formulary |
Advantra Silver (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
50% | 50% | None | $56.66 |
Browse Plan Formulary |
Advantra Silver (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
50% | 50% | None | $56.45 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$20.00 | $60.00 | None | $42.10 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$20.00 | $60.00 | None | $55.37 |
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 Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$20.00 | $60.00 | None | $45.40 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$20.00 | $60.00 | None | $55.97 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$20.00 | $60.00 | None | $55.93 |
Browse Plan Formulary |
UPMC for Life HMO Deductible with Rx (HMO)
|
$18.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$10.00 | $20.00 | None | $59.20 |
Browse Plan Formulary |
AdvantraOne (PPO)
|
$29.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
50% | 50% | None | $56.78 |
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 | None | $60.26 |
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 Ruby (HMO SNP)
|
$33.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | None | $60.26 |
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 | $51.98 |
Browse Plan Formulary |
UPMC for You Advantage (HMO SNP)
|
$33.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$7.00 | $21.00 | None | $59.20 |
Browse Plan Formulary |
HumanaChoice H5525-006 (PPO)
|
$34.00 |
$320* |
Yes, but No Gap Coverage for this drug. |
2* |
Non-Preferred Generic |
$18.00 | $0.00 | None | $38.69 |
Browse Plan Formulary |
UPMC for Life PPO High Deductible with Rx (PPO)
|
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$10.00 | $20.00 | None | $59.20 |
Browse Plan Formulary |
HumanaChoice R5826-002 (Regional PPO)
|
$39.90 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$18.00 | $0.00 | None | $38.69 |
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 |
Security Blue ValueRx (HMO)
|
$42.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$12.00 | $30.00 | None | $60.31 |
Browse Plan Formulary |
Gateway Health Medicare Assured Gold (HMO SNP)
|
$46.30 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $60.26 |
Browse Plan Formulary |
Advantra Silver Plus (HMO)
|
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
50% | 50% | None | $56.59 |
Browse Plan Formulary |
Humana Gold Choice H8145-052 (PFFS)
|
$62.00 |
$320* |
Yes, but No Gap Coverage for this drug. |
2* |
Non-Preferred Generic |
$18.00 | $0.00 | None | $38.69 |
Browse Plan Formulary |
Advantra Silver Plus (PPO)
|
$67.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
50% | 50% | None | $56.40 |
Browse Plan Formulary |
Gateway Health Medicare Assured Platinum (HMO SNP)
|
$77.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $60.26 |
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 HMO Rx (HMO)
|
$78.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$8.00 | $16.00 | None | $59.20 |
Browse Plan Formulary |
Freedom Blue PPO ValueRx (PPO)
|
$105.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None | $60.31 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$116.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
50% | 50% | None | $56.45 |
Browse Plan Formulary |
Geisinger Gold Preferred Select Rx (PPO)
|
$119.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $55.52 |
Browse Plan Formulary |
Geisinger Gold Preferred Select Rx (PPO)
|
$119.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $45.40 |
Browse Plan Formulary |
Geisinger Gold Preferred Select Rx (PPO)
|
$119.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $55.97 |
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)
|
$129.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $55.97 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$129.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $55.93 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$129.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $42.10 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$129.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $55.37 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$129.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $45.40 |
Browse Plan Formulary |
Freedom Blue PPO Select (PPO)
|
$137.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$12.00 | $30.00 | None | $60.31 |
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 Rx Enhanced (PPO)
|
$139.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$10.00 | $20.00 | None | $59.20 |
Browse Plan Formulary |
Security Blue Standard (HMO)
|
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$12.00 | $30.00 | None | $60.31 |
Browse Plan Formulary |
UPMC for Life HMO Rx Enhanced (HMO)
|
$223.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$8.00 | $16.00 | None | $59.20 |
Browse Plan Formulary |
Security Blue Deluxe (HMO)
|
$237.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$12.00 | $30.00 | None | $60.31 |
Browse Plan Formulary |
Freedom Blue PPO Classic (PPO)
|
$280.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$12.00 | $30.00 | None | $60.31 |
Browse Plan Formulary |