LEVETIRACETAM TABLETS 1000MG 60 BOT (60 BOT) (NDC: 13668001760)
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 | 2 |
Non-Preferred Generic |
$12.00 | $30.00 | None | $34.06 |
Browse Plan Formulary |
Advantra Silver (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$13.00 | $39.00 | None | $34.55 |
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 | $30.55 |
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 | $31.33 |
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 | $30.55 |
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 | $45.48 |
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 | $30.55 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$20.00 | $60.00 | None | $45.48 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$20.00 | $60.00 | None | $30.55 |
Browse Plan Formulary |
Humana Gold Plus H6859-001 (HMO)
|
$0.00 |
$200* | Yes, but No Gap Coverage for this drug. | 2* |
Non-Preferred Generic |
$18.00 | $0.00 | None | $23.39 |
Browse Plan Formulary |
UPMC for Life HMO Deductible with Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$10.00 | $20.00 | None | $29.42 |
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 | $44.53 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$27.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $11.33 |
Browse Plan Formulary |
Cigna-HealthSpring Achieve (HMO SNP)
|
$28.50 |
$280* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
$10.00 | $30.00 | None | $44.62 |
Browse Plan Formulary |
AdvantraOne (PPO)
|
$29.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$19.00 | $57.00 | None | $34.28 |
Browse Plan Formulary |
Cigna-HealthSpring Preferred (HMO)
|
$29.50 |
$280* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
$10.00 | $30.00 | None | $50.38 |
Browse Plan Formulary |
Cigna-HealthSpring Preferred (HMO)
|
$29.50 |
$280* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
$10.00 | $30.00 | None | $38.81 |
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 | 2 |
Tier 2 |
15% | 15% | None | $34.60 |
Browse Plan Formulary |
AmeriHealth VIP Care (HMO SNP)
|
$33.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $24.76 |
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 | $35.16 |
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 | None | $35.16 |
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 | $33.73 |
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 | $23.39 |
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 | 1 |
Generic |
$10.00 | $20.00 | None | $29.42 |
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 | $23.39 |
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 | $35.16 |
Browse Plan Formulary |
Advantra Silver Plus (HMO)
|
$49.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$22.00 | $66.00 | None | $34.34 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (HMO)
|
$49.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$15.00 | $30.00 | None | $57.49 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (PPO)
|
$49.00 |
$230* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
$8.00 | $16.00 | None | $10.70 |
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 |
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 | $23.39 |
Browse Plan Formulary |
Advantra Silver Plus (PPO)
|
$67.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$9.00 | $27.00 | None | $34.46 |
Browse Plan Formulary |
Freedom Blue PPO HD Rx (PPO)
|
$70.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$12.00 | $30.00 | None | $39.76 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$70.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $45.48 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$70.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $30.55 |
Browse Plan Formulary |
SeniorBlue - Option 2 (PPO)
|
$72.40 |
$0 | to be determined | 2 |
Tier 2 |
$17.00 | $51.00 | None | $31.20 |
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 | 2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $35.16 |
Browse Plan Formulary |
Freedom Blue PPO ValueRx (PPO)
|
$95.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$12.00 | $30.00 | None | $39.76 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$116.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$8.00 | $20.00 | None | $34.55 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$124.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$15.00 | $45.00 | None | $57.66 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$124.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $30.55 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$124.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $45.48 |
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. | 2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $30.55 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$124.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $31.33 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$124.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $30.55 |
Browse Plan Formulary |
Aetna Medicare Select Plus Plan (PPO)
|
$139.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$3.00 | $7.50 | None | $65.40 |
Browse Plan Formulary |
SeniorBlue - Option 1 (PPO)
|
$191.90 |
$0 | to be determined | 2 |
Tier 2 |
$10.00 | $30.00 | None | $31.20 |
Browse Plan Formulary |
Freedom Blue PPO Standard (PPO)
|
$246.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$12.00 | $30.00 | None | $39.76 |
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 |
Freedom Blue PPO Deluxe (PPO)
|
$296.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$12.00 | $30.00 | None | $39.76 |
Browse Plan Formulary |