PACERONE 200MG TABLET (90 BOTPL) (NDC: 00245014790)
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 |
Advantage Health NY - SNP (HMO SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $8.80 |
Browse Plan Formulary |
Advantage Silver - NY (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$4.00 | $8.00 | None | $8.80 |
Browse Plan Formulary |
Aetna Better Health FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
0% | 0% | None | $8.01 |
Browse Plan Formulary |
Affinity Medicare Passport Essentials (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $5.54 |
Browse Plan Formulary |
AgeWell New York FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
0% | 0% | None | $6.46 |
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 |
Amerivantage Specialty + Rx (HMO SNP)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$20.00 | $40.00 | None | $16.42 |
Browse Plan Formulary |
CenterLight Healthcare FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
0% | 0% | None | $10.60 |
Browse Plan Formulary |
EmblemHealth Dual Assurance FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
0% | 0% | None | $13.12 |
Browse Plan Formulary |
Fidelis Fully Integrated Dual Advantage (FIDA) (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
0% | n/a | None | $6.72 |
Browse Plan Formulary |
GuildNet Gold Plus FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
0% | 0% | None | $13.12 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $6.37 |
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 |
Healthfirst AbsoluteCare FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
0% | 0% | None | $6.37 |
Browse Plan Formulary |
Integra FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
0% | 0% | None | $7.26 |
Browse Plan Formulary |
Liberty Health Advantage Preferred Choice (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $8.65 |
Browse Plan Formulary |
North Shore-LIJ FIDA LiveWell (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
0% | 0% | None | $5.31 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (Regional PPO)
|
$0.00 |
$225* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$2.00 | $4.00 | None | $4.72 |
Browse Plan Formulary |
VNSNY CHOICE FIDA Complete (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
0% | 0% | None | $6.59 |
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 |
VNSNY CHOICE Medicare Enhanced (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$9.00 | $27.00 | None | $6.59 |
Browse Plan Formulary |
WellCare Advocate Complete FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
0% | 0% | None | $7.99 |
Browse Plan Formulary |
WellCare Choice (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$14.00 | $35.00 | None | $7.80 |
Browse Plan Formulary |
Fidelis Long Term Care Advantage (HMO SNP)
|
$3.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $6.72 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$28.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $14.09 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$28.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $12.14 |
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 |
EmblemHealth Essential (HMO)
|
$28.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $13.73 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$30.30 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $4.74 |
Browse Plan Formulary |
LiveWell (HMO)
|
$32.90 |
$250 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $6.46 |
Browse Plan Formulary |
Humana Gold Plus H3533-010 (HMO)
|
$33.00 |
$320* | Yes, but No Gap Coverage for this drug. | 2* |
Non-Preferred Generic |
$25.00 | $0.00 | None | $5.99 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
|
$34.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $6.37 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Classic (HMO)
|
$34.10 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $6.59 |
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 Dual Advantage Flex (HMO SNP)
|
$35.40 |
$320* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.72 |
Browse Plan Formulary |
Healthfirst AssuredCare (HMO SNP)
|
$36.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $6.37 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO SNP)
|
$36.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $6.37 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO SNP)
|
$36.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $6.37 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Preferred (HMO SNP)
|
$36.30 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $6.59 |
Browse Plan Formulary |
Advantage Value One NY - Dual (HMO SNP)
|
$36.90 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Tier 1 |
$0.00 | $0.00 | None | $8.76 |
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 |
Affinity Medicare Solutions (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $5.54 |
Browse Plan Formulary |
Affinity Medicare Ultimate (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $5.54 |
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 | None | $6.46 |
Browse Plan Formulary |
CareWell (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $6.46 |
Browse Plan Formulary |
CenterLight Healthcare Direct Complete Plan (HMO SNP)
|
$36.90 |
$320* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
$7.25 | $21.75 | None | $10.60 |
Browse Plan Formulary |
EmblemHealth Dual Eligible (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$9.00 | $27.00 | None | $13.12 |
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 |
EmblemHealth Dual Eligible (PPO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$9.00 | $27.00 | None | $13.12 |
Browse Plan Formulary |
EmblemHealth MLTC PLUS (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$9.00 | $27.00 | None | $13.12 |
Browse Plan Formulary |
FeelWell (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $6.46 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$36.90 |
$240* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.72 |
Browse Plan Formulary |
GuildNet Gold (HMO-POS SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $13.14 |
Browse Plan Formulary |
Liberty Health Advantage Dual Power (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $8.65 |
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)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $4.73 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Maximum (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $6.59 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $6.59 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$3.00 | $7.50 | None | $7.98 |
Browse Plan Formulary |
Affinity Medicare Passport Select (HMO)
|
$46.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $5.54 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$48.00 |
$310 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$22.00 | $44.00 | None | $25.67 |
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 |
Advantage Platinum Plus NY (HMO)
|
$49.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Tier 1 |
$0.00 | $0.00 | None | $8.76 |
Browse Plan Formulary |
Empire MediBlue Freedom I (PPO)
|
$71.00 |
$304 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$22.00 | $44.00 | None | $22.90 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
|
$89.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $14.09 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
|
$89.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $13.73 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
|
$89.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $12.14 |
Browse Plan Formulary |
Affinity Medicare Passport Elite (HMO)
|
$126.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $5.54 |
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 Plus H3533-019 (HMO)
|
$163.00 |
$320* | Yes, but No Gap Coverage for this drug. | 2* |
Non-Preferred Generic |
$18.00 | $0.00 | None | $5.99 |
Browse Plan Formulary |
EmblemHealth Advantage (PPO)
|
$199.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $13.43 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$253.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $14.09 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$253.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $13.73 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$253.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $12.14 |
Browse Plan Formulary |