PROMACTA 25 MG TABLET (30 BOT) (NDC: 00007464013)
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 |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $3,124.28 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $3,124.28 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $3,124.28 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $3,124.28 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $3,124.28 |
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 |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $3,083.54 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $3,094.13 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $3,182.33 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $3,182.33 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $3,182.33 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:62 /31Days | $3,124.28 |
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 Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:62 /31Days | $3,124.28 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:62 /31Days | $3,124.28 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:62 /31Days | $3,124.28 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:62 /31Days | $3,124.28 |
Browse Plan Formulary |
HumanaChoice R5826-006 (Regional PPO)
|
$28.20 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:30 /30Days | $3,146.37 |
Browse Plan Formulary |
Fidelis Secure Comfort (HMO SNP)
|
$30.40 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | P | $3,096.80 |
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 Secure Freedom (HMO SNP)
|
$31.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Specialty Tier |
25% | 25% | P | $3,096.80 |
Browse Plan Formulary |
HAP Midwest Health Plan (HMO SNP)
|
$31.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Brand |
$0.00 | n/a | P | $3,176.40 |
Browse Plan Formulary |
BCN Advantage HMO ConnectedCare (HMO)
|
$41.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $3,124.28 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$55.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P | $3,293.29 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$58.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | P | $3,094.13 |
Browse Plan Formulary |
McLaren Advantage Sapphire (HMO)
|
$68.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
29% | n/a | P | $3,178.05 |
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 |
McLaren Advantage Sapphire (HMO)
|
$68.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
29% | n/a | P | $3,177.94 |
Browse Plan Formulary |
Humana Gold Plus H8908-001 (HMO)
|
$78.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $3,135.98 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $3,094.13 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $3,182.33 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $3,182.33 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $3,182.33 |
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 |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $3,083.54 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$100.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:62 /31Days | $3,124.28 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$100.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:62 /31Days | $3,124.28 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$100.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:62 /31Days | $3,124.28 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$100.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:62 /31Days | $3,124.28 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$100.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:62 /31Days | $3,124.28 |
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 |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$106.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | 30% | P | $3,293.29 |
Browse Plan Formulary |
McLaren Advantage Diamond (HMO)
|
$108.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
29% | n/a | P | $3,178.05 |
Browse Plan Formulary |
McLaren Advantage Diamond (HMO)
|
$108.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
29% | n/a | P | $3,177.94 |
Browse Plan Formulary |
Alliance Medicare PPO (PPO)
|
$126.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P | $3,293.29 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$138.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $3,124.28 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$138.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $3,124.28 |
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 |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$138.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $3,124.28 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$138.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $3,124.28 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$138.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $3,124.28 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$146.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $3,094.13 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$159.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:62 /31Days | $3,124.28 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$159.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:62 /31Days | $3,124.28 |
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 Plus Blue PPO Signature (PPO)
|
$159.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:62 /31Days | $3,124.28 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$159.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:62 /31Days | $3,124.28 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$159.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:62 /31Days | $3,124.28 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$178.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $3,182.33 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$178.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $3,094.13 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$178.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $3,083.54 |
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 |
PriorityMedicare Select (PPO)
|
$178.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $3,182.33 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$178.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $3,182.33 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$192.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
31% | 31% | P | $3,293.29 |
Browse Plan Formulary |
Alliance Medicare PPO (PPO)
|
$210.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
29% | 29% | P | $3,293.29 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$262.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $3,124.28 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$262.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $3,124.28 |
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 |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$262.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $3,124.28 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$262.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $3,124.28 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$262.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $3,124.28 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$283.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $3,124.28 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$283.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $3,124.28 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$283.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $3,124.28 |
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 Plus Blue PPO Assure (PPO)
|
$283.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $3,124.28 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$283.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:62 /31Days | $3,124.28 |
Browse Plan Formulary |